Monday Morning, April 16, 1951

9:00 A.M. Business Meeting

9:30 A.M. Scientific Session.

1. Progressive Changes of Pulmonary Function After Pneu-monectomy: The Influence of Thoracoplasty, Pneumo-thorax, Oleothorax and Plastic Sponge Plombage on the Side of the Pneumonectomy.

Edward A. Gaensler (by invitation) and John W. Strieder,

Boston, Mass.

It is generally recognized that significant overexpansion of the remaining lung after pneumonectomy is undesirable, both from a pulmonary functional standpoint and because of the danger of reactivation, if resection was carried out for tuberculosis. Previous detailed physiologic studies have chiefly dealt with single observations of the static cardiopulmonary status on one or two occasions after pneumonectomy.

For an understanding of the development of functional defects of the remaining lung and for a rational approach to the prevention of overexpansion, it was thought necessary to study the dynamic aspects of these changes of the single remaining lung, both before operation and at weekly and later monthly intervals after resection. To appreciate small changes of lung volume, an accurate technic of residual air determination was needed. Further, a method was required by which the residual air of both lungs could be studied separately and simultaneously before operation. These technics were developed and are described.

Forty patients were studied before and after pneumonectomy for diseases other than carcinoma. The total lung volume and its subdivisions, resting and maximal function, breathing reserve at rest and during exercise, and alveolar mixing were studied before operation in both lungs separately and in the remaining lung, at least at monthly intervals from five months to three years after operation.

The effects of postoperative management of the empty hemithorax were observed after the following procedures: no treatment, preoperative thoracoplasty, early and late postoperative thoracoplasty, oleothorax, pneumothorax and plastic sponge plombage.

The following conclusions were made: Some overexpansion of the remaining lung cannot be avoided without treatment of the contra-lateral side. The severity of this overexpansion varies greatly from patient to patient and its extent is not predictable before operation. The overdistention is most rapidly progressive during the first two months after operation and progresses only slowly after this period. Progressive overdistention is not always accompanied by decreasing maximal function.

Pneumothorax and oleothorax completely confined the remaining lung to its preoperative space and preoperative overdistention, due to contralateral atelectasis, could be corrected by these procedures. Early thoracoplasty prevented overdistention almost completely, while thoracoplasty four or more months after resection resulted only in a partial return of the lung to its proper space. Pneumothorax and oleothorax caused no further loss of maximal function, while both early and late thoracoplasty further decreased the function of the remaining lung. The effect of plastic sponge plombage is still under investigation.

Eight patients were studied after extensive thoracoplasty over completely functionless lungs. It was concluded that while resection of a destroyed lung causes no loss of maximal function, thoracoplasty over such a lung results in a considerable further loss of total function.

2. Pulmonary Function in Traumatic Hemothorax Treated by Decortication.

James H. Forsee and Major Stephan L. Kylar

(by invitation) Denver, Colo.

The war in Korea has resulted in a relatively large number of patients suffering from traumatic hemothorax with or without retained metallic foreign bodies being treated at Fitzsimons Army Hospital by pulmonary decortication. The estimation of pulmonary function based on roentgenographic evidence is notoriously inaccurate and studies in the form of external spirometry and bronchospirometry were undertaken to ascertain pre- and postoperative function values. These studies have also been employed as aids in the selection of patients with thoracic trauma for surgical intervention, and in evaluating the results of surgery. Streptokinase and streptodornase have been employed in several patients in preparation for decortication. The findings relative to pulmonary function in 17 patients furnished interesting data which was often not predictable.

3. Late Changes in Ventilatory Function Following Thoracoplasty.

S. R. Powers, Jr. (by invitation) and A. Himmelstein

New York, N. Y.

Ventilatory function studies have been performed on a group of patients with pulmonary tuberculosis who were treated with a thoracoplasty between five and twenty-seven years ago. Many of them had similar studies done preoperatively and in the immediate postoperative period. A rather high incidence of progressive scoliosis and limitation of Ventilatory function was found. These changes are discussed in relation to: the number of ribs removed, the extent of the thoracoplasty, and the possible anatomical reasons for the changes observed. The results presented seem to warrant a reevaluation of the indications for thoracoplasty, especially in view of the more recent developments in the surgery of tuberculosis.

4. Lung Function Studies in Poudrage Treatment of Recurrent Spontaneous Pneumothorax.

Lt. Col. John Paul (by invitation), Edward J. Beattie, Jr.

and Brian Blades, Washington, D. C.

More than 30 patients with unilateral or bilateral recurrent spontaneous pneumothorax have been treated by thoracotomy and talcum powder poudrage during the past nine years. The patients have been operated upon only if they have had at least three attacks of idiopathic spontaneous pneumothorax. All patients have done well, and there have been no instances of recurrent pneumothorax after operation.

Lung function studies consisting of total and individual lung oxygen consumption per minute, minute ventilation, vital capacity, and maximum breathing capacity, have been determined before and after operation in three patients and before and after operation in one case of bilateral pneumothorax. All lungs were fully expanded when the lung function studies were done. In general, individual lung function studies done preoperatively have shown decreased minute ventilation and oxygen consumption of the involved lung. Lung function studies done postoperatively have shown no significant decrease attributable to the poudrage procedure.

5. Effect of Position on the Rise in Carbon Dioxide Tension During Thoracic Surgery and the Effect of Artificial Ventilation in the Several Positions.

Henry K. Beegher, Thomas J. Quinn, Jr., John P. Bunker

and Genesio L. D'Alessandro (all by invitation)

Boston, Mass.

Our demonstration that carbon dioxide tension rises to serious levels during open thoracic surgery has now been confirmed in several places. In the present study the effect of the lateral, the prone and the supine positions on the pCO₂ levels is investigated during thoracic surgery. The lateral position is found to offer the greatest obstacle to the elimination of carbon dioxide. The effectiveness of artificial ventilation (bag pressure type) is compared for the three positions.

6. Mucoid Impaction of the Bronchi.

Robert R. Shaw, Dallas, Tex.

Mucoid impaction of the bronchi is a newly recognized pathological entity within the lungs seen in patients who are either asthmatic or suffering from obstructive bronchitis. The underlying pathology is an impaction of viscid mucus into a bronchus distending the bronchus to much more than its normal size and actually destroying its walls.

This impaction takes place at the second order branch bronchus. Beyond the impaction there is cystic destruction of the lung. On roentgen examination the condition is indistinguishable from neoplasms, and even at surgery it may be difficult to distinguish between neoplasm and mucoid impaction of the bronchus by palpating the underlying lung. Differentiation between the two conditions, however, is important since a much more limited resection can be done for this condition than would be desirable for neoplasm. Eight patients having this condition have been seen by us. Six have had pulmonary resection and two others have remained under observation. Significant points in the history, the underlying basic pathology, the life history of the condition and the indications for surgery are discussed.