Iron Lung Research Articles

The Hypoxia Hilton: recollections of a visit, with a postscript by J W Severinghaus on mechanisms of acute mountain sickness.

During a training fellowship thirty years ago at the Cardiovascular Research Institute (CVRI) in San Francisco, I joined an expedition led by Professor John Severinghaus. Its purpose was to study pulmonary complications of acute hypoxia after a one-day ascent, by helicopter and hike, from sea level to the summit of White Mountain, 14 246 feet (4342 m) above sea level1, on the California—Nevada border. Originally a physicist at the Massachusetts Institute of Technology, Severinghaus became a physician then chief of anaesthesia research in the University of California at CVRI. He invented the first reliable PO2 and PCO2 blood gas analysis systems, which are now used routinely in hospitals throughout the world. His research into the control of breathing, altitude physiology and oximetry continue to the present day. Before I joined the expedition he tested my ventilatory drive with a vital capacity breath of 15% CO2 in nitrogen2 (i.e. no oxygen). For what seemed like ages nothing happened. I gazed at the posters on the walls of his laboratory and continued to breathe normally into the spirometer. Then, suddenly, it was like the first huge breath that I experienced in an iron lung, but at 40 breaths per minute. The spirometer bell leapt out of the water. Severinghaus was expressionless. Then I lost consciousness.

Iron increases expression of iron-export protein MTP1 in lung cells.

Accumulation of reactive iron in acute and chronic lung disease suggests that iron-driven free radical formation could contribute to tissue injury. Safe transport and sequestration of this metal is likely to be of importance in lung defense. We provide evidence for the expression and iron-induced upregulation of the metal transporter protein-1 (MTP1) genes in human and rodent lung cells at both the protein and mRNA levels. In human bronchial epithelial cells, a 3.8-fold increase in mRNA level and a 2.4-fold increase in protein level of MTP1 were observed after iron exposure. In freshly isolated human macrophages, as much as an 18-fold increase in the MTP1 protein level was detected after incubation with an iron compound. The elevation in expression of MTP1 gene was also demonstrated in iron-instilled rat lungs and in hypotransferrinemic mouse lungs. This is similar to our previous findings with divalent metal transporter-1 (DMT1), an iron transporter that is required for iron uptake and intracellular iron trafficking. These studies suggest the presence of iron mobilization and/or detoxification pathways in the lung that are crucial for iron homeostasis and lung defense.

Effects of Intermittent Negative Pressure Ventilation on Effective Ventilation in Normal Awake Subjects

Previous studies have shown that an increase in inspiratory pressure during nasal intermittent positive pressure ventilation (IPPV) does not result in increased effective minute ventilation (E) due to glottic interference. To test the consequences of increases in negative pressure ventilation (NPV) on V(E). Eight healthy awake subjects underwent NPV delivered by an iron lung. First, NPV was started at a respirator frequency (f) of 15 cycles per minute with an inspiratory negative pressure (INP) of - 15 cm H(2)O (F15-P15). Then, f was increased to 20 cycles per minute and INP was kept at - 15 cm H(2)O. Next, f was kept at 20 cycles per minute and INP was reduced to - 30 cm H(2)O (F20-P30). Finally, f was decreased to 15 cycles per minute and INP was kept at - 30 cm H(2)O. At each step and for each breath, effective tidal volume (VT), V(E), and end-tidal carbon dioxide pressure were measured. In three subjects, the glottis width was assessed using fiberoptic bronchoscopy. From spontaneous breathing to the first step of NPV (F15-P15), we observed an inhibition of the phasic inspiratory diaphragmatic electromyogram concomitant to a significant increase in V(E) (p < 0.0005). For the group as a whole, the increase in mechanical ventilation (from F15-P15 to F20-P30) resulted in significant increases in VT and V(E) leading to hypocapnia (p < 0.0005). Moreover, the glottis width did not decrease with the increase in mechanical ventilation. We conclude that in normal awake subjects, NPV allowed a significant increase in V(E). These results differ from those previously obtained with nasal IPPV in which the glottic width interferes with the delivered mechanical ventilation.

