·AMERICAN LECTURE SERIES
A merry and
AMERICAN LECTURES IN CHEST DISEASD
JA MIYERS, Ph D D
Pryaw Mata
TIN AI
Varles, 4

·Diagnosis And Treatment
Of Diseases Of The
Trachea And Bronchi
8,
HERHANJ MOERSCH, MD
Hone
HOWARDA ANDASIN MD
from
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RA
OP
PUBLISHER
CHARLES C THOMAS
Springfield
U.S.A
S.M.
LEGE,
JAIPUR
LEBARY

·CLARIES C THOILAS PUNJSHER
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·CONTENTS py 3 4 6 I troduction Anatorale Appects Anomabas of the Techcobronchial Trec Acut Laryngotracheobronchitus Vucular Defects Developmental Anomalias Right Sided Aorta Pervigent Double Aortke Arch Right Sabclavian Artery Organic Changes in the Vascular Syrian Tumors of the Tracha Malignant Tomors Benign Timor Papiloma Tracheopathia Oncoplegica Traunent 9 11 11 11 13 14 14 17 17 10 18 18 19 Chronde Broochi Dugnads Traupent Compbaadona Proochlect Edology P thakor 21 21 24 26 26 2 ·Pey 28 29 yo Clinical Features Rocntgenographic Features Bronchoscopic and Bronchographic features Studia of Pulmonary Function Surgical Treatment Medical Treatment Prognoals and Prevention J6 36 40 42 45 Forago Bodia in the Tracheobronchial Tree Type I Partial Bronchial Obstruction Type 2 Exprutory Check Valve Obstruction Type 3 Complete Bronchul Obstruction Type Inspiratory Check Valve Obstruction Roentgenographic Stud a 46 46 46 50 Tuberculous of the Tracbrodronchial Trec Pathologic Aspects Sigm and Symptoma Indications and Contraindications for Bronchoscopy Treatment 51 55 56 59 60 61 Bronchogenic Cardiota Symptoms Symptoms of Secondary Infection Conscal Finding Roentgenologic Fatures Patbaloglc Aspects Cyrolag) of Sputum and Bronchial Secretion Bronchoscopy Biopty of Lymph Nodai Treatment 70 70 71 Alveolar Cal T mor of the Lung Symptoh Roentgenologic Features 74 74 75 1

·Pert
75
76
32
83
86
Broncboopy und Cytologic Emoztoa
Treatment
Proochlal Adenocoa
Benlyn Bronchial Timon
Broocholithia's
Bronchoseos
Atelectas
Broxxchual Obstruction by Compreson
Aroachochopharmal and Tracheo-csophageal Fistula
Asthma
Syphill of the Tracheobronchital Tree
Hennopsd
Trauma
Refartaca
91
95
98
100
101
103
106
vil

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·DIAGNOSIS AND TREATMENT OF DISEABES OF THE TRACHEA AND BRONCHI

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·INTRODUCTION The tracheobronchiał trec s kructure of contderable importance for t us the pathway through which air and games are transported to and from the lungs, a function that centual for the maintenance of life in man Itu a dynamic, rather than a fatic tructure that elongates and expands with inspiration and shortens and contracts with expiration. The tracheobronchial tree is a tube lined by glandular cpithelion that produces mues The mucus normally u eliminated in the capxred gues and by the action of the specialized aluated cells that line the tracheobronchial tree and sweep the recretion toward the larynx Anything that nterfere with thex normal procena plays an important role in the variations of the physical findings and clinical symptoms in tracheobronchial disease Unfortunately a great variety of discaro and anomalia can involve the tracheobronchial tree The clinical rymptoms and phyacal finding produced will vary with the nature of the disease or anomaly ts location, and the degree of bronchual obrtruction that it produces It is advantageous n the diagnoos and proper tratment of tracheobronchial dicure to have an accurat knowledge of the normal ana tomic structure 3 ·ANATOMIC ASPECTS The he trachea begins as a continuation of the larynx As it enter the thorax, it deviates slightly to the right and postenor to the midlice At the level of the cond costal cartilage, it bifurcatos into the right and left main broochu The posterior membranous portion of the trachea lics in contact with the anterior wall of the csophagus in the cervical region, the trachea is in contact with the thyrord glaod which, owing to premure may alter the shape of the trachea Directly in front of the trachea, and approadmately at the bifurcation lies the ascending sorta The arch of the Horta las close to the lower portion of the left wall of the trachca The bifurcation of the trachca lies immediatdy above the left auricle and behind not only the arch of the aorta but also the pulmonary artery The trachea divdes into the two main, or rem, bronchi, which in turn divide into the secondary broochu that run to the various loba of the lungr. In the cleft between the trachea and the csophagus lies the symmetrically arranged chap of peritracheal lymph node In the neighborhood of the bifurcation, there soda are arranged in a thick clump and us a result of ducax, may produce progant on the trachea and bronchus The segmental distribution of the bronchi to the various lobos of the lung follows a rather intricate but falrly con sant pattern. Thorough knowledge of this normal anatomic arrangements of paramount importance in the proper interpretation and understanding of tracheobronchual ducak. Excellent anatomic descriptions of the bronchul segmental anatomy have been published by ruch authoni u Boyden' 4

·Anak Let's
5
and Jackson and Huber The terminology deknbing the
nrlow regmencal bronchi that was introduced by Jack on
und Huber is the one most widely employed

·ANOMALIES OF THE TRACHEOBRONCHIAL TREE Congenital anomalies of the tracheobronchial tree are relatively rare It u remarkable how weldom cven minor deviations from the normal bronchial pattern occur in the human bang On extremely rare occanon, the ventral bud of the primitive pharynx may fell to develop rerulang In agerhety of the lung Improper development of the ventral bud may produce lobar agencils and may be accompanied by anomalous pulmonary venou drainage It is also porable to have aplaua of the lung with the appearance of a nadi mentary bronchis but with elaboration of an alveolar parenchyma In hypoplana, much rudimentary bronchi are anociated with meager alveolar dutbuuon in the entire lung or in part of it A bronchus occasionally may anx from an abnormal portion of this abnormality is not recognized, it may lead to considerable confusion and even to serious consequences if surgical procedures are attempted Such an abnormality u well illustrated in Figure 1 lo thu care the laſt main bronchu Laminated in a blind pouch approxmately 2.5 cm from the bifurcation of the trachea and the bronchu that tupplied the left lung originated from the medial wall of the night main bronchus, 1 cm below the carina tracheae Similar bronchial openings at ama may originate from the incha o from the bronchi that ripply aberrant lung titue (Fig 2) It is important that arch abnormal bronchi be rerogpired because tbb alertant toque may becompc 1- volved in ruch d cards as tuberculos, carcinoma and 6 ·the Sanalus of the I cheekrenckel Te L Fi Aboormality in which the left main bronchur ands to hud poocha and the late mai broochu oroata from thenght mun brunchus Fly 2 Aa Adoodoo brooch ning from the touches and peong to the right upper bbc ·8 Deum and Trnbuti of Dreas of the Trocne od Brush abecess if not properly localized, sich involvement may offer considerable difficulty from the standpoint of treatment An unusual anomaly b a tracheal diverticulum, which wally onginato in the lower portion of the trachea on the right side The walls of the diverticulum usually have the name structure as the trachea itself and are covered with normal mucous membrane According to Chian, arch an anomaly represent the incompletely developed offshoot of a third bronchus originating about the bufurcation When multiple diverticula of the trachea are present, the con dition frequently has been termined trachiectans, or more properly "trachcocctans On rare occasion, tracheo ccties has been awocuted with a tracheocele However a trachcocele may occur without tracheoectans. Bronchlal diverticula situated on the merial wall of the stem bronchi between the bronchi to the upper and middle lobet have been described Congenital cysts arising in the wall of the trachea also are encountered occasionally ·ACUTE LARYNGOTRACHEOBRONCHITIS Acule laryngotracheobronch (U u un interc inflammation of the larynx, trachea and major bronchi commonly occurring in dudren. It may start with coryza un cammon cold but soon followed by boarne croupy cough Andor and dyipna When respiration difficult, cyanosu may enrie The child frequently a keverely ill and may be truggling to brath but the degree of lever is not related to the severity of the dixere The mucou perbrands are med rollen und dera tous, and they may obstruct mochaar cally the page of ur to the glotto or the rubglotte region. Secretions may be thick and sticky which also plays a role in rapiratory obstruction. Bacteriologic eumination of pharyngeal or tracheal more trore frequently reveals Staphylococcus pyogenes, Diplococ cu pneumoniac or Hucidophillos nfluenzac but the etralagic fent in root cases is probably a virus, with those organions secondary nvader Bacteriologic guda can help du ferentuate this cond tron from diphtheria (Corynebacterium drphtheriac) aod whoop ng cough (H pertum!) Exposure to woke and fame mucrogen mutand go or the utoke of white phosphora i capable of producing a omilar clinical picture Treatment should be directed primanly toward mantenance of restoration of an adequate way Immediate broncho copy followed by tracheotomy may be recentary and lifeaning Ocraronally the role of the bronchroncoput u merely that of being prepared to insert the bronchoscope total obeunktion should develop while tracheoton bang performed When the candloon # la revete, It u 2 ·10 Diguas ad Treatment of Diseases ſtk Tracher od Brenda reasonable to deler these procedures and observe the child closely while adminstenng cool moist air or oxygen Mouture most effectively added by acrosolized water detergent solutions of antibiotich, such as penicillin Sometimes the addition of small dora of isopropylarterenal (ifuprel hydro chloride) or cpraephone to the acronolized solution reduces the laryngeal and tracheal edema fufficiently to improve the passage of air Parenteral use of anubrotias also b adviable After an adequate airway has been established the prog nosu u favorable Unul then, however the outcome is uncertain and the prognoms is grave ·VASCULAR DEFECTS Alterations in the tracheobronchial tree may be produced by vascular abnormalities and direcs, wh ch may be either intrinsic or extrac in origin Intrinec vascular lexons are comparatrvely rare and con mit mainly of hemangiomas and gnall aneuryans involving the mall bronchial venes Such lenons, for appreciable are and situated in the tracha or the man sem bronchi an be wen readily on bronchoscopre cumination and treated adequately by bronchoscopic means Bleeding u wually the most likdy symptom produced by such a lemon, although lenons considerable sze occasionally may give na to bronchial obstruction Extrina vascular lesions are mich commoner and may be drvided into two main types, namely (1) thote raulting from developmental anomalies, and (2) thox due to or ganic change involving the vascular item. Developmental Anomalies. Developmental lexon may be of a great many varieties Symptoms, present wually occur carly in ức The diagnow of vascular anomalia that may produce clnkal symptoms can be made readily n mon cars from the history and the roentgenologic examination Roentgeno opic Audia while the patient swallows barium are of tremendous value in the diagnoos of wh leron In addition useful nformatsoo often u obtuned on bronchoscopic as well as csophagoscopac cumnation Anglocardiography Occaronally may be necaury to determine the nature of the laron Right-sided Aorte. Among the commoner developmental anomal a that may produce tracheobroochual symp- 11 ·12 Desmosis and Treatment of Disaks / tke Tracker and Brosch I 3 Right-eded worth which produced deformity of crophagues and pertial comprendon of whea. toms 11 a right uded aorta (Fig 3) Normally the aorta aries from the persistence and development of the left fourth branchual arch However should the aorta ans from the right fourth arch, the result is a right+ded vertel The right aortic arch may follow one of two courry may arch over the right primary bronchu and docend behind the lung and to the ngit of the exoplager in whic! t usually deugnated as an interior night sided arch or it may pas backward and then to the left and behind the crophagus, in which case it k designated a type of right-sided aortic arch In the latter type, great a posterior ·tanda Defects 13 Tx 4 Exophorus 10 chake a double sortic arch varutions may occur n the branches that come off the aort. arch. The major arch aone may par behind the csophagus or there may be in add ton, a retro-esophageal Jeft rubclavian artery that impinge on the crophagus at a higher level In some mstances, the left common carourd artery antes on the right from the prodmal arch and extends acron the arch and in front of the trachea, producing cornprerdon of the anterior all of the trac a and symptoms or obstruction Pasistent Double Aortic Arch - In those rare cars m which both the nght and left dort archas peruut, the anomaly may g ve rise to bnical symptoms As a rule, the left arch k prone to pan anterior to the tracha and is usually maller (Fly 4) In most instances, both the trachea and the cophagus will be enclosed between the two branches ·14 Dramas de Trebant of Discess of the Trache ad Bruch of the aorta but on rare occapons only the tracha may be enclosed Although the pace between the two branches of the aoruc uch ometima i sufficient to accommodate boch the trachea and the csophagus without the production of symptoms, it is much more likely that the space will not be adequate and cither the trachea or the bronxbw may be compressed when this occur, stridor cyanosa and choking spells are frequent. If the crophagus is also involved, dyr phagia and regurgitation often occur The symptoms wually manifest themselves carly in life, and the infant has difficulty 10 breathing dunog the nursing period The degree of compremon may be so great u to rerult in death unless the condition is recognized at an arly stage and adequate rurgical mearura are insututed Right Subdaolan Artery - One of the componest of the vascular anomalies that may cause tracheobronctual rymptoms is a nght rubclavian antcry that originates us the last left-nded branch from the distal part of the aortic arch. Such an anomalow nght rubclavian artery wally ponds to it normal position by courung from the left to the right ade in front of the trachea, or between the tracbea and the csophagus, or behind the cophagia, crowing the midline of the trunk at the level of the third thoranc vertebra in Cuptor of this band the symptoms are more likely to be cropha geal than tracheal in nature, and the primary symptom frequently as transtory dysphagra which often has been termed dysphagia lusoria As a rule dysphaga lux i mort prone to occur alter the second decade of life than aarlier Organic Changes in the Vascular Sytem -An enlarged hart muy impinge on the esophagus and cause symptoas, but it ha comparatively rare for such a lesion to involve the trachea Although enlargement of the heart may lead to dhplacement of the bronchis, it is unusual for this to produce bronchial symptoms Dilatation of the left ventuck, LA mitral stenosis, may give ide to broochial obstruction, which always invohas the left main stem bronchus.

