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Fiberoptic Bronchoscopy Combined with Selective Bronchography
Fiberoptic Bronchoscopy Combined with Selective Bronchography* A Simplified Technique MAJ]oseph G. Koval, MG, USA; MA] Samuel G. Joseph, MG, USA; MAJ Paul S. Schaefer, MG, USA; and LTG Michael F. Tenholder, MG, USA, F.G.G.P.
Since bronchography is helpful in certain clinical settings, we describe a simplified method for performing selective bronchography in conjunction with fiberoptic bronchoscopy. Selected cases are presented which illustrate that this technique is easily performed, has minimal risk, and produces bronchograms of high quality. _Br.!Ln~hQgr:apJ1Y, ~!~nti.Y9Jy_~'!f.c_nr.Q..c;Q~l u r!;l_ f.Qt:'-Cy.lll llllting
FIGURE 1. Outer protective sheath of Microbiology Specimen Brush the anatomy of the tracheobronchial tree, has been a (Medi-Tech) fitted with I6-gauge needle. useful adjunct in the evaluation of hemoptysis, obstructive minimize compromise of pulmonary function, no more than 30 ml of disease of the airways, bronchiectasis, broncho-occlusive the undiluted contrast material is used during the procedure, and disease, foreign-body aspiration, fistulae, and malignant bilateral studies are not performed on the same day. Roentneoplasms. Contrast material can be introduced into the genograms in the standard anteroposterior, lateral, and oblique airway by aspiration or through a catheter placed in the projections are obtained. tracheobronchial tree. The catheter can be introduced via Immediately after the procedure, the protective sheath is rethe nose, mouth, or cricothyroid membrane, or over a guide moved from the bronchoscope, and the instrument is easily cleaned wire initially placed through the aspirating channel of a and sterilized in the routine manner. bronchoscope. 1-4 CASE REPORTS Technologically advanced procedures such as flexible fiberoptic bronchoscopy, pulmonary angiography, computerCASE 1 ======iilt.f.~iJ=lUltlUgllll'lt tJ , ttlltl - lIIagll eHc eseuune ittlagfi'ijf""li1taflvitc~=~~~~==:=:===========:======================== A I9-year-old man was referred with an I8-month history of substantially reduced the utility of bronchography. Since recurrent fever and productive cough. He had been treated with bronchography is still helpful in certain clinical settings, we antibiotics for a left lower lobe infiltrate on three occasions, with describe a simplified method for performing selective bronresolution of symptoms. Bronchoscopy had revealed no endochography in conjunction with fiberoptic bronchoscopy. This bronchial lesions. Culture of multiple samples of sputum showed no procedure may reduce the risks associated with bronevidence of pathogenic bacteria or fungi. A complete blood cell chograms and is well suited to the current clinical indications for bronchography. TECHNIQUE
In the fluoroscopic suite, fiberoptic bronchoscopy is performed in the usual manner. The segment of the lung to be evaluated is localized, and the bronchoscope is modified as follows. The outer protective sheath from a Microbiology Specimen Brush (Medi- Tech) is advanced through the aspirating channel of the bronchoscope until it extends just beyond the tip of the bronchoscope into the localized segment. A I6-gauge needle, 3.4 em long, is snugly fitted into the proximal end of the protective sheath (Fig 1). Smaller gauge needles or sheaths have not proven effective for the instillation of contrast material. This modification protects the bronchoscope from direct contact with the contrast material, Dionosil (a solution of organically bound iodine in peanut oil). The contrast material is prewarmed to 37°C in a water bath. It is diluted to a maximum of a 50:50 mixture with isotonic saline, stirred vigorously, drawn up into a 20-ml syringe, and directly instilled through the needle and sheath. To *F rom th e Pulmonary Dise ase Servic e , Department of Medicine, Walter Heed Army Medi cal Center, Washin gton , DC . and Uniform ed Services Univer sit y of th e Health Science s, Bethesda , Md . Th e opinions or assertions contained herein arc th e private views of th e authors and are not to be cons true d as official or as reflectin g the view s of th e Depa rtment of the Arm y or th e Department of Defens e . Reprint requests: Dr. Tenh older, Walter Reed Army Medical Genter, Washlngtoll , DG 20307·5001
