pneumothorax indications

7/27/2019 pneumothorax indications

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DISEASES OF THE CHEST A P R I L

Indications for PneumothoraxIT HAS been conceded for

many years that rest isthe important factor whichenters into the curing ofany organ of the body. It has been foundthat in surgical tuberculosis rest playsthe most prominent part of the treat-ment. It has been recognized for the lastten years that this also applies to thelung. In 1822 James Carson, thinkingover the serious accidents which hap-pened to many of his advanced cases oftuberculosis when a spontaneous pneu-mothorax took place, realized that inmany cases this spontaneous pneumotho-rax was a beneficial procedure for, al-though many of them died immediately,many others were benefited by the hap-pening. Thus he conceived the idea thatit might be well to effect an artificialpneumothorax.

In 1822 he published a paper aboutthis and a man named Sloan, who wassuffering from tuberculosis, came to Car-son and presented himself for this treat-

and was apparently moreB Y fortunate in his selection

WILLIAM DEVITT, M.D. Qf & cage.thigmanhadftAl l enwood , Pa. free pleura an(J he W R S

able to induce some air. That same yearin Chicago, Murphy, working along thesame line and without any thought of thework Forlanini was doing, was struckwith the same idea and was able to suc-cessfully carry it out.

The operation did not come into favorimmediately, but in the last ten yearsmuch work has been done on it. The tech-nic has been bettered greatly though Ibelieve we are not yet at the end. Theaim of this procedure is to introduce intothe pleural cavity air or gas which willcompress the lung and put it at rest. Restis just as essential to the lung as to anyother organ. When we realize that thelung moves up and down at the rateofabout 23,000 times a day, that it neverrests, that it is always in a state of dis-tention, that even the strongest exhala-tion does not expel all the air, that the

ment. Four members of Sloan's family air cells never approximate each other,had died with tuberculosis and he had weare Psed with the quantityofjust returned from the West Indies wherehe had gone in an unsuccessful searchfor health. Carson and one of the bigsurgeons, Bickleman of London, attempt-ed to do this artificial pneumothorax bythe open method. They cut down throughthe intercostal muscle, through the pleu-ra, and attempted to puncture the pleura,believing they could, perhaps, let air infrom the outside. Unfortunately, Sloanwas not a good case for experimentation.He was an advanced case, with densepleural adhesions and it was impossibleto separate the pleura. Carson was dis-couraged and did not again attempt it un-til years later, and again was unfortunatein his selection of a case and was unableto do it. In 1894 Forlanini, thinkingalong the same line as Carson, attemptedit much after the technic we use to-dayPer SocMy' A l l e n t o w n '

work this organ must do. The presentplan calls for introducing air at atmos-pheric pressure or greater; this over-comes the condition of negative pressurewhich is the normal condition of thepleural cavity; expresses air out of theair cells and in so doing collapses thelung. The completeness of the collapsedepends more or less on the amount ofpleural adhesions and the location ofsuch adhesions. As a result of this pro-cedure the lung is immobilized; the 23,-000 movements a day are ceased; no airenters into it. The same procedure takesplace when a surgeon puts a splint on abroken arm. The splint does not heal thearm any more than the air in the pleuralcavity cures the lung, but with the lungat rest the diseased part has a chance toheal.

There is also a relaxation of the elas-tic tissue taking place as a result of this

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1 9 3 6 DISEASES OF THE CHESTcompression. One of the greatest benefi tsd e r i v e d is that the lung empties itself o fi t s contents. We are often asked by ourpatients w h y , w h e n th e l ung is collapsed,t h e y do not get wel l immed ia t e ly . Theya r e not able to see the process that istaking place. I should l ike to compa r et h i s process wi th that which takes placei n an old sponge which has become ve rym u c h soiled f rom neglect and has not apleasant look nor a pleasant odor . W ec a n conceive it being filled wi th wat e ra n d after th e w at e r is squeezed f r om it ,b e i n g of mu c h smal l e r vo lume , but wem u s t r e m e m b e r w e still have th e s ameo l d dirty sponge; we do not h a v e a n e w ,s w e e t smelling sponge, a del ight to feela n d handle. The same thing applies tot h e lung that has been empt ied of itsa i r ; w e still have th e same pus pockets,w e still hav e th e wal ls of the cavitiesw h i c h have been filled wi th pus , w e havet h e lung exactly th e s ame as we had i tb e f o r e we did the a r t i f i c i a l pneumotho -r a x but mi n u s the air and m i n u s m u c ho f the pus which has been squeezed out .T h e fact that i t is quiet , the fact thatw e have no w approximat ed th e alveolarw a l l s , brings about th e heal ing of thediseased areas and also prevents a spreado f the toxin through the l ymph channe l s .