Effect of assist negative pressure ventilation by microprocessor based iron lung on breathing effort

Background: The lack of patient triggering capability during negative pressure ventilation (NPV) may contribute to poor patient synchrony and induction of upper airway collapse. This study was undertaken to evaluate...

The Smith-Clarke Respirator

The iron lung, or cabinet respirator, devised in 1929, was a life-saving device. But early models were alarming and uncomfortable for patients, inconvenient for nurses, and expensive. Credit for inventing the iron lung must go to Philip Drinker of Harvard University, USA, but it was the chairman of a Warwickshire Hospital Management Committee in the UK who, in the 1950s, made this device vastly more user-friendly. Captain G T Smith-Clarke (1884–1960) became chairman of Coventry Group HMC in 1951, after retiring from the Alvis Motor Company.

Iron Lung vs Mask Ventilation in the Treatment of Acute on Chronic Respiratory Failure in COPD Patients: A Multicenter Study

Evaluation of the effectiveness of negative-pressure ventilation (NPV) with the use of the iron lung vs noninvasive positive-pressure ventilation (NIPPV) in the treatment of COPD patients with acute on chronic respiratory failure. A retrospective case-control study. Four Italian respiratory intermediate ICUs. Of a total of 393 COPD patients admitted to the ICU in 1996, 53 pairs were treated with the iron lung (NPV group). Patients treated with NIPPV (NIPPV group) were matched according to mean (+/- SD) age (70.3 +/- 7.1 vs 70.3 +/- 6.9 years, respectively), sex, causes of acute respiratory failure (ARF), APACHE (acute physiology and chronic health evaluation) II score (22.4 +/- 5.3 vs 22.1 +/- 4.6, respectively), pH (7.26 +/- 0.05 vs 7.27 +/- 0.04, respectively), and PaCO(2) (88.1 +/- 11.5 vs 85.1 +/- 13.5 mm Hg, respectively) on admission to the ICU. The effectiveness of matching was 98.4%. Five patients from the NPV group (9.4%) and seven patients from the NIPPV group (13.2%) needed endotracheal intubation (EI). The treatment failure rate (ie, death and/or need of EI) was 20.7% in the NPV group and 24.5% in the NIPPV group (difference was not significant). The mean duration of mechanical ventilation (29.6 +/- 28.6 vs 62.3 +/- 35.7 h, respectively) and length of hospital stay (10.4 +/- 4.3 vs 15 +/- 5.2 d, respectively) among the 35 concordant surviving pairs were significantly lower in the NPV group than in the NIPPV group (p = 0.001 and p = 0.001, respectively). These data suggest that both ventilatory techniques are equally effective in avoiding EI and death in COPD patients with ARF. Prospective trials are needed to confirm these preliminary results.

Pharyngeal pressure and flow effects on genioglossus activation in normal subjects.

Pharyngeal dilator muscles are clearly important in the pathogenesis of obstructive sleep apnea syndrome. Substantial data support the role of local mechanisms in mediating pharyngeal dilator muscle activation in normal humans during wakefulness. Using a recently reported iron lung ventilation model, we sought to determine the stimuli modulating genioglossus activity, dissociating the influences of pharyngeal negative pressure, from inspiratory airflow, resistance, and CO(2). To achieve this aim, we used two gas densities at several levels of end-tidal CO(2) and a number of intrapharyngeal negative pressures. The correlations between genioglossus electromyography (GGEMG) and epiglottic pressure across a breath remained robust under all conditions (R values range from 0.71 +/- 0.07 to 0.83 +/- 0.05). In addition, there was no significant change in the slope of this relationship despite variable gas density or CO(2) levels. Although flow also showed strong correlations with genioglossus activity, there was a significant change in the slope of the GGEMG/flow relationship with altered gas density. For the group averages across conditions (between breath analysis), the correlation with GGEMG was robust for negative pressure (R(2) = 0.98) and less strong for other variables such as flow and resistance. These data suggest that independent of central pattern generator activity, intrapharyngeal negative pressure itself modulates genioglossus activity both within breaths and between breaths.

Sacrifices for the miracle: the polio vaccine research and children with mental retardation.

