Treatment of Complications Arising in the Course of Pneumothorax Therapy of Pulmonary Tuberculosis

Treatment

of

Course

of

Complications

Arising

Pneumothorax

Therapy

Pulmonary MORTON

Tuberculosis

R. GIBBONS

JR.,

Corona,

in

the of

*

Commander

(MC)

USNR

California

Introduction The

tuberculosis

California, unit was pulmonary

to

officers, and

unit

was

care for tuberculosis.

the

staff

therefore

a

of

institution The

unit

of

Unit

The

their in

or

Following

Veterans’ It will pital the

of in this

tempt means

‘

officers

the

policy,

be

been of

Hospital,

date,

able

patient not

July,

Corona, 1943

to May

2,838 1,713 18 1,025 82

enlisted

it

has

been

the

for

been of and

hospital

these of

retired

men the

aim

by of

follow

its

treatment

cases

for

reason to

the

convalescent that the

is

Fleet

until except of

their

Reserve.

hospital

infection by the patient or further staff of the a determination

a

about

patients treatment

belonging

a tuberculous then to transfer

hospital for this explanation to

In

care

termination

have

of

the activity Indicated

the

the

other

who

case

Administration evident from not

the

the care of the patients in course of treatment of tuber-

usual

does or

control may be

results

Naval

opening

‘

of

Navy

to as

has end

,

recovery

case

of

same.

,

stay

The

ultimate the

shown

policies

,

characteristic, from the

average only.

disease

change has

the

the

active of medical

patients

the S.

of

follows:

one significant hospital varies

8 months

various

U.

from

Corona,

purpose

continuous

although

concerning

,

culosis.

established rotation

care

Total admissions Total discharges Readmissions Patients remaining Deaths In Naval

from usual

concepts, remained

at

The

and general,

Hospital

1943.

individual

data

is as

Naval of

experienced

Tuberculosis

1, 1946

July

has

in

statistical

California,

this

methods

have,

States in

patients suffering By reason of the

of

the

variety

of United

commissioned

to

atsuch to a care. hosof

instituted.

ePresented at the Twelfth Annual Meeting, American College of Chest Physicians, San Francisco, California, June 29, 1946. **) om the Tuberculosis Service, United States Naval Hospital, Corona, California. This paper reflects the views of the author and is not to be considered as representing the policies of the Medical Department, U. S. Navy. 67$

674

MORTON

The

purpose

have

been

treatment of

of

this

evolved

R.

paper

in

Is

the

Bedrest

set

which

Nov.-Dec.,

forth

the

above

have

methods

which

described

developed

1947

for

during

the

the

course

therapy.

has

instituted

to

JR.

organization

of complications

pneumothorax

GIBBONS,

been

and

the

essential

associated

factor

with

all

in

other

all

treatment

and

of

treatment

methods

is

discussed. Pneumothorax proved minimal

been

except

Is

The

pneumothorax elsewhere.

attempted,

and

not

considered

tuberculosis

involvement.

going Instituted it

has

active

majority

therapy All suitable further

routinely

those in

of

are

is a general

disinclination

to

its

institution

Interruption

of

the

phrenic

febrile

considered

Temporary

carried

under-

out

dense

only

pneumothorax

and

during

if

pneumonic

an

there

acute,

has

institutions.

gratifying, In

a paper

the more to limit

results in

could having

radical discussion

with

a rather

The

therapy

above

connection

had

particularly

collapse

nerve

has

been

been used alone, with pneumothorax, and other procedures. We have in its use in many cases under varying in

diaphragm,

other

toxic

be the

more of this

those

paralysis extensive

cases

or with experienced conditions. of

use

procedure

no

one

wing

than

have

where

practiced

at

likewise other

of some been

form

of

adopted. scope

of

this,

surgical procedures, of complications

it

is not

possible

to

discuss

and therefore, it is proposed to those experienced in the

procedures.

The or

be

has

Pneumoperitoneum,

two

for

now

reaction.

extensively and pneumoperitoneum gratifying results the

unsuitable

of

stable

had their procedure have pneumothorax

demonstrating

tuberculosis

cases

a fairly

cases

unit should

should

Individuals

all

show

minimal

the cases

procedures

successful.

in

which

complications groups:

refilling

(I.e.,

pneumothorax)

Classification I Incident a.

of pneumothorax

immediate

of to

and,

the

performance

Early 1. “Pleural

of

embolism pneumothorax injury-hemorrhage emphysema.

