Open Pneumothorax Research Articles

Historical development of pulmonary surgery

W HEN in the second haIf of the Iast century a new, important phase in the deveIopment of surgery dawned-when the introduction of anesthesia, of antisepsis and asepsis, new discoveries in anatomy and physioIogy, and deveIopments in pathoIogic anatomy finaIIy ushered in the “golden age of surgery”operative technic was aIready estabIished on a fairIy sound basis. OnIy the endothoracic organs remained an area of which surgeons stiI1 fought shy. True, there are cases reported by surgeons of the MiddIe Ages and the Renaissance in which resection of the puImonary tissue was performed. Back in the thirteenth century RoIando of SaIerno removed the gangrenous part of a Iung that had proIapsed as a resuIt of an injury to the thoracic waI1. In the seventeenth century, under simiIar conditions, Fabricius HiIdanus performed puImonary resection with a red-hot iron. Yet in the numerous descriptions of thoracic and pulmonary injuries contained in the surgica1 Iiterature of the Ancients and of the MiddIe Ages, there is not one mention of pneumothorax and seIdom of subcutaneous emphysema. This is a sign that cIinica1 observation in those days, aIthough we11 advanced in other respects, stiI1 feIl short when it came to studying intrapIeura1 diseases, or else perhaps, was of no practica1 interest for lack of the means to treat such cases. Even the treatment of empyema-one of the outstanding achievements of the Alexandrine schoo1 of surgery-had so fallen into disrepute that Dupuytren (1777-1835), enterprising surgeon though he was, refused to aIIow this operation to be performed on himseIf. thorax, refused to remove the spear point from his breast unti1 he Iearned that the Thebans had won the day. Even in the earIy days of the first World War the ruIe was stiI1 not to intervene in such cases, and the reaIization that it was enough to transform an open pneumothorax into a closed one to remove a11 immediate danger only sIowIy found acceptance. MeanwhiIe the reticence shown toward open thoracotomy gave pIace to an important advancement which fifty years Iater was to become one of the cornerstones of the postoperative treatment of intrathoracic interventions. In 1876 BtiIau, a Hamburg physician, introduced the method of subaqueous drainage into the treatment of empyema. This he was induced to do by the unfavorabIe experiences encountered in performing open thoracotomy in chiIdren. His work shows that he had a cIear conception and understanding of the dangers of the open pneumothorax, and from this time onward surgeons reaIized the need to reduce or eliminate these dangers during and after intrathoracic interventions. The immediate effect of this realization was, admittedIy, to hamper rather than to assist. The dangers of opening the pIeura were grossly overestimated; and although in 1884 KrfinIein, a Swiss surgeon, performed resection of a lung, manv vears went by before others foIIowed suit. It \;a; not until the turn of the century that isoIated cases were reported (by Murphy, Tuffrer, Heidenhain, KBrte, GarrC: and Quincke, Len hartz and others).

ANESTHETIC MORTALITY IN INTRATHORACIC SURGERY

DURING past thirteen years rapid advancement has been made in the surgical management of intrathoracic lesions. In 1933 Graham1performed the first successful removal of the entire lung for carcinoma of the bronchus. Adams and Phemister2made the first successful one stage resection of the lower part of the esophagus and esophagogastrostomy for carcinoma performed through the thorax in 1938. Gross3in 1939 reported closure of a patent ductus. Crafoord and Nylin4in 1944 were the first to relieve successfully the ill effects of coarctation of the aorta by resection and anastomosis. Blalock and Taussig5in 1944 performed the first operation in human beings for the correction of pulmonary stenosis. Intrathoracic surgery is accompanied with many unusual surgical and anesthetic hazards. The dangers of an open pneumothorax were understood by Andreas Vesalius,6who in 1555 demonstrated to his students at Padua not only the

Anæsthesia in Chest Surgery, with Special Reference to Controlled Respiration and Cyclopropane