·I ende Defect 15 #2 Ft S Ancury of the porta bonding the left mam broochu A much commones cause of tracheobronchial difficulty Impingonent on the trachea and bronchu by an aortic ancuryum (Fug 5) An aneurysın of the toru not only may preh on the bronchus, producing bronchial obetruction, but t may nade the wall of the bronchus and protrude Into the bronchial lumen, causing obstruction and a dintcal picture closely dimulating that of tumor of the broochu. The development of an aortic aneuryum with impingement on the trachen or bronchun may be extremely low or comparatively rapid The degree of bronchial obstruction may be pronounced Bleed ng a rather common in care of sortic aneuryan in which the lumen of the tracher or bronchus n foyded The bleeding may be intermittent, although to much more prone to be made ind faul. In addition to involvement of the bronchu or trachan un aortic aneuryun may mpinge on the crophagus and ·16 Dywa od Tromno D HKS the Trackm od Bruce produce csophageal obstruction or invade the crophagus, with perforation into the crophagus itself The diagnosu of aortic aneuryu may offer some difficulty especially of the aneurysm occurs in a younger person and u not associated with positive result of serologic test for typhulu. In case of this type roentgenologic examination of the thorax may be confusing because the findings are compauble with those scen in bronchial tumor Bronchoscopy may be of great value in the diagnoms, but cart must be exercised in the remon al or thrue froin such a lasion for microscopic diagnoru because it may cause fatal massive bleeding When the presence of an aortic ancuryan nupected it u extremely important that the patient have the benefit of a thorough clinical and fluorosopic camina tion before any tigue 4 removed for microscopic study ·TUMORS OF THE TRACHEA Tracheal tumon are comparatively rare Because of the dramatic rymptors that tumors of the trachea may produce they are always of special interest. They may rerult from a great variety of causes but for purposes of diacungon they are best divided into two categories, namely malignant and benign. Of 82 proved tracheal tumor sudied at the Mayo Clinic 47 were malignant and 35 were benign (wce table) Malignant Tumors. Although no portion of the trachea immune to carcinoma It occurs more frequently in the lower half than in the upper portion It urias more fre quently from the lateral and pogterior wall of the trachea but occaronally may completely cucircle the lumen It occurs more frequently in men than n women, in & ratio of approxmately 41 Although it may occur at any period of uſe it is most often seen in the later decades of Wre, like carcinoma Lewhere nth body Malignant tumon of the tru hea mayatta n congderable Axe before giving rise to symptoms, at the rymptoms, praxent, may be of ruch indefinite character that they may be couly ditregarded Dyspnea, strdor cough and, lom often hemoptysis and hoarsenes are the symptoms mont frequently encountered The patient symptoms sometimes are monterpreted as being due to asthma, and this well eueinplifies the old aphorum or Jackson that all that wheezes b not urthma Although the dugnows of a tracheal tumor often can be spected or cablished by rocntgenograms of the thoru or by tomography is dependent in mout us on bronchoscopic examination The bronchoscopic appearance of the ladion 17 ·18 Dragons And Truunal of Draed y like Tiem ad Brush is variable depending largely on the type of the malignant tumor As in primary carcinoma of the bronchus, the cact diagnokt u dependent on the microscopic appearance of cells found in the recretion or of the removed from the tutor Squamous cell carcinoma u by far the corronet car cinoma of the trachea. Adenocarcinomas art encountered len frequently and it u poable that there all onginate priminly in a main stern bronchus and extend into and involve the lower end of the trachea. Adexoma of the trachea occurs with a frequency almout equal to that of squamous cell caranama. Sorphologically the adenomas in our series were all of the cylındroma type They may sbow evidence of penitracheal extension and may invade contguiona structura Widaspreed metastant la rare. Beniga Tumon. - Benign tumors of the tracheobronchul tree are comparatively rare They may produce the same symptoms that occur with maligoast Jenion inolving the trachea As wen in the afort mentioned table, a variety of benign tumors may orginate in the trachea Papiloma - This is by far the commonext benign tracheal tumor It originates from the surface epithelium and may be angle or multiple When present in children auch tumori caur mort respiratory difficulty than they do in adulo because of the greater relative impingement on the tracheal or bronchial lumen Tracheopathia Osteoplashca - This is one of the most intertxung of the benign tuinons of the tracha (Fig 6) 10 appears under the mucosa, between the cartilaginous ning as a nodule composed of cartilage and bone in most cas the nodules ar nuluple, may involve the coure length of the tracha and may extend down into the bronch. It u most likely to occur in the fifth and Exth decades of luc Such tutory may produce tymptors that are dependent on their rize, number and datribution The condition may be recognized from roentgenologic examination, apecially como graphic studies ·To the Tector 19 Fy 6 Calefied depoza in trdam womeopathia cucopt Imet bow broocho copre Pparance of th body Dodules in the unchan ycan have Amyloid tuma u thara aad hondromna occur with great rinty All five much tumon luted in the table gave ne to symptoms. Tratmcat. --The treatment of tracheal tumor depends largely on the type of lovon present. The past 5 keen great advance in the rurgical removal of segment or portion of the wall of the trachea With this improvemetit in surgical technic, tumor that formerly had to be treated pallu tively now can be removed in their entirety with food chance of are Carcinomas the trucha if the tumor has rot Infiltrated into contiguon structura or metastazed bcwhere, an be rerrored rurgically th continuity of the trachea being maintained by d rect anastomos or the use of a plastic or ·70 Dit gross and Treatme Dunes of the Tracker and brouck metal tube to replace the severed trachea The local cochon of tumori rich u cylindroma, with reconstruction of the tracheal well, is being accomplished with increasing fre quency If the tumor cannot be removed by exculon, great deal often can be accompluhed by destruction of the tumor by clertrocoagulation don directly through the bronchoscope or by means of tracheotomy The implanta tion of radon, the use of roentgen therapy and exposure to the cobalt bomb have a definite place in the treatment of malignant lesions of the trachea.

·CHRONIC BRONCHITIS Chronx bronchic is a term frequently wed a "wante basket" when a cum for chronic cough a not evident The conditions actually exasu, hou ever and is cxocdingly Como It consis or inflammation of the branchial mucos membrane that is whually standary to infections, mich ss the cominon old, meades, whooping corrgb and afluense, or to inhaled irritanty, euch as crgarct moke farin or industrial dusts and chemical furys Other conditions, ruch as bronchial uthma, may have an asociated broncho wth cough conversely chronuc broochius with count may be followed by bronxhonpasm or wheening, comstonly called asthmaoc branchus Broochiectasos, lung absces or any Rippurative process in the Ju may be secured with miative bronch w in those bronch bathed with purulent arctica Purulent bronchitis may exist without permaneat changes in the bronchi nuch as accur in bronchiectaris. Bronchlu with cough may result fron nocturnal aspiracion of the content of a pharyngo-crophageal diverticulum or of material regurgitated from the crophagw in cardmagnum Esophageal hutal IxTOUS with an Wocialad kompetence of the cardu may allow gastric coatents to be regurgitated and artrosed socturnally Aspiration of content of the nand pumgeways, wh u Daly nove drops or purulent material drwning from infected parananal Surina, may cause the ume type of riut e reaction on bronchial mucona Finally the mechanical milation of the act of cough ng is in itxi capable of perpetuauns bronch tu Dragooris. - Cough and expectonitxa are the clue symp tobort. Cough may be merely an occasional kuury expulaie 22 ·22 Duft u Tomi y Demaks of the Tochte w Brunch effort or may be to severt that the patient ha frequeat prolonged paroxysms asociated with laryogapath. There episodes may be terribly frightening to the uninituled Anxrety with its awocuted hyperventilation may enoue and tha may precipiute similar and more alarming peraryumu A habit cough, or one pot caused by any demonstrable descare o frequently deep rasping cough that may occur tevere paroxyumis Secretion may be absent scant or prarwx Mucord purum is described a dear kringy of bubbly and it may range from colates (white ) to yellow Puruleat sputum á thick or creamy and may be gray gray green or yellow.green The physcian should inspect a specimen of sputum, if at all ponable rather than depend on the patient a dexipcion The diagnot of chronic broochitu should be mude onty after other dimaka ruch as cumors, tuberculants, fungou descans, foreign bodies in the branchus, congestive cardiac falure, cmphysema or any other disease capable of cawang a cough have been excluded The evaluation should include adequate husconical information and phyoral examination. roentgenogram of the there thould be made to exclude other docara as much u porsible and bronchoscopy ollen When purulent sputum sprekent bilateral bronchograms may be centul to exclude the posibility of bronchiectasis Bacicologue invatigation of pututa is Advable pot only to and in excluding ach conditions as tuberculcow and fungous diseases but because it may be al belp in outlining treatment. The dlagnat's of chronk brone chuw is hazardous without a thorougt expIDANDO Treatment. The treatment of chronic bronchita de peods an elimination of the underlying cause By all odds the componet broochual imtant is inhaled cigaret smoke Thu, any person with chronk bronchitis has a good chance of being helped by stopping the ide of cigarets. One should cllmusate other inciung unang honeet Whether these be intuled, infectious or mechanical elements ·Obmx bro 23 Coroaic bronchitis frequently to perpetuated by the act al coughing lowelfu already mentioned Many patient belleve they should do thor best to cough up even any amount of accretion and will make utrenuous expulave efforts to do so Calm reapunance by the phyacian that nothing is seriously wrong and teaching patients the fallacy of this habet frequendy auffice The act of coughing may be compared to the rubbing of und paper up and down the inflamed air panages Rot and freedom from imaton are required for the haling of most tuvas, uod the pronounced "overcougto should be cluninated Little tict for the Rippremon of cough, much as the caution of brathing when the Luckle or other stunut for coughing u first Doted, may be helpful The patient should concentrate on the fuppreniod of cough rather than on an attempr to rule mall umount of micoxd secretion that not on titant Anditurve agenu are chiefly narcotic drug and should be avoided except for short tern use Codeioc, dihydrocodanone, methadone Rad dihydromorphinoor hydrochloride (dilaudid) are the agenu ured man frequently They usually are combined 10 a syrup with expectorants, anche pothum todxde or ammonium chlonde and may be helpful for terdponary we in order to provide rex for the bronchial mucous membrane Nannascot agents ruch a carbetapestede atrate (toclav) caramiphen ethaneduulfonate (toryn) and dextromethorphan hydrobromide (romilar) are never anutumve drug Thus far it has beeu difficult to evaluate their efficacy clinically A person with nocturna) cough may benefit from sedaton at bedume in order to obtain two or three consecutive nigha of rest and brakhi cycle or "habit" of coughing Expectorand are genu that are supposed to increase the volume and decreme the Vikosty of sputum, making it tuemble normaal mutuo, which endly Creted by dillary uod Dormal broochial action Thoxe agents include potanum lodide, sodium iodide armonium chloride antimony (ut in ·BRONCHIECTASIS Bronchiectasis is an infiammatory discare of the bronchopulmonary tree characterized by dilatation and partial destruction of the bronchial wall In addition, parenchymal changes usually occur in the pulmonary segmeto xrved by thex bronchi The disease is becoming less common and it u generally conceded that thus decreased incidence o largely due to the availability of anubtotics for treatment of pulmonary infections Etiology --- Although Laennec first described bronchi ectus almost 150 year ago, the pathogenesis in all cases H Dot known with certanty Bronchial obstruction and its resultant inflammatory process in the bronchial walls and pulmonary times are Lactors common to most cards of bronchrectasThis obstruction s obvious when bronchiectasis is asociated with inhaled foreign bodica, endobronchial tumor, catricial bronchual stenors or bronchial comprension from lymph noda Bronchial glands continue to screte mucus that cannot be expelled, and the bronchu dilates. Whether this dilatauon become permanent depends on the amount of damage to the bronchial wall, which depends in turn on the duration of obstruction and the amount of inflammatory reaction in the bronchus and surrounding parenchymal toue Bacteral and viral paeumonias are common antecedents of bronchiectasu The factor of bronchial obstruction, cyto though not w obvious, u still present in asociation with parenchymal inflammatory diseaux The mucou of Inflamed bronchi may swell cufficiently to block the passageiras 26 ·Brocuratu 27 uan Plugs of mucopurulent recretion may obstruct pull or large bronchi, wbich then become duated Thu dilatation may revert to normal perudobronchiectass) or muy progres to permanent bronchiectus. The Oct of the dear fre quently can be traced to attacks of measta or perton's or to the event influenza epidano 1918 and 1919 in this country Axpirational parumonia may rent in bronchiectum and prosent the combination of bronchial obtruktion and infoc Tomillectomy dental extra tions or other operation 11 the sot south or pharysx are fraught with the danger of aspirational preumonitu or abans. The amor may be uid for any abdaroal operation with manipulation of organs of the upper intestinal tract regurgitation and asparation of goerse content coranonly occur Esophageal dporders tuch as achalana (cardiopa) and pharyngocrophagcal diverticulum art Associated with nocturnal regur gitation and aspiration of contents of the crophagus ar pouch, Cawang preumont and brooctuctos Uxri of only nemal drops or those who take mineral oil rost before going to bed art candidata for development of Ipord pneunodth and bronchiectauis. Sinuir o frequently found in anociation with brooch mtaon, but to probably a cotnplication rather than a cawal factor Most patients with thu aworzation have noted sytnptoms of bronchiectask before those of Anuntut How evo trc txact relationship is not completely clear hartrener 1 tyndrome is trued of branchuectam, anus its and stu invern Onginally dexribed by Kartagener other have conuluded that brochucctam occurs un 15 to 20 per cent of all padou #th destrocardia Cyptu fibrom of the pancreas frequently u accompanlod by broochxcd. The mettons are thick, sticky and incid, and the tot muramadows" has been applied to the dhux Ito a diffux proces mong all lobos ind may progren to generalized obstruct terdpływema Respiratory ·2B Dragons Trocal Dimers of the Traine Bruke symptoms and recurrent episodes or pneumonia are olten the most predominant featura. Agammaglobulinemia un dururbanoc of the immunotogrc response of a person unally resulting in a chrome or recur rent puppurative procene Bronchiectasis has been demor strated in appraumately 20 per cent of the reported cases Healed tuberculosi, lung abscess and other pulmonary fuppurative proces may cause rendual broochiectares, Pathology --The fundamental changes la bronchiectas are those of inflammatory datruction of peripheral bronchl, which are not only dilated but lengthenmd uod thickened Variable amount of parenchymal lavoliement of the lung occur from chronic interdual and alveolar pacunoauth which may result in fibrous and contraction of that portion of the lung The bronchial mucos may show ulceratroo or metaplana with low of Lula and a tendency to squamatization The submucot u infiltrated by infiammatory cells and a variable amount of fibrous. The mucosa glands may decrease in number The musculaturc, elastic tiwe and cartuage of the bronchil wall are destroyed to varying degree. Changer in the blood reuels sre frequent and consist of endarterita. Enlarged inflammatory lymph noda muy puntound major bronchi cung bronchittatic lungs, Cipial Featura. --Cough with production of purulat putum is the predominant rytoprom. The amount of sputum varies greatly from home at all ruch as in dry bronchiectare, to a cup or more daly Its puruleat charac ter is doonbed variably as thick and yellow yellowestettu, gray-green or green. It may be malodoro One glimpse of the sputum a much more valuable than + description u sputum u not readih aspectonied, the physcun should not hantate to obtain some by the use of postural draini of the bronchi Ths is most casily performed by having the paticot kneed on a clumu or davenport, placing the hands on the floor and staying la thu poction for a mnuit or.

