Wednesday, March 29, 2017

1900: Park-Davis Glaseptic Nebulizer

The Glaseptic nebulizer was used to aerosolize
Solution to the respiratory tract: nose, mouth
and lungs.  It was a "handy apparatus" and
produced a fine spray by squeezing the rubber
bulb.  The nebulizer and throat piece were made
of glass because some solutions chemically react
with metals.  It was easy to use and portable.(3)
When epinephrine was discovered at the turn of the century, and it was proven to be useful in ending asthma attacks, a device was sought out to deliver the medication directly to the lungs. 

The only logical options at the time were glass nebulizers that worked by squeezing a rubber bulb.  One such product was the Park-Davis Glaseptic Nebulizer made by Parke-Davis & Company in Detroit, Michigan.

Older nebulizers were made of metal, and some medicines reacted with metal.  So the newer nebulizers were made of glass.  On the box is written:  "Ready for instant use, easily kept clean and efficient with either oily or watery liquids. Effective in producing a spray with only small quantities of liquid. No metal to corrode or affect the medicinal properties of solutions".

The product was described by the editors of Therapeutic Notes in 1910 this way: (2, page 215)
The working parts of this apparatus consist of one piece of glass, with one rubber bulb and tube and glass throat piece. The base is of metal, nickel plated. Under light pressure upon the bulb the medicament is drawn by the air current to the top of the inner tube and expelled as a fine spray. Oils of all densities, as well as aqueous, spirituous and ethereal liquids, are nebulized instantly, though there may be only a few drops in the reservoir. The Nebulizer is three and one-half inches high, and is marketed in a neat carton.
1907 Ad for Adrenaline Solution and Glaseptic Nebulizer (1) It provided
another option for physicians and their patients.
Another article in the same magazine notes: (4)

MEDICATED VAPORS—HOW TO EMPLOY THEM.
We have an interesting pamphlet bearing this title which we shall be pleased to send to any of our readers on request. It deals with our line of Inhalants and also our Glaseptic Nebulizer. The latter is a big advance on other atomizers. As its name implies, every part of it with which the contained liquid comes in contact is of glass and can easily be kept aseptic. There are no loose parts to be lost and no metallic tubes to corrode. As it operates effectively with only a few drops in the reservoir it is a most economical apparatus; moreover, it can be securely sealed by the introduction of a single cork, thus preventing evaporation and spilling of contents, and facilitating transportation in the pocket or instrument bag. It produces an excellent spray, when either an aqueous or oily liquid is used.
The Glaseptic Nebulizer came in boxes as seen here.  It was
manufactured and sold by Park-Davis & Co., Detroit, Michigan
An advertisement on page 212 of the same catalog notes there is only one glass part of the nebulizer, and it's the part the solution goes into. The only other working part is the throat piece, which costs $1.25.

Epinephrine (Adrenaline) came in small glass ampules that were snapped open, and the liquid contents were spilled into the glass reservoir.  Water could be added to the solution for a longer treatment. The patient would place the mouthpiece up to her lips and create a mist by squeezing the bulb.

Other medicines were also recommended for inhalations, such as Acetozone and Chloretone for hay fever.  For hay fever, either of these, or adrenaline, was squirted into the nasal passages for quick relief of symptoms.  (2)

