Classic Papers Revisited  |   September 2001
From Control of Airway and Breathing to Cardiopulmonary–Cerebral Resuscitation
Author Notes
  • Received from the Department of Anesthesiology and Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania.
Article Information
Classic Papers Revisited
Classic Papers Revisited   |   September 2001
From Control of Airway and Breathing to Cardiopulmonary–Cerebral Resuscitation
Anesthesiology 9 2001, Vol.95, 789-791. doi:
Anesthesiology 9 2001, Vol.95, 789-791. doi:
Anesthesiology’s revisiting of our article in the Journal of the American Medical Association  1 of 1958 arouses memories. That study documented step A (airway control) and step B (breathing control by mouth-to-mouth ventilation) and the failure of the then-taught methods of back pressure (prone) or chest pressure (supine), with or without arm lift. The paper thereby initiated modern cardiopulmonary resuscitation (CPR) research. In October 1956, when I attended the American Society of Anesthesiologists meeting in Kansas City, Missouri, I was initiating chief of an academic department of anesthesiology at Baltimore City Hospital (now called Johns Hopkins Bayview Medical Center), Baltimore, Maryland. At that meeting, I met anesthesiologist James Elam, M.D., then chief anesthesiologist at the Roswell Park Memorial Hospital in Buffalo, New York, and on duty at the US Army Chemical Center in Edgewood, Maryland. He told me that he had shown in apneic humans that intermittent positive-pressure ventilation by mouth-to-mask or mouth-to-tracheal tube could maintain normal blood gas values. 2 Elam’s personality and data and the fact that his findings lay dormant motivated me to research resuscitation. Starting in December 1956, I studied and documented the failure of the manual methods and the superiority of direct mouth-to-mouth ventilation without devices. 3 Simultaneously, our team investigated patterns of upper airway obstruction. 4 I presented the data of this revisited 1958 article 1 for the first time at the American Society of Anesthesiologists meeting in Los Angeles, California, in October 1957 (during the week the Soviets launched Sputnik). There were two other articles invited simultaneously by the Journal of the American Medical Association  : one by Elam regarding blood gas data and one by Archer Gordon, M.D., surgeon at the University of California in Los Angeles, California, regarding mouth-to-mouth ventilation versus  manual ventilation in children (data obtained in 1957 after my first results became known). 3 Within 1 yr, this triumvirate convinced the world to switch from teaching the manual methods to teaching head tilt plus mouth-to-mouth ventilation.
Curarized and sedated adult volunteers without tracheal tubes were needed because in coma, the natural upper airway of humans is kinked, whereas most animals’ airways are straight, and conscious humans cannot relax in apnea. There were no institutional review committees then. Volunteers were ultrainformed. I obtained approval from peers and from the US Army, which supported our research. Two courageous colleagues deserve special recognition for having volunteered several times, including the making of documentary movies by the US Army, which helped convince the world: Felix Steichen, M.D., then chief resident in surgery (he later became a professor), and Richard Fredricks, M.D., then resident in pathology, both at the Baltimore City Hospital.
We documented, with roentgenograms and ventilation volumes, what many anesthesiologists instinctively knew—providing airway patency with backward tilt (extension) of the head, forward displacement of the mandible (“jaw thrust”), or both. I called it step A, airway control. Some believe that backward tilt of the head for coma 3,4 has saved more lives inside and outside hospitals than standard external CPR for cardiac arrest. Epidemiologic outcome data for this are needed.
William Kouwenhoven, Ph.D., professor of electrical engineering at the Johns Hopkins University, Baltimore, Maryland, had conducted since the 1940s dog studies of electrical fibrillation and defibrillation. In 1957, he and I agreed that a closed-chest method for emergency artificial circulation is needed. In 1958, Guy Knickerbocker, Kouwenhoven’s Ph.D. student, made the brilliant, serendipitous rediscovery that pressure (by paddles) on the chest caused an arterial pulse. That became step C. Kouwenhoven saw the importance of this and had it documented in dogs. Johns Hopkins’ surgeon Henry Bahnson, M.D., and surgery resident James Jude, M.D., were the first to try it in patients. 5 Conveniently, the new potent inhalation anesthetic halothane, introduced without precision vaporizers, sometimes produced transient pulselessness. The anesthesia team of Donald Benson, M.D. (Johns Hopkins University), provided steps A and B while Jude performed step C.
Sternal compressions alone are not CPR. In 1960, at the Baltimore City Hospital, I questioned the ability of sternal compressions alone to ventilate the lungs. We documented in humans with or without cardiac arrest, with or without tracheal tube, that no reliable ventilation is produced by sternal compressions alone. 6 Recently, cardiology-based colleagues of the American Heart Association CPR Guidelines Committee, considering basic life support with step C only, have ignored these data 6 and those of this revisited paper. 1 Our results made me assemble and teach steps A, B, and C together as CPR basic life support since 1959.