·brdos Children and won romeume have difficulty spectanting putum for mamination because of their habit of swallowing anything cougbed Prolooged cough and spatum after a coromon cold are frequent in patients who have bronchiectasis. Some rate they have no cough except for one that perkats 1 or 2 months ulter an ordinary upper respiratory infection Prequent eperoden of pneumom and pleuritic pærn abould make 010 Rupicious of the presence or broochiectare pecially if epeated rontgenogram bow the pneumonitis in the ame locabod ot pleunc per salvar on the me nde. Hemoptys 4 comxon and vines from light gresking in sputum to a pinkash, homogencowly colored peamed to frank bemoptysis of a ap or more of blood Fatal hemor Hage s nrc. Hemoptysis frequently produced by over ccrtion and often it isocrated with acute infection of the respiratory tract It u typical of upper lobc broochiectans and "dry bronchitectws" of the other lobes to have recent hemoptym a the only tymptoon. Dyapoca and cyanoes in imodation with bronxhuectmas my rocan extensive draax or may be indicative of the development of emphysema late in the course of the docente They are ominou maalfestatsorat. Landtud fatigability malan, anorexia and love of weight are manifestations seen almost any chronic infection Aletastatic abscere in other portion of the body much as the brain art uncommon Ance antibiotiq have become available Pulm mary osteoarthropathy us ind cuttve a long-standing dbear when erociated with bronchita locuct catre unknown but It u ont commonly manifested by clubbing of the fmgan and toc Tendette may be present along some of the long bones, ruch uthe ubio = Uxc mult of peronical proliferation Roentgenographi Seatu e-Several feature n stereo xopkc poteruuntorfor view of the thorax DC Areative of ·30 Dragnosis ad T cent of Destaw of Uk Ticche ad Brock bronchiectasis These agus are not pathognomonic of the dixeare however the more of them that are present, the more certain one can be of the diagnosis Increased pulmonary marlango are the most common of there fcatures They consist of linear shadows atending from the hilus in a direction corresponding to the dutribution of thc bronchial trec They may be due to fibrotic changes in the bronchial wall and rurrounding time, or they may reflect the callechon of purulent secretion in the bronchos. They are the least dependable of the roentgenologic nigru because they are found in other conditions, such as congestive cardiac folure, and becaux it u extremely difficult to make the dutinction between normal and slightly in creard markings Chronic pneumonitis u found lem frequently and usually anociated with the other features. Honcycombung or ring shadows may be seen in any type of pulmonary fibros with secondary emphysematous ar maa but sometimes occur in branchiectuu Contraction of a portion of the lung rich as an atelectatc or collapred lobe, u kmetimes due to bronchiectant. When the nght muddle lobe u involved a hory triangular shadow extends laterally from just below the hilus (Fig 7a) On the lateral roentgenogram, a dense liocar shadow extends dingonally anteriorly and downward from the hilus (Fig 76) When clther lower lobe u callapad a densc trlangular shadow is seen in the cardiophrenic angle. On the left, thus 11 wually ruperimposed on the cardiac Rlhouette (Fig 8) on the nght, the cardiac border merely muy appear to be straightened The lateral view may be normal or may show only diffuse hazino in the region of the lower lobe. Bronchoscopic and Bronchographic Fatarel-Thedug nons of bronchiectass u made with a reasonable degree of certainty by bronchography However before an opaque medium is lastilled into the tracheobronchial tree, it is W210 to do a bronchoscopre examination chrefly in order to

·Brucos
a
17
31
od b T. Porotgenographite tem bowlog contrated right middle bbc.

·32 Durunt ad Treatment of Draws of the Track ad Brunch Fx 8 Roentgenographic appearance of contracted left bower lobor aclude an obstructing lezen One frequently can deter mine the ade from which most of the purulent secretion is cooning Furthermore if bronchoscopy u done fut prior to bronchography secretion may be ispirated to allow better filluog by the opaque madiun Bronchograms are best perforated with the patient under topical anathesia, but in children it I ugually necesary to un general anathaala After adequate apathetization or the pharynx, larynx, trachea and major bronchi, a atheter пау be introduced into the bronchi and the opaque medium may be installed with or without fluoroscopic guidance by ·Brochucens 33 2 poddoning the patient so that ach broschw is filled. Ominion of use of the fluoroscope is simpler for both patient and phyrician, and proper positioning of the patient provides adequate filling or cach wyment The type of opaque medium und hos varied Powdered bismuth oride was used us early as 1905 but it was not until 1922 that an vodited out wu used for the next 25 or 30 years, the zodiad cale, auch u leprodal (poppy#cod oil) Lodochloral (peanut oil) and liporodine (cramexced ou) were the most commonly used media. Their chuid duad vintage u their How disappearance from the lung There als occapoually have produced lipotd pneumonitb or graauloma in the lung Mater-oluble media were introduced in 1948 and have the advantage of npid roentgenologic disappearance Within 2 houri, one cannot tell roentgenologically whether an opaque medium has been given. There water Holuble medu include table organxc lodde, namely rodopyracet (diodrast) in vod um carboxymethylcelluloos, rich a rumbradıl vtmcow B (Astra) and ioduron B (Cilag) More recently propyliodooc (dropoul) has been introduced n boch aqucow and oily forms. It has the advantage of napad roentgenologse disappearance (2 to 4 days) and the only form fa len urritating to the bronchu than as the water olublc forin At present, this med um has gained wide ac ceptance Barium sulfate aod chelated compounds of bear meul have been proposed a bronchographic media but ther compounds need further study at prescat. Reactions of sensitivity occur occaskaally with the use of any of these rubstances. Todism, maniſented by malaise light fener tender swelling of the salivary glands umulating mumps, and lacrimation, may appar within 4 to 6 hours It usually disappan within 3 day shocklike reaction is mort lutely to occur in patients with loven allergies. It appear within 20 to 40 minuta and sometime is asociated with a convuldve rizure. Eprephrine should be given 1 ·19 Marm brooctorum . Rubteb. Lol dde.

·Brnardas 35 1x 10 Bronchographic ppeurme la broschiector of the moralar type. immcdiately and a mi ture of cygen and hel um should be administered by mask Technically utlåfactory bronchograja kould show filling of each segmental brunchus, including the upper loben. A tapdard ryutem of pomenclature of bronchopulmonary me menu badedrable nd that suggested by Jackson and Huber the most videly accepted Al rolar filling with opa que melum o undearable but should not be too duturbing became t alldott alvay means that the bronchl string tlicte alveoli are normal even though they may not be well Ieen. Ideally trosrever a normal broachogram would resemble a tree without lave (hinter tree pattern) nather than the summer-ce pattern of alscolar filling (Fig 9) Broochiectasis may be detonanted in a cylindnc cic or incular form (Fg 10) It is more carunon in th lower Loba but may occur in any Kyleent la discote of the lower ·16 Dramas Od Tren Dess of the Trainod Brot lobes, the superior segment u laually spared but the middle lobc on the nght or the ſingular segment on the left [re quently may be involved The anterior segment of the night upper lobe u also commonly affected. The right middle labe may be the only portion of the lung affected and may be associated with the middle lobe syndrome. Studies of Polmonary Function --At present, phyrologie studia of the lung appear to play a minor role in appranog a poron with bronchiccuse. The tests are not of diagnostic value but may be of help in evaluating the patient usa rurgical rek In thus regard however the exercbe tolerance of the patient, the depth and vigor of respiration the force fulnes of the cough and the diaphragmatic cxcurton as determined by percumon are just as helpful As a general rule of the patent can perform a normal day's activity studies of pulmonary function may not be useful acept a a bax line for postoperative comparison Bronchapirometry with evaluation of each lung separately provides the orient helpful data, especially if one u contemplating bilateral surgical procedura. Surgial Treatment. -Permanent bronchrectors can be eradicated only by furgical removal of the discared portion of the lung Thus treatment should be given worlow conaderation in every adult who has unilateral discurc and in many who have bilateral discare The mortality rate in properly selected and prepared patients operated on by experienced surgeom u only 1 or 2 per cent. Indications for surgical treatnent depend on the degree of symptoms, age of the patient, extent of discase, and the deure of the patient. We the disease is symptomatic or when a localized Lone of bronchiectas o discovered in sarching for the cause of allght hemoptyzu, one should be reluctant to advise arch a major operation IVhco pulmonary suppuration or hemoptysu u moderate to mere or when recurrent pneumooltis and pleurdy are problems furgia intercation diould be considered In patient la ·Brochurians 37 than 5 or more than 50 years of 285 the operation should be entertained only under exceptional arcumstance. Thore whow tolerance for exercix s fimted usually have ruch aterative disease that rurgical treatment is inadviuable The mawnal amount of pulmonary there that should be com udered for surgical removal k one entire hung or segment of two lungs totaling not more than those none jung Some patienu have had the night lowes and middlc lobes ibe left lower lobe and the lingular segment of the left upper lobe reinoved, but other factors such a age and general cond ton must be kaal in ruch patients or pulmonary function will be dangerously compromised Somcuman balateral drets resection of the affected to tuc on the nde in which the greater amount of descue s located provda o much benefit that further resection cither inadvisable or u refused by the patreni Preoperative preparation by postural drainage and ad ministrat an o anubrotics u desirable to climinaic purulent bronchial xcretions as much as porable at the time of operation When upodol or iodochloral 1 used for bron chography is probably best to defer surgical tratment for 4 to 6 ectu or until evacuation of the medium is Larrty complete with the water Holuble media or ouly dional, however such a delay does not appear to be necessary Tncheotomy done either preoperatively or immediately postoperatively while the patient u suall under anesthena, may be denrubic when bronchial Secreton copon or when cough a trenk. The surgeon should renone the involved wegments of Jobe by areful dinection and ndividual tigation 1hc advisability of retalaing the piperor Kyment of the lower lobe ather tun retecting in th the died basal keg ment when I not nyol ed by bronchiectas, i debatable recent evidenc indkata that postoperative omplications might be increased by such retention but that long term rerulus juruly an attempt to une thu segment.

·38 Dufwad 7 sedal of Desturs afike Trace od Brmerter Medial Tratment.-- When surgical acblon is not ad viable palliative medical treatment should be given. The principal aim of thu is to mlnimize the suppurative process or secondary infection as much as pooble. Good food adequate rast, sufficient humidification of the home and avoidance of bronchial irritants such as tobacco moc are helpful Upper respiratory infections are deteterou to bronchiectauc patients and sometimes a change to a warm dry climate decrease the incidence of them However dust commonly encountered in such a location may be enough of an intent to produce an increase in bronchorrhea and a permanent change of readence should not be conndered without a temporary tral Sinugtis may require separate treatment, but as a rule it be helped by controlling bronchiectarls with medications or by eliminating pulmonary suppuration by surgical Intervention. Treatment of Asociated bronchial asthma may be necerary although frequently broncbicctasu u the trigger mechanim Thunding of thich vied bronchial scretions may be detrable and can be done in various ways. An adeguote intake of fluid is erxential and may be supplemented by the use of iodida or ammonium chloride Inhalation of rtcam or crorolized solutions such as atenute water someuma red u a diluent for antibiotics, wetting agents rich us inton A 20 or proteolytic enzymes such as trypoa ar streptokinako may loosen sticky recretons Postural drainage should be designed to cvacuate property the parts of the lung affected Inaanuch as the lower lobes or the dependent portions of the lungs are involved most commonly the act of lying across a bed with clbows on the floor or kneeling on a davenport and placing the hands on the floor should allow kcrction to be expelled by gravity Thus should be done three or four time daily for 10 or 15 pinutos at the beginning of treatment. Later the patkot may become discouraged because he does not produce much sputur and is likely to stop Rather he should decreas and ·Brochures increak the frequency of posural drainage in accordan with the amount of material avilable for expectoration Intbuolia combined with intermitent portural drainage are valuable aids in the treatment of bronchiectan Opunions vary concerning the amount and type of and brotia to be wed, but all observeti agree that their um has changed considerably the outlook of a bronchiectauc patient. In order to choose the prope medicament, it is best to know what organums are present in the sputum. This is especially true of antibiotics have been given previously thereby altering the fora Once the predominant organisms are obtained by culture, their snotivity to vanou antibiotics an be determined n vitro and the proper medicament can be administered. However t must be admitted that dramatic response to the proper" antibiotic us not always obtained in actual treatment of a patient and one is some uma forced to try others. Penicillin and broad-spectrum antibiotics acha tetra cycline are the agents emaployed inost commonly at present Penicillin may be used orally parenterally or by Acrocoliza log Tetracycline urually is given orally The amount necewry varies with each petient, but in general it be bent to start with a large dom wuch as 1 000 000 to 2,000 000 umu of penicillin or 2 gm of tetracycline gren daily in divided doses. Administration should be continued until the amount of mutum u greatly deetard and this periods usually not more than a wech of affective postural drainage uxd also The berigth of the period may depend of course, on the extent of dixas the amount of suppuration and the monitivity of the organism Other antibiotics, such as treptomycin or dihydrostreptomycin and erythrom cin, may be ndicated depend og on the bacterul lora, but there anumkTobial agents plan «ler important role The frequency with which administration of antibrouet recommended and among physkuan. Some rate that ·40 Dramas o Try Destes e Treku un Druck the agents should be saved for serious infection so that they will still be effective when needed. Othen use mod crutely large doses for long periods, ſcellog that mich do ability u prevented Still other condder that certain medicamenta ruch as the broad-spectrum antibiotics puppress the usual flora allowing the emergence of orguolums such as Prudomonas acruginou or Bacillus protew that here sriow potentialities and that are more difficult to endicale It be our opinion that antibiotics such as pecillin and tetracyclloc should be administered to patient who have bronchiectars with each upper respiratory infection or common cold and that it is safe to use rich agente intermittently for 4 or 5 days at a time to control coptous puppuration, which is annoying to the patient and hu asociate. The frequency of theke periods of administration will vary from person to person, and it is safe to let most of these padeda regulate the interval between treatment of they are cop ICNOLO enough to um postural drainage diligently and wisely Prognoou and Prevention - Prior to the advent of surgical treatment and antibroucs, pauent who had broachiectasias lived shortened and unhappy lives Pocumonia, empyema brain abeces and amyloldone frequently mere fatal complications. At present, many patients with broa chlectus purvive, with the subsequent development of pulmonary emphysema. When nurgial excinon is poolbla however one can expect 75 per cent of the patients to return to full vocational activity with few or no remaining symptoms. Surgical inter vention commonly us recommended for bronchiectas's in children but a recent study showed that the rould are pot po good as they are in adult ufc. New lesions of bronchiectasis or zonas of residual brorschiectasu are likely to be found after operation in a higher proportion ( children than Adults, probably because of postoperative complications, Arch u retention of scretion.

