Changes in regional ventilation and perfusion of the lung after endoscopic laser treatment.

To determine whether endoscopic laser treatment improves both ventilation and perfusion in patients with advanced lung cancer, krypton-81m ventilation and technetium-99m labelled macro-aggregate perfusion scanning was performed immediately before and two or four days after treatment in a consecutive series of 28 patients. Twelve patients had not received any other treatment before laser therapy and 16 had undergone previous treatments that included radiotherapy. Ventilation and perfusion were quantified by expressing the number of counts in the affected lung as a percentage of the total counts. Ventilation and perfusion improved after laser treatment in 23 patients (82%). The mean ventilation score in the affected lung rose by 50% (p less than 0.001) and the mean perfusion score rose by 24% (p less than 0.001). Incremental changes in ventilation and perfusion scores were positively correlated (r = 0.80). Mean spirometric values, six minute walking distance, the Karnofsky performance index, and breathlessness and wellbeing scores also improved significantly. Patients with main bronchial obstruction who had had no radiotherapy showed the most striking improvements. It is concluded that the removal of intraluminal tumour from the bronchial tree leads to matched improvements in ventilation and perfusion in most patients and that this is associated with valuable improvement in symptoms.

Increased ventilation requirements during obstetric general anaesthesia.

The inspiratory fresh gas flow rate (FGF) required to produce an end-tidal carbon dioxide tension (PE'CO2) of 4 kPa during general anaesthesia, neuromuscular blockade and artificial ventilation, was compared in a group of 46 obstetric patients and a matched group of 50 non-pregnant female patients. The non-pregnant patients required a mean (SD) inspiratory FGF of 77 (10.6) ml kg-1 min-1, whereas the pregnant patients required a mean FGF of 121 (24.6) ml kg-1 min-1 before delivery (in those who reached a stable state), and 109 (19.3) ml kg-1 min-1 after delivery. These represent significant (P less than 0.0001) increases of 57% and 42%, respectively, over the non-pregnant state.

Laser treatment for tracheobronchial tumours: local or general anaesthesia?

Ninety seven patients with tracheobronchial tumours have been treated with the neodymium yttrium-aluminium-garnet (Nd YAG) laser over a period of 33 months. Fifty one of these patients were treated under local anaesthesia and 46 under general anaesthesia. The results obtained with the two methods have been compared retrospectively. The numbers of patients responding to treatment, the magnitude of the response, and the duration of palliation were similar in the two groups; significantly more treatment sessions, however, were required during each course of treatment under local anaesthesia. This advantage of general anaesthesia was thought to arise from the ability to continue treatment for longer and with greater efficiency. The use of the rigid bronchoscope with jet ventilation under general anaesthesia was also thought to provide better control of the airway and to allow more efficient clearance of blood and mucus. Two operative deaths occurred under local anaesthesia, when bleeding led to asphyxiation, but none have occurred under general anaesthesia. Treatment under general anaesthesia is not, however, without risk and is potentially hazardous in patients with severe chronic hypoxic lung disease.

Role of the neodymium YAG laser in the management of tracheal tumours.

Twenty one patients with tracheal tumours (10 primary and 11 secondary) have been treated with the neodymium YAG laser under general anaesthesia. Fourteen of these patients presented with impending asphyxia and in 11 cases this was dramatically relieved with emergency laser treatment. The improvements in peak expiratory flow (PEF) ranged from 26% to 512%. The three patients who did not respond were immediately given other treatments but died in hospital. The remaining seven patients were not in severe respiratory distress and were treated electively; all were thought to have benefited from their treatment, the mean increase in PEF being 36%. The improvement obtained in the 11 patients who responded to emergency laser treatment provided time in which to assess the disease carefully and plan the most appropriate longer term management with surgery, radiotherapy, tracheal stenting, or repeat laser treatment. The patients who were treated electively have either not required further treatment of have been managed with repeat laser treatments alone. Laser treatment provides an excellent method of resuscitating patients with life threatening tracheal obstruction and enables subsequent management to be carefully planned. In some cases this longer term management should be with further laser treatment alone.

Adverse reactions to intravenous codeine phosphate in children. A report of three cases.

Adverse reactions ranging from tachycardia and cutaneous vasodilatation to severe hypotension and apnoea occurred in three children who were given codeine phosphate intravenously. The cause of these reactions is discussed and a review of the literature on the parenteral use of codeine phosphate is presented. The findings indicate that the standard reference formularies and pharmacopeoiae, with one exception, deal inadequately with the parenteral use of codeine phosphate. On the evidence of the cases presented we would support the conclusion of the American Medical Association's drug evaluations, that codeine phosphate should not be used intravenously in children.