O n e of the most benef ic ia l e f fects as Is e e it is that mixed in fec t i ons canno t en-t e r th e lung. I believe that most of theunpleasantness o f tuberculosis is due nots o much to the tuberculosis itself as tot h e mixed infect ion , enter ing through th ebronchial channels and coming in con-t a c t with th e toxin of the tubercle baci l l ia n d th e diseased areas. It is this infec-t i o n which causes in great part the nightsweats, headaches and ext remely hightemperature we so o f t en encount e r . I be-l i e v e th e straight tubercle bacilli seldo mc a u s e s a t empera tu re of 103 and 104 de-g r e e s . This , however , is f ound in m a n yc a s e s when a mixed infect ion gains ac-c e s s to the lung.

Artificial pneum otho ra x a lso p reven tsa spread of the disease to the other lung.Y o u can ve ry r ead i l y unde rs t and thatw h e n a person is an open case and ex-

pectorates billions o f tubercle bacilli ,m a n y others are not expectorated but arelodged in the bronchial tubes and arevery easi ly inspirated into the contra-lateral lung.It is believed by some author i t i es thatthe reason certain cardiac cases with theweakened compensat ion show so m u c hresistance to tuberculosis is due to thepassive congest ion which takes place be-cause of the broken compensat ion . Theybelieve that this passive hyperemia is ad e t r i men t to the tubercle bacilli; that iten t e r s much into the de fense of tissue.

The same condi t ion is found in a lungthat has been subject to art i f icial pneu-mothorax; the blood stream is slackenedvery appreciably . Not only is the bloodstream slackened but the lymph s t reamis also compressed.The l ymph stream plays a great partin ca r ry ing the tubercle bacilli from onepart of the lung to another and w h e nthis lymph stream is compressed andslackened, this passage is broken. Thiswas demons t ra t ed some years ago by aG e r m a n w ho compressed th e lung o f sev-eral animals and then compelled them toinhale large quantities of soot. The au-topsy showed that the uncompressed lungwas m uch m ore f i ll ed w ith soo t than thecompressed lung.Selection of Cases.All cases are notsui table for artificial pneumo t ho r ax andit is di f f icul t to know which case wi l lr espond more readily. Many cases whichw e conside r absolutely unsuitable give usthe best results, and vice versa.

Acute Progressive Case.The acuteprogressive case may be part icularly suit-able and give us good results at the t imebut later we are of ten much d isappointedto f ind th e case begins to slip and doesnot respond to the treatment in the m a n -ner we hoped . This is due to the factthat the resistance in the acute case isvery low . They have not had t ime tobuild up this resistance, with the resultthat walls break down, disease spreadsand the case terminates unfavo rab ly .

Chronic Cases.A chronic case, on theo the r hand , which may not seem to be



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DISEASES OF THE CHEST A P R I La good case at the start, may respondvery wel l even if pleural adhesions pre-vent a complete collapse. This is due tothe fact that these cases have good resis-tance. Over the period of years which thepatient has been aff l icted he has buil tup this resistance that is so vital and soimpor t an t as a curat ive factor .Cases Not Doing Well.Then w e hav ethe cases that are not do ing we l l unde rgeneral treatment. It is conceded by allm en w h o d o tuberculosis work that m a n ycases do wel l unde r the o rd ina ry regi-menrest, f r esh air and good f ood . Hereagain it is di f f icul t to tell which casewill get well , and again it is the ques-t ion of resistance. In fact the quest ionof resistance in tuberculosis is the m a i nfac to r , d e t e rmin ing whe the r the case isgoing to get wel l or going to slip, andentering into the pneumotho rax case itm u s t be given the same considerat ion asin eve ry treatment. These cases, not do-ing well u n d e r general t reatment , shouldundoub ted ly be given th e benef i t o f arti-f icial pneumo t ho r ax treatment. The f ac tthat the case is one of f ibrosis does notin ter fere wi th this select ion even thoughboth lungs are involved . This is espe-cially true if there is cavi ty fo rmat ion inone. It is important , however , that thiscavi ty does not have thick walls , but hereagain w e will f ind that i f we follow thisrule too closely we will miss many caseswhich might have been benef i t ed .Cavities. It is safe to believe that inall treatment of tuberculosis it is imper -ative to close all cavities, either smal l orlarge. I believe we will get very fewcures in cavity cases unless this law isobserved . Pneum othorax w i ll accom plishthis in m a n y cases.Many t imes it is necessary to assistthe pneum o w i th some m ethod o f phrenicne rve treatment or, in case of adhesionshold ing and preventing closure, by pneu-molysis . If these do not suffice, and othercondit ions warrant it, a thoracoplastyshould be considered.