·Breacherrian Bronchiectars may be prevented by carly removal of bronchial obstruction due to foreign bodies and by adequate prevention and treatment of pulmonary cofecuons. Pertust: can be prevented by stoculation, and measa frequently can be attenuated Pneumonia and tuberculosis usually can be treated with effertive chemotherapy and anubrotin.

·FOREIGN BODIES IN THE TRACHEOBRONCHIAL TREE The aspiratoa of a foreign body into the tracheobronchu) tree usually is accompanied by auch dramatic sequelac that the diagnosis in most cao u made with care and bronchofcopic removal of the foreign body is advised Unfortunately Instanca still remain in which prompt removal of the foreign body s not advised, there being a tendency to procrasti nate in the hope that the foreign body will be coughed out. The chance of such a termination is extremely remote The seriouser of permitting a foreign body to remain in the lung u well realized when it u pounted out that the mortality rate u more than 50 per cent if such a course is followed In contrast, the mortality rate attendant on bronchoscopic reinoval of foreign bodias from the tracheobronchial tree in the hands of a skilled bronchoscopist in less than 1 per cent. A more difficult problem u the recognition of the att looked or forgotten upirated foreign body It u amporong how frequently a paucnt may forget the inadent during wtuch ne morated a foreign body The possibility of the presence of an aspirated foreign body must be kept in mind comtantly in every intance of pulmonary aippuration and in cards in which uncxpuned wheerc is present (Fig 11) Unfortunately a typical dugnostic picture for all intances of upirated foreign body does not exist. The sequence of events that usually follows aspiration of a foreign body van with the character uze and shape of the foreign bod's and the age of the patient The initial act of uspinung a foreign body into the tracheobronchial tree generally : associated with a violent perotyto of coughing and, less frequently 42 ·Fwan Beda ut I crebrod To 43 HILTOK Fhg 11 Pulovan rappuration due to wpirated foreign body (bone) Ta patkent did not recull operatio tb forego body Inact a foreign body wheeting Unlco the foreign body u of ruch wzc as to produce interference with respiration, i period generally follows in which the patient is free of pulmonary symptoma. The asymptomatic period varla in durat on and may last for hveral hour or even for years, dependent again on the character and size of the foreign body It is during this period that the foreign body to mog lihcły to be overlooked The late rymptoms of an apinated foreign body are usually those of pulmonary cuppi rat c discar, namely cough, a pettoration, hernopty and occasionally wheeze Vegetabl foretga matter is more likely to care vor od acute pwmonary damage then are metalle foreign bodies Vegeuble foreign bodies produce reverc bronchith, ·44 Daw od Trend Dishes of the Tracke od Bruck Flc 12 Roentgenographic appearance in che in which foreign body had been prenant la bronchu for 17 yeur which w characterized by rapid accumulation of thick, purulent secretion and pronounced hyperemia swelling and cdema of the bronchial mucou The bronchi dustal to the point of the foreign body tend to fill with purulent exudate A nonobstructive foreign body may remain dormint 10 a bronchus for months or even yean without producing any appreciable degree of pathologic change in the broachu! tube (Fig 12) This delay in effect is frequent when straight pins have been aspirated into the bronchi Corrosion and mechanical irritation eventually lead to the developuxent of obstruction of the bronchus and concomitant xcondary pulmonary suppuration. If a foreign body aspecully of ·Fran Elmes the Tchebruckte Trre 45 metallic material ballowed to remain in the bronchin for . long period, a treture generally will develop at the str where the foreign body has lodged. With time, the bronchus below the ite of the Aricture tends to dilate and the forcign body may drop into this dilated bronchus This is tech plaally important in removal of an aspirated fordyn body from the bronchial trec because wben it takes place dllation of the tricture o necemury before the foreign body an bc Lafely withdrawn from the bronchus The phyval findings on camination of the thoni in cua of appirated tracheobronhual foreign body vary with the Aze, character and location of the foreign body and with the degree and character of bronchial obstruction produced In add tion, recondary rippuntive changa may greaty alter the płyoal findings in the interpretation of physical findings in cases of foreign body n the tracheo bronchial tree, it must be recalled that the brooch are not uatic tubes but constantly change in pic and length during respiraton Areals, constant variations ant in the case with which air can pay through the bronchus add about the foreign Lody during respiration The bronctual obstruction resulting from uspinated foreign bodia has been described by Jackson and Jadson as of four typa, e clasification that of special value in the nterpretatio of physical fisdings Type 1 Partial Bronchial Obaruction. — The type of outruction is mamrated by interference with free panuage of air through the bronchu in which the foreign body to lodged and Interference with normal dn mage of the bronchu distal to the point of obstruction At a correquenct limita thos of exporxuon of the lung on the imahird side s presco On pertunton, ght impairmmt in roonance may be pored Over the thorax in the region below the point of bronchial obtrurtion Auscultauon may reveal hand blowing respira tory bounds with pomoc of air about the foreign body The topiratory sounds are diminhhad set the region of ·46 Dyna A Truonnal of Diseases of the Toke od Brnach increased dullness, vocal and tactile fremitus may be impaired, and malas are often prezent Type 2 Espiratory Check Valve Obaruction - Inter ference with free cgress of air dunng expiration to the characteristic of thu type of obstruction This is cspecially likely to occur in the presence of round foreign bodies or vegetable matter With expiration the bronchus carton closing about the foreign body and thus interfering with the expulmon of air Marcault, the lung in which the obstruction ants becomes an erdistended with air and shoma great limitation of expertion Percummon over the involved lung reveals tympanitic sounds Ropiratory rounds are dimittuhed or absent Rales are not heard on the invaded ode, although they may be present on the free ude Tocal raronance and fremitu are altered but little Type 3 Complete Bronchial Oburuction — The type is charactenzed by interference with entrance of zur into the lung beyond the point of obstruction The air that was in the lung distal to the obstruction is soon absorbed, and secrcuons rapidly accumulate on the ade of involvement, producing the typical picture of atelectus. As a rout, Innstation of expansion grat Impairment of the percussion dote, and an absence of respiratory sounds and of ralos ut nored in the involved lung The heart unully shults 10ward the ade of invohrnent, and the diaphragm o elevated on the side Compensatory emphysema is present on the frec odc. Type 4 Inspiratory Check Valve Obstruction - This form of obstruction is the reverse of type 2 and probably in luate precedat type 3 Ituor extremely short dura tion and little practical ugnificance. Roentgenographic Studia, — Roentgenographic cumination of the lungi should be done in all cas in which usponuon of a foreign body is Auspected In addition to the routine anteroposterior and lateral thoracic roentgenograma, It us recommended that soenigenograms be made at the end of both inspiration and exp ration ·Forng Bed as the Tamil T 47 F 12 AA ponied forces body bucla produced ype olobaruction caporatordect in The roentgenographxc findings vary with the type of foreign body and the degree and character of bronchial obttnxulon Opaque foreign bodies are recognized readily greater diffcury will be experienced with ponopaque foreign bodian Roentgenographic camination of the thora bronchial obstruction of type 1 do not reveal caracter the finding in one of type 2, the expiratory hechualve obstruction, thaspecially important that the roentgenogram be made at the cod of exp natron 2 other use the inc utc of aflan may be med The condition is characterized by greater transparency of th lung on the obstructed de dlaplacement of the heart to the involved ide ad de premton and Matieping of the dome of the diaphragro with lunitation of diaphragmatk ournon on the ude of obstruc tron (Fug 13) In cma of type 3 the atelectatc form of obstruction Teard denty a procent aer the regron from which actation w drainage to the lung have been cut ol (Fig 14) Depending on the degree of atchectars, the heart may be suited to the hardede, with homo lateral levation of the diaplıraqm Wher kerondan rupturatie charts take place in the

·+
Dragtens ad T f Diwas ft Tua Bucu
F 14 2 Collapoolet lung cacd by Inhaledon of piece of woolen blanket. b Appearance In mo
care 12 boon tot roboval of fordyn body from left mai bronchus

·Todos of the Tractorecha Tin 49 lung sa renult of an aspinted foreign body they may over shadow completely the roentgenographic find ngs pat den xribed Although none of the secondary roentgenographuc changes are dlagnostic of the presence of a foreign body they should be interpreted as Hrongły indiating that special march should be made to rule out the porebility of an underlying foreign body It must be emphasized that a normal roentgenogram of the thon doas box ellminate the existence of forengn body in the tracheobronchial tree The presence of a foreign body in the trachea or bronchus always thoukl be looked on us an emergency and the foreign body should be removed u woon u posible However it is weldon that its presence indicates rich a 10us einergency that bronchoscopre cumination should be done without the advantage of fall and careſul clinical study under the best ponible circumtances. The practice of inverting the paucot in an attempt to dblodge the foreign body from the tracheobronchial tree has to be condemned ai unuſe os the changt of poultion may dlslodge the foreign body so that it may become wedged in the glotths, exulting in spasm and complete asphyxia of the patient Although fe removal of a foretgn body at the first bronchoscopy can be accomplished in practically all carry a stond or third bronchoscopy occanonally may be required A chancterlath of an aspirated foreign body in the tracheobronchial tree is that in most cas, even after the foreign body has been in the lung for a conderable length of time and has ret up catershe pathologic proceres, the difficulty will clear up promptly on removal of the foreign body ·TUBERCULOSIS OF THE TRACHEOBRONCHIAL TREE Tuberculosis of the trachen and bronchi has been recognized for many years. According to Smart, Richard Morton, in 1694 was probably the first to describe lostons of the bronchi duc to tuberculosu Since then numerous reports, based primarily on accropsy studia, have appeared It has been only in the part 2 or 3 decades, with the mort widespread wc of the bronchoscope as a diagnostic and lo the study of pulmonary ducase, that the true clinical ag nificance of the disease has been appreciated the advent of thoracic surgery and the introduction of antituberculouc drum in the treatment of pulmonary tuberculow have added immcaprably to knowledge concerning its development, cause and complications A difference of opinion exoti among observen us to the incidence of tuberculous tracheobronchitis. It has been stated that it occurs in from 10 to 60 per cent of all cases of pul monary tuberculosis. This doscrepancy as to inadece is chiefly dependent on whether the aberrations are based on bronchoscopic appearance alone or on the study of operative or recTop matemul To a lesser extent, the discrepancy depends on the state of advancement of the pulmonary tuberculosis in the particular group of cases reported Although tuberculous tracheobronchitis is more Lely to be present in advanced pulmonary tuberculous than in carly ducak, it may occur at any stage. The manner in which the trachea and bronchu become involved in the tuberculow process has not been definitely ortabilhed they are xldom the primary ute of the decease.

·I keelers of the Tracheobrach Tree 51 Experience indicates that tuberculoms of the trucha and broochi mug develop through a number of routa. Io the first place, tuberculos may spread to the bronchi and trachea by way of the lymphatic system into the mucon glands. The lymphatic structures curtounding the major bronchi, the trachea and the medlarunum abrorb infected material from the periphery of the lung As a result of the close contact of th mucous glands with beard lymphatic tiruen the glands are attached and thus carry nfected material through the walls of the bronchl into the mucou merobranc. Secondly the dixar muy extend directly to the bronchus or trachea from neighboring tuberculous time Thirdly direct implantation may occur from infected putum or recretlor rxcl us accompany the discharge from a tuberculous locus pto a bronchin. Pathologic Apecti.-The bronchoropic appearance of the lesions of tuberculour incheobronchin yana with the particular forn taken by the disease and its sage of develop ment. lo children, the carliest broochoscopy finding are mually thouc prodoced by enlargement of mediastinal, tracheal and bronchial lymph nodes, which impinge on the tracheobronchial tree and cause fixation and narrow ing of the alrway In contrast, the cartreut finding ondales con most of reddening and edemua of the mucous membrane thexe changes may be diffuse but tpore often are localized to a mall region Atuated about or oppovle the opening of the bronchurt. The reddened mucova koon arancs a granuar apprannct due to the muluple small discrete cubertles n the subancona (Fg 15) Such an ofiltratne process may undergo prolution and leave utuc evidence of its previou cwce or may go on to the hyperplastic or ultad form The hyperplasik form claracter by thickening of the Loronchial mucon membrane associated th Ribmucoval lymphocytic Infiltration The mucous membrane klem flouble with a decrease in the diameter of the Ironchial or ·52 Dames and Treatment of Diseases of the Takend Brwash Fr 15 Tuberculon uker of trachen und LroochL trachcal lumen The submucosal tubercles tend to conglomerate. Tho may go on to the formation of a tuberculorna that protrudes into the lumen of the bronchus and present the appearance of a benign tumor (Fig 16) In the ulcerative form, mall pin point zona of ulceration appear It is difficult at first to distinguish these small ulceri from flects of mua. The wall ulcers tend to coalexe and fum, forming larger zones of ulceration that vary in size, perhaps involving the enure circumference of the trachea or bronchus. The edge of the ulcerated region i generally ragged and the base covered with a dirty grayish crudate. Granulation tissue, wluch generally is regarded as indicativt of ulceration, u frequently present and projects into the lumen of the trachea or bronchis, presenting the appearance of tumor and sudetima completely obliterating the zone a ulceration. The tendency of the ulcerative hyperplastic proces s to heal, and this may lad to fibrostenom. The fibrostenotic stage is chincterized by narrowing or the lumen of a bronchus or the trachea. The stopotic zone is firm and the lumen may be reduced to a pio-point opening The mucous membrane orizing the structure may be ·Teberatan of the T cheebreached To 53 I 16 Twbacoarne otcom mooth or may chilut sestral areas of ukeration or gram lation Th MODO occun usually as the result of bealing of tuberculow ulceration la frequently it roult from localized rubmurosal Inflluntion Purulent material woully exudes from the stonote opening When the cause of the Unicture is not clear it advisabl to aspirate cretion from below the incture for cum nation for add-fost organ ons and fung' once proof of the cause of the lexon often can be the obtained (Fig 17) Tuberculods of the hilar and trxcheal lytoph noda may lead to hanges in the trachea and bronchi that may produce ·54 Diamans odd Trell of Dustests of the Tucked Brott Fr 17 Atclcctadas due to tuberculour wakture clinical symptoms. This u cpecially common in infants and young children Continued pressure on the branchur or trachea u accompanied by an inflammatory reaction in the Mucow membrane overlying the tuberculotic code. The mucows membranc which at first appears congested, grad wally becordes paler in color and thinned out at this stage, determination of the cause underlying the process may be imposable Although the letion may retrogress at the stage without performuon of the tracheal or bronchial wall the node or its contents more frequently may rupture loto the lumen of the tracheobronchial tree and be evacuated (Fig 18) If the patient u camined at the stage the opening through the wall of the trachea or bronchus can be xen readily Study of these ar settetions obtained from the opening may lead to the correct diagnosis. An anthracotic node ·Threas of the T chumche Tre 55 I IL Datorady of lower cod oloncha due to tutorulou nock may produce a anular plet re 1a rule after the rode or { contents ha e been cacuated into , broaches or the trachea the entire proces may rubode or a wall pitting u may be left at the ate of the perforation Homeser hould evacuation take place into the tophagus at the same time, an copługotracheal or esophagulronc lal fistula may be formed Sigas and Symptomi - Although tuberrulous wacheobronch tis may produce a definite train odnal s mptoms them implora are not neerully character of tubertus lous but may be produced by carcinorta benign tumor, farerga bodkes or other losioni ·56 Dynas Tree y Desmases of the Tache and Break Partual stenosis of the tracheobronchial tree and a wheczing stridulous type of roxpiration that is opecially noticeable with excrtion of speech and when the patients recumbent The patient may have attacks of usthma and increased dyspnea with exertion. Dependent on the degree of bronchial obstruction, varatons may occur in the amount of sputum Fever may be present when there interference with drainage of secretions with evacuation of the retained KOCtetion, the fever subarda promptly Ormerod" stated that pain wluch generally u aggravated by coughing frequently present behind the sternum in ulcerative tuberculonu of the trachea and bronchi Bleeding may occur Warten and DocIATA found cvidence of tuberculous bronchial ulceration or atenco in 57 per cent of the code of pulmonary tuberculosis in which the afore-mentioned trun of rymptoms was prosent. The phyucal findings in tuberculous tracheobronchiti also depend on the degree of mechanical obxtruction procent in the tracheobronchual tree. Atelectasis of one or more lobe may result from obstruction caused by stricture or tuberculona (Fig 19) The presence of atclectors, aspecully atelectasu that fluctuates in degree, abould strongly suggest tuberculou tracheobronchitu of the ball valve type Mclodoe and co-workers' stated that the rocntgenologic findings of importance in fuggesting tuberculous Inchcobronchute include (1) the presence of atelectas, aspecully of fluctuating (2) a tendency to unexpected and unexplamed spread of the decax, and (3) evidence of a partially obstructed cavity with a fluld level While these findings are not pathognomonic of tuberculous tracheobronchitis, they are strong prorumptive evidence in the face of active pulmonary tuberculous or all thox, telectus is by far the most ngnificant Indication and Contraindiations for Bronchoscopy It has become a routine procedure in many Anatorium to perform bronchoscopy on all pedeat at the time of their