Problems in chest surgery: Cases with prolonged toxæmia or amyloid disease require an anæsthetic agent of low toxicity. When sputum or blood are present in the tracheobronchial tree the anæsthesia should abolish reflex distrubances and excessive sputum be removed by suction. The technique should permit the use of a high oxygen atmosphere; controlled respiration with cyclopropane or ether fulfil these requirements. Open pneumothorax is present when a wound of the chest wall allows air to pass in and out of the pleural cavity. The lung on the affected side collapses and the mediastinum moves over and partly compresses the other lung.The dangers of an open pneumothorax: (1) Paradoxical respiration-the lung on the affected side partially inflates on expiration and collapses on inspiration. Part of the air entering the good lung has been shuttled back from the lung on the affected side and is therefore vitiated. Full expansion of the sound lung is handicapped by the initial displacement of the mediastinum which increases on inspiration. The circulation becomes embarrassed.(2) Vicious circle coughing. During a paroxysm of coughing dyspnœa will occur. This accentuates paradoxical respiration and starts a vicious circle. Death from asphyxia may result.Special duties of the anæsthetist: (1) To carry out or supervise continuous circulatory resuscitation. During a thoracotomy a drip blood transfusion maintains normal blood-pressure and pulse-rate.(2) To maintain effcient respiration.Positive pressure anæsthesia: Risk of impacting secretions in smaller bronchi with subsequent atelectasis; eventual risk of CO(2) poisoning without premonitory signs.Controlled respiration: (1) How it is produced. (2) Its uses in chest surgery.Controlled respiration means that the anæsthetist, having abolished the active respiratory efforts of the patient, maintains an efficient tidal exchange by rhythmic squeezing of the breathing bag. This may be done mechanically by Crafoord's modification of Frenkner's spiropulsator or by hand.Active respiration will cease (i) if the patient's CO(2) is lowered sufficiently by hyperventilation, (ii) if the patient's respiratory centre is depressed sufficiently by sedative and anæsthetic drugs, and (iii) by a combination of (i) and (ii) of less degree.The author uses the second method, depressing the respiratory centre with omnoponscopolamine, pentothal sodium, and then cycloprȯpane. The CO(2) absorption method is essential for this technique, and this and controlled respiration should be mastered by the anæsthetist with a familiar agent and used at first only in uncomplicated cases.The significance of cardiac arrhythmias occuring with cyclopropane is discussed.The place of the other available anæsthetic agents is discussed particularly on the advisability of using local anæsthesia for the drainage of empyema or lung abscess.Pharyngeal airway or endotracheal tube? Anæsthesia may be maintained with a pharyngeal airway in many cases but intubation must be used when tracheobronchial suction may be necessary and when there may be difficulty in maintaining an unobstructed airway.A one-lung anæsthesia is ideal for pneumonectomy. This may be obtained by endotracheal anæsthesia after bronchial tamponage of the affected side (Crafoord, v. fig. 6b) or by an endobronchial intubation of the sound side (v. figs. 9b and 9c). Endobronchial placing of the breathing tube may be performed "blind". Before deciding on blind bronchial intubation, the anæsthetist must examine X-ray films for any abnormality deviating the trachea or bronchi. Though the right bronchus may be easily intubated blindly as a rule, there is the risk of occluding the orifice of the upper lobe bronchus (fig. 9d) when the patient will become cyanosed. If the tube bevel is facing its orifice the risk of occlusion will be decreased (fig. 9c).Greater accuracy in placing the tube can be effected by inserting it under direct vision. Instruments for performing this manœuvre are described.In lobectomy for bronchiectasis the anæsthetist must try to prevent the spread of infection to other parts. Ideally, the bronchus of the affected lobe should be plugged with ribbon gauze (Crafoord, v. fig. 6c) or a suction catheter with a baby balloon on it placed in the affected bronchus. In the presence of a large bronchopleural fistula controlled respiration cannot be established during operation. As the surgeon is rarely able to plug the fistula, if pneumonectomy is to be performed intubation for a one-lung anæsthesia is the best method. During other procedures it is essential to maintain quiet respiration.In war casualties it is almost always possible, with the technique described, to leave the lung on the affected side fully expanded and thus frequently to restore normal respiratory physiology. Co-operation between surgeon and anæsthetist is essential.

