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A frequent complication in abdominal and thoracic surgery is bronchial obstruction by mucous secretion with atelectasis in a part of the lungs. The author introduces two patients and describes clinical symptoms and the possibility of false diagnosis. Prevention and therapy are discussed.
Forty randomly selected patients admitted for elective cholecystectomy were entered into the study after they have given informed consent. Arterial blood gas analysis, FVC and FEV1 were measured preoperatively and on the second postoperative day. Preoperatively and on the third postoperative day, roentgenograms of the chest were obtained. The frequency of administration of narcotics was recorded through day 3. The double-blind method selected 17 patients for infiltration of 50 milliliters of 0.25 per cent bupivacaine hydrochloride into the wound and 23 patients for infiltration of 50 milliliters of normal saline solution at the time of closure of the incision. In the saline solution group, postoperative FVC and FEV1 values were only 50 per cent of the preoperative levels (p less than 0.005), while in the bupivacaine hydrochloride group, the FEV1 value was 72 per cent of the preoperative values (p less than 0.05) and the FVC, 78 per cent (p less than 0.05). Roentgenographic evidence of atelectasis occurred postoperatively in four patients of the saline solution group and in only nine patients of the bupivacaine hydrochloride group (p less than 0.001). The saline solution group required 10.8 doses of narcotic through day 3 in contrast with 6.5 doses for the bupivacaine hydrochloride group (p less than 0.05). The hospital stay was 6.6 days for those in the saline solution group and 5.9 days for those in the bupivacaine hydrochloride group (p value, not significant). No complications occurred. Intraoperative infiltration of bupivacaine hydrochloride into the wound improves pulmonary function, reduces the incidence of atelectases and lessens the use of narcotics following cholecystectomy.
A concept of plate-like atelectasis in the corticomedullary junction of the lung is presented with illustrative case reports. Two processes can be considered as contributory causes: air trapping in the cortex of the lung and decreased distensibility of the whole lung due to interstitial infiltration.
A patient with deep vein thrombosis and pulmonary embolism was admitted after profuse hemoptysis. On the third day of heparin treatment intrabronchial bleeding recurred, leading to life-threatening atelectasis of the left lung. The bleeding coincided with a hypertensive attack. Intrabronchial bleeding after pulmonary embolisation is a rare but potentially lethal complication.
An atypical disturbance of ventilation supervening a pleural effusion may occur due to atelectasis by lung folding which is seen radiologically as a round image close to the chest wall with the appearance of a pseudo-tumour. The authors review the mechanisms and the clinical and radiological presentation of this disorder based on 7 cases and a review of the literature. The posterior basal type with adhesions to the chest wall are the most frequent. An intra-parenchymatous and a double-form are described. The diagnosis of this benign disorder is radiological. It is based on a characteristic displacement of the vessels and bronchi and associated pleural signs. Recognition of these signs avoids all invasive procedures.
This survey summarizes information on various factors that determine responses to hypoxic pulmonary vasoconstriction. The emphasis is on the clinical relevance of these responses for atelectasis. Flow diversion reduces the functional effect of lung collapse by redistributing the pulmonary blood flow so as to promote restoration of arterial oxygen tension. The factors shown to influence the outcome include size of the atelectactic segment, mixed venous oxygen tension, intrapleural and intraalveolar pressure (transpulmonary pressure), cardiac output, and pulmonary transmural vascular pressure.
A case is presented of a 28-year-old woman with right upper lobe atelectasis secondary to sarcoid adenopathy. As most chest surgeons and physicians would currently remove the offending lymph nodes for lung reexpansion and more definitive diagnosis, the case is considered primarily for its historical interest.
The effect of gravitation +Gz (2-8 Gz, 5 min) combined with air or pure oxygen breathing on the lung volume and expiratory airway closure was studied in 9 subjects. It was demonstrated that lung atelectasis induced by oxygen breathing causes restriction of lung ventilation and obstruction of the peripheral airways. The authors discuss the effect of restrictive and obstructive disorders of lung ventilation on gas exchange and development of circulatory hypoxia during acceleration.
Postoperative pulmonary complications frequently lead to increased patient morbidity and mortality, hospital length of stay, and resource utilization. Atelectasis and infectious complications account for the majority of reported pulmonary complications. Risk factors are thought to exaggerate pulmonary function deterioration, which occurs both during and after surgical procedures. This article reviews the literature and describes risk factors frequently identified in relation to pre-, intra-, and postoperative settings, impact of each risk factor on pulmonary function, and issues related to risk factor evaluation. Eighteen risk factors are reviewed regarding their pathophysiologic impact on pre-, intra-, and postoperative pulmonary function. Key issues related to risk factor evaluation are also discussed. Identification of risk factors and prediction of postoperative pulmonary complications are important. Early identification of patients at risk for postoperative pulmonary complications can guide our respiratory care to prevent or minimize these complications.
The authors describe one case of relapsing postoperative atelectasis occurring with considerable severity after an upper left lobectomy for malignancy in a man of 68. Said complication recurred no fewer than six times during a hospital stay of 44 days and constituted a major threat to the good outcome of surgery. The patient was finally discharged in good conditions, and a later recheck revealed no important alterations in the surviving lower left lobe.