Late 1. Pleural

of

shock”

3. “Spontaneous” 4. Chest wall 5. Subcutaneous

effusion

divided

with

the

indefinitely acts

of Instituting

late.

Complications

2. Pulmonary

b.

are

associated

Pneumothorax pneumothorax.

Treatment

into

xm

Volume

COMPLICATIONS

2. Spontaneous 3. II

Gross

Incident

OF

rupture

of pleural

interference

to

with

intrathoracic

675

PNEUMOTHORAX

adhesion

vital

capacity.

changes

caused

by

pulmonary

in-

fection. a.

Tuberculous

b.

Atelectasis

pleurisy

c. Bronchopleural d. III

Chest

a.

Pleural

adhesions

Tension

cavity.

Prevention

is

patient

inch

then

22

the

gauge

by

needle. that

usually -8 to

ranging -4 cm.

50

cc.

into

Before

following

an

for

prior

recording slowly the

change

estimate

of

In the

to

100

every

by

cc.

4th

preferred

air,

the

it

Is

absolutely

be

obtained,

be day

reading,

50 cc. of

about pleural

made. It introduction but

pneumo-

reading

brought the

In a

on inspiration and of initial adminis-

a second of

and

of

manometric

can initial

inch

a small incision the skin with

cm. H20 At the time by

of line

anesthesia,

readings

the

site

axillary

is generally

of

pressure

given the

The

same being

18 gauge 1 ‘/2 of the pneumothorax

insertion

patency

at

been

been to between

contra-indicates.

to make to puncture

followed

be safely 300 cc.

this

-8 of

has

pneumothoraces,

manometric

the amount that can practice to administer increase

It

initial

to the

-14 to expiration.

skin

Following an

administration

negative

between of H,O on

area

space.

used

it is helpful or, better,

the

good

below

pleural

be

needle

introduced air,

the

is used, scalpel,

From of

anterior

withdrawn and to the manometer

needle

18 gauge

manometer.

procaine.

this

needle is by tubing

in

of

a rib.

essential

space

the

underlying

bevel

and

injection

rather

the

to follow through the reached, this structure

than

bevel

is

then is

further

proce-

procedure has skin stretched

immediately

when such needle the skin with a

air

after The in

above

is inserted

tration,

needle

intercostal

the

explained. Sedation, pentoadministered to initial cases. and it is injected through a

merthiolate. injection and pleura

complications.

pneumothorax,

go

a short

thorax

immediate

initial

5th

the infiltration needle, attached

sharp

for

the

infiltration

forefinger parietal

disease

that

pneumothorax.

the

should

machine,

infection

adequate

treatment for

tincture of by intradermal and the

is

unless One

of

best

anesthetized

election

secondary

results desired being grs. 11/2, is usually Is 1 per cent procaine

cleansed with raise a wheal the thumb wheal until

and

with

is prepared

dure and the barbital sollum The anesthetic

empyema

abcess.

interfering

b.

The

11/2

fistula

wall

Conditions

and

rarely

by space

has of

been air

exceeding

the the and the and

676

MORTON

500

cc.

at

bed

for

the

is

any

routinely

mined

the

be

of

actually

syncope

air

ways except nervous

to

surgical for one system

chogenic Inasmuch

origin. as

thorax

not

ently

a greater

so,

fluoroscopy

a

24 hours the

of air

small,

from has

than

The only

patient when

All at

Neither The is

thorax factorily, ance of collapse

tasis

collapse

under the allowing,

parts that

outweighs

endotracheal

or of an

and

with relative bronchoscopy

bronchial

effective

check-valve

should

air be

only.

fluoroscoped

regular

of

danger.

pneumosatisappearper cent collapse

healthy on every

lung. case

procedure of the

The

considerably and

or

introduced volume.

The value of this of the’ condition

disease

do of by

expectant

About 50 a selective

possible

from

and degree

has been established on the basis of the

pneumothorax cavity

the

re-expansion be performed

any

air

angle. since

In it

the has

fluid

reduces

predlsposes

the

to atelec-

formation.

absence no

bearing

containing and is usually of on

no

symptoms the

success

bacteria confined its

presence of

the

frequently accomto the costophrenic can treatment.

