Foreign bodies, exogenous & endogenous triggering mechanical effects, good/bad, in the airways. The anesthesiologist as the diagnostician

Abstract 

Fifty odd years ago, in his historic book, ‘The Silent World,’ Jacques Cousteau told us that scuba divers breathing compressed air were apt to get a ‘high,’ which he called, ‘Rapture of the Deep,’ and a form of cerebral arrest, which he termed, ‘Nitrogen Narcosis’. Furthermore, these submarine soloists, also like persons under general anesthesia, are prone to mysterious sudden death. All this reminds us of ‘ether parties,’ and contemporary snorters and huffers, sniffing such foreign bodies as, glue, cocaine, paint-thinner, gasoline, spray-can-propellant, etc. Relevant is the fact that the endogenous and other soporifics which arise within the body proper (endo-integumentarily) do not induce general anesthesia, which is cerebral arrest, until they have entered the extra-integumentary mucosal compartments called airways. Nitrogen is an inert gas, so its actions are neither toxic nor chemical, but mechanical. The effects of endogenous soporifics such as acetone, carbon dioxide, alcohol, and ammonia, are usually assumed to be toxic and endo-integumentary. Therefore, I must emphasize the fact that they do not cause ‘Highs,’ somnolence, nor deaths until/unless they have entered the extra-integumentary airways. Certainly those agents may also have some endo-integumentary actions. I must also stress the fact that foreign bodies in the airways which do not pierce the integument to enter the body proper, such as endotracheal or tracheostomy tubes, lumps of meat, mucus plugs (boogers), etc., can also occasionally trigger cerebral, respiratory and even cardiac arrests locally and mechanically in the airways, depending on which trigger points they stimulate and how powerfully.

Four points explain the mechanism of general anesthesia: (a) Endogenous soporifics do not induce sleep until they have entered the extra-integumentary airways, and contacted the mural mucosa; (b) however administered, intravenously, rectally, or by inhalation, exogenous general agents do not anesthetize until they enter the airways and contact the extra-integumentary mucosa; (c) other foreign bodies, e.g., mishandled endotubes in the airways, which cannot pierce the integument to enter the body proper, can and do trigger cerebral/respiratory/cardiac arrest locally, mechanically, and extra-integumentarily. These effects are neither toxic, nor chemical; (d) Some agents, which can and do pierce the integument, having induced anesthesia, will later exit the body chemically unchanged by their endo-integumentary sojourn, which suggests that their modus operandi is mechanical.