Bullous Emphysema(?) or Bilateral Pneumothorax(?)

Acknowledgment We are prompted to write this article because of a paper entitled “Chronic Bilateral Spontaneous Pneumothorax” recently published by Joseph Lewis (1). Lewis describes a case in which the clinical and x-ray findings justified a diagnosis of chronic bilateral spontaneous pneumothorax. He made an exhaustive search of the literature and was unable to find a like case. We have had the privilege of observing two such cases; in the first one we made a diagnosis of bilateral pneumothorax, but after further experience with the second case, after familiarizing ourselves with the physiologic factors concerned, and after a review of the literature, we came to change the diagnosis to that of bullous emphysema. The experiences of Haahti (2) proved especially illuminating to us in this respect. Physiological Considerations.—The laws governing the diffusion of gases in a closed body cavity are such that a closed pneumothorax cannot persist without marked contraction of the affected side of the chest. When the spontaneous pneumothorax first occurs, the partial pressure of the gases in the cavity is the same as that in the atmosphere and much greater than that of the gases in the blood and tissues. There immediately begins a diffusion of the gases from the pneumothorax into the blood, with a progressive drop of pressure in the pneumothorax cavity. Only after the pressure drops to about 95 cm. of water below atmospheric pressure will there be an equilibrium established so that further absorption will not occur (3). As a result of the low pressure in the pneumothorax, the overlying chest wall is compressed and the abdominal viscera are crowded upward by the atmospheric pressure. In the cases reported by Lewis and Haahti as well as in our own two cases, there were no signs of contraction of the chest, and the pressure in the air chambers was not much below atmospheric. These findings alone are sufficient to rule out pneumothorax. Even open pneumothorax leads to contraction of the chest unless the outside opening be larger than the glottis, which is hardly compatible with life. Moreover, an open pneumothorax invariably becomes infected and fluid develops in it. In the cases under discussion, there were no symptoms of sepsis and no fluid in the air chambers. Lewis' Case.—A man aged 49 years had been developing increasing dyspnea for 7 years, and had been treated for asthma. There was hyperresonance over the upper lobes and no vesicular breath sounds. The x-ray appearance resembled closely that of our Case 1. There were no lung markings above the level of the third anterior rib on each side, suggesting bilateral pneumothorax. However, collapsed lungs do not show at the lung roots, and there can be seen no line of separation of the lung from the chest wall.

A RECONSIDERATION OF THE QUESTION OF THE EFFECTS OF AN OPEN PNEUMOTHORAX

One of the most fundamental necessities for the progress of thoracic surgery is a better understanding of the physiology involved. Of the physiologic problems, there is none more important than an accurate knowledge of just what happens when an opening is made in the chest. The effects of open pneumothorax, therefore, should be studied and discussed until as much knowledge as possible has been obtained on this subject. My reason for presenting the matter again is chiefly to encourage a more accurate study of the problem and to dispense with much of the conjecture which exists in the literature. In 1918, in association with R. D. Bell, 1 I reported the results of experiments both on human cadavers and on animals which seemed to change the existing conceptions of the effects of an open pneumothorax. The most important finding in our experiments was that in a normal thorax, one in

