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The history of emergency airway management.


The first reliable description of airway management is by the Arab physician Ibn Sina, alSo known as Avicenna. His al-Qanun fi ilm at-tibb, or Canon of Medicine, was published in the first half of the 11th century and translated into Latin in the early 16th century. "When necessary, a cannula of gold or silver or other suitable material is advanced down the throat to support inspiration" (1,2).

In 1530, Paracelsus reputedly used a fireside bellows and tube in the nostril in an attempt to restore a patient to life. Then in 1543 the Belgian anatomist, Andreas Vesalius, wrote the first clear description of animal resuscitation: "That life may in a manner of speaking be restored to the animal, an opening must be attempted in the trunk of the trachea, into which a tube of reed or cane should be put; you will then blow into this, so that the lung may rise again ... the lung will swell to the full extent of the thoracic cavity, and the heart become strong and exhibit a wondrous variety of motions" (3).

In 1667 Robert Hooke, Curator of Experiments to the Royal Society, read in a paper before the Society," ... the dog being kept alive by the reciprocal blowing up of his lungs with bellows, and they suffered to subside, for the space of an hour or more, after his thorax had been so displayed, and his Aspera Arteria (trachea) cut off just below the epiglottis and bound upon the nose of the bellows." He also punctured the lung surface with a sharp penknife and observed air pumped into the trachea, escaping via the holes. He concluded that life required sufficient supply of "fresh air" (3).

In 1776 the English surgeon John Hunter wrote "The muzzle of these bellows was fixed into the trachea of a dog, and by working them he was kept perfectly alive ... I took off the sternum of the dog, and exposed the lungs and heart; the heart continued to act as before, only the frequency of its action was considerably increased. When I stopped the motion of the bellows the heart became gradually weaker, and less frequent in its contractions, till it entirely ceased to move. By renewing the action of the bellows the heart again began to move, at first very faintly and with intermissions; but by continuing the artificial breathing, its motion became as frequent and as strong as first" (3).

He recommended the blowing of air into the lungs of drowned persons, noted the potential problem of time delay in instituting artificial respiration, and suggested, "Perhaps the dephlogisticated air (oxygen) described by Dr Priestly (in 1774) may prove more efficacious than common air. It is easily procured and may be preserved in bottles or bladders for that purpose" (3).

In 1767, the Society for the Recovery of Drowned Persons was founded in Amsterdam. Within two years it reported 44 cases of successful resuscitation and other societies soon sprang up in Europe. The Society's handbook was translated into English in 1773 by Dr Thomas Cogan who, with Dr William Hawes, called a meeting of interested physicians at the Chapter Coffee House, near St Paul's Cathedral on 18 April 1774. They formed the Institution for Affording Immediate Relief to Persons Apparently Dead From Drowning, soon to be renamed The Humane Society and later The Royal Humane Society. They sought advice on resuscitation from John Hunter and Dr William Cullen, Professor of Physics at Edinburgh. Cullen advised also that the lungs should be inflated with bellows, recommending the system used by Professor Monro Secundus, Professor of Anatomy in Edinburgh who used similar live animal preparations to those prepared by John Hunter (3).

Many devices for inflation of the lungs during resuscitation resulted; in particular those of Charles Kite (1788) and James Curry (1792). Curry's set included a silver endotracheal cannula and an oesophageal tube with slideable obturator to prevent air being forced into the stomach. Kite noted that pressure on the "prominent part of the windpipe" could prevent regurgitation and gastric distension. Soon after, the Royal Humane Society produced their own apparatus including a bellows and variety of cannulae, and distributed them all over Great Britain (3).

At this time there was also an interest in the resuscitation of asphyxiated newborns. The first true endotracheal tube was described in 1754 by Benjamin Pugh, a Surgeon of Chelmsford in England, to provide an airway to infants during obstructed labour. "The Air Pipe as big as a Swan's Quill in the inside, 10 inches long, is made of a small common wire, turned very close, ... and covered with thin soft leather, one end is introduced up the palm of the hand, and between the fingers that are in the child's mouth, as far as the larynx" (4).

Francois Chaussier, an obstetrician of Dijon, designed a reservoir bag in 1780 that could be filled with air or oxygen and connected to a facemask; this was an improvement on household bellows filled with ash and dust. He originally used a tube inserted in the nostril, but in 1806 described a laryngeal cannula which connected to the bag and was sealed with a small sponge near the laryngeal end. Adapted from the tubes in resuscitation sets, this was the forerunner of many subsequent designs (3).

In 1827, Jean Leroy d'Eoilles in a paper to the French Academy of Science condemned inflation of the lungs with bellows as his animal experiments demonstrated that insufflation could lead to fatal tension pneumothorax. Dumeril and Magendie confirmed his findings in 1829 on human cadavers and despite Leroy's invention of a safety bellows, the practice of artificial inflation of the lungs fell into disfavour for many years.

In the mid-19th century, Anne Jean De Paul modified and revived Chaussier's tube for resuscitation of newborn infants. He provided a mouthpiece for the operator and made the distal opening at the tip, rather than the side. It eventually became part of the obstetrician's outfit of his time (3).

These developments in airway instrumentation occurred prior to the introduction of anaesthesia which created new issues in airway management with some early practitioners showing remarkable foresight. In 1877 Joseph Clover reported that he corrected respiratory obstruction during anaesthesia by inserting a curved cannula through the crico-thyroid membrane, and that although he had not previously needed to use it, he had carried the cannula at some thousands of anaesthetic cases (5).


(1.) Brandt L. The first reported oral intubation of the human trachea. Anesth Analg 1987; 66:1198-1199.

(2.) Haddad FS. Ibn Sina (Avicenna) advocated orotracheal intubation 1000 years ago--documentation of Arabic and Latin originals. Middle East J Anesth 2009; 17:155-162.

(3.) Mushin W, Rendell-Baker L. The Principles of Thoracic Anaesthesia, Past and Present. Blackwell, Oxford 1953.

(4.) Wilkinson DJ. Benjamin Pugh and his air-pipe. In: Marshall Barr A, Boulton T, Wilkinson DJ. Essays on the history of anaesthesia. International Congress and Symposium Series 213. Royal Soc Med 1996

(5.) Clover JT. Laryngotomy in chloroform anaesthesia. BMJ 1877; 1:132-133.


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Title Annotation:COVER NOTE
Author:Westhorpe, R.N.; Ball, C.
Publication:Anaesthesia and Intensive Care
Geographic Code:8AUST
Date:Jan 1, 2010
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