Intratracheal Atomization in the Treatment of Infectious

Intratracheal
Atomization
Infectious
Diseases
in
of
the
PEDRO
LUIS
de
M. LOTT,
M.D.,
F.A.P.H.
treatment
with
of
aerosols
has
due
in
are
used
for
condensed
fine
and
in
small
The
to
this
we
the
System
and
pulmonary
Harold
Technical
Therapy
and
VIII,
recommends
the
general
where
We
the
de
We
ary
Vias
and
Tests
years,
particles
outflow
diameter.
on
1942)
few
nebulizers
of droplets
July
aspiration
are
of
much
very
thicker
Mucosography
of
that
these
the
terminal
The
Bronchi
with
(New
England
use
the
our
droplets
bronchi
anesthesia
to
the
be
used
was
used,
system
of Tuberculosis
Havana
(Instituto
Doctor
presented
of
our
could
its
the
pulmonlungs,
Investigation
this
method
considered,
and
of
A. Antonetti).
different
abscess
of
first
part
conditions
solution
Center,
atomization
respiratory
of
Profesor
The
what
of
used.
Department
University
del
reference
Medical
the
be
patients
who
as bronchiectasis,
etc.
under
of
should
General
work
on
his
Special
technique
diseases
liquids
Servicio
of
of
in the
of the
the
lungs,
to prove
the
Commanding
Service,
in
and
the
tolerance
volume
by
the
tract.
were
performed
with
penicillin,
peroxide
and
sulfa
drugs.
Finally
the
first
series
of applications,
action
and
Its known
tolerance.
Direct
last
thick
the
in
works
tract
present,
Peroxide
of
of
Respiratorias,
concentration
bronchial
outflow
our
Staff
of
Warfare
the
selected
a group
of
suppurations
such
applied.
an
Lung
our
studies
of Medicine
gangrene
of
was
directed
be
the
Hydrogen
amounts
began
Faculty
the
only
micra
(Radiology,
pulmonary
treatment
great
the
At
which
in
respiratory
during
allowing
than
two
of the
Chemical
of
to Penicillin
1946),
M.D.
alveoli.
A. Abramson
Division,
Aerosol
in
cause
the
antibiotics.
in
demonstrated
F.C.C.P.,
REVUELTA,
of
popular
of
procedure
sprayers
have
the Respiratory
reach
by gravity
and
use
the
apparatus
particles,
less
common
and
diseases
quite
the
RENE
Cuba
infectious
become
particular
M.D.,
and
Havana,
The
System
F.C.C.P.,
BUSTAMANTE,
M.D.,
of
Report
L. FARIAS,
SUAREZ
Treatment
Respiratory
Preliminary
0.
the
examination
was
made
of
546
Downloaded From: http://journal.publications.chestnet.org/ on 11/17/2016
streptomycin,
we decided
bearing
in
the
patients
hydrogen
to use penicillin
mind
its
antibiotic
sputum
from
in
the
Volume
XV
INTRATRACHEAL
bacteriological
in
to
point
all the
cases.
demonstrate
the
blood.
of
the
Cultures
determinations
conditions
antibiotics
in the
of
by
therapy
view.
of
sputum.
were
out
routinely
series
were
performed
of the
antibiotics
made
absorption,
were
carried
in
for
the
retention
Comparative
inhalation
547
were
Several
determinations
the
levels
or concentrations
Other
studying
ATOMIZATION
or
studies
purpose
of
elimination
with
other
in
of
methods
made.
Technique
The
one.
technique
We
the
end
(Fig.
1)
we
and
atomization
sprayer
that
gives
may
be placed
easily
in
or in the
trachea
under
is very
obtained.
start
the
intratracheal
a long
designed
sults
We
of
take
our
satisfactory
procedure
trachea
by
During
the
atomization
lean
inhale
towards
strongly
the
FIGURE
in
1:
side
order
The
of
atomizer
Downloaded From: http://journal.publications.chestnet.org/ on 11/17/2016
we
are
the
of
1/2
in the
larynx
above
with
pharynx,
per
cent
the
the
re-
larynx
pantocaine.
have
treat
and
the trachea
difficult
the epiglottis
The
apparatus
the
we
to
a
atomization,
pleased
pantocaine
are
going
anesthetize
not
fine
behind
cords.