Hemorrhage. The most spectacularcase which enters into the treatment isthat of hemorrhage. I know of no way1 0

to control a hemorrhage except by com-pression. I know of no drug that hasany in f luence on it, but often after th einduct ion of 300 or 400 c.c. of air, whichseems in m a n y of these Cases to have aselective action and goes to the weakenedplace, the result is astonishingthe hem-orrhage ceases. In attem pting this pro-cedure on hemorrhage cases w e must re-m e m b e r that we a re deal ing with an al-ready broken lung. If our enthusiasm orour fear compels us to proceed with to om u c h haste, putting in large quantitiesof air wi thout knowing th e condition ofo ur pleura , w i tho ut know ing w he the r th etube rcu lous process has worked out intoth e visceral pleura and al ready caused anadhesion between th e visceral and thepar ie ta l p leura , we m a y do m o r e damageto the pat ient than the hem orrhage i sgoing to do, because an excess of pres-sure m ay pull off a part of the visceralpleura . I f we do this we get a sponta-. n e ou s pneumotho rax wi th r esu l t an t pyo -pneumo t ho r ax .Ev en a smal l quant i ty of air seems tohave a selective action. This is due , ofcourse, to the fact that in the involve-m e n t of the per iphe ry of the lung, thisarea is much so f t ened and the air is ableto exert m uch mo r e p re s su r e on the soft-ened area than i t does on the well por-tion of the lung.Sometimes i t is very diff icul t to knowf rom which side th e hemor rhage is com-ing. Y ou must t hen use you r ow n judg-m e n t and if, af ter several air treatments,the hemo r rhage persists, I believe youshould discontinue the treatment on thesupposedly involved lung and inducepn e u m o on the other side. In our expe-rience this has been successful in severalcases.

Bilateral Cases.The fact that bothlungs are involved i s no contraindication,provided the one side is fa i r ly good. Mostof our ar t i f ic ia l pneum otho rax cases havebilateral tuberculosis . There is a compen-satory emphysema which t akes place inth e contralateral lung causing a dilationof the a lveolar wal l s and th e bronchiolesso that the pat ient is using just as much



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1 9 3 6 DISEASES OF THE CHESTa i r as before the one lung w as partiallyc o l l a p s e d . However, this is not alwayst r u e . The strain o f adjustment for theo t h e r lung, which is also somewhat in -v o l v e d , m ay prove to o great for it andi t m ay break down and may even go ont o hemorrhage. It is then a question ofdetermining th e right procedurewhe th -e r to risk small hemorrhages in the con-tralateral lung and continue pneumotho-r a x on the badly diseased side or allowt h e badly diseased side to reexpand, per-h a p s helping it to reexpand by drawinga i r out of the pleural cavity, and theninstituting a partial pneumothorax o nt h e heretofore contralateral side.It is important and good c o m m o n senset h a t in bilateral cases both sides shouldn o t be started at the same time. Suff i -c i e n t time should be allowed for the sta-bilization of the circulation, both respi-ratory and cardiac, to take place beforeattempting th e closure of the contralat-e r a l lung. If this precaution is taken iti s remarkable how wel l most patientsh a n d l e a bilateral operation.

In some bilateral cases w e f ind aw a l l e d cavity in one lung and evidenceo f a more acute spread in the otherl u n g . Matson has suggested closing th erecent involvement first, disregarding, fo ra time, th e cavity. He has f ound it iso f t e n possible to bring enough pressureo n the cavity by displacing the medias-t i n u m , thereby getting beneficial results.W e have tried it several times and arew e l l pleased with it.

