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PubMed1994

A thoracoscopic peek: what did Jacobaeus see?

More than 80 years ago, Jacobaeus inserted a cystoscope into the pleural space of patients with pleural diseases to visually examine the pathology. Subsequently, he courageously inserted a galvanocautery instrument into the pleural space through a separate entry site to divide adhesions between the lung and chest wall under direct vision. This was done to establish therapeutic pneumothorax for patients with pulmonary tuberculosis. The discovery of effective antituberculosis chemotherapy eliminated the need for lung collapse therapy, and thoracoscopy was discarded as no longer useful. Today, the enthusiasm for thoracoscopic surgical intervention, both diagnostic and therapeutic, is a result of applied technologic innovations. Rediscovery of thoracoscopy is exciting and expands the vision for both diagnostic and therapeutic applications predicted by Jacobaeus.

History, 19th Century↗
PubMed1994

Hemodynamic effects of carbon dioxide insufflation during thoracoscopy.

As more complex thoracoscopic procedures are performed, adequate exposure becomes increasingly more important. The insufflation of CO2 has been demonstrated to aid in the compression of lung parenchyma and the effacement of subpleural lesions, and to act as a retractor when combined with changes in patient position. However, a recent study demonstrated that CO2 insufflation during thoracoscopy in the pig had adverse hemodynamic consequences. We prospectively studied 32 patients undergoing thoracoscopy to evaluate the effects of CO2 insufflation in the clinical setting. The end-tidal CO2 pressure, arterial oxygen saturation, mean arterial pressure, heart rate, and central venous pressure were monitored. Measurements were determined at baseline, at the initiation of one-lung ventilation, and at intrapleural pressures of 2 to 14 mm Hg. We found that the insufflation of CO2 of 2 to 14 mm Hg had no significant effect on the end-tidal CO2 pressure, arterial oxygen saturation, heart rate, or mean arterial pressure, but the central venous pressure did rise from 7.00 +/- 1.5 mm Hg to 17.30 +/- 2.53 mm Hg (p < 0.05). We conclude from this that the insufflation of CO2 during thoracoscopy does not have adverse hemodynamic effects in the clinical setting. Therefore, we propose that low-pressure (< 10 mm Hg) insufflation is a safe adjunct to the conduct of routine thoracoscopic surgical procedures.

Adult↗
PubMed1988

Sputum wax-worms after plombage.

Paraffin wax plombage was one of several plombage operations used for pulmonary tuberculosis about 40 years ago, and Shepherd included seven patients treated with wax plombage in her review of plombage in 1985. We describe another patient with wax plombage who coughed up wax 28 years after plombage, followed by much larger amounts of wax 15 years later. The pieces of wax were like worms and spirals, and we discuss possible causes for these shapes.

Aged↗
PubMed1981

Bronchial length and diameter behavior during bronchial collapse in excised dog lungs.

We compared changes in bronchial diameters (Dbr) and lengths (Lbr) in six excised dog lobes at 4 volume levels during deflation from 30 cm H2O under two conditions. First, intrabronchial and alveolar pressures were kept equal to zero during lung deflation; then, bronchial collapse was induced by negative intrabronchial pressure at several constant lung volumes. During the two procedures the major intrapulmonary bronchi were isolated from the rest of the lung by 10-15 beads blocking all tributary bronchi as previously described. Lbr was estimated with a linear displacement transducer connected by a thin rod to the most distal bead. Mean Dbr was calculated from Lbr and bronchial volume at each lung recoil pressure (PL) and at each intrabronchial pressure (Pbr). When PL decreased from full inflation in Condition 1, Dbr and Lbr decreased almost proportionately; however, in Condition 2 when PL (and thus lung volume) was kept constant and Pbr was reduced from 0 to -80 cm H2O, Lbr was reduced by only 5% (mean) whereas Dbr was reduced by 70% (mean) from initial near-homogeneous values. This suggested that, due to the interdependence in intact lungs, Lbr in intact lungs is almost constrained by changes in lung volume. By contrast, Dbr can undergo large reductions and the stiffness of intact bronchi is related mainly to PL. Thus, the intact bronchus has some of the characteristics of a thick-walled cylinder (where the wall includes surrounding parenchyma) in which longitudinal strain is small by comparison with circumferential strain.

Animals↗
PubMed1986

Tuberculous empyema--a case history extending over 30 years.

A patient with chronic tuberculous empyema is described. The condition had been present for 30 years, following treatment by outpatient pneumothorax. A broncho-pleural fistula developed, the symptoms of which were aggravated during air-flight.

Bronchial Fistula↗
PubMed1982

Quantitative analysis of methods for reducing physiological brain pulsations.