air

presence

Effusion A clear, sterile panies pneumothorax,

a

this

collapse

and more an undesirable

fluoroscope. if possible,

be

unrecognized is

preceding

therapy is indicated. the determinatIon

definitely

of

usually

to

been

If

massive

condition

only

appar-

has may

extrusions

therapy

the collapse is maintained,

belief

pneumothorax,

in

are

this

a pneumothorax administered

possibility

all

pneumo-

always self-limiting any unwarranted

they

After are

in which collapse in diagnosis and of

of

in

Is

parenchyma

result

of

Immediately

of the diseased It Is recommended

passages

case

pneumothoraces. such

the

and

treatment

the

of

are or

weekly,

refills. refills

initial what

that

do

undergoing

twice

an of

initial

fluoroscoped regularly lung has re-expanded

tile

patients

least

no now

similar

traumatic

most

experience

emphysema

patient.

deterbeen

occasional

presence

puncture of

our

effusion.

the

then

Is believed

following

self-limiting

inadvertant

been

subcutaneous

an

introduced,

lung into the pleural space produce fistulae, empyemata

pleural

from

be

has

disturbances,

shows

phenomenon it

Aside

may

there

which

in

He

shock, there have been no untoward reactions case which displayed a bizarre form of central stimulation which was diagnosed as being of psy-

that

concurrent

shock,”

vaso-motor

amount

presumably

the not

with

infrequently

advanced

is

embolism.

associated

unit

1947

flat

procedure. course

the

“pleural

remains

initial

subsequent At

Nov-Dec.,

patient

the

visualized.

so-called

JR.

The

following and

picture

case

GIBBONS,

administration.

24 hours

fluoroscoped

by

recorded to

one

first

R.

be

ignored

Volume

COMPLICATIONS

XIII

OF

677

PNEUMOTHORAX

Empyema Empyema is taining bacteria.

any

collection Etiological

1. Tuberculosis

of fluid classification

of the

a.

Acute

b.

Chronic

the pleural is as follows:

space

con-

pleura.

2. Spontaneous

pneumothorax.

3. Spontaneous

rupture

4. Bronchopleural

in

of pleural

adhesions.

fistula.

5. Postoperative. The

above

taneously of

the

these

conditions or

as

subject

as and

the

the underlying based on the pyema, The which

may

the

and

asymptomatic Again onset every

analysis, In

of

and

not

which in

the

which

and the

a fourth presence

of

of a

the

may actual

the

pleura, at

be

be

by

of

fairly

sedimentation removed

should

by

any

hidden

discovered of

readings

complicated

is

be em-

reaction

and elevation the fluid should

physician

of

might of the

may

fluid

systemic

be

control

of

onset

be

an

interruption

there will or collapse

be no of the

shift to a positive empyema. This

there

might of

collapse

The

visceral pleura, the configuration the

degree

pneumothorax

be

fever, of

emp.yema

the

condition. is tuberculosis

manometric

empyema,

by

the

presence may

Intrapleural

marked of

sign

to

therapy.

the

lying lung and no ing the development those

simul-

consideration

of

and

with the

there

the in

from

classification

tuberculosis the patient

of

the continuity of immediate change

nostic

occur

a discussion

individual

present

chest pain, case a sample

tuberculous

may

Therefore,

than

associated course and

radiography.

they

another.

of the cause of cause of empyema

become

during

In

of

fluid

pulmonary reaction of

time

sudden rate.

type of

regardless commonest

one

indicated.

third types

interlocked,

of

rather

seems

A second on

result a whole

conditions

based

are

the

for taken. of

marked under-

pressure accompanywill serve as a diag-

differentiate

this

or

secondary

potential

condition In-

fection. treatment

The

the

of

such

as

fluid

and

the

lung.

No

attempt

Pneumothorax

upon

the

of

degree

of

Is at manometric resorption

pneumothorax the

condition the

pleural

first

the of

made for

of or

space

depends

fluid,

control

is continued

to the usual spontaneous occurs,

this

nature

the to

as

the

of

evacuate

long

as

underlying completely

several

factors

collapse

disease

readings. Many the empyema becomes

upon

type

In the

under

the

the

underlying

fluid

material.

possible

and

according

of these without

cases adverse

lung.

as

If,

obliterated

show a effect

occasionally by

fluid,

678

MORTON

and the

if the underlying pneumothorax

gradual

of

resorption

tient.

If,

of

acute,

the

will

be

disappear

lung

within

severer

a week

or

so and

without

Inconvenience found

to

in the space,

patient particularly

following when

the that

space.and

the

empyemas types, and

and

obliteration

pus sinus

is present. or chest

into

the

In which

spontaneous may bring

are one

of the To wall

pleural

from be

underlying

lung

more is more

dangerous inclined

avoid abcess,

space

the

as

taneous

emphysema

may

result.

