using the fiberoptic bronchoscope. patients. Selective ...

Treatment for collapsed lung in critically ill patients. Selective intrabronchial air insufflation using the fiberoptic bronchoscope. T C Tsao, Y H Tsai, R S Lan, W B Shieh and C H Lee Chest 1990;97;435-438 DOI 10.1378/chest.97.2.435 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/97/2/435

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1990by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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Treatment for Collapsed Ill Patients* Selective Fiberoptic

Intrabronchial Bronchoscope

Chang-Yao Tsao, M.D.; Lan, M.D., F.C.C.P;

Thomas

Ray-Shee Cheng-Huei

Lee,

M.D.,

Lung in Critically

Air Insufflation

Using the

Ying-Huang Tsai, M.D. , FC.C.P; Wen-Bin Shi#{128}h,M.D., F.C.C.P; and

F.C.C.P

A new,

simpler method to re-expand collapsed lungs was in 14 procedures in 12 critically ill patients. To close the bronchus, we wedge the fiberoptic bronchoscope into each segment or subsegment of the collapsed lung instead ofusing a balloon cuff. Room air was then insufflated into the atelectatic alveoli after repetitive sputum suctioning and bronchial washing with normal saline solution. Com-

plete re-expansion was achieved in 12 of the 14 procedures and partial in two. The average alveolar-arterial oxygen pressure difference (P[A-a]01) declined from 217.5 before the procedure to 200.3, 150.0 and 152.2, respectively at 30 minutes, 12 hours and 24 hours after. There were no complications. (Chest 1990; 97:435-38)

introduced

C ollapsed

lung is a common problem in critically ill patients. Although respiratory therapy is a priand effective method of treatment, it is not

mary suitable

for

some

patients,

fractures, hemothorax, tients are too critical respiratory In 1973, expand scope 5Fmm

‘

as

care or cannot tolerate a bedside procedure was the

.

such

collapsed

This

lung

procedure

Department

those

or pneumothorax. to wait for the results

using

Chang

Gung

Hospital, Taipei, Taiwan, Republic of China. Manuscript received February 28; revision accepted Reprint requests: Dt Tsao, Chang Gung Memorial Twig thea N Road, Taipei, Taiwan, ROC

Table

1-Clinical

Data

and

Chest

lung.

bronchial

collapse

and

washing

is left

a secondary

with

trabronchial

Memorial

endotracheal tube cuff was introduced. fortunately, available.

199

Film Findings

on Patients

pressure

Undergoing

the

Many

lower pressure.

lung In-

using

an

with a balloon results.2 Un-

are complex and a simpler method

Fiberoptk

become

occur.

ventilation

or a bronchoscope All attained good

these devices We designed

saline

may

it

may

to overcome critical opening

positive

normal

collapse was resome were relung compliance in the collapsed

untreated infection

devices were invented compliance and higher

sputum

July 6. Hospital,

X-ray

If the

chronic

broncho-

repetitive

Medicine,

rib

therapy. to re-

a fiberoptic

and

solution. Although most of the lung expanded with the above procedure, fractory. This may be due to a lower and higher critical opening pressure

Other paof repetitive

vigorous introduced

includes

of Chest

with

suctioning

not readily to accom-

Procedures

Bronchoscopk Collapse

Case

Age

Sex

Underlying

1

24

M

R’t rib

2

52

M

Traumatic

fracture

with

3

56

M*

R’t rib fracture

4

24

F

Esophageal

5

18

F*

L’t renal

6

64

M

R’t lower

limb

7

48

F

Diabetic

mellitus

8

29

M

NPC

Area

Condition

hemothorax,

septic

shock,

acute

renal

failure

RLL

hemopneumothorax

post

with

cell

with

large

skin with

9

28

F5

SLE

with

pulmonary

30

M

BAT

with

internal

11

52

F

RHD

12a

16

M

Traumatic

C5,

with

uremia

post

myelopathy infection

with

infection, CPR,

interposition

septic

hypoxic

shock

encephalopathy

CR1’ lung

CR

RLL

CR

L’t lung

CR

RUL

PR

L’t lung

CR

L’t lung

CR

LLL

CR

LLL

CR

L’t lung

CR

annuloplasty

RLL

CR

quadriplegia

LLL

above

and post

+ tricuspid

C6 dislocation

s/p colon

nephrectomy

defect

bleeding

AVR + MVR

injury

radical

radiation

10

post

for corrosive

cancer

B/F,

Ct

hemopneumothorax

stricture

Result

respiratory

C2

level

with

quadriplegia

failure

splenectomy

+ RLL

CR

12b

LUL+RUL

PR

12c

RUL

CR

*Chest tCR,

x-ray PR:

film

complete

with and

air bronchogram. partial

re-expansu)n.

