BRONCHOGRAPHY (a bronchial tube [i] + grapho to write, represent) — X-ray inspection of bronchial tubes and to a lesser extent a trachea after preliminary filling of their gleam with a contrast agent by means of series of roentgenograms.
Bronkhografichesky researches at the person for the first time executed Jackson (Ch. Jackson, 1918) and Veyngertner (M. Weingartner). They received the image of a tracheobronchial tree by means of inflation via the bronchoscope of powders of bismuth and oxyhydrate of thorium. Widely began to apply B. in diagnosis Sikar and Forestye (J. Sicard, J. Forestier, 1922) who used lipiodolum as a contrast agent. The first experimental and clinical experiments on B.'s carrying out in the USSR were described by S. A. Reynberg and Ya. B. Kaplan (1924).
B. is carried out for specification of topical diagnosis of bronchopulmonary process at various diseases of bronchial tubes, lungs and mediastinums (malformations, damages and hron, diseases of bronchial tubes and lungs when clinical and usual radiological data are insufficient for specification of the diagnosis). In particular B. is important for a research of those departments of a bronchial tree which are unavailable or inaccessible for survey at bronkhoskopiya (see), and also during the scoping of the forthcoming surgical intervention on lungs.
B. it is contraindicated at intolerance of iodide drugs, at a serious illness of internals (e.g., dekompensirovanny damages of heart, liver, kidneys), acute inflammatory respiratory diseases, pulmonary bleedings, acute infectious and serious mental diseases.
At serious condition of the patient the issue of B.'s possibility shall be resolved individually.
Training of the patient
Training of the patient for B. includes preliminary assay on individual portability of iodide drugs, and also an explanation to the patient of the purpose and essence of the forthcoming research. At considerable department of a purulent phlegm in 3 — 4 days prior to a research actions for clarification of a bronchial tree are recommended: a drainage of bronchial tubes the relevant provision of the patient in beds, xerophagia, expectorant and bronchodilatory means, at the corresponding indications — antibiotics parenterally and vnutribronkhialno, a sanatsionny bronkhoskopiya.
In 30 — 60 min. prior to B. carry out premedication: phenobarbital (0,1 g) and atropine subcutaneously (1,0 ml of 0,1% of solution); according to indications appoint Seduxenum, Pipolphenum, a cortisone.
Depending on diagnostic problems and features of a specific case apply an anesthesia or local anesthesia. The anesthesia facilitates B.'s carrying out at children and patients with a labile nervous system; provides a possibility of a complex bronkhologichesky research — a combination of a bronkhoskopiya and B., a toilet of a bronchial tree before administration of contrast medium that increases quality bronkhogramm. B. it is under anesthetic shown to patients with widespread processes in lungs, at respiratory insufficiency and in the early postoperative period. At the same time B.'s carrying out under anesthetic requires the special equipment and anesthesiology crew; receiving bronkhogramm in two projections is under anesthetic complicated and the functional research of air-conducting ways is impossible.
The main anesthesiology principle of subnarcotic B. consists in a combination of a superficial anesthesia, a full muscular relaxation and artificial ventilation of the lungs.
For the main anesthesia use Trilenum, Ftorotanum (flyuotan), nitrous oxide. Artificial ventilation of the lungs is carried out at all stages, stopping it only for the period of X-ray shooting.
B. under local anesthesia simplicity of a technique and a minimum of technical means distinguishes that allows to use it in the conditions of small hospital and policlinic. At the same time spontaneous breath of the patient and contact with it remains during the research that provides ease of polyposition observation, a possibility of «planimetric» contrasting and reproduction of respiratory tests during B. (a breath, an exhalation, the forced exhalation, cough). Apply 2% to local anesthesia solution of Dicainum, 3 — 5% solution of cocaine or 5 — 10% solution of novocaine. Because of a possibility of intoxication it is recommended to use these solutions in mix, e.g., with adegony which liquefies a phlegm, promotes the best contact of anesthetic with a mucous membrane and by that to reduction of a dose of the last by 25 — 30%. Insignificant toxicity, long and more expressed, than novocaine, anesthetic effect possesses 1% solution of a xycain (lignocainum, xylocainum, xylotonum, lidocaine etc.).