Advanced Cases.Some believe that alladvanced cases should be given a chancew i t h artificial pneumothorax and thiss e e m s logical to m e. Ten years ago Fish-b u r g felt that only th e acute and appar-e n t l y hopeless cases should be given thistreatment. Many authorities d i f f e r ed withh i m then and I think many more d i f f e ra b o u t it today. My own opinion is thati n f i v e years from now we will be usingartificial pneumothorax in many casesw h e r e today we are not considering th etreatment.

Spontaneous Pneumo. A spontaneousp n e u m o should always be converted into

an artificial one. Great care must be ta-ken not to increase the rupture. This iswhere the x-ray plate and the f luoro-scope are so important.Positive Sputum. Positive sputum is

always an indication fo r pneumothoraxtreatment. While it is true some casesafter f ou r or six months of bed rest be-come negative, yet I see no reason towait if it is possible to do a pneumo.It must be remembered that if we waitto o long there is always the possibilityof adhesions forming which m ay minim-ize th e results of our treatment. Of all

the forces that lessen the value of thetreatment certainly adhesions play thebiggest part. We must always keep inmind the possibility of a spread to theother lung.Pleurisy With Effusion.I believe thatin all cases o f pleurisy with effusion th ef luid should be aspirated and replacedwith air. I do not believe that we shouldstrive for a complete collapse in all casesbut in many cases o f tuberculosis, pleu-risy with effusion is one of the cardinalsymptoms. I f we allow th e inflamedpleura to contact, all hope of doing alater pneumo is lost. This neglect willlead to much regret later on in the casesw e were led to believe were not of tuber-culous origin.Contra-Indications. A t Devitt's Campw e recognize few centra-indications. Theacute miliary tuberculosis is certainly one.The disease advances so rapidly and inm a n y cases so much damage to tissuetakes place even before a diagnosis canbe made that this type of treatmentseems to be of no avail.

The dense fibroid cases with emphyse-ma are not suitable unless there is ableeding cavity or one that we are afraidwill bleed, even then this is only at bestpalliative treatment and no beneficial ul-timate results can accrue from it.We do not recognize involvement of thelarynx or intestines as a centra-indicationunless these conditions are severe. Fish-berg, however, found that all of his pneu-m otho r a x cases that died suffered from(Continued to page 26)

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A P R I L 1936IND ICAT IONS FOR PNET JMOTHORAX

a severe intestinal tuberculosis.A mild cardiac or renal condition is nocentra-indication although a severe one is.Age may be a factor. We do not lookwith favor on cases over 50 though, tobe sure, these are rare. Early pregnancy

or diabetes are not centra-indications.Pleural adhesions themselves are notcontra-indications but may interfere verymuch with getting a satisfactory col-lapse. In many of these cases the bestwe can do is f ind a pocket and uponthe size of the pocket depends the de-

gree of benefit given the patient. Thispocket acts the same as the fibroid casethe treatment is only palliative as theadhesions tend to hold open the part youwish to close.I feel asthma is a very strong contra-indication unless the asthma can beproven to be of bacterial origin. In thesecases a vaccine may work wonders. Itis true of course that if the paroxysmscan be controlled we eliminate the causeand the patient, under strict observation,may stand the pneumo well.

Pneumo on Left Side.Matson believeshe gets better results in left-sided cases.He thinks this is due to the fact that inthe right-sided case there is pressure onthe right heart and superior vena cava.Every man who is doing much artifi-cial pneumothorax work would greatly

( C o n t i n u e d f rom page 11)rejoice if there were some standard bywhich we could determine the length oftime the lung should be collapsed. It d e -pends on so many factors that it is d i f -f icul t to decide just when a lung shouldbe allowed to reexpand. W e believe, h o w -ever, the best results are obtained incases where the lung has been collapsedfour or five years. This must be decidedby the general condition of the patient.As long as the patient shows any sipsof activitytemperature elevation, rapidpulseI would suggest keeping it col-lapsed. At the Camp we allow it to re-expand slowly, watching it carefully.There is no reason, of course, why hepatient should no t return to work afterthe symptoms of activity have ceased andthe resistance is somewhat built up. Thephysical signs would be of no benefit inmaking this decision, constitutional symp-toms must be the guide.I believe it is essential to watch allpneumothorax cases very closely with thefluoroscope. At the Camp we fluoroscopeour patients every week. It is certainlynecessary to have the patient under closeobservation when the treatment's start-ed. It should not be started at home or ,if started at home to control a severehemorrhage, the patient should be m o v e dimmediately to a hospital before the nexttreatment is given.

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pneumothorax indications

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