The classic fairy tales of Hans Christian Anderson and the Brothers Grimm are testaments to the enduring fascinations and fears that children have shared across the generations. The Grimm’s ‘‘Hansel and Gretel’’ and ‘‘Cinderella’’ and Anderson’s ‘‘Ugly Ducking’’ and ‘‘The Emperor’s New Clothes’’ continue to entertain children and to reassure them of the ultimate conquest of good over evil. There are other joys and anxieties of childhood, however, that are more generation-specific. For the children of the 1990s, for example, school violence and the horror of AIDS had an impact unimaginable to previous generations. The decade of the 1950s, on the contrary, is often portrayed as a period of idyllic childhood. What is forgotten in the nostalgic accounts of this period, however, is that along with Davey Crocket and coonskin caps, the children of the 1950s were taught to crouch under school desks in case of a Russian nuclear attack. Another nightmare for the children of that generation was polio. Polio, commonly called infantile paralysis because it most frequently affected children, reached epidemic proportions in the early 1950s. This viral disease paralyzed and killed thousands of children each year. Images of patients and the ‘‘iron lungs’’ used to enable them to breathe terrified both children and their parents. Although the means by which the disease was transmitted was uncertain, swimming pools were closed, public gatherings were avoided, and school cancellations were common during the worst outbreaks (Klein, 1972). Then, in early April 1955, newspaper headlines announced that a safe and effective polio vaccine had been developed by Dr. Jonas Salk. Before the end of that month, thousands of children were vaccinated against polio. By 1961, an oral vaccine for polio had been developed by Dr. Albert Sabin. In 1971, only one case of polio was documented in the United States (Chase, 1982).

Respiratory intensive care units in Italy: a national census and prospective cohort study

BACKGROUNDIn Italy, respiratory intensive care units (RICUs) provide an intermediate level of care between the intensive care unit (ICU) and the general ward for patients with single organ respiratory failure....

“The Steel Cocoon”: Tales of the Nurses and Patients of the Iron Lung, 1929-1955

“The Steel Cocoon”: Tales of the Nurses and Patients of the Iron Lung, 1929-1955

Special article: Polio: Its history and its eradication

Poliomyelitis has a long history, dating back at least to the Egyptian eighteenth dynasty (1580-1350 BC). In 1835, the first account of an outbreak of the disease was described by John Badham, and in 1840, Jacob von Heine, a German orthopedist, provided the first description indicating the spinal cord as the primary site of the paralytic form of the disease. During the late 19th and early 20th centuries, numerous epidemics began to occur with increasing frequency and severity. Many of these epidemics were accompanied by hysterical reactions. Because the paralyzed patients experienced respiratory compromise, artificial breathing support was needed. One of the devices most effectively used to manage the breathing for paralytic polio patients was the iron lung. In 1949, John Enders, Thomas Weller, and Frederick Robbins showed that poliovirus caused visible damage to primate cells derived from tissues other than those of the nervous system. This technology ultimately provided the means for producing large quantities of standardized poliovirus for the production of the killed vaccine (Salk vaccine, inactivated polio vaccine) and, eventually, the live poliovirus vaccines (Sabin vaccine, oral polio vaccine). The last case of wild strain poliomyelitis in the United States occurred in 1979. In 1998, the national vaccine advisory bodies responsible for recommending immunization began advocating the use of the enhanced inactivated polio vaccine as an alternative to the oral vaccine. Copyright © 2000 by W.B. Saunders Company

Ernst Trier Mørch: inventor, medical pioneer, heroic freedom fighter.

Ernst Trier Mørch: inventor, medical pioneer, heroic freedom fighter.

A paper which changed clinical practice (slowly). Jacob Holler on potassium deficiency in diabetic acidosis (1946).