776
FIGURE 2. Left lower lobe anteroposterior bronchogram demonstrating cylindrical bronchiectasis (case 1). Fiberoptic Bronchoscopy Combined with Bronchography (Koval et al)
DIS CUSSION
FIGURE 3. Posteroant erior chest roent genogram demonstrating left upp er lobe density (case 3). count and sweat chloride levels were normal. Quantitative assay of immun oglobulins revealed an isolated deficiency of IgA. Fiberoptic bronchoscopy combined with selective left lower lobe bronchography confirmed the diagnosis ofcylindrical bronchiectasis (Fig 2). The patien t has done well with daily chest physiotherapy. CASE
In order to limit th e am ount of contrast material used, ye t obtain hi gh-quality ana tom ic d etail, several techniques for bronch oscopy combined with sel ective bronchography have been proposed. In one method, after ro u tine flexibl e fiberoptic bronchoscopy is performed, the bronchoscope is us ed as a laryngoscope to guide a soft catheter through the vocal cords. " The bronchoscope is withdrawn, and prior to in stilling the contrast material, the catheter is fluoroscopically guided in to the se gme n t to be examined. Another m ethod e mp loys a modified Seldinger technique wherein a guide wire is p assed through the aspirating channel of the bronchosco pe into the seg men t to b e evaluated." The bronch oscope is withdrawn over the firmly held guide wire . A cathete r is advanced in to po sition over the wire , and th e guide wire is th en rem oved. Proper po sition is assess ed, and the contrast material is instilled with th e aid of fluoro scopy. More recently, direct instillation of contrast material through the aspirating channel of the bronchoscope has been advocated ." The ad van tages of bronchoscopy co mbine d with se lec tive b ron chography have been previou sly d escribed. Pati ents d o not have to undergo th e discomfort, p otential morbidity, and expense of two se para te procedure s.' Also, the relatively sm all amount of contras t m aterial us ed d ecreas es the risk to patients who have pulmonary or cardiac insuffi cien cy. 1 Our simplified techniqu e ha s three potential benefits: (1) pl ace m ent of the contrast-instilling catheter into the segment or
2
A 22-year-old man suffered a basilar skull fracture and loss of consciousness as a result of a motorcycle accide nt. He developed an empyema secondary to aspiration pne umonia. After parent eral treatment with antibiotics had failed, he underwent thoracotomy with open drainage. Prior to chest wall reconstru ction, a fistulagram was performed in order to ascertain the presence ofa bronchopleu ral fistula, but the stud y was technically limited and nondiagnostic. Bronchoscopy with selective right middle and lower lobe bronchography showed no evidence of a fistula. CASE
3
A20-year-old woman had been well until the age of12years, when she developed recurrent bronchitis. A chest x-ray film at that time showed a left upper lobar density. Bronchoscopy wasnondiagnostic, and subsequent x-ray films showed resolution of the density. At th e age of19 years, the patient developed cough and fever, and an x-ray film showed reappearance of the left upp er lobe density. Treatment with antibiotics resulted in partial clearing of this density, and bronchoscopy was again nondiagnostic, The patient was referr ed to our medical facility for further evaluation. Her chest roentgenogram showed a left upp er lobe density without interval change from the evaluation six months earlier (Fig 3). A comput erized tomographic scan suggested bronchiectasis and confirmed the presence of a homogeneous density in the left upper lobe. A complete blood cell count, quantitative assay of immunoglobulins, and sweat chloride levels were normal. Bronchoscopy combined with selective bronchography showed dilatation of bronchi, with a normal pattern of arborization. The bronchi circumvented the density, which did not fill with contrast material (Fig 4). At thoracotomy, performed for recurr ent infection, a mucus-filled bronchogenic cyst was removed with an apical segment ectomy.
