The Reign of the Ventilator: Acute Respiratory Distress Syndrome, COVID-19, and Technological Imperatives in Intensive Care.

In the early phase of the COVID-19 pandemic, a dispute arose as to whether the disease caused a typical or atypical version of acute respiratory distress syndrome (ARDS). This essay recounts the emergence of ARDS and places it in the context of the technological transformation of modern hospital care-particularly the emergence of intensive care after the 1952 Copenhagen polio epidemic. The polio epidemic seemed to show the value of manual positive-pressure ventilation, leading to the proliferation of mechanical ventilators and the expansion of intensive care units in the 1960s. This created the conditions of possibility for ARDS to be described and institutionalized within modern intensive care. Yet the centrality of the ventilator to descriptions and definitions of ARDS quickly made it difficult to conceive of the disorder outside the framework of mechanical ventilation and blood gas levels, or to acknowledge the degree to which the ventilator was a source of iatrogenic injury and complications. Moreover, the imperative to understand and treat ARDS with mechanical ventilation set the stage for the early confusion about whether patients with COVID-19 should receive mechanical ventilation. This history offers many crucial lessons about how new technologies can lead to new and valuable therapies but can also subtly shape and constrain medical thinking. Moreover, ventilators not only changed how respiratory disorders were conceived; they also brought new forms of respiratory illness into existence.

AJRCCM: 100-Year Anniversary. Homeward Bound: A Centenary of Home Mechanical Ventilation.

The evolution of home mechanical ventilation is an intertwined chronicle of negative and positive pressure modes and their role in managing ventilatory failure in neuromuscular diseases and other chronic disorders. The uptake of noninvasive positive pressure ventilation has resulted in widespread growth in home ventilation internationally and fewer patients being ventilated invasively. As with many applications of domiciliary medical technology, home ventilatory support has either led or run in parallel with acute hospital applications and has been influenced by medical and societal shifts in the approach to chronic care, the creation of community support teams, a preference of recipients to be treated at home, and economic imperatives. This review summarizes the trends and growing evidence base for ventilatory support outside the hospital.

Ventilación mecánica: una breve historia / Mechanical ventilation: a short history

This review is a short history of mechanical ventilation, from its origins to the present day. This changing history provides the basis for speculation on the future innovations in the ventilatory support.

Se revisa la historia de la ventilación mecánica desde sus orígenes hasta el presente, una historia cambiante que permite especular sobre las futuras innovaciones en el soporte ventilatorio.

History of Mechanical Ventilation. From Vesalius to Ventilator-induced Lung Injury.

Mechanical ventilation is a life-saving therapy that catalyzed the development of modern intensive care units. The origins of modern mechanical ventilation can be traced back about five centuries to the seminal work of Andreas Vesalius. This article is a short history of mechanical ventilation, tracing its origins over the centuries to the present day. One of the great advances in ventilatory support over the past few decades has been the development of lung-protective ventilatory strategies, based on our understanding of the iatrogenic consequences of mechanical ventilation such as ventilator-induced lung injury. These strategies have markedly improved clinical outcomes in patients with respiratory failure.

Neonatal revolution - the introduction of PEEP.

Fifty years ago, a baby born at 24-26 weeks was not considered viable. It was a tragedy for the mother having carried it for so long. I witnessed such an event as a student. The scourge of premature deliveries was the lack of surfactant in many tiny babies. In general, if a premature infant with hyaline membrane disease, as it was called respiratory distress syndrome (RDS), could not maintain a pO(2) above 60 mmHg in 100% oxygen, it was not expected to survive. In late 1969, two babies with suspected RDS came to ICU and were treated by the author with the buffer (tris hydroxyl amino methane, [THAM] which reduced both metabolic and respiratory acidosis and did not contain sodium) and an isoprenaline infusion (ß(1) stimulant and pulmonary vasodilator). The X-ray appearances of RDS disappeared. Unfortunately, one died of portal vein thrombosis because the drugs were administered by umbilical catheter, which were commonly used at the time. The other one recovered but the physicians then said the diagnosis must have been wrong!

Positive-pressure ventilation, spinal anesthesia, and Rudolph Matas: the anesthetic contributions of an inquisitive surgical legend.

