Karl E. Karlson

Respiratory Mechanics Following Open-Heart Surgery for Acquired Valvular Disease

1. Pulmonary mechanics were determined preoperatively and postoperatively in 20 patients following open-heart surgery for acquired valvular disease.2. The surviving patients had minimal increase of the work of breathing, associated with an increase in nonelastic resistance during the early postoperative period. These changes in pulmonary mechanics are insufficient to explain the respiratory difficulties experienced by these patients.3. In the fatal cases compliance decreased to half the preoperative level, and respiratory work increased to five times the preoperative value. In these individuals excessive work of breathing produces a significant demand on physiological resources, and controlled mechanical ventilation is indicated.

Severe blunt chest trauma. Studies of pulmonary mechanics and blood gases.

here has been considerable interest in the past few years in the clinical management of severe closed thoracic trauma, comT monly called crushed chest. This interest is justified by the increasing number of automobile accidents, bringing more of these patients to the hospitals, and by the high mortality and morbidity associated with these injuries. Emphasis has been placed on the extent of the bony injury, paradoxical respiration of the flail chest, and control of the deleterious effects of paradoxical respiration by traction, internal fixation, tracheostomy, and positive pressure ventilation [l, 2, 6, 10-121. The prognosis after blunt trauma to the chest has been greatly improved with this type of management. However, little attention had been paid to the traumatized lungs and the effect of lung injury upon the respiratory

Valvular Heart Disease: Comprehensive Evaluation and Management

DR. GRILLO: Dr. Pearson, thank you for your remarks. They are very pertinent, and I think you have underlined the important points very strongly and well. The question of later laryngectomy did not come up in any of the patients having resection. That has surprised and pleased us. All patients who died except 1 did so without airway problems. One required tracheostomy shortly before death. Two of the patients in the exenteration group did not have laryngectomy initially. We thought we might later reconstruct the trachea in stages. One died, and it was not feasible in the other. Dr. Kirschner, bronchoscopic management of thyroid cancer is certainly an option. I didn’t mention in this brief presentation that there were also 9 patients who had unresectable invasion of the airway. Some were managed by palliative coring out of the trachea. Nowadays you can use a laser, but that isn’t really better than coring out, if you know how to do it. It takes a shorter time and costs less to do with a rigid bronchoscope than with a laser. Many of our patients had already had I3’I ablation. It causes residual thyroid tissue to not function and works variably against cancer. In some cases it doesn’t really touch the cancer, but it is certainly part of the total armamentarium for dealing with these diseases. In general, we have obtained longer and better palliation by resecting the airway lesion when possible. I shall again confirm what Dr. Pearson said, that if done by a knowledgeable surgeon at the time of the original resection, little is added to the extent of the operation because everything has been dissected out by that point. I did not dwell on it, but I believe there is a place for radical resection of anaplastic cancers of the thyroid, which are generally considered to be inoperable lesions. The candidates have to be selected well. If you carefully scan the literature and look at this experience, there are clearly some who can be palliated by radical resection and possibly even cured.