- Email: [email protected]
AN ANAESTHETIC TECHNIQUE FOR THE REPAIR OF BRONCHOPLEURAL FISTULA
Brit. J. Anaesth. (1962), 34, 817
AN ANAESTHETIC TECHNIQUE FOR THE REPAIR OF BRONCHOPLEURAL FISTULA BY
J. G. FRANCIS* AND K. GLENNIE SMITH!
London Chest Hospital and The Middlesex Hospital, London SUMMARY
The anaesthetic technique for the repair of bronchopleural fistula used by ourselves until recently was that advocated by Dennison and Lester (1961). The main considerations of their technique are those of safety for the patient. To this end, endobronchial intubation is performed under topical analgesia, (a) in order to minimize the risk of soiling the contralateral lung, and the residue of lung (if any) on the side of the operation, and (b) by avoiding the use of general anaesthesia and muscle relaxants, to preserve spontaneous respiration—thus preventing the development of a tension pneumothorax which might be produced by positive pressure ventilation. The aim of our method, which follows very closely that advocated above, is to retain the safety of the technique but at the same time make the procedure less unpleasant for the patient. Many of these patients who develop a bronchopleural fistula following lung resection for carcinoma are ill. By the time they present at the anaesthetic room for the repair operation, they will already have been subjected to various procedures in the ward, such as bronchoscopy, aspiration of pleural fluid, insertion of intercostal drain, physiotherapy, and X-ray examination; they are therefore often
nervous and weary of "interference". To quote the above paper, "It is felt that the disadvantages of performing these manipulations (i.e. bronchoscopy, intubation, etc.) on a conscious patient are outweighed by the safety of the method. Experience has shown that these ill and frightened patients will co-operate if time is spent on explanation and reassurance." We believe, however, that using the method of general anaesthesia to be described, the whole procedure can be performed with equal safety, but without subjecting the patient to what may at best be described as an unpleasant experience. PRESENT SERIES
Pre-operative treatment follows exactly that outlined by Dennison and Lester. The method described has been used for eleven operations (ten patients) for the closure of bronchopleural fistula, as shown in table I. Of these patients, two died. One (No. 4) died following operation for the repair of a second recurrence of his fistula: this patient was an extremely poor risk before this final operation, and although his general condition improved somewhat following the operation, the improvement was not maintained and he died later on the same day. The other death occurred in patient No. 5, three months after operation: •Present address: St. Thomas's Hospital, London. during this period he developed an oesophagot Present address: Poole General Hospital. 817
Downloaded from http://bja.oxfordjournals.org/ at McMaster University Library on July 2, 2015
A method of anaesthesia for the repair of bronchopleural fistula, based on that described by Dennison and Lester (1961) but with certain modifications, is presented, together with the results of a series of ten patients (11 operations) so managed. By using general anaesthesia as described, from the commencement, avoiding the use of muscle relaxants until the patient is safely positioned on the operating table, and by ensuring that spontaneous respiration is maintained during this period, it has been possible safely to dispense with the necessity for intubation of the conscious patient under topical analgesia. Furthermore, this method (in which the hazard from contamination of healthy lung tissue by spill-over of infected pleural fluid is not increased) has the advantage of being much less unpleasant for the patient.
Downloaded from http://bja.oxfordjournals.org/ at McMaster University Library on July 2, 2015
TABLE I
Anaesthetic methods used in ten patients undergoing repair of bronchopleural fistula.
No.
Sex
Age
Premedication
Anaesthetic
Intubation
Position on table
Original operation
Subsequent course
L.endobronchial Carlens
L.lateral
R.pneumonectomy
Discharged
Remarks
1
M
56
Papaveretum 20 mg Thiopentone Hyoscine 0.4 mg N a O.O a halothane NaO.O2 d.t.c.
