I understood the essence of geographic correctness in the distribution of genes.
But it took an average of two weeks to three months to support only one patient with diaphragmatic paralysis, and the number of such patients increased every day.
First of all, Lassen divided all incoming severe patients into four streams: 1) those in need of tracheotomy and ventilation with positive pressure (the most severe group of patients with accumulated mucus in the upper respiratory tract, ineffective cough, inability to swallow, increasing respiratory failure), 2) needing only in tracheotomy, in addition to postural drainage and a feeding tube – these patients have normal ventilation, but there is no swallowing and cough reflex, 3) those who need only a negative pressure respirator are simply patients with respiratory failure, without accumulation of secretions in the airways, 4) those who could not swallow normally, but whose lungs were properly ventilated, who did not accumulate mucus in the airways, they needed a feeding tube and postural drainage. Most patients with severe polio, according to Lassen’s notes, belonged to the first group.
Next, a standard manual bag ventilation scheme was developed based on Ibsen’s demonstration. An air mixture of 50% O2: 50% N2 was fed through a humidifier to the endotracheal tube, the exhaled CO2 was absorbed by soda lime. The flow rate of the air mixture was 5–10 l / min. Later, the scheme was improved by removing soda lime (it got into the respiratory tract) and adding a special exhalation valve so that carbon dioxide is immediately released into the surrounding atmosphere (which, in turn, required an increase in the speed of the inhaled gas mixture). The developed patient ventilation scheme was cheap and easy to assemble, and, what is most remarkable, its use did not require special skills. That is why it was possible to solve the problem of ventilation simultaneously for a large number of patients.
Diagram of an apparatus for manual mechanical ventilation of the lungs. Illustration from the article: Lassen H. C. A. A preliminary report on the 1952 epidemic of poliomyelitis in Copenhagen with special reference to the treatment of acute respiratory insufficiency // Lancet. 1953; 261: 37-41
Eight days after Ibsen’s successful experiment with the girl Vivi, three new departments were organized in the hospital, each with 35 beds. Then they were called monitoring stations, today we would talk about intensive care units. All patients with impaired breathing were placed in them, who were observed by a whole team of doctors, consisting of an anesthesiologist, an epidemiologist, an ENT doctor, a doctor of laboratory diagnostics; later they were joined by a physiotherapist and a radiologist. Clear criteria for hospitalization of patients in these wards were formulated: 1) respiratory failure, 2) paralysis of the neck muscles and inability to swallow, 3) ascending, rapidly growing paralysis of skeletal muscles, which can very quickly turn into paralysis of the respiratory muscles. Initially, tracheotomy was performed under local anesthesia, but due to the large number of complications arising from this method, it was decided to perform the operation under general anesthesia with preliminary orotracheal intubation (that is, with the preliminary introduction of a breathing tube into the trachea through the mouth).
Each patient was measured every 5 minutes blood pressure, pulse rate and respiratory rate, and in ventilated patients blood acidity, CO2 and O2 content in it, and CO2 content in exhaled air were also measured. These indicators were assessed on a daily walk-through involving all doctors at the monitoring stations. The level of hemoglobin and other proteins in the blood was also regularly checked, and the indicators characterizing the functioning of the liver and kidneys were also regularly assessed. Finally, at a relatively early stage of treatment, pressure sore prophylaxis, breathing exercises and physiotherapy activities began, which markedly increased the chances of treatment success.
As mentioned above, there were no permanently working anesthesiologists in the infectious diseases hospital at that time, and there were only twenty of them in the whole of Copenhagen. And hundreds were needed – to ventilate patients, in a timely manner to clear the airways of mucous secretions, treat shock and, ultimately, carry out general anesthesia during tracheotomy. Therefore, a non-standard decision was again made: to call for help from students of the medical and dental faculties. Before the beginning of ventilation, each was trained for no more than 10 minutes, the shift lasted 6 hours, thus, a team of 4 people was required for each patient to provide round-the-clock manual ventilation. However, this was not pure volunteering; each student received little money for a shift. On average, 250 students every day, along with 35–40 doctors and 260 nurses, worked in new departments. At the peak of the epidemic, up to 75 patients were manually ventilated. For many weeks and months, students, replacing each other, around the clock squeezed air from a rubber bag into the respiratory tract of patients, giving them a chance to survive. It is estimated that by the end of the epidemic, more than 1,500 medical students were employed and worked 165,000 hours.
Medical students manually ventilate children with polio at Blegdam Hospital in Copenhagen. 1953 year. Photo: Museum of Medicine, University of Copenhagen
In April 1953 Lassen took stock of the Copenhagen polio pandemic. During the first month of the epidemic, the mortality rate was 87% (of 31 patients requiring special respiratory therapy, 29 people died). After the introduction of manual ventilation with a bag and the reorganization of the hospital’s work, the mortality rate decreased to 38% (out of 300 patients with severe respiratory failure and bulbar disorders, 186 people recovered). It was an unequivocal success.
Bjorn Ibsen is considered the father of modern intensive care, and some European anesthesiologists call August 26 – the day he proposed using positive pressure ventilation outside the operating room – “Bjorn Ibsen Day”. Since that time, throughout the world, intensive care units began to be organized in hospitals, which began to receive anesthesiologists who became anesthesiologists-resuscitators.
In 1953, the Swedish company Engstrom designed a ventilator that created positive pressure in the airways during inhalation – doctors jokingly called these devices "mechanical students". It was the "mechanical students" that became, in fact, the prototypes of modern ventilators, fundamentally different from the previous "iron lungs". But even a whole fleet of state-of-the-art mechanical ventilation devices is nothing without the experienced hands of an intensive care physician and his colleagues.
