Treatment for Collapsed
Ill Patients*
Selective
Fiberoptic
Intrabronchial
Bronchoscope
Chang-Yao
Tsao, M.D.;
Lan, M.D.,
F.C.C.P;
Thomas
Ray-Shee
Cheng-Huei
Lee,
M.D.,
Lung in Critically
Air Insufflation
Using the
Ying-Huang
Tsai, M.D. , FC.C.P;
Wen-Bin
Shi#{128}h,M.D.,
F.C.C.P;
and
F.C.C.P
A new,
simpler
method
to re-expand
collapsed
lungs was
in 14 procedures
in 12 critically
ill patients.
To
close the bronchus,
we wedge the fiberoptic
bronchoscope
into each segment
or subsegment
of the collapsed
lung
instead
ofusing
a balloon
cuff. Room air was then insufflated
into the atelectatic
alveoli after repetitive
sputum suctioning
and bronchial
washing
with normal
saline solution.
Com-
plete re-expansion
was achieved
in 12 of the 14 procedures
and partial
in two. The average
alveolar-arterial
oxygen
pressure
difference
(P[A-a]01)
declined
from 217.5 before
the procedure
to 200.3,
150.0 and 152.2,
respectively
at 30
minutes,
12 hours
and 24 hours
after.
There
were
no
complications.
(Chest 1990; 97:435-38)
introduced
C ollapsed
lung is a common
problem
in critically
ill
patients.
Although
respiratory
therapy
is a priand effective
method
of treatment,
it is not
mary
suctioning
suitable
for some
patients,
such
as those
with
rib
fractures,
hemothorax,
or pneumothorax.
Other
patients
are too critical
to wait for the results
of repetitive
respiratory
In 1973,
expand
scope
5Fmm
care or cannot
tolerate
a bedside
procedure
was
the
.
‘
collapsed
This
lung
procedure
Department
using
vigorous
introduced
includes
of Chest
repetitive
Medicine,
Chang
1-Clinical
Data
and
Chest
chronic
Gung
and
washing
a secondary
sputum
trabronchial
Memorial
endotracheal
tube
cuff was introduced.
July 6.
Hospital,
X-ray
bronchial
with
infection
devices
were
invented
compliance
and higher
broncho-
Hospital,
Taipei,
Taiwan,
Republic
of China.
Manuscript
received
February
28; revision
accepted
Reprint
requests:
Dt
Tsao,
Chang Gung Memorial
Twig thea N Road,
Taipei,
Taiwan,
ROC
Table
therapy.
to re-
a fiberoptic
and
solution.
Although
most of the lung
expanded
with
the above
procedure,
fractory.
This may be due to a lower
and higher
critical
opening
pressure
lung.
If the collapse
is left untreated
fortunately,
available.
199
Film Findings
on Patients
pressure
Many
lower
pressure.
lung
In-
using
an
with a balloon
results.2
Un-
are complex
and
a simpler
method
Fiberoptk
saline
occur.
the
ventilation
or a bronchoscope
All attained
good
these
devices
We designed
Undergoing
may
to overcome
critical
opening
positive
normal
collapse
was resome
were
relung compliance
in the collapsed
it may
become
not readily
to accom-
Procedures
Bronchoscopk
Collapse
Case
Age
Sex
Underlying
1
24
M
R’t rib
2
52
M
Traumatic
fracture
with
3
56
M*
R’t rib fracture
4
24
F
Esophageal
5
18
F*
L’t renal
6
64
M
R’t lower
limb
7
48
F
Diabetic
mellitus
8
29
M
NPC
Area
Condition
hemothorax,
septic
shock,
acute
renal
failure
RLL
hemopneumothorax
post
with
cell
with
large
skin
with
9
28
F5
SLE
with
pulmonary
30
M
BAT
with
internal
11
52
F
RHD
12a
16
M
Traumatic
with
uremia
post
myelopathy
infection
bleeding
with
infection,
CPR,
interposition
septic
hypoxic
shock
encephalopathy
CR1’
lung
CR
RLL
CR
L’t lung
CR
RUL
PR
L’t lung
CR
L’t lung
CR
LLL
CR
LLL
CR
L’t lung
CR
annuloplasty
RLL
CR
quadriplegia
LLL
above
and
post
+ tricuspid
C6 dislocation
s/p colon
nephrectomy
defect
AVR + MVR
C5,
injury
radical
radiation
10
post
for corrosive
cancer
B/F,
Ct
hemopneumothorax
stricture
Result
respiratory
C2
level
with
quadriplegia
failure
splenectomy
+ RLL
CR
12b
LUL+RUL
PR
12c
RUL
CR
*Chest
tCR,
x-ray
PR:
film
complete
with
and
air bronchogram.
partial
re-expansu)n.