2
M
56
Pethidine 75 mg O a halothane Promethazine 25 mg N a O.O a d.t.c. Atropine 0.6 mg pethidine
Macintosh Leatherdale endobronchial tube
L.lateral
R.pneumonectomy
Discharged
3
F
49
Papaveretum 20 mg NjO.O, halothane Hyoscine 0.4 mg NaO.Oa d.t.C. pethidine
Modified Gordon-Green
R.lateral
L.pneumonectomy
Discharged
4
M
59
Pethidine lOOmg N a O.O 8 halothane Promethazine 25 mg NaO.O, d.t.C. Atropine 0.6 mg phenazocine
Modified Gordon-Green
L.lateral
R.pneumonectomy
Wound broke down and recurrence of bronchopleural fistula
When thorax opened, endobronchial tube was not effectively isolating fistula-cuff more inflatedsatisfactory
Atropine
0.6 mg Thiopentone suxamethonium, Oa halothane
Modified Gordon-Green
L.lateral
Resuture woundRepair bronchopleural fistula
Wound broke down and recurrence of bronchopleural fistula
Suxamethonium used because fistula not suspected pre-op. Small fistula found at operation for resuture of chest wall
Atropine
0.6 mg
Methohexitone O a halothane N a O.O a gallamine phenazocine
Carlens
L.lateral
Resuture wound. Repair bronchopleural fistula
Diedsudden collapse
Condition very poor preoperatively. Better postoperatively
Atropine
0.6 mg Thiopentone NaO.Oa halothane N,O.O, d.t.c.
Carlens
L.lateral
R.pneumonectomy
Discharged. Then developed oesophagopleural fistulagastrostomy. Died.
5
M
53
When thorax opened, endobronchial tube was not effectively isolating fistula-Carlens tube substituted-satisfactory
Downloaded from http://bja.oxfordjournals.org/ at McMaster University Library on July 2, 2015
TABLE I—continued
Position on table
Original operation
Subsequent course
Modified Gordon-Green. Magill blocker in L.bronchial stump
R.lateral
L.pneumonectomy
Discharged
Papaveretum 20 mg O 2 halothane Promethazine 25 mg N2O.O2 d.t.c. Atropine 0.6 mg phenazocine
Carlens
L.lateral
R.pneumonectomy Wound infection. Rib resection Pleural space drained. Discharged.
57
Papaveretum 10 mg Thiopentone Hyoscine 0.2 mg NaO.O2 halothane N2O.O2 d.t.c. pethidine
Modified Gordon-Green
R.lateral
L.upper lobe
Discharged
M
64
Papaveretum 10 mg Thiopentone Hyoscine 0.2 mg N S O.O, halothane N2O.O2 d.t.c.
Carlens
L.lateral
R.pneumonectomy
Wound broke down and recurrence of bronchopleural fistula (aspergillus). Repaired. Fistula recurred; tube drainage. Discharged
M
51
Papaveretum 20 mg NSO.O2 halothane Hyoscine 0.4 mg N2O.O2 d.t.c. phenazocine
Carlens
L.lateral
R.pneumonectomy
Discharged
No.
Sex
Age
Premedication
Anaesthetic
Intubation
6
M
56
Promethazine 25 mg Atropine 0.6 mg
N2O.O2 halothane N2O.O2 d.t.c. pethidine
7
M
50
8
M
9
10
d.t.c. = d-tubpcurarine
Remarks
Residual pneumonectomy carried out.
820
BRITISH JOURNAL OF ANAESTHESIA
ANAESTHETIC TECHNIQUE
Premedication was not a routine matter, but each patient was assessed pre-operatively and an appropriate premedication was prescribed. Poorrisk cases were commonly given atropine alone; others were given papaveretum, pethidine, promethazine and hyoscine by intramuscular injection, either singly or in combination as considered desirable, at a suitable time-interval before induction of anaesthesia. In some patients, particularly when atropine alone was given, the premedication was given intravenously in the anaesthetic room before induction. The patient was brought to the anaesthetic room in his bed, sitting well propped up with pillows, and leaning over with the affected side lowermost. If a pleural cavity drainage tube was present, this was undamped before induction of anaesthesia so that in the event of the patient coughing, pleural fluid would not flood the bronchial tree, and a tension pneumothorax would not be produced. The patient was asked to cough and expectorate as much as possible at this stage. Cricothyroid puncture was performed, using 2 ml of 4 per cent lignocaine, to guard against the possibility of laryngospasm during induction. One hundred per
cent oxygen was then administered to the patient from the anaesthetic facepiece for some 5 minutes. With the patient still breathing oxygen and in the sitting position described, induction of general anaesthesia was carried out, using either a 2% per cent solution of thiopentone, 1 per cent solution of methohexitone, or halothane and oxygen, with or without nitrous oxide. During this period, and until the patient was safely intubated and positioned on the table, great care was taken to ensure that the patient continued to breathe spontaneously throughout. During this period anaesthesia was maintained with oxygen and halothane, with or without nitrous oxide. When the patient's jaw muscles were sufficiently relaxed, the larynx, pyriform fossae, and trachea down to the carina, were sprayed under direct vision using a Macintosh laryngoscope, with 4 per cent lignocaine using a