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SURGERY IN EMPHYSEMA AND ASTHMABy L. L. BROMLEY, M.CHIR., F.R.C.S.

Surgeon in Charge of the Thoracic Department, St. Mary's Hospital, London

Emphysema and asthma are two chronic lungdiseases which are often together associated withchronic bronchitis. The interrelationship of thesethree conditions is complex and poorly understood,but there is a great surge of interest in this fieldwhich presents a vast clinical problem in an ageingpopulation. Asthma is due to transient narrowingof large air tubes caused by acute mucosal swellingwith or without associated spasm of the bronchialmusculature and is initiated by allergic or psycho-genic stimuli. The essential lesion in chronicbronchitis seems likely to be a hypersecretion ofmucus from large and small air tubes, there isinterference with normal bronchial ciliary actionand infection develops as a secondary manifesta-tion. Chronic bronchitis and asthma are diseasesof bronchi and in both there is, at times, acute orchronic bronchial obstruction which is incomplete.Emphysema, on the other hand, is a disease of distallung tissue; its cause is not known, but it seemscertain that it is very intimately related to partialbronchial obstruction.

EmphysemaSurgical treatment will be considered in relation

to various types of emphysema as they presentclinically:

I. Obstructive emphysema.2. Acute emphysema in infancy.3. Pure hypertrophic emphysema.4. Bullous emphysema.5. Pneumothorax complicating emphysema.

Obstructive EmphysemaThe commonest cause of obstruction is an in-

haled foreign body. Fig. i. shows emphysemaaffecting the middle and lower lobes of the rightlung due to an inhaled peanut which has producedvalvular obstruction in the descending (inter-mediate) bronchus. This acute process, wherethere is trapping of air distal to the obstruction, isquite reversible. It is seen initially followinginhalation of the foreign body, but soon the picturecan change to that of lobar collapse as inflam-matory oedema at the site of lodgement now addsto the obstruction and makes it complete. Removal

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FIG. i.-Obstructive emphysema of the middle andlower lobes of the right lung due to an inhaledforeign body.

of the foreign body through a bronchoscope at thestage of obstructive emphysema is the best in-surance against further trouble, for if collapseensues, and distal infection in the lung develops,irreversible bronchiectatic changes may occur.The discovery of zonal emphysema in a child,with or without a history of inhalation of a foreignbody, makes bronchoscopy a most necessary andurgent examination.

In older children and in adults localized em-physema of a lobe or of a whole lung may beencountered, and here the mechanism can some-times be shown to be a valvular obstruction pro-duced by a redundant fold of mucous membraneor by an abnormality of the bronchial cartilages, sothat an extremely lax bronchial wall is present.Bronchoscopy and bronchography may be of helpin assessing this condition. Surgery is onlynecessary where there are symptoms, such asdyspnoea or those of recurring pulmonary in-fections, and if there is obvious displacement and

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FIG. 2.-Emphysema of the left lung due to a congenitalbronchial cyst.

compression of normal lung. Excision of theinvolved lobe is indicated; very rarely it may befound possible to provide support to a bronchuswhich has a deficiency of cartilage by the intra-mural placement of wire sutures (Cleland, 1956).Acute Emphysema in Infants

Infants can develop gross emphysema and thismay appear within a few days of birth and progresswith very great rapidity. It causes tachypnoea,cyanosis during feeds, a tympanitic percussionnote and bulging of the chest on the affected side.The condition would appear to be acute obstructiveemphysema, but the actual cause of the obstructionis seldom apparent: in most cases there is a giantair cyst within a lobe which expands and com-presses normal lung; in others one lobe is grosslyenlarged due to generalized distention of alveoli.Fig. 2 shows acute emphysema in an infant wherethere is an obvious cause; a congenital bronchialcyst (from misplaced foregut tissues) lies justbelow the carina and is pressing on the left mainbronchus thus producing unilateral obstructiveemphysema. In early infancy there may be somedifficulty in distinguishing emphysema from alarge diaphragmatic hernia where, however,intestinal symptoms are usually present and abowel pattern may be evident on the chest radio-graph. Thoracotomy is indicated for infants pre-senting with progressive dyspnoea due to em-physema, as they are unlikely to survive withoutoperation. The early part of the procedure may be

hazardous, but as soon as the infant's chest isopen ventilatory conditions improve and theemphysematous lung can be excised without hasteor undue difficulty; a lobectomy is the usualrequired procedure. The results of surgery areexcellent; the remaining lobes expand readily tofill the space previously occupied by the em-physematous lung.Pure Hypertrophic Emphysema