Anesthesia can be carried out by greasing, spraying and aspiration. The way of greasing is almost not used. Anesthesia spraying demands the special device — the sprayer operating by the principle of a spray. The most physiologic and simple is the aspiration way, at Krom the anesthetizing substance is entered through a nose during a deep breath by means of a pipette or a slow dropping on a root of language with the subsequent inhalation of drug via the probe for anesthesia of bifurcation of a trachea and large bronchial tubes.
the contrast agents Applied to B. on physical. - to chemical properties are subdivided into powdery, oil, viscous water suspensions, viscous water-soluble contrast agents. The powdery and oil emulsions of salts of heavy metals brominated and the iodated oils (napr, Iodolipolum) in pure form in a crust, time do not use. Yodo-maslyanye connections do not irritate a mucous membrane of bronchial tubes and have big contrast, but owing to small viscosity quickly get into alveoluses where, it is long being late, cause development of paraffinomas and fibrosis. Therefore use more viscous drug sulfoyodol — a suspension of sulfanamide powder in Iodolipolum (3 — 4 g of Norsulfazolum on 10 ml Iodolipolum and). Oil suspension of iodinated organic compound of a propilyodon (dionosil) belongs to oil contrast agents; 60% oil suspension of a propilyodon has good contrast, does not cause an iodism, however has small viscosity and quite often causes lipoid pneumonia. Viscous water suspensions of salts of heavy metals — salts of barium, bismuth in aqueous solutions of carboxymethylcellulose and gelatin find very limited application. Carboxymethylcellulose is late in lungs and leads to emergence of granulomas. Viscous water suspensions of iodinated organic compounds, mixing up with a bronchial secret, give clearer picture of bronchial tubes, than oil drugs, rather seldom get into alveoluses.
In the USSR aqueous slurries of a propilyodon — bronkhodiagnostin-1 and bronkhodiagnostin-2 in which as a viscous basis solutions of synthetic blood substitutes — polyvinylpirrolidone and Polyglucinum are applied are developed. These contrast mediums of a malotoksichna, give bronkhogramma of high quality and are quickly removed from an organism. Viscous water-soluble contrast agents are mix of various water soluble chemical compounds of iodine with colloidal solution of cellulose, dry human plasma, glucose, gelatinous.
The USSR applies zheliodon — sol gelatin (5,0 g dry food gelatin) in aqueous solution of Cardiotrastum (20 ml of 50% of solution). Zheliodon possesses irritant action on a mucous membrane, demands heating before the use, has non-standard viscosity, however sufficient contrast, bystry and full removal from an organism is favourably distinguished zheliodon from other viscous water-soluble contrast mediums. The mixed drugs find also application: bariyodol, barium-sulfoyodol, propilyodon-barium and others, differing in big contrast. Developments on receiving contrast agents for B. which are in an aerosol state are conducted.
There are three main kinds of B.: 1) bilateral — single-step or consecutive in the course of one research, 2) unilateral, 3) aim (segmented, directed, the selection).
enter the Contrast agent into a bronchial tree chrezgortanny, epiglottidean or subguttural in the ways. The subguttural transtracheal puncture with introduction of a catheter has extremely limited use — only at impossibility of performance of B. by other ways. The epiglottidean way B. by a transoral and transnasal instillation of a contrast agent on a breath also lost value. The epiglottidean inhalation way B. bribes the simplicity and physiology. At the same time a contrast agent is entered by means of the aerosol sprayer.
The greatest use was received by chrezgortanny ways B. with introduction of a catheter transnazalno or transorally. The technique of transnasal introduction of a catheter (fig. 1) is most widespread, simple and available. At a transoral chrezgortanny way the catheter is entered via the bronchoscope, an endotracheal tube (it is better dvukhprosvetny) or a dvukhprosvetny tube of Karlens. These methodical receptions use at subnarcotic B. with the managed breath. The Dvukhprosvetny endotracheal tube prevents flowing of a contrast agent in an opposite lung, and the dvukhprosvetny tube of Karlens which use is possible also under local anesthesia allows besides to aspirate contents of bronchial tubes to p after contrasting.