Multicaine spray. The facepiece was reapplied for a few minutes to allow the local analgesic solution time to act, and then bronchoscopy was performed using a Negus bronchoscope. The anaesthetic gases were now delivered to the side arm of the bronchoscope and the patient continued to breathe spontaneously. Aspiration of any fluid in the bronchial tree was performed by suction through the bronchoscope; any anatomical abnormality was also noted. For intubation in cases of right-sided fistulae a Carlens catheter was used in the majority of cases. Our experience with left endobronchial tubes has led us to believe that the latter are more easily displaced, with potentially serious consequences. In case No. 1, although the left endobronchial tube was considered to be in a satisfactory position at the beginning of the operation, when the chest was opened the fistula was in fact found to be not effectively isolated from the left lung. A Carlens catheter was substituted while the surgeon maintained suction at the site of the fistula. The conditions were thereafter satisfactory, and fortunately no detectable spillover had occurred. For left-sided fistulae we used the Pallister's modification of the Gordon-Green endobronchial tube. The appropriate tube was passed following bronchoscopy, carefully secured in position, and the cuffs inflated and tested for leaks as described by Dennison and Lester; the subsequent management was identical with their method. In one case
Downloaded from http://bja.oxfordjournals.org/ at McMaster University Library on July 2, 2015
pleural fistula and subsequently underwent gastrostomy. Neither of these deaths was considered directly attributable to the anaesthetic technique. The remaining eight patients were discharged from hospital. Patient No. 7 developed a wound infection for which the pleural space was drained after rib resection. Patient No. 9 had a recurrence of his fistula on two occasions, due to an aspergillus infection; he was finally treated by tube drainage of the pleural space. Nine of the patients were male, and one female. Ages of the males ranged from 50 to 64 years; the female was 49 years old. Of the original operations, seven were for right pneumonectomy, two were for left pneumonectomy, and one was for left upper lobectomy. At operation for repair of the fistula, thoracotomy was performed, the bronchial stump dissected, re-amputated and repaired. In the case (No. 8) in which left upper lobectomy had been performed, a residual pneumonectomy was carried out. This obviated the need for protecting the remaining lobe on this side from spill-over.
ANAESTHESIA FOR THE REPAIR OF BRONCHOPLEURAL FISTULA ACKNOWLEDGMENT
We wish to thank the surgeons of the London Chest Hospital for permission to cite cases under their care. REFERENCE
Dennison, P. H.. and Lester, E. R. (1961). An anaesthetic technique for the repair of bronchopleural fistula. Brit. J. Anaeslh., 33, 655. SOMMAIRE
On presente une methode d'anesthe'sie pour la reparation d'une fistule broncho-pleurale. Cette methode est basee sur celle decrite par Dennison et Lester (1961), mais elle comporte quelques modifications. Elle est presentee ensemble avec les re'sultats obsenus chez 10 malades (11 operations) traites de cette facon. L'emploi d'une anesthe'sie ge'ne'rale des le d£but evitant l'emploi de relaxants musculaires jusqu'a ce que le malade soit installe en security sur la table opeVatoire et en s'assurant durant cette periode que la respiration spontan£e est conservee, on a pu eviter en toute security d'intuber les malades conscients ayant recu simplement une anesthesie locale. Bien plus, cette methode n'augmente pas le risque d'une contamination du poumon sain par les liquides introduits dans la plevre. Elle a en outre l'avantage d'etre beaucoup moins desagre'able pour le malade. ZUSAMMENFASSUNG
Eine Narkosemethode zur Operation einer bronchopleuralen Fistel nach der von Dennison und Lester (1961) beschriebenen, aber mit gewissen Modifikationen wird mitgeteilt, zugleich die Ergebnisse bei einer Reihe von 10 Patienten (11 Operationen), bei denen so verfahren wurde. Durch Anwendung der beschriebenen Allgemeinnarkose war es von Beginn an bei Vermeidung von Muskelrelaxantien bis zu dem Zeitpunkt, wo der Patient sicher auf dem Operationstisch gelagert ist, und bei Sicherstellung, dass die Spontanatmung wahrend dieser Zeit aufrechterhalten bleibt, moglich, in sicherer Weise die Notwendigkeit einer Intubierung des Patienten unter ortlicher Analgesie bei Bewusstsein zu umgehen. Ferner hat diese Methode, bei der die Gefahr der Verunreinigung gesunden Lungengewebes durch Ueberfliessen injizierter Pleurafliissigkeit nicht erhoht ist, den Vorteil, ftir den Patienten viel weniger unangenehm zu sein.