Surgical treatment in this very common type ofemphysema has little to offer the patient. Thedisease is diffuse, generalized and bilateral.Pneumoperitoneum has had its advocates, but lungfunction studies performed before and afterestablishing the pneumoperitoneum have shownthat there is no lasting increase in the maximumbreathing capacity nor in exercise tolerance (Mannand Murphy, 1954). Attempts have been made totreat emphysema by operations on the autonomicnervous system with the proposed rationale thatemphysema, if not actually due to incompletebronchial obstruction, is made worse by it, andthat if the air tubes could be widened air flow inthe lungs would be unhindered and air trappingwould be avoided. In order to remove all broncho-constrictor fibres, both parasympathetic and sym-pathetic fibres must be divided, but the results ofoperations for pure hypertrophic emphysema havebeen disappointing (Abbott, I953). Crenshaw andRowles (1952) recommended excision of theparietal pleura combined with neurectomy foremphysema. They considered that this mightpromote the growth of vascular adhesions betweenthe emphysematous lung and the chest wall andincrease the blood flow to lung undergoing pro-gressive degeneration due to a poor systemicblood supply. It is difficult to assess the possiblebenefits that this procedure may afford, as it hasbeen combined with neurectomy and its isolateduse has not been reported.

It is hard to foresee how surgery may developso as to help these patients unless some prophy-lactic procedure emerges. It seems likely that thisdiffuse form of the disease will remain a medicalproblem.Bullous Emphysema

It is in this type of emphysema that surgery hasa great deal to offer, particularly in improvingexercise tolerance. In the lungs of these patientsthere are three macroscopical features, blebs,bullae and hypertrophic emphysema. Blebs aresuperficial air cysts, usually not larger than 3 cm.in diameter, and are immediately subpleural,appearing to be due to the rupture of superficialalveoli with the production of blisters on the sur-face of the lung. Bullae, also known as pneumato-

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FIG. 3.-X-ray chest of an asthmatic man aged 21.

coeles, are within the lung substance and areprimarily due to intrapulmonary rupture of alveolior terminal bronchioles with progressive dis-tension of the lung parenchyma. They aremultiple, one or two are larger than others and bytheir bulk they ultimately compress surroundinglung. The severity of the third feature, hyper-trophic emphysema, varies greatly; it is most oftenseen at the fringes of the lobes. It is important torealize that bullae and blebs take no part inrespiration, as there is a negligible gas exchangethrough the few small bronchiolar or alveolar con-nections with their interior. Although the pressurewithin the bullae is only a few centimetres ofwater above atmospheric, it is, nevertheless, highenough to compress surrounding lung and thebullae act as intruders on the space required bynormal alveoli.

Patients with bullous emphysema may be young,but most are over 50. They give a history ofprogressive diminution of exercise tolerance andthis may reach the stage of dyspnoea and cyanosison the slightest exertion. Many of the patientsgive a history of asthma and of mild recurrent pul-monary infections. Fig. 3 is the radiograph of aman aged 2I who was subject to asthmatic attacks;it appears normal. Fig. 4 is of the same man fiveyears later and it shows the replacement of theupper parts of each lung field by giant bullae,with now gross limitation of exercise tolerance.

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FIG. 4.-Same man as in Fig. 3, now aged 26, showinggiant bullae on each side.

The investigation of such patients is importantand should include bronchoscopy to exclude anendobronchial abnormality and to assess the degreeof any bronchial distortion that may be present.Fluoroscopy and bronchography are helpful andpulmonary function tests are undoubtedly of valueand if facilities exist they should be performed onall patients with bullous emphysema. Functiontests will provide some objective evidence of thetype and degree of impairment of lung functionand the results of surgery can be to some extentquantitated. However, although very desirable,they are not absolutely necessary in those caseswhere the bullae are reasonably localized and thepatient is clearly short of breath as a result of them.

