the treatment of acute respiratory infection in infants · the removal of these secretions by...

Brit. J. Anaesth. (1958), 30, 419

THE TREATMENT OF ACUTE RESPIRATORY INFECTION IN INFANTSBY

H. I. ARMSTRONG NISBET

Alder Hey Children's Hospital, Liverpool, England

AND

FRANK WILSON

Alder Hey Children's Hospital and Royal Liverpool Children's Hospital, Liverpool,England

THE mortality from acute respiratory infection ininfants has been considerably reduced in recentyears by the advent of antibiotic therapy. Theapplication of new' knowledge concerning fluidbalance and feeding, together with advances inthe nursing care, and attention to such factors astemperature, posture and humidity of the atmo-sphere have played important roles in reducingmortality.

Despite this progress, a certain proportion ofcases still fails to respond to treatment. Such maybe the case where antibiotics are used empiricallyor in inadequate dosage. Certain infections appearto be resistant to all antibiotic therapy. In someinfants in whom there is a paucity of physical andradiological signs, the severity of the conditionmay not be fully appreciated. Treatment maythen be delayed until the development of anobvious severe bronchopneumonia with cyanosis,dehydration and extreme toxaemia. Hypoxia andtoxaemia lead to depression of the cough reflex.In such circumstances failure to clear secretionsfrom the air passages results in severe respiratoryobstruction.

The purpose of this paper is to show how it ispossible to re-establish an adequate airway andimprove aeration of the lungs. A series of casesis presented treated by methods that have beenevolved using standard equipment readily avail-able in all hospitals.

PRINCIPLES OF TREATMENT

The Relief of Respiratory Insufficiency

Respiratory insufficiency exists where gaseous ex-change between the lungs and the blood is lessthan that between the tissues and the blood—thatis, where external respiration cannot keep pace

419

with internal respiration (Woolmer, 1956). Theinfant's own efforts towards increasing exchange,by increased respiratory rate and effort, aredemonstrably inefficient as they inevitably in-crease oxygen demands.

This discrepancy between oxygen supply andoxygen demand can be relieved in two ways.

(a) By increasing gaseous exchange.(b) By reducing oxygen demands.

Increased Gaseous Exchange.This may be effected by:

Removal of obstructing secretions.(a) By suction applied to the nose, mouth and

pharynx.(b) By suction applied to the lower respiratory

tract via an endotracheal tube, a bronchoscopeor a tracheotomy tube.

The necessity to remove secretions which obstructthe air passage is well recognized in the operatingtheatre, and in the management of anterior polio-myelitis, tetanus and many varieties of coma. Thereis less appreciation of the possible effects of mechani-cal obstruction arising in the infant's airway duringthe course of acute respiratory infections.

The value of oxygen therapy must be severelylimited if it cannot reach the alveoli. Similarly, anti-biotics, although invaluable, will do little good unlessthe airway remains adequate long enough for thepatient to benefit from their action.

Re-expansion of collapsed segments.(a) By suction through an endotracheal tube or

bronchoscope.(b) By the use of positive pressure after suction.(c) By aspiration of pus and/or air from the

pleural cavity.(d) By suitable posture.Restoration of function to areas of lung by these

means must inevitably increase gaseous exchange.

Reduction of deadspace.(a) By endotracheal intubation.(b) By tracheotomy.

420 BRITISH JOURNAL OF ANAESTHESIA

Suitable posture.It has been shown that posture affects:(a) the relative ease with which the various lung

segments expand (Jackson Rees, 1958);(6) overall compliance (Attinger, Herschfus and

Segal, 1956);(c) the efficient drainage of secretions from the

bronchial tree (Quinn and Mayer 1929;McLaurin, 1934).

Reduction of Oxygen Demands

This may be achieved by:Re-establishment of the airway, using any or

all of the methods above.

Since hypoxia and carbon dioxide retention incertain degrees provide the stimuli for the increasein respiratory work, removal of these stimuli by ade-quate aeration of the lung will reduce effort.

Removal of secretions which increase the resistanceto the flow of gases in the air passages must reduceenergy requirements.

Respiratory obstruction, by causing increased intra-thoracic negative pressure, may facilitate the formationof transudate. This in turn may result in limitation ofgaseous exchange, a decrease in compliance and anincrease in respiratory work in addition to impairingthe diffusion of gases across the membrane.

Use of assisted or controlled respiration.Judicious use of sedatives.Avoidance of respiratory stimulants, which

must increase the metabolic rate and oxygendemand.

Maintenance of Nutrition and Hydration

This paper is primarily concerned with the ap-plication of the principles • enumerated above.Nevertheless, the maintenance of nutrition andhydration remains an essential aspect of treat-ment.

Dehydration results from respiratory distressand toxaemia, which impair the ability to feedadequately. The immature kidneys (Rickham,1957) function even less efficiently as the high"volume obligatoire" required by the infant isnot readily available. Acid-base balance in theblood is impaired not only by faulty ventilation,but by poor renal compensation.

Feeding may be maintained by a catheter in-serted into the stomach. It is preferable that,where possible, this should be passed through themouth, thus leaving the nasal passages clear. Thepresence of an endotracheal tube in the oro-pharnyx precludes normal feeding, but as thesechildren are so ill that they will not feed by mouth

in any case, this is of little consequence. In suchcircumstances, feeding by tube becomes essential.Some additional benefit may be derived from theremoval of air and gas from the stomach, thusreducing the work of the diaphragm.

The Early Institution of Efficient AntibioticTherapy

A detailed discussion of antibiotic therapy is out-side the scope of this paper, but it must be appre-ciated that, if this is to be efficient, reliableinformation regarding the nature of the infectingorganism must be obtained early in the course ofthe disease.

The empirical use of drugs to which the organ-ism may subsequently be proved insensitive isunavoidable in the early stages of treatment.However, secretions aspirated from the tracheaand bronchi provide the bacteriologist with farmore reliable diagnostic material than do eitherthroat or laryngeal swabs. Thus endotracheal in-tubation and suction may facilitate the early useof a suitable antibiotic.

MODE OF TREATMENT

It is desirable that the atmosphere, posture,humidity and temperature should be readily con-trollable and that the respiratory movementsshould be easily observed. Such conditions maybest be achieved where the infants are nursednaked in incubators.

Restoration of the airway by intubation andsuction forms the essential feature of the treat-ment in all cases we describe. In some instances,intubation has had to be repeated many times andin others it has been necessary to leave an endo-tracheal tube in position for prolonged periods.Controlled respiration has been found to be bene-ficial where exhaustion has been so severe as torender ventilation inadequate. On occasion seda-tion has proved helpful. Where secretions havebeen particularly tenacious, streptokinase hasbeen used. Certain of our cases have requiredbronchoscopy and in others tracheotomy has beennecessary. These aspects of treatment requiresome detailed description.