BELGIUM

<h3>Dyspnea and Pneumothorax</h3> At a recent meeting of the Academy of Medicine, Dautrebande and Spehl presented an important study on the causes of dyspnea and of death in open pneumothorax. They conclude that surgical pneumothorax induces dyspnea owing to anoxemia, and that this condition, characterized mainly by a superficial and rapid respiration that soon becomes dangerous, can be combated by the administration of oxygen. <h3>Spermatic or Seminal Cysts</h3> Before the Belgian Urologic Society, Dr. Cantinaux presented recently the results of his researches on the origin of bilateral spermatic cysts, and discussed their relationship with syphilis. <h3>Drainage in Empyema</h3> Speaking before the Belgian Surgical Society, Willems stated that he had tried several times reversible drainage, but that he had obtained only mediocre results; for generalized purulent pleurisies, at least, he regards it as insufficient. In the case of patients confined to the bed, he performs a posterior thoracotomy (Walther method) in

SCOLIOSIS ACCOMPANYING CHRONIC INFECTED OPEN PNEUMOTHORAX: ITS CAUSATION AND CORRECTION

Long-continued suppuration of large cavities in open pneumothorax is followed by a deviation of the spine to the healthy side. During the last two years, I have had an unusual opportunity to study this type of case. 1 As a result of these observations, I believe it has been demonstrated that the cause of the scoliosis in these cases is pressure, due to the ribs on the diseased side, proof of which is afforded by the effect of extensive thoracotomy in correcting the deformity. When the lung is firmly held in a collapsed state by the dense enveloping membrane, which develops in long standing cases of large empyema cavities, nature attempts to obliterate the dead space by approximating the chest wall to the fixed lung. The anterior extremities of the ribs fall, making their horizontal direction more vertical; the intercostal spaces become obliterated, and in very long standing cases, such

THE NEGATIVE CHAMBER IN OPEN PNEUMOTHORAX

Open pneumothorax is the complete, sudden collapse of the lung which inevitably occurs when an operation requires the wide opening of the chest wall, in the absence of adhesions between visceral and costal or diaphragmatic pleura, or when an attempt is made to drain the chest after the method employed in other parts of the body. The importance of preventing this physical phenomenon was fully realized by Dr. Matas more than twenty years ago, when, as one of the pioneers in the field of thoracic surgery in America, he had his assistant, Dr. Parham of New Orleans, excise a tumor of the chest wall with the help of a differential pressure apparatus, the Fell-O'Dwyer combination, as modified by Matas. Ever since that time, open pneumothorax has been a topic for discussion. Our association considered it, at the second annual meeting, in 1919, when the president's address, which dwelt on the

A CLOSED SYSTEM OF DRAINAGE FOR PENETRATING WOUNDS OF THE CHEST

No satisfactory system of drainage for infected war wounds of the chest has been employed that does not produce a more or less open pneumothorax. It is well known that open pneumothorax seriously disturbs the mechanics of respiration and circulation, and exposes large areas of pleural membrane to infection. It is well known also that open pneumothorax is very seldom cured spontaneously. Recent war surgery has demonstrated satisfactorily that the pleura is able to overcome a very extensive contamination and even a severe infection in a comparatively short time. But to do so the pleura must be in practically a normal condition otherwise, that is, free from accumulations of air or fluid. Patients operated on early and left with open drainage invariably have done badly. Patients not operated on have developed empyema or become septic. The middle ground offers the best chance, and patients operated on at a selected time

Treatment of Open Pneumothorax by Immediate Suture of the Thoracic Wall

Treatment of Open Pneumothorax by Immediate Suture of the Thoracic Wall

THE STATUS OF RESPIRATION IN THE METHODS OF DIFFERENTIAL PRESSURE COMPARED WITH THAT UNDER THE METHOD OF INTRATRACHEAL INSUFFLATION

