·No text on this page.

·TREATMENT OF
RESPIRATORY EMERGENCIES
INCLUDING
BULBAR POLIOMYELITIS

·Publication Number 163
AMERIC.IN LECTURE SERIES
A onograph 17
AMERICAN LECTURES IV OTOLARYNGOLOCY
AUDIOLOG! AVD BRONCHO ESOTILIGOLOGI
Edited by
NORTOV CU FIELD, M.D
A85001ale Chinical Professor of Ololan ngology
Yale University School of Mediane
New Haren, Connecticut

·Treatment of
RESPIRATORY EMERGENCIES
Including
BULBAR POLIOMYELITIS
By
THOMAS C GALLOWAY, M.D.
Professor Emeritus of Otolaryngology
Northwestern University Medical School
Accending Otolaryngologist
Evanston Iospital
Evanston, Illinois
Tormerly, Attending Otolaryngologist
Cook County Hospical
Chicago, Illinois
Ir
.
CHARLES C "THOMAS PUBLISHER
Springfield · Illinois • USA.

·Publication Number 103
AMERICAN LECTURE SERIES
Monograph in
AMERICAV LECTURES I OTOLARYNGOLOGY
1UDIOLOGY AND BRO\CITO ESOPUTACOLOGI
Edited by
NOR IOI CA FIFLD, MD
Associate Clinical Professor of Molanagalog
lale Unnes School of Mediane
New Ilsien, Connecticut

·Treatment of
RESPIRATORY EMERGENCIES
Including
BULBAR POLIOMYELITIS
By
THOMAS C GALLOWAY, M.D.
Professor Emeritus of Otolaryngology
Northwestern University Medical School
ditending Otolaryngologist
Evanston Hospital
Evanston, Illinois
Formerly, Attending Otolaryngologist
Cook County Hospital
Chicago, Illinois
.
CHARLES C THOMAS PUBLISHER
Springfield • Illinois, U.S.A.

·CHARLES C THOMAS. PUBLISHER
BANNERSTONE HOUSE
301-327 East Lawrence Arenue, Springfield, Illinois, U.SA.
Published simultaneously in the British Commonu'ealth of Nations by
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Published simultaneously in Canada by
THIE RIERSOY PRESS, TORO TO
This monograph is protected by copyright No
part of it may be reproduced in any manner
without written permission from the publisher.
Copyright, 195}, by CHARLES C THOVASPUBLISHER
Printed in the United States of America

·FOREWORD T NIE IDEAS and procedures presented in these few pages were developed by discussion and trial in conjunction with a group of alert, thoughtful, and always cooperative colleagues over a period of years. The expression of these vens is my own for which I must accept full responsibility in the treatment of any given case involving respiratory problems there is now seldom important disagreement within the group who form a coordinated team and ask and give consultation freely. Attending and house staff, nurses and technicians, all contributed by sugges- Lion, discussion, and by unuiring and attentive care of patients, with the result that an unusual degree of con certed team work has been achieved It is not possible to give credit to all of those who merir 1t To mention only a few to whom I am indebted, the late Dr C A Aldrich gave especial help in problems of tracheobronchitis Dr Jerome Head converted me to the importance of pastural drainage. Dr. Martin Seifert directed much of the general care on polio patients and helped der elop the treatment here outlined Dr. Lowell Snorf gave us important consultation and advice. Dr. 3. Earl Remlinger gave much aid in respiratory problems Drs Louis Sauer, Herbert Lussky, Alvah Nen comb, and Benjamin Rappaport did the same in pediatric cases Drs Vernon Turner, Frederick Hiller, Meyer Brown, Gail Soper, John Elsen, Jolina Ballenger, and many others collaborated in working out our problems. Mrs Alice Nuel, for many years charge of the contagious ward, felped greatly to comer cliquezas to the V

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·CONTENTS FOREWORD V 3 I INTRODUCTION II. THE MECISAMICS OF RESPIRATORY OBSTRUCTION 6 III ANOXIA IN CLINICAL STATES 21 . 31 31 35 IV ACUTE, BULBAR POLIOVY FLITIS Concepts of the Disease Types of Respiratory Difhculty Nature of the Disease Treatment Postural Drainage and Aspiration 44 Nutrition and Fluids 48 Electrolyte Balance 49 Vitamins and I'rotein 51 Tracheotomay 52 Indications for Tracheotomy 53 The Respirator in Bulbar Polioinyelitis 57 Outline of Treatment Go Special Apparatus 61 Other Complications 63 Atelectasis 61 Pulmonary Edema in Poliomyelitis GG Conclusions 69 V TRACTIEOTOMY-ITS EXPANDED ROLE AND TECHNIQUE O VI TRACHEOTOMY IN OTHER DISEASES WITH RESPIRATORY OASTRUCTION 76 Tetanus Diphtheria 79 Botulism 80 Y11

·Respiratory Emergencies
Anesthetic and Postoperative Emergencies
Barbiturate Poisoning.
Craniocerebral Injuries
In Neurosurgery
Conclusion
81
82
82
84
85
BIBLIOGRAPETY
87

·TREATMENT OF
RESPIRATORY EMERGENCIES
INCLUDING
BULBAR POLIOMYELITIS

·No text on this page.

·CHAPTER INTRODUCTION IS NOW RECOGNIZED that anoxia, previously unsis. associated with respiratory obstruction It is also appre. ciated that secretional obstruction may be one of the most important types of obstruction, in addition, it is well established that marhed changes in the pulmonary area may develop secondary to blocking of the airway. These changes may include atelectasis, pneumonitis and pul monary edema We believe that the timely recognition of these factors and the treatment based upon such recwynition have been effective in a variety of conditions. Methods of care based on such a concept of disease have apparently saved many lives, not only in bulbar poliomyelitis but in acute infectious tracheobronchitis, flame and gas injuries of the respiratory tract and diseases where spasm or secretion may be important. These in. clude tetanus, botulism, cranio-cerebral injuries, vascu. lar accidents and other conditions where simlar secondary effects dominate the picture This discussion is written so that men having to core with such emergencies may find their decisions easier and may not easily be overwhelmed by a spirit of featism in situations whuch, with understanding, may prove amena. ble to proper management, While the approach to this problem has been chefy clinical it is based on considerable study of the underlying physiopathology. There is ble herein wich is original ·Respiratory Emergencies The writer las weighed the ideas of known physiology and pathology, often borrolled from apparently unrelated! fields, and lias accepted or rejected them on the basis of clinical trial. He feels that he lias arrived at a rather clear picture of what happens in the conditions to be described and hopes to convince the reader that treatment based on such ideas and experience is logical and effective. When my first case of bulbar polio was thrust upon me as a full-blown emergency, I had had almost no previous knowledge of that clisease nor any experience with it. There was not time for discussion, for consultation, or csen for detailed analysis. I was conditioned by previous study and experience with tracheobronchitis and allied obstructive disorders of respiration to recognize that there was time only for a decision that must be made in a fraction of a minute. That that decision was right in this particular case at Icast, nas amply justified in the light of the patient's almost miraculous rocoscry on clearing the airway The experience was repeated in tro cases immediately afterward, but my position was assailed by those with preconceptions which generally prevailed at that timc As I studied the disease and talked with those who were committed to the older ideas of this disease, my con- Viction wasered for a time, loncier, alter more experi. ence a belief developed and lias remained firm that my first picture was clear and accuratc. I should file for the reader to retrace with me in the pages that follow some of the steps that have led to my present convictions in the care of the conditions discussed, including bulbar poliomyelitis lle will then. I think, find our thesis a littic more con incing Some of the le ats lic explore may appear too diversionary at first but should prove of considerable interest. This apparently devious iste should lead us to the goal of better under.

·Introduction standing of the problems of disturbed respiratory plıysiol. ogy. Such a study, combined with practical experience, seems to me to provide a surer basis than that reached by academic or laboratory consideration. Many interesting pliases of conditions discussed can be merely ouilined. For instance, there is much recent investigation of arclectasis which can barely be mentioned. There is also a great ferment of research into the types of poliomyelitis viruses, the method of their transmission and the modes of their action which cannot be touched upon. To avoid these may appear to be oversimplification, but the presentation has advisedly been stripped bare of obscuring details which would only blur the picture. There have also been omitted many controversial issues because their deterniination in the present state of our knowledge has little bearing on the basic premises of this outline. Fundamental to our concepts in diseases associated with respiratory obstruction aje two main considerations, (1) the secondary effects of respiratory obstruction, and (z) the effects of anoxia The first of these will be developed in relation to acute infecuous laryngotracheobronchitis in the second chapter Anoxia will be discussed in the fol lowing one Later chapters will develop their application to bulbar poliomyelitis and other conditions associated with respiratory obstruction and secretion ·CHAPTER II THE MECHANICS OF RESPIRATORY OBSTRUCTION HIRTY YEARS ago the entity now recognized as acute infectious laryngotracheobronchitis was at about the stage where bulbar poliomyelitis has been until very recent years. Acute tracheobronchitis was considered an overwhelmingly toxic respiratory infection Relief was souglit only in the stage of cyanosis, rapid puise, and failing respiration, which we nou know was the stage of irreversible changes The reported mortality of the disease was from 50% to 70(1). Later, even without sulfa drugs and penicillin, Davison (2) was able to report 15 consecutive recoveries in patients requiring trache. otomy. My oun experience was almost that good. l'ew patients are now permitted to succumb to this discase. In 1924 Baum (3) proposed the idea that obstruction was an important factor in thus descasc. Descloping on that basis and aided by the work of the Jacksons (1). Gittins (1), Richards (5), Orion (6). Ilolinger (7). Nefſson (8). Daudson (2), and many others (9), troutment has taken away most of the dread of this condition. It has been one of the satisfying miracles of medicine to sec tiny patients with acute tracheotsroncluitis, cyanotic and restless or semicomatose, and fluttering on the brink of eternity, become ross pink and alert or drop off in casy sleep in a short time after proper treasures are taken To my mind to factors fave seemed most important 6 ·Mechanics of Obstruction in this disease First, the mechanical effects secondary to respiratory infection associated with obstruction and increased negative intrathoracic pressure, and second, the effects of hypoxia--or as it is generally denoted, "anoxia" —with associated accumulation of carbon dioxide in the blood stream. The latter will be more fully discussed later. Sepsis in these cases is I believe not of primary importance, and when it is serious is more likely to be due to infection superimposed on atelectasis In acute obstruction at the laryngeal level, the urgency of impending asphyxia may grant only seconds to save life If the airway is cleared the emergency may be safely past. If however, the obstruction is not critical but is unrecognized and persists, definite serious secondary effects usually develop The causes of acute respiratory obstruction are many. The most important are outlined below: 1 Simple edema associated with iodides, cardiovascular and renal disease, gout 2. Allergy with edema, spasm and mucus plugs. 3 Acute infections, especially diphtheria, acute laryn, gotracheobronchitis, abscesses within and without the airway. 4 Sectional obstruction and/or spasm, bulbar polio. myelius, tetanus, botulism, other central brain disease 5 Positional obstruction due to coma, shock or weakness 6 Chronic infections including tuberculosis, syphilis, leprosy, scleroma and other granulomata 7 Trauma from instruments, caustics, gases, flame. fracture of the larynx and irradiation 8 Tumors, benign and malignant 9 Congenital malformations, webs, tracheal collapse.

·Respiratory Emergencies 10 Foreign bodies. 11. Paralyses, especially bilateral abductor paralysts of the larynx. As a typical condition acute infectious laryngotracheo bronchitis will be discussed in detail. It gives perhaps an extreme picture, but this may be approached by various other conditions, even not primarily infectious First, it occurs usually in very young children where the lax areolar subglottic tissues permit much edema with consequent marked obstruction; and second, associated infection is often grave. This may be secondary rather than primary. Laryngotracheobronchitis has often been over. looked or confused with atypical bronchopneumonia. It does appear however to occur as a primary condition and seems to be a definite clinical entity. The symptoms are typical. Following an ordinary cold a child may develop hoarseness, croupy cough, restlessness, stridor and then perhaps rapidly increasing obstructive dyspnea. There may follow marked cyanosis and rapid pulse, or the more serious pale cyanosis of exhaustion scen especially after sedatives Obstructive symptoms with retraction, suprasternal, intercostal and substernal rusually are outstanding but they may be lackng iſ opiates have been given or, as pointed out by Gittins (1). if the obstruction is low Marked delıydration often excurs, perhaps because the demand for oxygen is more urgent than that for water These patients cannot take time out from the fight for air long cnougla to swallow Nuids The exact pathologic process is probably not truly represented by the postmortem findings cracheotomy and instrumentation The Jacksons (1) frase given a truer picture by bronchoscopy in the living. Apparently a descending mucositis occurs with first a stage of dry inflammation followed by congestion, edema and exces.