Endotracheal IntubationWhen severe respiratory embarrassment resultsfrom acute infection in infancy, the indications forintubation are:

THE TREATMENT OF ACUTE RESPIRATORY INFECTION IN INFANTS 421

(a) Where obstructing secretions cannot becleared effectively in the normal way, that is,where there is an ineffective cough.

(b) Where the child is too ill to maintain ade-quate ventilation by its own unaided efforts.

The presence of an efficient cough mechanism isundoubtedly the most effective way of removingsecretions. It follows that intubation is seldomnecessary where this exists. On the other hand,failure-to cough effectively, as evidenced by theaudible accumulation of secretions in the largerair passages, or by the presence of atelectasis, willpresent a strong indication for intubation.

In such circumstances, the introduction of anendotracheal tube offers several advantages.(a) Mechanical obstructions presented by the

relaxed tongue, blocked nares and pharyn-geal secretions are overcome.

(b) Repeated endotracheal and endobronchialtoilets can be carried out by suction throughthe tube. Owing to the more vertical descentof the right bronchus, toilet of the rightbronchial tree is easily performed, while itmay be necessary to resort to bronchoscopyto clear the left bronchus.

(c) Deadspace is reduced. If the tidal volume ofan infant is 10 ml and the deadspace is 5 ml,the effective tidal volume which takes part inrespiratory exchange will be 5 ml. If, how-ever, the tidal volume is only 6 ml, the effec-tive tidal volume will be only 1 mL

Intubation with an 00 gauge endotrachealtube reduces the deadspace above the sub-glottic region from 5 ml to 1 ml. Thus theeffective tidal volume will be greatly in-creased with a corresponding reduction intachypnoea.

Although an endotracheal tube offers increasedresistance to breathing in a normal infant, wherethis resistance is already high due to the presenceof secretions in the air passages it is likely thatthe removal of these secretions by intubation andsuction will actually effect a reduction in resist-ance. Our cases have shown a marked fall in res-piratory rate following such treatment. Thiswould seem to indicate a diminution in respira-tory effort and therefore in oxygen demand.

Technique.A sterile tray containing apparatus necessary

for intubation should now be standard equipmentin the medical wards of children's hospitals.

Intubation of an infant in extremis is not technicallydifficult. Any material present in the pharynx isquickly removed by suction. The laryngoscope is gentlyinserted, advanced down the pharynx into the oesopha-gus and withdrawn until the. tip catches the epiglottis,when the larynx slides into view. A sterile Magill tubeis now introduced. This should be of too small a borerather than too large, and should pass into the larynxto a point just below the vocal cords. The length canroughly be estimated by measuring one and a halftimes from the corner of the mouth to the lobeof the ear. If the tube is too long, it will enter theright bronchus, thus adding to the respiratory em-barrassment Size 00 Magill tubes are used in mostcases. Kinking of the tube will occur less readily ifa firm tube is selected.

While infants up to two or three weeks of age,and those who are moribund present little diffi-culty, it may be wiser to produce muscular relaxa-tion in older and more active children if intuba-tion is to be accomplished with a minimum oftrauma. Intravenous injection of 5-10 mg ofsuxamethonium will cause complete paralysisand thereafter intubation may be performed withease following inflation of the lungs widi oxygenfrom a face mask.

Following intubation a fine no. 3 Jacques rub-ber catheter, from which the end has been re-moved, is introduced into the. trachea. Suction isapplied and whatever secretion present is re-moved As this forms valuable diagnostic material,the contents of the sterile catheter mount shouldbe sent for investigation.

The lungs are now inflated with oxygen, thetube being connected to the T-piece circuit asshown in figures 1 and 2. If the lungs fail toexpand when gentle pressure is applied to thebag, suction should be repeated until inflation ispossible.

Further Management.The subsequent treatment depends upon the

child's response. Where the condition is obviouslymuch improved, with rapid return of normalcolour to the mucous membranes and whencoughing, stimulated by the presence of the tube,is active, then the tube should be removed. Afterinflation of the lungs with oxygen and carefulpharyngeal suction, the tube is withdrawn in onesmooth rapid movement. Auscultation near themouth confirms that the airway is clear and thatno laryngeal spasm exists.


FIG. 1Rees's modification of Ayre's T-piece circuit with Venturi device for the

entrainment of air.A humidifier is normally interposed between the Venturi device and the

T-piece.

Careful observation of the infant's condition isessential, as the lung segments may well collapserepeatedly. Special attention should be paid to thepresence or absence of an effective cough and tothe nature of air entry on auscultation near themouth or nose. This latter measure may give anearly indication of the gradual accumulation ofsecretions. Repeated examination of the chestis necessary as the signs may vary markedly fromhour to hour. Careful attention should be paid tothe state of hydration. Radiographic and bio-chemical investigations should not be delayed.

Repeated Intubation.Should secretions continue to accumulate in the

absence of an effective cough, repeated intubationand suction may well be required. It is desirablethat all manoeuvres should be performed as gentlyas possible and that trauma to the larynx beavoided. A small dose of suxamethonium mayhelp greatly to attain this aim.

, In certain cases we have experienced consider-able difficulty in distinguishing between areas ofcollapse and consolidation. If the air entry to anarea of the lung should suddenly becomemarkedly diminished then the diagnosis is usually

obvious. The presence of moist sounds, in associa-tion with an area of diminished air entry may alsosuggest that accumulated secretions have resultedin collapse. On the other hand, the absence ofmoist sounds in such an instance is no proof thatthe signs are due to consolidation. We have beensurprised to find that some areas thought clini-cally to show consolidation have been re-aeratedfollowing suction and positive pressure. Wheresuch uncertainty exists intubation and suctionmay be a useful diagnostic procedure.

Prolonged Intubation.Where the child is exhausted and respiration is

inadequate to maintain oxygenation, the endo-tracheal tube must perforce be retained and con-trolled respiration instituted.

In such a situation, expert, detailed and cons-tant nursing care is essential The nursing staffhas played an invaluable part in the managementof these cases. The organization of specialized res-piratory units for the management of these caseswould seem desirable.

The nurse should be taught to watch and listenfor any change in the character of breathing. The


FIG. 2Rees's modification of Ayre's T-piece circuit in use, with safely device.

A green rubber bag, as supplied by B.O.C., is connected to the T-piececircuit. Into the "tail" of this bag is inserted a Y-shaped glass connection.The second limb of this connection is attached to the glass tubing in atransfusion bottle, which is half full of water. The glass tubing dips well

below the surface of the water."Inspiration" is effected by closing the third limb of the Y-shaped con-nection with the thumb of one hand, while the thumb of the other com-presses the bag. The pressure in the circuit is then limited by the escapeof gases through the limb of the Y connection attached to the transfusionbottle. "Expiration" is effected by releasing the pressure on the bag and re-

moving the thumb from the limb of the Y connection.

circuit should be demonstrated and specialemphasis laid upon all the possible means bywhich the airway may be blocked and the ways inwhich it may be restored.