Surgical TreatmentIn all cases with symptoms treatment is initially

on medical lines. Tobacco should be renounced;any nasal, oral or pulmonary infection should beappropriately treated; anti-spasmodics should begiven and breathing exercises taught. It hasbeen shown that, whilst breathing exercises donot actually increase lung function, they do resultin improved diaphragmatic movement, and this,if operation is undertaken, is an important andvaluable acquisition. Operation is recommendedif disabling shortness of breath is still present aftera period of full medical treatment. Thoracotomyis performed under general anaesthesia andimmediately the parietal pleura is opened thelargest bulla will herniate through the incision.

Fig. 5 shows a large bullous cyst of the left

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January 1958 BROMLEY: Surgery in Emphysema and Asthma

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FIG. 5.-Bullous cyst of left upper lobe at operation.

upper lobe; the ribs have just been spread apart.In order to appreciate the situation fully a smallnick is made in the wall of the presenting bulla,which causes its partial collapse and allows roomfor thorough inspection of the whole lung. Asalready stated, it is usual to find blebs and zonesof hypertrophic emphysema besides other smallerbullae. The possibilities that are now open tothe surgeon are pneumonectomy, lobectomy, seg-mental resection or simple plication obliterationof the cyst. As a general principle, the surgeon'sattitude should be to preserve as much normallung tissue as possible and with this aim in viewthe most satisfactory form of surgery is cystplication. The bulla is opened more widely andany bronchial communications that can be identi-fied are closed by fine silk stitches; it is thenobliterated by a combination of suture of its wallsand the invagination and suture of its thin present-ing outer shell. Smaller cysts and blebs can besimilarly managed. Lobectomy or segmentalresection is justifiable only with very localizeddisease. The lung should be made as airtight aspossible before closure of the chest and it isimportant that the anaesthetist is not encouragedto over-inflate the lung in order to make it fill thehemithorax immediately. It will not do so at once,and there is great danger of seeing new blebs, andeven bullae, appear from new intrapulmonary airdissections as a result of over-enthusiastic hyper-inflation. Autonomic neurectomy and removal ofthe parietal pleura has already been mentioned and

can now be carried out. Although there is nocertain evidence that these procedures will help toprevent the development of further emphysema,and it would seem very difficult to see how suchevidence is to be obtained in man, there is possiblysome justification for carrying them out wherethere is asthma in association with bullous em-physema. Opinions differ, but it is considered thatan open mind should be kept, for emphysema is notnecessarily a single disease: it is possibly due to acombination of influences and surgical treatmentmight logically be directed at the outside con-nections of the lung as well as at the lung itself.Neurectomy may be empirical, but no evidencehas yet been presented showing that harm can bedone, although inevitably it adds time to theoperation. Apical and basal drainage tubes areinserted and moderate suction applied to them.The lung will take some time to expand sufficientlyto fill the hemithorax; the tubes are removed whenair leaks stop; any residual pneumothorax isrepeatedly aspirated and when small allowed toabsorb slowly.The operative mortality depends on the type of

patient accepted, but generally the surgery is welltolerated and there is immediate improvement inthe patient's breathing and capabilities. Surgerycan be undertaken even in the very breathlessindividual, but such patients require especiallycareful preparation. For the critically disabledpatient with dyspnoea at rest and cyanosis there issometimes a place for Monaldi type suctiondrainage (Head and Avery, 1949), where a two-stage procedure is usually required. At the first,pleural adhesions are locally produced by leavinga gauze pack against the outer aspect of the parietalpleura, having resected a small segment of riboverlying the bulla; two weeks later the pack isremoved and a catheter is introduced into thebulla, there now being no danger of producing apneumothorax. Suction is applied and in a smallbulla it may be possible, over the next o days,to suck the walls together and, with their ad-herence, obliterate the air space. In the largerbullae, however, a limited reduction in size isachieved, but this may put the patient in a betterposition to undergo thoracotomy.Pneumothorax Complicating Emphysema

