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Post-operative Pulmonary Complications
May, 1 9 3 3 ]
POST-OPERATIVE PULMONARY COMPLICATIONS
TUBERCLE. MA Y, 1933.
Post-operative Pulmonary Complications. FoR many years past the question of the tetiology, prevention and treatment of pulmonary complications following abdominal and other operations has been extensively studied, and the literature has grown to considerable dimensions. One of the most recent contributions on the subject is a paper by Dr. D. S. King [1], who discusses the r6le of carbon dioxide inhalations in the prevention of such complications in a controlled series of patients at the Massachusetts General Hospital His conclusions, which are briefly summarised below, are somewhat disappointing in that they are at variance with the favourable opinions entertained by other workers as to the value of the routine use o~ COg as a preventive measure. The administration of CO 2 immediately following the operation, for the purpose of de-anmsthetising the patient, was first suggested by Henderson, Haggard and Coburn [2]. Brunn and Brill [3] have noted bronchoscopieally that the administration of CO~. after, inhalation anaesthesia produced: (1) Increase in the rate and depth of respiration ; (2) production of violent movements in the tracheobronchial tree and alterations in the shape of the lumenm of its branches, tending thereby to free adherent mucus ; (3) induction of a distinct blanching of the mucous membranes of the trachea and bronchi. If the patient is placed in such a position that the involved area is uppermost and the bronchial opening leading from it is dependent, Brunn and Brill found that the COg inhalations led to a satisfactory drainage and expectoration of secretion. In treatment of an already established pulmonary ateleetasis, these workers urge that ~O 2induced hyperventilation, combined witla frequent postural changes, according to the principles of intra-bronchial drain-
359
age, should be used as soon as the complication is recognised. A large number, they believe, will clear up rapidly under this r6gime, while for those who do not a bronchoscopy may be indicated. P.N. Coryllos [4] pointed out that under the influence of COg inhalation the bronchial exudate appears to lose its viscosity, is transformed into a thin frothy secretion which is more easily expectorated or aspirated by the bronehoseope or resorbed, and the lung can therefore drain and become aerated. Work carried out on dogs with experimental pneumonia [5] showed that these animals had a far lower mortality rate after several hours' respiration of 6 per cent. carbon dioxide and air mixture, coming with impressive rapidity out of the toxic condition. Both laboratory and clinical investigations convinced Corvllos and his coworkers that this method constituted a far more efficient means of preventing post-operative lung complications than any other methods hitherto employed. Nevertheless, the frequent change in position of the patient is also insisted on, a moderate Trendelenburg being desirable in the absence of any special contra-indieation. It might also be recalled in passing that Langton Hewer [6] pointed out that in deetherisation the hyperpncea caused by inhaling a C02-O 2 mixture will expand and aerate the bases of the lungs, thus minimising the risk of congestion and consolidation, while it also seemed reasonable to suppose that pulmonary embolism would be less likely to follow. On the other hand, in the new study reported by D. S. King, carbon dioxide inhalations were found to be of no greater value in preventing post-operative pulmonary complications than frequent changes in position of the patient--so much so that in the Massachusetts General Hospital the routine prophylactic use of carbon dioxide has been discontinued, and the search for a more effective method is still being pursued. The eases studied consisted of 648 patients who had had laparotomies or hernia repairs. These patients received CO 2 inhalations or carbon dioxide and oxygen mixtures from three to twelve times in each
360
TUBERCLE
twenty-four hours for the first three post-operative days. The percentage of pulmonary complications of the type including "broncho-pneumonia," " pneumonitis," and " collapse" is recorded for the total group and for the different types of abdominal operations, and the results in this group are compared with the percentage of complications developing in 667 controls. During the first four months of the study, the comparison seemed to show a marked reduction in favour of the treated group, especially in the percentage of " moderate and severe" complications. In the last eight months of the study, however, there was a marked reduction in the complications in the untreated group, due apparently to a change in the post-operative nursing care, providing frequent change in position, thus favouring better bronchial drainage. The percentage of complications in the treated group remained fairly constant, irrespective of the method of administral;ion of the carbon dioxide or its frequency or duration. Two further
[May, 1933
points of interest in this study are the observation that massive collapse as a post-operative complication appears to have been practically eliminated by better bronchial drainage, either by postural cbange or by carbon dioxide inhalations; and also that neither method of treatment has materially affected the percentage of complications occurring in the " bad r i s k " group, which included males with operations on stomach, gall-bladder or intestines. While Dr. King's study is better controlled than those of most of the other contributors to the literature, it would seem at least possible that a combination of the two methods--postural change and CO 2 inhalations--might still further reduce the incidence of post-operative pulmonary complications. REF:EREI'~CES. [1] Journ. Ar Meal. Assoc,, 1933, lflO,121. [2] Ibid., 192U, 7~I, 783. [3] A~mals of S~,rgery, 1930, 92, 801. [6] Sur.q., Gyn. and Obst., 1930, 50, 795. [5] Arch. Intern. Med., 1930, 45, 72. [6] China Medical Journal, 1927, 41,852.
