POLIO AND THE BIRTH OF RESPIRATORS
Headlines
during the Coronavirus epidemic have emphasized a critical shortage of respirators. The shortage is reminiscent of earlier epidemics associated with inqdequate respirator
supplies: polio epidemics.
Polio spreads fear partly
because patients with upper body paralysis are unable to breathe, signaling a death
sentence before the invention of respirators. The earliest devices to aid
breathing were tilt tables, allowing the abdominal contents to push up against
the diaphragm when tilted head-down and pull down when more erect. They had
limited success. In 1928, Phillip Drinker, holder of a degree in chemical
engineering and an instructor on ventilation and illumination at Harvard’s new
School of Public Health, was consulted by Boston’s Children’s Hospital to help young polio victims, unable to breathe. Drinker had already developed a respirator
for industrial cases of gas poisoning. With the help of Louis Agassiz Shaw, Drinker placed
a cyanotic eight-year-old girl into the new device - an “iron lung” – a large
metal tank, closed at the neck, that generated negative pressure to expand the
lungs in a rhythmic fashion. The girl’s color pinked up quickly as the device
took over her breathing. The
“Drinker respirator” came into common use for polio patients. It was soon
modified by John Emerson, a gifted man engaged in developing research apparatus
for Boston-area medical schools. The Emerson respirator was more efficient,
quieter, and cheaper, and was soon adopted as a standard. Drinker sued Emerson
over patent rights, but eventually he lost both the suit and his patent rights.
Tracheostomy as a way to control secretions while in the iron lung also was employed.
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| Polio Ward at Rancho Los Amigos National Rehabilitation Center, 1953. (Wikipedia) |
In 1952, polio’s devastation was unprecedented,
the number of afflicted rising to almost 58,000 nationwide. Schools, churches,
pools, and other public gathering spots were shut down and children kept
indoors. In hospitals, Emerson respirators worked overtime, and thousands were
in use. In far-away Denmark, the virus was equally relentless, with 5,722 cases
throughout the country. In Copenhagen, one hospital, the Blegdams Hospital,
with 500 beds, was assigned to handle polio patients. But the hospital, still
suffering economically from the war, had only one “iron lung”, and six smaller,
weaker versions, covering only the chest. Polio admissions ran as high as 30 to
50 a day, with 6 to 12 a day needing respiratory help. Doctors agonized over
having to decide who got a respirator and who did not. An anesthetist, Björn
Ibsen, was called to help, and help he did.
Ibsen, while a medical student in
Copenhagen, had spent a rotation administering anesthesia at a provincial
hospital in Jutland, using an ether mask. He had never intubated a patient and
anesthesia was not a specialty in Denmark. To obtain further training he accepted
a position at Massachusetts General Hospital as an anesthetist,
working under
Henry K. Beecher. When he arrived in 1949, open drop ether was the method used and
medical students had to induce at least 10 patients before graduating. A year
later Ibsen was back in Copenhagen, working as a freelance anesthesiologist.
 |
| Henry Beecher (Wikipedia) |
When Ibsen arrived at the beleaguered
Blegdams Hospital, the few tank respirators available functioned poorly.
Twenty-seven out of thirty-one respirator cases died in spite of tracheostomies
done to control secretions. Further, knowledge of blood gases was just emerging
and not widespread among clinicians. Having just read an article on the buildup of
carbon dioxide in the body in such cases, Ibsen suspected this was part of the
problem.
A 12-year-old girl, turning blue and
struggling to breathe, was Ibsen’s first patient. He showed quickly that CO2
narcosis developed at times of diminished
breathing (by measuring the expired CO2),
even with proper oxygenation. He relieved her distress
with a tracheostomy and
a bag respirator. Tracheostomy and artificial breathing with a bag respirator became
routine as a supplement to tank respirators or as the sole breathing
assistance. Medical students were called in to hand operate the respirator
bags, working in 6-hour shifts around the clock. It was emotionally exhausting
work, breathing for a child who was paralyzed and unable to speak. Standbys
were also needed in case a student was sick or cancelled. (For an image of this
see: https://www.nature.com/articles/d41586-020-01019-y?utm_source=Nature+Briefing&utm_campaign=64fb5afbff-briefing-dy-20200406&utm_medium=email&utm_term=0_c9dfd39373-64fb5afbff-44774997 ).
 |
| Björn Ibsen (Wikipedia) |
Anxiety about contracting polio from the
work and worry about finishing the medical curriculum led many students to drop
out of the program after a few weeks. Dental students were next recruited.
Eventually about 1,500 students put in 165,000 hours hand-ventilating. Bang
& Olufsen designed and made mechanical respirators to relieve the strain, though the
firm later concentrated on audio equipment.
Many patients who were maintained on
continuous bag respiration recovered to breathe on their own. Ibsen’s first
polio patient, the 12-year-old girl, lived to the age of 31, when she died of
pneumonia and diabetes.
Ibsen also pioneered in the treatment of
tetanus, using curare to paralyze the respiratory muscles while breathing for
the patient, a treatment he had been advised against while in Boston. Later he
was asked to consult on fluid replacement postoperatively in another hospital. He
turned that hospital’s recovery room into the precursor of an ICU, said by some
to be the world’s first, and later wrote a book on shock.
It is an old truism that war spawns
innovations in medical treatment. The same might be said of epidemics. The
hand-operated respirators of the Blegdams Hospital, later mechanized, replaced
iron lungs. And the successful Salk vaccine entered its first trials the year
after the 1952 epidemic.
SOURCES:
Wackers, G L Constructivist
Medicine. 1994; Thesis, University of Maastricht.
Lassen, H C A. “A Preliminary
Report on the 1952 Epidemic of Poliomyelitis in Copenhagen.” 1953; Lancet
Jan 3, pp 37-41.
West, J B. “The Physiologic
Challenges of the 1952 Copenhagen Poliomyelitis Epidemic and a Renaissance in
Clinical Respiratory Physiology.” 2005; J Appl Physiol 99(2): 424-32.
Shaw, L A and Drinker, P. “An
Apparatus for the Prolonged Administration of Artificial Respiration: II. A
Design for Small Children and Infants with an Appliance for the Administration
of Oxygen and Carbon Dioxide.” 1929; J CVlin Invest 8(1): 33-46.
Phillip Drinker, obituary. 1973;
Ann Occup. Hyg. 16: 93-4.
Berthelsen, P G and Cronqvist,
M. “The First Intensive Care Unit in the World”. 2003; Acta Anaesthesiol Scand 47:
1190-5.
Senelar, L R. The Danish
Anaesthesiologist Björn Ibsen: A Pioneer of Long-term Ventilation on the Upper
Airways. 2009; Thesis, Johann Wolfgang Goethe University, Frankfurt am
Main.
Lassen, Bjorneboe, Ibsen, and
Neukirch. “Treatment of Tetanus with Curarisation, General Aneasthesia, and
Intratracheal Positive-Pressure Ventilation.” 1954; Lancet Nov 20, pp
1040-4.
Oshinsky, D. Polio, An American Story.
2005; Oxford Univ Press.