In 1961, I added steps D, E, and F (drugs; external electrical countershock pioneered by Gurvich, 7 Kouwenhoven, 8 and Zoll 9; and fluids) as advanced life support for restoration of spontaneous circulation and prolonged life support. For prolonged life support, G was for “gauged” (titrated), H was for “humanized” (brain-focused, with hypothermia), and I was for “intensive care.” In 1958, we at Baltimore City Hospital had introduced America’s first multidisciplinary, physician-staffed intensive care unit for patients with any acutely life-threatening vital organ system failure. 10 After 1961, I promoted the extension of CPR to cardiopulmonary–cerebral resuscitation (CPCR). 11 For the delivery of CPCR, we composed guidelines in the early 1960s for community-wide emergency medical services systems—from the site via  transport to the most appropriate hospital’s emergency room, operating room, and intensive care unit. 12 My associates and I also initiated CPR education research.
In the 1950s and ’60s, postarrest moderate resuscitative hypothermia (30°C) was used sporadically but without controlled data. It was then given up for 25 yr, probably because of adverse effects and management problems. For cerebral resuscitation, we revived resuscitative hypothermia research in the mid 1980s because of disappointing pharmacologic strategies. We used our novel, clinically realistic cardiac arrest outcome models in dogs. With cerebral blood flow promotion (by hypertensive hemodilution) and mild hypothermia (34°C), the efficacy of which we discovered in dogs in 1987, we could normalize cerebral outcome after normothermic cardiac arrest of 11 min without blood flow. 11 Also, compared with standard external CPR, open-chest CPR or emergency cardiopulmonary bypass proved more effective for the heart and brain. 11 
Dr. Raja asked me:“Which aspects of your research have become most satisfying to you?” I answered: (1) Having recognized in the 1950s the importance of resuscitation research and having seen our results on CPR steps A and B and the need for the CPCR system withstand the test of time; (2) having helped clarify the pathophysiology and reversibility of acute dying processes (inspired by Vladimir Negovsky, M.D., Ph.D., Institute for General Reanimatology, Russian Academy of Medical Sciences, Moscow, Russia); and (3) having helped many young colleagues to become creative clinician-scientists. Now, focusing on unresuscitable conditions, my associates and I are exploring “suspended animation for delayed resuscitation,” for the rapid induction of preservation of the organism at the start of cardiac arrest, for transport and repair without pulse, to be followed 1–2 h later by resuscitation with emergency cardiopulmonary bypass. 13 
No single investigator “invented” CPCR. Much knowledge about resuscitation existed around 1900, but for half a century, there was no implementation. Currently, the implementation of knowledge in resuscitation is still suboptimal. In 2001, let us hope that increasingly more effective CPCR for “hearts too good to die” (a term coined first by Claude Beck, Case Western Reserve University, Cleveland, OH) and “brains too good to die” (a term coined first by the author) will be researched by multidisciplinary teams and implemented rapidly, without repeating the mistakes of 1900.
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Elam JO, Brown ES, Elder JD Jr: Artificial respiration by mouth-to-mask method: A study of the respiratory gas exchange of paralyzed patients ventilated by operator’s expired air. New Engl J Med 1954; 250: 749–54Elam, JO Brown, ES Elder, JD
Safar P, Escarraga LA, Elam JO: A comparison of the mouth-to-mouth and mouth-to-airway methods of artificial respiration with the chest-pressure arm-lift methods. New Engl J Med 1958; 258: 671–77Safar, P Escarraga, LA Elam, JO
Safar P, Aguto-Escarraga L, Chang F: Upper airway obstruction in the unconscious patient. J Appl Physiol 1959; 14: 760–4Safar, P Aguto-Escarraga, L Chang, F
Kouwenhoven WB, Jude JR, Knickerbocker GG: Closed-chest cardiac massage. JAMA 1960; 173: 1064–7Kouwenhoven, WB Jude, JR Knickerbocker, GG
Safar P, Brown T, Holtey W, Wilder R: Ventilation and circulation with closed chest cardiac massage in man. JAMA 1961; 176: 574–6Safar, P Brown, T Holtey, W Wilder, R
Gurvich NL, Yuniev SG: Restoration of a regular rhythm in the mammalian fibrillating heart (abstract). Am Rev Sov Med 1946; 3: 236Gurvich, NL Yuniev, SG
Kouwenhoven WB, Milner WR: Treatment of ventricular fibrillation using a capacitor discharge. J Appl Physiol 1954; 7: 253–7Kouwenhoven, WB Milner, WR
Zoll PM Linenthal AJ, Gibson W, Paul MH, Norman LR: Termination of ventricular fibrillation in man by externally applied electric countershock. New Engl J Med 1956; 254: 727–32Zoll, PM
Safar P, DeKornfeld TJ, Pearson JW, Redding JS: Intensive care unit. Anaesthesia 1961; 16: 275–84Safar, P DeKornfeld, TJ Pearson, JW Redding, JS
Safar P: Resuscitation of the ischemic brain, Textbook of Neuroanesthesia with Neurosurgical and Neuroscience Perspectives. Edited by Albin MS. New York, McGraw-Hill, 1997, pp 557–93
American Society of Anesthesiologists’ Committee on Acute Medicine (Safar P, chairman): Community-wide emergency medical services. JAMA 1968; 204: 595–602American Society of Anesthesiologists’,
Safar P, Tisherman SA Behringer W, Capone A, Prueckner S, Radovsky A, Stezoski SW, Woods RJ: Suspended animation for delayed resuscitation from prolonged cardiac arrest that is unresuscitable by standard cardiopulmonary-cerebral resuscitation. Crit Care Med 2000; 28 (suppl): N214–8Safar, P Tisherman, SA