BACKGROUND: Bronchial healing remains one of the dominant issues in lung transplantation. Among other factors the quality of airway protection during lung procurement may contribute to improve bronchial healing. METHODS: Thirty-three pigs were divided into four groups: controls (n = 6), those receiving antegrade delivery of Euro-Collins solution with (n = 4) and without prostacyclin (n = 9), and those receiving retrograde delivery of Euro-Collins solution (n = 14). In addition, the atelectatic and nonatelectatic regions of the lungs from all groups were compared. After preparation and cannulation, cardioplegic solution and Euro-Collins solution for lung preservation were given simultaneously. After removal of the heart the double-lung bloc was harvested. During each experiment lungs were assessed by the following methods: dye-labeled microspheres for total and regional lung perfusion, tissue water content, pulmonary artery, left atrial and left ventricular pressures, cardiac output, lung temperature, and microscopic examination. Data were expressed as mean +/- standard error of the mean. RESULTS AND CONCLUSIONS: Our data show that (1) injection of modified dye-labeled microspheres is a useful method to determine absolute flow in lung parenchyma and airways, (2) determination of tissue water content is a simple and reproducible method to investigate the distribution of hyperosmolar lung preservation solutions, (3) atelectasis leads to a significant maldistribution of lung preservation solutions regardless of the route of delivery (0.7 +/- 0.2 versus 6.5 +/- 1.0 ml/min/gm lung wet weight, p = 0.0001) and a severe increase in water content (80.6% +/- 0.4% versus 79.0% +/- 0.5%, p = 0.024), (4) prostacyclin added to the pulmonary artery flush solution results in only a slight improvement in the distribution, and (5) retrograde delivery of Euro-Collins solution through the left atrium is technically feasible and seems to improve flow to the airways even without the addition of prostacyclin.
Postoperative pulmonary complications, specifically atelectasis and pneumonia, are the leading cause of postoperative morbidity and death. It is crucial that the clinician have a thorough understanding of the pathophysiology, risk factors, and scientific basis for currently used respiratory interventions to tailor the patient's care in the preoperative, intraoperative, and postoperative settings. Given the changing healthcare environment and increasing economic constraints, all respiratory interventions must be reevaluated for use in patient care, keeping in mind the factors of scientific basis, patient needs, appropriate utilization, and quality patient outcomes.
Although insertion of expandable metallic stents in cases of tracheobronchial stenosis is effective as palliation for respiratory distress, the potential risk of creating obstructive atelectasis and aggravating symptoms of patients should be noted. The authors' experience in two cases is presented, and prevention of this potential complication is discussed.
Five patients with acute pneumonia and transitory atelectasis without bronchial obstruction are presented. The reduced lung volume in these cases, in a case of shock lung, together with a similar phenomenon in pulmonary embolism, is tentatively related to a possible disorder of the surfactant system.
Rounded atelectasis (RA) is a special type of peripheral lung collapse that develops as a result of pleural disease. Most cases have been attributed to asbestos inhalation, but many other causes have also been implicated. It is usually detected incidentally in an asymptomatic older man. RA can be diagnosed by a constellation of radiologic findings. It appears as a rounded masslike opacity in the peripheral lung adjacent to thickened pleura and with curvilinear opacities of bronchi and vessels (comet tail) extending from the site of RA toward the hilum. Volume loss of the affected lobe is uniformly present. In addition to the classic lesion, a spectrum of atypical lesions has also been described. Computed tomography (CT) and high-resolution CT demonstrate the full extent of disease better than chest radiography. Familiarity with this benign condition is important to differentiate it from other pulmonary and pleural diseases and to prevent unnecessary invasive procedures and surgical resection.
We present a case of rounded atelectasis (RA) observed continuously following decrease of pleural effusion. The collapsed right lower lobe adjacent to pleural effusion changed its shape from wedge-shaped consolidation with air-bronchogram to oval and flat formation at last. The vessels and bronchi curving into RA were detected by CT and we called it horizontal comettail sign. When a mass is detected following decrease of pleural effusion and vessels and bronchi are curving into the mass, the mass may be diagnosed as RA and no further examination may be necessary.
We report the case of a 35 years old female patient suffering from Staphylococcus aureus induced abortion in the 7th/8th week of gestation. Sepsis with acute respiratory failure (ARDS) developed, which could be treated successfully. Pneumonia, caused by Pseudomonas aeruginosa, induced a recurrence of ARDS, complicated by a persistent incomplete atelectasis of the left lung. Independent ventilation of both lungs with increased pressure on the left side combined with bronchoscopy guided instillation of 1 g of bovine surfactant (Alveofact), caused improvement of arterial oxygenation and radiological signs, signalling airation of collapsed lung areas.
A 60-year-old woman was admitted for evaluation of an abnormal shadow in her chest X-ray. A chest roentgenogram revealed middle lobe atelectasis and a tomogram showed masses mainly in the right intermediate bronchus. In bronchoscopy, the bronchus was severely narrowed by irregularly surfaced masses. Microscopic examinations of transbronchial biopsy specimen showed the mucosal and submucosal tissue diffusedly infiltrated mainly by lymphocytes composed of small lymphocytes, centrocyte-like cells and monocytoid cells. The B-cell origin was suggested by a positive L-26 stain. Monoclonality of lymphocytes was proven by Southern blot analysis and in situ hybridization. The diagnosis was primary endobronchial lymphoma of mucosa-associated lymphoid tissue. The case was treated with chemotherapy protocol (CAMBO-VIP) and has been in complete remission for 20 months.