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Artificial Ventilation: History, Equipment and Techniques 755 Thorax 1990;45:753-758 753 Assisted ventilation 1 Series editor: John Moxham Artificial ventilation: history, equipment and Thorax: first published as 10.1136/thx.45.10.753 on 1 October 1990. Downloaded from techniques J D Young, M K Sykes A brief history of artificial ventilators expedited research into powered mechanical ventilators. An artificial ventilator is essentially a device that replaces or augments the function of the Classification of artificial ventilators inspiratory muscles, providing the necessary The lungs can be artificially ventilated either energy to ensure a flow of gas into the alveoli by reducing the ambient pressure around the during inspiration. When this support is thorax (negative pressure ventilation) or by removed gas is expelled as the lung and chest increasing the pressure within the airways wall recoil to their original volume; exhalation (positive pressure ventilation). Negative pres- is a passive process. In the earliest reports of sure ventilators use a rigid chamber that artificial ventilation this energy was provided encloses either the thorax (cuirass) or the by the respiratory muscles of another person, whole body below the neck (tank respirator or as expired air resuscitation. Baker' has traced "iron lung"). The pressure in the chamber is references to expired air resuscitation in the reduced cyclically by means of a large volume newborn as far back as 1472, and in adults displacement pump, thus causing the lungs to there is a report of an asphyxiated miner being expand and contract. Negative pressure ven- revived with mouth to mouth resuscitation in tilation is fully discussed in article 5 of this 1744. In the eighteenth century artificial ven- series. These ventilators were used extensively tilation became the accepted first line treat- for poliomyelitis victims, and are still in use ment for drowning victims, though the use of for long term respiratory support or overnight bellows replaced mouth to mouth resus- support for patients with respiratory muscle citation.2 Automatic artificial ventilators that weakness, Tank ventilators occupy much http://thorax.bmj.com/ did not require a human as a power source space, access to the patient is poor, and the took another 150 years to appear, being first neck seal can create problems. They are not suggested by Fell3 and then made available suitable for use in general intensive care units. commercially by Draeger4 in 1907. These There has been a recent revival in interest in were still devices for resuscitation, for the negative pressure ventilators in paediatric Draeger company at that time was noted for intensive care units to avoid the need for its mine rescue apparatus. endotracheal intubation.5 The introduction of artificial ventilators The basic classification of positive pressure on September 25, 2021 by guest. Protected copyright. into anaesthesia proceeded slowly until sur- artificial ventilators was first proposed by geons ventured into the chest. During Mapleson.6 Artificial ventilators are devices thoracic surgery on spontaneously breathing that control inspiration; expiration is usually patients the inevitable pneumothoraces and passive, and so the classification is based on mediastinal shift ("mediastinal flap") that the mechanism of gas delivery during inspira- occurred as the pleural cavity was opened tion. There are two types of machine. A flow caused a high mortality, which was generator produces a known pattern of gas substantially reduced when positive pressure flow during inspiration, and the lungs fill at a ventilation was used. A further boost to the rate entirely controlled by the ventilator and development of automatic artificial ventilators independent of any effect of lung mechanics. occurred in 1952, when a catastrophic A pressure generator produces a preset pres- poliomyelitis epidemic struck Denmark. sure in the airway and the rate of lung infla- There was a very high incidence of bulbar tion depends not only on the pressure gen- lesions and 316 out of 866 patients with erated by the ventilator but also on the res- paralysis admitted over a period of 19 weeks piratory resistance and compliance, which required postural drainage, tracheostomy, or determine the time constant of the lungs. respiratory support. By using tracheostomy With a square wave pattern of pressure the Nuffield Department of Anaesthetics, John and manual positive pressure ventilation the lungs fill in an exponential fashion. The Radcliffe Hospital, Danish physicians reduced the mortality from effects of the two types of ventilator on ins- Oxford poliomyelitis from 80% at the beginning of piratory flow and lung volume are shown in J D Young M K Sykes the epidemic to 23% at the end. The artificial figure 1. ventilation was entirely by hand, a total of In general, the flow generator ventilator is Address for reprint requests: Dr J D Young, 1400 university students working in shifts to used for adults and the pressure generator Nuffield Department of keep the patients ventilated. The fear that ventilator for children, or adults when control Anaesthetics, John