The

separation of occur without ment

be

and

how

been

the

dosage units

of

secondary

the

pleural

it is

necessary

not

be

pressure

in

leakage sary.

to the

from If

a

the large

fall

pleural lung,

pleural obliter-

controlled.

later

Thick,

thoracoplasty

of

when

a pleuro-cutaneous needles be inserted

that

possible.

we are faced with of several undesirable

Interference in

the

though into the

visceral

a

condition compli-

pleura,

Infection

space and

broncho-pleural

is only

Where

This

to

is done

reduced fistula

the when

permits

the there

all

every chance

the

escape

preferably should

The sealing

increased off

absolutely too

3

embarrass

pressure

pressure. to

of

is administered

intrapleural aid

can treat-

Where

great

atmospheric Is an

reaction

itself.

passed. air.

the

capacity

spontaneous

intramuscularly every day, until

sufficiently

remove

and

a

the

for penicillin

has is

to below

on

units

vital

of

this latter condition pleural cavity. The

cares

Is 20,000 intrapleurally space

case

depends

condition

pneumothorax, allowed

the

than serous or seroto attempt reexpansion

as

true

and the

air

reverse

There

with

evidence

respiration,

chest. improvement

of fluid in or completely

with

all

gross holds

of by

the

com-

and

well of

In

fre-

rests

relatively asymptofistula, subcu-

or

into

or

expectant,

The 50,000

symptoms

patient

is well

lung

small, self-limiting and atelectasis, broncho-pleural

same

rupture

Immediately. hours, and

and

Pneumothorax

pleural adhesions, the escape of air

should

patient has

be

pa-

more permof empyema

subjective

infrequently

pneumothorax, about one

This may but empyema,

the

the

control

toxic fluid

development is advised

it

of to

other type

the

development fluid almost

pleural

space

the

1947

control, that the

presence

under

or this

a marked

Spontaneous

cations. matic,

the

-Dec.,

by contra-selective fluid, allow the

of

the

under hope

beneficial

is not

that

infrequently

the

well the

in

prove

thoracoplasty the onset

If

found

fortably

ates

lung will

underlying

is not

purulent purulent

Nov.

lung is being jeopardized wiser to evacuate the

and consider procedure.

It

quently

underlying

empyema

if healthy it would seem

to re-expand, anent surgical is

the

the

however,

particularly collapse,

JR.

pulmonary disease is be abandoned with

may

expansion

slow

R. GIBBONS,

much

of

the

necesair

to

Volume

COMPLICATIONS

XIII

escape,

continuous

for this ence of

to

comes

on

must

interference subcutaneous

refill

the

679

PNEUMOTHORAX

decompression

depends extending

necessary

OF

be

established.

with vital emphysema.

pneumothorax

capacity or Obviously,

space

.unless

the

The

need

the it

presis not

fistula

be-

closed. Broncho-pleural

The

diagnosis

of

instillation

of

the

space

pleural

fistulae

can

tunity

to

should

lie

We

have

broncho-pleural

1 per

cent

and

close

do

its

before

the

and

by

methylene in

should

the

bile

the

be

intervention

into

sputum.

given

Such

an

is tried.

oppor-

The

patient

side.

experience

pleural space by oxygen The same considerations surgical

established

of

recovery

surgical

no

is

solution

subsequent

affected

had

following

fistula

aqueous

spontaneously,

this

on

Fistula

with

attempts

lavage, oleothorax as those given

invasion

of

the

to

or above

pleural

obliterate

detergent apply

the

solutions. empyema

to

space.

Atelectasis

Atelectasis ably thoraces. or

is a frequent

present

in The

the

are

establishment of

the

tionships

by

might

be

Institution If

the

early

or

occurs

in

called

“blocked,”

type

estimate

“blocked”

of

cavity

the in

following If the

mediastinum,

and

“blocked

cavity”

the

is adherant

apex

falls away mechanical the The ing

partial

suggested and

decrease

are

not

likely

lateral of the

to

complete during the

this

collapse

is

atelectasis may

occur.

made an

the

be

quite

the

likely

and

be

concurrent

from

hilus, If,

the

on

the for

a

the

operator few

and

the

other

and,

on

hand, collapse,

medlastinum, is possible for

collapsed a

type

atelectasis

produced. is an indication of

to An

initial therapeutic falls away from

towards the lobe bronchus

alternately

to

“check-valve.”

pleura upper

procedure,

the rela-

condition

prior

it or

medlastinum

reexpansion

of

The

to the

under discussion can of extensive atelectasis or

that

of

toward

medially

from the angulation

conditions presence

area,

the establishment of apex, when collapsing, collapses

dis-

angulation anatomical

cases.

