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The Roentgenographic Signs Of Expiratory-valve-like Bronchial Obstruction

Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery

The roentgenray signs in expiratory valve-like obstruction of a
bronchus are those of an acute obstructive emphysema (Fig. 74),
1. Greater transparency on the obstructed side (Iglauer).
2. Displacement of the heart to the free side (Iglauer).
3. Depression and flattening of the dome of the diaphragm on the
invaded side (Iglauer).
4. Limitation of the diaphragmatic excursion on the obstructed side

It is very important to note that, as discovered by Manges, the
differential emphysema occurs at the end of expiration and the plate
must be exposed at that time, before inspiration starts. He also noted
that at fluoroscopy the heart moved laterally toward the uninvaded
side during expiration.*

* Dr. Manges has developed such a high degree of skill in the
fluoroscopic diagnosis of non-opaque foreign bodies by the obstructive
emphysema they produce that he has located peanut kernels and other
vegetable substances with absolute accuracy and unfailing certainty in
dozens of cases at the Bronchoscopic Clinic.

[FIG. 74--Expiratory valve-like bronchial obstruction by
non-radiopaque foreign body, producing an acute obstructive emphysema.
Peanut kernel in right main bronchus. Note (a) depression of right
diaphragm; (b) displacement of heart and mediastinum to left; (c)
greater transparency of the invaded side. Ray-plate made by Willis F.

Complete bronchial obstruction shows a density over the whole area
the aeration and drainage of which has been cut off (Fig. 75).
Pulmonary abscess formation and drowned lung (accumulated secretion
in the bronchi and bronchioli) are shown by the definite shadows
produced (Fig. 76).

[140] Dense and metallic objects will usually be readily seen in the
roentgenograms and fluoroscope, but many foreign bodies are of a
nature which will produce no shadow; the roentgenologist should,
therefore, be prepared to interpret the pulmonary pathology, and
should not dismiss the case as negative for foreign body because one
is not seen. Even metallic objects are in rare cases exceedingly
difficult to demonstrate.

[FIG. 75.--Radiograph showing pathology resulting from complete
obstruction of a bronchus with atelectasis and drowned lung resulting.
Foot of an alarm clock in left bronchus of 4 year old child. Present
25 days. Plate made by Johnston and Grier.]

Positive Films of the Tracheo-bronchial Tree as an Aid to
Localization.--In order to localize the bronchus invaded by a small
foreign body the positive film is laid over the negative of the
patient showing the foreign body. The shadow of the foreign body will
then show through the overlying positive film. These positive films
are made in twelve sizes, and the size selected should be that
corresponding to the size of the patient as shown by the
roentgenograph. The dome of the diaphragm and the dome of the pleura
are taken as visceral landmarks for placing the positive films which
have lines indicating these levels. If the shadow of the foreign body
be faint it may be strengthened by an ink mark on the
uncoated side of the plate.

[FIG. 76.--Partial bronchial obstruction for long period of time
Pathology, bronchiectasis and pulmonary abscess, produced by the
presence for 4 years of a nail in the left lung of a boy of 10 years]

Bronchial mapping is readily accomplished by the author's method of
endobronchial insufflation of a roentgenopaque inert powder such as
bismuth subnitrate or subcarbonate (Fig. 77). The roentgenopaque
substance may be injected in a fluid mixture if preferred, but the
walls are better outlined with the powder (Fig. 77).

[FIG. 77.--Roentgenogram showing the author's method of bronchial
mapping or lung-mapping by the bronchoscopic introduction of opaque
substances (in this instance powdered bismuth subnitrate) into the
lung of the patient. Plate made by David R. Bowen. (Illustration,
strengthened for reproduction, is from author's article in American
Journal of Roentgenology, Oct., 1918.)]

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