Sudden onset of respiratory distress, with inter-costal recession, cyanosis and diminished air flowthrough the tube, requires prompt attention. Thesmaller sized endotracheal tubes are thin walledand may kink. Such difficulties may be preventedif a reasonably firm tube is secured in the mid-line, the connection lying between the teeth orgums, where it cannot be blocked by biting. Agag made from a cut-down Guedel's airway maybe useful in this connection. Careful packing ofthe mouth and pharynx with a lightly oiled gauzepack also limits the tendency of the tube to kink.Failure to make a firm connection between the

tube and its metal connection may lead to inhala-tion of the tube.

Should it be necessary to retain the tube inposition for periods of longer than twelve hours,it is advisable to change it frequently in order toavoid blockage by inspissated secretions.

SuctionThe majority- of these children suffer from ageneralized infection of the respiratory passages.Copious secretions may accumulate in die nose,pharynx, trachea and bronchi. As infants show apredilection for nasal breathing, it is desirablethat the patency of the nasal passages should bemaintained. Furthermore, if nasal secretions arenot efficiently removed they will collect in thepharynx, giving rise to a mechanical obstruction.Pharyngeal suction, therefore, is a valuable thera-


peutic measure. It should be performed hourly,preferably before the child is due to be fed, inorder to avoid regurgitation. Even when an endo-tracheal tube is in position, these measures shouldnot be neglected. An adequate exposure is neces-sary and is easily obtained by depressing thetongue with a sterile spatula or spoon handlewithout causing trauma to the palate or posteriorpharyngeal wall.

Suction through an endotracheal tube is notwithout certain hazards, and should only be per-formed by those who have received instruction.Care should be taken to ensure that the cathetersare sterilized by boiling before and after use.Sterilization by means of solutions or by formalinvapour cannot be too strongly condemned. Afirm rubber catheter of a thickness such as willpermit the passage of air between itself and thewall of the endotracheal tube should be passed asfar down the bronchial tree as possible. Care isnecessary to avoid trauma to the tracheal walland the catheter should be firmly compressed asit passes down. Suction is then applied as thecatheter is withdrawn, removing secretions on theway. Failure to observe these precautions mayresult in considerable collapse of the lungs. Fol-lowing suction, inflation of the lungs with oxygenshould always be performed, further to minimizethis danger. Some measure of restraint is advisablein the use of suction. It should only be appliedwhere secretions are thought to exist and not as adiagnostic test of their presence or absence. Strictattention should be paid to asepsis.

Controlled Respiration

Controlled positive pressure respiration may pro-duce certain adverse effects on the cardiovasculardynamics of adult subjects. It is believed that, inhealthy infants, such effects are minimal (Rees,1958). This is less likely to be true where circu-latory collapse exists due to toxaemia, dehydra-tion or the effects of prolonged hypoxia.

When the tidal volume is inadequate to main-tain oxygenation, however, or the child is apnoeic,there is little choice but to control respiration.Beneficial effects should result from the improvedventilation and the reduction in oxygen demandconsequent to diminished respiratory work. It isunlikely that positive pressure respiration will in-jure a normal lung provided that it is performed

with care. Rees (1958) states that quite a highnegative intrathoracic pressure may be reached ininfants. The negative intrathoracic pressure pro-duced by diaphragmatic movement is inverselyproportional to the radius of the domes. As thisradius is small in infants, they can produce pres-sures in the region of - 45 cm H3O. Similarly,high positive intrathoracic pressures are known tobe developed in the act of coughing—pressuresfar in excess of those used in positive pressurerespiration.

The Rees modification of Ayre's T-piece circuitis shown in figure 1. As it stands, it is not suitablefor use by untrained personnel. A further modifi-cation, described in figure 2, limits the pressurewhich may be applied to the lungs by manualinflation of the bag.

Controlled respiration with this equipment maybe carried out safely by the nursing staff, providedthat adequate instruction is given. Points to stressare that the bag must not be allowed to fill com-pletely, being partially grasped in the ball of thehand, while pressure to inflate is exerted by thethumb. Pressure should be gentle and sufficientto ventilate adequately as judged by the move-ments of the chest. The pressure during the ex-piratory phase should be zero.

Ayre (1956) states that in clinical practice afresh gas inflow of 1̂—2 times the minute volumeof the patient will ensure that there is no re-breathing.

HumidificationHumidification of the atmosphere is essential inall cases. Marshall and Spalding (1953) state thatthe aim should always be 100 per cent humidity.This is difficult to obtain where the incubatorsare frequently opened for feeding, auscultationand routine nursing care. Incubators should beopened, therefore, as seldom as possible, both topreserve the oxygenated humidified atmosphereand to avoid falls in temperature which may beserious in collapsed hypothermic infants. WneTean endotracheal or a tracheotomy tube is in place,failure to provide adequate humidification willlead rapidly to the encrustation of secretions. Inboth these instances, the mouth and nose, whichnormally add most of the water vapour to theinspired air, are by-passed.

It is wise, therefore, to keep humidity settings


on the incubators at the maximum. Clinical im-pressions are that the addition of alevaire to theatmosphere is useful.

If controlled respiration is required, 100 percent humidity can only be obtained by the useof a humidifier such as the "Radcliffe". Wherethis is not available the gases may be bubbledthrough water bottles in which the bubbles arebroken up by passing through gauze or sponge.This method gives a humidity below the desiredmaximum (Marshall and Spalding, 1953).

The Atmosphere

It is generally agreed that prolonged inhalation ofhigh concentrations of oxygen is undesirable. Theconcentration in many incubators, however, sel-dom reaches 50 per cent (Rickham, 1957). Whereincubators are more airtight, it seems advisablethat alevaire should be vaporized by air and anappropriate percentage • of oxygen added to theatmosphere through a separate inlet. Controlledrespiration with 100 per cent oxygen is likewiseto be avoided. The introduction of a venturiinjector device into the T-piece circuit enablesthe entrainment of air, so that the relative concen-tration of air and oxygen may be varied as desired.

Position of the Patient

If the child is to make the best use of its respira-tory efforts it is desirable:

(a) That the inhalation of material from the nose,mouth and pharynx should be avoided.

(b) That the position should be such as will en-courage the.drainage of secretions from affectedsegments.

(c) That the position should allow the infant toventilate its lungs with the minimum of effort.

These objectives, unfortunately, are not alwayscompatible.

Most of these children have muco-pus in thenasopharynx. Quinn and Mayer (1929) ,andMcLaurin (1934) have shown the ease with whichmaterial from the nose and sinuses may be aspir-ated into the lungs. The infant's predilection fornasal breathing has already been mentioned. Fromthis the head down position might appear to havecertain benefits to offer. Sticky mucus does notdrain from the mouth with such facility as liquidvomitus, however, and this position has manydisadvantages. Nasal secretions can and should beremoved frequently by suction.

