Incidence of Contralateral Pulmonary Atelectasis After Thoracotomy; An Evaluation of Preventive Aftercare

Incidence Incidence of of Contralateral Contralateral Pulmonary Pulmonary Atelectasis Atelectasis After Thoracotomy; Thoracotomy; An An Evaluation Evaluation of of Preventive Preventive Aftercare* P. A.

THOMAS" LT. COL." MC."

R. E.

LYNCH" .NCH, M.D.** M.D.** AND AND

PhoenixviUe,,Pennsylvania Pennsyloania

C

E. M.D.t E. H. H. MERRIGAN" MERRIGAN, M.D.~

from from 17 17 to to 72 72 years. years. Men Men predominated predominated in in aa ratio ratio of of six six to to one, one, as as anticipated anticipated for for aa milmilitary itary practice. practice. Two Two operative operative procedures procedures were perfonned on six were performed on six of of the the individuals individuals included included in in the the study. study. Four Four of of these t h s e six six patients patients required required staged staged bilateral bilateral operations operations and and two two needed needed staged staged unilateral unilateral operaoperations. tions. Two Two patients patients succumbed succumbed within within 30 30 One died of bronchodays of operation. days of operation. One died of bronchopleural pleural fistula fistula and and empyema empyema three three weeks weeks after after post-irradiation post-irradiation pneumonectomy. pneumonectomy. The The second second death death resulted resulted from from precipitous precipitous hehepatic patic failure failure after after pneumonectomy. pneumonectomy. Surgery Surgery was was done done in in an an attempt attempt to to control control bronchobronchogenic genic carcinoma carcinoma in in both both instances. instances. ContraContralateral lateral pulmonary pulmonan atelectasis atelectasiswas was diagnosed diagnosed by by chest chest roentgenogram. roentgenogram. This This was was accomaccomplished plished by by review review of of comparative comparative pre-and pre-and daily daily postoperative postoperative chest chest roentgenograms roentgenograms without without reference reference to to the the clinical clinical condition condition of of the the patient. patient. Portable Portable roentgenograms roentgenograms of of these these patients patients were were made made daily daily until until chest chest drainage drainage tubes tubes were were removed, removed, or or for for the the first first week week after after operation operation ifif prolonged drainage drainage was was neces;ary. necessary. The The contralateral contralateral lung field field only only was was evaluated evaluated for for presence presence lung of of atelectasis atelectasisto to avoid avoid inaccurate interpretainterpretation tion of of surgically surgically induced induced changes changes roentroentgenographically apparent apparent in in the violated genographically pleural space. space. The The appearance of any any 22 to pleural mm thick horizontal horizontal ororcurvilinear curvilineartisc;ue tissue 33 nun density tapering tapering peripherally peripherally was was judged density to to be be atelectasis. atelectasis. A retrospective retrospective review review of of postoperative postoperative A MATERIAL AND MATERIAL AND METHODS METHODS chest roentgenograms roentgenograms after after 84 consecutive consecutive chest One One hundred hundred ninety-two ninety-two patients patients who who thoracic thoracic procedures procedures was was made made as as an an initial initial submitted to to 198 198 thoracic thoracic operations operations at at this this submitted survey. This This was was accomplished accomplished to to establish establish survey. hospital during during the the period period July July 15, 15, 1963 1963 the hospital the incidence incidence of of post-thoracotomy post-thoracotomy contrathrough through April April 13, 13, 1966 1966 were were included included in in lateral lateral pulmonary pulmonary atelectasis. atelectasis. Postoperative Postoperative the study. studv. The The ages aees of of these these patients oatients ranged ranmd the nursing care care included included frequent frequent assisted assisted nursing *From *Fmm the the Department Dcp~mncntof of Surgery, Surgul. Thoracic ~ h o r ~Surc G r - coughing, coughing, transnasal aspirations aspirations transnasal tracheal gery sery Service Senice and and Department Department of of Radiology, R.diolow, ValVdley and occasional occasionalbronchoscopy. &y Forge Forge General Cenenl Hospital. Hapitd. bronchoscopy. The The patients and .*Present address: add-: W a p c , Pa. R. **Present Wayne, to the the subsequent subsequent 84 84 thoracic thoracic submitting to submitting fPresent tPresent address: address: Teaneck, Teaneck, N. N. J. J.