Downloaded from http://bja.oxfordjournals.org/ at McMaster University Library on July 2, 2015
(No. 6) a Magill endobronchial blocker was positioned in the left bronchial stump as an additional safeguard, before inserting the GordonGreen tube. Using this method, with the patient appropriately positioned, lightly anaesthetized and breathing spontaneously, the dangers from spill-over or the production of a tension pneumothorax as might occur with inflation of the lungs using a relaxant sequence, were no greater than when these manoeuvres were performed on the conscious patient under topical analgesia. Two additional refinements of technique are worth including in this description. First, when using a Carlens catheter, the tube leading to the right side is occluded, and a fine suction catheter passed down the lumen of the right side. Suction is applied and maintained whilst the patient is moved on to the operating table and turned into the lateral position. This turning is frequently accompanied by the appearance in the sucker bottle of fluid from the pleural cavity. Secondly, it is considered advisable to use two clamps ( for example, artery forceps) on each of the cuffinflating tubes. This is an additional safeguard against accidental deflation of the cuffs when the patient is paralyzed and in the lateral position, with resultant spill-over. This has been our practice since the occasion when one of us, whilst passing a hand under the head towels of the patient to feel a pulse, lightly brushed against one of these clamps, which immediately sprang off. Fortunately no harm came to the patient, but this could quite easily have resulted in disaster. For the same reason it is essential that the cuffs on the tubes to be used should be tested and beyond suspicion before use. Similar spare tubes of varying sizes should also be immediately available.
821
AN ANAESTHETIC TECHNIQUE FOR THE REPAIR OF BRONCHOPLEURAL FISTULA BY
J. G. FRANCIS* AND K. GLENNIE SMITH!
London Chest Hospital and The Middlesex Hospital, London SUMMARY
The anaesthetic technique for the repair of bronchopleural fistula used by ourselves until recently was that advocated by Dennison and Lester (1961). The main considerations of their technique are those of safety for the patient. To this end, endobronchial intubation is performed under topical analgesia, (a) in order to minimize the risk of soiling the contralateral lung, and the residue of lung (if any) on the side of the operation, and (b) by avoiding the use of general anaesthesia and muscle relaxants, to preserve spontaneous respiration—thus preventing the development of a tension pneumothorax which might be produced by positive pressure ventilation. The aim of our method, which follows very closely that advocated above, is to retain the safety of the technique but at the same time make the procedure less unpleasant for the patient. Many of these patients who develop a bronchopleural fistula following lung resection for carcinoma are ill. By the time they present at the anaesthetic room for the repair operation, they will already have been subjected to various procedures in the ward, such as bronchoscopy, aspiration of pleural fluid, insertion of intercostal drain, physiotherapy, and X-ray examination; they are therefore often
nervous and weary of "interference". To quote the above paper, "It is felt that the disadvantages of performing these manipulations (i.e. bronchoscopy, intubation, etc.) on a conscious patient are outweighed by the safety of the method. Experience has shown that these ill and frightened patients will co-operate if time is spent on explanation and reassurance." We believe, however, that using the method of general anaesthesia to be described, the whole procedure can be performed with equal safety, but without subjecting the patient to what may at best be described as an unpleasant experience. PRESENT SERIES
Pre-operative treatment follows exactly that outlined by Dennison and Lester. The method described has been used for eleven operations (ten patients) for the closure of bronchopleural fistula, as shown in table I. Of these patients, two died. One (No. 4) died following operation for the repair of a second recurrence of his fistula: this patient was an extremely poor risk before this final operation, and although his general condition improved somewhat following the operation, the improvement was not maintained and he died later on the same day. The other death occurred in patient No. 5, three months after operation: •Present address: St. Thomas's Hospital, London. during this period he developed an oesophagot Present address: Poole General Hospital. 817
Downloaded from http://bja.oxfordjournals.org/ at McMaster University Library on July 2, 2015
A method of anaesthesia for the repair of bronchopleural fistula, based on that described by Dennison and Lester (1961) but with certain modifications, is presented, together with the results of a series of ten patients (11 operations) so managed. By using general anaesthesia as described, from the commencement, avoiding the use of muscle relaxants until the patient is safely positioned on the operating table, and by ensuring that spontaneous respiration is maintained during this period, it has been possible safely to dispense with the necessity for intubation of the conscious patient under topical analgesia. Furthermore, this method (in which the hazard from contamination of healthy lung tissue by spill-over of infected pleural fluid is not increased) has the advantage of being much less unpleasant for the patient.