James, Brimblecombe and Weston Wells (1952)have shown that atelectasis in lower respiratoryinfection occurs most frequently in the lowerlobes. Most of the cases in this large series, how-ever, are in an older age group than those withwhich we have been concerned.

Certain considerations tend to show that theposition of choice may be head up. Goodwin(1934) reviewed cases of lipoid pneumoniasecondary to aspiration of oily substances. Hefound that the right lung was more often affectedthan the left and the upper lobes more frequentlythan the lower. Rees (1958) states that atelectasisdue to secretions is more common in the upperlobes of infants than in the bases. This he ascribesto the abdominal type of respiration and the res-tricted movement of the upper part of the thoraciccage.

The routine nursing care of changing the childfrom one side to the other at regular intervalsundoubtedly facilitates the drainage of secretionsinto the larger air passages, from which they maymore easily be removed by coughing or by suc-tion. Percussion of the chest wall also assists inthis aim

In respiratory distress there is an increase inrespiratory work due to a decrease in complianceand an increase in mechanical resistance. Attinger,Herschfus and Segal (1956) studied a group ofadults suffering from various cardiopulmonarydiseases. They found that compliance was highestand mechanical resistance lowest in the sittingposition. Thus these patients performed less workwhen sitting than when supine. Positions otherthan the sitting therefore produce a relativelygreater oxygen demand, a condition to be avoidedin pulmonary insufficiency.

It may be that these facts are applicable toinfants. Certainly marked clinical improvementmay be observed when they are made to sit up.This posture should allow the diaphragm to actat a better mechanical advantage. The infant mustnot be allowed to slump forward in a nest ofpillows, however, or this advantage is lost.

In view of these considerations we have electedto treat these cases with the head end of the bedsteeply raised on blocks, or with the incubatortray suitably tilted. The children are turned fromside to side at regular intervals and are not en-cumbered by pillows.


SedationIt may be considered that sedation in these casesis inadvisable, in view of the ever present dangersof hypoxia and carbon dioxide retention. Gaisfordand Lightwood (1953) have favoured the use ofpethidine in certain conditions of respiratory dis-tress. We have found that, in several instances, adose of 0.2 mg per lb. (0.45 mg/kg), by intra-muscular injection, has had a quietening effect inrestless infants. In such amounts it does not ap-pear to cause significant respiratory depressionand by virtue of its sedative effect, reduces oxygendemand.

Avoidance of Respiratory StimulantsWhile certain concentrations of carbon dioxidestimulate respiration it seems likely that raisedlevels already exist in the blood where ventilationis defective (Goodman and Gillman, 1955).Further increase in the concentration in the in-spired atmosphere may lead to respiratory depres-sion.

It has been shown by Alschultz and Sulzbach(1947) and McDonald and Simonson (1953) thatchanges in blood carbon dioxide level affect theadult electrocardiogram. Reversible changes simi-lar to those seen in ischaemic heart disease havebeen described by Pitman and Wilson (1955) incases of respiratory embarrassment with carbondioxide retention. It would be interesting to knowif such changes occur in infants.

Whether a stimulant effect, obtained by carbondioxide or by the use of such drugs as niketha-mide, is desirable in an exhausted child maybe doubted, in view of the increased oxygendemand which must inevitably result.

Temperature Control

It has been shown that adults adjust their rateand depth of breathing so that respiration isaccomplished with a minimum of effort (Otis,Fenn and Rahn, 1950; McHroy, Marshall andChristie, 1954). The theoretical minimum ofeffort in the newborn is thought to occur at arespiratory rate of 37 per minute (Cook et al.,1957). Work done increases as the rate rises abovethis figure and the metabolic rate may attainphenomenal levels.

From these considerations, it may be surmisedthat respiratory distress in infancy calls for amuch greater increase in effort than in adult life.

Reference has been made elsewhere (Freier et al.,1957) to the pyrexia and exhaustion which mayaccompany increased respiratory effort. In twocases of hyaline membrane syndrome describedby Cook and his colleagues (1957) the metabolicrate was increased by 400 per cent. As mechanicalefficiency is low, a high proportion of the energyused in the increased respiratory effort will appearin the form of heat. Small wonder that the dis-tressed infant, with its poorly developed heatregulating mechanism, commonly develops hyper-pyrexia, which may be accompanied by convul-sions.

It is surprising, therefore, to find that infantswith marked pyrexia are still commonly nursedunder layers of clothes and blankets, or in incuba-tors at high temperatures. Such treatment canonly have the effect of raising the metabolic rateand oxygen demand.

Where the child is collapsed and exhausted,however, the temperature rapidly falls, sometimesto levels well below 90° F. In such circumstancesit is essential to maintain the temperature of theincubator at a high level. Thus the number ofoccasions when it is opened for nursing purposesshould be kept to a minimum.

Bronchoscopy and TracheotomyIn many cases we have found it possible to re-expand the lungs simply by intubation and suctionfollowed by positive pressure. The right lung res-ponds well to this treatment but in many casesthe left lung also has benefited to such an extentthat bronchoscopy has not been required. Wherethe response has been less satisfactory broncho-scopy has proved useful.

Modern thought does not subscribe to the viewthat tracheotomy in infants invariably leads to afatal outcome. A planned operation in theatre,followed by judicious use of antibiotics, devotednursing care, atmospheres of high humidity andcareful endotracheal toilet, gives even theyoungest child a fair chance of survival.

It is not proposed to discuss the managementof tracheotomy, but some reference is made tothe subject later in the comment on case historyno. 8.

Streptokinase and StreptodornaseIn certain cases, where mechanical obstructiondue to tenacious or crusted material was causing

TABLE I

Course and Treatment of 18 Cases of Respiratory Infection.

Ref. No. Sex Age Birth weight Nature of diseasePresentingfeatures

Outline oftreatment

Immediateresponse

Subsequentcourse

Organismsisolated

Pallor. Hypothermia Prolonged intubation.Circulatory collapse. Controlled respiration.Cyanosis, longperiods of apnoea.Poor air entry in allareas.

Cyanosis, gaspingrespirations. Poorair entry all areas.

Pallor, cyanosis, dys-pnoea. Poor airentry, especially leftlung. Laryngealoedema.

Antibioticsused

Erythromycin.

Erythromycin.Streptomycin.

Penicillin.StreptomycinErythromycin.

Penicillin.Streptomycin.Erythromycin.

Chloramphenicol.

/


Erythromycin.



Complications

Prematurity.Dehydration.Diarrhoea.Circulatory failure.Patent ductusarteriosus.

Complete obstruc-tion of airway bysecretions.

Bronchopleuralfistula.Purulentpericarditis.Acute bacterialendocarditis.Completeobstruction bysecretions.

Prematurity.Laryngeal oedema.Cerebral oedema.

Complete obstruc-tion of airway dueto secretions.

Gastroenteritis.

Congenital heartdisease, ventricularseptal defect.

Encrustation ofsecretions.

Prematurity.

Fate

Died.

Died

Died.

Died.

Died.

Survived.

Survived.