ONTINUOUS EFFICIENT CONTINUOUS E F F I C I E N T TRACHEOBRONTRACHEOBRONchial chid toilet toilet after after thoracotomy thoracotomy isis uniunian important feature versally recognized as versally recognized as an important feature of of patient patient care care to to promote promote rapid rapid recovery mcovery of of respiratory respiratory stability stability and and prevent prevent comcomplication. This isis accomplished accomplished by by unhesiunhesiplication. This tating tating application application of of vigorous vigorous methods methods to to stimulate stimulate frequent f q u c n t cough cough and and deep deep breathbreathing. ing. The The contrast contrast between between the the aggressive aggmsive attitude attitude toward toward respiratory respiratory economy economy of of the the post-thoracotomy post-thoracotomy patient patient and and the the somesometimes times semi-neglectful semi-neglectful attitude attitude toward toward the the post-celiotomy postseliotomy patient, patient, may may be be strikingly strilingly demonstrated demonstrated by by the the incidence incidence of of roentroentgenographic .genographic atelectasis atelectasis occurring occumng in in these these two two groups groups of of surgical surgical patients. patienh A A prelimpdiinary inary prospective pmspectivc roentgenographic roentgenographic survey survey of of alxlominal abdominal surgery surgery cases cases attended attended at at this this hospital hospital revealed revealed aa 50 50 per per cent cent incidence inddence of of pulmonary pulmonary atelectasis.' atelectasis.' This This unacceptunacceptably ably high high rate rate of of pulmonary pulmonary complication complication was was favorably favorably influenced influenced by by adoption adoption of of an aggressive preventive preventive attitude attitude which which ininan aggressive ucol ytic cluded cluded administration administration of of the the m mucolytic agent agent acetylcysteine. acetylcysteine. By By impression, i m p k o n , the the inincidence cidence of of post-thoracotomy poet-thoracotomy atelectasis atelectasis did did not this ininnot seem seem to to be be alanning; alarming; however, however, this vestigation vestigation was was undertaken to to more more accuaccurately rately determine determine the the rate rate of of occurrence, occurrence, and to to assess the the clinical clinical usefulness usefulness of of the the and mucolytic agent, agent, acetylcysteine, acetylcysteine, employed employed mucolytic an adjunct adjunct in in management management of of thoracic thoracic sursuran gical gical patients. patients.

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Volume V o l u m 'I, 31. No.3 No. 3 Marcb. M.rrh. 1967 1%:

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PULMONARY PULMONARY ATELECTASIS ATELECTASIS AFTER AFTER THORACOTOMY THORACOTOMY

surgical surgical procedures procedures were were prospectively prospectively studied studied and and the the postoperative postoperative care care altered altered to to include include administration administration of of acetylcysteine. acetylcysteine. Immediately, Immediately, as as thoracotomy thoracotomy was was comcomPE 50 polyethylene catheter pleted, a pleted, a PE 50 polyethylene catheter was was percutaneously percutaneously placed placed in in the thetrachea tracheaasasdedescribed scribed by by Radigan Radigan and and King" King.' AcetylcysAcetylcysteine teine was was administered administered asas aa 10 10 per per cent cent solution ml every every solution through through the the catheter cathctcr 22 mI two two hours houn the the first first day day and and with with decreasdecreasing frequency thereafter for three ing frequency thereafter for three to to five five days days until until the the pleural pleural drainage drainage tubes t u b a were were removed removed or or drainage drainage subsided. subsided. Catheter Catheter placement placement failures failures and and complications complications among among the the treated treated patients patients were were insignifiinsignificant; however, premature dislodgement cant; however, premature dislodgementdid did occur The mucolytic mucolytic agent agent occur occasionally. occasionally. The was as an an aerosol aemsol by by interinterwas administered administered as mittent mittent positive positive pressure prssure breathing breathing appaapparatus the catheter catheter was was displaced displaced or or failed failed ratus ifif the to function. to function. Upon Upon completion completion of of the the aforementioned aforementioned series series of of cases, cases, postoperative postoperative management management was was modified modified to to permit permit administration administration of of the the mucolytic mucolytic agent agent by by intermittent intermittent posipositive tive breathing breathing apparatus. apparatus. Therefore, Therefore, in in the the final final 30 30 patients patients studied studied to to elicit elicit the the prepresence sence of of contralateral contralateral pulmonary pulmonary atelecatelec-