FIGURE 4. Left upper lobe right anterior oblique bronchogram demonstrating noncontrast-filling lesion which is circumvented by dilated bronchi. Arrows demarcate boundary oflesion (case 3). CHEST I 91 I 5 I MAY, 1987
777
lobe to be exami ne d is done under direct vision, minimizing fluoro scopic expo sure to both patient and physician ; (2) th e risk of pneumothorax, reported with th e procedure employing a guide wire," may be diminished; an d (3) thc inner channel of the bron choscope can be b etter protect ed and requires no ad ditio nal tim e or effort to clean than if bronchoscopy alone were performed , Althou gh clinical cir cumstan ces and improved imaging methods have limited its usc , we use bronchoscop y with sele ctive bronchography in th e following three circum stances: First, it re mains our method of choice to definitively diagnos e the presence and extent of bronchiectasis. Although co mp ute rized tomo graphic scann ing may b e useful in th e diagnosis of cystic br on ch iectasis, it is unreli abl e in detecting cylind rical and vari cose changes.' Bronch ography, th erefore, is still rec ommended to exclude diffu se bron ch iectasis prior to surgical resecti on of localized affectcd are as. Secondly, bronchography may also be us ed to define the presence and course of a bronchopleuralIistula when other studies are nondiagnostic . A fistulagram performed in our se cond patient was technically difficult du e to th e pati en t's discomfort and th e larg e dcfect in th e ch es t wall. Th e selective bronchography was eas ily p erformed \ and well tolerate d by th e pati ent. Thi rd and finally, bron ch ography is useful in th e investigation of some parenchymal lesion s. Such lesions would include bronchogenic cysts , bronchopulmonary sequestration, congenital bronch ial atresia, an d an ectopi c bronchus.Y Case 3 ' illustrates th at th es e typ es of paren ch ymal lesion s are occasionally diagn osed, an d bronchial ana tomy detailed, without resorting to surgical inter-
9 Ristema GR . Ectopic right bronchus: indication for bronchography. AJR 1983; 140:671-74 10 American Thoracic Society/American Lung Association. Training programs in respiratory disease: 1986 (21st) edition, Am Rev Respir Dis 1986; 134:369-90
Nonpenetrating Traumatic Rupture of the Tricuspid Valve* Formation of Ventricular Septal Aneurysm and SUbsequent Septal Necrosis: Recognition by TwoDimensional Doppler Echocardiography William Berkery, M,D,;t Christopher Hare, B,S,;
Jl.obe-it A:Warner; M:0 .if ]osiiph-BCittagliCi;-r;rb.;t and]ames L . Potts, M.D.t
'f'
Our technique for broncho scop y with sel ective bronchography is easil y p erformed , has minimal risk, and produ ces high- q uality bronchograms. As th e guidelines of the American Th oracic Society prop ose I' and as selected cases ind icate, broncho scopy with se lective bronchograp hy should re main in th e arm am entarium of the trained bronc hoscopist. ACKNOWLE DGMENT: We thank Ms. Ruth D. Lumbar for typing the manuscript.
N
on pe netratin g traumatic r up ture of both the tricuspid valve and interven tricular se p tum is a distinctl y unusual p athologic even t, I To our kno wledge, this is the first re por t of the two-dimension al Doppler echocard iogra phic confirmati on of thi s condition , and it emphasizes th e utility of this noninvasive examinat ion in the dia gn osis and follow-up of patients with blunt myo cardial trauma.
