Mostert, JW

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20 Augustus 1960 S.A. TYDSKRIF VIR GENEESKUNDE 703pensated instrwnent is both a convenience and a safetyfactor, care and experience should enable the impler typeto be used without undue risk.SUMMARYThe administration of halothane in a series of over -,000cases has been reviewed. With due appreciation of itsdominant pharmacological properties and its high potency,the claims that have been made for it as a safe anaesthetichave been confirmed. The effects of halothane on pul-monary ventilation have been further observed the con-clusion is that hypove~tilation is not a serio~s hazard;in cases showing marked tachypnoea the respiratoryexchange was more than adequate. The chief advantagesof halothane are its non-inflammability, potency andflexibility, and the ease with which pulmonary ventilationis controlled. It gives a rapid and comfortable inductionand is of great value where intravenous methods areinconven~ent or contra-indicated. Except on the groundof economy, closed methods are not favoured.We wi h to thank Prof. O. V. . Kok, of Pretoria University,for kindly lending the Wright pirometer which wa u ed intbe ob er ation on pulmonary ventilation.REFERE 'CESI. icholson, J. C .. Pitcher, J. S. I., Finn, M. S. and Leibovitz, J.(1959): S. Afc Med. J .. 33. 663.2. Raventos, J. (1956): Brit. J. Pharmacal., 11. 394.3. Burn, J. H. and Ep tein. H. G. (1959): Brit. J. Anaesth .. 31, 199.4. Burn. J. H., Epstein. H. G., Feigan, G. A. and PalOn, W. D. M.(1957): Brit. Med. J .. 2. 479.5. Dobkin, A. B. (195 ): Brit. J. Anaesth .. 30. 568.6 Brecher, G. A. (1956): Venous Return, p. 100. New York: Grune7. Musbin, W. W., RendeJl-Baker, L. and Thompson. P. W. (1959):Automatic Ventilation of the Lungs, p. 30. Oxford: BlackweU cienlificPublications.8. Matren, H. R. (1957): Brit. Med. 1.. 2, 331.9. Burton, P. J. C. (1958): Brit. J .. Anaesth., 30, 312.10. ewman, H. C. (195 ): Ibid., 30, 555.LUNG MASSAGE FOR TOTAL BRONCHOSPASM: A CASE REPORTJ. W. MOSTERT, M.B., D.A., F.F.A.R.C.S., Johannesburg General Hospital and Universily of rhe Witlllarersrand,JohannesburgThis report concerns a fit although over-weight middle-aged man, who gave no history of asthma, admitting onlya chronic "smoker's" cough, and who, after more than anhour of halothane anaesthesia, deve~oped a total broncho-spasm which responded dramatically to direct lung com-pression or 'massage' as recently described by Smol-nikoffYA European male aged 38 came to oper~tion for tantaluminsertion into a carcinoma of tbe bladder. He was obeseand noticeably anxious, and exhibited the smoker's respiratorysyndrome" and a classical 'bull-neck'; otherwise he wasunremarkable. Premedication consisted of 3 gr of seconaltbe nigbt before, and 50 'mg. of promethaZi~e with 100mg. of pethidine intramuscularly 75 minutes before tbeoperation. for induction of anaesthesia 400 mg. of thiopentonewas injected, and anaestbesia was maintained, with a mixtureof 1,000 ml. of oxygen and 2,000 ml. of nitrous oxide perminute, containing 2% halothane vaporized outside a circleabsorption system. A face mask was strapped over anoropbaryngeal airway. After 10 minutes of uneventful spon-taneous respiration the surgeon reported inadequate abdominalrelaxation, and partial laryngospasm manifested itself. Endo-tracbeal intubation was performed with a no. 10 cuffed Magilltube and facilitated, by 25 mg. of suxamethonium; and, for2 - 3 minutes only, controlled respiration yielded adequateoperating conditions, with the breathing sounds quite normal.Twenty minutes later relaxation was again inadequate, andthen 80 mg. of flaxedil was administered, and controlledrespiration was persistently used. After 70 minutes of anaesthe-sia 1·5. m!. of 4% Lignocaine was injected dpwn tbe endo-tracbeal tube because some resistance to inflation of the lungs,as well as abdominal rigidity, bad appeared during the pre-ceeding minute or two. Total broncbospasm nevertbelessupervened within 3 - 4 minutes, in spite of the continued useof 2'5% balotbane and inteonittent positive pressure' vigorouslyapplied to tbe airway. Wbeezing had previously indicatedbronchiolar constriction, but at no time was tbere any evidencef liquid in the broncbial tree. While 0·65 mg. of atropine,0'5 ml. of 1 in 1,000 ad,renaline, and 4 ml. of 10% calciumchloride, were being given intravenously, all pulses becameimpalpable. A thoracotomy was immediately performed whilean intravenous infusion of 1,000 ml. of normal saline con-taining 8 mg. of noradrenaline was started.The exposed left lung was so distended tbat it ballooned outof the pleural incision, rendering