It is often said that the introduction of insulin into clinical medicine made a 'dramatic' difference to the mortality resulting from diabetic coma. This is true in the sense that before 1922 it was almost uniformly fatal, but until the 1950s the mortality in many large hospitals was as high as 30-50%. Often autopsy did not establish a cause of death. Many may have been a result of hypokalaemia, a complication which was not recognized until 1946; in that year in the Journal of the American Medical Association, Jacob Holler described a patient who developed respiratory paralysis 12h into treatment that, after several hours in an iron lung, was cured by potassium infusion. In the 5 years after Holler's paper there were many reports of deaths resulting from hypokalaemia, as well as several 'near misses', but clinicians were extremely cautious about early replacement probably, as an editorialist in The Lancet suggested, because 'the frightening effects of intravenous injections of potassium made clinicians reluctant to believe in a lack of potassium as a cause of trouble, except in very rare conditions such as familial periodic paralysis'. It had been known since 1923 that insulin lowered serum potassium, but this was not of great interest because the symptoms of hypokalaemia were not known. Also, potassium was not an electrolyte with which clinicians were familiar. Until the introduction of flame photometry in 1950, it was only measured in research studies as chemical methods took several hours to complete.

Beginnings Count: The Technological Imperative in American Health Care.

Introduction 1. Blue Cross and the American Way in Health Care 2. The Iron Lung and Democratic Medicine 3. Medicare for the Middle Class 4. Dialysis and National Priorities 5. Rationing the Respirator 6. No Limits Epilogue Endnotes

Polio's Legacy: An Oral History

Reviewed by: Polio’s Legacy: An Oral History Daniel J. Wilson Edmund J. Sass, with George Gottfried and Anthony Sorem. Polio’s Legacy: An Oral History. Lanham, Md.: University Press of America, 1996. xviii + 278 pp. $57.00 (cloth), $28.50 (paperbound). Polio’s Legacy is a collection of thirty-five narratives of individuals who contracted polio between 1925 and 1959. Edited by Edmund J. Sass, a professor of education and a polio survivor, it provides a window into the experience of having had one of the most feared epidemic diseases of the twentieth century. Sass frames the individual narratives with a short introduction and conclusion. His introduction—based largely on John R. Paul, A History of Poliomyelitis (1971), and Jane Smith, Patenting the Sun: Polio and the Salk Vaccine (1990)—provides a brief review of what is known about poliomyelitis, its history as an epidemic disease in the twentieth century, and the emergence of post-polio syndrome in the 1980s. Sass’s conclusion highlights several themes that emerge in the narratives. Neither breaks new ground for the scholar, but they are helpful for the reader who knows little about the disease. The value of the volume for the historian lies in the thirty-five personal accounts. Concerned that the stories of polio survivors were being lost as the population aged, Sass worked through the Sister Kenny Institute to identify individuals willing to recount their histories. Most of those interviewed now live in the upper Midwest. They were asked questions designed to elicit their recollections of the onset of polio, their hospitalization, recovery, and rehabilitation, and their subsequent lives, including the late effects of polio. The transcripts were lightly edited for readability. Sass divides the narratives into ten somewhat arbitrary chapters, including experience with Sister Kenny, iron lungs and wheelchairs, scoliosis, surgery, braces, adult polio, and late effects. Each chapter opens with a brief headnote. Since the narratives are presented in their entirety, it is not always clear why they are placed in a particular chapter. For example, all of the individuals with scoliosis also wore braces and had surgery. For the historian, the volume provides a collective memory of the experience of polio. These personal accounts highlight the fears associated with the polio epidemics. They recall the chaos and the shortages of beds, iron lungs, and nurses that often accompanied a serious epidemic. These survivors remember the long, lonely days in isolation hospitals cut off from parents, family, and friends, and the weeks and months in rehabilitation hospitals seeking to recover strength and movement. Many wore heavy braces for years and endured numerous operations designed to compensate for wasted muscles. In and out of hospitals, these children and young adults attempted to get on with their schooling, make friends, find jobs, and fit into a society that had not yet heard of accommodation. It is clear that it was the polio survivor who was expected to make any accommodations. Almost all found ways to overcome their disability, marry, have a career, and minimize their physical limitations until the onset of the late effects of polio some twenty to thirty years after the acute attack. These are largely positive accounts by men and women who overcame often severe physical disabilities [End Page 575] to make good lives for themselves and their families. Even the painful return of muscle weakness and fatigue associated with post-polio syndrome does not dampen their sense of accomplishment. The story of the scientists, physicians, and fund-raisers who conquered polio by the 1960s has been often told. The narratives in Polio’s Legacy suggest the possibilities for another kind of history, a history of the epidemics focused on the experience of those who had the disease. That history lies beyond the scope of Sass’s volume, but he has given historians valuable biographical accounts that can contribute to that as-yet-untold story. Daniel J. Wilson Muhlenberg College Copyright © 1998 The Johns Hopkins University Press

The Assault on Specialty Medicine and the Modern Surgeon

I would like to talk wth you about specialty medicine and the contemporary thoracic surgeon. I shall briefly trace the development of specialty medicine, of which thoracic surgery is a leading example, describe the challenges to the authority of the specialist, and finally suggest some responses called for in this new, rapidly changing, and embattled era. I believe that an assault on the specialist is adding to the burdens of the modern surgeon and calls for a response affirming what we stand for.

