Bronchoscopic CO2 laser surgery

The problem of removing or palliating obstructing lesions of the trachea nd bronchi has been solved by using the CO2 laser in conjunction with an endoscopic adaptor. We have used this laser successfully in 18 patients who had this particular problem. The advantages of laser surgery in this area are 1) reduced bleeding, 2) minimal exposure of the surgical field, 3) decreased swelling, 4) decreased postoperative hospital stay and less discomfort, and 5) no tumor spread or seeding. Patient acceptability of this modality is excellent, and general general, as well as local, anesthesia can be used. The results of laser ablation in the tracheobronchial tree have been quite satisfactory and can be repeated as often as necessary.

Bronchoextrapleural fistula after extrapleural pneumonolysis

This case illustrates the development of a bronchoextrapleural fistula 40 years after extrapleural pneumonolysis with placement of a paraffin pack. The various diagnostic possibilities in the presence of such a radiographic presentation are reviewed.

Preoperative pulmonary preparation of patients with chronic obstructive pulmonary disease: a prospective study

A group of 157 patients with chronic obstructive pulmonary disease who were treated before surgery using a standardized pulmonary preparation underwent physiologic assessment both before and after the prophylactic program. The postoperative course of each patient also was evaluated to assess the incidence of respiratory morbidity and mortality. Although many physiologic values were statistically improved after the pulmonary preparation, most of the changes are of doubtful functional significance. It is difficult to determine which patients will develop pulmonary complications not requiring mechanical ventilation, but the group requiring this type of support appears to be predictable on the basis of the severity of their pulmonary functional impairment and their lack of response to the standard pulmonary preparation used. The single most reliable test for this purpose was the mean forced expiratory flow during the middle half of the forced vital capacity. The frequency of postoperative respiratory complications was related to the type of operation, with the highest incidence occurring in the group that had extensive upper-abdominal surgery. While the occurrence of these complications was significantly reduced in patients undergoing a standard preoperative pulmonary preparation, the explanation for the beneficial effect of this procedure is not apparent.

Permanent tracheostomy: a new surgical technique

A new method of permanent tracheal fenestration is reported, utilizing cervical skin and tracheal flaps. It has been performed on four patients without complications and has the advantage of being a quick, simple, one-stage operation that is reversible should conditions change. The procedure is utilized in patients with posttraumatic or postirradiation fibrosis of the larynx, chronic obstructive pulmonary disease and patients with sleep apnea.

"Prohibitive" lung function and major surgical procedures

Sixteen patients with preoperative pulmonary function testing data placing them in the "prohibitive" range underwent major surgical procedures with one mortality (6 per cent) and three major pulmonary complications (19 per cent). All complications were after pulmonary resections in patients with marked muscular weakness. Patients should not be denied necessary operative procedures on the basis of pulmonary function testing placing them in the "prohibitive" range of the Miller quadrant diagram alone. This term should be changed to "increased risk."

Enflurane as a primary anesthetic agent for patients with chronic obstructive pulmonary disease

For years, halothane has been the anesthetic agent of choice for patients with chronic obstructive pulmonary disease (COPD) and reversible airway disease (asthma). Enflurane was compared with halothane in 100 patients with COPD substantiated by spirometry and history. Intraoperative and postoperative complications in each relatively homogenous 50-patient group were assessed. Spirometry, blood gases, chest x-rays, incidence of complications involving secretions, coughing, wheezing, and cardiovascular problems were similar in both groups. Enflurane appears to be equivalent to halothane as an anesthetic in such patients.

Epidural anesthesia following thoracotomy in patients with chronic obstructive airway disease

Epidural analgesia for control of postoperative thoracotomy pain in patients with carcinoma of the lung and chronic obstructive airway disease is described. The rationale and procedure for its use are presented. Epidural analgesia used in 8 patients requiring pulmonary resection who had chronic obstructive airway disease resulted in an improved postoperative course and avoided use of narcotics or a respirator in 7 of the 8 patients.

Criteria of fitness for anaesthesia in patients with chronic obstructive lung disease

Twelve patients with severe chronic obstructive lung disease undergoing 15 operations were assessed with preoperative lung function tests and blood gas estimations. Their operative and postoperative course was followed. There were no deaths or serious complications. Patients fell into three groups: those with low respiratory capacity but normal blood gases, who required no special respiratory treatment apart from physiotherapy and antibiotics; those with hypoxaemia but normal arterial carbon dioxide pressure, who needed more prolonged oxygen treatment after operation; and those with hypoxaemia and hypercapnia, who needed postoperative ventilatory support. While forced expiratory volume in one second (FEV) is a good screening test in preoperative assessment it should be supplemented by arterial blood gas estimations in patients with an FEV of less than 1 litre.