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The relief of severe intractable bronchial asthma with cyclopropane anesthesia
THE RELIEF ASTHMA
OF SEVERE WITH
INTRACTABLE
CYCLOPROPANE
BRONCHIAL
ANESTHESIA”
REPORT OF A CASE NATHANIEL
E.
RIIEYER,
M.D.,
AND
SEYMOUR
SCHOTZ,
M.D.
NEW YORK, N. Y.
A
VAR,IETY of procedures, as hypertonic dextrose solution int,ravenously, lipiodol intrabronchially, various barbiturates intravenously,l ether in oi1,2 and avertin rectally, have been used to relieve an asthmatic attack when the patient has apparently received no benefit from adrenalin. Occasionally one of these procedures may interrupt the attack, but, at times none of them seem to induce more than very slight or temporary improvement. In such cases Kahn4 has recommended inhalation anesthesia with ether to a surgical level. He reported a series of cases so treated with good results. Troisier and Bouquien” in 1931 reported three cases in which inhalation anesthesia with Schleich’s solution, an ether-chloroform-ethyl chloride mixture, was used to relieve bronchial asthma, with apparently good results. Confronted with a patient of severe intractable bronchial asthma in whom every attempt at relief had failed, and in whom signs of cardiac failure had begun to be manifest, we decided to try anesthetizing the patient to a surgical level with cyclopropane. This anesthetic was used because induction could be performed much more rapidly and with less irritation to the respiratory tract than with ether. Moreover, higher concentrations of oxygen in the anesthetic mixture capable of producing the desired muscular relaxation were possible. The result was dramatic. CASE
REPORT
Mrs. E. R., a 54-year-old white female, was admitted to the Second Division, Medical Service of the Lincoln Hospital, on March 8, 1938, with the diagnosis status asthmaticus. She had had six previous admissions for bronchial asthma since June, 193G, and with the last two was in status asthmaticus and refractory to adrenalin. Since 1932, following a severe cold, she began to have attacks of bronchial asthma, appearing frequently with the onset of an acute upper respiratory infection. usually these attacks mere relieved by adrenalin. During an episode in June, 1937, she became refractory to adrenalin and had to be hospitalized. At this time the spasm was relieved by morphine and sodium amytal, and the patient was discharged after adrenalin had begun to take effect. She was again hospitalized in November, 1937, in status asthmaticus, two months before the present admission. At this time adrenalin, atropine, intravenous 50 per cent glucose, barbiturates by mouth and vein, ether rectally and orally, and oxygen all failed to give relief. Avertin vvas given rectally in dosage of 70 mg. per kg. with remarkable improvement. Following this the patient responded to ephedrine and was discharged on this drug. *From
the Lincoln
Hospital,
New
York.
239
240
THE,
JOURKAL
OF
ALLERGY
The present attack started three weeks before admission, following an acute respiratory infection. She was getting less and less relief with adrenalin, and for three days before admission had had no relief. From March 8 to March 28 everything tried produced only slight or no improvement. Morphine, chloral hydrate, paraldehyde intramuscularly and intravenously, various barbiturates by mouth, ether in oil rectally, and avertin by rectum, all merely served to give the patient a few hours ’ rest. While sound asleep, under the effects of arertin, asthmatic wheezing could still be heard on auscultation of the chest. Moreover, calcium gluconate and 50 per cent glucose intrarenously, benzyl benzoate by mouth, cocaine insufflntions, aminophyllin, and oxygen, all gave very temporary or no results. On March 27, the patient began to go downhill. Cyanosis increased even in an oxygen tent, and the pulse began to mount, indicating cardiac weakness. The Department of Anesthesia was consulted, and the following morning the patient xss anesthetized with cyclopropane to deep second plane (Guedel), kept there for ten minutes, and then allowed The result was very striking. During the induction, which proceeded to awaken. very smoothly, the pulse dropped from 12ti to 92, the asthmatic breathing grad ually subsided, and IThen the desired level was reached, no wheezing could be heard. The patient recovered from the anesthetic in a few minutes, with no vomiting and with breathing very much improved. She began to cough up greenish-brown sputum. This was encouraged with steam inhalat,ion and expectorant mixtures, and from March 28 to April 1 I, at the time of discharge, she had no recurrence of asthma.
We believe that in certain cases of bronchial asthma where every other measure has failed, a general anesthetic to a reasonably deep surgical level may be indicated. Cyclopropane seems to he an excellent agent for this purpose. In a patient who is partly anoxic, in whom the bronchial tree is partially plugged with mucoid secretion, and with 1.11~cardiac reserve threatened, it can be given with high percentages of oxygen with little or no irritat,ion to the bronchial mucosa. It induces rapid anest,hcsia so that the patient’s cardiac reserve will not be further imposed upon by a long period of struggling, yet produces the clesired degree of relaxation. A case is presented where a severe intractable seizure of bronchial asthma was interrupted by the use of c~clopropane anesthesia. REFERENCES
1. Xaytum, C. Ii.: Bronchial Asthma: Relief of Prolonged Attack by Colonic Ether, M. Clin. North America 15: 201, 1931. 2. Fuchs, A. N.: Interruption of Asthmatic Crisis by Tribromethanol (Avertin), J. A~,LERW 8: 340, 1937. 3. Troisier, J., and Bouquien, Y.: Bull. et m&n. Sot. n&l. d. hop. de Paris 7: 311, 1931. 4. Kahn, I. S.: Surgical Anesthesia Deliberately Induced by Ether for the Semipermanent Relief of Chronic Intractable Bronchial Asthma, J. ALT,ERGP 6: 556, 1935; South. M. J. 30: 6, 609, 1937. 5. Farmer, L.: influence of Sarcotics on Anaphylactic Shock, J. Immunol. 32: 195, 1937. 141s~
STREET
AND CONCORD
AVEKUE
OF SEVERE WITH
INTRACTABLE
CYCLOPROPANE
BRONCHIAL
ANESTHESIA”
REPORT OF A CASE NATHANIEL
E.