Normal movements of the mammalian brain, caused by the arterial and venous pressure fluctuations of each cardiac and respiratory cycle, have made obtaining stable intracellular recordings from neurons difficult. This study quantitated the movements of the cats' brainstem and examined the effects of traditional neurophysiological techniques used to reduce pulsation. Two components of brain movement were recorded: (1) an arterial component--relatively low amplitude (110-266 micrometers) and short duration (330-400 ms) excursions corresponding to the pressure wave of each cardiac systole [A-wave]; and (2) a pulmonary component--slower (10-12/min), high amplitude plateau-like displacement (300-950 micrometers) lasting for a time (2.4-5.1 s) corresponding to the inspiration of each respiratory cycle [P-wave]. Pneumothoraces and mechanical ventilation combined with elevating the animal's head reduced the pulmonary component by an average of 68% and the arterial component by 40%. Cerebrospinal fluid drainage could reduce the P-wave component of movement by as much as 50%. To reduce arterial pulsations below 100 micrometers, the mean arterial pressure (MAP) had to be lowered to less than 40 mm Hg, which was not compatible with maintaining normal brainstem auditory evoked responses. Residual movements at MAPs greater than 50 mm Hg were still sufficient to make stable intracellular penetration of small neurons difficult. The authors suggest the solution to this problem is the development of a cardiopulmonary bypass system which generates a non-pulsatile flow of oxygenated blood, described in a companion paper.

Animals↗
PubMed1990

Disturbed brain purine metabolism results in a gross opening of the blood-brain barrier in newborn piglets following experimental pneumothorax.

Changes in the permeability of pial-arachnoideal microvessels [30-210 microns), of the blood-brain barrier (BBB), were intravitally studied by fluorescent microscopy and compared to the hypoxanthine (HX) level of cerebrospinal fluid (CSF) in newborn piglets (n = 24) using the open cranial window technique. Eight animals served as controls (Group 1), the others were studied in the course of bilateral experimental pneumothorax (BEP) using low (Na(+)-fluorescein, MW 376, Group 2) and large molecular weight (FITC dextran, MW 40,000, Group 3) fluorescent tracer molecules. Cisternal CSF was sampled from the animals: 8 piglets from Group 1, and 4-4 piglets from Groups 2 and 3 at different stages of pathological condition: (i) at the critical (C) stage (severe acidosis, bradycardia, arterial hypotension and hypoxaemia) and also (ii) at the recovery (R) stage (mild metabolic acidosis, tachycardia, arterial hypotension) and the HX concentration was determined with high-pressure liquid chromatography. In Group 1 neither low (n = 4) nor large (n = 4) molecular weight tracers penetrated BBB. In Group 2, however, the fluorescein dye passed BBB as a spotty leakage in animals at C stage (n = 8). Diffuse fluorescein penetration was seen at R stage, too (n = 4). In Group 3 no change in permeability was found at C stages (n = 8), but at R stage (n = 4), 2 h after the primary hypoxic insult, when the animals had recovered from cardiovascular and metabolic shock, the tracer passed locally the microvascular wall and appeared as leaky spots (number of leaky sites = 2.3 +/- 0.4/0.10 cm2, means +/- SE).(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1987

Protective effect of antihistamines on cerebral oedema induced by experimental pneumothorax in newborn piglets.

As a consequence of general hypoxaemia evoked experimentally by bilateral pneumothorax, brain oedema of vasogenic type developed in newborn piglets after 4 h survival. Histamine receptor antagonists, mepyramine (H1-receptor blocker), metiamide, cimetidine and ranitidine (H2-receptor antagonists) were administered either intraperitoneally or intrathecally to check to what extent the formation of brain oedema could be reduced. Mepyramine and ranitidine decreased the accumulation of water, sodium and albumin in the parietal cortex. By measuring the concentration of histamine, the presence of a histamine pool was demonstrated in the cerebral microvessels. The results suggest that histamine, if released upon hypoxic injury from the microvascular store, can take an important part in the development of vasogenic brain oedema.

Animals↗
PubMed2005

Total videoscopic bypass graft implantation on the ascending aorta for lower limb revascularization.

An extra-anatomic bypass initiating from the ascending aorta, namely the ventral aorta, is a possible alternative for lower limb revascularization. However, acceptance of this technique is limited by the need of a median sternotomy and clamping of the ascending aorta. We report a new technique for the ventral aorta using a total videoscopic approach of the ascending aorta, which avoids the need for a median sternotomy. We discuss the advantages and perspectives of this new approach.

Aged↗
PubMed2001

Pneumoperitoneum for the management of pleural air space problems associated with major pulmonary resections.

BACKGROUND: The use of pneumoperitoneum to treat prolonged air leaks or space problems, or both, after pulmonary resection has been recently resurrected and used successfully. METHODS: During the last 3 years, 14 patients experienced short-term pleural space problems associated with prolonged air leaks after pulmonary resection for lung cancer. All patients, under sedation and local anesthesia, had a mean of 2,100 mL of air injected under the diaphragm, using a Veres needle after a mean time of 7 days (range, 5 to 10 days) from the operation. In 3 patients talc slurry was added to help control the air leak. RESULTS: No patients experienced complications during the induction of the pneumoperitoneum. No patients complained of dyspnea, although blood gas analysis showed a slight increment of carbon dioxide partial pressure (p < 0.0004). Obliteration of the pleural space was observed in all cases after a mean time of 4 days (range, 1 to 7 days). Air leaks stopped in all patients after a mean time of 8 days (range, 4 to 12 days). The mean postoperative hospital stay after lung resection was 18 days (range, 14 to 22 days). No patients had significant complications or long-term sequelae. We found that patients who had undergone induction chemotherapy had longer air leak durations than observed in noninduction patients (p = 0.03). CONCLUSIONS: Our experience supports the use of postoperative pneumoperitoneum whenever a space problem associated with prolonged air leaks is present. The procedure is effective, safe, and easy to perform.

Aged↗