anesthetizing
a solution
we
to
is
very
the larynx,
the
vocal
and
by
spraying
a
the
we
and
Vocal
patient
have
the
cords.
him
bron-
548
PEDRO
chial
tract
on
anesthesia
and
side.
is well
then
for
that
After
to
technique.
in
a straight
body
completely
spray
bent
to
the
segment
atomization
the
ponding
to
and
must
to
cough.
upper
to
the
placed
position
The
quantity
of
diseases
the
the
as
be
the
pulmonary
after
is
always
two
of
the
located
used
varies
or
the
corres-
trying
used,
one
and
Right
lesion
solution
the
treat,
possible
substance
in
to
be
and
position
the
long
to
is placed
on
the
blood,
sputum
The
this
of
period
disappeared
zones
of
develops.
eter
of
done
Petri
not
for
the
according
20
cc.
of
an
minutes.
1/10.
the
surface
or
Petri
time
of
the
with
the
it
agar.
to
for
in
the
through
the
culture
the
in
agar.
We observed
the
dish
where
no
our studies
100 units
of
hours,
the
after
rings
determine
the
demonstrates
a zone
antibiotic
of
has
circular
bacteria
diamthe
24 millimeters
in each
100
cc.
examined.
pertinent
studies,
action
in
and
numbers
of the
millimeter
per
In
to
24
of
with
antibiotic
are
inside
we
filled
for
liquid
antibiotic
action.
corresponds
antibiotic
graphs
expressed
are
tested
refrigerated
the
refrigerator,
the
With
a millimeter
crystal
ruler
we
the
zone
of inhibition.
This
diameter
material
in
rings
be
of
Washington)
hours
The
secretions
have
medium,
dishes
all
by difussion
Inhibition
of
extent
of
of inhibition
agar
from
24
we
determination
technique
solid
received
keeping
other
The
following
(strains
After
sputum
medium.
dishes
aureus
diluted
properties.
culture
was
in
It
action
going
special
control
as
action
investigators:
culture
on
the
sprayed
blood-agar
staphylococcus
whole
figures
be
bacteriological
cent
antibiotic
Oxford
All
a
spray
trachea,
up
to
should
the
and
may
exact
5 per
the
our
of
are
treatment.
as
adopted
the
straight
where
position
the
trachea
have
in
according
in
that
the
with
an air compressor
The
patient
must
we
segments
this
we
placed
head
the
so
in
1949
Investigations:
For
of
back
is
in
Laboratory
add
the
patient
pulmonary
solution
side
of
the
kind
the
minutes
solution
tube
pounds.
the
object
remain
lobe.
used
to
May,
sprayer
is
with
the
Trendelemburg’s
aqueous
of
or
is
the
to a rubber
or seven
towards
front
which
our
sprayer
position
AL
a few
place
with
the
six
bent
ET
waiting
we
Before
its container
is connected
allowing
a pressure
of
seated
FARIfiAS,
established,
commence
this
L.
units
in
units
per
this
cc.
each
of
the
Downloaded From: http://journal.publications.chestnet.org/ on 11/17/2016
with
per
each
way
which
are
older
method.
paper,
100
starting
in
100
the
those
cubic
cc., as
antibiotic
easier
to
Accordingly,
millimeter
material
action
handle
all
equals
tested
of
Fleming,
centimeter.
all humoral
express
We present
indexes
are
is
expressed
than
the
decimal
our graphs
are made
one
(blood,
unit
sputum,
of
antibiotic
etc.).
in
INTRATRACHEAL
xv
Volume
Clinical
549
ATOMIZATION
Considerations:
The
cases
selected
were
patients
who
formerly
had
received
oral
medication
or antibiotics
administered
parenterally.
During
the trial
of this
method,
intratracheal
crystalline
penicillin
was
used
exclusively.
any
other
Among
the
pital
for
diagnosis
of the
other
cases
in the
abscess
an
antibiotic
sulfa
chial
secretions
selected,
middle
lobe
operation.
of
lung,
with
and
No
lung
high
There
which
purulent.
