The Historical Trajectory of the Apnea Test in Brain Death Determination

By Eelco F. M. Wijdicks
First Online: 09 March 2021

In classical antiquity, absence of breathing was a less trusted sign than the absence of a heartbeat. The thinking at the time was that breathing regulated the heat of the heart. The anatomist Jacques Bénigne Winslow is credited with more serious attempts at defining death in his 1746 thesis, Uncertainty of the Signs of Death, but did not consider lack of respiratory movements as infallible signs. He not only irrigated the nostrils with juices of onions garlic and horse radish but also tried to stimulate tickle by the quill of a pen or a pointed pencil thrust up the nose.

It is self-evident that being unable to breathe leads to circulatory arrest. In patients with brainstem destruction, breathing often stops before the heart stops. When there is no breathing drive and no other signs of recoverable brain function are present, it is a medical scientific certainty that the patient is dead (not "with reasonable medical certainty," as the courts would like to say). So physicians need to know if the patient has a breathing drive—either spontaneous or after strong stimulation of the respiratory centers. This has become known as the "apnea test." (The test is positive when there is a negative result).

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