Downloaded from http://bja.oxfordjournals.org/ at McMaster University Library on July 2, 2015
TABLE I
Anaesthetic methods used in ten patients undergoing repair of bronchopleural fistula.
No.
Sex
Age
Premedication
Anaesthetic
Intubation
Position on table
Original operation
Subsequent course
L.endobronchial Carlens
L.lateral
R.pneumonectomy
Discharged
Remarks
1
M
56
Papaveretum 20 mg Thiopentone Hyoscine 0.4 mg N a O.O a halothane NaO.O2 d.t.c.
2
M
56
Pethidine 75 mg O a halothane Promethazine 25 mg N a O.O a d.t.c. Atropine 0.6 mg pethidine
Macintosh Leatherdale endobronchial tube
L.lateral
R.pneumonectomy
Discharged
3
F
49
Papaveretum 20 mg NjO.O, halothane Hyoscine 0.4 mg NaO.Oa d.t.C. pethidine
Modified Gordon-Green
R.lateral
L.pneumonectomy
Discharged
4
M
59
Pethidine lOOmg N a O.O 8 halothane Promethazine 25 mg NaO.O, d.t.C. Atropine 0.6 mg phenazocine
Modified Gordon-Green
L.lateral
R.pneumonectomy
Wound broke down and recurrence of bronchopleural fistula
When thorax opened, endobronchial tube was not effectively isolating fistula-cuff more inflatedsatisfactory
Atropine
0.6 mg Thiopentone suxamethonium, Oa halothane
Modified Gordon-Green
L.lateral
Resuture woundRepair bronchopleural fistula
Wound broke down and recurrence of bronchopleural fistula
Suxamethonium used because fistula not suspected pre-op. Small fistula found at operation for resuture of chest wall
Atropine
0.6 mg
Methohexitone O a halothane N a O.O a gallamine phenazocine
Carlens
L.lateral
Resuture wound. Repair bronchopleural fistula
Diedsudden collapse
Condition very poor preoperatively. Better postoperatively
Atropine
0.6 mg Thiopentone NaO.Oa halothane N,O.O, d.t.c.
Carlens
L.lateral
R.pneumonectomy
Discharged. Then developed oesophagopleural fistulagastrostomy. Died.
5
M
53
When thorax opened, endobronchial tube was not effectively isolating fistula-Carlens tube substituted-satisfactory
Downloaded from http://bja.oxfordjournals.org/ at McMaster University Library on July 2, 2015
TABLE I—continued
Position on table
Original operation
Subsequent course
Modified Gordon-Green. Magill blocker in L.bronchial stump
R.lateral
L.pneumonectomy
Discharged
Papaveretum 20 mg O 2 halothane Promethazine 25 mg N2O.O2 d.t.c. Atropine 0.6 mg phenazocine
Carlens
L.lateral
R.pneumonectomy Wound infection. Rib resection Pleural space drained. Discharged.
57
Papaveretum 10 mg Thiopentone Hyoscine 0.2 mg NaO.O2 halothane N2O.O2 d.t.c. pethidine
Modified Gordon-Green
R.lateral
L.upper lobe
Discharged
M
64
Papaveretum 10 mg Thiopentone Hyoscine 0.2 mg N S O.O, halothane N2O.O2 d.t.c.