“tension” lobes

passages pressure.

bronchoscopy

atelectatic

upper

air

endobronchial

adhesions.

by some

pneumo-

the external

from

pleural

possibility

the

of collapse pneumothorax.

an

by

result

and in

of

alteration and of intrathoracic

avoided

pneumothorax

cavitation of

may

It is prob-

established

a collapse

passages

and

all

obstruction

great

too

pneumothorax of

almost an

obstruction, of alteration

anticipated

to pneumothorax.

in

either

of

ease, mechanical bronchi as a result

be

degree

causes

Obstruction

companion

some

lung. may days

a and allowIt

is

increase to

try

to

680

MORTON

“juggle”

the

should

be

lung

release

remembered

is occasionally process therein, such

to

loss

any

that

the and

results

R. GIBBONS,

in

As

noted

above,

same.

of

under

of

control

the

“blocked such

will

occasionally

collapse to

when

tried

should

be

at

apex

interferes release such

can

produce

has

been

with

a

usually

view

over

effective

allow

to

performance

pull

of

the

lung

by

collapse, where the

have

inoperable tension

phrenic crush pneumothorax

lesser

measures,

the

other

size

adhesions

maintains

of

is

in

methods

caused

the

to

cavity”

increase

diaphragm

Falling

Pleural adhesions

it

collapsed

surgical

lung

procedures,

surgical

in In

staff,

the

at

phrenic

least

has,

tation

been

collapse, and

adhesions fective reexpanded

We

have

tension

of

adhesions

not

induce need not

demonstrated

by

of

prevent

the

the

tables

a 3 year existing

indicate

therapy. Table the institution period. in

patients

Table now

the

under

the

pneumonolysis where ada thoracos-

used

temporary

with

If

good

and the

occurence

results

collapse. prevent

The an

of

inoperable

1 indicates the and maintenance 2 indicates

a com-

disappearance

sputum. collapse,

collapse with

been

the established members of

adequate necessarily

therapy, procedures

accompanying

of

also

adequate

The

have

intrapleural

from pneumothorax and more severe surgical

tions of associated over

closed

performed.

conversion

definitely

location

and in almost every case to interfere with collapse

could adhesions as

the

results

of

to release

pneumono]ysis of pleural

adequate

and

something over 50 per cent the hands of the various results, thought

paralysis

where presence

size

operation

has given excellent hesions have been copy

Adhesions

of varying

plicating factor pneumothoraces.

present

If

the

thoracoplasty.

Pleural

apy

a “blocked

various

reexpansion

ate-

prior

Restraining

the

result.

to

the

and

lateral degree

a

policy

if

be

existing

of

them. the

with may

disappear

Where

and

associated handling

frequently

eliminate

with adequate tension to

an the

attributes

actually

if possible.

the

the cavities

to

tuberculous of a lobe

use

cavities

collapse,

effort

severed,

adhesions which may

an

be of

that

may Such

attempted

in

may

method

noted

on

therapy, reexpand.

undergoing

been

take

a

it lung

Cavity”

the be

of

the

disease.

cavity,”

case,

of

the

1947

but.

a portion

the

which

allowed

obstruction of

for the healing better to lose

in

pneumothorax,

use

price paid It may be

and It

Nov.-Dec.,

mechanical

loss

“Blocked

lectasis,

JR

cavi-

pleural interdict

ef-

lung should considered. of

be

complica-

various procedures of collapse therthe

treatment.

complications

at

Volume

COMPLICATIONS

XIII

OF

TABLE

Total tenance division,

681

PNEUMOTHORAX

1

number of procedures associated with the institution of collapse therapy at U. S. Naval Hospital, Corona, from open date, July 13, 1943 to May 1, 1946. Pneumothorax Pneumoperitoneum AspiratIons

34,464 482 534 212 233 764 259 97

Bronchoscopy

Temporary Phrenic Nerve Interruption Closed Intrapleural pneumonolysis Thoracoplasty (all types and stages Miscellaneous procedures

TABLE

Total number Patients

2

Minimal

Moderately Advanced

Far Advanced

106 (18.2%)

295 (50.7%)

181 (31.1%)

351 (60.2%)

13 (12.2%)

192 (65.1%)

146 (80.7%)

98 (27.9%)

2 (15.5%)

43 (22.4%)

40 (27.5%)

of 582

Pneumothorax Empyema (all types) Empyema, purulent Spontaneous

Pnx.

