- Email: [email protected]
Selective bronchial intubation for treatment of localized pulmonary emphysema
860
Editorial correspondence
without simultaneous tracing of inspiratory and expiratory flow or tidal volume, does not allow the determination of pleural pressure at end expiration. The peaks of the esophageal pressure tracing can be altered by active expiratory effort, and this can be increased by CDAP. Therefore, these peaks may reflect not only the changes in pressure transmission, but also this increase in expiratory effort. 77lo Gerhardt, M.D. Assistant Professor of Pediatrics Eduardo Bancalari, M.D. Associate Professor of Pediatrics Department of Pediatrics Division of Neonatology P.O. Box 520875, Biscayne Annex Miami, FL 33152 REFERENCES
1. Bonta BW, Nany R, Warshaw JB, and Motoyamar EK: Determination of optimal continuous positive airway pressure for the treatment of RDS by measurement of esophageal pressure, J PEmATR 91:449, 1977. 2. Bancalari E, Garcia OL, and Jesse M J: Effects of continuous negative pressure on lung mechanics in idiopathic respiratory distress syndrome, Pediatrics 51:485, 1973. 3. Yu VYH, and Rolfe P: Effect of continuous positive airway pressure breathing on cardiorespiratory function in infants with respiratory distress syndrome, Acta Pediatr Scand 66:59, 1977. 4. Herman S, and Reynolds EOR: Methods for improving oxygenation in infants mechanically ventilated for severe hyaline membrane disease, Arch Dis Child 48:612, 1973. 5. Fenn WO, and Rahn H: Handbook of physiology, Section 3: Respiration, Vol 1. American Physiological Society, Washington, D.C. 1964.
Repty To the Editor: The measurement of esophageal pressure (Pes) gives a good indication of changes in pleural pressure (Ppl), particularly in lateral positions. In supine position, however, Pes tends to be higher than Ppl because of esophageal compression by the mediastinal viscera? Thus the calculation of lung compliance using the supine Pes values may be misleading. With the increment of continuous positive airway pressure (CPAP) in a low function residual capacity (FRC) state, such as in idiopathic respiratory distress syndrome (1RDS), lung compliance should increase as FRC increases toward the normal level. This increase in compliance is in part the result of the recruitment of previously collapsed alveoli and in part due to the pressure-volume characteristics of the lung. Such increases in compliance have been reported. 2 In our study lung compliance appeared to be increased with CPAP although it was not measured directly. One supportive evidence is that changes in esophageal pressure during the respiratory ~ycle (APes) decreased in most cases at or near optimal CPAP. This dbservation is at variance with that of Bancalari et aP with continuous
The Journal of Pediatrics May 1978
negative pressure (CNP) in which APes increased and calculated compliance decreased. Their findings might have been due to upper airway obstruction caused by the collar around the neck, which would increase APes. Dynamic compliance would also decrease if CNP or CPAP exceeds the optimal pressure and the airspaces become overdistended. There is no evidence to support the idea that an increase in the end tidal Pes at optimal CPAP was the result of increased active expiratory effort. Such a pattern of breathing would increase APes; it was decreased in our study. Obviously, further studies are needed to examine accurately the changes in FRC and lung compliance below and above the optimal CPAP. In such studies Pes has to be measured in lateral positions. Etsuro If. Motoyama, M.D. Associate Professor of Anesthesiology and Pediatrics Director, Pediatric Pulmonary Laboratory Yale University School of Medicine 333 Cedar St. New Haven, CT 06510 REFERENCES
1. Milic-Emili J, Mead J, Turner JM, and Glauser EM: Improved technique for estimating pleural pressure from esophageal balloons, J Appl Physiol 19:207, 1964. 2. Suter PM, Fairley HB, and Isenberg MD: Cardiopulmonary effects of PEEP in respiratory failure, N Engl J Med 292:284, 1975. 3. Bancalari E, Garcia OL, and Jesse M J: Effects of continuous negative pressure on lung mechanics in idiopathic respiratory distress syndrome, Pediatrics 51:485, 1973.