Carlens
L.lateral
R.pneumonectomy
Wound broke down and recurrence of bronchopleural fistula (aspergillus). Repaired. Fistula recurred; tube drainage. Discharged
M
51
Papaveretum 20 mg NSO.O2 halothane Hyoscine 0.4 mg N2O.O2 d.t.c. phenazocine
Carlens
L.lateral
R.pneumonectomy
Discharged
No.
Sex
Age
Premedication
Anaesthetic
Intubation
6
M
56
Promethazine 25 mg Atropine 0.6 mg
N2O.O2 halothane N2O.O2 d.t.c. pethidine
7
M
50
8
M
9
10
d.t.c. = d-tubpcurarine
Remarks
Residual pneumonectomy carried out.
820
BRITISH JOURNAL OF ANAESTHESIA
ANAESTHETIC TECHNIQUE
Premedication was not a routine matter, but each patient was assessed pre-operatively and an appropriate premedication was prescribed. Poorrisk cases were commonly given atropine alone; others were given papaveretum, pethidine, promethazine and hyoscine by intramuscular injection, either singly or in combination as considered desirable, at a suitable time-interval before induction of anaesthesia. In some patients, particularly when atropine alone was given, the premedication was given intravenously in the anaesthetic room before induction. The patient was brought to the anaesthetic room in his bed, sitting well propped up with pillows, and leaning over with the affected side lowermost. If a pleural cavity drainage tube was present, this was undamped before induction of anaesthesia so that in the event of the patient coughing, pleural fluid would not flood the bronchial tree, and a tension pneumothorax would not be produced. The patient was asked to cough and expectorate as much as possible at this stage. Cricothyroid puncture was performed, using 2 ml of 4 per cent lignocaine, to guard against the possibility of laryngospasm during induction. One hundred per
cent oxygen was then administered to the patient from the anaesthetic facepiece for some 5 minutes. With the patient still breathing oxygen and in the sitting position described, induction of general anaesthesia was carried out, using either a 2% per cent solution of thiopentone, 1 per cent solution of methohexitone, or halothane and oxygen, with or without nitrous oxide. During this period, and until the patient was safely intubated and positioned on the table, great care was taken to ensure that the patient continued to breathe spontaneously throughout. During this period anaesthesia was maintained with oxygen and halothane, with or without nitrous oxide. When the patient's jaw muscles were sufficiently relaxed, the larynx, pyriform fossae, and trachea down to the carina, were sprayed under direct vision using a Macintosh laryngoscope, with 4 per cent lignocaine using a Multicaine spray. The facepiece was reapplied for a few minutes to allow the local analgesic solution time to act, and then bronchoscopy was performed using a Negus bronchoscope. The anaesthetic gases were now delivered to the side arm of the bronchoscope and the patient continued to breathe spontaneously. Aspiration of any fluid in the bronchial tree was performed by suction through the bronchoscope; any anatomical abnormality was also noted. For intubation in cases of right-sided fistulae a Carlens catheter was used in the majority of cases. Our experience with left endobronchial tubes has led us to believe that the latter are more easily displaced, with potentially serious consequences. In case No. 1, although the left endobronchial tube was considered to be in a satisfactory position at the beginning of the operation, when the chest was opened the fistula was in fact found to be not effectively isolated from the left lung. A Carlens catheter was substituted while the surgeon maintained suction at the site of the fistula. The conditions were thereafter satisfactory, and fortunately no detectable spillover had occurred. For left-sided fistulae we used the Pallister's modification of the Gordon-Green endobronchial tube. The appropriate tube was passed following bronchoscopy, carefully secured in position, and the cuffs inflated and tested for leaks as described by Dennison and Lester; the subsequent management was identical with their method. In one case
Downloaded from http://bja.oxfordjournals.org/ at McMaster University Library on July 2, 2015
pleural fistula and subsequently underwent gastrostomy. Neither of these deaths was considered directly attributable to the anaesthetic technique. The remaining eight patients were discharged from hospital. Patient No. 7 developed a wound infection for which the pleural space was drained after rib resection. Patient No. 9 had a recurrence of his fistula on two occasions, due to an aspergillus infection; he was finally treated by tube drainage of the pleural space. Nine of the patients were male, and one female. Ages of the males ranged from 50 to 64 years; the female was 49 years old. Of the original operations, seven were for right pneumonectomy, two were for left pneumonectomy, and one was for left upper lobectomy. At operation for repair of the fistula, thoracotomy was performed, the bronchial stump dissected, re-amputated and repaired. In the case (No. 8) in which left upper lobectomy had been performed, a residual pneumonectomy was carried out. This obviated the need for protecting the remaining lobe on this side from spill-over.
