Bronchiectasis.—In most cases of bronchiectasis there are strong indications for a bronchoscopic diagnosis, to eliminate such conditions as foreign body, cicatricial bronchial stenosis, or endobronchial neoplasm as etiologic factors. In the idiopathic types considerable benefit has resulted from the endobronchial lavage and endobronchial oily injections mentioned under lung abscess. It is probable that if bronchoscopic study were carried out in every case, definite causes for many so-called "idiopathic" cases would be discovered. Lung-mapping as elsewhere herein explained is invaluable in the study of bronchiectasis.
Bronchial asthma affords a large field for bronchoscopic study. As yet, sufficient data to afford any definite conclusions even as to the endoscopic picture of this disease have not been accumulated. Of the cases seen in the Bronchoscopic Clinic some showed no abnormality of the bronchi in the intervals between attacks, others a chronic bronchitis. In cases studied bronchoscopically during an attack, the bronchi were found filled with bubbling secretions and the mucosa was somewhat cyanotic in color. The bronchial lumen was narrowed only as much as it would be, with the same degree of cough, in any patient not subject to asthma. The secretions were removed and the attack quickly subsided; but no influence on the recurrence of attacks was observed. It is essential that the bronchoscopic studies be made, as were these, without anesthesia, local or general, for it is known that the application of cocain or adrenalin to the larynx, or even in the nose, will, with some patients, stop the attack. When done without local anesthesia, allowance must be made for the reaction to the presence of the tube. In those cases in which other means have failed to give relief, the endobronchial application of novocain and adrenalin, orthoform, propaesin or anesthesin emulsion may be tried. Cures have been reported by this treatment. Argentic nitrate applied at weekly intervals has proven very efficient in some cases. Associated infective disease of the bronchial mucosa brings with it the questions of immunity, allergy, anaphylaxis, and vaccine therapy; and the often present defective metabolism has to be considered.
Autodrownage.—Autodrownage is the name given by the author to the drowning of the patient in his own secretions. Tracheobronchial secretions in excess of the amount required to moisten the inspired air, become, in certain cases, a mechanical menace to life, unless removed. The cough reflex, forced expiration, and ciliary action, normally remove the excess. When these mechanisms are impaired, as in profound asthenia, laryngeal paralysis, laryngeal or tracheal stenosis, etc.; and especially when in addition to a mild degree of glottic stenosis or impaired laryngeal mobility, the secretions become excessive, the accumulation may literally drown the patient in his own secretions. This is illustrated frequently in influenza and arachidic bronchitis. Infants cannot expectorate, and their cough reflex is exceedingly ineffective in raising secretion to the pharynx; furthermore they are easily exhausted by bechic efforts; so that age may be cited as one of the most frequent etiologic factors in the condition of autodrownage. Bronchoscopic sponge-pumping (q.v.) and bronchoscopic aspiration are quite efficient and can save any patient not afflicted with conditions that are fatal by other pathologic processes.
Lues of the Tracheobronchial Tree.—Compared to laryngeal involvement, syphilis of the tracheobronchial tree is relatively rare. The lesions may be gummatous, ulcerative, or inflammatory, or there may be compressive granulomatous masses. Hemoptysis may have its origin from a luetic ulceration. Excision of fungations or of a portion of the margin of the ulceration for biopsy is advisable. The Wassermann and therapeutic tests, and the elimination of tuberculosis will be required for confirmation. Luetic stenoses are referred to above.
Tuberculosis of the Tracheobronchial Tree.—The bronchoscopic study of tuberculosis is very interesting, but only a few cases justify bronchoscopy. The subglottic infiltrations from extensions of laryngeal disease are usually of edematous appearance, though they are much more firm than in ordinary inflammatory edema. Ulcerations in this region are rare, except as direct extensions of ulceration above the cord. The trachea is relatively rarely involved in tuberculosis, but we may have in the trachea the pale swelling of the early stage of a perichondritis, or the later ulceration and all the phenomena following the mixed pyogenic infections. These same conditions may exist in the bronchi. In a number of instances, the entire lumen of the bronchus was occluded by cheesy pus and debris of a peribronchial gland which had eroded through. As a rule, the mucosa of tuberculosis is pale, and the pallor is accentuated by the rather bluish streak of vessels, where these are visible. Erosion through of peri-bronchial or peri-tracheal lymph masses may be associated with granulation tissue, usually of pale color, but occasionally reddish; and sometimes oozing of blood is noticed. A most common picture in tuberculosis is a broadening of the carina, which may be so marked as to obliterate the carina and to bulge inward, producing deformed lumina in both bronchi. Sometimes the lumina are crescentic, the concavity of the crescent being internal, that is, toward the median line. Absence of the normal anterior and downward movement of the carina on deep inspiration is almost pathognomonic of a mass at the bifurcation, and such a mass is usually tuberculous, though it may be malignant, and, very rarely, luetic. The only lesion visible in a tuberculous case may be cicatrices from healed processes. In a number of cases there has been a discharge of pus coming from the upper-lobe bronchus.
[Fig. 96.—The author's tampons for pulmonary hemostasis by bronchoscopic tamponade. The folded gauze is 10 cm. long; the braided silk cord 60 cm. long.]
Hemoptysis.—In cases not demonstrably tuberculous, hemoptysis may require bronchoscopic examination to determine the origin. Varices or unsuspected luetic, malignant, or tuberculous lesions may be found to be the cause. It is mechanically easy to pack off one bronchus with the author's packs (Fig. 96) introduced through the bronchoscope, but the advisability of doing so requires further clinical tests.
Angioneurotic Edema.—Angioneurotic edema manifests itself by a pale or red swollen mucosa producing stenosis of the lumen. The temporary character of the lesion and its appearance in other regions confirm the diagnosis.
Scleroma of the trachea is characterized by infiltration of the tracheal mucosa, which greatly narrows the lumen. The infiltration may be limited in area and produce a single stricture, or it may involve the entire trachea and even close a bronchial orifice. Drying and crusting of secretions renders the stenosis still more distressing. This disease is but rarely encountered in America but is not infrequent in some parts of Europe. Treatment consists in the prevention of crusts and their removal. Limited stenotic areas may yield to bronchoscopic bouginage. Urgent dyspnea calls for tracheotomy. Radium and roentgenray therapy have been advised, and cure has been reported by intravenous salvarsan treatment (see article by S. Shelton Watkins, on Scleroma in Surg. Gynecol. and Obst., July, 1921, p. 47).
Atrophic tracheitis, with symptoms quite similar to atrophic rhinitis is a not unusual accompaniment of the nasal condition. It may also exist without nasal involvement. On tracheoscopy the mucosa is thinned, pale and dry, and is covered with patches of thick mucilaginous secretion and crusts. Decomposition of secretion produces tracheal "ozena," while the accumulated crusts give rise to the sensation of a foreign body and may seriously interfere with respiration, making bronchoscopic removal imperative. The associated development of tracheal nodular enchondromata has been described. The internal administration of iodine and the intratracheal injection of bland oily solutions of menthol, guaiacol, or gomenol are helpful.