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Wednesday, November 6, 2013

Myth Buster: Mouth to Mouth breathing does not oxygenate patients

It has been a belief of mine that one of the reasons mouth to mouth breathing should no longer be performed was because exhaled air only contains 16 percent oxygen compared with inhaled oxygen containing 21 percent oxygen.  As it turns out, it was this myth that was one of the obstacles that was disproved just prior to its worldwide acceptance.

I'm going to give you a brief history of mouth to mouth breathing before I disprove the myth.  The most common cause of sudden death prior to the 1950s was drowning.  In the first century Galen believed a person inhales a vital spirit, and this vital spirit is absorbed and moves through the body to sustain life.  This theory was still believed in the 18th century.\

It also should be noted here that when a person died, the "vital spirit" left the body immediately.  It was probably for this reason that there were very few efforts to revive a presumably dead person.

In the ancient world, and into the 18th century, it was viewed as sacrosanct to touch a dead body except in preparing it for burial.  For this reason people were forbidden from toughing, let along performing autopsies, on dead bodies.

During the course of the 16th century men like Andreas Vesalius started inspecting the body, and therefore began doubting the words of Galen.  So it was in the 16th century that the science of anatomy was begun, whereby people started learning about the various structures of the human body.

During the course of the 18th century people started realizing that diseases were caused by changes within the body.  This began the science of pathology.  Realizing that changes within the body caused disease, some people started speculating that there was a reason a person suddenly dropped dead, and perhaps by rescue efforts a person could be brought back from the dead.

This was not a knew idea, although prior to this century it was not talked about much.  There were various efforts as far back as the primitive world where descriptions of artificial respiration were described, such as in Isaiah in the First book of kings, and Elisha in the Second book of Kings. Elijah pressed his body over a child three times to revive him (perhaps an early version of chest compressions) and Elisha performed mouth to mouth breathing to revive a child. Likewise, there were various stories of midwives providing mouth to mouth breathing to newborn babies, and the method working.

Yet in the 18th century, as people were learning about pathology, various efforts were made to save the lives of drowning victims.  And, lo and behold, some of the time these efforts worked.  Even though successes were rare, it was enough to inspire repeating of these efforts.

Noting success stories, in 1774 a British Physician named John Fothergill became impressed with accounts of successful efforts of mouth to mouth breathing, that he wrote about it as a safe and easy procedure that anyone could perform to reanimate a person in suspended animation.

Back then the term artificial resuscitation was not used, and instead it was referred to as resuscitation.  A person was suscitated at birth, meaning that he was given life.  Given the stories of some people being brought back to life, the period from when a person died and was reanimated was called "suspended animation."

Likewise, given these success stories, it was now believed that the vital spirit stayed in the body for a period of time after a person died.  However, it was not known how long before it left the body.  It was for this reason that you will read stories of reanimation attempts lasting for two hours or longer.  There was also no timetable for efforts to be started.

There were a variety of methods, that included mouth to mouth breathing, rolling a person over a barrel, hanging the person by his heals from a tree, performing chest compressions or abdominal thrusts, tickling his nose with a feather, covering his body with spirits, or breathing for him with bellows.

Mouth to mouth breathing was effective at times, although due to disease pandemics, it quickly went out of vogue.  It was replaced by using fireside bellows, which were readily available in most fireplaces.  Back then there were fireplaces in every house and place of work.

Mouth to mouth breathing made a brief appearance in 1909 when Dr. Robert H. Woods wrote about it, but people were so in love with other methods of resuscitation at the time, they ignored Wood's suggestion.  The preferred methods of breathing at this time were rolling a patient form side to side, providing abdominal or chest compressions, or applying pressure on the patient's back.

But during the 1950s Dr. James Elam and Dr. Peter Safar proved that mouth to mouth breathing was superior to any other method.  They proved that it was so simple that even a child could do it on an adult.  They even proved that it provided better tidal volumes.  The only obstacle that remained were critics who claimed that the 16 percent oxygen exhaled by the rescuer would be too little to oxygenate the victim.

This obstacle was hurdled by experiments by Elam and Safar.  I will allow Mickey S. Eisenburg, in his 1997 book "Life in the Balance, to explain the rest:
To prove the value of mouth to nose breathing (or mouth to mouth breathing), Elam first had to show scientifically that exhaled air was adequate to oxygenate a nonbreathing person.  It was widely believed that exhaled air, with 16 percent oxygen, was too low compared to air, which contained 21 percent... Elam needed irrefutable data collected in a rigorous fashion.  The year was 1952 and Elam was an assistant professor in the Division of Anesthesiology at Barnes Hospital in St. Louis.  he obtained permission from his chief of surgery, Dr. Evarts Graham, to do studies on post-op surgical patients before they recovered from ether anesthesia.  The endotracheal tube was left in place and succinylcholine (used ot keep the patient paralyzed) was continued as a drip.  By blowing into the tracheal tube with his expired air, Elam found that total arterial oxygen saturation could be maintained at 100 percent.  Nine patients were studies and the results were unequivocal: expired air was able to maintain adequate oxygenation.  In his scientific writings Elam called his technique expired-ari resuscitation, but he always thought of it as the "method of Elisha." 
 Surely this was a small sample, but this study was enough to convince the medical society that mouth to mouth breathing, when done effectively, was enough to provide adequate oxygenation. For those grossed out by the procedure, or worried about catching a disease, he invented what he called the Safar S-Tube.

The Safar S-Tube that was inserted through the oral opening into the pharynx.  On the opposite end (the end sticking out of the mouth) was a mouthpiece, whereby the rescuer would provide breaths.  The S-Tube, thereby, acted as both an oral airway and as a means of providing ventilation.

Now there were no obstacles preventing the method from being accepted.  By 1958 Elam and Safar had succeeded in convincing the experts of that era that expired-air resuscitation was far superior to other methods used, and it was accepted worldwide.

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