·d
Trktun of the rat uddk bolx ved in merretum
Putteroun ou Like in

·58 Dragons and In Disnes y le Tchad Bruce Admision except when some contraindication precot On the other hand wuch authon a Samson' have stated that this procedure is not indicated unlet the padenus present symptom indicative of tuberculous tracheobronchitish for in their experience such lanons peldom will be found in the absence of a characteristic rytsdrome The problema not so ample or clear-cut however when the physicians exponence u dot limited to the care of patient with tuberculosis. Brunchoscopy should be employed (1) In any case of pulmonary tuberculosis Lociated with wheeze, Hridor cvidence of atclectars, obstructive einphyma or variations in sputumn with aboclated symptoms that might wurrekt bronchual obstruction, (2) in any car in which a question exists us to the accuracy of the diagnonis of tuberculos, (3) in any case in which the patient contnuo to have putum containing tubercle bacilli in spite of the fact that the pulmonary lanon apparently has been controlled by aruficul pneumothorax or thoracoplasty (4) in event of spread al the discate to a bealthy lung when auch a complication in not cxpected on the bous of the adsting pulmonary comdition, and (5) as a routine procedure in all cases of pulmonary tuberculosis in which reaction of the lung or thoraroplasty to undertaken It has been imply demon strated that the operative result will be far fuperior of 20 intact mucous membrane axut then If such u pot the cek, even though the bronchial well 16elf may continue to harbor tuberculous disease in spite of mucanal healing Comparadvely few contraindications to bronchoscopy use prokcat 10 pulmonary tuberculosis If the procedure is dooc with caution It rarely aggravates the disease. Bronchoscopy should not be done (1) in the presence of acute laryngeal tuberculoas (2) on a patient with pulmonary tuberculosis who ho had recent extensive pulmonary hemorrhage or (3) on a patlent who has far advanced tuberculosis and who has toxemia and adieu ·Feng Batters 59 in Tratment. The introduction of ant tuberculovic drugs in the treatment of pulroonary tuberculos has changed completely the farmer concept of treatment of thn drar In most instances, a tuberculon proces involving the tracbea and bronchu will respond to such drug therapy with farly rapid epithelial healing The maximal benefit bronchual and tracheal lemon to be obtained by chemo therapy urually are endent within 6 to 1 months When surgical treatment is to be undertaken n pulmonary tubercu lon, it is well to adhere strictly to the rule that the most uldfactory results are obtained with a quxxent broochus In those instances in whixch a fibrontenotic Icon te leen brought under control much progress has been made in dealing with such lexon by means of plauk surgical pro cedures on the trachea or bronchus, along wth retuon When obstruction is caused by prewure from a tuberculou ty mph node a atidactory response to drug therapy also many be anucipated Only on rare occagons will surpal mersurts Tre required ·BRONCHOGENIC CARCINOMA Bronchogenic carcinoma accounts for more than 10 per cent of all carcinomas in the human body Like caranoma cloewhere in the body it is prone to occur primarily io persons who are more than 40 year of age. It occurs about eight tima u frequently in men as in women. Symptome. — Unfortunately carcinoma of the long is aften so imndiow in its onset and so rapid in to development that its earliest manifestations may be produced by extenmon of the tumor or by metastasis. The symptors depend in large measure on the location of the turnor lu aze, the degree of broochual obstruction and the presence of secondary infection beyond the ate of bronchial obstruction Tumans that are in the periphery of the Jung and are small seldom produce symptoms. However the majority of lesions origl nate in the larger bronchi and tend to cause symptoms Cough u wually the earliest and commonest symptom in carcinoma of the lung being present in 85 per cent of padicate It is often extremely difficult to evaluate this symptoti because wuch a large percentage of the patienu smoke cigareta and cough auch « prevalent finding in mokers The onset of cough or a change in the character or cough in a middle aged person alwayu should cause concert At first, when the tumor is omall, the cough is mully dry and ponproductive u the tumor increas in AIC, producing interference in drainage or the bronchus and krondary infection beyond the point of obstruction, the cough becomes productive of mucold or mucopurulent secretion Ulceration invariably occur with an enlarging aurainom slow proces and often awo Weeding which is prompt 60 ·Brook Carament 61 n at least 50 per cent of patients who have carcinoma or the lung The bleeding generally is not proruke often pro ducing only streaking of the sputum. Although loss of weight seldom is referred to au of duag nost significance in carcinoma of the lung its common in this dack More than tho thirds of parents who have carcinoma of the lung show evidence of such lon Weaknes often goo hand in hand with this finding Ipproumately one hall of patients who have carcinoma of the lung complain of some decor fort or fulloen n the thorax The longer the tumor has been present the more likely is this symptom to occur Severe pank not common but when present u unually indkathe on direct eximion of the growth into the thoracy wall pleura or mediastinum Constant dall pain in the back caurs one to suspect the presence of mediastinal invasion or crenon into the spinal column Pan extend ng down ather arm usually indicates involvement of intercostal neria or the brachial prexus Dyspnea n bronchogens carcinoma but usually appear late n the course of the dock lu mit Largely depends on the ate of the tumor the degree of bronchial obstruction and the extent or xcondar suppura ton When pleural effusion occurs, th degree of dyspnea invariably increases Wherzing respiration mored by th patient or detected at the ume of examination in approxi mately 10 per cent of cars. It is more likely to occur lat n the docar although in rare instanco it may be the initial symptom. Iloarte K not common n cartiporna or the lung but when present as indicaure of spread of the tumor to the med utimum, #th impingement on the recurrent Laryngeal PVC The posubalty of carcinoma of the lung must be ruled out in any case of unexplained heartea Symtoms of Secondary Infection - Ilth increase in ne of the bronchul grom th and interference with normal drainage nferuion of the broncuial tree beyond the growth ammon ·62 Diagmas and Treatment & Diseases of the Iaches and Branche tumor invånably tala place This infection may be nothing more than bronchies or it may develop into broschlectar pneumonius pulmonary abacom, pulmonary gangrene or empreuna Such infection, because of improper drainagt, frequently caut recurrent bouts of child and fever that moy last from 3 to 5 daya Any so-called pneumanu that dod not clear up promptly should be looked on with great Ropcion, and cvery effort should be made to aclude tbe posubility of an underlying carcinoma "Flu from which recovery a atremely alow in palkat past middle age should be regarded with anpicion Unexplained pulmonary abecera or cmpyema should be placed in the same ategory Clinical Findings The phy#cal findings in primary carcinoma of the bronchun depend on the Atuation of the its size, the degree of bronchul obstruction, the presence of secondary Inflammatory changes and the amount of pleural involvement. A wall learon in the periphery of the lung or in a large broncbw may scape detection eren vith the most careful cumination and may be doncorred only accidentally during the course of bronchoscopy or more likdy on rocntgenologic examination (Fig 20) An all too frequent tendency clats to neglect phyacal examination of the thorax or to disregard completely 10 results in evaluating the problem of bronchogenic arcinoma Although it is true that results of physical examination of the thorax aften are inconcluave or show oothung abnormal the procedure never should be omitted It u only by paying meticulous care to all diagnostic aids that progren an be made in prompt and early recognition of them losion This examination abo may add information that influence the physician in selecting the mont Altabic treatment A most valuable but frequently neglected ald in physical diagnosis is inspection of the thoror with the patient rerum bent Often auch inspection ducloses that one side of the thorax lago behind its mate on inspiration, which aboud coke one to anpect the proxnce of an jatrapulmonary ·Balerina Carme $. 3 (wwmind koon of broocbek arrom wh bacon wperiorpored on the anterior end of the hei muund W lesson on the affected suck Spot al attent on hould be directed to the presence of where Th an be licitou Irut bn flaving the recumbent patient weathe with the moutt open rumor or thre egion of pulmonan leciaus produced in the tumor K lose to the thorack Hall dullnet on perution may be found out th molied portion The most mportant find ng on usullaxon uppror on ollut tl sounds are the eg on of imal MKTII When wrondary infect on la deploped nd bronxi lal ols truriton ompli wattered coure ales may bx Wociated with uppreion of breath ound Fluxd in the ompletely obscures th forerung find non nd only dulinen or the on pet us on th wpprrveon or IKT or are th sound may be noted (Juhbany of the Ingen patient mos dun can onge cywils Wiken of recent ont and noted o con netton Hit thox Kw drew of short duration Jould cause not pleur 105 ·64 Dyms and Teal of Distans of the Toke ond Branca one to suspect the presence of pulmonary arcinoma, after the potability of eropyema has been excluded A careful search for metastatic latrons in lymph nodes obligatory in every case of nuspected pulmonary carcinoma. The rupraclavicular region and the ulllae mmt be palpated carefully for enlarged and firm lymph nodes. An undug noved pulmonary Iction that has been present for months often can be dugnced correctly by the umple procedure of identifying a hard lymph node in the supraclavicular region or anilla Thu finding often alter the problem of treatment. When a tunnot arvas na the apes of the lung which is the wo-called ruperior sulcus tumor (Papcoasts tumor) Horder a ryodrome olay be prezent on the homolateral de pomc atrophy of the muscles of the hand and arm may be present on the same nde These findings result fram invasion of the tumor from the apex of the lung into the fupraclavicular fore and mediastinum, with involvement of the rympathetic chain and the brachial plexu (Fig 21) Roentgenologic Fatura - Roentgenologic campatan of the thorax u of great value in the diagnogi o cargnana of the lung Unfortunately the classic Ngns of bronchogenic carcinoma usually are produced by changes present late in the durux. From the diagnostic standpoint, it adulto corunder the development of broochial carcinoma as occurring in ethos a ponphera) mall broochu or 2 central large por tion of the bronchul tret The signs of decar may be thom of the actual mu trelf or those produced by the effects of the mun, namely those of broachial obatur peripheral a fairly mas growing pridanly atraluminally ·Bentegrax Carrin 65 Suponer uku numu (Pac MA umor) pook hunt of bronhoscopy they may be located by the ww ute of body-crlon roentgenography or by bron hography The former method may rescal unrecogmized bronchial orcluron, umuported ca luation or enlargement of paratra local and hilar lymph nodes it may ard o the differenuation betheen a vold (umor and a collapred segment of lung Branchog raphy met rocal curet ntrabroechul or extra bronchial Jescons, but in seldom helpful in the diagnose of bronction TTC 200 nota Tlier de no curd nal roentgenologx sigon of arcinoma of the branchus because the features change with continwng gronth of the levon However when a large broncho pulmonan ment becomes obstructed, one may detert duninucon n wure of the portion of lung affected togethes mith increased rodroderity ruling from tom of an and accumulation of Tet om (in 22 and 3) If major bronchi are imoved there may be devation of tre dia ·66 Diagnosis ad T r ſ Diseat of the Tale od Bruce FK 22 Primary arciona o broncho producing called when Fly 23 Carcinoma of th lung with propounced rc gecgraphic courte

·Brmhorn Com
6
I 24
moral bruochan Aninom
dkfined border
lor poorh
phragm, narroning of the interconal puce spread ng or
the shadow of the unim ol od avular and bronchial
structures on the floated de and a shift of the mediatunum
to that ode
In the later of developm
en rol tumor
the grow tl characterium of the particula tumor and des
xocuted inflammator lange har great effect on the
rocntgenologic i turns Thu tumor spreading periph
Tally through is topluik channel prevent a poorly
defined peripheral border or
rfurulared appearance (1 g
21) Large hua me lordered bn clear lung or Lalateral
panmediavin I mayos are more ubet, io le caued by
eduart nal tumore than in bronchial inomas, althoug!