CHEST
Downloaded From: http://journal.publications.chestnet.org/ on 09/09/2014
I 97
I 2 I FEBRUARY,
1990
435
Arterial
scopic
blsal
gas
I)rocedure,
chest
x-ray
values
then
were
checked
30 minutes,
followed
examination
just
12 and
after
SO()fl
before
24 hours
the
the
after.
bronchoA portable
procedure.
RESULTS
After
12
showed
the
of
5 and
the
x-ray
film
showed
collapsed
full
Case
after
blood
the
third
gas
value
112.1
and
and
In
bronchoscope,
to a three-wa
MATERIALS
Twelve
for
patients
the
collapse
formed
before
during
The
were
not
the
mechanical
saline
sputum
solution
then
ment
of the
the previous
ranged
from
100 percent
cedure.
The
sible
Flu2
and
arterial
all the
h
four
mask.
line
The
vital
or frequent
visualized
at
P(A-a)02
152.2
(Fig
collapse
to
30
86.5,
minutes,
declined
from
2).
recurred
two
days
insufflated
180
eight
were
measurement
patients
the
clear.
air into
patients
monitored
the
keeping
the
higher
average
14 procedures
during
were
I
120
or subseg-
or 10 cmIL,O
intubated
“
normal
were
r(xm
ofthe
±29.7
140
studies.
with
minutes,
duration
ventilation
patients
T
150.0
connected
segment
30 cmII2O,
The
217.5
was
patients,
airways
each
to two
signs
RUL
11 procedures
procedure
respectively
The
and
12’s
three
airway
four
washing
rapidly
nonintubated
remaining
the
case
above
200
port
port
in previous
for one
The
other
adaptor
bronchial
and
by mechanical
the
after
the
±41.9
was
I)erlPheral
in the
hag
20 to 30 minutes.
per-
One
intubated
into
pressure.
the
was
adaptor
the
the
a swivel
bronchoscope
around
\Vhen
therapy
hag,
eight
done
airway
oxygen
the
and
pressure
12,
obtained
sepsis.
160
as described
lobe
after.
150.0
the
to underlying
intensive
atelectasis.
transnasally
suctioning
until
received
1).
ventilator
by Ambu
airway
Ambu
monitor
(Fig
220
of lung
bronchoscope.
to
through
collapsed
had
A three-way
by
performed
In
hours
excluded
because
procedure.
used.
perfonned
the
airways
peripheral
than
was
wedged
selected
air
iflttll)ated.
was
All
of the
gauge
mm
were
26
arte-
240
ICU
duration
of respirator
channel
room
90.6
and
260
even
or surgical
1). The
to prevent
hours
air insufflation
bronchoscopy
Repetitive
hours.
was
was
medical
bronchoscopic
suction
bronchoscopy
the
(Tal)le
120
fiberoptic
to a pressure
pressure
We
24
to introduce
connected
to
admission
to the
used
to
bronchoscope
connected
who
since
another
the
A fiberoptic
was
24
care
collapsed,
to
conditions
from
or
before
Hg,
24
METHODS
AND
admitted
critical
ranged
respiratory
lung
were
different
same
of the
79.0
12,
with
Their
they
excluding
Pa02
24
case
not
from
to 200.3,
217.5
plish
the same
results,
obtaining
the
greater
effect without
any complications.
was
shock
P(A-a)O2
be due
to
After
the
improved
a fiberoptic
connected
thought
days
case
1).
and
and
six
In
procedure.
worsened,
the
5 the
performed
of septic
of PaO2
procedure.
procedures,
included
gauge
were
value
12,
after
(Table
film
two,
case
care.
was
bronchoscopic
was
A blood
12,
completely
6 died
analysis
worsening
In
procedure
case
gas
the
from
in case
re-expansion
1 and
hours
procedure
pulmonary
bronchoscopic
x-ray
remaining
re-expansion.
reexpanded
intensive,
immediate
Fi;uiw
1 . The whole
apparatus
an ambu
hag and a pressure
adaptor
(arrow).
partial
lung
chest
in the
secondary
ofcontinuous,
a third
the
reexpansion;
case
rial
14 procedures,
complete
the
given
received
whole
as high
h
ECG
as posmonitor
by sphygomanometer.
436
Downloaded From: http://journal.publications.chestnet.org/ on 09/09/2014
-I,before
proFi:u,w
( P[A-a102)
choscopic
2. The average
improvement
ii
0
30Mm
-
l2hr
24hr
alveolar-arterial
oxygen
pressure
difference
during
24 hours
following
fiberoptic
bron-
procedure.
