AIRWAY MANAGEMENT AND RESUSCITATION
Masks and Airways
Ventilation during anesthesia was managed without specialized
airway devices for more than 50 years after Morton's discovery, and a survey of anesthetic
complications during this era attests to the relative safety of inhalation techniques
in the spontaneously breathing patient (see Chapter
42
and Chapter 78
).
Deaths occurred during this era, and in some reports the anesthetic death rate was
alarmingly high, but an obstructed airway was rarely mentioned as the primary cause
of death. Friedrich von Esmarch[394]
described
the jaw thrust ( Fig. 1-17
)
as a lifesaving maneuver in some cases of airway obstruction that resulted from chloroform
or asphyxia:
Press the lower jaw forwards with both hands by placing the forefingers behind
the ascending ramus ... by this movement the hyoid bone and root of the tongue, and
the epiglottis are drawn forwards, and the entrance to the larynx is thus freed from
obstruction.
Figure 1-17
Illustration in a treatise by Von Esmarch[394]
shows the technique of maintaining an open airway in an unconscious patient. (From
Von Esmarch F: Handbuch der kriegschirurgischen Technik. Hanover, Carl Rumpler,
1877.)
In 1874, the same maneuver had been previously described, but
not popularized, by J. Heiberg,[395]
a Norwegian
surgeon.
Various problems with the Morton inhaler in the United States
led to abandonment of inhalers in favor of a simple towel or sponge saturated with
ether. In 1850, John Warren,[396]
in his address
to the American Medical Association, described his preferred technique for ether
administration at the Massachusetts General Hospital: (1) no oral intake for at
least 3 hours before surgery, (2) a horizontal position for induction, (3) bleeding
the patient before surgery for bloodless operations, (4) pulse and respiration watched
carefully by an assistant to the anesthetist, (5) ether applied with a large sponge
soaked with ether, and (6) avoidance of cautery.
Several wire-frame masks were devised to replace the sponge or
folded towel. The popular mask devised by Curl Schimmelbusch (1860–1895) had
a trough-shaped rim to prevent liquid chloroform or ether from dropping onto the
patient's face. Friederich von Esmarch[394]
used
a wire mask with a clip that enabled it to be strapped to the patient. The advantages
of these masks were low cost, simplicity, and portability. Disadvantages included
delivery of vapor throughout the operating room, cooling of the patient, and waste
of anesthetic agent.
The development of the modern facemask originated with Francis
Sibson[397]
[398]
(1814–1876), who devised a mask made of pliable tinned iron and covered with
glove leather. The mask covered the mouth and nose and therefore eliminated the
need for noseclips. Snow quickly recognized the superiority of the Sibson mask and
incorporated it into his practice.
The first anesthetics were of short duration and rarely required
special devices to maintain airway patency. With the increasing complexity and duration
of surgical procedures, special devices were fashioned to facilitate an open airway.
Frederick Hewitt promoted a simple metal tube that projected through the mouth into
the hypopharynx.[399]
The commonly used Guedel
rubber curved airway was described in 1935.[400]
At the same time, cuffs were sometimes used on oral airways,[401]
a design that has been resurrected in the form of a modern product, the cuffed oral
pharyngeal airway (COPA).