·Mechanics of Obstruction site secretion. Plugs, crusting and ulceration may occur, especially after tracheotomy without proper humidification of inspired air Schiller (10), after studying the few postmortem specimens lie could find not modified by abnormal agonal processes, considered the condition essentially a cellulitis of the mucosa and submucosa with lymphangitis, edema, infiltration of white cells, focal necrosis and vascular changes. But an interpretation of the disease process in this and other obstructive conditions based on postmortem material gives a poor idea of what really happens. A perversion of the normal processes and functions of the whole respiratory tract apparently occurs For a true picture of this plıysiopathology there is important evidence in the work of Binger and Moore (11), Coryltos and Birnbaum (12), Kernan and Barach (13), Galbraith and Steinberg (14) and many others. These emphasize the far-reaching effects of increased negative intrathoracic pressure, of secondary vascular changes and of damage to the lungs and of superimposed infection Galbraith's and Steinberg's (11) beautiful experiments showed that bronchial obstruction with associated interference with respiratory movements leads to marked secondary vascular changes especially congestion, stasis, edema and transudation. Kernan and Barach (13) emphasized the importance of these circulatory effects and concluded that was a result of the continued obstruction and the elevated negative pressure in the chest, blood enters the right chamber of the heart and lungs more freely, but it is retarded in its departure from the lungs into the left heart as a result of the backward suction pressure on the left ventricle as it delivers blood into the extra thoracic aorta The elevated negative pressure within the chest exercises suction on the capillary walls which is the 9 ·Respiratory Emergencies important factor in the production of intra-alıcolar er. udate." Auer (15) in 1917 in a study of war gases pointed out that pulmonary ederna may be produced by a locally acting mechanism. "Each alveolus which is in connection with a stenosed bronchis or bronchiole will act like a miniature dry cup during inspiration." This initiates or facilitates the passage of a transudate into the alcolar spaces. More will be said about this later in discussing pulmonary edema Air absorption is believed to lead to atelectasis; and rupture of damaged alıcolar walls leads to emphysema. Increasingly greater respiratory effort heeps up a vicious cycle. Other mechanisms have been described for the production of arclectasis and the exact cyplanations are too controversial to be (letaile<liere. The facts seem to agree. however, with the effects outlined, in respiratory obstruction It would seem from a study of the above and other work that the important factoss m this and similar con. ditions are the mechanical ones of high obstruction and secondary vascular changes plus superimposed infection. The original infecting organisms have been reported to be cluicfly streptococci and II influenzac. At Cook County Children's Hospital in a series carefully studied, green forming streptococa strongly predominated. Bradford and Lcally (10) with a careful plating technique found this suine organisin predominating with less than 5% of hemolyut streptocexci in most cultures Tlie tissue reaction and sticky exudates seen clinically in tracheobronchuts would be in accord suith the finding of streptococcus viridans It mas cien lie that in olistructiic disease the picture can be much the same without preliminary infection. With arclectasis, however, there apparently is omformi, superimpxsed infection and pneumonitis If not relieved 10 ·Mechanics of Obstruction this may go on to focal necrosis or lung abscess and later bronchiectasis as Galbraith and Steinberg (14) found when bronchial obstruction was produced in healthy dogs. In six cases of flame injury where the primary injury was purely traumatic, the clinical and bronchoscopic picture was hardly different from that of acute infectious tracheobronchitis To sum up the pathogenesis of tracheobronchitis, it seems to me that this description is fairly accurate An infection involves the larynx and subglottic or supra. glottic tissues Congestion and edema lead so nearly to obstruction as to raise the negative intrathoracic pressure which causes added congestion, transudation and capil. lary damage From this as well as from direct infection thick exudate blocks the bronchi or bronchioles whose walls are already swollen As spreading secretion blocks the regional bronchioles, the interlobular tracts are cut off, air in the alveoli becomes absorbed, the dependent portions tend to become atelectatic, and the overlying ones may become emphysematous. Infection and local circulatory changes add to the exudate, Atelectasis and emphysema further embarrass the heart. Work on experimental pneumonia indicates that a wide variety of effects can occur secondary to blocking Nungester and Jourdonais (17) found it was easy to produce experimental pneumonia in dogs only if they introduced organisms protected from the action of phagocytes by mucin Loesschle (18) concluded from a study of human material that in pneumonia infection was spread chiefly by tidal flow of exudate into open alveoli and bronchioles The resulting condition is apparently simpler, more easily reversible and quite different from the pneumonitis which results from the infection of solid atelectatic lung In the experiments of Galbraith and Steinberg (14) ·Respiratory Emergencies already cited and in work on wat gases by Winternitz (19) and others, it was shown that when atelectasis and extdate or fluid persist for a period of one or two days infection is almost insariably superimposed. The result is pneumonitis or atypical pneumonia and their secondary effects such as focal necrosis, gangrene and bronchiectasis. In this connection it may be interesting to review our knowledge of the etiology of bronchiectasis There seems to be pertinent evidence that it may often result from a single obstructive episodc. Perry and King (20) in a careful study of a large group of patients with broncliiectasis found that the process did not progress during continued observation in more than possibly 6% of their cases. Goodale (21) established that in at least one third of his patients the condition developed before the age of ten. Anspach's (22) roentgenologic studies of children with bronchiectasis disclosed that on previous filins frequently taken several years before, a large proportion had shown the wedge shadows of atelcctasis. It has often been assumed that bronchiectasis was a slowly developing process due most often to the continued feeding of a nasal sinusitis, and countless operations liasc been done on the sinuses in that belief. It is a matter of observation that the eno condrions do frequently coexist. It is suggested, honcier, that the relationship is usually only coincidental and that the trio conditions may have a common etiology which is often allergy. Watson and Kibler (23) believed that one of their bronclicctatic patients were allergic They stated also that “thie funda. mental basis for chronic or recurring sinusitis is commonly an allergic rhinitis" which I believe is true. Miller and Piness (21) hasc reported a group of patients in sluch so-called atypical pneumonia had been 12 ·fechanics of Obstruction diagnosed, in which obstruction and atelectasis were the essential facrors. Allergy was present in a high percentage of my cases of acute laryngotracheobronchitis. Certainly in an allergic child with edematous mucosa, bronchial spasm and tena. cious plugs, anchored perhaps by the mechanism observed by Hilding (25), conditions are ideal for the production of blocking, atelectasis and a sequence following infection that might result in bronchiectasis. I have slides indi. cating the beginning of this process in an asthmatic child dying of measles encephalitis with atelectasis. There are. of course, many other mechanisms and explanations for the development of atelectasis (26, 27). Probably there are pathologic conditions similar to those outlined in many cases called atypicai pneumonias, especially when these are associated with emphysema, shifting roentgenologic and physical findings and delayed or incomplete resolution Snow and Cassasas (28) re. ported such a series in an influenza epidemic. They ascribed the findings to obstructive atelectasis and emplysema Holt (29) reported emplysema in a large percentage of autopsies in bronchopneumonia in one epidemic. It does seem clear, therefore, that a considerable vari. ety of diseases may be secondary to bronchial or higher obstruction which is frequently unrecognized These may include the so-called atypical pneumonias. lung abscess or gangrene, bronchiectasis and bronchostenosis. This detail has been given to show that the problem in any respiratory obstruction is not simpls one of blocked airway and anoxemia, but that grave progressive and irreversible changes may at any time supersene Any treatment then may be unsuccessful. Rest, fluids and oxygen therapy are successful in relieving most cases of acute infectious tracheobronchitis, 13 ·Respiratory Emergencies But if these do not give relief, tracheotomy is to be done without delay. It is frequently too long postponed to the point of marked cyanosis, rapid pulse and imminent heart failure. Patients with supraglottic edema, as pointed out by Neffson (8), are likely to be most urgent. Our treatment has been as outlined bclow: 1. Rest -- physical and mental so that mininum oxygen is required. 2. No opiates or atropine. 3. Oygen by catheter, hood or tent. 1. Fluids by mouth and parenterally to relieve dehya dration and liquefy secretions. 5. Moisture saturated air, especially after tracheotomy to lessen or prevent crusting. 6. Tracheotomy is not delayed if the foregoing procedures do not soon give relief. 7. Postural drainage and aspiration. 8. Postural irrigation if secrction, plugs or crusts cause blocking 9 Bronchioscopic remosal of crusts or plugs if neces. sary 10. Expectorants are of questionable value. Watcr parenterally is the best, but two to four grain closes of joides seem to help. The reason for most of the above are obsions. Opiates louer the struggle for air, and the margin is so Harrow that unless the patient uses all his power to get oxygen he will soon be overwhelmed Atropine thichens the already sticht secretions and it was obseried by an 1soci. ale at one hospital a few years ago that no child recovered from this disease alien atropine had been given. Oxigen is valuable If it brings any measure of selief and progressive improvement treatment should be er pectant and most patients will recover without cannula ·Mechanics of Obstruction tion If, honever, the battle proves a losing one, inter. vention must not be postponed until general and cardiac exhaustion have passed the possibility of recovery, nor until the secondary changes are irreversible Kernan and Barach (13) have emphasized the value of giving oxygen with positive pressure with or without helium. Indications for tracheotomy in this condition have been. 1. Impending asphyxia • Threat of cardiac or general exhaustion 3. Marled and persistent retraction unrelieved by oxygen 4. Restlessness 5. Cyanosis, especially of the gray type, and rapid pulse. These are often igns of imminent heart failure There has been much discussion of the relative value of intubation and tracheotomy In diphtheria intubation has generally been the treatment of choice It must, however, be done by an expert, and an expert must at any time be available to reinsert the tube which may be coughed out It is better done under direct laryngoscopy with aspiration of secretions and membrane which may even obviate the necessity for it Even here I believe tracheotomy is better. For all except very temporary obstructions it seems to this writer that tracheotomy is preferable it is more certain for the occasional operator It puts the larynx at rest and allows its earlier return to normal It permits suction through the tube with irrigation Plug and crust removal and bronchoscopy can be easily done through the Hound as is often necessary With tracheotomy crust formation is sometimes increased, but that can largely be prevented if the atmosphere is kept at Jackson's (1) dew 15 ·Respiratory Emergencies point. This is done hest by 1 meclianical humidifier as described by Davison (2). Bronchoscopy for aspiration and inspection of the mucosa should usually precede tracheotomy. With the bronchoscope Jeft in place the patient is usually relieved and the tracheotons can then be deliberate. When one has done tracheotomics over the bronchoscope, he is not likely by choice to do it otier. wisc. The Mosher life saver or endotrachcal tube are also of considerable value as a preliminary to tracheotomy. In the condition herein discussed bronchioscopic aspira. tion is often a necessary and life-saving procedure. As an adjunct postural drainage seems to haic been neglected. even though mention is frequently made of the adverse cffects of gravity on secretion. Postural treatment is widely used by chest surgeons and internists, but there lias been little about it in the medical literature until recent years. Nelson (30) showed that cien in bronchiectasis, in which sputun is viscid and tenacious, proper postural drainage was very effectie and resulted in at least tom. porary cures. Ile insisted on the patient lying inserted with the hips over a double inclined plane, with iho position muntained for days or even rechs with only very brief interruptions Cures by it hasc been seen in early cases of broncluectasis in children, and it is usually part of the medical routine in abscess of the lung. Dr. CA Aldrich (91), who sin many patients at the Chuldren's Memorial Hospital, stated that during one yer he treated influenza la postural drainage and did not hare one case of pneumonia de clop in such patients. Postural drainage must be such that a real gradient is maintained from the main ioner bronchial area to the trachea and Jarine According to Morioch (37) tliis should scan at least 15 degrees elevation of thc foot of ·Mechanics of Obstruction he bed, but better as much as the patient will tolerate, which will increase with use. In infants the prone posiion with the foot of the bed noderately ratsed provides a much better gradient and it is usually accepted easily. Having in mind the physiopathology of acute laryngotracheobronchitis it would seem that here postural drain age would be especially valuable. The usual protective mechanism fails Secrections are not moved by cough or tussive squeeze and ciliary action is probably limited Secretion as it is first formed, whether as mucus, transudate, exudate or hemorrhage poured out into the trachea, bronchi or bronchioles, is fluid and will flow some distance along the dependent wall before it forms plugs or crusts. At first ciliary action probably helps. Leonard Hill (33) showed that cilia from the horse's trachea moved material twice as fast in the horizontal as in the vertical position Murphy (34) injected material of the Viscosity of secretions found in asphyxia neonatorum into the bronchi of cats and demonstrated that gravity drainage alone could clear the tracheobronchial tree. If secretion can flow to the areas of greater cough reflex, tussive squeeze and cough will be much more effective If any cough, squeeze, or ciliary action is left the help of gravity will be important. If secretion stagnates it should then be as a spread dependent layer and not as an occluding mass lying in a bronchial well If plugs or crusts form they will be nearer the outlet as we have observed bronchoscopically after instituting postural drainage These will be more easily expelled by cough or will be more accessible to removal by aspiration or bronchoscopy Lavage of the respiratory tract has been proved feasible by Stitt (35) and by Minter (36), the latter using as much as 400 cc of fluid at a time in adults Gittins (4) in 17 ·Respiratory Emergencies tracheobronchitis used epinephrine and plıysiologic solution of sodium chloride in small amounts, aspirating it afterward. Richards (5) shoued that a solution of sodium bicarbonate tends to soften and dissolie plugs. Wetting agents such as sodium lauryl sulfate hase been adıocated to prevent cruisting and scem to be of rcal value. The quantity should be sharply limited as feximing may occur. In one case of bulbar poliomyelitis 1 [clt that this contributed to an unfavorable outcome Penicillin in normal saline has been used for its local antibiotic effect to soften plugs and to thin secrction. If one is to use huid it would seem that after it is instilled tlıc inserted posture should be used io guarantee its return and also to aid in the moscment of secrction and plugs toward the trachcotomy opening. In our cases 1 10 15 cc. of from 3 to 5 per cent of warm solution of soxdum bicarbonate at a time fasc been dropped into the tracheotomy tube during inspiration. usually with the gratifying result that vigorous coughing presumably churned the solution over crusts and plugs. This pro cedure was carried out with the head cleiated and the chuld turned toward the side out which the stethoscope indicated the greatest blexe king The hicad 1.25 then lousered and suction was sed fx a catlicter through the ira, hertomis tube Physiologie solution of sexium chloride or Ringers solution followed to wash out the solium bkarlxnate. Intermittently when there was much bloch. ing epinephrine solution 1 10,000 was used! (Stronger solutions are known to produce undesirable secondary congestion in the nose) Thus treatment luas proved of much value in recent cases, although it cannot entirely supplant bronchoscopic aspiration and forceps removal of crusts It proved esprex salli saluablc m cases 111 which, even ay; mm brun bos opxe could 1100 le puissee! A 18 ·Afechanics of Obstruction capable house officer can be trusted to use postural irri. gation and save the laryngolist constant attendance and the patient tiring bronchoscopies. This condition discussed in detail varies from other obstructive respiratory disease because it occurs in younger patients and because there is associated infection from the beginning But it seems to me that the condition is primarily mechanical and that as in experimental work cited, if obstruction is marked and prolonged, infection is likely to be superimposed The severity of the secondary effects will vary inversely with the age of the patient and is, of course, much less likely to be so serious in the older child or adult. For instance, in some cases of flame injury to the respiratory tract which I have seen, the end picture in addition to first or second degree burns was hardly distinguishable from that of acute infectious tracheobron. chitis The treatment probably should be almost the same Such cases probably are often overlooked because of associated serious injury Livingston (37) has reported three of these cases in which the symptoms had at first been ascribed to obvious carbon monoxide poisoning. He noted obstructive symptoms and performed bronchoscopies. First and second degree burns were found with intense congestion, edema and exudate in the trachea. Tracheotomy was done with recovery of all three patients. The other three cases I saw were due to inhaling faming gas in auto accidents and in these the picture was clouded by head injury In the Coconut Grove disaster "irritation from hot and noxious gases" apparently was responsible for many of the bad effects (38) Where the mechanical factors of obstruction are chiefly concerned the following conclusions seem valid 19 ·Respiralory Emergencies 1. In laryngcal obstruction relief of asphy via is the most immediate problem. 2. Persisting obstruction icads to marhed changes secondary to increased negative intrathoracic prossure. These are congestion, cdema, exudate or hemorrhage, atelectasis and emphysema. 3. Superimposed infection may lead to atypical pneumonia, pneumonitis, lung abscess or bronchicctasis. 4. Intervention must not be delayed until thesc irrc. versiblc changes are established. 5. Postural drainage and irrigation arc valuable aids after tracheotomy. 