bronchography with hytrast - thoraxithorax(1964), 19, 37 bronchography with hytrast b. t. le roux...

iThorax (1964), 19, 37

Bronchography with HytrastB. T. LE ROUX AND J. G. DUNCAN

From the Thoracic Surgical and Radiodiagnostic Departments, The Royal Infirmary, Edinburgh

Contrast media which outline tube systems arewell established radiodiagnostic adjuncts. Tech-niques and media may be changed both to increasethe margin of safety for the patient and to improveradiographic contrast. In the radiographic demon-stration of bronchi, early techniques, such as theinsufflation of barium powder through a broncho-scope (Jackson, 1918) and the instillation of oilysuspensions of bismuth, were quickly discarded asdangerous. Iodized poppy-seed oil (Lipiodol) wasthe first practical bronchographic agent (Sicardand Forestier, 1922) and was the only mediumin general use for many years. The main disadvan-tage of Lipiodol was its long retention in pul-monary parenchyma in a radio-opaque form,especially where alveolar spill had occurred, sothat the interpretation of serial radiographs usedto demonstrate the progress of a pulmonary lesionwas complicated. A granulomatous reaction to theoil was also an occasional occurrence.Dormer (1940) used Lipiodol as a vehicle for

the introduction of sulphanilamide powder intothe bronchi as a topical therapeutic agent in thecontrol of bronchial infection. The sulphonamideincreased the viscosity of the iodized oil, and itwas soon recognized that by its addition alveolarspill was diminished, contrast was greater becausethe oil was less widely dispersed, and more com-plete post-bronchographic evacuation of thecontrast medium was achieved by coughing, sothat subsequent chest radiographs commemoratedless frequently and grossly previous broncho-graphic attempts. The combination of 8 g. ofsulphanilamide powder with 20 ml. of Lipiodolwas used for bronchography in the ThoracicSurgical Unit in Edinburgh between 1950 and1955. Some 800 bronchograms were made. Twopatients experienced such severe dyspnoea as aconsequence of bronchial obstruction by theviscous material that they very nearly suffocated,and in a third patient the subsequent developmentof acute nephritis was related to bronchography.Other complications were not encountered, and75% of the bronchograms produced were then

regarded as satisfactory. In a more critical retro-spective evaluation of these bronchograms fiveyears later (le Roux, 1962), it was thought thatthere was justification for dissatisfaction in 45%rather than 25% of the bronchograms. Improve-ment in bronchographic technique had made un-acceptable that which in the past had beenregarded as adequate. With more general use ofthe combination of sulphonamide with Lipiodol,marketed as Visciodol (Burrascano, 1955 ; Johnsonand Irwin, 1959), the hazards of sensitivity tosulphonamide, of the formation of methaemo-globin, and of widespread bronchial obstruction bya too viscid preparation became apparent.

In the attempt to obviate these disadvantages,water-soluble media were prepared. The first ofthese was diodone, combined with a thickeningagent such as carboxymethylcellulose or polyvinylpyrrolidone. This contrast medium proved clinic-ally unacceptable because it was excessively irri-tating to the bronchi. In 1953 a new compound,propyliodone, was described. It was originallyintroduced as an aqueous suspension (DionosilAqueous) for which the advantages of rapid dis-appearance from the lungs and relative freedomfrom the risks of iodism were claimed. Its usewas, however, often followed by a febrile reactionin the patient and, although isotonic with bodyfluids, it also proved irritating to the bronchialmucosa. The hazards of local anaesthetic side-effects were enhanced because of the need tosuppress more effectively the cough reflex withlarger doses of topical anaesthetic. Propyliodonein arachis oil (Dionosil Oily) was then introducedas an alternative to the aqueous suspension, andthis was shown to be less irritating and, on serialradiographs, was rarely retained in the bronchi oralveoli for longer than 48 hours. In Edinburghafter 1956 the oily suspension of propyliodone wasadopted almost routinely as a bronchographicmedium. While radiographic contrast was oftenless effective than with sulphanilamide powder iniodized poppy-seed oil, reactions were notobserved, and the standard of bronchography was

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B. T. ke Roux and J. G. Duncan

regarded as adequate. When bronchography wasfollowed by pulmonary resection, granulomatousreaction to the oily vehicle was not observed.