Dr. Rudolph Matas, in addition to being one of the pioneering and most prestigious vascular surgeons of the 19th century, was an influential figure in the development of anesthesiology in the United States (US). His inquisitive nature and determination to understand medicine were tremendous influences in his development of innovative approaches to solve surgical and medical problems. Driven by such curiosity and determination, Dr. Matas made pivotal contributions in the historical timeline of current anesthesiological practice, including the use of spinal anesthesia and positive-pressure ventilation during thoracotomies.

Dominique-Jean Larrey: the effects of therapeutic hypothermia and the first ambulance.

The fields of emergency medicine and resuscitation are indebted to the Baron Dominique-Jean Larrey (1766-1842) for significant advances in patient care. Larrey was a great surgeon who served in the French army during Napoleon's rule. He developed one of the first ambulance services, utilized positive pressure ventilation, and introduced hypothermia as a form of therapy. He dedicated his professional life to improving the care of wounded soldiers on the battlefield. Larrey coined the term "Triage" to allocate resources to those most in need of emergent care. Today, many of his techniques still prevail in modern medicine.

History and epidemiology of noninvasive ventilation in the acute-care setting.

Although noninvasive ventilation (NIV) was first used to treat patients with acute respiratory failure in the 1940s, the history of this mainstay of today's respiratory care armamentarium has mainly been written in the last 20 years. There is now a robust evidence base documenting the efficacy of NIV in exacerbations of chronic obstructive pulmonary disease, cardiogenic pulmonary edema, and acute respiratory failure in immunocompromised patients, and evidence in support of NIV in other settings, such as hypoxemic acute respiratory failure and the management of patients who decline endotracheal intubation, is accumulating rapidly. Efficacy as demonstrated in clinical trials does not necessarily translate to clinical effectiveness in practice, however, and important barriers need to be overcome if NIV is to realize for the average patient the potential it has shown in research studies. However, although the expansion of its use in everyday patient care has lagged behind the growth of its evidence base, an increasing number of studies document the steadily expanding use of NIV in the acute-care setting. This article reviews the history of NIV as applied in acutely ill patients and summarizes the studies of NIV outside the research setting during the last decade.

Pinching, electrocution, ravens' beaks, and positive pressure ventilation: a brief history of neonatal resuscitation.

Since ancient times many different methods have been used to revive newborns. Although subject to the vagaries of fashion for 2000 years, artificial respiration has been accepted as the mainstay of neonatal resuscitation for about the last 40. Formal teaching programmes have evolved over the last 20 years. The last 10 years have seen international collaboration, which has resulted in careful evaluation of the available evidence and publication of recommendations for clinical practice. There is, however, little evidence to support current recommendations, which are largely based on expert opinion. The challenge for neonatologists today is to gather robust evidence to support or refute these recommendations, thereby refining this common and important intervention.

Notable Australian contributions to the management of ventilatory failure of acute poliomyelitis: with special reference to the Both respirator and Dr. John A. Forbes.

When Australia's 1937 epidemic of poliomyelitis created an urgent need for extra ventilating machines to compensate for respiratory paralysis, Edward Both, an innovative Adelaide biomedical engineer, invented a wooden-cabinet respirator capable of being made relatively quickly in sufficient quantity. His device, here called "the Both", alleviated the problem at Adelaide's Northfield Infectious Diseases Hospital and others, and in late 1938 was introduced into England when Both was visiting there. Appreciating its merits, Lord Nuffield financed assembly-line production at the Morris motor works in Cowley, Oxford. Then, through the Nuffield Department of Anaesthetics in Oxford's Radcliffe Infirmary, he had the Both distributed Commonwealth-wide, as a gift for treating ventilatory failure in polio - especially in children. For the 1937 epidemic in Victoria, and to the design of Melbourne University's Professor of Engineering, Aubrey Burstall, nearly 200 of another wooden-cabinet respirator were ultimately built. Some were installed at the Acute Respiratory Unit of the Infectious Diseases Hospital at Fairfield, then others "all over Australia". However, by the early 1950s, the Both had replaced Fairfield Hospital's "Burstall", which had functioned as Victoria's favoured respirator since 1937. Dr John Forbes at Fairfield became the foremost Australian clinician for expertise with the Both. Before the advent of intermittent positive pressure ventilation, the Both's usefulness had seen it tried for ventilatory failure in some non-polio conditions, but uptake of that application was limited. Nonetheless, Nuffield's philanthropy with the (Nuffield-)Both ultimately furthered progress along the 20th century pathway to intensive care medicine.