20 ·CHAPTER 111 ANOXIA IN CLINICAL STATES HILE IN GENERAL the academic and theoretical aspects of oxygen want are well known, it does not seem equally true that the importance and serious implications of anoxia are always appreciated, especially under the stress of emergency. A previous discussion by the author (39) was presented in somewhat greater detail to show that some degree of anoxia frequently is unsuspected and untreated, to indicate that even brief periods of hypoxia or anoxia may cause serious damage, to point out some conditions responsible for anoxia, to review the signs and symptoms which may indicate its development, and to present measures for its prevention and treatment It has been difficult to establish the true bustologic picture of damage from anoxia because the most notable injury is to brain tissue in which similar changes occur in association with other acute circulatory and degenerative disturbances Also anoxia is frequently associated in man with other grave conditions such as anesthetic depression and septic, degenerative or circulatory disease In addition it requires a survival time of from 24 to 48 hours for demonstrable histologic changes to develop in brain tissue after injury from anoxia. Agonal and postmortem changes in this tissue are also hard to prevent or evaluate Windle and Becker (40) have given a clear-cut demonstration of the effects of oxygen want in guinea pig 21 ·Respiratory Emergencies embryos at term. Tlie titerine circulation was interrupted until asphyxia occurred, tlie animals cic resus. citated, allowed to survive for a time and later Killed with the tissue fixed in sittt, Although it is accepted that brain tissue of the young is less sensitive to anoxia than that of adults, all animals in uliom the circulation was interrupted for eight minutes or more shoned neurologic symptoms and pathologic changes. Thic symptoms in. cluded incoordination, atavia, spasticity, tremors. con. vulsive seizures, diminished learning ability and cien decerebraic states llistologically, in 65% of the animals there occurred edema, chromatolysis, necrosis, capillary hemorrhages, glial proliferation and loss of brain cells with changes varying from slighe atrophy to marked sclerosis Morrison (11) demonstrated similar profound changes in the brain of clogs and guinea pigs subjected to repeated short periods of anoxia. The critical level scemed to be a reduction from the normal 20, to 12 of 13 solunes per cent of oxygen in inspired air following repeated cr. posures of 23 minutes. For greater degrees of anoxia thic time of dangerous exposure sccined to be correspond. ingly lessened llc found in the moules that a single exposure to a simulated altitude of 32.000 feet for 25 minutes was capable of producing extensic liminar NICCTOSiS of the cortex. Frank necrosis (curre usualls only after cpisoles of anova sulliciently sesere to proxlure cessation of respirat The frontal lole was frost often inolied, the temporal Jolie Icast often The cerchellom was more frequently molsed than the basal gangli, and the medulla least These experiments and many others from the lalxoratory shun definitel tlic graic and lasting ellects of periods of anoxia cien as short as three to fise minutes (12) 22 ·Anoria in Clinical States Yet these probably do not represent the extreme picture since it is very difficult to exclude such reservoirs of oxygen supply as the placenta and the lungs, as in Windle's experiments, or to completely exclude cerebral circulation through collaterals even after ligation of the carotid and vertebral arteries. In clinical conditions it has been somewhat difficult to establish the picture of anoxia The studies by Courville (43) of material obtained after death from nitrous oxide anesthesia are classical and his conclusions that these represent the effects of anoxia are quite generally accepted He lists such changes as sclerosis of scattered Pyramıdal cells, patchy necrosis, degeneration of limited portions of the cortex and lesions in the lenticular nucleus Degenerated areas tend to become confluent and to bring about necrosis of the various laminae. He states that only when the patient survived a sufhcient time, usually 24 to 48 hours, are histological changes found, and in the more fulminating cases these were not demonstrable. He believes irreversible changes may ocuur after three to eight minutes of anoxia Many authors have shonn similar changes, as for in. stance Schreiber (44) in asphyxia neonatorum and Hart. man (45) following surgical operations Since it is not beyond controversy that the effects of carbon monoxide poisoning are due solely to oxygen want the many reports on this disease are not cited The data so far presented are related to gross laboratory and clinical demonstrations But it is hardly to be doubted that in patients surviving there are important changes beside those effecting immediate circulatory col. lapse and general depression Courville (46) lists among sequelae of oxygen want, twitchings, ernotional flattening or psychic aberrations He believes that the condition of 23 ·Respiratory Emergencies lapse (53, 55. 56). Ill of these have been reported as symptoms of bulbar poliomyelitis Blaloch, Harrison and Il'ilson (53) deinonstrated in experimental respiratory obstruction that carbon dioxide PHYSIOLOGY OF RESPIRATORY OBSTRUCTION 100! 02 80 ART PCO, & Og SAT. 60 pCom 14 72 ARTERIAL 40 70 100 80 60 20 VENTILATION, % Figure i Upper scale represents arterial O, un per cent saturation and below it CO, tension in mm of Ng Lower scale shows arterial p! and the horizontal scule the adequacy of pulmonary ventilation, (Repreluced with permission from I'. Gray Ilic Physiology of Respirator Obstruction inn Osol, Rhindou Lanns, 1974, Varch, 1930) may reach dangerous lescls in the arterial bloxxl cien while ougon saturation is stil normal. This is shown graphically in the lustration from Gray (1). Fig. 1. With mxlerate lispun cntilation at 80% of normal dhe oxygen saturation is not detectbly affected, but the CO: cension rises to 30 mm of lig and pll falls to 7 37 which 26 ·Anoxia in Clinical States are definitely beyond the normal range. At 50% of normal ventilation the O, saturation falls to about 88%, equivafent to an altitude of less than 10,000 feet and readily tolerated Tlie CO, tension however, las reached 80 mm. Hg. which approaches the narcotic level for this gas. The pH has then fallen to 7.2 which is a real acidosis. Slightly further increase in CO, may be lethal. The facts cited make it increasingly clear that the administration of CO, to stimulate the respiratory center is not indicated in asphyclic states for the same reasons we have felt that the oximeter, which does not measure CO2, could not be relied on in place of close clinical observation. This should indicate also that mere administration of oxygen may add little Alveolı may be blocked by aspirated or imflammatory secretion or by transudate or exudate. Damage to respiratory cells by anoxia or edema may suspend their function The first essential is a cleared airway to allow not only absorption of oxygen but what is even more important the elimination of carbon dioxide The symptoms of anoxia are important to have in mind, especially in dealing with conditions associated with similar manifestations Close analysis will disclose that in many of these it is the anoxia itself which causes the disturbances which may have been ascribed to sepsis, decompensation, shoch, virus infection and the like. Mental symptoms occur early As Barcroft (52) points out, these may resemble those of acute alcoholism and may vary with the patient's temperament and surroundings There may even be preliminary exhilaration and excessive confidence in faulty judgments such as aviators have at high altitude More common, however, are depression, confusion, disorientation, irrationality, unre. sponsiveness, lethargy and finally coma. Antagonism and combativeness often occur Thuis fuas found in a consider- 27 ) ·Respiratory Emergencies able percentage of our bulbar poliomyelitis cases and has been important because it has inade necessary more active measures, such as traclieotomy, which could have been avoided if the patient had cooperated in simple aspiration. It was interesting in reviewing the nurses' records of bulbar poliomyelitis cases to find that confusion and irritability had been frequently noted before respiratory difficulty was yet suspected by the physician. Restlessness is an important early symptom both be. cause the active patient increases liis oxygen need and also because the unwary are too often tempted to atteinpt its relief by sedation. This may be followed by complete surrender by an overburdened respiratory mechanism Dyspnea is usually an carly symptom but may not be recognized easily in an exhausted patient or in one who has had sedatives. Cyanosis may be very difficult to recognize and evaluate. It may be a late symptom of oxygen need since it may not occur while iliere is compensation by incrcased rate or depth of respiration, and increased rate and stroke output of the heart If obstruction develops slowly, ganosis may be a late sign I believe that if sciere cyanosis develops in conditions of less acute onset, wc are Mikely to have overwaited the indication for tracheotomy Cyanosis may be alsent i anenia since it depends on an absolute amount of reduced lienioglobin in the capillarics. It may not be cudent in the type of trachicolronchitis described by Gittins (1) which may have only gray canosis and few obstructive signs. This may be, honeser, simply part of a shock picture. The effect of anoxia upon the licart is apparently not so great as that of the usually associated carbon dioxide excess. There #ill frequently be an early incrcase in rate and stroke output with later rise and finally serious dis 28 1 ·Anoxia in Clinical States turbance of rhythm. It is to be remembered that a rapid pulse of poor quality is a sign of impending heart failure which again may mean that we have kaited too long to intervene. The immediately adverse effect of anoxia on the respiratory center, on vasomotor control, on the adrenal glands, cardiac muscles and other organs (55, 56, 57, 58), and its part in the increase of permeability the capillaries of the lung bed (59) must be recognized and combatted early Any condition in itself depressing may make a patient unduly sensitive to slight degrees of oxygen want and such patients must be closely watched. Shoch is likely to be associated with a stagnant anoxia due to pooling of the blood in the splanchnic area Not only may oxygen administration then be of value, but it is important that the airway be kept clear and the patient, especially if unconscious, be placed in the best position to breathe easily Military surgeons report that unconscious shocked casualties were frequently greatly helped by turning the patients to the prone position with the face to the side. Anoxia in tracheobronchitis and respiratory obstrucsion has been considered chiefly as a phase of terminal asphyxia. It should rather hase been pictured like a wolf at the heels of a wounded animal, nagging, harrying and tiring until it closes in on its weary prey in one final * cruel slashing attack But from the moment in respiratory obstruction that any degree of oxygen want develops it begins to operate adversely and unless relieved it may be largely responsible for an unfavorable outcome It pro duces restlessness with further activity and increased oxygen consumption. It and the accompanying carbon dioxide accumulation lead to increased respiratory effort, increased negative thoracic pressure, increased conges- 29 ·Respiratory Emergencies tion, exudate and even capillary hemorrhage, increased lymph flow and increased capillary permeability showti by Drinker (59) to follow anoxin. This exudate leads to still further blocking of the bronchioles and the lung bed, with perhaps atelectasis and emphysema and deepening oxygen want. There is evidence also that Sasomotor tone is seriously impaired by depression of function of the suprarenal glands by anovia or by its ellect on the autonomic system (58). If laypoxia has persisted for some time or there is severe anoxia of cicn short duration, the ficart and respir. atory muscles cease to function efficiently due to oxygen want. The fight may quickly near its end. In most con. (litions associated with anovi lic physio pathologic dis. turbance must be visualized from the outset if it is not to become irreversible and if tragic scquelac are to be prevented. Oxygen administration, rest, postural drainage, aspiration of sccretion, parenteral fluids and otlıer incasures will relieve most cases of tracheobronchitis and other types of respiratory obstruction But undue complacency should not delay the usually certain and relatively safe relief by tracheotomy This discussion of the elects of anoxia should male the essential picture somcuhat more clear in the diseases we are considering Especially is this so in traclicobron. chitis, bulbar poliomyciitis and other secretional or spasmolic disturbances. It should help to separate in our muinds the cllect of infection or sepsis om those of anoxia and carbon dioxide excess But most important it should allow us 10 concentrate our efforts where the cncmy 15 vulnerable and licrc trcatinent may be calls effecuse. 30 ·CHAPTER IV ACUTE BULBAR POLIOMYELITIS T *HERE ARE Lwo extreme concepts of the disease of bulbar poliomyelitis One which prevailed up to about 15 years ago was that of a fulminating virus infection which often overwhelmed the central nervous system, especially the brain stem and vital centers The other concept is that it is more often chiefly a problem in respiratory obstruction Both factors probably contribute to the clinical picture to a varying degree. CONCEPTS OF THE DISEASE My first experience with bulbar poliomyelitis came as an acute and dramatic emergency The patient had quichly passed from restlessness and disorientation to deep coma An alert supervisory nurse who had assisted in the successful care of many patients with acute tracheobronchitis came upon the scene as internes were desperately trying to save this man. She suggested that this was a respiratory emergency and advised that a laryngologist be called I found the patient deeply cyanotic and almost pulseless Viscid secretion overflowed from the nose and mouth and was seen by direct laryngoscopy to cover the larynx The patient stopped breathing for an estimated three minutes There was no time for discussion or analysis In the light of my previous experience with obstructive disorders of respiration this seemed at a glance to fall in the same category A cracheotomy was hastily performed, the 31 ·Respiralory Emergencies trachea was aspirateri, manual artificial respiration started and the patient placed in a respirator. In go minutes the pulse and color were good and the patient was rational In 45 minutes he was demanding to be taken from the respirator. It seemed impossible to assume that relicſ of any purely infectious central process could account for such rapid Tecovery. In this and other respects it fitted into the picture of obstruction, with anoxia. Similar experiences folloned in the other cases shortly afterward, although one died before his tracheobronchial tree could be cleared of the thick secretion which mlied it. I liad had no previous experience with acute bulbar poliomyelitis, but had seen many cases of acute tracheo bronchitis at Cook County Hospital and in my osn practice. I was at first considerably confused with ideas then current, but with increased experience I have firmly continued to beliese that relief of sccrctional obstruction and its associated effects are the most important elements in recovery from bulbar poliomyclitis. This conuction lias been strengthened by the support gison to it by Dr. Martin Seifert and other colleagues at the Funston llospital It must be geimitted in fairness that some of my associates lase had reservations against complete accept ance of these Ideas Iloncier, most of the coxtors who have critically obseried the care aduocatori hanc hccny coni crted to its trse One member of the house stall lad opposed as strongly as an interne could the performance of a tracheotomy in the first case lie lid seon litcr lic had followed three such cases he thicii said. "If I get bulbar polemiclus I want a tracheotom done right oft!"--a more extreme xxxsition than I have yet talen On the basis of ms ar n cypericnce with other respita tors diffeulues postural damayc, sporation, and traclic + ·Acute Bulbar Poliomyelitis otomy under proper indications appeared to be logical measures in the treatment of bulbar poliomyelitis Apparently a good many other men have reached the same conclusions by other approaches I later found that Durand (60) in 1929 had advocated postural drainage "since many men must have noted that these patients tend to drown in their own secretions" Wilson (61) had suggested the guarded use of tracheotomy in this disease in 1931 although there had been few reports of its employment in the years immediately following. In 1943 the writer (62) presented his ideas of the disease, and treatment based on that concept of the disease, was outlined. Then and subsequently the writer (63, 64) and his colleagues attempted to visualize for clinicians the nature of the processes in this disease and the underlying patho-physiology It was emphasized that a prime requisite was to clear the airway and keep it so; that postural drainage and continuous aspiration greatly helped to attain this end, that tracheotomy, far from being a radical and dangerous procedure, in itself carried little risk; and that when indicated it should be done early and not withheld as a last resort until pathologic changes had become irreversible. It was further pointed out that the use of the respirator might be very valuable with these patients when they were exhausted or the respiratory center was depressed by anoxia and hypercapnia. It was also demonstrated that it was not dangerous to use the respirator if the airway was kept clear by performing tracheotomy to bypass secretions These ideas will be elaborated in the following pages In recent years great attention has been paid to the respiratory problem in poliomyelitis. Many reports have appeared of the widespread and successful use of tracheotomy The reports on a large scale by Priest, Boies and 33 ·Respiratory: Emergencies Goltz (65), by Milicr and Buck (66) and many others seem to have established that the combating of secretional obstruction is a sound basis for care in this discase. The experience of the past five years at the Evanston Ilospital is given in Table l. TABIFI Mortalin IURAR L'orlov TITIS Pace Year Total T'olio Bullar Bullar and ant Bulla- Bull spinal spinal Deaths Bullar ani! Bulbury spinal Rate Cards 15 0 127 31: 397 Franston Hospital Chicago Residents Illinois Outside Chicago Franston Hospital 711Now Outside Chicago 1917 48 1918 191749 1917 51 1917 57 10) 120 792 695 5018 19 39 11 *77 38$ TA • In the last two years a disproportionate share here more tous cases brought from Outlying areas and hopeals It is admitted that the scierity and the symptoms vary in the different types of the disease, of which at least three main classifications seem to be boon established. Our fiftcen consecutic recos cries crc sccti carly under deal conditions by a compact group well agreed on the prin. ciples of respirators obstruction. We find complete con. trol of our cases and intervened wlien se considerci it necessors Most of the pruents were young, and the strain of the virus may have been mil, sot C NCC sure six of thein rould have dice 11thout tracheotoms. Anothier group nere vigorous adults who came from greater dis tances, here treated after greater deliberation and did less well Phes were young adults and 11311. in purt, an wending spinal fertion and probably dod be greater central neri 03 $13tem molscmcit. 31 ·Acute Bulbar Poliomyelitis We have already discussed anoxia and the secondary effects of respiratory obstruction Bulbar poliomyelitis has many features in common with other respiratory obstructions Some of these are. the identity of many of the symptoms with those of anoxia and carbon dioxide excess, the rapid worsening at a critical level after a period of relatively moderate difficulty, the usually rapid amelioration of such symptoms when the airway is cleared before the stage of irreversibility is reached, and the large percentage of cures based on treatment directed to the relief of obstruction TYPES OF RESPIRATORY DIFFICULTY We classify respiratory difficulty in acute poliomyelitis clinically as of four types With the first three there is general agreement 1 Spinal. In the spinal type of respiratory difficulty the lesions are in the cervical and upper thoracic segments of the spinal cord with varying paralysis of the intercostal muscles and the diaphragm Patients with this type do well in the respirator and fall easily into rhythm with it. 2 Bulbar In this type there is interference with the swallowing mechanism and resultant accumulation of secretion, food and fluids, and vomitus in or over the airway If complications do not occur patients usually get over this difficulty in five or 10 days 3 Bulbar-spinal This is a combination of the two foregoing types 4 Other disturbances in rhythm and depth of respiration Theoretically these could result from a virus effect on the respiratory centers with a fulminating course We made no such diagnoses in the 15 consecutive cases already mentioned We considered the clinical effects observed in 35 ·Respiratory Emergencies so-called poliomyelitic encephalitis to be duc usually to peripheral secretional obstruction plus the effect of anoxia and carbon dioxide excess on the medulla and other centers. Most patients were relieved rather promptly by the measures directed at relief of the obstruction and anovia. The picture of the so-called arrhythmias is confusing. One often sces patients with shallow, interrupted, cogs wheel and was like respiratory movements at times the intercostal muscles and diaplıragın almost appear to oppose cach other. We have seen such arrhythmias con trolled (with serious results) for a time by thiopental soclium, which would hardly be the case if the arrhythmia were duc to central depression. o simpler explanation of this (3 pc ol respiration is that it comes from a reflex or voluntary conflict between respiratory demand and the protective mechanism which help to keep thic patient from drowning in lois oun secrctions. If the reader would try to imagine what would happen to himself iflic sere in the position of the patient uit poliomyelitis, unable to shallow, with secretion lyung in and over his airway, struggling for air, yet at the 3.3me time figling to loop fuid from flooling lis lungs, he might visualize the predicament of some of these patients and more casıls account for the type of respira. tion In mi esperience these irregularities usually dis appear if free respiration is prostried without delay We believe, then that the primary difficulty in bullar poliomchitis is difficulty with thic swallowing mechanism resulting in accumulation of sertation, fooxl. fluids and somitus in the aints as with concomitant anoya it is to be recalled that there is normalls sectored from 1.000 to 1,500> CC of salta per day which is likely to be increased in nenous disease and oth nausca (67). To this intust le 36 ·Acute Bulbar Poliomyelitis added inflammatory secretion, food or fluid injudiciously glen, and vomitus We have recovered by suction from the pharynx in 24 hours over 2,000 cc. of fluid above any added for irrigation. The usual mechanisms of expulsion of the fluid from the airway are ineffective in these patients Cough does not operate effectively except where perfect postural drain. age allows no fluid to accumulate at the level of the larynx or below it, since to get enough air for the expulsive force a deep quick inspiration would be necessary This results in aspiration of the overlying fluid as shown in Figure 2. Both voluntary and reflex control tend to inhibit such inspiration Cough may be difficult also because the medullary center is depressed even early, we believe, from anoxia and excess carbon dioxide Therefore, unless secretion is continuously removed by treatment it will lead to anoxia by presenting ingress of air, by blocking bronchioles and by flooding and secondary damage to the respiratory area of the lungs The best evidence for the importance of anoxia is that the symptoms are usually so promptly relieved when the airway is cleared. The chief objection to the ideas here presented seem to depend upon histologic eudence that in bulbar poliomye litus there is widespread damage to cells in the brain stem and medullary centers as well as other parts of the brain and spinal cord It has been assumed that derangement of function should correspond closely to the areas of microscopically indicated insolement and that symptoms are to be explained on that basis It has been shown that the reticular substance may show marked abnormalits in poliomyelitis (68, 69) It seems probable from the work of Ilang and Ranson (70) that this area is related to respiration and to vasomotor regulation The inference might then be made 37

