대한응급의학회지제 23 권제 2 호 Volume 23, Number 2, April, 2012 종 설 심폐소생술의역사 연세대학교원주의과대학응급의학교실 황성오 The History of Cardiopulmonary Resuscitation 서 론 Sung Oh Hwang, M.D. Resuscitation medicine, which is a relatively young field of clinical medicine, has emerged as an endeavor to resuscitate victims suffering sudden death. Cardiopulmonary resuscitation (CPR) is utilized in order to treat a transient, reversible, sudden unexpected death. Currently, it is expected that millions of lay people worldwide learn CPR and millions of patients suffering sudden cardiac arrest receive CPR. Even though the history of CPR includes folklore related to various attempts that have been made to save lives, modern CPR based on clinical research and evidence has been introduced and developed over the last several decades. Researchers and organizations have contributed to the development of resuscitation skills by establishing CPR guidelines and disseminating this knowledge to lay people. Despite recent advances in CPR technique, sudden death remains a major health issue in developed countries and the survival rate resulting from out-of-hospital cardiac arrest remains low. This review provides insight into the progression of resuscitation medicine by evaluating the history of CPR. Key Words: Cardiopulmonary resuscitation, Cardiac arrest, History Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea 책임저자 : 황성오강원도원주시일산동 162 연세대학교원주의과대학응급의학교실 Tel: 033) 741-1611, Fax: 033) 734-9994 E-mail: shwang@yonsei.ac.kr 접수일 : 2012년 1월 28일, 1차교정일 : 2012년 2월 10일게재승인일 : 2012년 3월 3일 161 인류문명에의학이도입된이래인간의수명을연장시키기위한연구는두가지측면에서진행되었다. 질병의예방, 치료와노화를억제하기위한의학적연구는의학의발생초기에서부터시작되어의학연구의주류가되었으며, 인체가죽음에이르게되는과정을예방하거나지연시키는데중요한역할을하고있다. 반면, 죽음의단계에도달한인체를회복시키는것은인간의능력을벗어나는영역으로인식되었기때문에이분야에대한연구는비교적최근에시작되었다. 심폐소생술 (cardiopulmonary resuscitation: CPR) 은심폐정지가발생하여사망의과정이시작된인체를소생시키는술기로서, 일시적가역적원인에의한사망으로부터인류를구하는데기여하고있다. 심장박동과호흡이정지된사람에게인공순환과인공호흡을하는단순한술기로부터시작된심폐소생술은지난수백여년에걸친소생의학분야의발전에힘입어심폐정지를치료하는포괄적의술로발전하였다. 현재의심폐소생술에는전기적제세동 (electrical defibrillation), 약물치료등전문소생술분야가포함되었으며, 최근에는심정지후증후군 (post-cardiac arrest syndrome) 의치료가심폐소생술의새로운영역으로포함되었다. 심폐소생술이정립되기까지의수많은연구, 치료방법의개발을되돌아보는것은현재의심폐소생술에대한이해와미래의연구방향을설정하는데중요한계기가될것이다. 1. 소생술의역사소생술 (resuscitation) 의역사는인간이죽음의과정을역전시키겠다는의지로부터시작되었다. 죽음으로부터인간을소생시키는것은 1700년대이전까지신의영역으로간주되었다. 죽음에이른사람을소생시키려는인류의체계적의지가처음시작된것은 1767년 Amsterdam Rescue Society가구성된이후이다. Amsterdam Rescue Society는당시연간 400명이상의익사자가발생하였던암스테르담에서활동을시작하여 4년이내에 150명이상의익사자를구조하였다 1). 이후약 200년동안