The
bronchial
in
solutions
application
following
of
lesions.
by our
maximal
morphine
method,
doses
was
been
made
penicillin
was
no
was
employed
at
a
definite
treatments
with
in
quite
pharyngeal
by
giving
atropine.
the
the
24 hours
day,
had
and
and
using
In each
reflex.
previously
Following
no
of
We
an
the
bloody
anemia
most
aggravating
not
show
tracheowere
noticed
obviated
injection
second
to
given
crystalline
application
We
bron-
were
moderate
a
did
saline.
hos-
hospital
amount
applications
every
with
the
suspecting
an abscess
given
simultaneously
toxic,
at night
examination
neoplasm
entered
to
in
cc.
Intratracheal
one
a
who
and
were
reduction
300
of 400,000
units
15 to 20 cc. of isotonic
of
lung
admission
had
of
patient
had
right
his
reached
Five
patient
the
Before
tumor
doses
drugs.
one
of
with
much
cough,
especially
dyspnea.
The
bronchoscopic
him
medication
time.
penicillin
and
the
in
this
of
in
first
in the
1.0 mg.
application,
the continuous
coughing
of the patient
was relieved,
the expectoration
began
to diminish
and at the end of the fourth
application it had come
down
to 15 cc. in 24 hours.
The patient’s
general
condition
Improved
and his recovery
was maintained
for several
weeks,
when
refusing
surgical
intervention,
he left the hospital.
In bronchiectasls
toration
in 24 hours
we have
observed
with
a modification
quick
of
reduction
of
the bacterial
expecflora.
The graphic
curve
of concentration
of antibiotic
of sputum
and
blood
simultaneously
obtained
in this group
have
been
very Interesting.
We observed
that
the concentration
of antibiotic
In the
blood
was
maintained
during
the
first
eight
hours,
fluctuating
between
15 and
2 units
per each
100 cc. In the sputum,
in the
same
number
of hours,
the antibiotic
action
fluctuated
between
125 and
35 units
per
each
100 cc. In case
number
5 (FIg.
2),
multiple
bronchiectasis
of both
lung
bases,
using
always
300,000
units
of penicillin
at a time,
with
our method
a remarkable
difference
has been
observed
in the levels
simultaneously
obtained
from
sputum
and blood.
In case
number
2 (Fig.
3), abscess
of the vertex
of the lower
lobe
of the left lung
cleared
promptly
under
the effect
of our
treatment.
This
case,
a 31 year
old farmer,
with
a lung
affection
Downloaded From: http://journal.publications.chestnet.org/ on 11/17/2016
550
PEDRO
L.
FARI1AS,
ET
AL
May,
1949
-4
.3,
4
.
.
.
.t
.:j00E
-.4
-1
.0“3
“3
C)
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n
I
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E
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ri
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Downloaded From: http://journal.publications.chestnet.org/ on 11/17/2016
4
Volume
XV
INTRATRACHEAL
of seven
months’
duration,
high
temperature,
with
asthenia,
month
of
was
characterized
coughing,
loss
Illness
parenterally,
with
examination
showed
abundant
of
energy
sulfa
drugs
no
551
ATOMIZATION
and
by pain
anorexia.
were
given
improvement
in the flank,
purulent
expectoration,
During
orally
and
in his condition.
a noticeable
oral
his
penicillin
The
sepsis, “watch
second
physical
glass”
and a condensation
syndrome
at the left-scapular-vertebral
with
several
subcrepitant
rales. Mucopurulent
sputum
numerous
pyogenlc
staphylococcus
cocci.
aureus.
Its culture
There
was
revealed
slight
young
cells predominating.
On
ination
we
found
very
originating
lower
lobe
In
secretions
presence
anemia,
leucocytes,
fetid
the
nails
zone,
showed
with
of
15,000
bronchoscopic
exam-
from
the
left
bronchi.
all, twenty-five
intratracheal
applications
were
made
in this
case, with maximum
dose of 400,000 units of penicillin in a solution of 5 cc. of isotonic saline. After the fourth
application
we
noticed
was
that
the
expectoration
less, his appetite
application
applications
coughing,
the
and
patient
his
fever
general
weight.
Nothing
important
tion of the chest. In the
of
tion
the
contrast
(Fig.
catarrahlis
medium
4). In
the
cocci
were
FIGURE
and
condition
asthenia
coughing
condition
felt better
general
and
diminished,
was
had
improved.
at the
good.
ceased.
used
in
the
culture
observable
Fig.