Survived.

Survived.

C.K.

G.W.

I.E.

J.M.

D.L.

C.L.

G.S.

E.K.

S.M.

1 Female

Male

Male

Male

Male

6 (twin Maleof 5)

Female

8 Female

Male

4 weeks 5 lb. 9 oz.(2.5 kg)

6 weeks 8 lb. 5 oz.(3.75 kg)

5 weeks 8 lb.(3.5 kg)


6 weeks 4 lb. 8 oz.(2 kg)

6 weeks 4 lb. 8 oz.(2 kg)

8 weeks 6 1b. 12 oz.(3 kg)

24 weeks 7 lb. 12 oz.(3.5 kg)


Bronchopneumonia.

Bronchitis.

Staphylococcalpneumonia.

Bronchiolitis.

Bronchiolitis.

Bronchiolitis.

Bronchopneumonia.

Laryngo-trachealbronchitis.

Bronchiolitis.

Repeated intubationand suction.

Prolonged intubation,and suction.Bronchoscopy.Pleural drainage.Controlled respiration

Pallor, cyanosis,dyspnoea, periods ofapnoea. Poor airentry throughout.Moderate laryngealoedema.

Repeated intubationand suction.Prolonged intubationBronchoscopy.

Controlled respiration.Tracheotomy.

Grey, long periods of Intubation andapnoea. Air entry suction,absent in most areas. Prolonged intubation.

Controlled respiration.

Grey. long periods of Intubation and suc-apnoea. Poor air tion.entry. Prolonged intubation.

Controlled respiration.

Cyanosis, gaspingrespirations. Littleair entry left side.

Laryngealobstruction.


Tracheotomy andsuction. Repeatedbronchoscopy.

Cyanosis, rib reces- Intubation andsion. Poor air entry, suction.Vomiting. Bronchoscopy.

Poor circulatoryresponse in spite ofadequate aerationof lungs.

Good.

Poor circulatoryresponse in spite ofimproved aeration.

Good.

Good.

Good.

Good.

Good.

Good.

Downhill.

Died suddenly.

Slow improvementuntil died suddenly.

B. coli.

B. coli.

Staph.pyogenes.

Periods of apnoeacontinued.Died suddenly.

Periods of apnoeacontinued.Died suddenly.

Gradualimprovement.

Gradualimprovement.

Gradualimprovement.

Gradualimprovement.

B. coli.Staph.pyogenes.Pneumococci

Staph.pyogenes.

None.

None.

None.

Staph.pyogenes.

facing pane 4261 [P.T.O.

TABLE I—Continued

Ref. No. Sex Age Birth weight Nature of diseasePresentingfeatures

Outline oftreatment

Immediateresponse

Subsequentcourse.

Organismsisolated

Antibioticsused Complications Fate

C.F.

P.H.

C M .

N.B.

L.G.

A.H.

C D .

R.F.

10

11

Female

Male

12

13

14

15

16

17

Female

Male

Female

Female

Female

Male

C.L.D. 18 Female

2 weeks 8 Ib.(3.5 kg)

5 weeks 5 1b. 6 oz.(2.5 kg)

8 weeks 6 1b.(2.75 kg)

10 weeks 8 lb.(3.5 kg)


6 weeks 7 lb. 3 oz.(3.25 kg)

2 weeks 5"lb. 13 oz.(2.75 kg)

6 weeks 5 lb(2.25 kg)

20 months 7 Ib. 4 oz.(3.25 kg)

Bronchiolitis.

Bronchopneumonia.

Bronchopneumonia.

Bronchiolitis.

Bronchiolitis.

Bronchitis.

Bronchiolitis.

Bronchopneumonia.

Cyanosis, rib reces-sion, periods ofapnoea, pallor. Poorair entry, right lungand left base.

Pallor. Cyanosis.Apnoea. Laryngealoedema. Massiveaccumulation of

secretions. No airentry left lung.

Grey, long periodsof apnoea. Poor airentry.

Intubation andsuction.

Repeated intubationand suction.Prolonged intubation.Controlled respiration.Tracheotomy.


Extreme dyspnoea, Intubation andcyanosis. Poor air suction,entry right lung and Bronchoscopy.coarse crepitationsover left lung.

Acutelaryngitis.

Extreme dyspnoea,cyanosis, poor airentry throughout.

Cyanosis.Respiratory distress.

Accumulation ofsecretions inpharynx.

Cyanosis. Massiveaccumulation ofsecretions. Poor airentry all areas.

Cyanosis. Gaspingrespirations. No airentry except at leftapex. Respiratoryrate 96 per minute.

Stridor, cyanosis,poor air entry in allareas, restlessness,and confusion.


Pharyngeal suction.Postural drainage.

Repeated intubation,and suction.Bronchoscopy.


Oxygen therapy,intubation,tracheotomy,humidification.

Good.

Good.

Good.

Good.

Good.

Good.

Good.

Respiratory ratedropped to 50 perminute within halfan hour.

Good.

Gradualimprovement.

Gradualimprovement.

Gradualimprovement.

Gradualimprovement.

Gradualimprovement.

Improvement.

Gradualimprovement.

Gradualimprovement.

Rapidimprovement.

Staph.pyogenes.

None.

Staph.pyogenes.

B. coli.Streptococcushaemolyticus.

B. coli.

Staph.pyogenes.

B. Coli.

Nil.

Staph.pyogenes.




Penicillin.Erythromycin.

Achromycin.


Penicillin.Streptomycin.

Oral penicillinand oralTerramycin.Penicillin.Streptomycin.Erythromycin.Aureomycin.

Penicillin.Streptomycin.

Congestive failure.

Laryngeal oedema.

Nil.

Congestive failure.Congenital heartdisease. *? Infundibularstenosis.

Prematurity.

Prematurity.Congestive failure.

Nil.

Nil.

Survived.

Survived.

Survived.

Survived.For cardiacsurgery.

Survived.

Survived.

Survived.

Survived.

Survived.

THE TREATMENT OF ACUTE RESPIRATORY INFECTION EN INFANTS 427

alarm, we have found these preparations valuablewhen instilled into the bronchial tree. In othercases, liquefaction of pus has appeared to causerapid spread of infection. It may therefore beadvisable to wait until systemic antibiotics havehad time to be effective before using these subs-tances.

TYPES OF CASES

From a therapeutic viewpoint it is desirable todefine several broad groups of clinical conditions.

(1) Upper respiratory tract infection may pre-dominate, as in cases of laryngotracheal bron-chitis, where subglottic oedema may be suffi-ciently severe to call for early tracheotomy.

(2) Bronchitis or bronchopneumonia may existwhere copious, sticky, muco-purulent secretionsremain uncleared from the larger air passages andmay be followed by atelectasis, consolidation orabscess formation. This group presents the anaes-thetist with the most promising field for inter-vention.