In 1957 a technique of bronchography inchildren was developed (le Roux and Masson,1962) which, since 1961, has been adopted for allpatients, children and adults, who require broncho-graphy. This technique depends on general anaes-thesia with sodium thiopentone and a relaxant(suxamethonium). After induction of anaesthesiaand inflation of the lungs with oxygen deliveredthrough a face-piece, the bronchi are examinedunder direct vision. On completion of broncho-scopy the lungs are again inflated with oxygen,and a cuffed endotracheal tube is introducedunder direct vision into the trachea. The cuff ofthe tube is inflated and the endotracheal tube con-nected to a Boyle or similar machine. Inflation iscontinued with oxygen or oxygen and nitrousoxide. The patient is then turned on his right side,lies on an x-ray cassette, and the x-ray tube anodeis positioned. A catheter is passed through theendotracheal tube and, from a 20 ml. syringe, thecontrast medium is injected rapidly into thetrachea. The rubber bung of the Magill T-piece isreplaced, and the lungs are inflated for fivebreaths. Inflation is forceful since it is by pul-monary inflation that the contrast medium isblown into the dependent lung. The radiographicplate for the right lateral bronchogram is thenexposed, the patient turned on to his back, asecond cassette placed under him, and an antero-posterior view of the right side made. During themoment of radiographic exposure the anaesthetistholds the lungs inflated to depress the domes ofthe diaphragm. The same procedure is thenadopted for the left side, where an oblique and nota lateral view is made. The entire procedure, in-cluding bronchoscopy, occupies usually less thanfive minutes, and it is rarely necessary to injecta supplementary dose of relaxant. The anaesthetisthas full control of ventilation except during bron-choscopy, and the technique of bronchography byinsufflation, as opposed to a technique whichdemands changes in posture, is time-saving.Tracheo-bronchial toilet at the end of the pro-cedure usually results in the elimination by suctionof a considerable volume of the contrast medium.Another feature of this technique of broncho-graphy is that it has removed from the investiga-tion all element of mystique. The need for posi-tioning the patient at a number of arbitrary anglesfor arbitrary periods of time lent, for the uniniti-ated, an air of profundity to the experienced bron-chographer. And there are no longer thosemoments of suspense while the radiographs are

being developed and before the scrutiny of whichit was not known how complete a bronchogramhad been achieved or whether only an outline ofthe oesophagus would be visible. The insufflationtechnique is precisely definable in terms of posi-tion, either right or left lateral, and number ofpulmonary insufflations with the patient paralysed.This technique produced uniformly satisfactorybronchograms with the oily suspension of Dionosil.More than 500 bronchograms were made andfewer than 2% were inadequate for reaching adecision on management of the patient.At the end of 1962 the Thoracic Surgical Unit

and the Department of Diagnostic Radiology atthe Royal Infirmary in Edinburgh were asked toassess the value of Hytrast' as a bronchographicmedium. Hytrast is an opaque white suspensionwith a pH of about 7, obtained by the dispersionof a mixture of fine crystals (2-5 microns) ofN(propyl-2: 3-diol)-3:5 diiodo-4-pyridone and3: 5-diiodo-4-pyridone in a slightly hypotonicaqueous solution of sodium carboxymethylcellu-lose. These compounds differ from propyliodoneand diodone in that they are not esters and donot have labile functional groupings. Esters hydro-lyse in the bronchi and produce acidic ions whichare thought to be responsible for the local irritantproperties of diodone and propyliodone. Theiodine concentration in Hytrast (05 g. /ml.) isgreater than in propyliodone (0-28 g. /ml.) so thatradiographic contrast should be increased, and,being chemically relatively inert, Hytrast shouldexcite little in the way of reaction in the bronchi.In mice, oral feeding produces evidence neither ofacute nor of chronic toxicity. Both in experimentalanimals and in clinical practice elimination fromthe bronchi is rapid, two to seven days, and in-flammatory or granulomatous reaction has beenobserved neither in experimental animals norclinically in operative specimens removed afterbronchography with Hytrast.

Hytrast was used as the bronchographicmedium in 50 consecutive investigations. Inchildren the quantity of contrast used wascalculated from the age of the patient plus 2 ml.for each side; in adults 15 to 20 ml. was used foreach side.