162 / 대한응급의학회지 : 제 23 권제 2 호 2012 여러유럽국가와미국의주요도시에인명구조를위한조직이생겨났다. 당시소생술의술기는주로익사자를소생시키기위하여개발되었으며, 익사자에게인공호흡을하고폐속의물을빼내기위한다양한술기가시도되고일반인에게교육되었다 2). 작하였다 3,4). 의식이없는사람의기도를개방하는술기는 Dr. Peter Safar가자원봉사자를마취한후단순히머리기울임 (head-tilt) 과턱들어올리기 ( 하악견인, jaw-thrust) 만으로기도를유지할수있다는것을증명함으로써기구를사용하지않고기도를유지하는방법을고안하였다 5). 2. 현대심폐소생술의역사현재사용되고있는심폐소생술은 1950년대말부터각술기의효용성이증명되었으며, 1960년대초에심폐소생술이라는용어로의료인과일반인에게보급되기시작하였다. 심폐소생술에포함되어있는기도유지 (airway), 인공호흡 (artificial ventilation), 인공순환 (artificial circulation), 제세동 (defibrillation) 등은각각다른연구자에의하여다른과정으로개발된후에심폐소생술에도입되었다 (Table 1). 1) 기도유지과거소생술은주로익사자에대한치료로서활용되었다. 따라서기도유지술기는익사자의기도를막고있다고생각한물을제거하기위하여환자를거꾸로들거나둥근통위에엎드린자세를취해주는것이었다. 1889년기관튜브 (endotracheal tube) 가도입되고 1895년후두경 (laryngoscope) 이발명되어기관삽관술이발달하기시 2) 인공호흡마취과의사인 James Elam이입-입인공호흡을시도하기이전까지호기 (expired air) 에는심정지환자의혈액을산소화시키기에충분한양의산소가포함되어있지않다고믿었다. 1800년대부터 1950년경까지 chest-pressure method와 chest-pressure arm-lift method 등폐환기를유발하는술기가인공호흡방법으로사용되었다 6). 입-입인공호흡에대한기록은 1732년영국의외과의사인 William Tossach가광부에게처음시도한적이있었으며, James Elam에의하여재발견되었다 7). 소아마비가유행하였던 1949년 Dr. Elam은청색증이발생한소아환자에게입-입인공호흡 (mouth-to-mouth ventilation) 을하였더니청색증이사라진경험을하였다 8). 이경험을바탕으로그는기관삽관이되어있는수술환자를대상으로호기로인공호흡을하여정상범위의동맥혈산소포화도를유지할수있었다는연구를보고하였다 9). 또한 Peter Safar는실험대상으로자원한의사, 의과대학생, 간호사 32명에게큐라레를투여하여호흡을마비시킨후입-입 Table 1. The chronicles of the history of modern cardiopulmonary resuscitation Year The person concerned Historical event 1732 Willian Tossach 7) First trial of mouth-to-mouth ventilation to human 1892 Friedrich Maass 13) First report of external chest compression to a cardiac arrest victim 1906 Crile and Dolley 28) Use of epinephrine in treating cardiac arrest 1947 Claude Beck 24) First successful (internal) defibrillation of ventricular fibrillation in human 1949 James Elam 8) First report of mouth-to-mouth ventilation to a cardiac arrest victim 1955 Paul Zoll 25) First successful external defibrillation of ventricular fibrillation in human 1958 Peter Safar 10) First report of ventilatory efficacy of mouth-to-mouth ventilation 1960 William Kouwenhoven group 15) Application of external chest compression to patients with cardiac arrest 1960 Safar, Jude, Kouwenhoven 7) The birth of cardiopulmonary resuscitation 1962 Archer Gordon 32) Use of mnemonic symbol (CPR-ABC) 1966 American Academy of Science 33) First CPR guidelines 