Radcliffe Hospital, Oxford OX3 9DU. another epidemic might afflict Europe of peak airway pressure is important. The 754 Young, Sykes Thorax: first published as 10.1136/thx.45.10.753 on 1 October 1990. Downloaded from C) 0 co._ U) La 0 Figure 1 Lung volume and gasflow during one respiratory cycle with pressure andflowgenerator ventilators. pressure generator is particularly useful in controlled by a pair of scissor valves and children where uncuffed endotracheal tubes monitored with pressure and flow sensors. are used and there is a leak of gas around the The control unit adjusted the scissor valves to endotracheal tube during inspiration. A pres- ensure that the flow patterns measured by the http://thorax.bmj.com/ sure generator tends to compensate for this sensors corresponded to those selected by the leak by increasing the flow into the airway, operator. This method of control is termed a whereas with a flow generator a proportion of servo or feedback system and is very flexible. the tidal volume is lost. Potentially one machine could mimic all the A ventilator must also have a mechanism to previously described categories of ventilator. cause it to cycle between inspiration and expiration. Ventilators are usually subclas- Modern intensive care unit ventilators sified as time cycled, pressure cycled, or Most modern intensive care unit ventilators on September 25, 2021 by guest. Protected copyright. volume cycled machines. Time cycled ven- use similar technology. A simplified diagram of tilators switch between inspiration and expira- such a ventilator is shown in figure 2. The tion after a preset time interval, pressure respiratory gas is held in a pressurised reservoir cycled ventilators switch when a preset airway and delivered to the patient via an inspiratory pressure threshold has been reached, and valve. The inspiratory valve and hence the volume cycled ventilators cycle when a preset inspiratory flow is controlled by the electronic tidal volume has been delivered. Cycling from control unit. The airway pressure and flow of expiration to inspiration is usually effected by gas into the patient are monitored by the a timing mechanism or by a patient triggering pressure and inspiratory flow sensors. The device that senses the subatmospheric pres- expiratory flow can also be monitored to check sure or the flow generated in the inspiratory for leaks and disconnection of the patient from tube by the patient's inspiratory effort. the ventilator. This design enables the ven- This traditional classification was devised tilator to be used as either a flow or a pressure during a period when ventilators were totally generator. For example, ifthe operator selects a mechanical, and driven either by compressed constant flow during inspiration the ventilator gas or by an electrically powered piston or will open the inspiratory valve until the flow bellows. By 1954, however, Donald had used sensor measures the required flow. If the an electronic trigger that initiated inspiration inspiratory flow decreases the inspiratory valve and in 1958 an electronic timing device was will be opened further to compensate, and vice incorporated in the Barnet ventilator.7 In 1971 versa. If the operator wishes the ventilator to the Siemens-Elema company introduced the act as a constant pressure generator, the ven- Servo 900 ventilator, which combined a sim- tilator will open the inspiratory valve until the ple pneumatic system with a sophisticated pressure sensor indicates that the desired pres- electronic measuring and control unit.8 Gas sure has been reached. The ventilator will then flow to and from the patient's lungs was maintain the airway pressure at the desired Artificial ventilation: history, equipment and techniques 755 manage and suffered complications.9 To min- imise these problems many ventilated patients are sedated, and in some cases paralysed with neuromuscular blocking agents (for example, To pancuronium). In the early 1980s paralysis of Thorax: first published as 10.1136/thx.45.10.753 on 1 October 1990. Downloaded from patient ventilated patients was very common in British intensive care units,1011 and sedation was used to dissociate the patients from their surround- ings. Over the last decade the amount of sedative and paralysing drugs given to inten- sive care patients has been reduced consider- ably. Paralysis ofventilated patients is not without risks.'2 The paralysed patient is unable to make any spontaneous respiratory effort, so a discon- nection from the ventilator is rapidly fatal. The patient may be aware ofhis or her surroundings Figure 2 A block diagram of a modern ventilator. The shaded area indicates the gas but is unable to communicate, and the risk of path during inspiration. pulmonary embolus is probably increased. Even sedative drugs are not without risk,'3 as shown by the substantial increase in mortality level by opening or closing the inspiratory in trauma patients given etomidate infusions. valve. The bulk of a modern ventilator is now This was subsequently shown to be caused by the electronic unit and the pneumatic units are suppression of adrenal activity by the drug.
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