The H. Barrie Fairley Seminar in Intensive Respiratory Care Dedication Ceremony

 

The first SFGH Respiratory Care Seminar was on Post-Traumatic Respiratory Insufficiency and was held in 1982. It was organized by Kevin Corkery and co-sponsored by Barrie Fairley. Since then, the event has continued as an annual Bay Area educational event. As this seminar is about Respiratory Care in general but specifically highlights the ZSFGH, let's take a step back in time to provide a history of critical care at UCSF and SFGH.

It begins in 1958, with Stuart Cullen’s appointment as the first Chair of the Department of Anesthesia.  Dr. Cullen was a nationally recognized anesthesiologist and Chair of the Department at University of Iowa, a powerhouse department at the time. Dr. Cullen and his faculty expanded the department’s clinical activity including OB and ICU at Moffitt and included anesthesia training at SFGH.

Morley Singer, an anesthesiologist, was named first director of the ICU at Moffitt Hospital  in 1964,

Joe Lee, a Canadian, became the 1st ICU Director at SFGH in 1967, and Richard Barber in 1969.

 

In addition to being an outstanding anesthesiologist, Dick Barber dabbled in acting.  He had a cameo role in a code blue scene in the 1968 Movie, Bullitt, starring Steve McQueen.  He was very proud of his acting role in the movie. 

 

Next on the UCSF anesthesia timeline was the appointment of Dr. Hamilton as Chair of Anesthesia. Dr. Cullen was promoted to Dean of the UCSF Medical School and Dr. Hamilton, who followed Cullen at Iowa, followed him again as Chair of Anesthesia at UCSF in 1967. Two Key recruitments stand out: Dr. H. Barrie Fairley (Chief VAH/SFGH) & Dr. Richard Schlobohm, Director of SFGH ICU. William K. Hamilton supported clinical research in the ICU. 

The Department of Anesthesia had a wonderful New Year’s eve in 1970 with back to back original articles in NEJM on oxygen toxicity during MV.

 

A special acknowledgement of Dr. Schlobohm (aka “Schlo”) is in order considering his longevity as Director of the SFGH ICU and his dedication to Respiratory Care. 

Who could forget Schlo’s annual volley game and picnic at his home, where ICU doctors, nurses and respiratory care practitioners would mingle for a fun day at his home in the Mill Valley.

 

Now back to Dr Fairley, an extraordinary teacher, clinician, investigator, and administrator.  A role model for anesthesia residents and faculty to emulate.

 

 

Dr. Fairley’s professional journey began in the UK where he trained as a clinical anesthesiologist with special training in anesthesia for thoracic surgery.
In 1955, he moved from England to the University of Toronto, initially working on induced hypothermia for cardiac surgery.
While at Toronto, a British Neurologist, Richard Chambers, asked Dr. Fairley for assistance on how best to manage paralyzed patients with respiratory failure.
In the late ‘50s, they co-founded the Respiratory Failure Unit.  Dr. Fairley and colleagues published numerous articles on the organization of ICUs and the use of prolonged mechanical ventilation in the management of respiratory failure, thus, beginning Dr. Fairley’s interest on how to optimize mechanical ventilation of the lungs.

Pictured here are Morley Singer and Barrie Fairley (with Dick Barber, center) celebrating their founding membership in the Society of Critical Care Medicine.

 

Dr. Fairley’s guiding role in research on respiratory mechanics in acute pulmonary failure is recognized on the UCSF Department of Anesthesia Timeline of important events, discoveries and innovations. Optimum PEEP, published in 1975 (42 years ago) is but one several seminal articles authored by Dr. Fairley that provide the foundation for contemporary protective lung ventilation strategies in ARDS.

In the late ‘60s-‘80s, large tidal volume ventilation with PEEP was the standard approach for acute hypoxemic respiratory failure. Dr. Fairley was skeptical that a one-size tidal volume approach was appropriate and was concerned about lung over distension and pulmonary injury. PEEP was considered essential in maintaining end-expiratory lung volume but how much to apply remained elusive. Fairley and Suter postulated a compromise between lung recruitment and over-distention by ventilating the patient’s lungs on the steep portion of pressure volume curve. Static compliance was to identify this position on the curve. But how this would relate to cardiopulmonary function was to be determined. 

 

The principal findings of the study are reflected on this graph.  Instead of grouping the data by PEEP level, a common approach in most literature at the time, they grouped the data according to level of PEEP that resulted in the maximum compliance, and termed this as best PEEP. They examined the physiologic data at PEEP levels above and below the best PEEP level.
As it turned out, the best PEEP coincided with maximum oxygen transport and lowest physiologic dead space.  At PEEP levels above best PEEP, compliance decreased, as did O2 transport, reflecting a decline in cardiac output.  Also, as PEEP increased above the best level, physiologic dead space increased.

A prescient commentary is found in the discussion of the paper: “The concept of not distending a lung beyond the point of maximum compliance regardless of gas exchange is probably reasonable from the stand point of minimizing pulmonary damage, and although such distention may be necessary transiently as an acute physical therapy maneuver, we do not recommend its sustained use.” In the optimum PEEP study “tidal volume was kept constant at different levels of PEEP, other variations are possible e.g. a constant end-inspiratory pressure with variable PEEP and tidal volume.”

In a follow-up paper, the same authors demonstrate the effect of different tidal volumes on respiratory system compliance during PEEP titration.  At physiologic tidal volumes of 5 or 7 ml/kg, compliance increased even at a PEEP level of 15, in contrast compliance decreased as PEEP was increased with larger tidal volumes.

 

While Dr. Fairley was a driving force behind the research, there were a cadre of faculty and research fellows who also contributed. In the top center is Dr. Peter Suter, the Swiss internist-intensivist, the first author of NEJM as well as others.  He later became Dean of the Med School at the University of Geneva. In the bottom right corner is Mike Isenberg, an anesthesia research fellow who assisted Suter. Dr. Richard Schlobohm, as previously mentioned was involved in various projects and papers with Dr. Fairley and Suter.  In the top right is Dr. Ozanne, a faculty in the Department of Anesthesia and co-PI on an NIH grant with Dr. Fairley on Acute Respiratory Failure.  Bottom left is Steve Zinn, and Jeff Katz is at the bottom/middle.  We were anesthesia fellows who contributed to the research on respiratory mechanics in acute pulmonary failure.