1979 Andrew Diack 27) Development of the prototype of automated external defibrillator 1991 AHA 38) Introduction of the concept of Chain of Survival 1993 AHA, ERC Foundation of ILCOR 2000 ILCOR 44) First international CPR guidelines 2005 ILCOR 45) Change in compression:ventilation ratio from 15:2 to 30:2 2006 KACPR 47) First Korean guidelines for CPR and ECC 2010 ILCOR 46) Change CPR-ABC to CPR-CAB Introduction of hands-only CPR AHA: American Heart Association, ERC: European Resuscitation Council, KACPR: Korean Association of Cardiopulmonary Resuscitation, ILCOR: International Liaison Committee on Resuscitation, CPR: Cardiopulmonary Resuscitation, ECC: Emergency Cardiac Care, ABC: airway, breathing, circulation, CAB: circulation, breathing, airway
황성오 : 심폐소생술의역사 / 163 인공호흡을시행하고동맥혈산소압과이산화탄소압을측정하여입-입인공호흡이구조호흡으로서효과적이라는사실을증명하였다 10). 이연구를바탕으로미군 (1957년), 미국의사협회 (1958년) 가입-입인공호흡을구조호흡으로인정하였으며, 1958년미국의사협회가심포지엄을통해널리전파되기시작하였다 8,11). 3) 인공순환인공호흡을위한시도는 1500년대부터시작되었지만, 순환정지를극복하기위한인공순환의시도는 1800년대에시작되었다. 1874년 Moritz Schiff는개에게개흉술을한후심장을압박하면맥박이발생한다고보고하였다. 1800년대까지가슴을압박하는것은인공순환을위한것이아니라인공호흡을위한술기로여겨졌다. 인체에서인공순환을목적으로가슴압박 (external chest compression) 을처음시도한기록은, 1892년 Friedrich Maass가심정지가발생한환자에게심장부위를압박하자환자가소생되었다는보고에서찾을수있다. Dr. Maass는구개열수술을위해클로르포름으로마취를한 9세남아에서심정지가발생하자검상돌기부위를분당 30~40회압박하여소생시켰다고보고하였다 13,14). 그러나 Dr. Maass의발견은 1958년 Dr. Kouwenhoven 그룹이가슴압박을재발견하여보고할때까지 70년간잊혀져있었다 15). 개흉심장마사지 (open-chest cardiac massage) 는 1901년마취중에심정지가발생하였던환자에게처음시도되었으며, 1960년이전까지수술중심정지가발생한환자의인공순환방법으로사용되었다 16,17). 1958년제세동실험연구를하던 Guy Knickerbocker는심실세동을유발한개에게제세동을위하여패들을흉곽에대고누르자대퇴동맥의압력이상승하는것을발견하였다. Dr. Knickerbocker의발견을바탕으로 William Kouwenhoven 그룹은가슴압박방법이심정지가발생한인체에게인공순환을제공할수있는술기임을임상적으로증명하였다 15). 가슴압박에대한이들의재발견으로심폐소생술에서인공순환의술기가정립되었으며, 일반인도심폐소생술을할수있는초석이마련되었다. 4) 제세동 1700년대중반에전기가발견된이후로생체에전기를가한첫번째기록은 1775년 Abildgard가실험중이던닭에게전기를가하여소생시켰다는것이다 18,19). 그후일부기록에서인체에전기를가하였다는기록이있으나, 당시에는전기가심실세동등의심장의전기적이상을치료하기위하여사용된것이아니라, 의식이없는환자에게전기충격을가하는방법으로사용되었다. 인체에서심실세동이심정지의원인이될수있다는개념은 1889년 Dr. John McWilliam이개를포함한여러동물을사용한실험을바 탕으로제시되었다 20). 심장에전기를가하면심실세동이발생하고강한전기충격으로심실세동을제세동할수있다는사실이보고된것은 1899년의일이다 21). 이후직류전기가제세동에유용하다는사실이알려졌고, 에디슨전기회사의지원을받은미국의사들의실험연구에의하여심장에직접전기를가하지않고흉곽에전기를가하더라도제세동을할수있다는사실이알려졌다 22,23). 인체에적용된첫번째성공적인제세동의예는 1947년 Claude Beck이흉곽기형교정을위한 14살소년의수술중발생한심실세동을치료하기위하여심장에직접전기를가하여성공적으로치료함으로써이루어졌다 24). 인체의흉곽에전기를가하여심실세동을치료한첫예는 1955년제세동기의선구자인 Paul Zoll이기록하였다 25). 