By Hayk Manuk-Hakobyan, MD
The CSA Committee on the History of Anesthesia congratulates Dr. Hayk Manuk-Hakobyan, the 2nd place winner of the 2023 CSA History of Anesthesia Essay Contest!
Dr. Manuk-Hakobyan is a CA-2 resident at Cedars-Sinai Medical Center. He grew up in Los Angeles, where he attended college at UCLA before medical school at Georgetown University. He enjoys skiing, playing pickle ball with friends, and going on hikes with his husky!
After a mere three months of on-the-job anesthesia training, Dr. Jonathan Benumof was sent to serve as an anesthesiologist in the Vietnam War. He would dedicate himself to saving the lives of critically injured soldiers in operating conditions in which the heat would exceed 120 degrees Fahrenheit, often while his Mobile Army Surgical Hospital (MASH) unit was under attack.1 Married to his wife, Sherrie, for just six months, they agreed to write daily letters to each other. These letters, in addition to Sherrie’s care packages that included his favorite banana oatmeal chocolate chip cookies, served as Dr. Benumof’s mental lifeline of peace and sustained him through a year of disheartening conflict.1 His grounding in medicine would ultimately set in motion the events that led to the creation of the first American Society of Anesthesiologists (ASA) Difficult Airway Algorithm.
At the time, it was assumed that the responsibility of an anesthesiologist was to manage patients’ airways, but no guidelines existed to offer stepwise decision-making branch points to intubate patients safely. In fact, complications from difficult airways served as a significant source of morbidity and mortality in the practice of anesthesia. To combat this issue, the ASA Task Force was formed in 1991, with Dr. Benumof being recruited to lead this endeavor. Be it performing awake endotracheal intubations in hemodynamically unstable patients, troubleshooting “cannot intubate, cannot ventilate” scenarios, or recognizing predictors for difficult airways, much of his foundation for airway management was extrapolated from his wartime experiences. In addition, Dr. Benumof’s extensive experience in thoracic anesthesiology, which included a single-authored textbook and expertise in one-lung ventilation using double-lumen endotracheal tubes, made him an optimal candidate to lead this task force.
Dr. Benumof’s original 1991 article entitled “Management of the Difficult Adult Airway with Special Emphasis on Awake Tracheal Intubation” formed the basis for the first formal practice guidelines. His algorithm began by answering the most basic question: Has the presence of a difficult airway been recognized? Emphasizing pre-operative evaluation for pathologic and anatomic causes of a difficult airway allowed anesthesiologists to prioritize patient safety and formulate an appropriate plan for airway management.3 A fundamental branch point included awake endotracheal intubations in patients who had recognized predictors for a difficult airway. In addition to topical anesthesia or nerve blocks involving the upper airway, Dr. Benumof stressed building rapport and involving the patient in the decision-making process as an imperative part of awake intubation success.3
If intubation proved difficult in an anesthetized patient, the guidelines highlighted adequate mask ventilation as the best maneuver to save the patient’s life.3,4 Proper respiratory gas exchange via mask ventilation served as a stepping stone to seek alternative plans for intubation and bought vital time for the anesthesiologist to explore other options, including waking the patient. In the event that mask ventilation was inadequate, Dr. Benumof offered the use of transtracheal jet ventilation as a quicker and safer step prior to an emergent cricothyroidotomy.3 However, even with the help of transtracheal jet ventilation, alternative options for a rescue step in the emergent pathway were needed.
Shortly after the release of the first ASA Difficult Airway Algorithm in 1993, the Food and Drug Administration (FDA) approved the use of the laryngeal mask airway (LMA). Dr. Benumof provided an update for the practice guidelines regarding its use as a routine supraglottic airway device during general anesthesia and as a conduit for endotracheal intubation in awake and anesthetized patients who could not be conventionally intubated.2 Most notably, the LMA served as the next best step in the anesthesiologist’s repertoire for providing rescue ventilation in anesthetized patients when mask ventilation and endotracheal intubation were impossible.2,4 Since its introduction, the use of the LMA has saved countless patients’ lives.
Although advancements in our understanding of airway management have produced subsequent iterations of the ASA Difficult Airway Algorithm, much of the core decision-making branch points from the initial iterations have been preserved. The emphasis on pre-operative evaluation, the approach to awake endotracheal intubations, and the integral use of the LMA all stem from Dr. Benumof’s algorithms and are still used by anesthesiologists today to manage difficult airways safely.
When Dr. Benumof returned home from the Vietnam War, he was awarded the Bronze Star and Purple Heart for his exemplary medical care as an anesthesiologist and for suffering a head injury after his MASH unit’s operating room was struck by an incoming rocket. He subsequently finished the remaining two years of his training at Columbia Presbyterian Medical Center and enjoyed a 47-year professorship at University of California, San Diego (UCSD), where he earned multiple teaching recognition awards and authored hundreds of journal articles in anesthesiology. For his contributions to the field, the Society of Airway Management presented Dr. Benumof with a lifetime achievement award in 2022.
Dr. Benumof currently resides in Rancho Mission Viejo, California, where he discovered a little storage box that contained the 282 letters he and Sherrie sent to one another during the Vietnam War. He published them as a collection in his book Letters from the Heart: A Young Doctor’s 1969 Vietnam War Experience. Demonstrating his compassion to serve for the betterment of those in need, he wrote, “As I gained confidence that I could do the job, and do it well, the studying was fueled by a desire to improve the care of the injured patients above and beyond what was presently being done.”1 In these ways, Dr. Benumof represents all physicians who strive to improve the practice of medicine and ensure the safety of patients that reside in our hands.
References
- Benumof J, Benumof S. Letters from the Heart: A Young Doctor’s 1969 Vietnam War Experience. Pacific Grove, CA: Park Place Publications; 2021.
- Benumof JL. Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology. 1996;84(3):686-699. doi:10.1097/00000542-199603000-00024.
- Benumof JL. Management of the difficult adult airway with special emphasis on awake tracheal intubation. Anesthesiology. 1991;75(6):1087-1110. doi:10.1097/00000542-199112000-00021.
- Heidegger T. Management of the difficult airway. New England Journal of Medicine. 2021;384(19):1836-1847. doi:10.1056/nejmra1916801.