Collapsed
Lung in Critically
III Patients
(Tsao
et a!)
after
the first
bronchoscopic
procedure.
two further
procedures
with
In case 8, the LLL collapse
subsequent
recurred
repeat
bronchoscopic
procedure
but was refused
by the patient.
at discharge
four weeks
later.
He underwent
Harada
reexpansion.
six days later.
reexpanded
A
was recommended
This lesion
remained
Collapsed
lung
is one
of the
ill patients,
and
rapidly.
Treatment
optic
bronchoscopic
introduced
procedure
and
good
at
results
studies.#{176}5’9This therapeutic
itive sputum
suctioning
normal
saline
solution;
sion of atelectasis
was
the
important
problems
in
the clinical
condition
with
a therapeutic
the
were
and
procedure
bronchial
complete
attained
may
fiber-
bedside
reported
was
in many
includes
washing
sure,
volume
and the
relationship:
T-alveolar
repetwith
or partial
re-expanin 60 to 90 percent
of
decreases,
alveolar
P’r
surface
=
the alveolar
tension,
is profound,
sion
can
not
and
the
alveolar
r’-alveolar
critical
lower
the reduction
the reduction
overcome
pressure
will
opening
pressure
lung compliance.
rise
and
radius).
into
But
the
atelectatic
to be distributed
oflower
airway
In order
alveoli
designed
alveoli
and
are espe-
area of collapse.
pressure
of the
to overcome
the
refractory
after
the
atelectasis
do
above
broncho-
It would
be useful
if we could
pressure
ventilation
directly
into
to overcome
the critical
opening
if we
can
not
alveoli,
suffiate
the
into the noncollapsed
resistance
and higher
to introduce
the
insufilated
This
will result
in a hyperinflated
which
in turn will compress
the
tatic
In
a higher
in the atelectatic
The above
findings
These
even
scopic
procedures.
introduce
positive
the collapsed
area
pressure.
air
lung
each
close
still
we
the trachea
to the lungs
however,
rupture
served
peripheral
sure
air selectively
into
lung
area.
gauge
the
atelec-
complex
and
simply
wedged
segment
or subsegment
the bronchus.
not
the
of the
readily
available.
bronchoscope
into
collapsed
lobe
to
about
of
to the
of
had
but
our
14
been
were
than
and
lung.
All
of
in complications
hemorrhage.
the
duration
48 hours.
the
was
it
higher
than
insuffiation.
the critical
above
of
In nine,
areas
were
limited
to one lobe.
x-ray film showed
air bronchograms
collapsed
ob-
study
the
by a pres-
10 cm H20
during
air
to overcome
procedures,
more
dogs
and found
no
30 cm H20;
alveoli
did not result
or pulmonary
cm
fluoroet al5
of adult
bronchoscope
30 cm H20, or
airway
pressure
was high enough
20
during
Mutsuda
lung
bleeding
the
In three,
in the
conditions
were
documented
to be handicaps
to reexpansion
of atelectasis in previous
studies.
“‘s
The
collapsed
lung
reexpanded
completely
soon
after 12 ofthe
bronchoscopic
in two. Arterial
blood
gas
procedures,
values
following
and partially
the proce-
dure
showed
apparent
improvement
of
P(A-a)O2
in all. No significant
complications
from
these
14 bronchoscopic
procedures,
transient
tachycardia
some
Manni
care had
et al’ described
the same effect
compared
our cases
injury.
hypertension
developed
in
that intensive
respiratory
on acute
lobar collapse
when
with bronchoscopic
suffered
from chest
These
intolerance
cases were
cases
were
procedures,
but half of
trauma
or spinal
cord
excluded
from
his
of respiratory
care.
Moreover,
in critical
condition
and might
correct
we
the
a new
selective
We just
wedge
or subsegment
the
pulmonary
suggest
to introduce
ventilation.
were
or
Pa02
and
resulted
although
cases.
balloon
cuff
simpler,
effective
positive
into
collapsed
to close
even
the
for
impairment
intrabronchial
of the
no complications
study
all of our
not survive
the bronchoscope
lobe
bronchus.
in critical
each
instead
There
cases.
REFERENCES
1 WannerA,
LandaJF,
Nieman
bronchofiberoscopy
RE,
for atelectasis
Delgado
VevainaJ,
and
lung
abscess.
I. Bedside
JAMA 1973;
224:1281-85
2 Sachdeva
by active
chial
SR Treatment
ofpost-operative
inflation
atelectatic
tube.
3 Bowen
refractory
TB,
Acta
ofthe
Anesth
Fishback
atelectasis.