CHEST

I 97

Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1990 American College of Chest Physicians

I 2 I FEBRUARY,

1990

435

Arterial scopic

blsal

gas

I)rocedure,

chest

x-ray

values

then

were

checked

30 minutes, followed

examination

just

12 and after

SO()fl

before

24 hours the

the after.

bronchoA portable

procedure.

RESULTS

After

12

showed

the

of

5 and

the

x-ray

film

showed

collapsed

full

Case

after blood

the

third

gas

value

112.1

and and

In

bronchoscope, to a three-wa

MATERIALS Twelve for

patients

the

collapse

formed

before

during

The

were

not

the

mechanical

saline

sputum solution

then

ment

of the

airway

the previous

ranged

from

100 percent cedure.

The

four

all the

airway

Flu2

h mask.

The

vital

and

arterial

line

or frequent

visualized each

rapidly

insufflated to two

30 cmII2O, The

nonintubated

eight

duration

was

P(A-a)02

152.2

(Fig

collapse

to 30

86.5,

minutes,

declined

from

2). recurred

two

days

were

measurement

217.5

180

was

T

150.0

monitored

clear.

air into

the

keeping

or 10 cmIL,O

I

120

or subseg-

r(xm

the higher

average

14 procedures

patients the

received whole

as high h

“

normal

were

minutes,

given

±29.7

140

studies. with

airways

ofthe

the

connected

segment

during

were

patients

patients,

adaptor

intubated

ventilation patients

signs

at

airway

four

washing

for one

The

RUL

11 procedures

procedure

respectively The

and

12’s three

200

port

port

in previous

bronchial

and

by mechanical

other

I)erlPheral in the

hag pressure.

remaining the

case

above

per-

One

intubated

into

around

the

after the

±41.9

the

was adaptor

the

the

a swivel

bronchoscope

pressure

\Vhen

therapy

hag,

eight

done

sible

436

the

and

lobe

12,

obtained

sepsis.

160

as described

by Ambu

after. 150.0

the

to underlying

intensive

atelectasis.

transnasally

suctioning until

received

1).

ventilator

20 to 30 minutes. oxygen

Ambu monitor

(Fig

220

of lung

bronchoscope.

to

through

the

had

A three-way

by

performed In

hours

excluded

because

procedure.

used.

perfonned

collapsed

airways

peripheral than

was

wedged

selected

air

iflttll)ated. was

All

of the

gauge

mm

were

26 arte-

240

ICU

duration

of respirator

channel room

90.6

and

260

even

or surgical

1). The

to prevent

hours

air insufflation

bronchoscopy Repetitive

hours.

was

was

medical

bronchoscopic

suction

bronchoscopy

the

(Tal)le

120

fiberoptic

to a pressure

pressure

We

24

to introduce

connected

to

admission

to the

used

to

bronchoscope

connected

who

since another the

A fiberoptic was

24

care

collapsed,

to

conditions

from

or

before Hg,

24

METHODS

AND

admitted

critical

ranged

respiratory lung

were

different

same

of the

79.0

12, with

Their

they

excluding

Pa02

24

case

not

from

to 200.3,

217.5

plish the same results, obtaining the greater effect without any complications.

was

shock

P(A-a)O2

be due

to

After the

improved

a fiberoptic connected

thought

days

case

1).

and

and

six In

procedure.

worsened,

the 5 the

performed

of septic

of PaO2

procedure.

procedures,

included gauge were

value

12,

after

(Table

film two,

case

care. was

bronchoscopic

was

A blood

12,

completely

6 died

analysis

worsening

In

procedure

case

gas

the

from

in case

re-expansion

1 and

hours

procedure

pulmonary

bronchoscopic

x-ray

remaining

re-expansion.

reexpanded intensive,

immediate

Fi;uiw 1 . The whole apparatus an ambu hag and a pressure adaptor (arrow).

partial

lung

chest

in the

secondary

ofcontinuous, a third

the

reexpansion;

case

rial

14 procedures,

complete

ECG

by sphygomanometer.

-I,before

proas pos-

monitor

Fi:u,w

( P[A-a102) choscopic

2. The average improvement

ii

0

-

l2hr

30Mm

24hr

alveolar-arterial oxygen pressure difference during 24 hours following fiberoptic bron-

procedure.

Collapsed

Lung in Critically

Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1990 American College of Chest Physicians

III Patients

(Tsao

et a!)

after two

the first further

In case

bronchoscopic

procedure.

procedures

8, the

with

LLL

collapse

recurred

repeat bronchoscopic procedure but was refused by the patient. at discharge

four

weeks

He underwent

Harada

reexpansion.

reexpanded

subsequent

six days

later.

