Revisiting the classics: An IDEA AND ITS IMPLICATIONS
George A. Gregory, MD
George Gregory is to my knowledge the ONLY person to have ever won both the American Academy of Pediatric’s Robert M. Smith Award and the Society for Pediatric Anesthesia’s Myron Yaster Lifetime Achievement Award. The author of some of the most important papers to have ever been published in pediatric anesthesia and a textbook that bears his name, I consider myself incredibly lucky to have him as a friend, colleague, and mentor. It is always a thrill to attend national meetings and listen to George as he critiques or presents his views at a clinical or scientific presentation. It is always done with wisdom, wit, and kindness, but, admittedly he does not suffer fools kindly. I asked George to pick one of his seminal papers to discuss; not only to describe what he discovered but the backstory of how the study came about. I am also including in this PAAD a history of pediatric anesthesia paper link that highlights his phenomenal career. Myron Yaster MD
Gregory GA, Kitterman JA, Phibbs RH, Tooley WH, Hamilton WK. Treatment of the idiopathic respiratory-distress syndrome with continuous positive airway pressure. N Engl J Med. 1971 Jun 17;284(24):1333-40 PMID: 4930602
Mai CL, Yaster M, Firth P. The development of continuous positive airway pressure: an interview with Dr. George Gregory. Paediatr Anaesth. 2013 Jan;23(1):3-8. PMID: 23170829
George Gregory, MD
Being in the right place at the right time and in the right situation is often life changing for us and others. For me it started in medical school when I learned in a lecture that racehorses born in barns developed hyaline membrane disease (HMD) and those born in the field did not, which fascinated me. Following residency, I was given the opportunity to work in a newly formed neonatal intensive care nursery where HMD was endemic and survivors few.
What we knew about HMD was that it was the result of a lack of surfactant. This lack led to atelectasis, severe hypoxemia, acidosis, and often death. Available mechanical ventilators were made for adults, not infants. Their compression volumes were often hundreds of times greater than the required infant tidal volume, which led to pneumothoraces, very inefficient ventilation, and death. A way out of this situation was suggested by a paper from Harrison and colleagues(1) who wanted to know why babies with HMD grunted during breathing. They measured blood gases and pH before and after tracheal intubation and found that lung function and blood gases worsened once they inserted a tracheal tube. When they took it out and allowed grunting to resume, everything improved. I had an ‘AHA moment’ when I read this. Grunting was applying end-expiratory pressure! If we applied a pressure to the endotracheal tube during expiration, the child could breathe spontaneously and increase her/his functional residual volume and improve gas exchange. The opportunity arose that night to test this theory. A young premature infant was in respiratory distress. Routine measures were often futile. I applied eight millimeters of pressure to the end of his endotracheal tube and the PaO2 rose from about 40 mmHg to over 200 mmHg. He survived and now runs a computer firm in Japan. Use of CPAP improved survival from HMD from about 30% to 85%.
CPAP was soon used throughout the world, and infant survival, especially in resource poor countries where they could not and cannot afford ventilators and surfactant. It is now applied “noninvasively” through nasal prongs and masks to avoid tracheal intubation and has expanded to the adult world for sleep apnea and lung disease, and recently, for the treatment of COVID lung disease. An observation, and interpretation, and acting on both can often provide changes that are effective and helpful, as it did here.
George A. Gregory MD
1. Harrison CV, Heese H de V, Klein M. The significance of grunting in hyaline membrane disease. Pediatrics 1968;41:549-59