Scand
ME,
Ann
1974;
Thorac
pulmonary
lobe(s)
Green
CHEST
Downloaded From: http://journal.publications.chestnet.org/ on 09/09/2014
under
observed
surgery.
in the
barely
ventilation
after tracheostomy
at pressures
under
connected
seven
of using
were
with
lung
pressure
tube
when
or
and
opening
pressure,
such as pneumothorax
segment
and devices
bronchoscope
atelectatic
under
60 cm H20.
So, in this
airway
pressure
was monitored
method
area
the
positive
pressure
if we could
not
immediately.
In conclusion,
tend
areas
because
compliance.
normal
collapsed
only, a few methods
using a rigid or fiberoptic
directly
air will
a balloon
cuff. After the bronchoscope
was introduced
into the collapsed
lobar bronchus,
the cuffwas
inflated
to close
the bronchus
during
air insufflation.
Although
these
special
devices
obtained
good
results,
they
are
Therefore,
positive
through
damage
atelectatic
the chest
to lower the
in surface
radius
and
But
if the
create
that
endotracheal
exerted
collapse
in surface
tenin alveolar
radius,
cially common
in cases
with a small
In these
cases,
the transpulmonary
atelectatic
alveoli
is often
too low
critical
pressure.”’3
not easily
re-expand
radius
pressure
rise according
2 T/r (PT-alveolar
pres-
these
conditions,
the surfactant
will work
alveolar
surface
tension;
this
reduction
tension
offsets
the reduction
in alveolar
prevents
alveolar
pressure
from
rising.
atelectasis
the
In
the lung
will decrease
to Laplace
through
kept around
the previous
This pressure
cases.”6’7’#{176}
When
stated
following
H2O airway
pressure
scopic
roentgenograms
DISCUSSION
critically
worsen
et al
through
atelectasis
an endobron-
18:65-70
DC,
Surg
Col
1974;
EF.
Treatment
of
18:584-89
I 97 I 2 I FEBRUARY,
1990
437
4 Harada
K, Mutsuda
expansion
balloon.
Chest
5 Mutsuda
T,
1983;
Shono
N, et al. Treatment
using
the
1980;
33:345-50
6 Barrett
CR.
7 Mahajan
VK,
bronchoscope
Taniki
using
T, Kimura
H.
a bronchoscope
Re-
with
Fiberoptic
a
84:725-28
H,
Gung
10
Takaya
N,
Harada
of pulmonary
K,
Mild
atelectasis
procedure.
K, Saoyama
by active
J
Jap
Thorac
inflation
Surg
Tokyo
11
Flexible
Catron
in the
RP, Lillington
in the
intensive
YF, Shieh
bronchoscopy
J
Med
fiberoptic
bronchoscopy
and
indication.
PW,
Huber
GL.
management
in the
Chest
The
critically
ill
1978;
73:746-49
value
of fiberoptic
ofpulmonary
collapse.
Chest
12
CE,
Flexible
fiberoptic
care
WB,
GA,
Parsons
unit.
Heart
Wong
SL,
GH.
& Lung
Lee
CH,
Fiberoptic
1981;
Lan
bronchoscopy
RS,
Tasi
IF, et al.
438
Downloaded From: http://journal.publications.chestnet.org/ on 09/09/2014
B,
Med
1974;
2:250-61
Bradley
CA,
in intact
Harada
K,
H,
J Thorac
H.
Assoc
Thorac
Marini
ratory
N,
care
unit.
Millen
E,
The
1981;
19:193-97
1980;
JJ, Pierson
DJ,
comparison
Chang
Grenvik
Forces
involved
1980;
48:29-33
K,
Hamaguchi
and
on
pleural
chronic
A.
medicine.
NB.
N,
surface
atelectatic
Crit
in lobar
Sasalci
M,
pressure.
J Jap
lung.
28:959-71
Hudson
L.
of fiberoptic
Rev
care
Physiol
Izumi
of re-inflation
Am
in critical
AppI
atelectasis
Surg
therapy.
J
Lobal
Dis
Effect
J,
Snyder
Anthonisen
dogs.
Saoyama
et al.
Mild
intensive
bronchoscopy
GT,
Jap
14
Oilman
Ford
prospective
10:1037-45
in the
8:87-93
Care
Shono
13
1984;
Lindholm
atelectasis
73:817-20
8 Steven
9 Lai
N,
atelectasis
endobronchial
patient-methodology
1978;
T, Saoyama
of refractory
Respir
Collapsed
Dis
Acute
lobar
atelectasis:
bronchoscopy
1979;
and
a
respi-
119:971-78
L.ung in Critically
III
Patients
(Tsao et a!)