A

was recommended This lesion remained

Collapsed

later.

lung

is one

of the

ill patients, and rapidly. Treatment

optic

bronchoscopic

introduced

procedure

and

good

at

results

studies.#{176}5’9This therapeutic itive sputum suctioning normal saline solution; sion of atelectasis was the

important

problems

in

the clinical condition with a therapeutic the

were

and

procedure bronchial

complete attained

may fiber-

bedside

reported

was

in many

includes washing

sure,

volume

and the relationship:

T-alveolar

repetwith

or partial re-expanin 60 to 90 percent of

decreases, alveolar P’r

surface

=

the alveolar

tension,

is profound,

sion

can

not

and

the

alveolar

r’-alveolar

critical lower

the reduction the reduction

overcome

pressure

will

opening pressure lung compliance.

into

But

the

atelectatic

to be distributed oflower airway

rise

and

radius).

In order alveoli

designed

create

In

a higher alveoli and are espe-

area of collapse. pressure of the to overcome the

refractory after the

atelectasis do above broncho-

It would be useful if we could pressure ventilation directly into to overcome the critical opening

if we

can

not

alveoli,

suffiate

the

into the noncollapsed resistance and higher

to introduce

the

insufilated

This will result in a hyperinflated which in turn will compress the tatic

air

lung

each close

still we

damage

to the

sure

air selectively

into

lung area. the

and devices bronchoscope

complex and simply wedged

segment or subsegment the bronchus.

not the of the

gauge

seven

lobe

of

had

to the

but

our

to

14

been

were

and

10 cm H20 during air to overcome

than

lung.

All

of

ob-

was

it

higher than insuffiation. the critical

in complications hemorrhage. the

duration

48 hours.

the

no H20;

study the by a pres-

bronchoscope

procedures,

more

dogs

30 cm

alveoli

did not result or pulmonary

cm

found

above

of

In nine,

areas were limited to one lobe. x-ray film showed air bronchograms

collapsed

the

In three, in the

conditions

were

documented to be handicaps to reexpansion of atelectasis in previous studies. “‘s The collapsed lung reexpanded completely soon after 12 ofthe bronchoscopic in two. Arterial blood gas

procedures, values following

and partially the proce-

dure showed apparent improvement of P(A-a)O2 in all. No significant complications from these 14 bronchoscopic procedures, transient

tachycardia

some

or

Manni care had

et al’ described the same effect

compared our cases injury.

developed

in

that intensive respiratory on acute lobar collapse when

with bronchoscopic suffered from chest

These

intolerance cases were

cases

were

procedures, but half of trauma or spinal cord

excluded

from

his

of respiratory care. Moreover, in critical condition and might

could

not

correct we

the

a new

selective

We just

wedge

or subsegment the

pulmonary

suggest

to introduce

ventilation.

were

hypertension

Pa02 and resulted although

cases.

of using

were with

and

of

30 cm H20, or airway pressure was high enough

20

fluoroet al5

of adult

under

bleeding

connected

opening pressure, such as pneumothorax

segment atelec-

lung

tracheostomy

at pressures and

about during Mutsuda

under 60 cm H20. So, in this airway pressure was monitored

method

readily available. bronchoscope into collapsed

lungs

barely

ventilation

under

in the

after

lung

pressure

observed surgery.

pressure

immediately. In conclusion,

area

atelectatic

tube when or

trachea

rupture

served peripheral

if we

tend

areas because compliance.

normal collapsed

only, a few methods using a rigid or fiberoptic

directly

air will

a balloon cuff. After the bronchoscope was introduced into the collapsed lobar bronchus, the cuffwas inflated to close the bronchus during air insufflation. Although these special devices obtained good results, they are Therefore,

the

atelectatic the chest

to lower the in surface radius and But if the

in the atelectatic The above findings

These even

scopic procedures. introduce positive the collapsed area pressure.

positive

through however,

the

positive

endotracheal

exerted

collapse

in surface tenin alveolar radius,

cially common in cases with a small In these cases, the transpulmonary atelectatic alveoli is often too low critical pressure.”’3 not easily re-expand

radius

pressure rise according 2 T/r (PT-alveolar pres-

these conditions, the surfactant will work alveolar surface tension; this reduction tension offsets the reduction in alveolar prevents alveolar pressure from rising. atelectasis

the

In

the lung

will decrease to Laplace

through

kept around the previous This pressure

cases.”6’7’#{176} When

that

following

H2O airway pressure scopic roentgenograms

DISCUSSION

critically worsen

et al stated

balloon

cuff

simpler,

effective positive

the bronchoscope

into

collapsed

to close even

the

for

impairment

intrabronchial

of the

no complications

study

all of our not survive

lobe bronchus.

in critical

each

instead There

cases.

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L.ung in Critically

Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1990 American College of Chest Physicians

and

III

Patients

(Tsao et a!)

Treatment for collapsed lung in critically ill patients. Selective intrabronchial air insufflation using the fiberoptic bronchoscope. T C Tsao, Y H Tsai, R S Lan, W B Shieh and C H Lee Chest 1990;97; 435-438 DOI 10.1378/chest.97.2.435 This information is current as of July 10, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/97/2/435 Cited Bys This article has been cited by 3 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/97/2/435#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.

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