tasis, tasis, placement placement of of an an intratracheal intratracheal catheter was was not not employed; employed;however, however,the theamount and and frequency f q u e n c y of of 10 10 per per cent aeetylcysteine acctylcystcine administered administ& was was not changed. changed. RESULTS RESULTS The The relationship relationship between between the the various various surgical surgical procedures procedures and incidence incidence of of concontralateral pulmonary pulmonary atelectasis atelectasis in in the the cases cases studied studied isis presented presented in in Fig. Fig. 1. 1. A .4 higher incidence incidence of of atelectasis atelectasis seemed m e d to to attend attend lobectomy, q u a 1I frequency frequency lobectomy, but but with with ee qua whether whether patients patients received received acetylcysteine acetylcysteine or or not. not. The The addition addition of of the the mucolytic mucolytic agent administered administered in in the the manners mannen described described did did not not influence influence the the incidence incidence of atelectasis atelectasis remarkably, remarkably, either either within within groups groups of of patients similar operations, operations, or or betients having having similar tween tween the the treated trtated and untreated untreated groups. groups. For For the the total series serics of of 198 198 operative operative procedures cedures studied, studied, aa 14 14 per cent cent incidence incidence of contralateral, subsegmental roentgenogof contralateral, subacgmental roentgenographic raphic atelectasis atelectasis was was recorded. recorded. ContraContralateral lateral lobar lobar atelectasis atelectasis was was not not observed; ohxrved; however, however, ipsilateral ipsilateral collapse collapse of of aa complete complete lobe lobe was was noted noted on on two two occasions. occasions. DIsCUSSION DISCUSSION

Voluminous Voluminous literature literature has has accumulated accumulated on the the subject subject of of pulmonary pulmonary atelectasis. atelectasis. It It on

SlJlGICAL SRGICAL PROCEOt.R: FROCEOURE AN> AN) ~ OCtURRUrCE a= OF JaB.ECTASIS ATELECTAS6 (NO. (NO.CASES CASES WITH WITH ATELECTASISITOTAL ATELECTASWTOTAL CASES) CASES1

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THOMAS, THOMAS, LYNCH LYNCH AND AND MERRIGAN MERRIGAN

isis sufficient sufficient for for the the purpose purpose of of this this comcomthat hypoventilation munication to suggest munication to suggest that hypoventilation coincident coincident with with stagnation stagnation of of tracheobrontracheobronchial chid secretions secretions results results in in frequent frequent atelecatelectasis. A multitude multitude of of contributing contributing factors factors task. A may may be be present present in in aa given given patient, patient, such such as as preexisting preexisting respiratory respiratory disease, d i m , habitual habitual smoking, smoking, age, age, obesity, obesity, anesthetic anesthetic managemanagement, ment, incisional incisional pain pain and and reluctant d u c t a n t afteraftercare. care. However, However, atelectasis atelectasis can can be be minimminimized ized as as aa surgical surgical complication complication by by aggresaggressive sive attention attention to to the the importance importance of of immeimmediate diate adequate adequate elimination elimination of of tracheobrontracheobronchial chid secretions secretions and and frequent frequent ventilation ventilation of of the the entire entire alveolar alveolar bed. bed. It It isis of of interest interest to to observe o k r v e that that during during aa period period of of roentroentgenographic genographic survey survey in in this this hospital, hospital, the the inincidence cidence of of atelectasis atelectasis among among patients patients subsubmitting mitting to to abdominal abdominal procedures procedures was was 50 50 per per cent, cent, while while the the incidence incidence of of contralatcontralateral eral atelectasis atelectasis among among thoracotomized thoramtomized papatients tients was was considerably considerably le$. l m . Although Although these the are are not not comparable comparable observations, o b ~ e ~ a t i o nthe the s , same same nursing personnel administered postopernursing pemnnel administered p t o p e r ative ative care care to to all all of of the the patients. patients.The The adaddition dition of of therapeutic therapeutic mucolysis muwlysL after after ababdominal surgery surgery resulted resulted in in aa dramatic dramatic reredominal duction duction in in pulmonary pulmonary atelectasis, atelectasis, whereas whereas the the same same dramatic dramatic effect effect was was not not demondemonstrated after thoracotomy. strated after thoracotomy. Although Although itit was was hoped hoped that that aa reduced reduced incidence incidence of of atelectasis atelectasis after after thoracotomy thoracotomy might might result result from from the the addition addition of of mucolytic mucolytic therapy, therapy, the the outcome outcome was was not not completely completely unexpected. The The attention attention of of both both physiphysiunexpected. cians and and nurses nurses has cians has always always been been orientoriented toto the the respiratory respiratory function function of of the the thothoed racic surgical surgical patient. patient. racic Prompt elimination elimination of of tracheobronchial tracheobronchial Prompt secretions after after thoracotomy thoracotomy isis of of greatest greatest secretions importance. This This can can usually usually be be accomaccomimportance. plished by by ff rr ee que q u e nn tt assisted asdsted coughing, coughing, plished transnasal tracheal tracheal aspirations aspirations and and occaoccatransnasal sionally sionally bronchoscopy bronchmopy in in aa difficult difficult situasituation. tion. The The addition addition of of aa mucolytic mucolytic agent agent to promote promote rapid rapid transport transport of of secretions secretions to and and increase increase effectual effectual coughing coughing should should be be helpful. Acetylcysteine A c e t y l c r J t ~ ewas was selected selected for for this this helpful. purpose because because reported reported clinical clinical expeexpepurpose riences have have been been encouraging; encouraging; itit does docshave have riences