the tboracotomy virtuallyimpos ible without some laceration of the lung - notwithstand-Ing the fact that tbe endotracbeal tube was di connectedentirely from the anaesthetic machine to demonstrate thattbere was no positive pressure being applied, at all. (Gas didactually escape audibly from the endotracheal tube on di-connection for a period tbat seemed to be at lea t 30 second .)Earlter the cuff was deflated and the tube replaced withanother in spite of the difficulty tbe patient's bull-neckpresente~ to laryngoscopy. Another desperate attempt to moveoxygen mto the already overdi tended lungs again failed com-pletely. Thereupon, bearing in mind Smolnikoff' experience,'"the surgeon was asked to empty the lung as much as possiblebetween his two bands. This promptly and impres ively resultedin an uneve.ntfully expanding lung on inflation, and a normallycollapsing lung during the intervening phases of zero airwaypressure.The surgeon tbougbt that tbe heart was beatine, but whenhe opened the pericardium tbe tip of the left ventricle waseen to contract rhythmically while the rest of the beartremained in standstill. Cyano is and wid,ely dilated pupils aswell as absent carotid impulses, even witb the cardiac massagepersisted for 35 minutes altogetber before a normal heart beatappeared sbonly after the intracardiac injection of 8 m!. of1 in 10,000 adrenaline and 2 m!. of 10% calcium chloride.A tracbeotomy was performed and hypothermia inducedpo toperatively, but the patient died, after 54 hours.co eLUSION AND COMMHHSThe case just described confirmed the value of lung'massage' for complete broncho pasm occurring duringanaesthesia. Although the manoeuvre did not save thipatient's Life, it may well be life-saving in these very rareinstances when absolutely fruitle s attempts at lung in-flation are 'just like pushing against a stone wall'. Judgingfrom an earlier case of my own in 1954, in which a fataltotal bronchospasm occurred in an insufficiently relaxedbut fit Bantu man during laparotomy when the surgeonunexpectedly lifted the peritoneum, and from those re-ported by Smolnikoff,l.~ Ga ~ and Kucher;5 and the ca enow de cri bed, cardiac arre t always foUow exceedinglyrapidly once total broncho pa m has become manife t.When this extremely rare contingency has to be faced ittherefore appears unwise to rely on the intravenou admini-704 S.A. MEDICAL JOURNAL 20 August 1960stration of drugs, because the venous return must beseverely curtailed or, more likely, altogether absent invie~ of the fact that the thoracic veins are actually col-lapsed rather than merely depleted. It is well known thatexcessive inflation of the lungs interferes with venousreturn even in the open chest by an increase of resist-ance in the pulmonary bed as well as by tamponade ofthe heart and great vessels.6 In any case, no certainlyefficacious bronchodilator drug exists.Quite apart from anaesthesia, death during an attack ofasthma is known to occur but not usually, if ever, fromtotal bronchospasm. As Smolnikoffl·~ points out, thereis an essential difference between the bronchospasm ofordinary asthma and the rare total variety seen' only inanaesthesia, general or local; the variety associated withanaesthesia is in fact not particularly feared in asthmatics,occurring classically in obese but otherwise healthy middle-aged men.7 Like 'true' instances of cardiac arrest duringanaesthesia there are usually little, if any, premonitorysigns. It represents a grave accident inherent in the practiceof surgery with anaesthesia, but is fortunately so rare thatfew anaesthetists encounter it more than once or twice ina lifetime. Heavy smoking, with its associated syndrome3.8is a predisposing factor.Finally, while muscle relaxant drugs for associatedskeletal muscular rigidity and bronchodilators like adrena-line, aminophylline and atropine are all valuable in theprevention of bronchial constriction, attention must begiven to effective circulation9,lo with exactly the sameurgency as in cases of cardiac arrest from other causes.Once manual compression of the lung has been institutedit will invariably be necessary for the assistant to massagethe heart, also using the palms of both hands, if necessary,to produce the absolutely vital palpable carotid pulsations.Although all this activity through the chest incision maylead to some inconvenience to the two 'masseurs', andenlargement of the incision, it is entirely feasible. It mustalways be remembered that interruption of the cerebralcirculation IS followed within seconds by a loss of con-sciousness, and witnin minutes by irreversible changes inthe brain.The most important