In April 2020, the cover of Time magazine, bypassing heads of state, industry titans and pop culture icons, made its first appearance as an anesthesiologist – a critical care intensive care physician!
Three months have passed. The world is still dominated by COVID-19. The virus that caused this epidemic has not receded, and it still does not recognize any ranks or titles. And if a virus infects someone, then this someone today, like seventy years ago, can only hope for a doctor – a professional in his field, a person who is able to make the right decision in extreme conditions, show observation, clinical thinking and ingenuity. Medicine today, from the exact digital science that it has been trying to be over the past decades, albeit for a short time, is again becoming an art.
Glossary for the article
Bronchospasm – narrowing of the lumen of small bronchi and bronchioles; occurs with various diseases of the respiratory system.
Bulbar disorders (or bulbar syndrome) occur when the glossopharyngeal, vagus and hypoglossal nerves are affected, which extend from the medulla oblongata. These nerves control the muscles of the mouth, pharynx, larynx, therefore, with bulbar syndrome, speech is impaired, it becomes difficult to swallow and breathe.
Hypoxia is a low oxygen content in the body or in certain tissues.
Respiratory volume is the volume of air passing through the lungs.
Soda lime is a mixture of caustic soda NaOH and hydrated lime Ca (OH) 2, which absorbs moisture and carbon dioxide.
Postural drainage (or drainage by the position of the body) is a set of procedures for the removal of excess bronchial secretions from the lungs. The patient takes a position so that the sputum flows to the large bronchi and trachea, where there are especially many cough receptors and from where it will be easier to cough up the sputum.
Respiratory acidosis is a shift in the acid-base balance of the body towards an increase in acidity (that is, an increase in pH), which occurs when insufficient ventilation of the lungs or when inhaling air with an increased level of carbon dioxide.
Thiopental components of an argumentative essay sodium is a short-acting non-inhalation anesthesia. It is used for short-term surgical interventions.
Tracheotomy is a surgical operation in which a tube is inserted into the trachea to help a person breathe if, for some reason (due to edema, spasm, etc.), there is an obstruction of the upper respiratory tract.
Uremia is a general poisoning of the body with renal failure, when the kidneys poorly remove metabolic products and poorly maintain the water-salt and acid-base balance in the blood.
Excursion of the chest – the difference in the circumference of the chest during inhalation and exhalation. An asymmetric excursion, or a lag in breathing of one half of the chest from the other, indicates some kind of pulmonary disease.
An endotracheal tube (it is inserted through the mouth into the trachea during intubation) is used for artificial ventilation of the lungs, during resuscitation, to remove accumulated sputum.
Literature1. Murray D. Infectious diseases in children. M., 2006. S. 148–150, 597–603.2. Lassen H. C. A. The Epidemic of poliomyelitis in Copenhagen, 1952 // Proceedings of the Royal Society of Medicine. 1953; 47 (1): 67-71. DOI: 10.1177 / 003591575404700119.3. Schlager Neil. Science and Its Times: Understanding the Social Significance of Scientific Discovery, Vol. 6: 1900-1950. Farmington Hills, Michigan: Gale. p. 348.4. Rockoff M. M. D. The Iron Lung and Polio.5. Sherwood R. J. Obituaries: Philip Drinker 1894–1972 // The Annals of Occupational Hygiene. 1973; 16 (1): 93-4. Doi: 10.1093 / annhyg / 16.1.936. Senelar L. R. The Danish anesthesiologist Bjorn Ibsen a pioneer of long-term ventilation on the upper airways. Doctoral thesis. Jan 2009.7. Bower A. G., Bennett V. R., Dillon J. B., Axelrod B. Investigation on care and treatment of poliomyelitis patients // Ann Western Med Surg. 1950; 4: 561–82.8. Bower A. G., Bennett V. R., Dillon J. B., Axelrod B. Investigation on care and treatment of poliomyelitis patients (Part II) // Ann Western Med Surg. 1950; 4: 686-716.9. Ibsen B. The Anesthetist’s Viewpoint on the Treatment of Respiratory Complications in Poliomyelitis during the Epidemics in Copenhagen, 1952 // Proceedings of the Royal Society of Medicine. 1953; 47: 72-74. DOI: 10.1177 / 00359157540470012010. Wunsch H. The outbreak that invented intensive care // Nature. 2020. DOI: 10.1038 / d41586-020-01019-y.11. Lassen H. C. A. A preliminary report on the 1952 epidemic of poliomyelitis in Copenhagen with special reference to the treatment of acute respiratory insufficiency // Lancet. 1953; 261 (6749): 37–41. DOI: 10.1016 / s0140-6736 (53) 92530-6.12. Andersen E. W., Ibsen B. The Anaesthetic Management of Patients with Poliomyelitis and Respiratory Paralysis // British Medical Journal. 1954; 1: 786-88. DOI: 10.1136 / bmj.1.4865.786.13. Astrup P. et al. Laboratory Investigations during Treatment of Patients with Poliomyelitis and Respiratory Paralysis // British Medical Journal. 1954; 1: 780-86.14. West J. B. The physiological Challenges of the 1952 Copenhagen Poliomyelitis Epidemic and a Renaissance in Clinical Respiratory Physiology // Journals of Applied Physiology. 2005; 99: 424-432. DOI: 10.1152 / japplphysiol.00184.2005.15. Berthelsen P. G. Manual positive pressure ventilation and the Copenhagen poliomyelitis epidemic 1952: An attempt at setting the record straight // Acta Anesthesiol Scand. 2014; 58 (5): 503-507. DOI: 10.1111 / aas.12311.
* Lassen H. C. A. The Epidemic of poliomyelitis in Copenhagen, 1952 // Proceedings of the Royal Society of Medicine. 1953; 47 (1): 67-71.
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