(3) Where the obstructing secretions aresituated mainly in the smaller bronchioles, effortsto remove them are likely to be less rewarding.Repeated suction may be required to removethem as they are extruded into the larger bronchi.The effort entailed in mainlining ventilation inthese cases of bronchiolitis is very great and manyhave required prolonged intubation and controlledrespiration. ^

(4) Abscess formation is frequent in staphy-lococcal infections. Such lesions may rupture intoa bronchus, causing sudden acute respiratoryobstruction. Not uncommonly, however, theyrupture into the pleural cavity, causing a pyo-pneumothorax, a condition which calls for carefulmanagement.

CASE HISTORIES

In view of the urgent problem presented by thecyanotic, gasping, collapsed infant, we have hadlittle choice in the cases we have treated. Somechildren are moribund on admission. Seven cases,not included in our series, have died before wecould reach them, even though the delay wasshort. In some, postmortem examination has re-vealed the presence of associated lesions, as canbe seen from table I.

Controlled investigation has not been possible

in these circumstances and early investigations bysuch means as radiography have often been pre-cluded. Results are therefore difficult to assess byany means other than by clinical examination.

The principal features of eighteen cases of acuterespiratory infection are indicated in table I. Inorder to avoid tiresome repetition, certain of thesecases which demonstrate particular methods oftreatment are presented and only two are des-cribed in detail. In this series there have been fivedeaths, which will be discussed collectively.

Case No. 15.

Pharyngeal Suction and Postural DrainageA female child aged 6 weeks, birth weight 7 lb. 3 oz.(3.25 kg), was admitted suffering from cyanosis andrespiratory distress.

On examination, the child was cyanotic and therespiratory rate was 48 per minute. She made effortsto cough, but was unable to clear the accumulatedsecretions from the. pharynx. Breath sounds wereharsh with crepitations throughout both lung fields.

The pharynx was cleared by suction and her colourimproved considerably. As she continued to cough,the pharyngeal suction proved sufficient to maintainher airway. She was nursed in the sitting position inan atmosphere of oxygen and alevaire. Postural drain-age aided by percussion of the chest was encouraged.She made an uneventful recovery.

Comment. This infant responded well to theusual medical care once the airway had beencleared and maintained. The value of repeatedpharyngeal suction was clearly demonstrated.

Case No. 14.

Intubation and SuctionA female child aged 3 weeks, birth weight 5 lb. 9 oz.(2.5 kg), was admitted with a history of "snuffles"and disinclination to feed of several days duration.

On examination she showed cyanosis, dyspnoea aridmarked rib recession. The breath sounds were harsh,with coarse crepitations at the left base.

On the evening of her admission her conditionworsened, with only a temporary response to pharyn-geal suction, oxygen and alevaire. She became un-conscious with shallow ineffective respirations, poorair entry into all areas of the lungs and periods ofapnoea.

Endotracheal intubation was performed withoutrelaxation and a considerable quantity of tenacioussputum removed by suction. Normal colour rapidlyreturned to the mucous membranes and she coughedstrenuously with the tube in place.

Following this procedure, tidal ventilation remainedadequate. The air entry improved in all areas andcough remained effective. Further intubation was notrequired. The child responded satisfactorily to anti-biotics and was discharged in due course.

M&D'CAL Ll&KAn.,U S. NAVALPHILADELPHIA.


Comment. Where the secretions are tenaciousand accumulate in quantity, anoxia will eventuallydepress the cough reflex. In such a case it is diffi-cult to see any alternative to intubation and suc-tion.

Case No. 17.

Repeated Intubation and Suction

A male child aged 6 weeks, birth weight 5 lb.(2.25 kg), was admitted suffering from cyanosis andrespiratory distress. For the three weeks prior toadmission he had been treated at home with oralpenicillin and terramycin.

Shortly after admission his condition deteriorated.Treatment was continued with penicillin, streptomycin,aureomycin and cortisone. During the next few hourshis respiratory rate rose to 96 per minute. He had noair entry except at the left apex.

Intubation was performed without relaxation and3 ml of blood-stained mucus were aspirated. In thenext 2 hours his respiratory rate fell to 50 per minute.During the next 5 days he required daily intubationand suction.

He made an uneventful recovery and was discharged3 weeks later.

Comment. This case illustrates the fact thatrespiratory distress may become more severe inspite of antibiotic therapy. When the respiratoryobstruction was removed by suction, the respira-tory rate fell markedly within half an hour andthere was progressive clinical improvement.

Case No. 3.

Prolonged Intubation, Pleural Drainage

A male child aged 5 weeks, birth weight 8 lb. (3.5kg), was admitted with a history of "snuffles", reluc-tance to feed and diarrhoea of 24 hours duration.

On examination his colour was good, there wassome nasal discharge and scattered rhonchi wereheard throughout the lung fields. The heart soundswere normal.

Thirty-six hours after admission the child collapsedbefore being fed. The skin was pale, mucous mem-branes blue-grey; rib recession was marked and therewas mediastinal shift to the left with no air entry tothe left lung. There were prolonged periods of apnoea.

Intubation was performed with the object of re-expanding the left lung. The response to suction waspoor and gentle positive pressure was required tomaintain ventilation. Bronchoscopy revealed thepresence of scanty secretions in both main bronchiwhich were removed by suction. A loud rough systolicmurmur was now evident across the entire praecor-dium.

As positive pressure resulted in a marked medias-tinal shift to the right, the presence of a broncho-pleural fistula was suspected. This was confirmed byradiographs which demonstrated a left pyo-pneumo-thorax.

The child was transferred to theatre, where drain-age of. the pleural cavity was performed. Followingthis procedure the child remained pale, blue, andcollapsed in spite of the presence of an efficient under-water seal. Respiration still required to be controlled.The loud systolic murmur was still evident. Intramus-cular erythromycin was administered.

During the night endotracheal suction was requiredrepeatedly. The tidal exchange improved slowly andit became possible to discontinue controlled respira-tion.

By the following afternoon the child's conditionhad greatly improved. He remained pink in theoxygenated and humidified atmosphere of the incu-bator; tidal ventilation was reasonable and coughingwas active. It was deemed advisable to remove thetube, which had by now been in position 24 hours,during which period it had twice been changed.

The following day saw this satisfactory progresscontinued. The systolic murmur became less marked.That night, however, the child again collapsed. Adelay of 8 minutes occurred before intubation, whenit was found that the trachea and bronchi were com-pletely blocked by secretions. Inflation of the lungsprior to suction was quite impossible and by the timethe airway was re-established the child was dead.

Postmortem examination showed staphylococcalpneumonia with left empyema; purulent pericarditisand acute bacterial endocarditis.

Comments. (1) Positive pressure must be usedwith caution in those cases where a staphylococcalabscess may have ruptured into the pleura. If thepresence of a bronchopleural fistula is suspected,it may be wise to confine treatment to clearingthe airway by intubation and suction and thenrefrain from exerting positive pressure until suchtime as the surgeon is ready to insert pleuraldrainage. "

(2) It is worthy of note that, in spite of thepostmortem findings in the heart, the immediatecause of death in this child was respiratory ob-struction due to massive accumulation of secre-tions, possibly arising from the sudden rupture ofa staphylococcal abscess into a bronchus.