Selective bronchial intubation for treatment of localized pulmonary emphysema To the Editor: Brooks and associates recently reported the use of selective right mainstem bronchus intubation in the management of pulmonary interstitial emphysema. It has been our experience that in addition to the selective intubation of the right mainstem bronchus, the left may also be selectively intubated. This approach would be utilized in patients with overdistension of the right lobe or lobes with shift of the mediastinum causing atelectasis on the left. Technically, it is more difficult on the left but still is accomplished with little extra equipment. The first time we selectively intubated the left mainstem bronchus, the procedure was accomplished under fluoroscopy. A piece of suture was anchored to the tip of the endotracheal tube. It was manipulated so tllat the tube turned into the left main stem. Subsequently, however, we have found this method too invasive and not very
Volume 92 Number 5
Editorial correspondence
practical. The method currently used is as follows: Careful measurement of the distance to the carina is made. The patient is then cautiously intubated with an endotracheal tube Of appropriate size. The tube is inserted with the tip and concave curve of the tube directed anteriorly. When it has been ascertained that the tip of the tube is at the carina (by approximating the measured distance), the endotracheal tube is slowly turned about 30 ~ to 45 ~ tO the left and slowly advanced. An associate may also turn the patient's head about 30 ~ to the right just prior to the turning of the endotracheal tube. A radiograph is then taken to ascertain the precise Position of the tube. We then follow the same precautions and procedures in management as those suggested by Dr. Brooks and associates. Gerald L. Dickman, D.O. 7532 N.W. 11 Oklahoma City, OK 73127 REFERENCE 1.
Brooks JG, Bustamante SA, Koops BL, Hilton S, Cooper D, Wesenberg RL, and Simmons MA: Selective bronchial intubation for the treatment of severe localized pulmonary interstitial emphysema in newborn infants, J P~OIATR 91:648, 1977.
Reply To the Editor: I appreciate Dr. Dickman's additional technical suggestions for intubation of the left bronchus. Chest auscultation has not been helpful to us in determining tube placement below the carina, since we have used this procedure only in severely affected patients with no clinical evidence o f air entry in the hyperinflated hemithorax. John G. Brooks, M.D. Assistant Professor Department of Pediatrics (Pulmonary) University of Colorado Medical Center 4200 E. Ninth Ave. Denver, CO 80262
Management of neonatal drug withdrawal To the Editor: During the last three years of managing and following prospectively an average of 52 heroin or methadone-addicted newborn infants per year at the Jefferson Davis Hospital, Houston, Texas (average deliveries 10,000 per year; 80% indigent black and Latin American population), we have documented only one seizure which could b e attributed solely to withdrawal.
861
At our nursery, infants are evaluated carefully for any symptoms of withdrawal in the delivery suite and the transitional nursery; even those who are asymptomatic are transferred automatically to one of the intensive care nurseries where evaluations of glucose, calcium, weight, vital signs, mottling, sweating, central nervous system irritability (hyper-reflexia, highpitched cry, tremors, hyperactivity, and irritability), gastrointestinal symptoms, and poor sucking are made routinely. We do not wait for gastrointestinal symptoms, hyperpyrexia, or severe manifestations of hyperexcitability before treating with paregoric. Possibly the high incidence of seizures (7.8% in the infants withdrawing from methadone; 1.2% in the infants withdrawing from heroin) in the study of Herzlinger, Kandall, and Vaughan 1 is due to: (1) more stringent criteria for the institution o f therapy, and (2) the use of nonphysiologic therapeusis; i.e. diazepam is not specific therapy for narcotic withdrawal, although it is certainly a proven anticonvulsant. Since diazepam use was discontinued after 1972, our major concern is that withdrawal symptoms in these infants (according to the authors' criteria for treatment, "progressive vomiting or diarrhea, hyperpyrexia, moderate or severe irritability and tremors, inability to sleep between feedings, or clinically apparent convulsions,") are allowed to progress to a rather severe degree before treatment is instituted, increasing the likelihood of Seizures and of further morbidity. Janette Goddard, M.D. Fellow, Pediatric Neurology Baylor College o f Medicine Geraldine S. Wilson, M.D. Assistant Professor o f Pediatrics Baylor College of Medicine Texas Medical Center Houston, TX 77030 REFERENCE 1.
Herzlinger RA, Kandall SR, and Vaughan HG Jr: Neonatal seizures associated with narcotic withdrawal, J PEDIATR 91:638, 1977.