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FT 25 Cavtatio u Dou cell
Note fuld keel 2 Anter

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69
fy 26 Cantang wadona al the hung
the former may produce bronchial ortauon by a
premur
It not alway possible to d lerenuat cavittime
arcinoma of the lang and a pulmonary abscon (Fg -5)
ktually the former may be considered as a special cumple
of the latter I thick wall with an irregular poorly defined
intcrror urface and relat els ll-defned external out
line ha bern conndered to ſavor the diagnous of a caricating
neopiron (Tik 20) Honde a casilat ng peoplaan at
te lo may present roentgenolagre endence of a law
beniga pulmonary abates, with a relatntly smooth interna
outine and a len well-demarrated cremal contour that
may lade mpercepubly into the poorly defined shador of
an inflammatory process

·70 Durmus ad Tom Deerns of the Tixi ad Brunch Pathologic Aspectu. --It has been recognised for a lagu ume that tranchogenic arcinoma vand greatly it is clinical manufcuations and its operahulty and resectability The factor that appean to be most respondble for these characteristics u the cellular type of the tumor cell Bronchogenic carcinoma may be dunded into anca groups depending on the nipe of cells involved. Vicharald and associata clasufied bronchogenic carcinoma into four group, namely (1) amall cell carcinora, (2) aderrocar noomne 13) squamous cell carCIDOMA and (4) large cell Some bronchogenic canciones are not made up of a wogle cellular type brut have a mixed hattopashology palier Parts of the ware rumor may be made up of different CARTITONA cellular typo omen In a study of 767 proved bronchogenic carcinoma som at the Mayo Clinic 38 per cent were of the large cell type H per cent of the squamous cell venety and 16 per cent of the small cell type the remaining 12 per cent cre adeta carcinoirias bques cell carcinoma occured 7 to more frequerily in men than in roma, and anal cel carcinoma nan 29 tunes as frequent in men as it was in women. In contrast, adenocarcinoma and large cell carcinoma op curred respectuels four and aux tima more frequenth in mca than in Me vanous types of tumor also differ in their predilectra as to the nte of origin in the lung Small cell and quino cell carcinos rend to originate primarily in the large Hem bronchu Adenocarcinoau tends to anginate inorc (requeous in penipheral bronchl, whertas large cell car cinoma brun about egually in the peripheral and in the central portion of the lung u might be anticipated the type of tumor u of rignificance in the cox of diagnosis Cytology of Spatum uad Broachnal Secretion --One of tre most important add valuable akts in the dugi on caranoma of the lung has been the development of a factory method for the cytologic study of sputum and bron ·Preces Com 1 Chlal secretion for malignant cells Woolner and Mcdonald were able to make a porative diagnosis of carcinoma of the lung from ytologke Rudy of pulum and brochual CTC tont in 68 per cent of routinr cos o carcinoma of the lung A poule qytologk diagnosis of carcinone of the lung an be mude much more readly in care in which the tumor anginates froin a large stem brookhu than those in wuch It urbes from a peripheral bonchus. In wall cell carcinoma and mquamous cell carcinoma jo which the tumor originales primanly in the large Hem broncti i postic cytolog darnom can be made in 95 per cent of cases Cooersely 6 adeporuciom which ears primarily in the penpheral bronchu cytologic diagnoo can be made in only 18 per cont of me Aroacbocopy - Bronchoscopy of aluen the study of carcinoroa of the lung from the randpont ol da nove and aho because it may andst is act location of the turtor Wihough carcinoma of the bronchus waually prexcots A churacteristic appearance as seen through the bronchoscope officulty may be experienced at ume in differenuating this Icwon from adenomas, tuberculomas or inflamatory lesom Consequently removal of trake from the feason for muto Kopsc cumination is imporain Negatnt results of bronchocopac caminatton by no mean rule out the powbality de pulmonan (UTCA Wyhle the great majority of bronchogonk carcinornas are from t1 Large uten bronchu and should be udbte readih dan bronchoscopat etamination me kom are located in aller vom bronchs that cannot be ctn brooctoxopcally or rached by means of twopy forcep The percentage of broochagear carcinomas that an be seen bronchoropeally and from what there can be remoned for microcopie diamoda depends on the type of lesion being comined It poribte to mal a pontne broncho opere diagnon 18 more than 80 per cent o cres dall cell carcinoma of the lung In contrast, a povint bronchoroptc dlagron can be made in only about 2 per ·72 Dreguns od Treatme Disease of the Track and Branca cent of adenocarcinomas, which anse from the peripheral bronchi Biopsy of Lymph Node --The removal and PDXTOXOPIC examination of nupciowy firm lymph nodos from the supraclavicular region in patients who have indefinite put monary lesions always should be conddered. Supratou lymph noda in the axalla or over the thoracic wall should be considered as suitable material for bropo, in unexplained pulmonary lasloos Occanonally when all routine dag nostic measures have faled and palpable supraclavicular lymph noda are absent, a lymph pode containing malignant cells can be found in the anterior medwstinal space or in the retrosternal fat pad Thoracenters and needle biopsy of the lung are other procedures that may be of value in the diagnols of carcinoitu of the lung In pite of all the diagnostic procedures arquable 1 uzable group of care remains in which the only method of atablishing the diagnosis is csploratory thoracotomy Tratmcat. - The treatment of carcinoma of the lungu prmanly surgical Early and complete surgical eradication, u in carcinoma clxewhere in the body to the procedure of choice The result to be anticipated from purgical later ference depeod largely on the cellular type of the carcinoma The most satisfactory results from surgical ronction arc obtained in adenocarcinoma and the squamous cell vanety Approamately 50 per cent of patient with squamous cell carcinorna and 58 per cent of patients with adenocarcinoma ore putable candidates for exploratory thoracotomy Tokec tion can be accomplished in 60 to 70 per cent of these patiente. Following resection, 40 per cent of patients who had squamous cell carcinoma and 54 per cent of those who had adepo carcinoma wa] be living and well 5 years after operation The rezults of rurgical treatment of tmall cell and large cell carcinoma are much la favorable and in pmall cell car ·Brugtx Cor J nooma especially it is imperative that some other form of therapy be only considered High-volcage roentgen therapy or use of radioactie Cotalt (Co") may be considered in cases in which the cardsoma not reccuble or it may be grien portoperat ele wten only paluative reaction done Treatment of this form muat be considered to be paluative Chemotherapeutic agent have been disappointing to the proxent uoc, but this form of treatment appean to hold the most promine for the future crogen mancard ghen latt veronty has provided temporary benefit for many patients with ronrrattabte broochopeni carnamn. This is par tcularly true of the amall cell variety ho claun for length colog lde can be made bul segrewon of ympions and trament decreer In re of the levom her been noted ·ALVEOLAR CELL TUMOR OF THE LUNG Alveolar cell tumor of the lung is a distinct cality that k frequently confused with bronchogenic carcincuna. The literature abounds with speculation u to its relationshup to jagzackie to sheep The facts available at present do not allow a complete resolution of thex problems. It is a comparately rare turnor being encountered in only 1 or? per cent of all bronchogenic malignant tumors. 11 cours ughty more frequently in men than in women (3.2) While it may occur at aaj 255 t u much more frequently men in the uxth decade of life. The tumor may involve varying segments of the lung It may occur w a circumscribed nodule or involve a complete lobe on Occaron, the entire lung may be affected Microscopically the aivcolar kept are lined by noncluated columnar cell. Some cells coolan mucus and pool of mucus may be prescat in the alveolat pacel Papillary projections into the alveolar speccu may be xen in some zor Symptome. - Cough u wually the earliest nad most common tymptom. In most cases, the cough a productive of thua mucand type of recretion that vara ready la amount but s mually coptou. Herbaptysts may occur but is most likely late manifestation of the direak, Dyreprica common, occurring in about half the patient it is invart ably constant and progressive once it develop Fever chith and lou of weight use other rytoptoms occasionally noted The physcal gou are dependent on the extent of the uodestying pathologic condition but are of little vakte sa xatolag an accurate durosis. 74 ·dhrala Coll T of L Lime 75 Fx 27 Alreolar cell tumor of hung Rocatgcaologic Fatures. ---Although oentgenologic ex amination of the thorax ha demontrated. laion in ceny caw we have encountered, there is nothing cntrcly chara cristke about the roentgenologre findings (Fig 27) poorly defined zone of consolidation laving the appearance of Tound glans wally K KT the may be localoed to one part of the lumt or reprialed spotty roner of infltrailon may be present in ourt portions of the Ame lung or in the contralateral lung Meural fluid u present n lout 10 per cent of casos. Bronchoscopy od Cyt logic Exmloatlon - Bronxhos com rolul direct alue in the diagnoru o al colar cdl tumor of the tum in only one of 11 ani of licolar celt tamor has it powable at bronchoscopy to obtain a sperimen olunur tiat on matoscopie czamination doned the tumor The presence of a coprour (roth mucoal mitetton coming ·76 Down and I ninn af Duraes of the Trache and Branch from an nidlved segment of the bronchial tree should cause the endoscopist to respect the poolbility of alucolar cell tumor and to collect scretion for cytologic studs (utologi cumination of the sputum and bronchial *Cection is an extremely valuable and in the diagnoru ol alicolar cell tumor In our experience, a ponunt dlagnose can be estabushed by this means in the out of three cases. Treatment. ---Surgical intervention the method of treatment generally employed but so far the results have been far from satisfactory ·BRONCHIAL ADENOMA Bronchill adenoma is a tumor of a lon degree of mulig nancy that arise from the mucous glands in the wall of the Lonchen Growly thex tumors vary grouy n zire and appearance Tey generally proyert pio ile luinon of the bronchin and are auached to the wall of the branchen pedrcle (fig Ba) Tlke pod che may be long and narrow pertutung free movement of the tumor in the branchus om it may be short and the bar artachment broad (Fag 285) Occmonally only a mall portion of the adenoma may project into the lumen of the bronchus the remoloder being tuated in the bronchual wall and in the adjacent pul monary issuxc. kerrota of the bronchos may be dided into two types namely carcinord and cylindromu 17 cartusord type more cominon, approumately 10 per ent of adenoma being of this variets acrocopkally Ar nord adenoma can display Korte fexubwlity in der hustalog, partem luxularity of the tumor may be the dominant characteTIC in this type, the cells appear at umies etno in the blood Twee It other nok, varulsni; u mutto pronounced. The cell may foren sold cord or may le grouped in a colar clumps with acitur formation chloin a prominent feature The hatologk pullen of the undrarulou adenoma ako Cod van om hal and may be of io pos. One umes e Smucheese pusteru in which the mugular rouodish and oral spaces are formed by cethene Pucts are Hitled with muroid xereuon Ide out the tultular pattern in which umple cubettks are formed 7 ·78 Disgrens and Trestnat of Desswer of the Trackers and Branche bi مهمانسية Fg 28 Bronchial adenouna a Leston with relatively narrow pedack (hemantylin ad eculo х4) b. Lalon with broad been of attachment (hetus taylto and como 3) Although it is frequently stated that adenoma of the broochus occurt pritanly in young women, our experience has not borne out this contention we have found approod mately the ume frequency in men u in wornica Although adenoma of the bronchus can atur at any period of life, it tcods to appear in younger persons thun docs aranarna of the lung The pulmonary symptoms produced by adenoma of the bronchia depend mainly on the location of the tumor its dze aod the degree of bronchial obstruction that it prodoret An adenone of mall size, aspecially one located to the

·Bruechua linea
79
fouladeroms of bronchu CD Licht grotaherd rornim
rphic har in the lung
periphery of the lung that does not nterfere th drainage
of the Uronchus or le obstruct parumon lo k likely to
De asympomatu (Pis >)) Lesrom aluated closer to the
hihs of the lung and the obserut a large stem bronchos
are much more likely to une pulmonary ymptoto (Fig 30)
Cough the most present symptom, being present in 35
per cent of patient with arteroma Hemoptysis orcon la
approumately lall the paixent Pan, Turrent bouts of
hills and leer dyrpare and respiraton wheese we ather
symptom frequently noted
The piyse I find ng like thimptomi, vary be the
of tre tumor
i oration and th degree of Croacial
oltrertion Korrigetographe erumunallos of the thorax
may Tord u deinit
Due to the dent tv o the ban If

