History and COVID-19, Part II: An Anesthesia Perspective

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  • Moon, Jane, MD
| Apr 20, 2020

JMoon photo2 (002)In what is now a familiar refrain, many of us in anesthesiology, including Surgeon General Jerome Adams, MD, MPH, are on the front lines of a global pandemic. This is an historic moment for our specialty.  

As we reflect on this occasion, it is inspiring to recall the anesthesiologists who have come before us. Their past innovations—now key components of COVID-19 care—have allowed us to be in this position to serve. We are thus part of a narrative that is larger than ourselves—one that Edmond “Ted” Eger II, MD, Lawrence Saidman, MD, and Rod Westhorpe, OAM, MB, MS, have called “the wondrous story of anesthesia.”1

An Epidemic and an Anesthesiologist

It was August 1952, and the infectious disease hospita­l in Copenhagen was flooded with polio patients. Within the first three weeks, nearly 90 percent of the 31 patients admitted with bulbar polio had died. The hospital’s modest ventilator supply, consisting of one iron lung and six cuirass shells, was quickly overwhelmed. These negative-pressure machines were insufficient to treat full-blown respiratory paralysis. Blood-gas analysis was non-existent.  

At this moment of desperation, it was an anesthesiologist who saved the day. Bjørn Ibsen, DrMed, rapidly determined that the elevated blood carbon dioxide content of these patients indicated not a primary alkalosis, as traditionally thought, but rather a severe respiratory acidosis.2 Aggressive ventilation was needed. His intuition came from a recent experience with a tetanic child who had required paralysis and manual bag ventilation to survive.  

Dr. Ibsen’s solution was to place a cuffed endotracheal tube through a tracheostomy, and to enlist 200 medical students to provide continuous ventilation by hand. Some patients were treated in this manner for weeks. Thanks to this extreme measure, the Danes witnessed a miracle—mortality dropped from ~90 percent to ~25 percent.  

Thus, an anesthesiologist initiated the first prolonged use of positive-pressure ventilation for respiratory failure. This also marked one of the first times that an anesthesiologist moved out of the operating room.2 In doing so, Dr. Ibsen created the first intensive care unit (ICU).  

Ibsen and the Story of Anesthesia

While Dr. Ibsen’s work was groundbreaking, he also built upon the work of prior anesthesiologists. Throughout history, most new ideas have developed from prior concepts. This human connection spans generations, and the humility that arises from this knowledge can facilitate learning, minimize error, and encourage collaboration.   

An anesthesiologist was able to rescue the Danish polio crisis due to expertise that was unique to the profession. The cuffed endotracheal tube had been introduced by Arthur Guedel, MD, and Ralph Waters, MD, in 1928. Dr. Waters’ portable “To and Fro” carbon dioxide absorber, invented in 1919, had been a mainstay in operating rooms. Dr. Ibsen applied a routine practice for anesthesiologists during surgery—the application of manual positive-pressure via a cuffed endotracheal tube connected to a to-and-fro canister3—to the treatment of respiratory failure. 

The concept of anesthesiologists as experts in pulmonary gas exchange had long been championed by Paluel Flagg, MD, who suggested that we change our professional name to “pneumatologists.”4 In The Art of Anesthesia (1919), an early American anesthesia textbook, Dr. Flagg stated that “the physician was more important than the specialty in which he practiced.” Since anesthesiologists were skilled at delivering inhalational agents, he hoped to expand our scope to the bedside management of asphyxia. Dr. Ibsen, by applying anesthetic techniques to the ICU, was fulfilling Dr. Flagg’s dream.  

Anesthesiologists’ Continued Innovation

The polio epidemic and Dr. Ibsen’s role in it changed the face of anesthesiology and medicine forever. Just as Dr. Ibsen drew upon the ingenuity of his predecessors, many anesthesiologists also built upon his work. Peter Safar, MD, inventor of modern CPR, began to envision critical care as a continuum from the prehospital setting, to the emergency room, and on to the ICU. He soon created the first multidisciplinary ICU (1959) and the first critical care fellowship in the U.S. (1961). Dr. Safar co-founded the Society of Critical Care Medicine (SCCM) in 1971.