REFERENCES
1 Fennessy JJ. Selective catheterization of segmental bronchi with the aid of a flexible fiberoptic bronchoscope. Radiology 1970; 95: 689-91 2 Schoenbaum SW; Pinsker KL, Rakoff SJ, Peavey RH , Koerner SK. Fiberoptic bronchoscopy: complete evaluation ofthe tracheobronchial tree in the radiology department. Radiology 1973; 109:571-75 3 Lutch JS, Ryan KG, Bronchography combined with bronchoscopy: a new method (letter to editor). Chest 1979; 75:108 4 Simelaro JP, Marks B, Meals R, Dickerson W. Selective bronchography following fiberoptie bronchoscopy (letter to editor). Chest 1979; 76:240-41 5 Wagner RB, Paidipaty BB. Another advantage of the flexible fiberoptic bronchoscope: an easytracheal cannulation in preparation for bronchography (letter to editor), Chest 1979; 75:108 6 Nakhosteen JA. Fiberoptic bronchoscopy, In: Simmons DR, cd. Current pulmonology Chicago: Year Book Medical Publishers, Inc, 1986; 7:241-72 7 Batcha K. Letter to the editor. Che~t 1980; 77:713 8 Muller NL, Bergin CJ, Ostrow ON, Nichols OM, Role of computed tomography in the recognition of bronchiectasis. AJR 1984; 143:971-76 778
CASE REPORT
A26-year-old man wasadmitted on April 5, 1985, following a highspeed deceleration injury, Initial evaluation revealed a contusion over the sternum, distended veins in the neck with prominent v waves, a right vent ricular S3 and S. gallop, and palpable v waves over the liver, There was no accompanying murmur, The peak level ofcreatine phosphokinase (CPK)was1,300IU, and a weaklypositive fluorescent MB band was present. The initial chest x-ray film was within normal limits. The electrocardiogram showed transient right bundle-branch block and multifocal premature ventricular contractions which suggested the possibility of myocardial contusion. An echocardiogram demonstrated a hyperdynamic right ventricle with paradoxic septal motion, flail tricuspid leaflets, and an echolucency consistent with a hematoma in the basilar portion of the septum . On April 8, 1985, the patient developed mild chest pain associated with tachypnea and hypotension. A loud pericardial friction rub was now audible. Right cardiac catheterization showed no evidence of a left-to-right shunt. A repeat two-dimensional Doppler echocar*From the State University of New York Health Science Center and Syracuse Veterans Administration Medical Centers, Syracuse, NY. t Clinical Assistant Professor of Medicine. tAssociate Professor of Medicine. Nonpenetrating Traumatic Ruptureof Tricuspid Valve (Berkery et al)
Since bronchography is helpful in certain clinical settings, we describe a simplified method for performing selective bronchography in conjunction with fiberoptic bronchoscopy. Selected cases are presented which illustrate that this technique is easily performed, has minimal risk, and produces bronchograms of high quality. _Br.!Ln~hQgr:apJ1Y, ~!~nti.Y9Jy_~'!f.c_nr.Q..c;Q~l u r!;l_ f.Qt:'-Cy.lll llllting
FIGURE 1. Outer protective sheath of Microbiology Specimen Brush the anatomy of the tracheobronchial tree, has been a (Medi-Tech) fitted with I6-gauge needle. useful adjunct in the evaluation of hemoptysis, obstructive minimize compromise of pulmonary function, no more than 30 ml of disease of the airways, bronchiectasis, broncho-occlusive the undiluted contrast material is used during the procedure, and disease, foreign-body aspiration, fistulae, and malignant bilateral studies are not performed on the same day. Roentneoplasms. Contrast material can be introduced into the genograms in the standard anteroposterior, lateral, and oblique airway by aspiration or through a catheter placed in the projections are obtained. tracheobronchial tree. The catheter can be introduced via Immediately after the procedure, the protective sheath is rethe nose, mouth, or cricothyroid membrane, or over a guide moved from the bronchoscope, and the instrument is easily cleaned wire initially placed through the aspirating channel of a and sterilized in the routine manner. bronchoscope. 1-4 CASE REPORTS Technologically advanced procedures such as flexible fiberoptic bronchoscopy, pulmonary angiography, computerCASE 1 ======iilt.f.~iJ=lUltlUgllll'lt tJ , ttlltl - lIIagll eHc eseuune ittlagfi'ijf""li1taflvitc~=~~~~==:=:===========:======================== A I9-year-old man was referred with an I8-month history of substantially reduced the utility of bronchography. Since recurrent fever and productive cough. He had been treated with bronchography is still helpful in certain clinical settings, we antibiotics for a left lower lobe infiltrate on three occasions, with describe a simplified method for performing selective bronresolution of symptoms. Bronchoscopy had revealed no endochography in conjunction with fiberoptic bronchoscopy. This bronchial lesions. Culture of multiple samples of sputum showed no procedure may reduce the risks associated with bronevidence of pathogenic bacteria or fungi. A complete blood cell chograms and is well suited to the current clinical indications for bronchography. TECHNIQUE