Five patients in the series of 50 had previouslybeen submitted to bilateral bronchography and re-quired repetition of this investigation. In four, theprevious examination had been with Dionosil Oilyand in one with sulphanilamide powder inLipiodol. In all five, good bronchograms wereachieved, and in all, contrast was improved in

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FIG. 1. Bilateral antero-posterior bronchogram madewith Dionosil Oily in 1960 for a girl then aged 14 yearswho was shown to have left basal and lingular bronchiecta-sis. The bronchiectatic segments were resected.

FIG. 4. Bilateral antero-posterior bronchogram made in1954 for an adult male patient with haemoptysis. The con-trast medium was Lipiodol with sulphanilamide powder.

FIG. 2. Routine post-operative bilateral antero-posteriorbronchogram made with Dionosil Oily a year later for thegirl whose pre-operative radiograph is shown as Fig. 1.

FIG. 5. In thepatient whose earlier bronchogram is shownas Fig. 4, haemoptysis recurred in 1963 and broncho-graph,v was repeated. Here the contrast medium is Hytrast.Peripheralfilling and contrast are good. In this radiographthere are reflected improvements in both bronchographictechnique and radiographic contrast. The bronchogramshown as Fig. 4 was acceptable at the time when it wasmade and would now, 10 years later, be entirely unaccept-able.

FIG. 3. Bilateral antero-posterior bronchogram made in1963 for the girl whose earlier films are shown as Figs. 1and 2. This further bronchogram was prompted by thecomplaint ofa single small haemoptysis,for which no causewas found at bronchoscopy. Hytrast was used for thebronchogram. Contrast is improved in comparison with thetwo earlier radiographs; there is no alveolar filling; rightsupra-phrenic filling is deficient.



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FIG. 6. In this bronchogram the contrast medium used onthe right was Dionosil Oily and that used on the left wasHytrast. The right bronchogram was made first and thisradiograph was the last offour in this patient, so that thecontrast medium in the right lung has been distally pro-pelled byfive pulmonary insufflations for the right broncho-gram and 10 for the left.

FIG. 7

FIGS. 7, 8, and 9. In these bronchograms the contrastmedium used on the right was Hytrast and that on the leftDionosil Oily. The right side was filled first, and, despite15 pulmonary inflations by the time these films were made,there is no alveolarfilling on the right. In Fig. 7 the rightposterior segmental bronchus is bronchiectatic.

FIG. 8

FIG. 9

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comparison with previous bronchograms (Figs.1 to 5).

In 20 patients, Hytrast and Dionosil Oily werecompared, in 10 by using Dionosil for the rightbronchogram and Hytrast for the left, and in 10by using Hytrast for the right and Dionosil forthe left. In every instance the right bronchogramwas made before the left. It was realized that resi-dual contrast medium in the trachea would becarried into the left bronchi so that a smallquantity of whichever contrast medium was firstused would be mixed with the contrast mediumused for the left bronchogram. In all 20 broncho-grams Hytrast, whether used for the right or theleft side, produced a bronchogram in which con-trast was better, alveolar filling was absent, andwhich was generally more pleasing, probably be-cause the bronchi were outlined rather than filled.The capacity of Hytrast to outline rather than fillbronchi is attributed to the viscosity of theexcipient (carboxymethylcellulose) (Figs. 6 to 9).

In some of the earlier bronchograms made withHytrast peripheral bronchi were incompletelyoutlined. This defect was quickly remedied by theanaesthetist inflating the lungs 10 times for eachside as opposed to five times for a bronchogram

FIG. 11

FIG. 10

FIGS. 1O, 11, and 12. Right lateral, antero-posterior, andleft oblique views; a complete bronchogram made withHytrast to which sterile water had been added in theproportion 20 ml. Hytrast: 1 ml. water. Peripheral fillingof the bronchi without alveolarfilling is good and contrastis satisfactory. Filling is uniform throughout the lungfields, and this is afeature ofbronchography by insufflationunder general anaesthesia with a relaxant. In patients withnormal bronchi this is the sort of bronchogram which canbe made routinely. FIG. 12