ANESTHESIOLOGY: Traditional Linkages to Critical Care Medicine

The introduction of neuromuscular blockade (d-tubocurarine) as an integral part of general anesthesia in the 1930s made positive-pressure ventilation a necessity. Scientific exploration of the pulmonary and cardiovascular alterations caused by positive-pressure ventilation was accomplished almost entirely by anesthesiologists prior to 1950. The routine use of positive-pressure ventilation necessitated the development of equipment and techniques to facilitate tracheal intubation. The development of safe techniques for endotracheal tube suctioning allowed for maintenance of adequate bronchial hygiene despite lung disease or anesthetic agents that increased bronchial secretions. During World War II, those intraoperative techniques and skills, and the sound physiologic and pharmacologic knowledge base of the anesthetist, were extended into the perioperative period, as positive-pressure ventilation became increasingly recognized to be more effective than negative-pressure ventilators (iron lungs). By 1945, therefore, there was an inexorable link between the developing medical specialty of anesthesiology and the inception of what we now refer to as critical care medicine.

Trying to have it both ways[review of "Beginnings Count: The Technological Imperative in American Health Care" (Rothman, D.) [Book review

This book examines the state of health care in the United States, focusing on health insurance and medical services. How can the United States spend so heavily on health care yet provide so poorly for so many people? The author describes some of the complex interactions between technology and health care that have helped bring this deplorable situation about. This is a book about three medical technologies (the iron lung, dialysis for treatment of chronic kidney failure, andthe ventilator) and three policies (Blue Cross, Medicare, and the failed Clinton health care initiative), artfully arranged as case studies.

Scotland's first iron lung.

The history of artificial ventilation and the development of the iron lung in the USA by Drinker and his colleagues is discussed. The building and use of an iron lung by Dr R G Henderson in Aberdeen in 1933 is described. The development of other types of ventilator in the UK is recorded and the circumstances whereby positive pressure ventilation was introduced in Denmark in 1952 is outlined.

The People's Health a Memoir of Public Health and its Evolution at Harvard

In The People's Health, author Robin Marantz Henig brings to life the compelling story of the successes and setbacks of public health. This engaging book documents the expansion of public health from a search for microbes to a global effort to secure a healthful environment--from physician John Snow's breakthrough in cholera prevention in mid-nineteenth-century Britain to the public health crisis emerging today from the war in Bosnia. Henig explores the multiple perspectives from which public health be viewed--well illustrated by the medical, behavioral, and social aspects of AIDS. In telling the stories of the wars on malaria, polio, and other diseases, she describes the machinery of public health and highlights the detective work of the early searches for pathogens. Since mid-century, most disease has related not to epidemics but to personal choices about smoking and eating that can lead to heart disease and cancer. Henig looks at the groundbreaking Framingham Heart Study, running nearly 50 years, from which emerged the concept of risk factors for disease. The People's Health discusses the link between health and human rights--for example, how legal and cultural practices force many African women into unprotected sex with HIV-infected husbands. The subtext of The People's Health is the contribution of the Harvard School of Public Health, direct descendent of the first professional training program for public health in America, where many of the advances of the past half-century originated. Throughout the book, Henig highlights individuals, such as Philip Drinker, who invented the iron lung, and Jonas Salk, who developed the polio vaccine. Also included is the story of Jay Winsten, who, as director of Harvard's Center for Health Communication, imported the designated-driver concept from Sweden and persuaded television's largest production companies to weave it into program plots. A fast-moving overview of humankind's effort to conquer disease and the public health challenges on the horizon, this volume is a must read for anyone concerned about public health.