EMS World Hall of Fame: Great Intubators—Innovators of Intubation Practice and Design

The short history of EMS has been driven by the wisdom, foresight, and innovation of countless individuals. As the field ages into its second half-century and its origins fade to the past, it’s worth commemorating the greatest pioneers of prehospital emergency medical services. This series honors these trailblazers. 

While the earliest known depiction of a tracheotomy dates back to a pair of Egyptian tablets more than 5600 years old, the development of nonsurgical tracheal intubation as it’s performed by modern EMS providers has its roots in the landmark work of several physicians throughout the 19th century. 

Or, in one case, a singer: Manuel Garcia, a vocal pedagogue from Spain, invented the first laryngoscope in 1854 using sunlight reflected by a pair of mirrors. This allowed him to look into his own glottis and upper trachea. The invention was of sufficient importance to be presented the next year to the Royal Society, the UK’s national academy of sciences. 

Three years after that French pediatrician Eugène Bouchut discovered he could counter the laryngeal obstruction of diphtheria by inserting a small, straight metal tube into the larynx, securing it with a thread, and leaving it there until the obstruction cleared. His idea was poorly received by the French Academy of Sciences, but Bouchut nonetheless produced a set of eponymous tubes for tracheal intubation in place of tracheotomy for that disease. 

In 1878 German physician Wilhelm Hack described the use of nonsurgical orotracheal intubation in removing polyps from a patient’s vocal cords—and then, in a second paper that year, in securing the airway of a patient with acute glottic edema by gradually introducing larger bougies. Two years later William Mac-ewen, a Scottish surgeon, used intubation instead of tracheotomy to help another such patient breathe. 

All these techniques achieved indirect visualization of the glottis and larynx using mirrors. That changed in 1895 when German physician Alfred Kirstein performed the first direct examination of the interior larynx using a modified esophagoscope he called an autoscope. The advance was a happy accident; in trying to pass a scope into a patient’s esophagus, a fellow physician named Rosenheim accidentally got it in the trachea, surprisingly providing a “perfect view of the bronchial bifurcation.”¹ 

In 1913 American physician Chevalier Jackson—a laryngologist known for extracting more than 2000 foreign objects swallowed by patients—introduced a laryngoscope blade with a light at the distal end and an improved design that allowed passage of an endotracheal tube or bronchoscope. Henry Janeway designed the first laryngoscope specifically for anesthesia and added batteries, a notched blade for staying midline, and a curve to the end of the blade. 

After World War I Irish anesthetist Ivan Magill developed the technique of awake blind nasotracheal intubation and created a new type of angulated forceps to facilitate it. Magill’s other inventions included an eponymous laryngoscope blade. 

American anesthesiologist Robert Miller contributed his Miller laryngoscope blade in 1941; Sir Robert Macintosh added his curved alternative in 1943. Macintosh’s remains the most popular blade used for orotracheal intubation today. 

Inspired by a Macintosh case report describing use of a gum elastic urinary catheter to facilitate a difficult intubation, anesthetist Paul Hex Venn created an endotracheal tube introducer, known as the Eschmann and first produced in 1973. 

The 21st century added video laryngoscopy to providers’ arsenals. The first commercially available video laryngoscope was Verathon’s GlideScope, designed by John Pacey, MD, and introduced in 2001.  

Reference

1. Hirsch NP, Smith GB, Hirsch PO. Alfred Kirstein: Pioneer of direct laryngoscopy. Anaesthesia. 1986; 41(1): 42–5. doi: 10.1111/j.1365-2044.1986.tb12702.x

John Erich is the senior editor of EMS World.