5: One month
first 20
expectoration,
had
his
normal
of the
examina-
patient’s
sputum
(Fig. 5). Concentration
appex
later: Complete
of
the
left
lower
only
of peni-
5
FIGURE
abscess
Downloaded From: http://journal.publications.chestnet.org/ on 11/17/2016
every
bronchographic
of the
4
4: Pulmonary
After
of the
His
He
night
was noticed
in the physical
examinax-ray
picture
we only observed
traces
final
Fig.
end
at
lobe.
resorption of the process.
552
PEDRO
L.
cillin in the blood
and
to those
in our former
described
in the hospital
ing
any
infection.
sputum
for several
further
clinical
FARIRAS,
curves
SUMMARY
during
May,
AL
treatment
observation.
weeks
or
ET
after
without
made
daily
3) We preferred
crystalline
erated;
the volume
used has
advantage,
for it delays
the
pharyngeal
irritation.
with
kept
observ-
of
the
CONCLUSIONS
2) ThIs preliminary
report
covers
a group
of cases
penicillin
which
we have
used in different
concentrations,
100,000
and 500,000
units
disolved
in isotonic
saline
was
similar
was
manifestations
1) We have
used a technique
developed
by us for
of the respiratory
tract
and applied
to the treatment
tive diseases
of the lung.
application
of penicillin.
was
patient
treatment,
radiographic
AND
This
1949
progressive
increase
mucosography
of suppuratreated
with
between
solution.
The
in the
doses
penicillin
because
it is better
tolbeen
5 cc. Larger
amounts
show
no
method,
and
the patient
develops
4) It is an easy method
to use, with
the patient.
The amount
of anesthesia
ization
of 2 cc. of 1/2 per cent pantocain
some
patients
we have
sprayed
without
good tolerance.
no risk or disturbance
to
used
is very
small,
atomsolution
is sufficient.
In
anesthesia,
and
noticed
5) We perform
the atomization
continuously.
That
is, In both
phases
of respiration,
in order
that
the patient
may
keep
open
the glottis
to avoid
coughing
and pharyngeal
contractions.
6)
fer
We have
used
the supreglottic
FIGURE
the supra
technique
6: Petri.dishes
and infraglottic
technique.
We
because
it is better
tolerated.
showing
the different intensity
action of sputum and blood.
Downloaded From: http://journal.publications.chestnet.org/ on 11/17/2016
pre-
of the antibiotic
Volume
7)
XV
The
INTRATRACHEAL
results
obtained
succeeded
in improving
some
of which
were
having
been
previously
and
sulfa
553
ATOMIZATION
are
definately
encouraging.
and
curing
suppurative
of more
than
six
month’s
treated
without
success
We
have
lung
conditions
duration
and
with
penicillin
drugs.
8) It is Interesting
to point
out that
the simultaneous
study
of
sputum
and
blood
in our patients
shows
high
antibiotic
action
in the sputum
and quite
low antibiotic
action
in the blood.
It is
easy to see in our graphs
that
the antibiotic
action
of the sputum
fluctuates
between
130 units
as maximum
and 40 units
as minimum,
the antibiotic
action
of the
blood
fluctuates
between
30
units
as maximum
and 2 units
as minimum.
These
facts
to explain:
bring
forth
(a) Does
the high
represent
the whole
any other
antibiotic
(b) Does
acumulative
certain
questions
which
bacteriostatic
penicillin
action?
power
concentration
found
or
the high
bacteriostatic
or eliminative
action?
action
(c) Do proteins
of the expectoration
have
anything
to do with the “delayed
the penicillin
deposited
in the bronchi?
9)
tance
The results
obtained
of the topical
action
10) Finally,
monary
area
of the drug
other
method
Atomizer
FIGURE
with
this
the highest
used,
which,
of Inhalation
described
7:
Petri
point
toward
of antibiotics.
try
in the sputum
is it related
to
found
correspond
(mucins,
mucolds,
effect”
in connection
the
shall
extraordinary
to
etc.),
with
impor-
method
we can direct
to a certain
pulpercentage
in volume
and concentration
to our belief
Is not obtainable
by any
used up to the present
moment.
manufactured
dishes
we
by
the
DeVllbiss
Company.
showing
the different intensity of the antibiotic
action of sputum and blood.
Downloaded From: http://journal.publications.chestnet.org/ on 11/17/2016
554
PEDRO
L.