(3) Intubation and suction over a period of 24hours had no ill effect on the larynx or trachea.

Case No. 16.

Prolonged and Repeated Intubation

A female child aged 14 days, birth weight 5 lb. 13 oz.(2.75 kg) was admitted suffering from distressed res-piration, cyanotic attacks and inability to suck at thebreast

February 6, 1958.11 p.m. On examination the temperature was 95°F,

the pulse and respiratory rates were 142 and 64 perminute respectively. The infant was cyanosed and hadmarked respiratory distress with intercostal recession.


Air entry was absent except over the right upper zone.A marked systolic murmur was audible over thepraecordium.

A laryngoscope was inserted into the pharynx andpurulent secretions were seen to well up from thelaryngeal aperture. The aryepiglottic folds weremarkedly inflamed.

An endotracheal tube was inserted and 3-4 ml ofthick yellow pus were aspirated. Air entry was imme-diately evident over the right lung except at the base.A definite but less marked improvement was notedin the left side of the chest.

The endotracheal tube was strapped in position andshe was nursed in an incubator with the head elevated.The oxygen was humidified by alevaire.

February 7, 1958.1 a.m. Moist sounds were evident in all lung fields

and 1 ml of thick pus was aspirated from the endo-tracheal tube.

3 a.m. 3-4 ml of thick yellow pus were aspiratedfrom the endotracheal tube. The respiratory rate fellto 34 per minute and the colour became pink.

8 a.m. She became dyspnoeic and a further 1 mlof pus was aspirated from the endotracheal tube withsome improvement.

10 a.m. Baby collapsed, became apnoeic and theheart rate slowed to 24 per minute. It was impossibleto inflate the lungs by positive pressure. The endo-tracheal tube was removed and found to be completelyblocked by inspissated secretions. Another tube was

' immediately inserted, secretions aspirated and thelungs reinflated by positive pressure with restorationof air entry to both lungs. Widespread crepitationswere audible.

1 p.m. 1 ml of streptokinase (100 units) was intro-duced into the endotracheal tube and left for half anhour. Aspiration of a quantity of pus was associatedwith improvement in colour and activity.

Aspiration of smaller quantities of secretions wasperformed every 1-2 hours according to their presencein the endotracheal tube. Streptokinase was introduced3-hourly.

11 p.m. Respirations were regular at 36 per minute,the air entry was good but widespread crepitationswere present. The colour was satisfactory and theendotracheal tube was removed. The systolic murmurwas barely discernible.

The pharynx was sucked out hourly and care takento remove all secretions, an adequate exposure beingobtained by placing a spatula in the baby's mouthand depressing the tongue.

February1 8, 1958.Moist sounds were audible at both bases. The. res-

piratory rate had risen to 50 per minute. She wasintubated and 1 ml of pus was removed. One hourlater, the respiratory rate had fallen to 40 per minute.She took her feeds well and started to cry.

February 9, 1958.She developed cyanosis, oedema of the sacrum,

hepatomegaly and splenomegaly. The crepitationswere more obvious on auscultation.

Intubation later on in the day resulted in the aspira-tion of 1 ml of whitish secretions.

February 10, 1958.The hepatomegaly had decreased and oedema of

the sacrum and the cyanosis had disappeared.Intubation produced several plugs of yellow secre-

tions. A considerable quantity of nasal secretions wasalso aspirated.

During the next 3 days the general condition andair entry improved. She was intubated daily andsmaller amounts of secretions removed.February 16, 1958.

The chest was clinically clear. She remained in hos-pital for a period of 2 weeks because of social con-ditions.

Comments. This baby was moribund on admis-sion with secretions pouring from the pharynx.

(1) A phenomenal quantity of purulent secre-tions was aspirated during the first 24 hours. Eventhough the initial suction produced considerableaeration of both lungs, it was necessary to repeatthe aspiration at frequent intervals in order tomaintain this improvement.

(2) At one stage of the treatment blockage ofthe endotracheal tube with inspissated secretionsresulted in collapse, bradycardia, apnoea andcyanosis. Fortunately the airway was quickly res-tored.

To avoid this complication, it was our policy tochange the tube every 12 hours even if it appearedto be patent. We now consider, however, that thepresence of abundant tenacious secretions warrantsa change of endotracheal tube every 6 hours. An-other reason for changing the tube periodically isthat its junction with the metal endotracheal con-nection is often soaked in saliva. This tends tomake the union less secure and the two may comeapart.

(3) It is essential to have a sterile endotrachealtube ready for insertion in an emergency.

(4) In view of the fact that the larynx was veryinflamed on admission, it may be considered thatintubation would necessitate a tracheotomy. Thebaby was intubated seven times in all and in theinitial stage the endotracheal tube was left in posi-tion for 24 hours. In spite of this treatment therewas no evidence of any laryngeal stridor.

Case No. 11.

Repeated Intubation, Prolonged Intubation, Con-trolled Respiration, Tracheotomy

A male child aged 1 month, birth weight 5 lb. 6 oz.(2.5 kg), was admitted with a history of reluctance tofeed, "snuffles" and cyanotic attacks.

On examination he was cyanosed, deeply uncon-


scious, with atony of all limbs. His colour improvedin oxygen but respiratory distress remained severe,with marked rib recession and long periods of apnoea.

The percussion note was dull over both lung fieldsBreath sounds were absent over the whole left lungand crepitations and expiratory rhonchi were markedon the right side.

The larynx, when visualized, was found to showmarked inflammation and a thin stream of pustrickled through the rima glottidis. The child was in-tubated, without relaxant, and a large quantity offluid secretions removed by suction, aided by postureand percussion of the chest.

Following this procedure the air entry was greatlyimproved in all areas, the mucous membranes werepink and the child was coughing actively. The endo-tracheal tube was removed and the airway at this stageappeared satisfactory.

Improvement was maintained during the next 2days. Feeding by tube was accomplished and theairway maintained by nasal and pharyngeal suctionwith posture and percussion of the chest.

Thereafter the condition again became critical, withcyanosis, rib recession and little air entry into theleft lung. During this -period he required repeatedintubation and suction. The laryngeal oedema becameso severe as to cause respiratory obstruction.

In view of this and the fact that periods of apnoeawere frequent, the endotracheal tube was retained forsome hours and respiration controlled. Tracheotomywas later performed as an elective procedure intheatre.

During the next week the child improved. Suctionwas maintained through the tracheotomy tube, oneach occasion being followed by reinflation of thelungs through a cut-down MagiU tube inserted intothe tracheotomy tube. Periods of restlessness res-ponded well to small doses of pethidine by intramus-cular injection.

After 10 days the larynx being reasonably healthy,it was possible to remove the tracheotomy tube. Pro-gress thereafter was satisfactory and the child wasdischarged home 26 days after admission.