Diseases of the Chest

aa distinct distinct mucolytic mucolytic property property and and itit does docs on pulmonary not have a deleterious effect not have a deleterious effect on pulmonary 3 7 surfactant. surfactant.'"' This This study study did did not not demondemonstrate strate aa reduction reduction in in incidence incidence of of contracontralateral lateral atelecta~ atelecta* in in the the group group of of cases cam receiving receiving acetylcysteine. acetylcysteine. However, However, the the nurnursing care of treated cases was simplified. sing care of treated casa was simpliied. Direct Direct intratracheal intratracheal administration administration of of the the mucolytic mucolytic agent agent frequently frequently stimulated stimulated efeffective fective secretion-clearing secretion-clearing cough cough and and transtransnasal aspiration was was less less often often rerenasal tracheal tracheal aspiration quired. However, some patients complainquired. However, some patients complained ed of of nausea nausea and and anorexia, anorexia, attributed attributed to to the the constant constant offensive offensive odor odor and and taste taste of of acetylcysteine acetylclsteine administered administered in in this this way. way. Greater Greater patient patient acceptance acceptance of of the the mucolytic mucolytic agent agent given given by by intennittent intermittent positive positive presprcssure sure breathing breathing apparatus apparatus was was achieved. achieved.The The apparent apparent therapeutic therapeutic effectiveness effectiveness of of the the agent agent was was not not compromised compromised by by this this modmodification ification of of management. management. The The necessity deep ininnecessiv for for intennittent intermittent deep to avoid hypoventilatory spiration, sighing, spiration, sighing, to avoid hypoventilatory pulmonary pulmonary atelectasis atelectasis isis widely widely recognized recognized I However, by by anesthesiologists. anesthesi~lo~isu.' However, postoperapostoperative tive patients patients find find itit difficult difficult to to breath breath deepdeep ly ly even even when when encouraged encouraged to so. LogiLogito do do so. cally, cally, intennittent intermittent positive positive pressure prasure assisted misted breathing breathing should should overcome overcome resistance resistance to to full full inspiration. inspiration. However, However, clinical clinical investiinvestigations gations directed directed toward toward eliminating eliminating postpostoperative ploying assisted operative atelectasis atelectasis em employing assisted ventilation ventilation did did not not demonstrate demonstrate substansubstanI 1I • Intennittent tial tial benefit. benefit."" Intermittent positive positive pressure pmre the group breathing was freely employed in breathing was freely employed p u p of of cases cases reviewed retrospectively retrospectively who who did did not receive receive acetylcysteine. acetylcysteine. Direct Direct intraintratracheal tracheal instillation instillation of the the mucolytic mucolytic agent agent was employed to to eliminate eliminate any any complicompliwas employed mentary mentary benefit benefit of of positive positive pressure pressure breathing ing in in the the initial initial evaluation evaluation of of mucolysis. mucolysis. Up U p 0o nn completion completion of the comparative comparative study, study, the the program program of management management was was modified modified to to take take advantage of the the potenpotential tial benefits benefits of of both both ventilatory ventilatory assistance aetance and mucolysis. and mucolysis. It It isis interesting interesting to to observe observe that that through this this entire entire period period of special special interest interest and and emphasis emphasis on on postoperative postoperative pulmonary pulmonary atelatelectasis, the incidence incidence of this this complication complication ectasis,

Volume No.3 Volumc ~I. >I. Nu i March. March. 196':' 196'