In the fluoroscopic suite, fiberoptic bronchoscopy is performed in the usual manner. The segment of the lung to be evaluated is localized, and the bronchoscope is modified as follows. The outer protective sheath from a Microbiology Specimen Brush (Medi- Tech) is advanced through the aspirating channel of the bronchoscope until it extends just beyond the tip of the bronchoscope into the localized segment. A I6-gauge needle, 3.4 em long, is snugly fitted into the proximal end of the protective sheath (Fig 1). Smaller gauge needles or sheaths have not proven effective for the instillation of contrast material. This modification protects the bronchoscope from direct contact with the contrast material, Dionosil (a solution of organically bound iodine in peanut oil). The contrast material is prewarmed to 37°C in a water bath. It is diluted to a maximum of a 50:50 mixture with isotonic saline, stirred vigorously, drawn up into a 20-ml syringe, and directly instilled through the needle and sheath. To *F rom th e Pulmonary Dise ase Servic e , Department of Medicine, Walter Heed Army Medi cal Center, Washin gton , DC . and Uniform ed Services Univer sit y of th e Health Science s, Bethesda , Md . Th e opinions or assertions contained herein arc th e private views of th e authors and are not to be cons true d as official or as reflectin g the view s of th e Depa rtment of the Arm y or th e Department of Defens e . Reprint requests: Dr. Tenh older, Walter Reed Army Medical Genter, Washlngtoll , DG 20307·5001
776
FIGURE 2. Left lower lobe anteroposterior bronchogram demonstrating cylindrical bronchiectasis (case 1). Fiberoptic Bronchoscopy Combined with Bronchography (Koval et al)
DIS CUSSION
FIGURE 3. Posteroant erior chest roent genogram demonstrating left upp er lobe density (case 3). count and sweat chloride levels were normal. Quantitative assay of immun oglobulins revealed an isolated deficiency of IgA. Fiberoptic bronchoscopy combined with selective left lower lobe bronchography confirmed the diagnosis ofcylindrical bronchiectasis (Fig 2). The patien t has done well with daily chest physiotherapy. CASE
In order to limit th e am ount of contrast material used, ye t obtain hi gh-quality ana tom ic d etail, several techniques for bronch oscopy combined with sel ective bronchography have been proposed. In one method, after ro u tine flexibl e fiberoptic bronchoscopy is performed, the bronchoscope is us ed as a laryngoscope to guide a soft catheter through the vocal cords. " The bronchoscope is withdrawn, and prior to in stilling the contrast material, the catheter is fluoroscopically guided in to the se gme n t to be examined. Another m ethod e mp loys a modified Seldinger technique wherein a guide wire is p assed through the aspirating channel of the bronchosco pe into the seg men t to b e evaluated." The bronch oscope is withdrawn over the firmly held guide wire . A cathete r is advanced in to po sition over the wire , and th e guide wire is th en rem oved. Proper po sition is assess ed, and the contrast material is instilled with th e aid of fluoro scopy. More recently, direct instillation of contrast material through the aspirating channel of the bronchoscope has been advocated ." The ad van tages of bronchoscopy co mbine d with se lec tive b ron chography have been previou sly d escribed. Pati ents d o not have to undergo th e discomfort, p otential morbidity, and expense of two se para te procedure s.' Also, the relatively sm all amount of contras t m aterial us ed d ecreas es the risk to patients who have pulmonary or cardiac insuffi cien cy. 1 Our simplified techniqu e ha s three potential benefits: (1) pl ace m ent of the contrast-instilling catheter into the segment or
2
A 22-year-old man suffered a basilar skull fracture and loss of consciousness as a result of a motorcycle accide nt. He developed an empyema secondary to aspiration pne umonia. After parent eral treatment with antibiotics had failed, he underwent thoracotomy with open drainage. Prior to chest wall reconstru ction, a fistulagram was performed in order to ascertain the presence ofa bronchopleu ral fistula, but the stud y was technically limited and nondiagnostic. Bronchoscopy with selective right middle and lower lobe bronchography showed no evidence of a fistula. CASE