·Respiratory Emergencies
Without
tracheotorty
b
Without by-pass
With tracheotomy
Har indst by.es
}
1
38

·Acule Bulbar Poliomyelitis that disturbances of respiratory rhythm and of sasomotor tonus might be explained on that basis From the clinical viewpoint it does not appear to be that easy Pathologic considerations also raise considerable doubt Bodian (71) after intensive study from : 4 fatal human cases of poliomyelitis and from studies on experimental monkeys, concluded that "the use of pathologic material from such fatal cases in the correlation of symptomatologic lesions is dangerous " He further said, “As far as the pathologist is concerned all cases of poliomyelitis are encepha- Jilic." He adds, "Apparently severe destructive lesions are necessary to produce dysfunction at the clinical level" It is also important to emphasize," said Bodian (72), "that although lesions appear in certain centers in the central nervous system, symptoms attributable to such injury need not result Injury must reach a certain threshold of severity, varying with the margin of safety of each center before a clinical effect is observed" He also saw no evidence in this material that edema plays a conspicuous role in paralysis Neuberger (73) and others have suggested that some of the brain damage is due to hemorrhage and anoxia. Courville (74) states that "alterations in the nerve cells are due to the combined effect of the specific virus and of the Figure 2 Model showing the effect when secretion lies in the upper airway When by pass is open fluid is not drawn in by voluntary or mechanical respiration as shown in lower diagram upper diagram shows the effect without by pass or tracheotomy With moderately Viscid fluid, intravenous tube connector and asepto sytinge, model acts as shown (As indicated, the process in patient with bulbar polio probably approximates this without and with tracheotomy) (Modified from illustration in Arch Otolaryng, 46 125. Aug, 1917, with permission) 39

·Respiratory Emergencies
&
Without
tracheotorty
b
Without by-pass
&
With tracheotomy
b
Air inlet bypass
Air
JMC
38

·Acule Bulbar Poliomyelitis that disturbances of respiratory rlıythm and of vasomotor tonus might be explained on that basis from the clinical viewpoint it does not appear to be that easy Pathologic considerations also raise considerable doubt. Bodian (7) after intensive study from 24 facal human cases of poliomyelitis and from studies on experimental monkeys, concluded that "the use of pathologic material from such facal cases in the correlation of symptomatologic lesions is dangerous." He further said, " As far as the pathol. ogist is concerned all cases of poliomyelits are encepha- Hitic" He adds. "Apparently severe destrucne lesions are necessary to produce dysfunction at the clinical level" It is also important to emphasize," said Bodian (72), "that although lesions appear in certain centers in the central nervous system, symptoms actribucable to such injury need not result. Injury must reach a certain threshold of sever. ity, varying with the margin of safety of each center before a clinical effect is observed" He also saw no evidence in this material that edema plays a conspicuous role in paralysis Neuberger (73) and others have suggested that some of the brain damage is due to liemorrhage and anoxia Courville (74) states that "alterations in the nerve cells are due to the combined effect of. the specihc virus and of the Figure 2 Model showing the effect when secretion lies in the upper airway When by pass us open duid is not drawn in by voluntary or mechanical respiration as shown in loner dragran, upper diagram shows the effect without by pass or tracheotomy With moderately essed fud, mtravenous tube connector and asepso syringe, soodel acts as shown (As indicated the process in patient with bulbar polio probably approximates the without and with tracheotomy) (Modified from allustration in Arch Oralaryng. 46 123. Aug, 1917, with peribassion) 39 ·Respiratory Emergencies holds true in human drotvning. It is probable that in many cases if flooding occurs, it is in the terminal asphyxial depression. The experiments of Coryllos (77) on asphyxia by submersion are of interest in comparison with secretional obstruction Dogs, he found, succumbed after four or five minutes of submersion. He divided the process into four phases each lasting about one minute. In the first phase there was apnea caused by reflex closure of the glottis. Rise in blood pressure also occurred which, lie states, "is a constant phenomenon in all forms of asphyxia." Stage two in the second minute is characterized by labored respiratory movements and continuation of the rise in blood pressure (This might parallel the rise seen often in bulbar polio, ascribed by some, and I believe rightly so, to carbon dioxide accumulation ) At the end of this phase consciousness disappears and tonic and clonic convulsions appear. In the third phase respiration is arrested, blood pressure drops and reflexes and muscle tonus disappearincluding loss of corneal and glottic reflexes The fourth phase is characterized by progressing weakness and arrest of cardiac contraction Prognosis varied greatly in each phase. If submersion was interrupted before the middle of the third phase immediate and spontaneous resuscitation always followed. At the end of this phase even artificial resuscitation was difficult or impossible In the late third stage, as the heart began to fail, there was a period of only 10 or 25 seconds when resuscitation might succeed Coryllos' statement that "seconds count in asphyxia and often determine the life or death of the patient" should spur to decision any one who temporizes with any form of respiratory obstruction In some of our patients with bulbar poliomyelitis with 42 ·Acule Bulbar Poliomyelitis asplıyxtic symptoms he found almost no fluid on opening the trachea although the hypopharynx nas flooded This indicates that spasm was most important in these cases. Kelleher (79) reports that a patient with poliomyelitis choked on a single teaspoonful of water and died before relief could be given One of our patients apparently convalescing well as guien cracked ice and choled, became cyanotic and died in a short time. One might well ascribe thus to strangulation by spasm It has seemed to me that spasm is much more likely to be a factor than obstructive median paralysis of the voxal cords We are not sure we have even seen much paralysis in poliomyelitis Furstenberg (80) has pointed out that supranuclear bilateral paralysis is extremely unlikely and nuclear or infranuclear paralysis of the cords is flaccid and not spastic. Abductor paralysts due to securrent laryngeal injury is unhlely in this disease Sjoberg (81) postulates, largely from x-ray studies in poliomyelitis, that a combination of spasm and paralysis of the muscles of the tongue, jaw and pharynx with the head extended blocks the airway While some of our cases with respiratory distress relieved bs tracheotom had dry louer airways, from most of them varying amounts of secretion could be aspirated through the trachea is previous shown this could come in part as the result of increased negative intrachoracic pressure caused by the obstruction it would be more likely to come with more slowly developing obstruction, I believe, due to a combination of habituation to secretion or suction tubes in the hypopharynx, loss of the swallows. ing reflex, inabiliti to cough and slowly developing cen. tral depression Even in these patients spasm may pre (putate a crisis Spasm is especially important un other conditions to be discussed in another chapter. Strobel ·Respiratory Emergencies and Canfield (82) suggest that a partial paralysis destroys the protective function of the larynx. This could be so, especially if the paralysis were of the flaccid type. The comparison to drowning is useful since in poliomyelitis the time may be almost as short and the moment for favorable action may as quickly pass. Ignorance or indecision and inertia may hold to stupid inaction a man who would without hesitation leap into a raging torrent to save a child in hardly graver danger. TREATMENT Treatment of these patients may be relatively simple or hopelessly involved. It undertaken carly, decisively and with a clear idea of the problem, it usually offers little difficulty although it requires meticulous and unremitting care. If delayed by lack of early opportunity or indecision, it may require the utmost in experience, skill, team work and equipment. These cases should have the services of a well integrated team of general clinician, internist or pediatrician, anesthesiologist, neurologist and laryngologist The last is an important member of the group. He should see these cases early and frequently to be able to note any unfavorable course. Decisions for or against tracheotomy should not be made by men who have not had experience with respiratory obstruction without consulting the laryngologist. POSTURAL DRAINAGE AND ASPIRATION Postural drainage and continuous suction, best obtain. able by a Venturi type pump or central vacuum tank are in our opinion the most important steps early in treatment When the patient first gives evidence of pharyngeal paralysis by muffed voice and inability to swallow secrecions, even though he can apparently cough or push them 44