The maintenance of life of an individual with an open double pneumothorax under differential pressure depends essentially upon the normal position of the lower lobes of the lungs and their close approximation to the diaphragm, especially of the posterior parts of the lobes. A complete dislodgment of both lower lobes leads invariably to the death of the individual, which may occur in a very short time, or after fifteen to twenty-five minutes. In all cases the respiration is affected first; it slows almost at once and stops invariably before the heart. The result is the same whether the vagi are intact or both nerves are cut. Exceptionally, respiration may continue even after the separation of the lungs from the diaphragm, but only by having all the lobes well approximated to the thoracic walls. When by dislodgment of the lower lobes the respiration is stopped and the heart is feeble and slow, or stopped completely, it is rarely possible to restore life by artificial respiration or by other appropriate means. The extent of the exchange of gases occurring in normal respiration, with closed thoracic cavity, exceeds greatly the need for the maintenance of life, since normal respiration is provided with an abundance of factors of safety. Under differential pressure, however, life is carried on with an exchange of gases which amounts to a small fraction only of the extent of the exchange that takes place in normal respiration; respiration under differential pressure is, therefore, deprived of all factors of safety and is incapable of resisting the dangers of exceptional incidents. Deaths occurring in connection with the differential pressure have their cause essentially in this unguarded state of the function of respiration. Under tracheal insufflation, the function of respiration is surrounded with effective safeguards, at least as much as is normal respiration. Dislodgment of the lungs has no detrimental effect. After complete collapse of the lungs, capillary adhesions within the alveoli and the small bronchi become an additional obstacle to the redistension and respiration. Differential pressure holds this obstacle in abeyance. When the lungs become collapsed during an open pneumothorax, it should be kept in mind that the force which is required for redistension is greater than that which is sufficient to keep the lungs continually distended. At the beginning of a redistension, therefore, a higher pressure should be employed for a short time.

PNEUMOTHORAX AND POSTURE

THE LAST MENTIONED FACT MAY PERHAPS FIND ITS EXPLANATION IN THE FOLLOWING STATEMENTS: the two pleural cavities are separated by the layers of the anterior and posterior mediastinal septa. Between the two lies the heart. In the dog, the posterior seems to be somewhat tougher than the anterior septum, and somewhat more fixed and tense. With violent respiratory movements, it is the anterior septum which more especially flaps to and fro and bulges when an opening in the pleura has been made, and it is the anterior septum which is so apt to rupture and thus cause double pneumothorax and the death of the animal. When the dog is on its back, the heart falls backward and the bulging of the anterior mediastinal septum is made more easy. It is different when the animal is on its belly. The heart falls toward the anterior chest wall and thus supports the anterior septum: hence the flapping of the septum, the interference with the respiration of the lung on the sound side, the bulging on expiration on the open side, can not so readily occur. The danger of the open pneumothorax is greatly lessened when the animal is in the prone position. In the supine position the danger of the pneumothorax is due to the falling back of the heart and thus facilitating the rupture of the fragile anterior mediastinal septum; the danger is therefore obviated by fixing the pericardium to the anterior wall of the thorax.

Pneumothorax and posture

The sudden entrance of air into the normal healthy pleura often gives rise to a train of grave symptoms. These symptoms have been studied experimentally in dogs. Most of the animals died from the pneumothorax when a large opening was made. Gluck lost all of the dogs he used; Biondi lost 4 of 5; Block, Marcus, Schmidt, Pourrat and Rodet, Tuffier, Murphy, Quenu and Longet, had similar experiences.In some recent experimental investigations of open pneumothorax I obtained similar results. Many of the dogs either died suddenly as soon as an opening into the pleura was made, or a violent expiratory dyspnea ensued, soon followed by rupture of the mediastinal septum, double pneumothorax, and death. The method of operating on the dogs was the following: The animal was given a hypodermic injection of morphin, and a few hours later was anesthetized with ether; tracheotomy was performed, a cannula inserted, and the administration of ether continued through the cannula. One or more ribs were resected, the intercostal ...

Valsalvaʼs Experiment in Open Pneumothorax after Costal Resection as a Measure of the Expansibility of the Lungs

Valsalvaʼs Experiment in Open Pneumothorax after Costal Resection as a Measure of the Expansibility of the Lungs