The polio epidemic also revealed a gap between advances made by respiratory physiologists during World War II and their translation into clinical practice. Sobered by the lack of laboratory values available to guide ventilation, scientists were galvanized to action.2 Physiologist Julius Comroe, Jr., MD’s book The Lung (1955) signified a sea change in the field. When Dr. Comroe moved to UCSF in 1957 to direct a new Cardiovascular Research Institute (CVRI), he brought two anesthesiologists—Stuart Cullen, MD, and John Severinghaus, MD—along with him.

Animated by the deficiencies revealed by polio, Dr. Severinghaus, along with lab technician A. Freeman Bradley, and leading scientists Richard Stow, PhD, and Leland Clark, PhD, worked to fine-tune electrodes for measuring pCO2 and pO2. By 1958, all of their efforts culminated in the first three-function blood gas analyzer. Now, pH, pCO2, and pO2 could be derived from a single blood sample, almost instantaneously.  

In the late 1960s, two pediatric anesthesiologists—John Inkster, MBBS, FRCA, of England, and George Gregory, MD, of UCSF—reported similar findings, adding to the growing field of respiratory physiology. They discovered that PEEP or CPAP—novel concepts at the time—could reverse neonatal lung dysfunction.  

In 1978, Stanford anesthesiologist William “Bill” New, MD, PhD, developed the Nellcor N100 pulse oximeter, which could measure oxygenation without puncturing skin. (While the first pulse oximeter appeared in Japan, the Nellcor N100 was the first to achieve clinical use.) It revolutionized patient safety, first in the operating room, and then in all other care settings. Not only was it portable, it also used a sound that modulated to heart rate and oxygen saturation.  

Due to the stressful nature of intubation and ventilation, sedative and analgesic agents have also been vital to critical care. Anesthesiologists played a crucial role in developing these drugs.  British anesthesiologists first studied propofol clinically in the late 1970s. In the early 2000s, Stanford anesthesiologist Mervyn Maze, MB, ChB, thoroughly examined the pharmacologic properties of dexmedetomidine.  

Furthermore, anesthesiologists led the development of crisis simulation education. Judson “Sam” Denson, MD, (USC, 1967) created the first simulation mannequin; David Gaba, MD, (Stanford, Palo Alto VA, 1988) developed the first full operating-room simulator. Now, simulation is widely used to help health care workers manage resources and act decisively during crises.  

COVID-19: Anesthesia History in the Making

Our ability to serve on the front lines of this pandemic builds in large part upon the prior achievements of anesthesiologists. Endotracheal intubation, positive-pressure ventilation, intensive care units, blood gas analysis, positive end-expiratory pressure, pulse oximetry, modern sedatives, and crisis simulation—all were once novel concepts that are now essential elements of COVID-19 care.  

Thus, we stand on the shoulders of giants as we combat this disease. In the meantime, the remarkable spirit of innovation—a true trademark of physician anesthesia—carries on.  

To fulfill our duty as doctors while minimizing personal risk, anesthesiologists have devised novel ways to decrease aerosolization during intubation and extubation, to sterilize and reuse personal protective equipment (PPE), and to create effective masks from available supplies. To mitigat­­­e the global shortage of ventilators, anesthesiologists have participated in the creation of lower-cost, simple respirators. Some are taking the form of mechanized Ambu® bags—a throwback to the Danish polio epidemic of the 1950s, when patients were painstakingly ventilated by hand.  

Just as polio revolutionized the worlds of anesthesia, physiology, and medicine in the 1950s, COVID-19—an even more widespread disease—will change us as well. It is our hope that when the next pandemic occurs, we will be armed with even newer solutions that will echo Dr. Flagg’s idea that we are physicians first, and specialists second. 

This is part two of a two-part series on history and the COVID-19 pandemic. 

References:

1.  Eger EI, Saidman LJ, Westhorpe RN. The Wondrous Story of Anesthesia. New York, NY: Springer; 2014.

2. West JB. The physiological challenges of the 1952 Copenhagen poliomyelitis epidemic and a renaissance in clinical respiratory physiology. J Appl Physiol. 2005;99(2):424-32.

3. Calmes SH. Why a paper on anesthesia and polio in 2016? Anesth Analg. 2016;122(6):1748-51.

4. Larson MD. Paluel J. Flagg and the “art” of anesthesia. CSA Bulletin. Winter 2009;88-92. 

 

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