·Acute Bulbar Poliomyelitis
out of his mouth, he should be placed with the feet
elevated and the neck extended, or with face douin if a
child, so fluid mas accumulate in a pool at the naso
Figure 2 water suction fixed to the wall connected by a fairls
suff tube tu collecting boule (2), this to catheter through patients
nose to the pharm (3) is a standby nechanx al suc Can Bevcled
and whistle tip catheters are shoun in insert (Reproduced with
permission from the Tanngoscope funt 1431)
phan hypopharsax or cheek There it may be picked
up as quickly as it comes the opening of a perforated
rubber tube connected to continuous nater Suction
Remembering the few minutes of 3noxia necessary to
produse meiersible dam ige it must be obvious that
• Vanuatured by the SVRC Lox Angeles Galat
15

·Respiratory Emergencies dependence cannot be placed on intermittently applied mechanical suction. We know of no mechanical apparatus which will bear constant use except one attached to a vacuum tank or with continuous water suction The device pictured (see Fig 3) is easily attached, effective in the pressure desired, almost foolproof and does not get out of order. Some plumbing codes interdict its use, yet if it is connected to a half liter collecting bottle filled with antiseptic solution, contamination of the general water system seems impossible. Thirty years of experience with postural drainage in respiratory obstruction, especially in acute infectious tracheobronchitis, has persuaded me that it is of the utmost value and without danger if used early Lateral X-ray with radiopaque oil outlining the tracheobronchial tree indicates that elevation of the foot of the bed in the supine position must be at least 17 to 20 degrees to prevent flow of secretion into dependent lung bed (Fig 4). We have advocated 35 degree elevation but now believe that is extreme and seldom obtainable. Twenty to twenty-three degrees is usually satisfactory if the patient will lie prone with the head to the side, as usually only infants will do, drainage is effective and normal physiol. ogy is not disturbed. By the use of special foam rubber supports the face down position has been made easier to maintain (83) If this can be made comfortable so that the patient will easily accept it, it should be valuable. We have found it difficult, however, to get adult patients to cooperate with this position It is, of course, important also to shift the patient's position frequently in order to prevent congestion and atelectasis in dependent por tions of the lung Bower (76) and his group hase raised a question as to 46

·doute Bulbar Poliomyelitis
Figure 4 The trachea and bronchi are outlined with radiopaque oil
A represents the declisity of trachea and main bronchi from body
axis B show's minimum elevation desirable (Reproduced, with
permission, from Arch Otolaryng , x6 Aug 1947)
47