The Glaseptic Nebulizer only cost $1 and was readily available for those who needed it.  Plus it could be used either in the doctor's office or in the comfort of your own home. 
This article and picture are from the Therapeutic Times. The nebulizer produced a fine spray
that was ideal for atomizing soluble medicine to the respiratory tract, particularly the nose and
throat.  It was also an ideal way to apply adrenaline directly to the respiratory tract.  It was simple,
and portable, meaning it could be used in the doctor's office or by asthmatics at their homes.
I am posting it here mainly because I think its a good close up of the nebulizer.
(From Therapeutic Times, volumes 28-32, Park, Davis & Co., 1921)
References:
  1. Advertisement from Surgical journal, Volume 14 By International Association of Railway Surgeons, American Association of Railway Surgeons, page 472, railway surgical journal, 1907.  You can find another ad in Pharmaceutical Review, 1907, volume 25, Hoffman, Fredrick, Edward Kremers, editors, advertisement page 78
  2. "SUGGESTIONS AS TO THE LOCAL TREATMENT OF HAYFEVER AND ACUTE AND CHRONIC CATARRHS," Therapeutic Notes, Volumes 17 and 18, Park Davis and Company, 1909 and 1910, page 215
  3. Leyden, Hans, "Preliminary Remarks in regard to the Percutaneous Method of Applying the "Ehrlich-Hata 606," Therapeutic Notes, Volumes 17 and 18, 1909 and 1910, Park Davis and Company, page 168 (also see advertisement on page 212)
  4. "Medicated Vapors and how to employ them," Therapeutic Notes, Volumes 17 and 18, 1909 and 1910, Park Davis and Company, page 5

Monday, March 27, 2017

1930s: Spiess-Drager (Apneu) Nebulizer and Inhalatoriums

Figure 1 (4, page 4)
The modern nebulizer is based on the work of Professor Spiess, who was working for Drager in Frankfurt, in 1902.

His nebulizer used a flow of oxygen from a compressed nebulizer to atomize solutions placed in a reservoir cup.

The system essentially consisted of the nebulizer, which was connected to a compressed air or oxygen tank.  The flow was set between 5 and 12 liters per minute.  (3, page 7)

The product was connected to a rubber mouthpiece by a rubber hose.  The system used the Venturi principle to atomize the solution to be inhaled.

The inhaler, sometimes referred to as the Spiess-Drager, Apneu, or collision inhaler, was used to study the effects of various inhaled medications.  The medicine most commonly used was Glycerin (a mixture of epinephrine, water, and glycerin) to patients with chronic bronchitis, chronic laryngitis, croup related pneumonia, interstitial pneumonia, and tuberculosis.  (3, page 7)

It was, in effect, the first nebulizer/inhaler device to utilize an oxygen tank, and was the first such device that allowed physicians to give oxygen and nebulized therapy simultaneously.  (4)

W.E. Collision, in his 1935 book "The Inhalation Therapy Technique," described the history of this inhaler. He said:
In 1902 Professor Speiss of Frankfurt introduced his inhaler, which incorporated the use of oxygen and atomized liquids.  His method was extensively used throughout Germany and during the Great War.  This apparatus was introduced into England by Mr. P.S. Douglas-Hamilton and myself in 1924 and was exhibited at the British Medical Association Exhibition (which was held in Bath in the following year), and in subsequent years until 1932, when the Collision inhaler was exhibited for the first time at the Association's Exhibition at the Imperial Institute of London. (4, page 4)
The London Inhalatorium... afforded
a comfortable treatment room
to those being treated."  (2, page 134)
Since most people with lung disorders could not afford to bring this equipment to their homes, this inspired London physicians to open up an inhalatorium in Grosvenor Place.  This created a comfortable, and affordable, setting for patients to inhale medicine with oxygen. (2)

Other medicine inhaled by the device was  epinephrine (adrenaline), menthol, eucalyptus, terpentine and insulin. (2).

The treatment would last about 10-15 minutes.

This spawned an inhalatorium fad of sorts.  Other inhalatoriums opened, and similar collision nebulizers were introduced to the market.  One such copycat was Hirth's Jet Nebulizer.

Asthmatics might also enjoy the pleasures of an inhalatorium.  They may only visit when having trouble breathing, or they might visit 3-4 times a day as a preventative measure.

The Spiess-Drager Inhaler, and the inhalatoriums it spawned, provided a unique opportunity for inhaling medication.  This was a nice set up for the time.