·80 Dawand Tretom Demers the trucks a Britt FY 30 Adenoma of bronchos, with atefected and cuteo Torneo graphic change the adenoma has reached rufficxcat are to cut a shadow it tends to produce our of niro datinct rocnigenologic pattern The moore common u that which demonstrate evidence of obstruction of the airway or ao cadire lung a lobe or a pul monary xgmnt. The lets common form i charactented by a round or oval shadow on the rochigenogram. Bronchoscop, is of great value in the diagoon of adenouna of the bronchus As ren through the bronchoscope, the tumor presents a rather characterutx appearance The fWtor ordinarily is pedunculated and the murdu metabrane that com it u usually reddith yellow with small veeb couring over the surface The mucous membrane xldom u ulcerated but pun ually exude about the growth The tutror u a rulc is firm and tends to bleed adly on manipu ·Brentad dont 1 lation. True thould be removed from the tumor for meroxoptc examination in all caxes Cylotogk cumination of sputumn and bronchial secretions is of no value in the dug DOO of thb loon, Opinion varia to the most tactory treatment of bronchial adenoma The deciron generalh rau between removal or destruction of the tumor by bronchoscopic means and surgical atrpauon of the tumor by bronchotomy lobectomy or pneumonectomy Varying with circumstances, an adancing that b pedunculated and stuched to the bronctual wall by a nanow pedicle and nin uch a location that its removal by meam of thoracotomy would require pneumonectomy best excred and sendoned through the bronchoscope Idenomas n people of advanced ytan or with physcal ents that would incrcase lul of thoracotomy are also better removed bronctoxopically ul other adenomas are best treated by thoracotomy and complete surgical removal ·BENIGN BRONCHIAL TUMORS It is unusual for a tumor that is primary in a major bronchus to be anything but a carcinoma or an adenoma Hamartomas arc wally peripheral pulmonary twbon but occsnonally they occur in a major bronchus providing a bronchoscopic problem Approximately 32 much tumon in a major bronchus have been recorded in the literature. It u believed that tumor formerly clawfied a chopdrama, osteochondromas or lipochondromas probably would be clatified as hamartomas by protest creris Lepornas lipofibromas fibrolipome and fibroms are closely related hostologically and perhaps should be placed into one of only two groups, namely tipoone or fibrom, depending on the predominant traue Lipoma occa vonally extend through the bronchial wall and present both lotta bronchial and extrabronchial portions In A dumbbell fashion Tumor-formung amyloid s found even less commonly theo art the tumon already mentioned It localized collectron of amorphous material giving the staining characteristict of amyloid It u not associated with generalized amylordons. The syruptoms presented by patients having these tumors are those of other bronchul tumors Cough hemoptyu's wheezing and pneumopius munt Icad or to swpect the presence of bronchul obstrucuon These cumon accesonally can be muccessfully removed bronchoscopaally but more frequently they require surgiral extirpation. When the tumor occun in a major bronchus, the surgeon should attempt transbronchial removal rather than pulmonary axcalon upless the portion of lung dinal to the tumor u sufficiently ditcased to warrant removal ·BRONCHOLITHIASIS Broochal thin's has been recognized for many years Up 10 the time of the American Revolution, approximately 100 authors had described cakuli or toph that had been coughed up or found in the lung In spite of the long period of its recogmtion, it remains one of the most overlooked lanons of tbe broochial tree. Broncholithus may develop in the tracheotropcbial trec from a number of fourca. It may originate (1) in the lumen of thxc broncha, us seen in the core of a long retained aspirated foreign body (2) in the broncblal wall due to calcification of the bronchlal cartilage, or (3) around the bronchus, with subsequent crosion through the wall of the bronchus. Of the three sources, the most frequent ba perfanation of calcifed tuberculous or anthracouc hilar lymph nodes into the tracheobronchu) tree. Pollak, according to hebler in 1906, was probably the Errot to obrerve perforation of a tuberculow lymph node into the trachea. Although the studs of Schwartz indicate that much tuberculous lymph noda frequently etode into the bronchus, the crodon of calified lymph nodes o much les common. Sternberg in a review of 6132 Curso pulmonary tuberculante in which necropre we performed nored 32 instances in which there was evidence of perforation into the tractxcobronchial tree owing to anthracodic ooda Broncballthimit may atur at any period of life but rs might be anticipated it is more likely to occur late in lue than carly in our aperience at the Vryo Qime more than 70 per cent of the patients were more than 40 y no age Broncholithiaus o encountered with equal frequency 13 ·BENIGN BRONCHIAL TUMORS It is unusual for a tumor that is primary in a major bronchin to be anything but a carcinoma or an adenoma Hamartomas are usually peripheral pulmonary tumor but occanonally they occur in a major bronchus, providing a bronchoscopic problein Approximately 32 ruch tumor in a major bronchus have been recorded in the literature It s believed that tumory formerly clasified as chondromas, osteochondromas or llpochondromas probably would be clasified as hamartomas by prezent criteria Lipomas, lipofibroma, fibrolipomas and fibromas are closely related histologically and perhaps should be placed into one of only two groups, namely lipoma or fibroma, depeoding on the predominant tistuc Lipomas octogonally extend through the bronchial wall and prexent both Inun bronchial and extrabronchial portions in a dumbbell fashion Tumor forming amyloid u found even los commonly than are the tumors already mentioned It is a localued collection of amorphous material giving the stalning characteristics of amyloid It s not ussociated with generalized amyloxoch. The symptoms presented by patients having these tumor are those of other bronchil tuman Couglı hemoptyu wheezing and pncumonitis mint led one to kupect tlc presence of bronchial obstruction These tumors occasionally an be succerfully removed bronchoscopically but more frequently they requre soglal extirpation. When the tumor occur in a major bronchus the surgcon should attempt transbronchial removal ratlar than pulmonary exchilon unless the portion of lung distal to the tumor o ufficiently diseased to warrant removal 82 4 ·BRONCHOLITHIASIS Broocholithuania has been recognised for many yean Up to the time of the American Revolution, approximately 100 authon had decribed calculi or tophi that had been coughed up or found in the lung lo spite of the long period of its recognition, t remains one of the most overlooked laions of the bronchial tree Broncholithiada may develop in the tracheobronchual tree from a number of sourcer. It may anginate (1) in the lunch of the branchis, as seen in the case of a long reu ned aspirated foretyn body (2) in the bronchul wall due to calification of the bronchial cartilags, or (3) wound the branchus, with subacquent orodon through the wall of the broochus Of there three pourcen the most frequent la perforation of a ched tuberculous ar anthncotic bilar lymph node into the tracheobronchial tree, Pollak, according to hahler 1906, was probably the first to obrerve perforation of a tuberculorn lymph node into the trachea Although the studio of Schwarto indicate that arch tuberculown lymph nodes frequently crode into the bronchus, the erosion d akefied lytoph noden ba much low common. Sternberg, narestew of 6137 of pulmonar tuberculo's in which necropry was performed noted 3? Tortance to which there was andence of perſon ton nto the encheobronchu tree owing to anthracooc nodes. Bronchollthis may occur at any period of life bui, * maght be anticipated, to more likely to occur late in life thun arly In our experience at the Alayo Cliole core than 70 per cent of the patients were more the 40 yuan of * Broncbolithtaus ta encountered with equal frequency .

·84 Diegna ad T ratan of Dasters of the T shed and Branch n men and women Broncholiths may occur in any part of the tracha or bronchial tree but, s might be expected because of the greater number of lymph nodes occurng adjacent to the nght bronchial tree than to the left, a higher percentage of broncholiths will be found on the right ode. After the broncholith u ciuded into the bronchial tree, it may be coughed from one side to the other The syndrome of broncholithimis that of pulmonar suppurative diseas. The severity of sytoptoms depends on the dire and location of the bronchrolith. Perforation of the bronchut or trachea by a broncholith a unually accompanied by premonitory symptoms of cough wheeze and dyppoca. The patient occanonally may expectorate a mall cakulu with no more than a mild cough.. More frequently the cough severe and protracted. With the perforation, hemoptysis may occur and a paroxymn of coughing fre quently obtain. If the perforating nod 3 largs, it may produce alarming dyspnea that may terminate in mphyxla if the code is not removed promptly Broncholiths 12) considerably in nize Urually they are grayish white und irregular They may show black zond of anthracos. As a rule, the perforating node s pot large and after the initial paratyon a coughing remain asymptomatic until secondary suppuraint change develop Pieces may break off from the calcified broncholith and in turn cause other calafied deport whuch may reach large number The posibility of a broncholith should be condered in any case in which the patient gho a hostory of pulmonar suppurative discar aspecially if roentgenographic examina tion of the thorax reveals an abundance of calcarcous material at the huus (Fig 31) The bronchoscopic appearance in broncholithuone vano with the stage of development of the bronchiolithe If exam nation is performed before perforation of the rode ha occurred, one may see pothing abnormal or may notice an inward buging of the tracheal or bronchial wall into the

·Hus
8
Per
Fx 31
Broncholith in het maua broocho Ipet bom the calctud
Dulerat after bron bocop muna!
lumen correspond ng to the underlying nod Len frequently
one may leave the good fortune to me a nod jut de I
about to perforate into the tra heobronchial lumen and to
remont it More frequently one may find the hole in a
bronchus ar rachea through which the code perforated and
be able to pick out
alcified material from the depths of
the cavity One or more broncholiths may be found loose
in the tracheobronchial tree or embedded in a
man of
Granulation lietu
The type of treatment depend on whether or not th
broncholiths are loose in the tracheobrazch tree and
whether or not they are causing symptom. If the bronchol th
can be remnaned by endoxoph mean, th
Kthe auront end
mont sainfactory method of treatment
If I cannot be
Terrored by endoscopy and scaung pulmonan staplars
labertoms or even pacumonertoms may be required

·BRONCHOSTENOSIS Bronchual obstruction may be due to a great many couL It may be complete or incompleto, contot or intermittent For an understanding of the mechanics of bronchual obatruc top it must be appreciated that the bronchlui tree boot a ryater or rigid tube As mentioned previously the lumen of cach bronchus widers and lengthens with inspiration, and it berTOWS nad shortems with pration the rhythm.c change to bronchial dumeter ellow certain lexions to obstruct the bronchus inore nearly completely during expire ton than during inspiration In the present dbacunion, bronchial obatruction due to a foreign body benigo or malignant tumors, or tuberculo will not be considered Ephraim, Mann von Schrotter" and others called attention to the fact that swelling of the mucous membrane may take place in chronic bronchiti, which in turn may lead to obstruction of a bronchus of small caliber Such obstruction a most likely to occur in a second ary or tertiary bronchw Bronchotenosis characteutically awer repeated attacks of chills, fever cough and the putum-retention syndrome, in which rymptoms dar rapidly when the patient arcceeds in expectorating the infected retained crction Obstruction of the branchus duc to swelling of this type wally luus 3 to 5 days Patients may become yo accustomed to their symptors that they are unaware of them and pes no heed to the underlying auc. The epuoda of chill and fever may occur at various internal aod often may be mbtaken for attacks of poeumoni, malaria or rheumatic fever Physical and roentgenographie carmination between auch attoa may reveal no abdorma! 86 ·Brochastmas 87 ities, but during an cpuode of fever and cough they may give evidence of consolidation of the segment or lobe dostal to the obstruction If the narronad bronchus can be found and the branchus adequately dilated, the patients symptoms will prompdy subaude However the duation may ha c to be repeated at various intervals, # fenons may recur ·ATELECTASIS Aceleciau w a complicated phenomenon, and conuderabic controversy ont definition of the term has taken place Although, according to Gairdaer Low first distingulthed poeumonu from arelectus in 1829 it was not unlu 1890, with Puteur 34 dexnipuon of mamie atclectons, that the attention of the medical profcruton wu attracted to this conditon Many theories have been advanced to account for the development of atclectani, For chpical purposes Adamson has offered a warful clauficauon of the type of atelecross as follom (1) congenital arelectams with bronchial auena, aragenan or alveal with a terference in seratron damall or large portions of the lung (2) adjustment atelectatis, which reprekend decreax in the volume of the hung occasioned by pleural cd/ mon, paralyou of respiratory muscles, and other forectors that decrease the effective intrathoracx space (3) Oburuk tive arelectass, which renulus from broochul occlusion The third type or chier practical importance It is clownfied laco two subgroups, namely that occurring after an operative procedure and that due to other me. It bald to occur in 10 per cent of operatow performed on the thorax or upper part of the abdomen The sequence of eventa la postoperative Atelectors and in metove atelectas's of monsurgical ongin s w follone. Ata rault or shock, suppressed cough reflex and dehydration, thuck tenacious accretion as fortid and may plug the bronchua! tree As a rule most parents who uspiratr material into the lung while under anesthets are able to rd themelyes of the material on recovering concloume through other the GB ·Aldertas 89 cough reflexos allary action If the material o not expelled however and u permitted to remain n the bronchu 1t poon kads to atelectasis of the port on of lung beyond the paint bronchual obstruction The syndrome assocuted with atelectasis follows a rather definite pattern. The patient usually complains of dyspoca that is frequently out of proportion to the degree of pula monary involvement, and also of a xine of docomfort over the thorax corresponding to the involved lung The pulpe accelerates and the temperature suddenly increases Cyanoes borten present, its degree depending on the amount of troue unvolved in manrve atelectass, the heart and mediat nal fructure shift toward the ode or mvolvement, and the respiratory excursion on the affected ude decreases Part operative atelectus tell us not primanly a ruppurative procery, but secondary infection may develop rend lyst * permitted to perist. Bronchoscopy is of the greatest value not only in the treat ment of all types of atelectas but also in the prevention of postoperative atelectasis, for thu condition can be largely prevented by climinating the Lector that give rise to development No patient should be permitted to leave the operating table with a valled wet tung Most pauents who have postoperative atelectasis are able to overcome the difficulty simply by rolling one on the unm arved ade and coughing up the retained xcretion In carton caxa, bow ever this procedure does not suffice and more drat measures mare be employed A catheter may be introduced into the trachen to stimulate cough If thns neflective bronchoscop can be of great value In the early stages utenaciou plus tuually can be seen at the ume of bronchoscopy and can be aptrated, with prompt aubad nee of the zone of atelectas (Fig 32) If atelectus ha persisted for an appreciable period, the plug of mxus may hat undergore resolution and the broochus will be filled with mokopurulent or even Xron material As much as 500 to 500 ml dithis material ts ·90 Dusus and Treatmsal of D sess of the Trecke od Bradlo Fe 2 Muadro elected's b. Tb day after broocho copie aspiration often can be aspirated from the brokk hus with pronounced improvement in the patients condition ·BRONCHIAL OBSTRUCTION BY COMPRESSION Compression of the trach 2 or bronchi may be produced by structura in apposition to the airway It w almost in ponible to dlatingush the cunical symptom and am produced by rich obetruction from those caused by jona bronchial and intratracheat obstruction The trachea la susceptible to compresa by Rxh lenom » Vitular ancenabia, intrathoracic thyrordal adenoma. nedlastinal tumon and cya, broochial cytts and metastatic depadu in lymph node. The bronchi aroan be comprend by similar lesions, along with orch caliucs a thymic tuman or lymphosarcoon. Enlarged peribronchial lymph noda may cause bronchial compromiton (Fig 33) Although much obtruction may be encountered in any pulmonary lobe, the bronction of the middle labe on the right bespecially prorre to much occlusion by enlarged lymph noda 1 rerule of wxh obtruction, the lobe decreut un aire and become coooldated, with dlatation of the bronchi there may be etdence of suppuration, depending on the duration of obutruction. This change when prosent in the modelle lobe bo often described us the Diddle lobe syndrome (Fig 34) Obatructive pacurbonitis with broochiectasis may occur in any part of the lung Rocnogenologt cunotion of the thorax, especially tomography may reveal the ctect location of an obarucvon of the broochut Bronchography ako may be al value in the respect. Unfortunately it does not indicate the ast nature of the awative lepon. Although broncharcopy may demonstrate the dite of obstruction and on acavon furnish

·d
b
H 33 Compreson of bowet end of truchico by a clafied lymph pocke
Anteropostcnor r b Tornim

·le
Shop H. Droordopraptuse pper ott i stockdette strook
broocboll
Antetoponctior b Lakal me
udba

·94 Drynes ou Trretard of Discenes of Trochu od Bruch A clue as to its powible cause this the sception natha than the rule When indicated surgical resection of the segment of the lung affected by the obstruktion u unually curative. On oocanon at operation and on pathologic study an obstructing lenon cannot be idennfied because it ether has croded into the bronchus or has undergone retrogression, leaning only the readuc of the damage produced When compresionin aused by enlargement of the thyroid gland or a thymom, the tumor may be accerfully rerected The collapec of the trachea that occun after removal of an adenomatou gouter that has comprened the trachea may be obvlated at times by insertion of a bronchoscope or tracheotomy tube into the trachea. Collapse of the trachea following thyrordectomy may be permanent. Carcinoma of the thyrod occasionally perforata into the trachce and causes respintory symptoms it may be posible in auch cases to obtain there from the trachea at the time of bronchoscopic cuninabon and atablish the correct diagnosis.