RESUMEN
1) Hemos
empleado
la mucosografia
una
tratado
unidades
Se
aplicO
respiratorio
May,
por nosotros
y aplicada
para
al tratamiento
incluye
un
grupo
de casos
en concentraciones
de 100,000
una soluciOn
isotOnica
de cloruro
el tratamiento
1949
del pulmOn.
preliminar
con peniciina
disueltas
en
AL
t#{233}cnica
perfeccionada
supuradas
2) Este informe
ET
CONCLUSIONES
Y
del aparato
de las enfermedades
FARIfAS,
diariamente,
con
aumento
que
hemos
a 500,000
de sodio.
progresivo
en
la dosis de penicilina.
3) Preferimos
Se
ha
usado
ofrecen
volumen
ventaja,
irritaciOn
4) Es
la penicilina
un
pues
cristalina
de
porque
es m#{225}s
tolerable.
5 cc. Cantidades
demoran
m#{225}s
grandes
el m#{233}todoy el paciente
un
m#{233}todof#{225}cil
de usar
al paciente.
Es
que
muy
no
tiene
pequefla
la
tesia a algunos
pacientes
5) Ejecutamos
fases
y lo han
la pulverizaciOn
de la respiraciOn,
glotis abierta
para
evitar
6) Hemos
empleado
soportado
peligro
cantidad
t#{233}sico
empleada,
es suficiente
la pulverizaciOn
soluciOn de pontocalna
al 0.5 por ciento. Hemos
ferimos
de
farlngea.
desasosiego
dos
no
sufre
bien.
es decir, en
el paciente
mantenga
la tos y las contracciones
la t#{233}cnica
supraglOtica
la t#{233}cnica
supraglOtica
porque
e infraglOtica.
es ms
algunos
meses
y
penicilina
hablan
sido tratados
y sulfonamidas.
de
8) Es Interesante
los cuales
indicar
simult#{225}neodel esputo
y de
hablan
en
existido
sin
nuestros
la sangre
la
Pre-
tolerable.
previamente
que,
las
faringeas.
7) Los
resultados
obtenidos
son definitivamente
Hemos
logrado
la mejorla
o la curaciOn
en estados
pulmOn,
anes-
de 2 cc. de una
rociado
sin anes-
continuamente,
a fin de que
ni causa
de
alentadores.
supurados
del
m#{225}sde
por
buen
pacientes,
demostrO
una
el estudio
acciOn
biOtica elevada
en el esputo
y una
acciOn
antibiOtica
baja en la sangre. Se puede
ver en nuestras
gr#{225}ficas
que
antibiOtica
del esputo
fluctUa
entre
130 unidades
y 40 unidades
como
minimo,
y la acciOn
antibiOtica
flucta
entre
30 unidades
como
m#{225}xlmo y 2
seis
#{233}xito
con
anti-
bastante
la acciOn
como
m#{226}ximo
de la sangre
unidades
como
minimo.
Estos
hechos
sugieren
ciertas
preguntas
que
trataremos
de
contestar:
(a)
,Representa
la entera
alguna
(b)
acciOn
el elevado
concentraciOn
otra
acciOn
Corresponde
acumulativa
poder
bacteriost#{225}ticodel
de la penicilina,
esputo
o est#{225}
relacionado
con
antibiOtica?
la elevada
o eliminativa?
Downloaded From: http://journal.publications.chestnet.org/ on 11/17/2016
acciOn
bacteriost#{225}tica
a
una
Volume
INTRATRACHEAL
XV
que ver las proteinas
etc.) con el “efecto
(C)
Tienen
algo
(mucinas,
mucoides,
china
9) Los
portancia
depositada
resultados
en
10) Finalmente,
con
pulmonar
el porcentaje
de la droga
empleada,
#{149}
medlante
ningun
otro
tualidad.
de
la
demorado”
expectoraciOn
de la peni-
los bronquios?
obtenidos
de la acciOn
555
ATOMIZATION
tOpica
demuestran
la extraordinaria
im-
de los antibiOticos.
este
m#{233}todo podemos
aplicar
a una zona
m#{225}s
alto, en volumen
y en concentraciOn,
lo que, en nuestra
opiniOn,
no es obtenible
m#{233}todo de InhalaciOn
usado
hasta
la ac-
Downloaded From: http://journal.publications.chestnet.org/ on 11/17/2016