Rep To the Editor: We thank Drs. Goddard and Wilson for their comments. Although our observed incidence of withdrawal-associated seizures conforms closely to published series, we recognize that other groups have observed lower incidences of such seizures. This may be related to a number of factors, such as exclusion of my oclonic jerks from the seizure group, nonrecognition of subtle seizures due to technique of care (e.g., swaddling of the infant in a darkened room), and geographic variations in maternal drug patterns. We cannot tell from the above letter whether any of these considerations apply. We agree that early institution of specific therapy might reduce the incidence of seizures. Since not all infants undergoing withdrawal will require treatment, however, and since treatment
Editorial correspondence
without simultaneous tracing of inspiratory and expiratory flow or tidal volume, does not allow the determination of pleural pressure at end expiration. The peaks of the esophageal pressure tracing can be altered by active expiratory effort, and this can be increased by CDAP. Therefore, these peaks may reflect not only the changes in pressure transmission, but also this increase in expiratory effort. 77lo Gerhardt, M.D. Assistant Professor of Pediatrics Eduardo Bancalari, M.D. Associate Professor of Pediatrics Department of Pediatrics Division of Neonatology P.O. Box 520875, Biscayne Annex Miami, FL 33152 REFERENCES
1. Bonta BW, Nany R, Warshaw JB, and Motoyamar EK: Determination of optimal continuous positive airway pressure for the treatment of RDS by measurement of esophageal pressure, J PEmATR 91:449, 1977. 2. Bancalari E, Garcia OL, and Jesse M J: Effects of continuous negative pressure on lung mechanics in idiopathic respiratory distress syndrome, Pediatrics 51:485, 1973. 3. Yu VYH, and Rolfe P: Effect of continuous positive airway pressure breathing on cardiorespiratory function in infants with respiratory distress syndrome, Acta Pediatr Scand 66:59, 1977. 4. Herman S, and Reynolds EOR: Methods for improving oxygenation in infants mechanically ventilated for severe hyaline membrane disease, Arch Dis Child 48:612, 1973. 5. Fenn WO, and Rahn H: Handbook of physiology, Section 3: Respiration, Vol 1. American Physiological Society, Washington, D.C. 1964.
Repty To the Editor: The measurement of esophageal pressure (Pes) gives a good indication of changes in pleural pressure (Ppl), particularly in lateral positions. In supine position, however, Pes tends to be higher than Ppl because of esophageal compression by the mediastinal viscera? Thus the calculation of lung compliance using the supine Pes values may be misleading. With the increment of continuous positive airway pressure (CPAP) in a low function residual capacity (FRC) state, such as in idiopathic respiratory distress syndrome (1RDS), lung compliance should increase as FRC increases toward the normal level. This increase in compliance is in part the result of the recruitment of previously collapsed alveoli and in part due to the pressure-volume characteristics of the lung. Such increases in compliance have been reported. 2 In our study lung compliance appeared to be increased with CPAP although it was not measured directly. One supportive evidence is that changes in esophageal pressure during the respiratory ~ycle (APes) decreased in most cases at or near optimal CPAP. This dbservation is at variance with that of Bancalari et aP with continuous
The Journal of Pediatrics May 1978
negative pressure (CNP) in which APes increased and calculated compliance decreased. Their findings might have been due to upper airway obstruction caused by the collar around the neck, which would increase APes. Dynamic compliance would also decrease if CNP or CPAP exceeds the optimal pressure and the airspaces become overdistended. There is no evidence to support the idea that an increase in the end tidal Pes at optimal CPAP was the result of increased active expiratory effort. Such a pattern of breathing would increase APes; it was decreased in our study. Obviously, further studies are needed to examine accurately the changes in FRC and lung compliance below and above the optimal CPAP. In such studies Pes has to be measured in lateral positions. Etsuro If. Motoyama, M.D. Associate Professor of Anesthesiology and Pediatrics Director, Pediatric Pulmonary Laboratory Yale University School of Medicine 333 Cedar St. New Haven, CT 06510 REFERENCES
1. Milic-Emili J, Mead J, Turner JM, and Glauser EM: Improved technique for estimating pleural pressure from esophageal balloons, J Appl Physiol 19:207, 1964. 2. Suter PM, Fairley HB, and Isenberg MD: Cardiopulmonary effects of PEEP in respiratory failure, N Engl J Med 292:284, 1975. 3. Bancalari E, Garcia OL, and Jesse M J: Effects of continuous negative pressure on lung mechanics in idiopathic respiratory distress syndrome, Pediatrics 51:485, 1973.