BOOK N O T I C E S AND ABSTRACTS. Book Notices. Die Verwendbarkeit des Rt~ntgenpapiers auf dem Gebiete tier Lungenuntersuehung. :By Dr. E. Haeger. Miinchen: Otto Gmelin. 1932. (Heft 44 of S~mmlung diagnostisch-therapeutischer Abhandlungen fiir den praktischen Arzt.) :Pp. 44. Rm. 3.25. The introduction of the paper film marks a definite advance in radiography of the chest, and this is, we believe, the first monograph devoted to a consideration of the subject. It is not claimed that the paper film will replace the ordinary celluloid film ; this is far from being the case. But for what the author calls qualitative diagnosis without bringing out the finer points the paper film gives satisfactory results, and, of course, is very considerably cheaper than the celluloid film. For routine work such as repeat films in artificial pneumothorax treatment and
similar purposes it is likely therefore to be useful. The monograph gives a good description of the use of the paper film with simple technical details, and a comparison with the celluloid film, with a few suitably chosen examples. Radiologie Maxims. By Harold Swanberg, M.D. Radiological Review Pub. Co., Quincy, Illinois. 1932. Pp. 126. Price $1.50. The author, who is founder and editor of the Illinois t~adiological Beview, has in this volume collected a number of " m a x i m s " which have appeared month by month in the pages of the review. The three sections into which the book is divided deal respectively with radiology in general, X-ray diagnosis, and radiation therapy. In each ease the maxims are followed by quotations on radiological subjects from the current literature, mainly by physi-
POST-OPERATIVE PULMONARY COMPLICATIONS
TUBERCLE. MA Y, 1933.
Post-operative Pulmonary Complications. FoR many years past the question of the tetiology, prevention and treatment of pulmonary complications following abdominal and other operations has been extensively studied, and the literature has grown to considerable dimensions. One of the most recent contributions on the subject is a paper by Dr. D. S. King [1], who discusses the r6le of carbon dioxide inhalations in the prevention of such complications in a controlled series of patients at the Massachusetts General Hospital His conclusions, which are briefly summarised below, are somewhat disappointing in that they are at variance with the favourable opinions entertained by other workers as to the value of the routine use o~ COg as a preventive measure. The administration of CO 2 immediately following the operation, for the purpose of de-anmsthetising the patient, was first suggested by Henderson, Haggard and Coburn [2]. Brunn and Brill [3] have noted bronchoscopieally that the administration of CO~. after, inhalation anaesthesia produced: (1) Increase in the rate and depth of respiration ; (2) production of violent movements in the tracheobronchial tree and alterations in the shape of the lumenm of its branches, tending thereby to free adherent mucus ; (3) induction of a distinct blanching of the mucous membranes of the trachea and bronchi. If the patient is placed in such a position that the involved area is uppermost and the bronchial opening leading from it is dependent, Brunn and Brill found that the COg inhalations led to a satisfactory drainage and expectoration of secretion. In treatment of an already established pulmonary ateleetasis, these workers urge that ~O 2induced hyperventilation, combined witla frequent postural changes, according to the principles of intra-bronchial drain-
359
age, should be used as soon as the complication is recognised. A large number, they believe, will clear up rapidly under this r6gime, while for those who do not a bronchoscopy may be indicated. P.N. Coryllos [4] pointed out that under the influence of COg inhalation the bronchial exudate appears to lose its viscosity, is transformed into a thin frothy secretion which is more easily expectorated or aspirated by the bronehoseope or resorbed, and the lung can therefore drain and become aerated. Work carried out on dogs with experimental pneumonia [5] showed that these animals had a far lower mortality rate after several hours' respiration of 6 per cent. carbon dioxide and air mixture, coming with impressive rapidity out of the toxic condition. Both laboratory and clinical investigations convinced Corvllos and his coworkers that this method constituted a far more efficient means of preventing post-operative lung complications than any other methods hitherto employed. Nevertheless, the frequent change in position of the patient is also insisted on, a moderate Trendelenburg being desirable in the absence of any special contra-indieation. It