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with Dionosil Oily. If 1 ml. of sterile water isadded to each 20 ml. of Hytrast a bronchogram ofexcellent contrast without alveolar fiSling is -achieved with inflation of the lungs seven times ;for each side. Consistently good peripheral fillingwithout loss of contrast was demonstrated bymaking 10 bronchograms with Hytrast diluted inthe ratio 20 ml. Hytrast: I ml. water (Figs. 10 to12). In a further 10 patients Hytrast alone wascompared with Hytrast diluted in the previouslymentioned ratio with water; in five of these 10, :_.; _ -undiluted Hytrast was used on the right and thediluted suspension on the left, and in the other five ;-this relation was reversed. That some of the con-trast used for the right bronchogram would ;remain in the trachea and be carried into the leftside when the left bronchogram was made wasagain realized, but in all 10 bronchograms it wasclear that with inflation of the lungs seven timesfor each side a more complete bronchogram withgood peripheral filling was achieved without lossgodcontrastwiphera ilutgwasachievedwitrast(Fig. a FIG. 14. In this bronchogram dilute Hytra.st was used onof contrast with the diluted Hytrast (Figs. 13 and the right and undiluted Hytrast on the left; the right side14). Dilution of Hytrast has now been adopted was filled first. It is again clear that peripheral filling is

improvedby dilution of the Hytrast without loss ofcontrast.

routinely since it shortens the duration of the pro-cedure and decreases the number of relativelyforceful inflations of the lungs required for a goodbronchogram. Dilution may be unnecessary whenbronchograms are made under local anaesthesiawith an aspiration rather than an insufflation tech-nique. When Hytrast was diluted in the ratio20 ml. Hytrast :2 ml. water, contrast wasdiminished and alveolar filling was produced withinflation of the lungs five times for each side. Thiswas demonstrated in five bronchograms (Fig. 15).

In 35 of the 50 patients there were traces ofHytrast visible on chest radiographs made 48hours after bronchography, and in 15 there wasno trace. Of the 35, all but five had clear chestfilms four days after bronchography. In onepatient with gross bilateral bronchiectasis Hytrastwas present in a chest radiograph made nine days

_ after bronchography but had disappeared at 27days. It may have disappeared earlier, but it wasinconvenient for the patient to attend for chestradiography between the ninth and the twenty-

FIG. 13. In this bronchogram Hytrast was used on the seventh days after bronchography. Hytrast hadright, and on the left Hytrast diluted 20 ml: 1 ml. water, cleared in the remaining four patients by theThe right side wasfilledfirst. Thfe lungs were iniflated seven seven te ronchography.times. Peripheralfilling is improved by the dilution of the seventh day after bronchography.Hytrast on the left, without loss ofcontrast. The improv- In none of the 50 patients was there evidencement in filling on the left is the more obvious when it is of bronchial irritation as a consequence of bron-remembered that this radiograph was the last offour to be chography during a minimum of three days ofmade, so that the right lung has been inflated 14 times with observation after the investigation. Pyrexia, nevercontrast medium in its bronchi. higher than 100° F., was observed in 12 of the

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three less than two weeks after bronchography,and in one four weeks after bronchography; innone of the operative specimens was there evi-dence of inflammatory or granulomatous reactionto the contrast medium.

SUMMARY

Hytrast, blown into the bronchi, is recommendedas a contrast medium for bronchography follow-ing its use in 50 patients in whom bilateralbronchograms were made under generalanaesthesia with a relaxant.

REFERENCES

FIG. 15. Bilateral antero-posterior bronchogram madewith Hytrast to which sterile water had been added in theratio 20 ml. Hytrast: 2 ml. water. Contrast is less good andthere is alveolarfilling. The lungs were inflatedfive times.

50 patients on the first or second day after bron-chography; none had fever after the third dayand none was disturbed. In four patients pul-monary resection followed bronchography, in

Burrascano, J. J. (1955). Visciodol in bronchography. Sea View Hosp.Bull., 15, 149.

Dormer, B. A. (1940). Personal communication.Jackson, C. (1918). The bronchial tree: its study by insufflation of

opaque substances in the living. Amer. J. Roentgenol., 5, 454.Johnson, P. M., and Irwin, G. L. (1959). An evaluation of the

pharmacological hazards resulting from use of " Visciodol " inbronchography. Radiology, 72, 816.

le Roux, B. T. (1962). The bronchial anatomy of the left upper lobeJ. thorac. Surg., 44, 216.and Masson, A. (1962). Bronchography under general anaesthe-sia. Brit. J. Anaesth., 34, 200.

Sicard, J. A., and Forestier, J. A. (1922). Methode generale d'explora-tion radiologique par l'huile iodee (lipiodol). Bull. Soc. med. H6p.Paris, 46, 463.

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