References:
  1. Green, Henry-Lionel and W.R. Lane, Particulate Clouds: Dusts, Smokes, and Mists, Second Edition, Spon Ltd., London, 1964. (linked to from Inhalation.net, "Atomizers for Droplet Aerosol Generation," accessed Oct. 8, 2012)
  2. Sanders, Mark, "The London Inhalatorium," Inhalatorium.com, page 134, http://www.inhalatorium.com/page134.html accessed 10/9/12
  3. Bisgaard, Hans, Chris O'Callaghan, Gerald C. Smaldone, editors, "Drug Oxygen Delivery," 2001, New York, Marcel Dekker, page 7
  4. Collision, W.E., "Inhalation therapy technique," 1935, London, William Heinemann

Sunday, March 26, 2017

1991: Study finds albuterol works just as well as epinephrine

In my quest to write a little history of Sus-phrine (epinephrine) I finally found an article I'd been looking for for quite some time. The article was regarding a study comparing the long-acting version of epinephrine with Ventolin (albuterl). It was a breakthrough study. It's basically why we give albuterol breathing treatments for asthma instead of epinephrine injections.

Before I delve into the study, I think a little background is pertinent here. Epinephrine was established as a very effective treatment for asthma during the first few decades of the 19th century. So, if you suffered from severe asthma and went to your doctor with an asthma attack, there's a good chance you were given an epinephrine injection.

Epinephrine was great because it opened airways within only a few short minutes. The down side was that it only lasted 3-4 hours. This often meant that repeated injections were needed to keep airways open long-term. This problem was solved in the 1970's with the introduction of Sus-phrine, which was essentially a long-acting epinephrine: it lasted 6-8 hours.

During the 1970's and 80's if you went to your doctor for severe asthma, you might be given a Sus-phrine shot instead of the traditional epinephrine. My mom kept track of this kind of stuff for me when I was a kid, and I know I was given Sus-hrine in the early 1970's. In 1976, when I was only six-years-old and my family wanted to travel from Michigan to California, my doctor wrote a note saying that if this boy has a severe asthma episode, Sus-phrine works great.

I was initially given these shots in the doctor's office. However, later on I had to go to the hospital. It got to the point that, by 1980, I was literally asking for "the shot." An I got it every time. This came to an end in 1991. This year I went to the emergency room and I asked for "the shot." But, the doctor had never heard of what I was asking for. I said, "It's called Sus-phrine."

After talking with the pharmacist he was able to find one. He gave me the shot. This was the last time I was ever given a Sus-phrine shot. A few months later I had another asthma attack and went to the emergency room. This time I was given a bunch of albuterol breathing treatments. They worked just as well as the shot at opening me up. And, as a bonus, I didn't feel like doing laps when I was done; my heart didn't feel like it was going to explode.

This probably wasn't the only such study, but a 1991 study published in Pediatric Emergency Care tiled, "Effect of injected long-acting epinephrine in addition to aerosolized albuterol in the treatment of acute asthma in children." The study basically showed that Sus-phrine was no better than albuterol at opening airways and ending asthma attacks. 

Considering side effects of albuterol are essentially negligible, and the fact that doctor's generally feel comfortable giving high doses of it in the emergency room when needed, the study was a breakthrough study. It pretty much removed epinephrine as a top-line treatment for severe asthma attacks and moved albuterol up to the top. 

As anyone who works as a respiratory therapist knows, albuterol has remained at the top ever since. In fact, albuterol is considered so safe by the medical community. that it's given indiscriminately to anyone who comes into the emergency room with shortness of breath or wheezes regardless of the cause. If it works, great. If it doesn't work, it was worth a try. 

References and further reading:

Friday, March 24, 2017

1894: Alabone's compressed air inhaler

In 1894, Edwin W. Alabone became the first to develop an inhaler that used compressed air "pumped up by hand," according to W.E. Collision in his 1934 book "Inhalation Therapy Technique. (1, page 3-4)

Collision said Alabone probably wasn't the first to come up with this idea, and that he probably got it when he was in the United States.  He was, however, the first to introduce this type of inhaler to Britain.  (1, page 3-4)

This was a significant invention, because in 1902 Professor Speiss of Frankfort would use a similar concept in creating a nebulizer that would become very commonly used in inhalatoriums during the 1920 and 1930s.