lesson, however, to be learnt fromthis case is the need for adequate suppression of thepatient's reflex response to stimuli, and the fact that, inspite of numerous claims to the contrary, phenothiazinederivatives do not always provide this; neither does halo-thane or ether guarantee absence of reflex irritability evenduring the deep stages of anaesthesia. Thus Edwards'et alll found no case of the undoubtedly genuine idio-pathic variety among 16 cases in which the anaesthetistrecorded that bronchospasm occurred during anaesthesiaand played an important role in the subsequent death ofthe patient.I am indebted to Dr. J. C. Nicholson for advice andencouragement in the writing of this article. The MedicalSuperintendent of Johannesburg General Hospital kindly gavepermission for its publication.REFERENCES1. Smolnikoff, ,V. P. (1959): Anaestbcsist. 8, 350.2. Idem (1960): Anaesthesia. 15. 40.3. Waldboll. G. L. (1953): J. Amer. Med. Assoc.• 151. 1398.4. Gast. W. (1955): Anaestbesist. 4. 179.5. Kucber. R. and Steinbereitbner. K. (1960): Ibid.• 9. 116.6. Brecber, G. A. (1956): Venous Return. p. 100. New York: Gruneand Stranon _ ~7. Wylie. W. D. and Churchill-Davidson. H. C. (1960): A Practice ofAnaesthesia. p. 27. London: Lloyd-Luke.8. Waldboll, G. L. (1953): Ann. Intern. Med.• 39. 1026.9. Vellen. K. B.. Wilson, V. H .• Crawshaw. G. R. and Nicbolson, J. C.(1955): Brit. J. Anaesth .. 27. 2.10. Jackson, B, (1958): S.Afr. Med. J .• 32. 917.11. Edwards, G., Monon, H. J. V .• Pask, E. A. and Wylie. W. D(1956): Anaestbesia. 11, 194.ADDENDUMExtracts from the detailed but largely non-contributory autops}report are as follows: 'Section of the specimen of lung lihowsthe presence 'of an acute fibrinous pleurisy, marked congestionand oedema, hyaline membrane formation, numerous pig-mented and unpigmented alveolar phagocytes, a focus of acuteinflammation and. some metaplasia of the epithelium of therespiratory bronchioles and ducts . , . marked curling of theepiglottili . . . small foci of pyelonephritis with a granularcast . . . moderate fatty changes in the liver . . . bruismyocardium ... fibrinous pericarditis ... no metastases ... 'In the brain nothing was found, except, on histologicalexamination, 'some extravasation of blood into the perivascularspaces.'THE 'MEDICAL AID SOCIETY OF SOUTH AFRICA'A letter dealing with the relations existing between doctors and<the 'Medical Aid Society of South Africa' appears in theCorrespondence Column of this issue of the Journal.Members of the Association, especially those in the CapeWestern Branch in whose area the Society appears to be.operating, are urged to read this 'letter carefull'y and, for thepresent, to have no dealings with the Society whatsoever.There are several cogent reasons for this.In the first place, the Society is still in negotiation withthe Cape Western Branch of the Association and has not yetsatisfied the requirements for recognition as a benefit societyby the Association. Until this recognition is granted, memberswould be doing themselves, and the Association, harm byjoining the panel of the Society.Secondly, the name of the Society is misleading. It is nota 'medical aid' society as we understand the term, but a benefitsociety and, until its name is altered, confusion is likely to be.present in the minds of doctors and the public alike.Thirdly, it is a condition of their recognition that benefitsocieties will cater only for persons earning up to £750 pe'annllm (with dependants) and up to £400 per annum (withoudependants), with the proviso that not more than 10% imembers of the society may earn up to £1,750 per annum.The Medical Aid Society of South Africa appears to be opento all members of the public earning up to £2,500 per 'annumFourthly, the circular letter quoted by our corresponden'merits serious study. If members of the Association compl:with the request therein to submit lists of their patients foapproval as members of the Society, they may well becomeparty to an undertaking of which the South African Medica.and Dental Council may take cognizance, whatever th,sponsors of the Society may say to the contrary.The Council of the Cape Western Branch is pursuing th,matter vigorously, and hopes to have the situation c1arifie,..as soon as possible; until such time it is trusted that memberwill have the good sense not to become committed in anIway to a course of action which may have grave professiona,results for them. '

Lung massage for toatal bronchospasm: a case report

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Lung massage for toatal bronchospasm: a case report

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