Treatment of Compression Stenoses of the Trachea.—If the thymus be at fault, rapid amelioration of symptoms follows roentgenray or radium therapy. Tracheotomy and the insertion of the long cane-shaped cannula (Fig. 104) past the compressed area is required in the cases caused by conditions less amenable to treatment than thymic enlargement. Permanent cure depends upon the removability of the compressive mass. Should the bronchi be so compressed by a benign condition as to prevent escape of secretions from the subjacent air passages, bronchial intubation tubes may be inserted, and, if necessary, worn constantly. They should be removed weekly for cleansing and oftener if obstructed.
Influenzal Laryngotracheobronchitis.—Influenzal infection, not always by the same organism, sweeps over the population, attacking the air passages in a violent and quite characteristic way. Bronchoscopy shows the influenzal infection to be characterized by intense reddening and swelling of the mucosa. In some cases the swelling is so great as to necessitate tracheotomy, or intubation of the larynx; and if the edema involve the bronchi, occlusion may be fatal. Hemorrhagic spots and superficial erosions are commonly seen, and a thick, tenacious exudate, difficult of expectoration, lies in patches in the trachea. Infants may asphyxiate from accumulation of this secretion which they are unable to expel. The differential diagnosis from diphtheria is sometimes difficult. The absence of true membrane and the failure to find diphtheria bacilli in smears taken from the trachea are of aid but are not infallible. In doubtful cases, the administration of diphtheria antitoxin is a wise precaution pending the establishment of a definite diagnosis. The pseudomembrane sometimes present in influenzal tracheobronchitis is thinner and less pulpy than that of the earlier stages of diphtheria. The casts of the later stages do not occur in influenzal tracheobronchitis (Bibliography I, p. 480).
Edematous Tracheobronchitis.—This is chiefly observed in children. The most frequently encountered form is the epidemic disease to which the name "Influenza" has been given (q.v. supra). The only noticeable difference between the epidemic and the sporadic cases is in the more general susceptibility to the infective agent, which gives the influenzal form an appearance of being more virulently infective. Possibly the sporadic form is simply the attack of children not immunized by a previous attack during an epidemic.
There is another form of edematous tracheobronchitis often of great severity and grave prognosis, that results from the aspiration of irritating liquids or vapors, or of certain organic substances such as peanut kernels, watermelon seeds, etcetera. Tracheotomy should be done if marked dyspnea be present. Secretions can then be easily removed and medication in the form of oily solutions be instilled at will into the trachea. In the Bronchoscopic Clinic many children have been kept alive for days, and their lives finally saved by aspiration of thick, tough, sometimes clotted and crusted secretions, with the aspirating tube (Fig. 10). It is better in these cases not to pass the bronchoscope repeatedly. If, however, evidences of obstruction remain, after aspiration, it is necessary to see the nature of the obstruction and relieve it by removal, dilatation, or bronchial intubation as the case may require. It is all a matter of "plumbing" i.e., clearing out the "pipes," and maintaining a patulous airway.
Tracheobronchial Diphtheria.—Urgent dyspnea in diphtheria when no membrane and but slight lessening of the laryngeal airway is seen, calls for bronchoscopy. Many lives have been saved by the bronchoscopic removal of membrane obstructing the trachea or bronchi. In the early stages, pulpy masses looking like "mother" of vinegar are very obstructive. Later casts of membrane may simulate foreign bodies. The local application of diphtheria antitoxin to the trachea and bronchi has also been recommended. A preparation free from a chemical irritant should be selected.
Abscess of the Lung.—If of foreign-body origin, pulmonary abscess almost invariably heals after the removal of the object and a regime of fresh air and rest, without local measures of any kind. Acute pulmonary abscess from other causes may require bronchoscopic drainage and gentle dilatation of the swollen and narrowed bronchi leading to it. Some of these bronchi are practically fistulae. Obstructive granulations should be removed with crushing, not biting forceps. The regular foreign-body forceps are best for this purpose. Caution should be used as to removal of the granulations with which the abscess "cavity" is filled in chronic cases. The term "abscess" is usually loosely applied to the condition of drowned lung in which the pus has accumulated in natural passages, and in which there is neither a new wall nor a breaking down of normal walls. Chronic lung-abscess is often successfully treated by weekly bronchoscopic lavage with 20 cc. or more of a warm, normal salt solution, a 1:1000 watery potassium permanganate solution, or a weak iodine solution as in the following formula: Rx. Monochlorphenol (Merck) .12 Lugol's solution 8.00 Normal salt solution 500.
Perhaps the best procedure is to precede medicinal applications by the clearing out of the purulent secretions by aspiration with the aspirating bronchoscope and the independent aspirating tube, the latter being inserted into passages too small to enter with the bronchoscope, and the endobronchial instillation of from 10 to 30 cc. of the medicament. The following have been used: Argyrol, 1 per cent watery solution; Silvol, 1 per cent watery solution; Iodoform, oil emulsion 10 per cent; Guaiacol, 10 per cent solution in paraffine oil; Gomenol, 20 per cent solution in oil; or a bismuth subnitrate suspension in oil. Robert M. Lukens and William F. Moore of the Bronchoscopic Clinic report excellent results in post-tonsillectomy abscesses from one tenth of one per cent phenol in normal salt solution with the addition of 2 per cent Lugol's solution. Chlorinated solutions are irritating, and if used, require copious dilution. Liquid petrolatum with a little oil of eucalyptus has been most often the medium.
Gangrene of the Lung.—Pulmonary gangrene has been followed by recovery after the endobronchial injection of oily solutions of gomenol and guaiacol (Guisez). The injections are readily made through the laryngoscope without the insertion of a bronchoscope. A silk woven catheter may be used with an ordinary glass syringe or a long-nozzled laryngeal syringe, or a bronchoscopic syringe may be used.
Lung-mapping by a roentgenogram taken promptly after the bronchoscopic insufflation of bismuth subnitrate powder or the injection of a suspension of bismuth in liquid petrolatum is advisable in most cases of pulmonary abscess before beginning any kind of treatment.
Bronchial Stenosis.—Stenosis of one or more bronchi results at times from cicatricial contraction following secondary infection of leutic, tuberculous or traumatic lesions. The narrowing resulting from foreign body traumatism rarely requires secondary dilatation after the foreign body has been removed. Tuberculous bronchial stenoses rarely require local treatment, but are easily dilated when necessary. Luetic cicatricial stenosis may require repeated dilatation, or even bronchial intubation. Endobronchial neoplasms may cause a subjacent bronchiectasis, and superjacent stenosis; the latter may require dilatation. Cicatricial stenoses of the bronchi are readily recognizable by the scarred wall and the absence of rings at or near the narrowing.