A contrast agent can come to these or those departments of a bronchial tree by change of position of a body of the patient, flowing down in a certain direction owing to the weight (position B.), or by separate filling under pressure of previously kateterizirovanny bronchial tubes (aim B.). In practice sometimes use a combination aim and position B.
Use special sets of semi-elastic rubber probes which tips are bent under various corners corresponding to corners of an otkhozhdeniye of separate bronchial tubes (probes of Meter) to aim filling of bronchial tubes. A step forward was the idea of the catheters managed by means of thread (Rozenshtraukh's catheters, Rozenshtraukh — Smulevich), the Crimea at the right time under roentgenoscopic control it is possible to give a necessary bend (fig. 2). At a pandiculation for the thread removed outside the tip of a catheter can be bent and by rotation is sent to this or that bronchial tube (fig. 3). In recent years the managed catheters made of the transparent plasts containing the radiopaque substance concentrated in the form of a fine end in a wall of a catheter enter practice.
On the nature of filling of air-conducting ways distinguish hard and planimetric contrasting. At planimetric a contrast agent covers with a pellicle walls of bronchial tubes which gleam remains free for breath. It more physiologically and more stoutly reflects details of an inner surface of bronchial tubes. For planimetric contrasting aspiration B.'s method when a contrast agent moves in the small portions on a breath in a gleam of a bronchial tree is offered. Apply so-called trailer B. for which the contrast agents like zheliodon which entirely are removed from lungs are suitable to a research of the smallest branchings of a bronchial tree.
The direction of the probe, filling of bronchial tubes and their further research carry out under control of usual or television roentgenoscopy. In the course of B. make survey and aim roentgenograms of a bronchial tree in various projections. If necessary apply a bronkhotomografiya.
The X-ray analysis of a bronchial tree at its planimetric contrasting at height of a deep breath, exhalation and the forced exhalation allows to judge functionality of air-conducting ways. Detailed studying of function of bronchial tubes is possible with the help X-ray cinematographies (see) and the video magnetic record (see. Television in medicine ). The main attention should be paid to changes of diameter of bronchial tubes during respiratory tests. Normal during a breath bronchial tubes extend and extended, and at an exhalation there is a reduction of their diameter and length (fig. 4). At the same time equal outlines of bronchial trunks remain. The great influence on respiratory mobility of bronchial tubes is exerted by a tone of air-conducting ways. At increase in a tone reduction of amplitude of respiratory mobility of walls of bronchial tubes at the general narrowing of bronchial trunks is observed. Spasms of mouths of bronchial tubes are possible, spastic deformation of air-conducting ways, edges has segmented character and remains in an inspiratory phase. At hypotonia of bronchial tubes amplitude of respiratory mobility of walls of bronchial trunks increases: on a breath bronchial tubes it is excessive extend, and in an expiratory phase (the forced exhalation) there is a sharp rapprochement of walls, i.e. the exhaling valve stenosis forms.
Complications at B. can be connected with anesthesia, with reaction to administration of contrast medium and with a delay of the last in lungs. Patients with hypersensitivity to anesthetics, and also at overdose of the anesthetizing substances can have heavy toxic phenomena. At B. under local anesthesia, and also under anesthetic, especially at bilateral contrasting, the phenomena of a hypoxia and asphyxia can be observed. After B. the temperature increase caused by effect of contrast mediums and bronkhografichesky «stress» — reaction of an organism to intra bronchial manipulations is possible. During the use of oil contrast agents lipoid pneumonia and the phenomena of an iodism is sometimes observed. The long delay in lungs of oil drugs, particles of barium sulfate, carboxymethylcellulose leads to development of paraffinomas and fibrous changes. The accounting of contraindications, training of the patient, a right choice of a method of anesthesia and a contrast agent, appropriate maintaining B. allow to avoid complications.
A bronchography at children
The bronchography at children is important especially in connection with a possibility of early detection of malformations and acquired diseases of lungs and their timely surgical treatment. At B. children Armand-Delill and Darbua for the first time applied (P. Armand-Delille, J. Darbois, 1924). They entered a contrast agent into a trachea by its puncture in subguttural area, the research was carried out under local anesthesia. This technique was not widely adopted. Widespread introduction of B. in pediatric practice became possible only with development of methods of the general anesthesia. Performance by subnarcotic B. at children is most optimum.