·BRONCHO-ESOPHAGEAL AND TRACHEO-ESOPHAGEAL FISTULAS ure Tracheo-crophageal and broncho-csophageal fontsla comparad ely rare condluons that may be congenital or ucured in origin. Congenital fotulas generally are anoch ated with crophageal atreu T allowed to petiit, they rupidly give rise to pulmonary wppuration and death Moch progre has been tuade In recent year in their early diagnous, and definite advancements have been made in their ricorful mirglal clowure. One variety of congen 1 broncho-rophageal fatula crisis that is not asociated with cropbogeal atrau and is compatible with life In the type the opening between the esophagin and bronchus sof exch wote and powtion that solid foods, especially do not readily gain accen to the broncho (Fig 35) While Ingurds can and do par through the futua, the patient soon learns to ratrict the intake of daid and learns that its potable by drinking in certain posutions to react the amount of fluid that cpict the bronchus It b Purprrung how the bronchlal trec in voch boy accomodater tell to the imitation from the oftending lunds and solida Acquired incheo-csophageal and broncho-csophageal fixtur las may be due to a great variety of conditions Carcinoma of the crophagu, Wally terminal on nature s the componta autor auch laion Foreign bodies in the crophagus may au fostula between the crophagus and the tracheo bronchial tree. The removal of ruch a formon body often followed by spontaneon closure of the fistulous tract. Fistulas repulung from trauma art waually amenable to Rotkul Intervention Syphilic furules are best treated by 95 ·96 Dymas ad T cent of Dish Tracke od Bewerte Ty 35 Bruncbontophe real fistula measures directed toward the ryphilluç infection and often will close without further treatinent. Fistulas secondary to tracuon diverticula usually do not appear unul after the wecond decade of life, for traction diverticula of the crophagus do not manifest themselves until after the age In a futwa asociated with traction diverticula a calated rode or Dodes invenably will be found along the course of the futur lou tract and must be removed at the time of operation 11 the fistula # to be closed accesfully fungous disease, purch As actinomycors, may produce broncho-csophageal fistula. The local application of caustics to the fistulous tract widoma brings about closure

·Brexch-Ebeynel ad T c-Funk Festwas
97
The differentual diagnose between trachico-crophageal
igrala and bubar palsy at time may offer considerable
difficulty Exophagascopy bronchoscopy and studies of
rophageal notity along with roentgenemaplut cumina
bon and the latlllation of opaque medu may be receptary
to allow a correct dugnault

·ASTHMA The present durinion will pot exemped the caure problem of bronchial athma but will be limited to the role of bronchoscopy in dealing with the dturdoa. Bronchoscopy has been recognized for a long tinc u of value in the trat ment of asthmut. Peniarek, in 1905 was probably the first to carry out an endoscopic camination on a patient dunng the course of an ashmatic attack. He found that the bronchi were greatly congested with considerable stenoch of the smaller bronch during the period of attack besc finding aubrequently have been confirmed frequently by other obecrvent. The bronchi often are filled with a tenacious relatnow scretion. In the intervals between attack of asthma the bronchial mucous membrade Iday oppar per feculy pormal. In many cas, however residui cvideoce of bronchitis will be found Sunce Pieniareks report, many wniens huse painted out that good results may be obtained in the treatment of asthmua by bronchoscopic aspiration. The staple process of opinating forretor from the broochus may result in improvement in the condition, but u ruke improvecot is only temporary An important complication of either allergic or infectious Asthma i bronchostenad's. This branchestepowy Inflammatary in orgia and be not referable 10 allergie edessa or bronchial asthme Two outstanding disturbances of function rerult when a bronchu become morosed numer (1) move meat of ur catering or leaning the pulmonary toaxes beyood the region of stenous is inhibited, rod (2) bronchial TCtion, which usually are excedive In whma ust retained below the stenotic ronte ao that a region of partial or complete 98 ·Ads atelectus's rahulu. The poudbality of broncbosteooria should be entertained in any wthmatic patient who has bad attacks in which the cough becoma nooproductive and is asociated with febrile episoda either with or without preceding chill. As a rule the lever louts 2 to 5 day. With pubescence or fever the amount of putun urally increasa It should be emphanteed that febrile episode, hardoptynis or purulent sputum does not wctompany uncompliated uthma Hronchoscopic examinations may disclor Ox or more #cools bronchl. The superior branches of the bronchi to the lower lobes are involved most frequently The stepouc bronchus is dilated arefully after which ball amount or purulent scretion wually can be aspirated When broncbon Henost is present and the stenots bronchin o dilated adequately the patient usually experiences prompt mprove ment of the uthma Racucice of broochostenots may take place in wich instances, ſurtbet bronchoscopic dulation of the itenotic zone indicated ·SYPHILIS OF THE TRACHEOBRONCHIAL TREE Syphulu of the tracheobronchul tree is extremely rare at present It tends to asume one of two types, namely (1) lesions of gummatous inGitative nature, and (2) Icsoms that are produced by secondary cicatncial structure. No charac terustic symptoms are ascribable to the disease A diagnotus of syphilis based only on positive results of xrologic tests doo not always ugnify that a lesion involving the tracheo bronchial tree is of syphilitic origin Whilc microcopac examination of time removed from the Icuon may be suggestive of syphilas, the final diagnons arten depends on the response of the lesion to antisyphiliuic therapy ·HEMOPTYSIG Bronchoscopy indicated in any cix of une plained hermoptysis Such a statement asume that tuberculou, preumonia, 20eury or cardiac decompensation hu been cicluded us an etlologic factor Sonne difference of opinon to have won alter pulmonary flemorthuge bronchocopy should be performed Vytan reromroended that at least 10 days thould clapre between the hemorrhage and bronchoscopy We agree wth Arbuckle that tuale and the best results are obtained, of the camination is done MS roon as pouble after the bleeding has subsided It thus pordbtc by ndng the blood in the bronchial tree to deterru ne more easily from which bronchin the beeding B Arbung and also the cause of the heroarttuage When rosulu of Lronchoscopic examination are negat e bilateral bon chography should be performed Among the more common aures of bomopty vs are tuberculom, carcinoma mitral Acnos ben gn tumor bron chrecuaris, pulmonary abres, broncholithions, foreign body acute iracheobronchutn mich follom Inhalaton of anots Tuung gasa, and diffure polypord lan ngotracheobron th The opinion most frequently reached which the source of grow temorrupt not readily pparent that the bleeding met Ixe due to varices. It has been ou Experience that much rart and that the bleruling usually carries from some other source (ong reported three care of hemoptym duc 10 mou shosts of the hea in which treatment in Cautery sund great dilterence extsun the tendency of mucous membranes to Werd. It nox porabi 141 to drien det nat ly the 101 n ain arxar n rome ·102 Drama od TI K Derness of the Trache and Bronchi cause of bleeding which appears to be duapedesu. Thr condition aften u asociated with hypertennon Various methods of treatment have been advocated for pulmonary bleeding of indeterminate origin, among which may be mentioned the use of venom from the moccasin make Beneficul results sometimes may be obtained, accord ing to Vinson," in cares of unexplained pulmonary hemor rhage, such as in diffuse tracheobronchitis, by curettage or the involved bronchus followed by Insufflation of powdered Aulfanilamide. When the bleeding is attributable to other causes, the hemorrhage may be controlled at times by local application of cocaine and cpinephrine, u well as by local pres sure with a tampon at theatcorbleeding The local applicadon of a small amount ofer-dc-lance venom to the site of bleeding will adequately control the hemorrhage ·TRAUMA Rupture of the tracher and broochi may repult from severe blow's or ahing injuno to the thorax. Such rupture may occur without fractured ribs. Shanng forca cause the tear which b located most commonly within a few cent meton of the blfurcation of the trachca Separate t an of the tracher and bronchu may occur amultaneously but the injury la localed non frequently in one of the mujor bronxclu It appaan that rupture of the tracher alone s le common thun o rupture of the bronchi Clinical findings remult from th escape of blood and a Hemoperate and hemothonat may be present Medustinal or subcutaneou emphysema or pneumothorax u boted Lalage of large amount of air o comandon and frequently perusts even after the application of apposedly adequate ochures, Fuch a constant ninaplamal turtion of bronchial rupture may becounc maled, preventing 10 of air but the lung then may fail to re-expand and lead on 10 mupect the correct dua nonds Dypnea, cyanosis and The at shock are common Bronchoscopy should be done to verify the diagnog when the presence of rupure a superted Inammuch a the tea balty in a major bronchus bronebworopx Pouliraton of the defect should not be difficult Treatment should consist of prompt emergency meauty If the pathent to to survive. Wequate intrapleural auction Otyren, general merutos to combat shock and attention to wachated Injuries are esential In 1917 hmella and Jotunud reported that only 19 of 10 patients wth rupture of a bronctru had arrived Those who lived had bronchul 103 ·104 Dungsod Treatment f Dead the Tracket and Breache TADLC CLARATICATION OF 2 PAR NEOPLAN OF TTE TOT Adre Squamous cell carcinoma Cylindrorda (DOG) Hemango-todoxhcloth Afytofibrochondro-teogeok Aroma Adrdornanome Buyt Popullore Trebeopathu paroplatia Avoyberi tumor Ymthom (bondroms *** Resort atrctures, with collapsed lungs. Patients treated prior to 1947 seldom had surgical intervention at present, primary bronchul repair through a thoracotomy is to be recommended a woon on the general condition will permit One need not be concerned about the blood supply to the destul moment of the ruptured bronchus, because sufficient collateral and to axure an adequate wource of blood Late restoration of the bronchial luinen hu been accompluhed both experimencally aod cinically Excalon of the structure, with end to-end anastomode, hu resulted in it Cipanuon and restoration of the function of the collapod luog even keveral year after the bronchua wo injured The late treatment of trachel stricture will present a problem Conservative treatment consting of placement ora ngid tube for 3 months or mort, may be ined When the rtricture is in the lower part of the truches, this may be done by we are tracheotomy rube. If the sincture be in the upper portion of the traches tracheotomy should be per formed fint and then a nord tube may be inserted Retroval of the tube before 3 months have elapsed (requently result JD Currence of the stricture It thb treatment is unsucco ful in retalning rufficient lumen and if the acidon of the

·105
Trrett
uncture would require removal of no more than three or
four tracheal cartilagan, it is reasonable to conder excison
and primary anastomosis

·REFERENCES 1 Adamon, JD Pulmonary Atelected, I Myan, J t and Mckinlay CA. Tly Cheet and the Bleet Springfield Thorn 1948 vol. 1 pp. 537 547 2 Arbuckle, M. F Pulmonary Hemortage Studied and Treated by the Bronchoscopist. tur. O del Riur & Lorry 15 1114- 1121 (Dec.) 1936 3 Boydea, EA Samuel Anety of Ww Lays 1 Sowy dla Pelletu of the Sword Broncla o Road Pway Icons New York, Blakurton Company 1955 276 pp. 4 Chlart, H Ucxer eloen neuen Typw von Almhildung • der Tracha da Menschen. Brate Park A 5 329-344 1889 5 Ephraim, A Grundlagen und Erretnine der lokalen Beband lung chronisch entzündcbat Bopchialerk rolungen. Drische Mod. I clansch 2 2079-2002 (Nov ) 1911 6 Gurdocs WT Os the Patbological Sute of the Lung Coopected With Broochitis and Bronchlal Oburuxton. Aliud ; 11 $c 11.122 230 1850 12 440 13 238 1851 7 Galings, PG Bronchoscopy Hatmoptynie I Lore Old 51.508-320 (Aug ) 1936 8 Jackson, C. L. ad Huber JF Correlated Applied Anatomy of the Bronchial Tree and Lung With System of Nonclature. Dus Quo 9 319-326 (July-Aug ) 1943 9 Jackooc, Chevallet and Jackson, C. L. Bruchsany Esplant run oud Getrestyy A Blard of Prrera Eras Lorand Sam Ed. 3 Podleddpblu, S. nders, 19K 185 PP 10 Kabler DO Broocboscopy and Eropheta copy Thor Indication and Cootrafindication Lay 11 894- 922 (Sept.) 1911 106 ·107 Rdens 11 hiruger 11 Zur Pathogroese der Broochlektrico ! Indlung Pronchietanen bd Situs vixerum Inveren Ent KL To B3 489-901 1933 12 Woolla, T J and J horrod, LU Traumatic Rupture of Bronchu 1 Thorstc Ser 16 571 583 (Oct ) 1947 13. Mann, MG Tramunt of Trechos restomp (Trbone and Practical) (Translated bs A R Moodle ) New York, Wood, 1921 292 PP 14 McDonald, JR McAurocs RP Carlise JC and P tloo MM The Significance of Cell Types in Broocbogenke Carcinoma į The Sure 11 62 (Juhy) 1951 15 McIndoc R B., Sicoke, J D Sannon, PC Anderson, RS und Leulle, GL Rotilde Broocho copy a Puents With Active Pulmonar Tuberculose 1 Rn Time 34017 628 (11xy) 1939 16 Mycron, MI C Broncboroptc Aspects of Hemopty ** Ola Rom. & Larry 45 1101 1108 (Dec ) 1936 17 Orocrod, F C Tuberculous Tracbeo-bronchita At Twberre 33 29-36 (Jan.) 1939 18 Pasteur W Respiratory Panalyus After Daphthone Cauac od Pulmonary Compcathoors, With Surrearons us to Traiment Am. ) M S 100 242 257 1890 19 Pienlaict Bemarhungen aber das Asthma bronchiol. liar klu. It courke 18 1201 1212 Mon 16) 1905 20 Seroth, PC Diffum Polypold Laryngotracheobroochius With Prelimioary Vox on Endoscopic Curetter ] Therex Sur 9 679-688 (Aug ) 1940 21 on Schritter Hermann hincher Beitru tur Broncho kopte. Work wd 11 heurdlo 11241 1243 (Junc) 1905 n Schwartz, Philip Medical Serion on Tuberculods The Role of the Lymphato in the Pathogenesis of Bronchopenie Tuberculonta T 1 Tb 48 202-216 1952 23 Sman, Joseph Endo-bronchial Tuberculosh B1 ] Taherte 43 61-68 (Apr ) 1951 24 Sternberg, Gert Ueber die Ennocbung brooctualer Lympta driten und ihre Folgen 13 1214. 1215 (Nov 16) 1905 25 limon, PP The Erbology and Traloxat of Pulmonary Ilemonter. With Especial Reference to Bleeding la Cerca

·108 D mo Trento Diners with Trachrend Bruce
of so-called "Dr Broochiectadı" Soul 17 34 203-206
(Feb ) 1041
26 Warren, Wod worth, Hamond and Tuitle Il M
The Duagoods and Treatment of Tuberculous Tracheo
bronchitu, As Rot Tahrir 37 315-335 (Mar) 198
27 tloolner LB and McDonald IR Cytology of Sputum
and Bronchial Secretory Studies on 588 Patey With
Miscellaneous Pulmonary Lovioas. in l. V U 1166
1174 (Nov ) 1950

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