Selective bronchial intubation for treatment of localized pulmonary emphysema To the Editor: Brooks and associates recently reported the use of selective right mainstem bronchus intubation in the management of pulmonary interstitial emphysema. It has been our experience that in addition to the selective intubation of the right mainstem bronchus, the left may also be selectively intubated. This approach would be utilized in patients with overdistension of the right lobe or lobes with shift of the mediastinum causing atelectasis on the left. Technically, it is more difficult on the left but still is accomplished with little extra equipment. The first time we selectively intubated the left mainstem bronchus, the procedure was accomplished under fluoroscopy. A piece of suture was anchored to the tip of the endotracheal tube. It was manipulated so tllat the tube turned into the left main stem. Subsequently, however, we have found this method too invasive and not very
Volume 92 Number 5
Editorial correspondence
practical. The method currently used is as follows: Careful measurement of the distance to the carina is made. The patient is then cautiously intubated with an endotracheal tube Of appropriate size. The tube is inserted with the tip and concave curve of the tube directed anteriorly. When it has been ascertained that the tip of the tube is at the carina (by approximating the measured distance), the endotracheal tube is slowly turned about 30 ~ to 45 ~ tO the left and slowly advanced. An associate may also turn the patient's head about 30 ~ to the right just prior to the turning of the endotracheal tube. A radiograph is then taken to ascertain the precise Position of the tube. We then follow the same precautions and procedures in management as those suggested by Dr. Brooks and associates. Gerald L. Dickman, D.O. 7532 N.W. 11 Oklahoma City, OK 73127 REFERENCE 1.
Brooks JG, Bustamante SA, Koops BL, Hilton S, Cooper D, Wesenberg RL, and Simmons MA: Selective bronchial intubation for the treatment of severe localized pulmonary interstitial emphysema in newborn infants, J P~OIATR 91:648, 1977.
Reply To the Editor: I appreciate Dr. Dickman's additional technical suggestions for intubation of the left bronchus. Chest auscultation has not been helpful to us in determining tube placement below the carina, since we have used this procedure only in severely affected patients with no clinical evidence o f air entry in the hyperinflated hemithorax. John G. Brooks, M.D. Assistant Professor Department of Pediatrics (Pulmonary) University of Colorado Medical Center 4200 E. Ninth Ave. Denver, CO 80262
Management of neonatal drug withdrawal To the Editor: During the last three years of managing and following prospectively an average of 52 heroin or methadone-addicted newborn infants per year at the Jefferson Davis Hospital, Houston, Texas (average deliveries 10,000 per year; 80% indigent black and Latin American population), we have documented only one seizure which could b e attributed solely to withdrawal.
861
At our nursery, infants are evaluated carefully for any symptoms of withdrawal in the delivery suite and the transitional nursery; even those who are asymptomatic are transferred automatically to one of the intensive care nurseries where evaluations of glucose, calcium, weight, vital signs, mottling, sweating, central nervous system irritability (hyper-reflexia, highpitched cry, tremors, hyperactivity, and irritability), gastrointestinal symptoms, and poor sucking are made routinely. We do not wait for gastrointestinal symptoms, hyperpyrexia, or severe manifestations of hyperexcitability before treating with paregoric. Possibly the high incidence of seizures (7.8% in the infants withdrawing from methadone; 1.2% in the infants withdrawing from heroin) in the study of Herzlinger, Kandall, and Vaughan 1 is due to: (1) more stringent criteria for the institution o f therapy, and (2) the use of nonphysiologic therapeusis; i.e. diazepam is not specific therapy for narcotic withdrawal, although it is certainly a proven anticonvulsant. Since diazepam use was discontinued after 1972, our major concern is that withdrawal symptoms in these infants (according to the authors' criteria for treatment, "progressive vomiting or diarrhea, hyperpyrexia, moderate or severe irritability and tremors, inability to sleep between feedings, or clinically apparent convulsions,") are allowed to progress to a rather severe degree before treatment is instituted, increasing the likelihood of Seizures and of further morbidity. Janette Goddard, M.D. Fellow, Pediatric Neurology Baylor College o f Medicine Geraldine S. Wilson, M.D. Assistant Professor o f Pediatrics Baylor College of Medicine Texas Medical Center Houston, TX 77030 REFERENCE 1.
Herzlinger RA, Kandall SR, and Vaughan HG Jr: Neonatal seizures associated with narcotic withdrawal, J PEDIATR 91:638, 1977.
Rep To the Editor: We thank Drs. Goddard and Wilson for their comments. Although our observed incidence of withdrawal-associated seizures conforms closely to published series, we recognize that other groups have observed lower incidences of such seizures. This may be related to a number of factors, such as exclusion of my oclonic jerks from the seizure group, nonrecognition of subtle seizures due to technique of care (e.g., swaddling of the infant in a darkened room), and geographic variations in maternal drug patterns. We cannot tell from the above letter whether any of these considerations apply. We agree that early institution of specific therapy might reduce the incidence of seizures. Since not all infants undergoing withdrawal will require treatment, however, and since treatment