1962년 Bernard Lown 은직류전기가교류전기보다제세동에우수하다는것을증명하였으며, 최초의자동제세동기 (automated external defibrillator) 는 1979년에개발되었다 26,27). 5) 약물 Epinephrine은 1906년에 Crile과 Dolley이심정지치료에처음사용하였다 28). 그들은 epinephrine을투여하지않으면대동맥이완기압을유지할수없다는사실을밝혔으며, 이후 epinephrine은심정지치료에관행적으로사용되었다. 1960년대이후동물실험을통하여 epinephrine 의교감신경작용중알파교감신경수용체항진작용이심정지의소생과관련이있으며, 베타교감신경수용체항진작용은심근손상을초래하는등심정지의소생에해가될수있다는사실이알려졌다 29-31). 5) 인공호흡과인공순환의결합과 CPR-ABC (airway, breathing, circulation) 의탄생 1957년 Dr. Safar는소생술의순서를 A-B 약자를사용하여서술하여, 심폐소생술순서를 ABC 약자로표기하는기초를마련하였다 32). 입-입인공호흡과가슴압박을결합시켜심폐소생술로탄생시키게된계기는 1960년 9월미국 Ocean City에서개최되었던 Maryland Medical Society의연례학술대회였다 7). 여기에서 Safar, Jude, Kouwenhoven이각각입-입인공호흡과가슴압박에대해발표한후, 이두방법이심정지환자에게동시에사용되어야한다는의견이제시되었다. 그후심폐소생술을일반인에게교육시키기위한움직임이시작되었으며, 1962년 Dr. Gordon이 The Pulse of Life 라는 27분짜리심폐소생술교육용필름을제작하여배포하면서심폐소생술이의과대학생을시작으로일반인교육으로확산되기시작하였다. 이필름에서심폐소생술의순서를 A( 기도유지 )-B( 인공호흡 )-C( 인공순환 ) 의약자로표기하면서 ABC는지난 2010년이전까지심폐소생술순서의약자로사용되었다 7).
164 / 대한응급의학회지 : 제 23 권제 2 호 2012 3. 가이드라인개발심폐소생술가이드라인 ( 지침 ) 의개발은심폐소생술을표준화하여높은수준의심폐소생술을심정지환자에게제공하고일반인에게심폐소생술을보급하는중요한계기가되었다. 심폐소생술지침은 1966년 American Academy of Science에의하여최초로제정되었다 33). 이후미국심장협회 (American Heart Association) 와미국적십자사 (American Red Cross) 에의하여심폐소생술및응급심장치료를위한가이드라인이제정되었고, 미국심장협회는심폐소생술에관한최신의연구결과를통해 1974년이후 1980년, 1986년, 1992년에개정된가이드라인을발표해왔다 34-37). 특히 1991년에는심정지환자를소생시키기위한요소로서 Chain of Survival 의개념을도입하여, 심정지치료에대한포괄적접근이라는개념을창조하였다. 유럽은유럽국가들로구성된유럽소생위원회에서 1992 년, 1996년, 1998년, 2000년, 2005년, 2010년에심폐소생술가이드라인을제정하여발표하여, 유럽지역심폐소생술의표준화를기하고있다 38-43). 심폐소생술에관한표준가이드라인의국제화를위하여 1993년미국심장협회와유럽소생위원회가중심이되어심폐소생술국제연락위원회 (International Liaison Committee on Resuscitation: ILCOR) 를구성하였다. ILCOR는 2000년이후 International Guidelines을발표하여 2005년, 2010년심폐소생술지침을발표하여각국가에서사용할수있는심폐소생술지침의과학적근거를제공하고있다 44-46). 우리나라에서는 2006년대한심폐소생협회가보건복지부의 공용심폐소생술가이드라인의개발및배포 연구사업을통해, 국내최초의심폐소생술지침을개발하여발표하였다. 이후 2010년심폐소생술국제연락위원회의새로운지침을근거로 2011년심폐소생술지침을개정하여 한국심폐소생술지침 으로발표되어현재사용되고있다 47,48). 4. 최근의발전기본소생술 (basic life support) 과정에서기도유지, 인공호흡및인공순환방법은심폐소생술초기에시도하였던방법과큰차이가없다. 인공호흡의빈도, 호흡량및호흡속도, 가슴압박의위치, 속도및깊이에대한지침의변화가있었으나, 현재에도입-입인공호흡과가슴압박이심폐소생술의기본술기로자리잡고있다. 지난 50년간기본소생술에서가장중요한변화는심폐소생술순서의변경, 가슴압박과인공호흡의비율및자동제세동기의사용이다. 전문소생술분야에서는심폐소생술중혈류량을증가시키기위한새로운방법들이고안되었으며, 심정지후증후군에대한관심이고조되면서심정지후치료를위한새로운방법이도입되고있다. 1) 기본소생술심폐소생술의순서는최초로제안되었던 A-B-C 순서가 2010년지침을기점으로 C-A-B 순서로변경되었다 46). A-B가우선되어야한다는개념은심폐소생술의역사와관련이있다. 전술한바와같이심폐소생술의기원은익사자의치료에서비롯되었기때문에기도유지와인공호흡이우선적으로시행되어야한다는개념이유지되어왔다. 