·Respiratory Emergencies the safety of the Trendelenberg position in seriously ill patients. They found in a limited number of patients. that at an elevation of 15 degrees for 15 minutes the average drop of tidal air was 20 per cent. This, however, left an average tidal air of about 350 ml. on which a patient at rest, I believe, may be carried, especially if aeration of the lung is uniform and if adequate oxygen is given. My experience with postural drainage for over 30 years in the treatment of acute laryngotracheobronchitis has been highly favorable. The dangers do not seem to outweigh its great benefits in a patient who may have important amounts of secretion or fluid in the trachea or bronchi. It frelps to insure that the lower air. way is not flooded and that the whole alveolar area is accessible to inspired air; that the absorption of oxygen and excretion of carbon dioxide is well distributed throughout functioning lung; that areas of atelectasis with or without pneumonitis do not develop. It is true that long continued postural drainage must be used with caution in patients with marked vasomotor disturbance or possible cerebral edema. To judge by the patient's response the procedure is usually beneficial, often dramatically fat orable NUTRITION AND FLUIDS Fluids and nutrition are to be maintained parenterally while there is any danger of flooding the airway because of disturbed deglutition Sufficient fluid must be provided to carry on norinal metabolism and to prevent dehydra. tion Secretions should be kept normally thin so they may be more easily removed from the respiratory tract, especially if tracheotomy is done. Excess fluid may overburden the circulatory system and promote cerebral or pul. monary edema Due allowance must be made, however, 48 - ·Acute Bulbar Poliomyelitis for the 1500 to 2000 cc. or more of fluid usually lost in salita, miammatory secretion or by regurgitation in the patient who is unable to swallow. Adults require about 3000 to 3500 cc per day. ELECTROLYTE BALANCE It is especially important that electrolyte balance be maintamed This can be discussed only briefly. Some aspects of the question are also too incompletely understood or to controversial to be covered here Sodium chloride is necessary but because when gnen alone it tends to increase the loss of potassium, Gamble (84) suggests that the customary ratio of normal salıne or Ringer's solution might well be further reduced We brave usually given fluid in the ratio of one part or less of saline to three parts of water or glucose solution One patient had marhed edema of the face and neck and probably of the brain as judged by depression of the sensorium Tlus had been ascribed 10 postural drainage but cleared up rapidly on withholding sodium The importance of proper levels of potassium in the cell and it is concerned chiefly with intracellular metabolism has only recently been investigated and appreci. ated Lou concentration leads to cardiac and general muscle weakness High concentrations may be lethal and cause cardiac death (85) The range of the critical level may be very narros Deficiency un potassium was found usually in poliomselites by the Los Angeles group This can are from cell destruction, from loss through saliva and other secretions and probabli in açıdosis But in poliomyelitis they demonstrated increased retention with renal impairment Levels rose from the normal 16 10 22 mgm to between 28 to 30 mgm Both anoxia and alkalosis due to mpers entilation may lead to renal im- 49 ·Respiratory Emergencies pairment and nitrogen retention. Adrenal damage by anoxia might lead to disturbed potassium balance since hormones of the type of desoxycorticosterone are potent in causing potassium excretion, and adrenal cortical insufficiency leads to a decrease in potassium excretion. Darrow (86) has stated that his solution containing potassium may be safely given subcutaneously and has reported favorable results with it Bower (87) has given potassium intravenously, but has carefully regulated its use by blood determmations. Hoyne and his associates (88) reported dramatic results in weak and lethargic patients to whom potassium was given intravenously. It was administered in dilutions of cwo to three grams per liter and given slowly at the rate of 8 to 12 cc. per minute Potassium serum levels were very carefully controlled by the use of the photometer. When levels became normal parenteral potassium chlo ride was reduced to 4 grams per day. This was stopped as soon as the patient could be fed Fox (89) and his group have recently proposed a physiological replacement solution winch contains sodium, calcium, magnesium and chloride ions in normal plasma concentrations Its potassium concentration is twice normal value and bicarbonate is provided in double its normal concentration in plasma Their data indicate that this solution prevents hypopotassemia without danger of toxicity, corrects moderate acidosis without inducing alkalosis, replaces extra-cellular electrolytes and induces copious secretion of urine and salt. Its use in poliomy. elitis secms reasonable Gamble (81) says, however, that "the danger of damage to the heart is so serious that I should not like to sce the parenteral use of potassium go at once into clinical currency " If so it should be controlled by careful routine 50 ·Acute Bulbar Poliomyelitis analyses best done by photometry which appears to be reasonably accurate If, however, potassium can be given by gasage or swallowed the organism appears to be able to absorb and retain the proper and safe concentration of this electrolyte from the gastrointestinal tract That is a good argument for earlier use of tube feeding, possibly by the third day, if a tracheotomy has already been done to lessen the danger from regurgitation The feeding tube also permits aspiration in the occasional gastric hemorrhage. On account of the danger from vomiting, we still choose to use only parenteral administration of fluids, glucose, electrolytes, vitamin C and B complex and protein hydrolysate until patients can swallow. VITAMINS AND PROTEIN For repair of tissue damage and the tracheotomy wound, and to avoid edema and promote general well being, it is essential to prevent vitamin deficiency and hypoproteinemia Vitamin C is given from the outset, but we have not thought there was special benefit from very large doses. Vitamin B complex has been given parenterally after the first week Some experimental work in mice (90) has indı cated that the virus of poliomyelitis was less virulent when vitamin B was deficient This was held to be an indication that the virus thrives best in healthy host cells That might explain some recent cases where vigorous healthy young men proved to be our poorest risks Bower and his associates (87) demonstrated that serum albumin levels drop early in poliomyelitis between the first and third day and progress unfavorably for at least ten days They found also that the serum globulin ratio was likely to be reversed They believe this drop in serum 51 ·Respiratory Emergencies albumin is an important factor in the development of edema, especially of the brain. This edema, they postulate, tends to further diminish circulation to brain tissue and thus increases anoxic effects They found this drop in serum albumin retarded or prevented by the use of pooled irradiated blood plasma with apparently considerable benefit to the patients. We have used plasma with benefit in severe cases especially where the patient's condition approached that of shock We give a protein hydrolysate or amino acids by vein after the second or third day in addı. tion to glucose from the outset. Gavage is begun after some return of ability to swallow starting with 50 to 75 CC. increased 10 300 to 400 cc. per feeding alternating with water and formula every hour. A balanced formula is used which gives a minimum maintenance requirement. In the adult this is at least 1800 calories daily. TRACHEOTOMY Wule the measures already outlined will carry many patients to recovery, in others certain danger signs point to the need for further relief Tracheotomy was apparently first suggested by Wilson (61) for use in some circumstances in bulbar poliomyelitis, but only in recent years has it come to be widely employed. A clear concept of conditions which make it necessary, more precise indications for its employment, the almost complete lack of danger in its use and the fact that it is life saving in a large percentage of cases have come to be generally appreciated. Probably its greatest value comes from the fact that it bypasses secretion in the pharynx and provides a clear air." way (see Fig 2). Although Wilson (91) has been conservalive in his advocacy of tracheotomy he has sell stated its value. He said, "Tracheotomy is a radical step but often lifesaving Its purpose is to furnish a free airway so that the air necessary for respiration does not need to be mored ·Acute Bulbar Poliomyelitis down a pharynx full of secretion and through a larynx continually in spasm." I believe the observation quite correct although I cannot agree with his condemnation of this simple operation by calling it radical under such circumstances. Secretions in the trachea and bronchi may easily be removed by suction through the tracheotomy tube, especially if the patient is placed in the position of postural drainage After tracheotomy the use of the respirator is safe and this may be important in a depressed patient Greater use of tracheotomy was adı ocated in 1913 (62) and an attempt was made to rationalize the procedure. Since then reports of large numbers of operations by Priest, Boies and Goliz (65), by Bower (76) and others offer definite proof that it is of great value and a relatively harmless procedure INDICATIONS FOR TRACHEOTOMY Our indications for tracheotomy in poliomyelitis are: 1. Progressive anoxia in spite of other treatment 2 Coma, irrationality or marhed restlessness or other signs of severe anoxia, not immediately relieved on suctioning 3. Marked restlessness or stupor in a patient in a respi rator, even if the disease appears to be spinal. 4 Fluid accumulation not certainly taken care of in any patient. spasm (or bilateral paralysis) of vocal cords. 6 Rapidly progressive bulbar symptoms or vasomotor paralysis 7 Bulbar involvement in any patient requiring a respi. rator 8 Low tidal air not corrected by aspiration or safe res. pirator pressures 9 Untrained attendants, inadequate equipment or poor 53 5 Marhed ·Respiratory Emergencies cooperation with any doubt that airway will be kept free of secretions. These indications merit further discussion. Symptoms of anoxia must be closely watched for, in. cluding restlessness, dyspnea, disorientation, mental de. pression, increased blood pressure, or later fall, and cyano. sis. No patient should become unconscious under observation. Under the third indication it is not always possible to diagnose exactly the type of involvement, especially be. cause an involvement originally spinal may spread quickly to the bulb. Moreover, fluid may accumulate not only from pharyngeal paralysis but because of bronchial or pulmonary inflammation or pulmonary edema. Additional indications have been given Sudden rise in blood pressure has been considered as evidence of carbon dioxide accumulation It has been observed that if blood pressure readings taken at half hour intervals showed a rise of 15 to 20 points, tracheotomy gave carly relief from developing anoxia On the basis of physiologic factors I am willing to believe that this might be an important indication We are not quite ready to recommend routine prophy. lactic tracheotomy of the clinician is prepared to interiene at any moment and realizes how rapidly such patients can fail But it is much better to do tracheotomy unnecessarıly in many cases rather than too late in a single one, and too early rather than after irreversible damage We have seen no important complication from the operation, nor any case in which it contributed to an unfavorable outcome That should be unnersally true if proper technique is rised This is discussed in a following chapter The high operation should be done-usually through the 54 ·Acute Bulbar Poliomyelitis first and second Interspace and the second or third trach ring to permit later use of the respirator if that becoi necessary. Tracheotomy is not to be withheld, as it is too often, the last forlorn hope. It should be done more often wit physician's first experience with the disease, as mi greater skill, training and equipment are required to ca on without it As Strobel and Canfield (82) state, ever very ill patients delay of tracheotomy is more danger than its performance. They point out also that trach omy permits a patient in a respirator to swallow m easily because the usual pause in respiratory action ing which a patient swallows is not possible with n tank respirators. Postoperative care of tracheotomized patients is e cially important since cough is impaired or absent, e cially if they are in a respirator for such a patier trained resident or interne should be on the floor at times Great gentleness to avoid trauma is required. W. continuous water suction from the pliarynx is contin through the nose, intermittent suction is used through tracheotomy tube, removing the inner cannula of ne sary A soft whistle tip catheter is gently used or a rubber catheter obliquely cut and smoothed in a flame with a small second opening near the end to bi excessive grasp of mucosa, while permitting remova secretion or plugs Dew point humidification, gentk rigation as indicated with warm three per cent soda bi bonate solution followed by normal saline, both remo by suction in postural drainage will usually pre atelectasis and obale the need of bronchoscopy Wetting agents (sodium lauryl sulfate) have been u but I have seen one case in which they caused foan 55 ·Respiratory Emergencies which contributed, I believe, to an unfavorable outcome. Grace (92) has added wetting agents directly to the water in the mechanical humidifier with what he thinks is a better effect. Forceps technique is employed for asepsis Antibiotics are used but not long enough to permit the overgrowth of monilia and other fungi. If penicillin and streptomycin are used instead of the broad spectrum antibiotics this danger appears to be greatly lessened. Sulfonamides are, we believe, sometimes harmful in poliomyelitis I have not taken a definite stand for prophylactic tracheotomy believing that with experience we could anticipate the need for intervention in time It had even seemed that with an appreciation of the mechanics involved and with meticulous care a patient with some difficulty might be safely carried in a respirator with postural drainage and continuous aspiration. Strobel and Canfield's (82) advice to operate when there are early and progressie bulbar symptoms, or when a long siege in a respirator is likely with any fluid accumulation now seems to be sound A growing belief in the importance of laryngeal spasm even with small amounts of fluid in the pharynx, unhappy experience sath reluctant consultants and untrained and skeptical house staff on whom final dependence rests for proper treatment, and delayed requests for help mahe me now tlunk it should be a fixed rule that any patient going into a respirator with any difficulty with secretion should have a tracheotomy. On studying our own records I was shocked to find that of nine patients with bulbar symptoms who were placed in a respirator without traclieotomy at any time, only one survived Jacobson, Colien and Carter (93) studied roentgenologically pulmonary complications in relation to tra. cheotomy in respirator patients. Of 26 patients who had S6 ·Acute Bulbar Poliomielitis . Isacheotomy the same day they were placed in the respi. rator only 1 developed atelectasis or other demonstrable changes. Of 17 who went into the respirator one day be fore the operation was done, 14 had such complications. It is not easy to detect beginning stelectasis cren with X-ras (28) nor always practicable to use it when once such a pathologic condition in the lung is established, si y also difficult or frequerly impossible to correct it. The con. scientious physician cannot easily brush off the self reproach that will follow the postmortem finding of exten. sneatelectasis that developed because he has done nothing because symproms, though definite, were not animate enough to slap him awake It is certainly much better to perform such an easy and sale procedure as tracheosomy many times too early or unnecessarily than to have failed to do it once in time to prevent serious consequences THE RESPIRATOR IN BULBAR POLIOMYELITIS It was at one time considered useless and dangerous to use the respirator in bulbar poliomyelitis, but now it seems to be widely employed in that disease This em. ployment has closely comcided with more widespread adoption of tracheotomy in treatment we have found in bulbar poliomyelius that it may be of tremendous xalue and without danger if a clear airway is insured It is easy to see this if the upper annay is filled with viscid secte: tion and suction produced below au by a normal or me. chanical respiratory mechanism, the air column will tend to push ah of at a diaphragm of viscid secretion Some air will bubble through This action is shon n by the model illustrated in Figure 2 ius evident that such a procedure might easily dronn a patient in his own secretions It will be indicated later in this chapter how such negatne pres 57 ·Respiratory Emergencies sure against obstruction also tends to produce pulmonary edema, It should be equally clear that if such secretion is bypassed by a tracheotomy so that changes in pressure are equalized, or nearly so, within and without the area of ventilation no fluid will be drawn in The immediate relief of depressed patients and their usual adaptation to the rhythm of the machine, as well as the greatful rest which they then enjoy, offer excellent proof of the respirator's safety and value. Bulbar patients may need a respirator for several rcasons. Occasionally we have seen a primarily spinal type of paralysis spread up to involse the medullary center. During the last year the process has seemed more widespread and purely classifiable types less frequent. Cases seen in 1951 have shown some bulbar involvement and some weakness of the respiratory muscle control at the same time. Our experience has indicated, however, that most often the medullary center is depressed by anoxia and carbon dioxide, and that the depression may have become rather profound before the anoxic factor is recognized and corrected There is usually a serious degree of exhaustion before action is taken. This is due in part to the muscular effort in breathing against obstruction In addi. tion there is on the nervous and mental side considerable uring and depression by the conflict between reflex and voluntary mechanisms which strne at the same time to ventilate the lungs yet prevent the aspiration of secretion. Also the respirator may, if the medullary center is out, tide over the patient during the difficult switchback from control of respiration through the chemoreceptors, effective under lypoxia, to a recovered medullary center which will normally respond to carbon dioxide and changes in hydrogen ion concentration Again the fact, 58 ·Acute Bulbar Poliomyelitis that usually in the serious cases, relief was rather rapid on clearing the airway and instituting use of the respirator, indicates that anoxia and not virus infection of centers was the vital factor. It is repeated that it should be the rule that tracheotomy should be done on the patient with accumulating secretions before he is placed in the respirator Wilson (94) has well described the general management of the respirator, and we have rather closely followed his directions We, however, feel that the respirator is both safe and very valuable in bulbar poliomyelits We follow Wilson's advice to initiate rates of 15 to 20 per minute for adults and 20 to go for children, but we allow the pa: tient's sense of well being to dictate moderate changes The slightly faster rate seems to be better accepted in the beginning, but we have thought that a slightly lower rate is more physiological and permits more complete diffusion of air in the lungs and greater change in the dead space We have used negative pressures as a rule between 15 to 18 and occasionally to 20 cm of water The positive pressure adjustment of the tank respirator seems of little or no value That, however, is not true of intermittent positive pressure such as it provided by the Bennet apparatus and synchronized with the negative pull of the tank This may be of considerable help in desperately ill patients, especially when pulmonary edema is threatened In unobstructed patients rates and settings described seem to give adequate ventilation to judge by the patient's comfort, absence of symptoms of anoxia, and good volume of tidal air as measured by the ventilation meter Except for short intervals greater negative pressure may slightly increase the danger of pulmonary edema, interstitia! emphysema or pneumothorax. Great caution should be used in attempting to secure 59 ·Respiratory Emergencies relief of discomfort, distress or symptoms of anoxia by marked increase in the rate or depth of respiration. Failure to secure adequate ventilation at or under 20 cm, of water of negative pressure should raise a question of blocked airway, atelectasis or beginning pulmonary edema. Every other means including aspiration and prob. ably positive pressure should be used to restore proper renulation without induly increasing the setting of the machine As described later higher pressures quickly released may help relieve atelectasis. OUTLINE OF TREATMENT Tieatment at the Evanston Hospital is outlined: 1. Postural drainage with continuous water or vacuum tank suction instituted at beginning of swallowing difficulty. 