Assisted Ventilation in Terminal Hyaline Membrane Disease.

Goldsmith and Karotkin' researched the history of assisted ventilation and found that a record of mouth to mouth methods goes back to Old Testament times, and Hippocrates himself reported his experience with tracheal intubation to support pulmonary function. These skills were ignored for about 2000 years as it was not until the 16th century that attention was again paid to this subject when bellows and an oral tube were used. Assisted ventilation in the newborn does not seem to have been used until the 1800s by which time methods for mechanical ventilation in adults were established. Through the 1950s positive and negative ('iron lung' type) pressure devices were tried as were intragastric oxygen, body tilting, phrenic nerve stimulation, and manual bag with mask or tube. Ian Donald and his colleagues, in 1953, were probably the first to use a positive pressure patient cycled respirator in the newborn, but it is strange that, like the early work on penicillin and phototherapy, the significance of their pioneering efforts seemed to go unrecognised. This certainly was the case concerning ventilation in the newborn in the United Kingdom as about another 10 years passed before a paper on assisted ventilation in hyaline membrane disease appeared in the Archives. This 1964 article from Toronto cited reports from only three other centres, one each in a Scandinavian, a South African, and an American journal, from the 11 years between. And even in 1964 it was still considered by many as ethical to use assisted ventilation in only the virtually moribund baby. Not much wonder that out of 18 babies only one survived. Birth weights were given of 12 of those who survived more than an hour of ventilation and they ranged from 1200 g to 3900 g. All but one had a pH below 7-00, a PCO2 above 100 mm Hg and eight had a carbondioxide content below 20 mm/l. The discussion continues: 'Infants in the worst condition evinced no appreciable clinical or biochemical response (to ventilation). The necropsy finding of massive pulmonary haemorrhage associated with hyaline memnbranes explains the failure of assisted ventilation to achieve gas exchange'.