PULMONARY AFTER THORACOTOMY THORACOTOMY PULMONARY ATELECTASIS ATELECTASIS AFTER

occurring occurring in in the the contralateral contralateral lung lung has has reremained mained constant. constant. Speculation Speculation as as to to the the exexplanation planation for for this this refractory refractory incidence incidence isis tempting. tempting. Presumably, Presumably, recognition recognition of of the the magnitude magnitude of of the the problem problem and and appropriate appropriate therapeutic therapeutic measures measures are are sufficient sufficient to to avoid avoid progression to more serious and threatenprogression to more serious and threatening ing complications. complications. At At the the present p m t time time we we reserve reserve placement placement of of aa transtracheal transtracheal cathcatheter probeter for for patients patients in in whom whom aa difficult difficult probis anticipatlem in tracheobronchial toilet lem in tracheobronchial toilet is anticipated ed or or develops develops in in the the postoperative postoperative period. period. SUMMARY SUMMARY A A comparative comparative investigation investigation of of the the inincidence cidence of of contralateral contralateral roentgenographic roentgenographic pulmonary pulmonary atelectasis atelectasis was was made made in in three three groups groups of of post-thoracotomy post-thoracotomy cases. cases. The The rust first 84 cases received adequate aftercare with 84 cases received adequate aftercare with good good tracheobronchial tracheobronchial toilet toilet without without ememphasis phasis on on mucolysis. mucolysis. The The second second 84 84 cases caw received received acetylcysteine acetylcpteine administered administered by by didirect rect intratracheal intratracheal instillations instillationsin in 10 10 per per cent cent concentration concentration in in addition addition to to accepted accepted afaftercare. tercare. The The third third group group of of 30 30 cases cases rereceived ceived the the mucolytic mucolytic agent agent administered administered by intermittent intermittent positive positive pressure pressure breathing breathing by apparatus. The The incidence incidence of of contralateral contralateral apparatus. pulmonary pulmonary atelectasis atelectasis for for the the total total series series of cases cass was was 14 14 per per cent cent and and did did not not vary vary of signir~canty between between the the groups groups studied. studied. significanty The incidence incidence of of atelectasis atelectasis isis recognizably recognizably The related to to moment moment by by moment moment supervision supenision related of tracheobronchial tracheobronchial toilet toilet after after thoracotthoracotof om!., rather rather than than aa specific specific technique technique or or omy, therapeutic agent. agent. However, However, the the addition addition therapeutic of acetylcysteine acetylcysteine may may be be aa valuable valuable adadof junctive agent agent to to promote promote easier easier and and more more junctive rapid elimination elimination of of undesirable undesirable secretions. secretions. rapid

A C K N O W L ~ ~ ; ~ The M The ~ Nacetylcysteine acetylcpteine T: (Mu. ACKNOWLEDGEMENT: (Mucomyst) thia investigation investigation was wan supplied supplied comyst) used ured in in this by Dr. Dr. Max M u D. D. Davis, Davis,Associate Anocinte Medical Medical Director Dimtor, by Mead-Johnson ' Mead-Johnson Laboratories. Laboratories. RESUMEN Resu~e

n

En tres tres grupos grupos de de post-toracotomizados post-toracotomhados se w En

practic6 practic6 lala investigaci6n investigaci6n sistematica sistemltica radiol6gica radiol6gica de de la la atelectasia atelectasia contralateral. contralateral. Los Los 84 84 primeros primems recibiemn tratamiento tratamienro postoperatorio postoperatorio adecuado adecuado recibieron con con efectiva efectiva toilet toilet traqueobronquial, traqumbronquial, sin sin insisinsistencia Lo, tencia en en elel empleo empleo de de agentes agentcs mucoUticos. mucoliticos. Los segundos 84 84 casos caws recibieron rccibieron acetilcysteina acetilcysteina admiadmisegundos ninvada por por instilaci6n instilaci6n directa directa uaqueo-bronquial traqueo-bronquial nistrada en concentraci6n concentraci6n al al diez d i n por por dento, ciento, ademas ademis de de en