References:
  1. Collision, W.E., "Inhalation therapy technique," 1935, London, William Heinemann

Thursday, March 23, 2017

1981: Nursing caps and smoking nurses

Nurses in the 1970s (2)
Not, that's not me.
But it's the only picture I could find
depicting nurses in their old uniforms.
The daughter of a patient of mine said she was a nurse in the 1970s. She said she remembers one nurse who would have a baby on either side of her. She said she would sit and chart like that for hours, and chain smoke. She said this was acceptable back then; the dangers of it were rarely, if ever, questioned.

This reminded me of when I was admitted to the hospital sometime in 1981. I remember the nurses wore the prototypical white nursing uniform and cap. I remember asking a nurse how she kept the cap on her head, and she said she used a bobby pin. She even went as far as to show me how it was done.

That night I smelled smoke. I also had trouble breathing. In the morning, my breathing was still tight when my doctor came around. I wasn't trying to get the nurses in trouble as I innocently mentioned smelling smoke during the night. My doctor stormed out of my room. I could hear him talking at the nurses station.

A year later I was admitted to the same room and for the same reason. This time the nurses were not wearing their uniforms. I asked about this, and the reason I got was, "They are now optional, and we decided not to wear them anymore." It was sad, in a way, not to see the uniform, although I understood why they wouldn't want to wear them.

Actually, they were in uniform. They were all wearing scrubs. And I suppose it was better for them, as they had more freedom as to what they could wear, and what colors. It was probably nice not to wear that hat. And, from what I read, they were more difficult to keep on your head than this nurse told me.

It was also during this visit that I remember, on the day I was admitted, hearing my doctor at the nurses station. He said: 
"I do not want any smoking while this asthmatic boy is admitted. That is an order."
Obviously I'm paraphrasing. But that was the gist of it.

It was bath time. A nurse came in to give me a sponge bath. I insisted on not doing this. But she insisted on doing it. We ended up compromising. There was a tub in a room across the hall. I insisted the door be shut. She insisted it be open. We compromised, and the door was shut but not locked. I cleaned up quick, because I knew nurses by then.

So I got clean. I did not have an asthma attack during this visit. And I ultimately went home after a few days. Anyway, it's neat to have this memory of being a patient at this transitional time in the history of nursing.

References:

  1. Getty Images: Neat old videos of nurses wearing their uniforms
  2. workessentials.com: History of Nursing Uniforms Through Time   

Wednesday, March 22, 2017

1885: Recommendations for inhaling medicine

There were so many different inhalers and nebulizers made and sold during the course of the 19th century that I could write about them adnauseum. If you want to see a larger sample you should check out a really neat site by Mark Sanders, who has amassed a copious supply of antique inhalers and nebulizers, and displays then on his website: Inhalatorium.com.

There were many devices, and every one was the best one available to the people who invented and sold it. And each one had different medicines recommended for it's use, such as some were specifically made for anesthetics, some for ether, some for opium, some for any other assortment of medicines.  

Various medicines inserted into the various nebulizers and inhalers were:
  • Iodine
  • Creasote
  • Carbolic acid
  • Camphor
  • Ether
  • Chloroform
  • Nitrate of amyl
  • Nascent chloride of ammonium
  • Opium
  • Strammnium
  • Atropine.
Depending on the device, the medicine could be inhaled by steam or mist, with the ideal method being by mist, because a mist can deliver both volatile and non volatile medicines to the airways of patients.


So how often should nebulizer therapy be prescribed?  How long should the treatments be?  At what temperature should the water be heated to?  What kind of breaths should the patient take?  These questions were answered differently by different physicians, and may vary depending on the instrument used, and the medicine used. 



It also depended on the malady the physician was trying to treat.  Is the patient having trouble breathing currently?  In such a case he may not mind sitting around for hours sucking in the mist of a device that requires frequent squeezing of a bulb or bellows.  