Spontaneous pneumothorax may be a complica-tion of emphysema, of the hypertrophic or of thebullous type and often there is a tension pneumo-thorax. Recurrent episodes are common. A patientwith emphysema who develops a tension pneumo-thorax is in a critical position, as he has littlerespiratory reserve, thus early diagnosis and treat-ment are important. For the acute episode aspira-tion of air from the pleural cavity may be urgently

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necessary and if, after an initial aspiration, airreaccumulates, the needle should be left in thechest and connected to an under-water seal, but ifthis channel of exit for air is not large enough anintercostal tube must be inserted and similarlyconnected to an under-water seal. After the acuteepisode is over the condition must be criticallyassessed, particularly if this has been the latest ofa succession of episodes or if pneumothoraces haveoccurred on each side. If large bullae are presentin the underlying lung, thoracotomy is advised andplication of the bullae carried out. Pleural ad-hesions will follow the thoracotomy and a furtherpneumothorax cannot occur. Where the bullaeare small or pure hypertrophic emphysema ispresent and the pneumothorax persists thoraco-scopy is done, the lung is painted with io per cent.silver nitrate and 0.5 ml. of the same solutionsprayed against the parietal pleura of the para-vertebral gutter and a tube connected to a waterseal left temporarily in the chest. An effusiondevelops which must later be aspirated as required;adhesion of the two layers of the pleura results.Where the pneumothorax has completely absorbedbut there have been several episodes of leak fromthe lung, air should be introduced into the pleuralcavity and into this induced pneumothorax 1.5 ml.of silver nitrate is injected; aspiration of theeffusion that forms is carried out.

This approach towards a pneumothorax com-plicating emphysema may appear aggressive, butpatients are in constant and considerable danger ifa laisser-faire attitude is adopted and treatmentconfined only to the initial management of thetension pneumothorax; if further attacks occur,treatment may not be available to the patient intime.

AsthmaThe only surgical treatment of asthma that need

be considered is autonomic surgery and present-day opinion is that it has little effect on the con-dition. It would appear, however, to have a morerational basis than autonomic denervation of thelung for emphysema, as asthmatic attacks can beinitiated by psychogenic stimuli, whilst vagalstimulation in the experimental animal, and inman, has been shown to produce intense broncho-spasm. Ideally autonomic surgery would be bestapplied to the asthmatic with no allergic componentto his condition, but such sufferers are rare. Inorder to divide all bronchoconstrictor fibres to thelungs, both sides of the chest must be operatedupon, and it is necessary to divide all vagalbranches to the anterior and posterior pulmonaryplexuses, to perform an upper dorsal sympathec-tomy down as far as the fifth ganglion, to circum-cize the sheaths of the pulmonary vessels and todivide the pulmonary ligament. There have beensome encouraging reports in the literature, butlate follow-up on patients who have undergoneautonomic nerve surgery has shown a high in-cidence of return of asthma. It would seem properto consider surgical treatment only where all otherforms of treatment have failed in a patient withintractable and severe asthma, where an allergicelement is excluded and where there is a favourableresponse to a ganglion-blocking agent, such ashexamethonium. There is yet no recognized placefor neurectomy as a standard approach to themanagement of the asthmatic.

BIBLIOGRAPHYABIBOTT"', 0. A., HOPKINS, W. A., VAN FLEIT, W. E., and

ROBINSON, J. S. (i953), Ibid., 8, I16.'L,ELAND, W. P. (1956), personal communication.CRENSHAW, G. L., and ROWLES, D. F. (1952), J. thorac.

Surg., 24, 398.HEAD, J. R., and AVERY, E. E. (1949), Ibid., I8, 761.MANN, B., and MURPHY, E. A. (r954), Thorax, 9, 87.

RUTHIN CASTLE, NORTH WALESA Clinic for the diagnosis and treatment of Internal Diseases (except Mental or Infectious Diseases). The

Clinic is provided with a staff of doctors, technicians and nurses.The surroundings are beautiful. The climate is mild. There is central heating throughout. The annual

rainfall is 30.5 inches, that is less than the average for England.The Fees are inclusive and vary according to the room occupied.

For particulars apply to THE SECRETARY, Ruthin Castle, North Wales.Telegrams: Castle, Ruthin Telephone: Ruthin 66

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