RIIEYER,
M.D.,
AND
SEYMOUR
SCHOTZ,
M.D.
NEW YORK, N. Y.
A
VAR,IETY of procedures, as hypertonic dextrose solution int,ravenously, lipiodol intrabronchially, various barbiturates intravenously,l ether in oi1,2 and avertin rectally, have been used to relieve an asthmatic attack when the patient has apparently received no benefit from adrenalin. Occasionally one of these procedures may interrupt the attack, but, at times none of them seem to induce more than very slight or temporary improvement. In such cases Kahn4 has recommended inhalation anesthesia with ether to a surgical level. He reported a series of cases so treated with good results. Troisier and Bouquien” in 1931 reported three cases in which inhalation anesthesia with Schleich’s solution, an ether-chloroform-ethyl chloride mixture, was used to relieve bronchial asthma, with apparently good results. Confronted with a patient of severe intractable bronchial asthma in whom every attempt at relief had failed, and in whom signs of cardiac failure had begun to be manifest, we decided to try anesthetizing the patient to a surgical level with cyclopropane. This anesthetic was used because induction could be performed much more rapidly and with less irritation to the respiratory tract than with ether. Moreover, higher concentrations of oxygen in the anesthetic mixture capable of producing the desired muscular relaxation were possible. The result was dramatic. CASE
REPORT
Mrs. E. R., a 54-year-old white female, was admitted to the Second Division, Medical Service of the Lincoln Hospital, on March 8, 1938, with the diagnosis status asthmaticus. She had had six previous admissions for bronchial asthma since June, 193G, and with the last two was in status asthmaticus and refractory to adrenalin. Since 1932, following a severe cold, she began to have attacks of bronchial asthma, appearing frequently with the onset of an acute upper respiratory infection. usually these attacks mere relieved by adrenalin. During an episode in June, 1937, she became refractory to adrenalin and had to be hospitalized. At this time the spasm was relieved by morphine and sodium amytal, and the patient was discharged after adrenalin had begun to take effect. She was again hospitalized in November, 1937, in status asthmaticus, two months before the present admission. At this time adrenalin, atropine, intravenous 50 per cent glucose, barbiturates by mouth and vein, ether rectally and orally, and oxygen all failed to give relief. Avertin vvas given rectally in dosage of 70 mg. per kg. with remarkable improvement. Following this the patient responded to ephedrine and was discharged on this drug. *From
the Lincoln
Hospital,
New
York.
239
240
THE,
JOURKAL
OF
ALLERGY
The present attack started three weeks before admission, following an acute respiratory infection. She was getting less and less relief with adrenalin, and for three days before admission had had no relief. From March 8 to March 28 everything tried produced only slight or no improvement. Morphine, chloral hydrate, paraldehyde intramuscularly and intravenously, various barbiturates by mouth, ether in oil rectally, and avertin by rectum, all merely served to give the patient a few hours ’ rest. While sound asleep, under the effects of arertin, asthmatic wheezing could still be heard on auscultation of the chest. Moreover, calcium gluconate and 50 per cent glucose intrarenously, benzyl benzoate by mouth, cocaine insufflntions, aminophyllin, and oxygen, all gave very temporary or no results. On March 27, the patient began to go downhill. Cyanosis increased even in an oxygen tent, and the pulse began to mount, indicating cardiac weakness. The Department of Anesthesia was consulted, and the following morning the patient xss anesthetized with cyclopropane to deep second plane (Guedel), kept there for ten minutes, and then allowed The result was very striking. During the induction, which proceeded to awaken. very smoothly, the pulse dropped from 12ti to 92, the asthmatic breathing grad ually subsided, and IThen the desired level was reached, no wheezing could be heard. The patient recovered from the anesthetic in a few minutes, with no vomiting and with breathing very much improved. She began to cough up greenish-brown sputum. This was encouraged with steam inhalat,ion and expectorant mixtures, and from March 28 to April 1 I, at the time of discharge, she had no recurrence of asthma.
We believe that in certain cases of bronchial asthma where every other measure has failed, a general anesthetic to a reasonably deep surgical level may be indicated. Cyclopropane seems to he an excellent agent for this purpose. In a patient who is partly anoxic, in whom the bronchial tree is partially plugged with mucoid secretion, and with 1.11~cardiac reserve threatened, it can be given with high percentages of oxygen with little or no irritat,ion to the bronchial mucosa. It induces rapid anest,hcsia so that the patient’s cardiac reserve will not be further imposed upon by a long period of struggling, yet produces the clesired degree of relaxation. A case is presented where a severe intractable seizure of bronchial asthma was interrupted by the use of c~clopropane anesthesia. REFERENCES
1. Xaytum, C. Ii.: Bronchial Asthma: Relief of Prolonged Attack by Colonic Ether, M. Clin. North America 15: 201, 1931. 2. Fuchs, A. N.: Interruption of Asthmatic Crisis by Tribromethanol (Avertin), J. A~,LERW 8: 340, 1937. 3. Troisier, J., and Bouquien, Y.: Bull. et m&n. Sot. n&l. d. hop. de Paris 7: 311, 1931. 4. Kahn, I. S.: Surgical Anesthesia Deliberately Induced by Ether for the Semipermanent Relief of Chronic Intractable Bronchial Asthma, J. ALT,ERGP 6: 556, 1935; South. M. J. 30: 6, 609, 1937. 5. Farmer, L.: influence of Sarcotics on Anaphylactic Shock, J. Immunol. 32: 195, 1937. 141s~
STREET
AND CONCORD
AVEKUE