ANAESTHESIA FOR THE REPAIR OF BRONCHOPLEURAL FISTULA ACKNOWLEDGMENT
We wish to thank the surgeons of the London Chest Hospital for permission to cite cases under their care. REFERENCE
Dennison, P. H.. and Lester, E. R. (1961). An anaesthetic technique for the repair of bronchopleural fistula. Brit. J. Anaeslh., 33, 655. SOMMAIRE
On presente une methode d'anesthe'sie pour la reparation d'une fistule broncho-pleurale. Cette methode est basee sur celle decrite par Dennison et Lester (1961), mais elle comporte quelques modifications. Elle est presentee ensemble avec les re'sultats obsenus chez 10 malades (11 operations) traites de cette facon. L'emploi d'une anesthe'sie ge'ne'rale des le d£but evitant l'emploi de relaxants musculaires jusqu'a ce que le malade soit installe en security sur la table opeVatoire et en s'assurant durant cette periode que la respiration spontan£e est conservee, on a pu eviter en toute security d'intuber les malades conscients ayant recu simplement une anesthesie locale. Bien plus, cette methode n'augmente pas le risque d'une contamination du poumon sain par les liquides introduits dans la plevre. Elle a en outre l'avantage d'etre beaucoup moins desagre'able pour le malade. ZUSAMMENFASSUNG
Eine Narkosemethode zur Operation einer bronchopleuralen Fistel nach der von Dennison und Lester (1961) beschriebenen, aber mit gewissen Modifikationen wird mitgeteilt, zugleich die Ergebnisse bei einer Reihe von 10 Patienten (11 Operationen), bei denen so verfahren wurde. Durch Anwendung der beschriebenen Allgemeinnarkose war es von Beginn an bei Vermeidung von Muskelrelaxantien bis zu dem Zeitpunkt, wo der Patient sicher auf dem Operationstisch gelagert ist, und bei Sicherstellung, dass die Spontanatmung wahrend dieser Zeit aufrechterhalten bleibt, moglich, in sicherer Weise die Notwendigkeit einer Intubierung des Patienten unter ortlicher Analgesie bei Bewusstsein zu umgehen. Ferner hat diese Methode, bei der die Gefahr der Verunreinigung gesunden Lungengewebes durch Ueberfliessen injizierter Pleurafliissigkeit nicht erhoht ist, den Vorteil, ftir den Patienten viel weniger unangenehm zu sein.
Downloaded from http://bja.oxfordjournals.org/ at McMaster University Library on July 2, 2015
(No. 6) a Magill endobronchial blocker was positioned in the left bronchial stump as an additional safeguard, before inserting the GordonGreen tube. Using this method, with the patient appropriately positioned, lightly anaesthetized and breathing spontaneously, the dangers from spill-over or the production of a tension pneumothorax as might occur with inflation of the lungs using a relaxant sequence, were no greater than when these manoeuvres were performed on the conscious patient under topical analgesia. Two additional refinements of technique are worth including in this description. First, when using a Carlens catheter, the tube leading to the right side is occluded, and a fine suction catheter passed down the lumen of the right side. Suction is applied and maintained whilst the patient is moved on to the operating table and turned into the lateral position. This turning is frequently accompanied by the appearance in the sucker bottle of fluid from the pleural cavity. Secondly, it is considered advisable to use two clamps ( for example, artery forceps) on each of the cuffinflating tubes. This is an additional safeguard against accidental deflation of the cuffs when the patient is paralyzed and in the lateral position, with resultant spill-over. This has been our practice since the occasion when one of us, whilst passing a hand under the head towels of the patient to feel a pulse, lightly brushed against one of these clamps, which immediately sprang off. Fortunately no harm came to the patient, but this could quite easily have resulted in disaster. For the same reason it is essential that the cuffs on the tubes to be used should be tested and beyond suspicion before use. Similar spare tubes of varying sizes should also be immediately available.
821