2 Parenteral fluids, electrolytes, vitamin C and glucose followed later with intravenons vitamin B complex and protein hydrolysate or amino acids 3 Oxygen administration, but as an adjunct to clearing the airway and eliminating carbon dioxide 4. Tracheotomy when signs of anoxia persist or develop in spite of the above 5 The respirator when respiration is depressed from anoxia, exhaustion or any other cause. 6 Antibiotics against infection (but not to the point of overgrowth or fungi) 7 Careful nursing and great care to maintain morale, to allay fear and to keep the patient reassured. Such treatment should be usually effective iſ undertalen early Certainly even without much experience with the disease these measures are to be preferred to special 60 ·doute Bulbar Poliomyelitis apparatus which perhaps places wrong emphasis and delays proper measures. These need special discussion as some are very valuable, especially in serious cases Oxygen has proven of great value in respiratory obstruction It should, however, be emphasized that much more important are the measures taken to provide for the elimination of carbon dioxide. A clear airway is the prime need and no special device to provide oxygen should divert attention from this SPECIAL APPARATUS The oximeter has been proposed to determine oxygen need It needs to be set against a normal base, is said by some not to be a reliable apparatus, gives no direct indication of carbon dioxide excess, and in our experience is chiefly of value in determining when a chronic respirator patient may leave the respirator The electrophrenic respirator has some value in emergencies but does not have the applicability or dependability of the tank respirator It is not well tolerated for long periods and does not seem to warrant the emphasis given it Bower (95) watched a trial of this device and discarded it as impractical Various portable respirators are of definite use in doing tracheotomy and in weaning the patient from the tank respirator They do not yet have the dependability or efficiency of the tank respirator The rocking bed seems to have proien of real value in making the convalescent patient independent of the respirator and shortening the transition period weeks or more It can not replace the tank respirator in a patient with serious respiratory depression 61 ·Respiratory Emergencies Attempts at determination of chemical acidosis in our experience have not replaced careful clinical observation. Respiratory acidosis, as pointed out by Gamble (96), gires opposite blood findings from those of metabolic acidosis and must be interpreted in the light of blood pH and compensatory mechanisms. To be significant, tests must be done on alveolar air, here impossible, or on arterial or capillary blood. We have not found them of great prac. cical value in individual treatment, but they are very important for research and to study the efficacy of methods. The Los Angeles group, under the lead of Bower and Bennet (76), have designed a number of mechanical de vices which careful physiologic studies indicate have much promise. They are only now becoming generally available. They include: 1. The Bennet ventilation meter which aids in deter. mining the setting of the respirator. It also shows when dangerous lessening of the tidal air indicates need of addıtional help by tracheotomy or the respirator. We have found this casy to use and of considerable value. 2. The intermittent positive pressure attachment which synchronizes through mask or tracheotomy with the negative pull of the respirator Some physiologists insist that in any case the true value of the negative pressure is the same as the algebraic suim of combined positive and nega. tive pressure Hovseter, the Los Angeles group scem 10 have demonstrated that the combined positive and negative pressure is definitely beneficial in more wide inflation of lungs and prevention or relief of pulmonary edema and atelectasis They found that when using the two together usually a smaller total pressure is required which is better tolerated by the patient Votley (97) believes that the reason oxygenation of the blood may be improved when 62 ·Acute Bulbar Poliomyeltis intermittent positive pressure is used to supplement the tank respirator is that there is a more uniform aeration of partially atelectalic areas. 8 The flow sensien e breathing units of Bennet appear to be valuable for emergency use, especially for tracheotomy, which can then be done out of the respirator. It also provides useful positive pressure for use in pulmonary edema, 4 The cam adjustment appears to make a more comfortable and normal timing of the respiratory cycle. The question of transportation of bulbar patients requires special consideration If patients are near a polio. myelitis center they can be better treated in hospitals properly equipped, by teams properly trained, since some patients may first be lost while experience is being gained by a group to whom the problem zs new. But travel and strain are so injurious to these patients except at the beginning of bulbar symptoms that they mighi do better to be treated locally, even by men of less experience, than to undergo time consuming and exhausung travel While early pregnancy may add little bazard, polio myelitis in adzanced pregnancy is a special problem with a rather unfavorable experience unul lately, The gravid uterus near term distends the abdomen, interferes with respiratory movements, embarrasses the heart and makes postural drainage poorly tolerated If early prelimmary tracheotomy is done, and the uterus emptied by Caesarean section, these patients seem to respond quite well to the treatment outlined OTHER COMPLICATIONS Emphasis has been put on the early and decisive relief of obstruction to prevent complications because if once 63 ·Respiratory Emergencies established it may be extremely difficult or impossible to correct. Especially is this so of atelectasis and its train of impaired respiratory function and secondary infection Likewise, pulmonary edema when once initiated in poliomyelitis may be irreversible. ATELECTASIS Some factors in the development of atelectasis have been discussed in Chapter II. Obstruction by spasm and secretion and impaired circulation operate especially adversely in poliomyelitis, and most patients dying of this disease present findings of atelectasis The condition may be hard to diagnose, but it is to be suspected when a patient previously doing well develops dyspnes and other signs of anoxia If these persist after the airway is cleared, and the ventilation meter then shows diminished cidal volume, the presence of atelectasis is more likely. If any important area of the lungs is not aerated we liaie found, especially in tracheobronchitis, that with the stethoscope over that area the breath sounds are muffled or absent. Roentgenograms may be of limited value since they will be taken under trying circumstances with a portable machinc. Anspach's (22) work indicated that unfortunately atelectatic areas usually did not give a shadow until infection was already present. To prevent atelectasis the airway must be kept clear, if necessary by tracheotomy, and the pulmonary circulation preserved by adequate lung mosement. Frequent change of position helps prevent stagnation and congestion of blood in dependent portions of the lung. Galbraith's and Steinberg's (14) experiments on dogs cited earlier, indicated that atelectasis after 24 to 48 hours might not be cleared sen by relief of obstruction, espe. 64 ·doute Bulbar Poliomyelitis cially if secondary infection had caused pneumonitis in the human patient with good nursing care and the use of antibiotics there is probably somewhat more leeway. Each hour the condition persists, however, adds to the difficulty of its relief and to the danger from anoxia and exhaustion The first indication is to clear the airway and to remove the obstructing secretion or mucus plugs, either by aspıration through tracheal catheter or by bronchoscopy But usually, if atelectasis does develop, this means that trache. otomy should probably have been done earlier and should not be further postponed After tracheotomy suction by catheter is frequently successful, especially if salıne or dilute soda solution or penicillin is used to thin, soften and dislodge viscid secretion If this is not effectue bronchoscopy with a small cube may be done without hesitation after the tracheotomy tube has been removed This manipulation should be done so gently that the mucosa is not traumatized and should not be repeated unnecessarily In an attempt to simulate cough and augment any tusse poner remaining Strobel and Canfield (82) used pressure on the thoracic cage in the stage of expiration by the hands inserted through the tank ports An effectie simulation of coughing with dilatation of bronchi and expulsion of secretion has been reported by Barach and his associates (98) A flow rate of high selocity was obtained by first building up a peak negatite intratank pressure of 40 mm of Hg and then abruptly terminating it by instantaneous opening of a special sale For this a device called the "exsufflator is used in connection with the tank respirator Colleagues who hase seen this mechanism used are enthusiastic about the dramatic relief they have seen with it 65 ·Respiratory Emergencies PULMONARY EDEMA IN POLIOMYELITIS Pulmonary edema in poliomyelitis has been sometimes ascribed, along with vasomotor and cardiac disturbance, to direct action of the sirus on brain stem and autonomic ganglia. Although the neurogenic theory has been used to explain the pathogenesis of pulmonary edema in skull injury and subarachnoid hemorrhage, others have con. sidered the effects due to secretional obstruction and laryngeal paralysis or spasm. The controiersy is not yet settled, But for poliomyelitis Polley (99) has assembled data, for which he provides good documentation, to explain pulmonary edema without directly involving factors of brain infection or damage. It can be explained on the mechanical effects of hydrostatic and osmotic pressure in the pulmonary circulation, plus greater negative intrapul. monic pressure associated with obstruction. To this may be added increased capillary permeability due to anoxia and carbon dioxide excess as shown by Drinker. Associated cardiac failure may further predispose to edema, as may also serum albumin deficiency The function of systemic capillaries is to surrender nutrition, electrolytes and fluid to general tissue cells and take up metabolites Excess fluid is remosed by lymph flow On the other hand in the lungs respiratory gas exchange is seriously hampered by fluids. Here excess can. not easily be disposed of by its relaticly scanty lymph fou Especially is this so when there is limitation of active lung movements on shich blood flow depends. A chart modified from Polley indicates varying condi. tions of hydrostatic and oncotic pressure in systemic and pulmonary capillaries This is described in the text which follouis 66 ·dcute Bulbar Poliomyelitis HIDROSTATIC AND O Coric (OsvOTIC) PRESSURES OF CAPILLARY CIRCLLATION (After Polley) Filtration Pressure Oncolic (Retaining) Pressure Result A Norbal Systeme *2 mm Hg hydrostatic pressure 15 mm H: Orcotic pressure 7 mm Hg filtration driving force B Morral Pulmonary to mm Hg hydrostatic (negligible intrapulmonary pressure) 25 mm Hg oncotic pressure No filtration 15 mm Hg opposing filtration с Pulmonary Circulation with Closed Airway 25 mm Hg oncotic pressure 25 mm Hg filtration driving force 10 mm Hg hydrostatic 40 mm Hg negative intra pulmonic 50 mm Hg Kleration pressure Pulmonary Curculation with Respirator- Airway Occluded 10 mm Hg hydrostatic 20 mm Hg 25 mm Hg Oricotic pressure 5 mm Hg filtration driving effectue neg force intrapulmonic pressure As outlined in the table from Polley (A) the systemic capillaries have a relatively high hydrostatic pressure of about 22 mm Hg They are surrounded by tissue cells and interstitial fluid so that the oncotic or osmotic balance tending to retain fluid is approximately 15 mm. Hg This leaves the filtration force of, mm Hg driving fluid out of the capillary. 67 ·Respiratory Emergencies On the other hand normally in the greatly widened lung bed the hydrostatic pressure is held to be as low as 10 mm Hg. (B). The als eolar cell lies against capillary endothelium without intervening interstitial fluid and oncotic pressure is about 25 mm. Hg. With unobstructed airway intrapulmonic pressure approaches zero. The difference, 25 minus 10, leaves a force of 15 mm. Hg. opposing filtration. This secures the fluid free surface at which gaseous interchange may take place. This force is so effective under normal conditions that Colin in 1873 was able to give a horse 21 liters of water intratracheally in three and one-half hours with no ill effects With obstruction of the airway the effect is quite different (C). The negare intrapulmonary pressure in forced inspiration may go to -40 mm. Hg. or higher. This would leave a filtration pressure of 25 mm. Hg. tending to force fluid into the lungs While such pressure might cause little harm in a short time in normal lung with good lymph flow, it seems reasonable that it might, if continued, be disastrous if the cells are injured by anoxia, hypercapnia and impaired circulation. If such obstruction persists pulmonary edema would be expected to occur. The filtration driving force in a respirator set at -20 is 5 mm. Hg which is not great (D), but if multiplied by the approximately 1000 cycles per hour of the apparatus it could be important It certainly allows no sale margin of any obstruction is allowed to occur. It is also a warning against an attempt to compensate for poor ventilation by undue increase of the negative tank pressure. The conditions with a smoothly working respirator, tracheotomy and free ainvay are the same as shown in condition B, that is, approximately normal Pulmonary edema is a relatively common finding post mortem. It is almost irreversible although Kernan and Barach (13) and Bower, Dillon and Bennet (76) have 68 ·dcute Bulbar Poliomyelitis shown that it may be favorably influenced by positive pressure. Recently the successful use of anti-foaming agents has been reported in pulmonary edema For this purpose Gooinick, Lipson and Turbin (100) found ethyl alcohol inhalation effective when used by mask in a vaporizer through which oxygen is passed Conversely, if would seem adi isable that foaming agents such as sodium lauryl sulfate (Duponol) should not be used to aid removal of secretion where there is any danger of pulmonary edema I saw increased foaming and a bad result in one case in which it was used Again, as 1ith other complications in polromschus, pulmonary edema is much easier to prevent than it is to control when once it is established Its occurrence signals the failure of compensatory and defensive mechanisms and all too often means defeat The mechanical effects of ob. struction and the chemical effects of anoxia and hypercapnia should be foreseen and forestalled long before chey eventuate in pulmonary edema CONCLUSIONS We conclude that the serious effects in bulbar polio myekts are not primarily due to overwhelming infection of the vital centers in most cases. If it is looked upon as a problem in secretional obstruction with resulung anoxia and carbon dioxide accumulation, this disease lends itself to treatment that should be favorable in an increasing percentage of cases This is a problem for a team of which one member should be fully trained in the problems of respiratory obstruction including bronchoscopy if possible He should be allowed to see bulbar patients at the first sign of sual. lowing difficulty and share fully in any decision made for or against further intervention 69 ·CHAPTER V TRACHEOTOMY – ITS EXPANDED ROLE AND TECHNIQUE U NTIL RECENTLY tracheotomy had been held in reserve as a rather liazardous and reportedly radical procedure to be used in bulbar poliomyelitis and other conditions rather as a last resort. However, in several papers reasons were given for considering it a relatively innocnous and effective procedure to use in respiratory obstruction before irreversible pathologic changes developed Long before this many physicians working with tracheobron. chitis and other obstructive conditions had realized the relative simplicity and frequently life-saving elfect of the operation In recent years it has come to be accepted by men in many fields, including internal medicine and contagious disease, anesthesia, surgery and neurology as having a wide field of application The good results from tracheotomy may be summed up as follow's i It prevents immediate asphyxia from obstruction, spasm, paralysis or flooding secretion 2 It prevents anoxia and carbon dioxide accumulation with brain damage and general and medullary depression. 3. It prevents exhaustion by reducing respiratory effort. It permits removal by suction of secretion, plugs and crusts If necessary, they may be renoved by irrigation from trachea and bronchu. 5 lt bypasses secretion and permits deglutition to function during respiration 70 ·Tracheotomy --Role and Technique 6. It greatly limits changes secondary to obstruction such as atelectasis, pneumonitis and pulmonary edema. lt permits the use of the respirator in the presence of accumulation of secretion and/or spasm The danger from the operation itself, wluch too often has not been separated from that of the disease requiring It, has been shonn by many men including Jackson (101). Negus (102). Figi (103), Von Leden (104) and others to be very small, having a mortality of only a fraction of 10 II done before the pauent's condition is critical it is usually rather easy and any graduate in medicine should be able to accomplish it in an emergency. The chief difficulties are associated with hemorrhage, infection and emphysema. It may be done deliberately if first a bronchoscope or endotracheal tube is passed by one skilled in its use to aspirate secreton and to relieve asphu xia so the patient is relaxed and not struggling If these helps are not giailable delay is much more ishely to be serious Some points of technique will be presented Lokal anesthesia is used employing 05 to 10% of procaine solution with tho to five drops of 1 1000 adrenalin chloride per ounce This reduces hemorrhage and helps to provide a dry field A lorenge shaped area of approach is outlined by injection with a fine needle and then the line of incision infiltrated, including the pretracheal fasci3 Injection during withdrawal of the needle or frequent aspiration are done to insure against injection into blood vessels General anesthesia 35 extremeh dangerous in condi. tions requiring this intervention It may add further serious depression, especially to tire medullary centers It takes more vital time It obtunds the cough reflex and destroys the patient's poner lo expel secretion In comatose or seriously depressed patients relatively small ·Respiratory Emergencies amounts of local anesthesia are required. If young patients struggle or are antagonistic it is usually because of anoxia. This can be prevented by preliminary bronchoscopy, or such patients can be controlled by mummy. ing The shoulders should be raised on a flat pad, and the head extended well if that does not increase the difficulty in breathing. It is important that rotation of the head and neck be prevented so that exact midline orientation is maintained. It is well to remember Jackson's tracheotomy triangle lying below the level of the cricoid cartilage and within the median borders of the sternomastoid muscles with its apex the suprasternal notch. No vital structure should be injured in that area, and the chief difficulty would be bleeding from the thyroid isthmus. The incision should be in the midline beginning below the thyroid notch which may be palpated by the forefinger with the thumb and middle finger fixing the thyroid cartilage for orientation. The emergency seldom justifies the collar incision except in some nech injuries. The primary incision should extend only far enough to give adequate exposure without an undermined wound in which emphysema and infection are more likely to occur Except for one horizontal incision through the thyroid fascia to mobilize the isthmus, all incisions should be made in the midline The strap muscles are separated exactly in the midline and the pretracheal fascia incised in that line so that no cartilage is left denuded. To do so increases the risk of perichondritis The isthmus may be pushed up or doun although I prefer to lift it on cursed Kelly forceps, cut sertically through it with scissors and transfix the ends with suture ligatures. Hemorrhage into the trachea is an important complication to be avoided. 