might also be recalled in passing that Langton Hewer [6] pointed out that in deetherisation the hyperpncea caused by inhaling a C02-O 2 mixture will expand and aerate the bases of the lungs, thus minimising the risk of congestion and consolidation, while it also seemed reasonable to suppose that pulmonary embolism would be less likely to follow. On the other hand, in the new study reported by D. S. King, carbon dioxide inhalations were found to be of no greater value in preventing post-operative pulmonary complications than frequent changes in position of the patient--so much so that in the Massachusetts General Hospital the routine prophylactic use of carbon dioxide has been discontinued, and the search for a more effective method is still being pursued. The eases studied consisted of 648 patients who had had laparotomies or hernia repairs. These patients received CO 2 inhalations or carbon dioxide and oxygen mixtures from three to twelve times in each
360
TUBERCLE
twenty-four hours for the first three post-operative days. The percentage of pulmonary complications of the type including "broncho-pneumonia," " pneumonitis," and " collapse" is recorded for the total group and for the different types of abdominal operations, and the results in this group are compared with the percentage of complications developing in 667 controls. During the first four months of the study, the comparison seemed to show a marked reduction in favour of the treated group, especially in the percentage of " moderate and severe" complications. In the last eight months of the study, however, there was a marked reduction in the complications in the untreated group, due apparently to a change in the post-operative nursing care, providing frequent change in position, thus favouring better bronchial drainage. The percentage of complications in the treated group remained fairly constant, irrespective of the method of administral;ion of the carbon dioxide or its frequency or duration. Two further
[May, 1933
points of interest in this study are the observation that massive collapse as a post-operative complication appears to have been practically eliminated by better bronchial drainage, either by postural cbange or by carbon dioxide inhalations; and also that neither method of treatment has materially affected the percentage of complications occurring in the " bad r i s k " group, which included males with operations on stomach, gall-bladder or intestines. While Dr. King's study is better controlled than those of most of the other contributors to the literature, it would seem at least possible that a combination of the two methods--postural change and CO 2 inhalations--might still further reduce the incidence of post-operative pulmonary complications. REF:EREI'~CES. [1] Journ. Ar Meal. Assoc,, 1933, lflO,121. [2] Ibid., 192U, 7~I, 783. [3] A~mals of S~,rgery, 1930, 92, 801. [6] Sur.q., Gyn. and Obst., 1930, 50, 795. [5] Arch. Intern. Med., 1930, 45, 72. [6] China Medical Journal, 1927, 41,852.
BOOK N O T I C E S AND ABSTRACTS. Book Notices. Die Verwendbarkeit des Rt~ntgenpapiers auf dem Gebiete tier Lungenuntersuehung. :By Dr. E. Haeger. Miinchen: Otto Gmelin. 1932. (Heft 44 of S~mmlung diagnostisch-therapeutischer Abhandlungen fiir den praktischen Arzt.) :Pp. 44. Rm. 3.25. The introduction of the paper film marks a definite advance in radiography of the chest, and this is, we believe, the first monograph devoted to a consideration of the subject. It is not claimed that the paper film will replace the ordinary celluloid film ; this is far from being the case. But for what the author calls qualitative diagnosis without bringing out the finer points the paper film gives satisfactory results, and, of course, is very considerably cheaper than the celluloid film. For routine work such as repeat films in artificial pneumothorax treatment and
similar purposes it is likely therefore to be useful. The monograph gives a good description of the use of the paper film with simple technical details, and a comparison with the celluloid film, with a few suitably chosen examples. Radiologie Maxims. By Harold Swanberg, M.D. Radiological Review Pub. Co., Quincy, Illinois. 1932. Pp. 126. Price $1.50. The author, who is founder and editor of the Illinois t~adiological Beview, has in this volume collected a number of " m a x i m s " which have appeared month by month in the pages of the review. The three sections into which the book is divided deal respectively with radiology in general, X-ray diagnosis, and radiation therapy. In each ease the maxims are followed by quotations on radiological subjects from the current literature, mainly by physi-