3
A20-year-old woman had been well until the age of12years, when she developed recurrent bronchitis. A chest x-ray film at that time showed a left upper lobar density. Bronchoscopy wasnondiagnostic, and subsequent x-ray films showed resolution of the density. At th e age of19 years, the patient developed cough and fever, and an x-ray film showed reappearance of the left upp er lobe density. Treatment with antibiotics resulted in partial clearing of this density, and bronchoscopy was again nondiagnostic, The patient was referr ed to our medical facility for further evaluation. Her chest roentgenogram showed a left upp er lobe density without interval change from the evaluation six months earlier (Fig 3). A comput erized tomographic scan suggested bronchiectasis and confirmed the presence of a homogeneous density in the left upper lobe. A complete blood cell count, quantitative assay of immunoglobulins, and sweat chloride levels were normal. Bronchoscopy combined with selective bronchography showed dilatation of bronchi, with a normal pattern of arborization. The bronchi circumvented the density, which did not fill with contrast material (Fig 4). At thoracotomy, performed for recurr ent infection, a mucus-filled bronchogenic cyst was removed with an apical segment ectomy.
FIGURE 4. Left upper lobe right anterior oblique bronchogram demonstrating noncontrast-filling lesion which is circumvented by dilated bronchi. Arrows demarcate boundary oflesion (case 3). CHEST I 91 I 5 I MAY, 1987
777
lobe to be exami ne d is done under direct vision, minimizing fluoro scopic expo sure to both patient and physician ; (2) th e risk of pneumothorax, reported with th e procedure employing a guide wire," may be diminished; an d (3) thc inner channel of the bron choscope can be b etter protect ed and requires no ad ditio nal tim e or effort to clean than if bronchoscopy alone were performed , Althou gh clinical cir cumstan ces and improved imaging methods have limited its usc , we use bronchoscop y with sele ctive bronchography in th e following three circum stances: First, it re mains our method of choice to definitively diagnos e the presence and extent of bronchiectasis. Although co mp ute rized tomo graphic scann ing may b e useful in th e diagnosis of cystic br on ch iectasis, it is unreli abl e in detecting cylind rical and vari cose changes.' Bronch ography, th erefore, is still rec ommended to exclude diffu se bron ch iectasis prior to surgical resecti on of localized affectcd are as. Secondly, bronchography may also be us ed to define the presence and course of a bronchopleuralIistula when other studies are nondiagnostic . A fistulagram performed in our se cond patient was technically difficult du e to th e pati en t's discomfort and th e larg e dcfect in th e ch es t wall. Th e selective bronchography was eas ily p erformed \ and well tolerate d by th e pati ent. Thi rd and finally, bron ch ography is useful in th e investigation of some parenchymal lesion s. Such lesions would include bronchogenic cysts , bronchopulmonary sequestration, congenital bronch ial atresia, an d an ectopi c bronchus.Y Case 3 ' illustrates th at th es e typ es of paren ch ymal lesion s are occasionally diagn osed, an d bronchial ana tomy detailed, without resorting to surgical inter-
9 Ristema GR . Ectopic right bronchus: indication for bronchography. AJR 1983; 140:671-74 10 American Thoracic Society/American Lung Association. Training programs in respiratory disease: 1986 (21st) edition, Am Rev Respir Dis 1986; 134:369-90
Nonpenetrating Traumatic Rupture of the Tricuspid Valve* Formation of Ventricular Septal Aneurysm and SUbsequent Septal Necrosis: Recognition by TwoDimensional Doppler Echocardiography William Berkery, M,D,;t Christopher Hare, B,S,;
Jl.obe-it A:Warner; M:0 .if ]osiiph-BCittagliCi;-r;rb.;t and]ames L . Potts, M.D.t
'f'
Our technique for broncho scop y with sel ective bronchography is easil y p erformed , has minimal risk, and produ ces high- q uality bronchograms. As th e guidelines of the American Th oracic Society prop ose I' and as selected cases ind icate, broncho scopy with se lective bronchograp hy should re main in th e arm am entarium of the trained bronc hoscopist. ACKNOWLE DGMENT: We thank Ms. Ruth D. Lumbar for typing the manuscript.