Although if the patient is has a chronic disease, and is taking the medicine as preventative therapy, the treatments may be schedules on a regular basis and taken for a recommended frequency.  Again, it may depend on the patient, physician, and ailment.  



Jacob Solis Cohen's recommendation is that the treatments should be taken at regular intervals, for a few minutes (how long can you sit around squeezing a bulb), and should be done before meals "because, as a rule, they are less apt to the empty than the full stomach; while, moreover, if they are to be of service, they often stimulate the appetite, or at least promote the desire for food."


He recommends the patient stay in the house at least thirty minutes after a treatment, "especially if warm vapors have been inhaled; as sudden exposure of the warmed-up respiratory tract to the change of temperature between in-doors and out-of-doors, may, under unfavorable conditions, be followed by injurious consequences."


He also describes the appropriate method of breathing:
"The proper method of inhaling gases and vapors from an inhaler must be acquired by the patient, otherwise the vapor will merely be drawn into themouth and reach the pharynx, and if it mixes at all with the air in the lungs, will do so by diffusion; but with a little effort the manner of effecting penetration into the lungs can be readily acquired." (1, pages 15-16)
He also recommended, if steam was the method of medicine delivery, that the water be heated to between 110 and 135 degrees Fahrenheit to create an inhaling temperature of 84 to 93.  He recommends the temperature not be higher unless the goal is to produce expectoration. (1, pages 17-18)

As with today's medical industry in regards to the inhalation of respiratory medications, there was speculation mingled with science.  Yet it would probably be a true statement if I said the patient, regardless of the doctors recommendations, came up with his own answers to the above questions.  When he found something to work, he repeated it as he so choose to get the desired results.  That's just how we asthmatics are.

References:
  1. Cohen, Jacob Solis, "Inhalation in the treatment of disease: it's therapeutics and practice," 1876, Philadelphia, Lindsay and Blakiston

Tuesday, March 21, 2017

1983: Mom's voice and the nice respiratory therapist

The highlight of any of my stays in the hospital was when my mom came to visit. Usually she would come early in the morning and stay until after the notice rang over head, "Visiting hours are over." During the day mom would read to me. One time, as there was nothing else to read, she read a story from reader's digest. The story was too complex for me to understand (or maybe I was too hyped up from all the medicines I was on to treat my asthma) and had trouble paying attention to the story. However, I loved to hear my mom's voice. Hearing mom's voice was therapeutic. It was almost as therapeutic as Sus-Phrine. There is just something soothing about hearing your mom's voice as she is reading a story. It is so relaxing. I loved it when she did it, and wish she would have more often. However, in our busy household, about the only times I remember her reading to me was in the doctor's waiting room or when I was in a hospital be. That's fine. I will take those memories wherever I can get them.

So mom left one day when i was eleven. A respiratory therapist name Star came into my room. She was a young therapist. She was really nice. I liked her probably because she would actually pay attention to me. She would sit on the edge of the bed and watch TV with me. One time I was flipping through the stations and came to a channel with some naked Aborigines. I started to turn the channel, but Star told me to keep it on this station. I wasn't interested in learning about them, but she was. I was too busy laughing. She kind of scolded me for laughing at them. I didn't do it intentionally, i was just giddy. It was probably from all the medicines I was strung on.

The next day mom brought my brothers to visit me. Mom had to take them home. When mom left I went to look out the window. This was when Star entered my room. She gave me my treatment, and then said "Let's play some cards." Of course, there was a deck of cards that mom brought me on my table. I don't remember what game we played, but she stayed in my room for quite some time. It was nice to have the company. I was so happy to have a therapist who paid attention to me like this. But, there was a page overhead, and she had to rush out of the room. Still, it was nice that she helped me pass the time.

Sixteen year's later, when I was hired at Memorial Medical Center in Ludington as a respiratory therapy, Star became my co-worker. Star would later tell me I was a very excitable kid.