72 ·Tracheotomy Role and Technique If the tracheotomy tube is to be worn a long time, the trachea should be opened in the third or fourth ring. I there is a possibility of a respirator being needed, the Deep cervical fascia 1st tracheal ringi Thyroid isthmus (cut) Trachcal stoma Figure 5 Illustrates high tracheotomy to permst use of respirator Shows exact midline incision with no undermining or denudation of cartilage Cut ends of Isthmus are caught in forceps for suture ligature Oroid of cartilage excised to provide watertight fit of tube stoma should be at the lesel of the first interspace and second ring or one ring loter, so that the tube may lie well above the collar of the respirator for easy aspiration 73 ·Respiratory Emergencies and care. I prefer to make a small transverse cut in the interspace and remove an ovoid of cartilage through which a tight-fitting tube will just pass with a nearly water-tight connection (Fig. 5). Jackson's cartilage hook retractors are useful for this maneuver as well as for lifting and holding the trachea in the wound while it is opened. If time permits, the needle of a hypodermic springe is passed into the trachea to identify it by aspiration of air. Preferably a few drops of 2% to 8% cocaine, depending on the patient's age, are then injected into the trachea to allow tranquil acceptance of the tube. The tube should be long enough and of a suitable curve so that it rests smoothly in front of or against the posterior wall without pressure or irritation. At first, the largest tube easily talen permits easier breathing, aspıration and care Later as the airway becomes more free a smaller tube shunts more air through the larynx and causes less drying and allows more effective removal of secretion by coughing. Packing is placed rather tightly below the cube to prevent bleeding, emphysema and infection, and it is usually removed after tko days A smaller pack is put above the tube for lemostasis and removed after one day, For packing I prefer a cod liver oil preparation such as "Gadamint" on strip gauze as it seems to cause less irrita tion and infection I formerly taught that leaving the wound open was less blely to cause emplıysema and infection, but now close rather tightly around the tube to hold the packing ughtly in place. Less scarting results and apparently less emphysema and infection. Emphysema, it has been rather well shoun, can usually be prevented if, by passage of bronchoscope or endocracheal or Mosher (ube, an open airway is guaranteed so that during operation air is not drawn into tissue spaces 74 ·Tracheotomy-Role and Technique by increased negative thoracic pressure Rather to my surprise no important emphysema has occurred in our poliomyelitis cases even when the respirator has been used it must be remembered that emphysema of the nech and mediastinum may be associated with atelectasis, with secondary interstitial emphysema or be due to rupture of biebs at the hilus or under the pleura Holt (29) years ago reported an influenza epidemic in which emphysema and pulmonary collapse were common complicarions without any interiention These opposing tracheotoms are hardly justified in citing the dangers of emphysema, collapse or injury to the pleural dome as due to the operation Bleeding is to be avoided, if possible. by careful hemostasis hich also permits easy orientation and dissection When ume permits the field should be quite dry before the trachea as opened, although if the situation is urgent, packing will usually control bleeding In spite of all forethought and care, emergency stab tracheotomy is occasionally required To perform it, the patient is held with the chin exactly in the radline, the neck extended, but not to the degree that the trachea is collapsed so the esophagus might be injured The thyroid natch is identified if possible, and the thyroid carulage fixed between thumb and middle finger A sharp blade carries a moderate length incision down to and through the trachea preferably high, but below the cricoid is luch never should be injured as it is the one continuous ring presenung collapse of the larynx Air will bubble in and out identifying the trachea and giving relief from Asphyxia Excessie bleeding must be controlled by the non-operating forehnger while a tracheotomy or impro sised tube is placed with packing around 1. 75 ·CHAPTER VI TRACHEOTOMY IN OTHER DISEASES WITH RESPIRATORY OBSTRUCTION IT HAS RECENTLY come to be recognized that respiratory obstruction plays an important role in inany conditions where anoxia and changes secondary to obstruction add a critical overload to an already depressed organism of these factors are recognized, patients previously condemned as hope may be saved by treatment directed to the relief of obstruction. Proper posture and change of position, temporary airway, oxygen and catheter or bronchoscopic aspiration may be enough in many cases of patients are not overwhelmed by the essential disease. If these measures are not sufficient tracheotony may be life saving Some of these conditions I have classificd as disorders due to secretional obstruction and/or spasm or paralysis of the larynx I have already stated why I consider spasın much more important than paralysis in discussing poliomyelitis Among these conditions are 1 derile infections and toxins. Bulbar poliomyelitis, tetanus, diplıthenia, botulism 1 Drugs and poisons, especially. Anestheucs and barbiturates. 3 Central injury Trauma, especially war rounds, rumors, vascular accidents, brain abscess 4. Systemic disease involving the bulb 76 ·Tracheotomy in Other Diseases General paresis, tabes, gummata, disseminated sclerosis, amyotrophic lateral sclerosis, syringo buibia, glossolabial paralysis 5. Myasthenia. The primary central injury may be severe and produce coma, swallowing difficulty, fuid accumulation, palmonary edema, atelectasis and atypical pneumonia. These findings are reported post mortem in many of these conditions, in up to 90% for instance in tetanus (105). Though the primary injury may be serious, it is often self limited, and the outcome may be determined by the depression due to unrecognized anoxia and carbon dioxide accumulation and the interference with respiration and secondary blocking of the lung bed Even those who lold bulbar poliomyelitis to be often an overwhelming entral vral infection must concede that peripheral facyrs are often vital determinants The crudest concept of these conditions should provide for clearing the airway and assisting oxygenation and respiration of such im. pairments are recognized Some of the conditions having the same common factor of respiratory obstruction, anoxia and carbon dioxide accumulation, respiratory weakness and the danger from drotning from aspirated secretion will be discussed in more detail TETANUS In 1919 Turner and Gallonay (106) reported that tetanus under control by curare presented almost the same picture as bulbar poliomyelitis and responded to the same measures With the primary focus eliminated this disease usually runs a self limited course of from eight to 12 days Curare has been used in the treatment of tetanus since 1891 as reported by Cullen (107); tra- 77 ·Respiratory Emergencies cheotomy had been advised for severe cases of the disease by Spaeth (108); Isaacson and Sivanson (109) used a respirator with apparent benefit but without recovery in one case of tetanus, but tracheotomy was not done. lle combined the three measures and in our experience the combination was very valuable. We outlined our treatment of severe tetanus as follows: 1. Drainage and debridement of the focus 2. Antitoxin-although there is doubt about its use: fulness except for prophylaxis. 3. Control of convulsions by (a) sedatives and anes. thesia, (b) curare 4. Tracheotomy which (a) presents asphyxia from spasm and should be done in all severe cases (b) by-passes secretion and prevents aspiration of secretion, (c) presents lung complications such as pulmonary edema, atelectasis and pneumonitis found in go of fatal cases. (d) allons tise of a loner level of curarization. 5 Respirator if needed. 6 Postural drainage and continuious nasal suction iſ there is any fluid accumulation. 7. Trachcal aspiration 8 Oxygen, usually 9 Parenteral fluids early and gasage ſeeding later. Some of these points need further discussion Sedatives in mild cases, especially if supplemented with small doses of curare may control spasm If consulsions at any time threaten to become sercre or generalized, tracheotomy, which is easy and safe if done at an early stage, should be performed It is very easy to precipitate a consion in which a patient may asphyxiate without tracheotomy. 78 ·Tracheotomy in Other Diseases With tracheotomy one may use a much smaller dosage of curare and this is much saler. If curare is long used un full enough doses to destroy oluntary muscle movement and tone, there is much danger of a state similar to shock perhaps associated with stasis of circulation We maintain the patients so there are mild tonic movements on using a needle for medication, A fairly ligh level of curarization lad to be maintained to present com ulsions. Il'idiout mechanical aid respira. tion was seriously depressed from the drug and also from the action of anoxia and carbon dioxide on the respiratory center Although probably not necessary in all cases, the resptrator seemed valuable for exchange of gases as well as for lung movements whuch probably luse much to do with pulmonary circulation and the prevention of atelectasis. Synchronization with the machine may not be perfect, and there may be minor ectopic respiratory movements, but the patient falls rather quickly into rhythm with the respirator and does not wish to be temosed unul several days after curare has been stopped and normal tone and strength are regained If tracheotomy has been done a feeding tube may be used relately early and electrolytes, especially potas stum, so gren will be taken up in the amount required The patient may need the respirator up to eight to 10 days and the tracheotomy tube should be lefe in a few days longer Tracheotomy should be done high to permit care in the respirator DIPHTHERIA Diphtheria may produce a complex of laryngeal and deeper obstruction and palatal, pharyngeal and deglutttory paralysis, along with severe toxic depression, as well as anoxia This may have been overlooked in earlier 79 ·Sex k hum gunshot wound through the frontal lobes turunt uith the tart down in moderate postural druir tum und shallon respintion appeared to be dying of Respiratory Emergencies safety it affords when the condition becomes threatening If, as Von Leden points out, aspiration by catheter or by bronchoscopy affords only temporary relief, tracheotoniy is the treatment of choice and should be done at once BARBITURATE POISONING In moderately toxic doses of barbiturates, after remot. ing the excess drug from the stomach, the patient sleeps off its effect. With larger doses the effect is a profound depression with slow elimination or detoxification te quiring up to five to eight days. Cough is obtunded, secretions accumulate and pulmonary complications de clop, or the patients may die of a combination of central drug and anoxic depression with atelectasis and pneu monitis Respiratory efforts may be produced by stimula tion with picrotoxin, ephedrine and other drugs, but such management alone is very hazardous Tracheotomy again is a slight step to take to save a life. It bypasses secretions, prevents anoxia by their obstruction and permits their can removal from the trachea. If respiratory depression i profound and persisting, the respirator should replace less centain methods of artificial respiration. Its use is muh sater after tracheotomy. By such techniques somme of these patients have recovered from very large doses of the labiturates CRANIOCEREBRAL INJURIES In culi exxerience impressed me with the importance of amena in head injur. A patient with sagging tonzuc Ou supuun foron broscopic aspiration was done and a larga murud clump was removed. With the patient ·Tracheotomy in Other Diseases age, recovery was fairly prompt In many central injuries anoxia and carbon dioxide accumulation may be an important part of the picture adding markedly to de pression and slioch Echols (114) and his group from the Ochsner Clinic state that in patients unconscious from head injuries "the airway is of first importance because of its aid in the prevention of cerebral anoxia, a devastating sequel to craniocerebral trauma" The use of tracheotomy for this purpose has been neglected, but more general interest in this procedure in neurosurgery has followed its employment in tetanus and bulbar poliomyelitis They report that tracheotomy was done in 69 patients solely to prevent or correct respiratory complications. In 37 patients it was done prophylactically. In head itijuries without tracheotomy the nasal passages as a rule are closed by traumatic edema, blood and mucus. The tongue drops bach, and hematoma or fracture of the mandible, hyoid or larynx may add to the difficulty Saliva, blood. vomitus and cerebrospinal fluid may pool in the pharynx and run down the trachea The unconscious patients present a grave problem as they are frequently oblivious to secretion, cough little, swallow poorly and breathe slowly with shallow respirations They are likely to have severe anoxia and to develop ateiectasis, pneumonitis and pulmonary edema. The improvement in such patients after tracheotomy, as Echols points out, is usually dramatic Color improves, the patient relaxes, and the labor of breathing dimintshes Secretions can easily be removed by suction catheter through the tracheotomy tube "The assurance that the patient will be free of respiratory complications the coming desperate days or weeks is a relief to all concerned." • for 83 ·Respiratory Emergencies Echols and his group performed tracheotomy in 15 patients with head injuries with gratifying results, although all did not survive. They advise the use of the endotra cheal tube if aid is needed for only 12 to 20 hours. If it is to be required for more than 24 hours they urge tracheotomy, If severe trauma involves the larynx or trachea itself, especially with fracture which may lead to speedy asphyxia by sudden spread of edema or liematoma, tracheotomy should be done prophylactically. IN NEUROSURGERY Recently Taylor and Austin (115) recorded the great usefulness of tracheotomy in certain cases in which neurosurgery had been done They point out that in such pa. tients consciousness is diminished perhaps for many days The cough reflex is depressed, liquids or foods may be aspirated into the lungs, the pharyngeal musculature and tongue are relaxed and fluid is likely to reaccumulate after tracheal aspiration Laryngospasm, they believe, may be important. Tracheotomy was in their opinion very valuable in selected neurosurgical patients in preventing an. oxia and pulmonary complications They reiterate that "patients in a diminished state of consciousness secondary to organic central nervous system disease may be unduly sensitive to even slight degrees of oxygen want." The clinician will not infrequently be gratified to find marhed and rapid improvement in the neurosurgical patient whose airway has been cleared or on whom a tracheotomy has been done This can be accepted as valid proof that severe symptoms considered due to the central disorder itself should have been ascribed to the overlay of anoxia If vascular accident, tumor, abscess and the like posi- 84 ·Tracheotomy in Other Diseases tively give such a serious prognosis that nothing could prolong life, intervention would be useless Though this may seem obvious, one cannot always be sure and we have repeatedly seen such patients recover on clearing the airway. The usual procedure is to remove mucus by catheter or bronchoscope sometimes inserting a pharyngeal airway or endotracheal tube If this procedure gives relief with subsequent recurrence of trouble then tracheotomy is done. It does not seem justifiable to let even hopeless patients die of asphyxia, especially if the process is pain. ful and prolonged In systemic nervous disease involving the bulb, if the condition is not terminal and death soon inevitable, intervention should probably be considered because the effect of anoxic overlay is not easily distinguished from the effects of other medullary damage In myasthenia gravis treated with neomycin a patient was unconscious and apparently dying with mixed muscle weakness, fluid accumulation and laryngeal spasm. After tracheotomy recovery was dramatic and a fairly normal state of well being was maintained. Others have reported similar cases Dr Martin Seifert and I surmise that tracheotomy might even be worth a trial in rabies CONCLUSION Recently a popular work has explored for us the teeming depths of the sea and shown how the actions taking place affect every other earthly activity, geological and human In a very modest way this essay has attempted to uncover facts commonly ignored or unknown that may have a vital effect in many disease processes Especially has the effort been made to show how easily the peripheral respiratory tract is deranged and set how far 85 ·Respiratory Emergencies reaching may be the effect of that disturbance. Respiratory obstruction, anoxia and carbon dioxide accumulation, unless recognized and relieved, perpetuate and augment themselves often to a fatal issue. If recognized and opposed even by relatively simple means they may give some of the most satisfying victories in the field of our endeavor. 86 ·BIBLIOGRAPHY 1 JACKSON, CHEVALIER, and Jacksov, C L. 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M.: Notes on Treatment of Tetanus New England ) ill., 235:8:6 (Dec. 12) 2916 106 TURNER, VE, and GALLOWAY, T. C.: Tetanus Trcatci as a Respiratory Problem. Arch. Surg , 58:478 (April) 1949 107 CULLEN, S. C., and QUINN, S. C.: Use of Curare in the Treatment of Tetanus Surgery, 14 256, 1913 108 SPAETTI, R in Tice, R. Practice of Medicine. W. F. Prior Co, Hagerstown, Md, Vol 5, 1921 109. ISAACSON, S. E, and SWAASON, S A Curare in the Trearment of Tetanus. Nebraska M ), 26 136, 1911. 120. BOWER, A G, and JESBERG Personal Communication. 11. BOFENKAMP, Band PRIEST, R. E.. Tracheotomy in Botul ism Ann Otol, Rhin, Laryng, 58 1093 (Dcc.) 1919 112 ORTON, H B Tracheotomy in Botulism and Residual Poho, Trans Am Latyng A, 1930. 113 AMINS, J P Tracheotomy for Prescntion of l'ulmonary Complications in Postoperative and Scserely Debili. tatcd Patients / AM A., 1.46 241 (May 19) 1951 114 ECHIOLS, DU, LLEWELLYN, VD, KIRCIS, H1 D, et al. Tracheotomy in Management of Scicre Head Injuries Surgery, 23 801 (Nov ) 1930 115 TAILOR, GW, and AUSTIN, GM Treatment of Pul monary Complications in Neurosurgical Parenus in Trachicorom (Lo Be published) ·This Book TREATMENT OF RESPIRATORY EMERGENCIES INCLUDING BULBAR POLIOMYELITIS By THOMAS C. GALLOWAY, M.D. was sel and painted by The Ord Bell Press, Inc., of Fulton, Missoun, and bound by the Pantagraph Pnnt ing Stationery Company, of Bloomington, Illinois. The engradings acte made by the Capitol Engra ang Company, of Springfield, Illinois The paze inm se us 544 by 814 inches The type paze u 33 by 39 picas The type face us Darkerille set it point on 13 point The text paper uropound Oxford Harnefold Enamel The CoreT u Pazco Lende, do 25 Embossing 32 Finish TT (Black) THOME POOKS AMIKO Bith THOVELS BOOKS careful attention is on to all details of manufartuning and danga li u the Publisher's desire to prevent book that are futur as to their physical qualities and artistic oathltv. and appropnate in their firikular us THOMAS BOONS will be true in those kriet of quality that auure a sound name and gas st!.

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·This Book TREATMENT OF RESPIRATORY EMERGENCIES INCLUDING BULBAR POLIOMYELITIS BY THOVAS C GALLOWAY, MD was set and painted by The Ord Bell Press, Inc, of Fulton, Missouri, and bound by the Pantagroph Print ing & Stanionery Company, of Bloomington, Illinois The engravings were made by the Capitol Engraving Company, of Springfield, Illinois The page trim six 15 sy by 813 inches The 1% pe page is 33 by 39 picas The type face u Baskerille set 11 point on 13 point the text paper is ro pound Oxford Marnefold Enamel The cover us Pajco Lexide. Vo 35 Embossing 32 Finish TT (Black) THOMAS BOKS SIMBOL fith THOMAS BOOKS careful attention is given to all details of manufacturing and design It is the Publisher's desire to present books that are satisfactory as to their physical qualities and artistic possibilities and appropriate for their particular use THOMAS BOOKS will be true to those laws of quality that assure a good name and good will