29 29'1

la grula debida debida atend6n atenci6n postoperatorio. postoperatorio. EI El tercer tercer grupo po de de 30 30 casas cams recibi6 recibi6 el el agente agente mucoUtico mucolitico adadministrado minirtrado por por medio medio del del aparato aparato de de respirarespiraci6n ~ O S ~ U Mintermitente. intermitente. La La inclincici6n aa presi6n presi6n positiva dencia dmcia de de atelectasia atelectasia pulmonar pulmonar contralateral contralateral en m el el total total de de casos casos fue fue de de un un catorce catorce por por ciento, ciento, sin sin variaclones variaciones signilicativas significativas entre entre los 10s distintos distintos grupos. grupos. La La incidencia incidencia de de atelectasia atelectasia esta esth relarelacionada cionada con con la la atenci6n atenci6n sostenida sostenida aa la la toilet toilet traqueobronquial traqueobmnquial en en el el postoperatorio postoperatorio de de los Ion tratraqueotomizados, queotomizados, mas m& bien bien que que con con tecnica tCcnica alguna alguna oo con con el el empleo empleo de de determinado determinado agente agente teraterapeutico. Sin embargo, embargo, la la adici6n adici6n de de acetylcisteina acetylcisteina pCutico. Sin puede puede ser ser 6tH htil en en cuanto cuanto aa facilitar facilitar la la eliminacliminaci6n ci6n rapida rlpida de de secreciones secreciones perjudiciales. perjudiciales. ZUSAMMENFASSUNG ZUSAMMENFASSUNG In In 33 Gruppen Gruoven von von Patienten Patienten nach nach ThorakoThorakotomie tomie wurde wurde eine eine vergleichende vergleichende Untersuchung Untenuchung angestellt anpestellt iiber iiber das das Vorkommen Vorkommen kontralateraler, kontralateraler. pulmonales r6ntgenologiwh erfaPter erfaoter Atelektase. Atelektaw. pulmonales rontgenologisch Die Die ersten errten 84 84 Patienten Patienten erhielten erhielten eine einr entspreentsprechende chende postoperative postoperative Betreuung Betreuung mit mit befriedibefriedigender gender Toilette Toilette des des Tracheobronchialbaums Trachmbmnchialbaums ohne, ohne, da~ dap auf auf die die Mucolyse Mucolyre besonders besonden geachtet geachter worden worden ware. wire. Die Die zweiten nveiten 84 84 Faile FBlle bekamen bekamen AcetylcysAcetylcystein tein und und zwar m a r durch durch direkte direkte intratracheale ~ntratrachealeInsInstallationen N tallationen einer einer 10% 10% igen igen LOsung G s u n g zusatzlich zusiulich zu der der anerkannten anerkannten postoperativen postoperativen Betreuung. Betreuung. Die Die dritte dritte Gruppe Gruppe von von 30 30 Patienten Patienten erhielt erhielt einen einen schleimlOsenden whleimlosenden Stoff, Stoff, der der durch durch ein ein Gerat Gerit mit mit intennittierender intermittierender positiver positiver Druckatmung Druckatmung zugezugefiihn fiihn wurde. wurde. Das Das Vorkommen Vorkommen einer einer kontralatekontralateralen ralen pulmonalen pulmonalen Atelektase Atclektase lag lag fUr fiir die die gesamte gesamte Fallreihe Fallreihe bei bei 14% 14% und und zeigte zeine zwischen m k c h e n den den eineinzelnen zehen Gmppen Gruppen keine keine signifikanten signifihnten Variationen. Variationen. Das Dar Vorkommen Vorkommen einer einer Atelektase Atelektase ist ist wie wie leicht leicht zu N erkennen erkennen ist, ist, eng eng verkniipft verkniipft mit mit der der pausenpauwnlosen losen Oberwachung Ubewachttng der der Toilette Toilette des des TracheaTrachmbronchialbaumes bronchialhaumes nach nach der der Thorakotomie Thorakotomie und und zwar m a r in in weit weit starkerem starkerem AusmaP Ausmap als als die die im im eineinzelnen echnik oder zelnen angewandte angewandte TTechnik oder das das Heilmittel Heilmittel angeht. angeht. Es k.ann kann jedoch jedoch der der Zusatz Zusatz von von Acetylcystein Acetylcywein Es eine eine weetvolle weetvolle Unterstiitzung Untentiiuung darstellen, darstellen, urn um eine eine leichtere leichtere und und schnellere rchellere Elimination Elimination unerwiinschunemiinschter ter Seluetbildungen Sekretbildungen zu zu fOrdem. fordem.

..