N
on pe netratin g traumatic r up ture of both the tricuspid valve and interven tricular se p tum is a distinctl y unusual p athologic even t, I To our kno wledge, this is the first re por t of the two-dimension al Doppler echocard iogra phic confirmati on of thi s condition , and it emphasizes th e utility of this noninvasive examinat ion in the dia gn osis and follow-up of patients with blunt myo cardial trauma.
REFERENCES
1 Fennessy JJ. Selective catheterization of segmental bronchi with the aid of a flexible fiberoptic bronchoscope. Radiology 1970; 95: 689-91 2 Schoenbaum SW; Pinsker KL, Rakoff SJ, Peavey RH , Koerner SK. Fiberoptic bronchoscopy: complete evaluation ofthe tracheobronchial tree in the radiology department. Radiology 1973; 109:571-75 3 Lutch JS, Ryan KG, Bronchography combined with bronchoscopy: a new method (letter to editor). Chest 1979; 75:108 4 Simelaro JP, Marks B, Meals R, Dickerson W. Selective bronchography following fiberoptie bronchoscopy (letter to editor). Chest 1979; 76:240-41 5 Wagner RB, Paidipaty BB. Another advantage of the flexible fiberoptic bronchoscope: an easytracheal cannulation in preparation for bronchography (letter to editor), Chest 1979; 75:108 6 Nakhosteen JA. Fiberoptic bronchoscopy, In: Simmons DR, cd. Current pulmonology Chicago: Year Book Medical Publishers, Inc, 1986; 7:241-72 7 Batcha K. Letter to the editor. Che~t 1980; 77:713 8 Muller NL, Bergin CJ, Ostrow ON, Nichols OM, Role of computed tomography in the recognition of bronchiectasis. AJR 1984; 143:971-76 778
CASE REPORT
A26-year-old man wasadmitted on April 5, 1985, following a highspeed deceleration injury, Initial evaluation revealed a contusion over the sternum, distended veins in the neck with prominent v waves, a right vent ricular S3 and S. gallop, and palpable v waves over the liver, There was no accompanying murmur, The peak level ofcreatine phosphokinase (CPK)was1,300IU, and a weaklypositive fluorescent MB band was present. The initial chest x-ray film was within normal limits. The electrocardiogram showed transient right bundle-branch block and multifocal premature ventricular contractions which suggested the possibility of myocardial contusion. An echocardiogram demonstrated a hyperdynamic right ventricle with paradoxic septal motion, flail tricuspid leaflets, and an echolucency consistent with a hematoma in the basilar portion of the septum . On April 8, 1985, the patient developed mild chest pain associated with tachypnea and hypotension. A loud pericardial friction rub was now audible. Right cardiac catheterization showed no evidence of a left-to-right shunt. A repeat two-dimensional Doppler echocar*From the State University of New York Health Science Center and Syracuse Veterans Administration Medical Centers, Syracuse, NY. t Clinical Assistant Professor of Medicine. tAssociate Professor of Medicine. Nonpenetrating Traumatic Ruptureof Tricuspid Valve (Berkery et al)