There are techniques providing administration of contrast medium through a catheter at a bronkhoskopiya. However B.'s technique under an intratracheal anesthesia without roentgenoscopic control is the most sparing. The research is conducted on an empty stomach, in 30 — 40 min. prior to the beginning of B. enter atropine in an age dosage. Anesthesia — an intubation anesthesia with muscle relaxants. After a hyperventilation within 1 — 1,5 min. through an endotracheal tube in a trachea enter a catheter into time of an apnoea. The trachea with an endotracheal tube in a neck is displaced aside, opposite to that lung, to-rogo want to enter a catheter (fig. 5, 1 and 2) into a bronchial tube, and then the catheter is advanced in the corresponding bronchial tube against the stop, being guided by length of a trachea and bronchial tubes at children of various age. Finding of a catheter in the right or left primary bronchus is defined, attaching Richardson's cylinder to a catheter and forcing air; during the listening by a phonendoscope noise of the entered air is defined over the right or left half of a thorax (fig. 5, 3).
Filling with a contrast agent is begun with a bronchial tube of the lower share, then the catheter is tightened, continuing to enter a contrast agent. The patient lies on one side, on the studied party — in this situation do the first roentgenogram; the second roentgenogram is made in position of the child on spin. At the known skill the research of one lung takes no more than 2 — 3 min. A contrast agent from bronchial tubes is deleted with a suction machine. Carry out ventilation, then start a research of other lung.
It is more preferable to use water-soluble contrast mediums. The amount of contrast medium necessary for contrasting of bronchial tubes of one lung, it is possible to determine by the following scheme: 4 ml + age of the patient advanced in years. Enter a half of this quantity, the second half into a bronchial tube of the lower share — gradually in process of pulling up of a catheter. Distance, on a cut it is necessary to tighten a catheter, children till 1 year have 1,5 cm; 2 — 3 years — 2 cm; 4 — 7 years — 3 — 4 cm; 8 — 12 years — 5 — 7 cm; 13 — 15 years — 10 — 12 cm.
At B.'s performance by the described technique the complications connected with errors of an anesthesia, extraordinary lengthening of an apnoea, insufficient suction of the entered contrast agent sometimes are possible.
Bibliography: Zlydnikovd. M. Bronkhografiya, D., 1959, bibliogr.; Murom Yu. A. Clinical radioanatomy of a tracheobronchial tree, M., 1973, bibliogr.; Sokolov Yu. N. and Rozenshtraukh L. S. Bronchography, M., 1958, bibliogr.; With t r at the h to about in V. I. and Lokhvitsky S. V. Bronkhologicheskiye methods at diseases of lungs, M., 1972, bibliogr.; Feofilov G. L., Mukhin Ε. Item and Amirov F. F. Elected heads of a bronchography, Tashkent, 1971; In e s s 1 e of of W. T. and. R e n n e rR. R. Selective bronchography, Amer. J. Roentgenol., v. 83, p. 297, 1960; R i en z about S. u. W e b e r H. H. Radiologische Exploration des Bronchus, Stuttgart, 1960, Bibliogr.; StutzE. u. V i e t e n H. Die Bronchographie, Stuttgart, 1955, Bibliogr.
B. at children — Klimanskaya E. V. Fundamentals of children's bronchology, M., 1972, bibliogr.; Klimansky V. A. A bronchography at children, M., 1964; Special methods of a research in surgery of children's age and bordering limits, under the editorship of S. Ya. Doletsky, page 55, M., 1970; And-m of a n d - D e 1 i 1 1 e P. e. a. Le diagnostic radiologique de la dilatation bronchique chez l’enfant au moyen des injections de lipiodol, J. Radiol. Electrol., t. 8, p. 134, 1924; Thai W. Kinderbronchologie, Lpz., 1972, Bibliogr.
BB. H. Falcons, B. I. Ovchinnikov; B. I. Geraskin (it is put. hir.).