REFERENCES Re~eaeNcea 11 THOMAS, P. TEOMAS, P. A., A,, LYNCH, LYNCB.R. R.E. E.AND AND MERRIGAN, MEWOAN. E. E. H. H.:: "Prevention "Prevention of of postoperative pmtopentive pulmopulmonary nary atelectasis," atelectaria," .dm. Am. Sur,., Surg., 32:301, 32:301, 1966. 1966. 22 RADIGAN, L. RW~OAN, L. R. R. AND AND KINO, &NO, R. R D.: D.: "A "A techtechnique nique for for the the prevention prevention of of postoperative patoperative atelatelectasis," Surg., 47:184, 47: 184, 1960. 1960. ectasir," Sur,., 33 REAs, R e ~ s H. ,H. W.: W.: "The 'The effect effect of of n-acetylcysteine n-accfylcptche on on the the viscosity virwity of of tracheobronchial tracheobmnchid secretions mretiom in cystic cystic fibrosis fibrosis of of the the Pancreas," Pancreas," ]. I. P.tl., Psd.. in 62:31, 62:31, 1963. 1963. 44 FINLEY, FINLEY,T. T. N.: N.: "Pulmonary "Pulmonarg surface surface activity activity and and the the problems problem of of atelectasis, atelectasis, wetting, wetting, foamfoaming detergency in in the the lung," lung," A1Iesth,sitJ Anrrthaia ing and and detergency and Anal,.sia, Analgesia, 42:35, 42:35, 1963. 1963. and

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5 THOMAS, T a o u s , P. A. AND AND TIlBA8UU, T u ~ r u n r . , R. L.: L.: "Effect of n-acctyl-l-cpteine n-acetyl-I-cyateine on pulmonary IUI'mrpulmface face activity," activity;' Am. Rev. Res,. Rasp. Dis., DL., 94: 94: 175, 1966. 6 POPPE, J. K.: "Clinical "Clinical experiences with acetyl.cetylPOPPE.J. cysteine M a mucolytic mucolpk qent," writ," Dis. DL. Chest, Chart, 46: cystcine as

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Cfi lOCA 66, "-, 1964. 7 WEBB, Weea, W. R.: R : ''Clinical 'Clinical evaluation of a new mucolytic asent, agent, acetyIC}'lteine," wtylcyrtcine," ]. Tho,4&ic and Ca,diovasc. Cardiouas. Su"., Surp.. 44:330, 44:330, 1962.

Diseases of

D8~1ln thr ol tM Chnf Chest

9 SANDS, ARMSTRONG, R., CYPERT C., AIYSTIONO, SANDS,J. H., CYPERT CWNG, QUINN, W. AND CHINO, S., TRAINER, TRAINEE, D., QUINN, AND STEWARD, using murouSTEWARD,D.: "A "A controlled study study tuing positive prevure preuure breathing tine intermittent intermittent poritive in the po~t-wrgical post-surgical patient," patient," DL. Dis. Chest, Chssl, 40: 128, 1961. 10 BECKER, BARACK, BRAUN, E. AND AND Becren, A., B A R A C K ,S., BRAWN, MEYERS, M. P.: treatment of postoperMevars, P.: "The "The tmatmcnt of portoprative pulmonary ntclecta*r atelectasis with intermittent intermittent positive pressure breathing," breathing," Surg., Su"., Gynec. poritive prrrmrr Cynsc. :517, 1960. and Obst., Obrt.. 111 111:517,

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8 BENDIXEN, BENDUSN, H. H., HEDLEy-WHYTE, H K D L E Y - W x m ,J. AND LAVER, L v a n , M. B.: B.: "Impaired "Irnplirrd oxy,enation oxygenation in IUI'surgica1 gical patients patimu during seneral wmnl anesthesia m u t h u i a with controlled ventilation," Eng. ]. I. M.d., Med., ventilation," Nn» New Era,.

269:991, 269:991, 1963. 1963.

For reprints, Thomas, Valley reprints, please write: Col. Thomas. Forge General Hospital, H a p i d , Phoenixville, Phoenimillc, Pa.

GONADOTROPIN-PRODUCING CONADOTROPIN-PA.ODUCING CARCINOMAS blood were available, aet1vlty wlu W88 ra reavailable. gonadotropic gonadomple aetlvlty covered w e d from fmm lung tumor (three (three cases) -) and from plasma (two cases). pituitary glands from three cases).The pltulUry fmm Uuw patients were studied of the patients studled and showed depletion of % gonadotropic Urinary estrogens were o W o t r o p l ~activity. actlvlty. Urlaary determined patients and were Increased. Increased. deterrmned In three three patlent. These carer cases probably represent first davmew documenThese rep-nt the flmt ted Led examples of gonadotropin gohadotmpln production by a bronbmb chogenic earclDoma. chosenle aubnoma.