그러나다수의구조자가입-입인공호흡을꺼리고있으며, 인공호흡이일반인구조자가시행하기에는어렵고시간이많이소요되므로, 심폐소생술의효율성을감소시키는효과가있다는보고가있다 49). 뿐만아니라최근가슴압박만을한경우 (compression only CPR 또는 hands-only CPR) 에도심정지환자의생존율이인공호흡과가슴압박을동시에한경우와유사하다 50). 이러한보고를바탕으로, 심정지의초기치료에서인공호흡보다는인공순환의중요성이부각되면서심폐소생술순서가 C-A-B로변경되었다. 가슴압박과인공호흡의비율은 5:1에서 15:2로변경되었다가 2005년지침에서부터 30:2로권장되었다. 가슴압박과인공호흡의비율은심폐소생술순서의변화와같이인공호흡보다는가슴압박의중요성이강조된결과이다. 자동제세동기의도입은심정지환자의생존율을급격히높이게된중요한전기가되었다. 1980년대에응급구조사에의한현장치료기기로도입된자동제세동기는 1990년대에 public access defibrillation (PAD) 개념에의해일반인제세동시대를열어가고있다 51). 특히 2000년이후미국의일부지역과일본에서심폐소생술교육및홍보와 PAD를실행함으로써단기간에심정지환자의생존율을높였다는보고는심정지환자에대한포괄적접근이매우효율적임을보여주는사례이다 52,53). 2) 전문소생술인공호흡분야에서는백-마스크, 다양한기도기, 기관삽관이전문기도유지술로서도입되었다. 2000년대에심정지현장에서의전문기도유지술을더이상심정지환자의생존율을제고하는데도움이되지않는것으로알려졌다 54). 또한후두마스크기도기 (laryngeal mask airway) 등고도의숙련을요하지않는전문기도유지방법이기관내삽관과유사한기도유지효과가있는것으로알려졌다. 가슴압박에의한혈류량이정상심박출양의약 1/3에불과하다는사실이알려진이후로순환혈류량을증가시키기위한다양한노력이진행되었다. Interposed abdominal compression CPR, simultaneous ventilation compression CPR, active compression-decompression CPR, CPR with load-distributing band, CPR with mechanical compressor, phased thoracic abdominal compression decompression CPR, simultaneous sternothoracic CPR 등다양한방법이시도되었으나, 아직까지표준심폐
황성오 : 심폐소생술의역사 / 165 소생술과비교하여심정지환자의생존율을증가시키는것으로증명된방법은없는실정이다 55-61). 1990년처체온에의한심정지환자에게체외순환 (extracorporeal circulation) 을적용하여성공적인소생사례가보고된이후, 체외순환소생술 (extracorporeal life support) 는소아심정지, 심장성쇼크에의한심정지환자에게로적용의범위가넓어졌다 62-64). 최근의연구에서는병원안에서발생한심장성심정지의치료와표준심폐소생술에소생되지않는병원밖심정지의치료에도적용되고있다 65,66). 심폐소생술중투여하는약물분야의연구는답보상태에있다. 1990년대동물실험을바탕으로 vasopressin이 epinephrine의대체약물로도입되었으나, 인체를대상으로한연구에서 epinephrine과비교하여우수한생존효과가증명되지않았다 67). 또한무수축과무맥성전기활동에의한심정지환자에게투여되던 atropine은 2010년지침에서는더이상사용이권장되지않는다 46). 3) 심정지후치료심정지로부터순환이회복된환자의대다수가심정지후증후군으로사망하는것으로알려지면서 2000년이후로부터심정지후치료 (post-cardiac arrest care) 에대한관심이고조되었다 68). 특히역사적으로 1970년대에 Dr. Safar가동물실험을통하여제안하였지만임상적으로사용하지않았던치료적저체온요법 (therapeutic hypothermia) 은 2000년대에들어서면서가장중요한심정지후치료의하나가되었다 69,70). 또한경피관상동맥중재술 (percutaneous coronary intervention: PCI) 의발달에힘입어심정지의주요원인인급성관상동맥질환의경피관상동맥중재술이심정지후치료의주요요소가되었다 71). 결론심폐소생술의역사는인류가죽음의과정을되돌리려는노력의과정이라고할수있다. 최근심폐소생술분야는지난수백년동안이분야의업적을뛰어넘는발전을거듭하고있다. 그러나인공순환, 뇌소생 (brain resuscitation) 등가장중요한분야의근본적해결책을제시하지못하고있으며, 그결과로심정지환자의생존율은다른어떤질환보다낮다. 심폐소생술의역사를되돌아봄으로써심정지환자의생존율을획기적으로개선할수있는새로운미래가열리기를기대해본다. 참고문헌 01. Johnson A. An account of some societies at Amsterdam and Hamburg for the recovery of drowned persons. London, UK; 1773. p.119. 