Adhesions

13 ( 3.7%)

0

3 ( 1.5%)

10 ( 6.8%)

15 ( 4.2%)

0

5 ( 2.6%)

10 ( 6.8%)

200 (56.9%)

Blocked

and mainTuberculosis

Cavity

-

5 (38.4%)

26 ( 7.4%)

Table 3 shows the pneumothoraces, surgical procedures performed on tories were presented to the Board charge, or retirement.

Pneumothorax Empyema (all types) Empyema, purulent Spontaneous Pnx. Adhesions

16(10.9%)

3

complications and more common 1,024 consecutive patients whose hisof Medical Survey for transfer, dis-

Patients

1,024

683 (67.7%) 78 10 19 357

94 (64.4%)

10 ( 5.2%)

TABLE

Total

100 (52.6%)

0

Pnx. abandoned Pneumonolysis done Aspirations Phrenic Crush Thoracoplasty

(10.2%i ( 1.5%) ( 2.9%) (53.8%,

54 8.1%) 273 (41.2%) (76.0%) 30 ( 4.5%) 54 ( 8.1%) 29 ( 2.8%)

SUMMARY This

paper

Tuberculosis treatment apy. Such

sets Unit

forth with

of complications complications

the

statistics

special are

of a large attention

associated classified

to

U. S. Naval the

occurrence

with Pneumothorax as those resulting

Hospital and Therfrom the

682

MORTON

performance

GIBBONS,

of pneumothorax

intrathoracic An outline with

R.

the

suggestion

cations.

In

is suggested that the than

cation

be

mere

and

consecutive

compli-

Intrathoracic

changes,

it

other

fluid,

adhesion

for

the

complications with

are

presented

or

of factor

the of the

institution

are

discussed

aim of their pneumothorax

measures

used

to

compli-

of

elimination and

surgical procedures. collapse procedures instituted,

the

cases

from

is

eliminate

presence

permanent of the

arising

will

interference; to his disease

various

more tables

technique

coincident

of

particularly abandonment

mance of Finally,

from

1947

patient suffer a minimum the patient and his response

determining

The

treatment, the forced

resulting

procedure

resulting

the of

the

procedures.

cations

proper

complications

the

those

Nov-Dec..

pneumothorax

that

that condition

rather

and

changes. of suggested

JR.

surgical

as

regards

the

without perfor-

the

combat

compli-

these

in

1,048

presented.

The author gratefully acknowledges the valued assistance of E. G. Brian, Capt. (MC) USN (Ret.), S. T. Allison, Capt. (MC) USNR, Norma C. Furtos, Lt. Comdr. (MC) (W) USNR, and James H. McCorkle, Lt. Comdr. (MC) USNR. RESUMEN Se para

presentan Tuberculosos

prest#{225}ndole compllcaciones sifican

esas

cuciOn

del

en

este trabajo de un gran

los datos estadisticos Hospital Naval de los

especial atenciOn asociadas con complicaciones y las

las

a la apariciOn y el tratamiento la Terapia Neumotor#{225}cica.

en

neumotOrax

de Estados

las

que

que

son

ocasionadas

se deben

Salas Unidos, Se

de cla-

la

eje-

por

a cambios

intrator#{225}clcos

coincidentes. Se

presenta

un

la administraciOn procedimlento plicaciones que

del correcto

de

someta

condiciOn

el

del

que

Ia

mera

sea

el

factor

qulr#{252}rgicos.

Finalmente,

consecutivOs.

alteraciones

de

discuten

un

se

a

Ia

diferentes

particularmente

presenta

con

una

la

se

tabla

que

enfermedad, u otra de

el obj eto

de

sugiere

intervenciOn;

aplicaciOn

y la

para

el empleo de un En las com-

complicaciOn, procedimientos en

de

ejecuciOn los

cuanto

eliminarlas de

sin procedi-

procedimientos

complicaciones que para combatirlas

la

m#{225}sbien

complicaciones

del neumotOrax m#{226}spermanentes.

se aplicaron, las que se emplearon

de

adherencias

para las

se recomienda

intrator#{225}cicas

minimo

reacciOn

liquido,

determinante

tratamiento,

t#{233}cnica que

y se indica que las complicaciones.

a y su

presencia

el abandono forzado mientos quirUrgicos colapso que las medidas

por enfermo

paciente

Se

una

neumotOrax eliminaria

ocasionadas

se

a su

bosquejo

sobrevinieron en 1,048

de y casos