Four men smokers rmakan with wlth C)'IIeClOIDUtIa .yoaomutll bad had el1Ddl%leal l a 1 findings f1ndIr.g~ typical t y p l d of bI'ondlogeD1e bmndmgclllc earelDoma. cudnonu. Necropsies ml~ Neemprl- were done In eaeb aeh cue. err. Some mlacscopic ebortocardm p l e sectlons seaions of of the tumor l'NeIDbled -bled dwuocardnoma. of the testes renoma. but serial seNaI sections &OM t e M . taUed laUed to rrveal tumor or "burned-out" "burnebout" eborloearc1Doma c i w r l o a r d m r ~ and extensIve dld not yield yleld evl4ence evldenn of extraextenrlve search did genltal patboloale cUaagLMW trophoblastic Mphoblastle neoplasia. n m p b l a . The The pathologic d h nom nose In in each ease au W88 w- IlIUlplut1e l ~ l p l u t l cJarKe-cell hrse-eu carcicudnoma of the luna. gonad~ lung. UrlDary UNnary exc:retlon exmetlon of p omdp tropic h all aU four patients, patlent.. Mplc activity actlvity W88 was elevated elwated In but not In ten others with bronebolenle bmnchoyenlc cardnoma -1noma who did have lYDecomaatla. gyneeomuu. When tlIsue Uvue and md dld not have

Fusco, P. F. D. AND ROSEN, S. "Gonadotropin·produc. FUICO. AND RMEH, 5. W.: "COnadotcopio.pd~d~(ing aaaplastic luw*rll laqc

bgl. Mell., 275:'07, h g l . ]. I . Mld.. 27>:507. 1966. 1%5.

EXTRINSIC COMPRESSION OF O F ESOPHAGUS BY TUBERCULOUS ADENOPATHY nodes and extramumbal extramucosal esophagorraphy The authors report aa cue oue of dyspbaala dyapb..la due to esophagomphy of of the muscular layers successfully carried extrinsic In of the the esophqus es0-s In a 22302layern were sumssfully -led out. The extrlnrle compression mnpreulon of diagnosis and therapy discussed. year old woman. woman. The The compresalon emngrsnlon W88 w u caused mused by dlagnosls therapy are am dlmssed. aa tubemlous tuberculous subcarlnal mbavllul adenopathy. .denopathy. Radiologic Radlologle and FIGUDOA, VILUGAS, A. H.: exesophqc)scople FBcuano*. M. M. A, A. AND *NO Vlrracu. H.: "Compresioa "Comprnion ex. esopbagorople fln4lnIrs flndtnpl were consistent mmlment with wlth aa triDSCCI del Ideaopltia tubcdma." tubaculosa." PI-. Pm. benign benlgn Intramural lnwamunl tumor, tumor. RIght FLUht thoracotomy, thoramtomy, empbnoph usarc. &I aofllO mhw pporr admopaw M,Il, kg",';.., )3:1166. B:1266, 1966. qolysis, block resection agolY.I~. black MeUm of ai the the subcarlnal mbcarlnd lymph M d . AI~RUU. I*.

-

PULMONARY ALVEOLAR PROTEINOSIS PROTElNOSlS A case protelDosls, pulease of pulmonary alveolar d v m m pmtelrmls, -1-

monary nocardlosls leukemeardlOlls and c:bronle EhlOtlle graDulocytle -uloeyUc leuke mia Is reported. ThIs Thlr Is 1. the tbe Orst Urn cue reported from flUU8 mla 1s Puerto In Puelto Rico Rlm and the alxth .Lrth I n which whlch pulmonary alveolar protelnoals pulpmtelnosis has hsl been eompUcated mmpllated by pub monary nocardlolls. noeardlodr. ThIs Thlr case oue supports w p p o N the concept mnfept

that thls this association enhanced susceptibilUlat auoelatlon Is one of enhand msceptlbllIty lty to infection lnfemon by spectflc sDeclfle agents. N.v.nNEZ·MALooNAOO, M. N. AND Lunuz Dt DE AMLLANO. AuLl.ANO, bf*.Tl~KZ.LLuoo~loo, *No R*Y1SS2 G. alveolar p pro eio nos nocardiosis snd and C.:: "Pulmonary "Pul-uy drro1.r r o rt c a s i s• •. nw.rdaaais graaulocytic lmkem*." leukemia," S So.tlHrrl M,Il. ]., cchronic bmic 8tmulqic o . l k n MIJ. I.. 59:901, >9:901. 1966. 1966.