02. Karpovich P. Adventures in artificial respiration. New York: Associated Press; 1953. p.32. 03. Head H. On the regulation of respiration. J Physiol 1889;10:1-70. 04. Kirstein A. Autoskopie des larynx und der trachea. Archiv Laryngologie Rhinologie 1895:3;156-64. 05. Safar P, Escarraga LA, Chang F. Upper airway obstruction in the unconscious patient. J Appl Physiol 1959;14:760-4. 06. Silvester HR. A new method of resuscitating still born children and of restoring persons apparently dead or drowned. BMJ 1858;2:576. 07. Kaye W, Bircher N. Cardiopulmonary Resuscitation. New York, NY: Churchill Livingston; 1989. p.1-53. 08. Ornato JP, Peberdy MA. Cardiopulmonary resuscitation. Totowa, New Jersey: Human Press; 2005. p.1-11. 09. Safar P. Advanced in Cardiopulmonary Resuscitation. New York, NY: Springer-Verlag; 1977. p.263-5. 10. Safar P. Ventilatory efficacy of mouth-to-mouth artificial respiration. JAMA 1958;167:335-41. 11. Dill DB. Symposium on mouth to mouth resuscitation (expired air inflation). Council on Medical Physics. JAMA 1958;167:317-9. 12. Feinsod M. Moritz Schiff (1823-1896): A physiologist in exile. RMMJ 2011;4:e0064. 13. Philippe J, Jean-Marie D. Cardiac massage: A method rescued from oblivion. Anesthesiology 1998;89:771-6. 14. Taw RL. Dr. Friedrich Maass: 100th anniversary of new CPR. Clin Cardiol 1991;14:1000-2. 15. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closedchest cardiac massage. JAMA 1960:173;1064-7. 16. Keen WW. A case of total laryngectory (unsuccessful) and a case of abdominal hysterectory (successful), in both of which massage of the heart for chloroform collapse was employed, with notes of 25 other cases of cardiac massage. Therap Gaz 1904;28:217. 17. Boczar ME, Howard MA, Rivers EP, Martin GB, Horst HM, Lewandowski C, et al. A technique revisited: hemodynamic comparison of closed and open-chest cardiac massage during human cardiopulmonary resuscitation. Crit Care Med 1995;23:498-503. 18. Driscol TE, Ratnoff OD, Nyqaard OF. The remarkable Dr. Abildgaard and countershock. The bicentennial of his electrical experiments on animals. Ann Intern Med 1975;83:878-82. 19. Lown B. Defibrillation and cardioversion. Cardiovasc Res 2002;55:220-4. 20. McWilliam JA. Cardiac failure and sudden death. BMJ 1889;5:6-8. 21. Revost JL, Battelli F. La mort par les courants electriques-
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