Comments. (1) Where mechanical obstructionof such degree exists, there would appear to be noalternative to intubation and suction, whether thelarynx be oedematous or not.

(2) In conjunction with modern antibiotics,tracheotomy gave rise to no difficulties other thanthose associated with the small size of the infant'sair passages.

Case No. 8.Tracheotomy

A female child aged 24 months, was admitted suffer-ing from respiratory distress and cyanosis.

September 26, 1957.On examination she was extremely ill, cyanosed and

restless. The breathing was shallow and irregular.Marked rib recession was accompanied by action ofall her accessory muscles of respiration. She wasunable to cry.

Auscultation showed diminished air entry through-out the chest, which was due to laryngeal oedema.There were no adventitious sounds in the lungs, butsecretions were audible within the trachea.

A tracheotomy was performed, and thick yellowpus was aspirated from the trachea. Restoration ofthe airway was accompanied by the disappearance ofall the signs associated with respiratory embarrass-ment.

She was nursed in an oxygen tent with alevaire, thesecretions were aspirated and the position changedperiodically. She progressed satisfactorily.

September 29, 1957.The mucus became more tenacious and within a

few hours she gradually developed her original signsof respiratory embarrassment. Radiography showedcollapse of the right middle and left lower lobes.

Bronchoscopy through the tracheostome undergeneral anaesthesia showed the presence of a con-siderable quantity of sticky, blood-stained secretions.These were removed and the airway restored withconsiderable clinical improvement

September 30, 1957.She again deteriorated. The airway appeared clear,

but on auscultation there was absence of air entryin the left side of the chest Bronchoscopy revealedthe presence of hard, inspissated and blood-stainedmaterial which wvas removed by forceps and suction.Her condition improved and radiography showed thatthe left lower lobe had expanded but there was"shadowing in the right upper and middle zones".

15 hours later. The above picture was again repeatedand bronchoscopy enabled further removal oftracheal casts.

October 1, 1957.A similar episode necessitated bronchoscopy with

toilet to the bronchial tree. Her clinical picture, how-ever, did not improve as well as previously. Respira-tion remained somewhat laboured and the child ap-peared to be exhausted.

3 hours later. Her dyspnoea increased and it wasconsidered unlikely that she had had time to formfurther tracheal casts. 5 ml (100 units) of strepto-kinase were injected through the tracheostome andthree hard inspissated clots followed by a fair amountof thin yellow pus were aspirated with considerableimprovement in her condition. Streptokinase wasinjected 3 times a day for a period of 3 days.

In view of her desire to cough spontaneously duringthe above period of treatment it was decided tomodify the standard tracheotomy tube. An Alder Heytracheotomy tube (figs. 3, 4) was inserted whichenabled her to cough effectively. The secretionscoughed into the larger bronchi were then removed(Wilson, 1958).

October 11, 1957.She gradually improved and the occluder was in-

serted into the tracheotomy tube.

October 22, 1957.The tracheotomy tube was removed.

October 30, 1957.She was discharged.


FIG. 3The Alder Hey Tracheotomy Tube.

The inner tube has been removed and the occluderinserted, thus restoring the normal anatomical airway.

FIG. 4The Alder Hey Tracheotomy Tube.

The inner tube is in place. Its expanded end pro-vides for the attachment of the T-piece circuit and

thus facilitates the use of positive pressure.C

Comments. (1) It is essential to humidify theinspired air of patients subjected to tracheotomy,especially if secretions are abundant. In this casewe had no humidifier, the inspired air beingbubbled through water. It was feared from thestart of treatment that tracheal casts would beproduced and our suspicions were soon found tobe correct.

It is probable that many of these complicationswould have been avoided if humidification hadbeen satisfactory.

(2) This child had attempted to cough through-out the disease, but was unable to dear thebronchi of secretions.

The smaller divisions of the bronchial treemay be cleared effectively by one method only.The secretions must be coughed up into the largerbronchi. Patients with tracheotomies, however,are unable to cough effectively because they areunable to build up the requisite intrathoracicpressure, as the larynx is partly deprived of its.natural function. In the adult, if the patient isconscious, this disadvantage may be obviated byasking him to inspire, when coughing may bemade effective by occlusion of the tracheostome.Smaller children and especially infants usuallywill not co-operate in this manner. Even if theydo, the respiratory rate is much higher and it isdifficult to correlate occlusion of the tracheostomewith the inspiratory and explosive efforts of thechild. Occlusion of the tracheostome at the wrongtime will cause distress due to the resultant feel-ing of suffocation. Also, the increased negativepressure arising in the alveoli may cause furtheralveolar collapse.

It was with the above factors in mind that itwas decided to modify the tracheotomy tubes inpresent use (figs. 3, 4). The occluder, when in-serted, restores the normal anatomical, airway. Ifthe child is trying to cough either spontaneouslyor after stimulation by catheter the inner tube mayquickly be removed and the occluder inserted.The normal airway being thus restored, coughingwill be instantly effective, provided the laryngealorifice is not completely occluded. Any sputumproduced may then be expectorated through thenormal channels or collected from the largerbronchi by means of a catheter, on removal ofthe occluder.


This method, therefore, has the advantage ofrestoring the normal anatomical airway whichmay again be converted into a tracheotomy in afew seconds.

DEATHS

Of the eighteen cases presented in table I therewere five deaths (cases 1-5).

(1) A malnourished premature infant, whose cir-culation failed to respond when adequate aeration ofthe lungs was re-established. The child remained pale,apnoeic and hypothermic in spite of controlled venti-lation and good air entry into all areas. She eventuallydied from circulatory tailure after efforts to correctthis had proved unsuccessful. It is probable that shehad been subjected to prolonged hypoxia.

Postmortem examination revealed scattered areasof consolidation in both lungs, free fluid in the pleuraland peritoneal cavities and a patent ductus arteriosus.

(2) This child responded well to intubation andsuction on two occasions. During the night he becametotally obstructed, due either to inhalation of vomitor massive accumulation of secretions, and died ofasphyxia before expert attention was available. Intu-bation was performed and inflation of the lungs foundto be impossible prior to the removal of obstructionmaterial by suction.

(3) This case has already been described andattention drawn to the fact that, despite grave cardiaclesions, death was primarily due to mechanical ob-struction of the airway.

(4) A premature infant whose respiratory distresswas due to bronchiolitis. He responded well to intu-bation and controlled respiration. After being intu-bated nine times, and for several prolonged periods,laryngeal oedema became so severe as to necessitatetracheotomy. His postoperative condition was verysatisfactory.

During the night he became cyanosed, failed torespond to inflation of oxygen through the tracheo-tomy tube and rapidly died. Unfortunately we werenot present and were unable to assess the state of theairway as the tracheotomy tube was removed soonafter death. The history obtained from those inattendance suggests that the tracheotomy tube hadbecome dislodged and was no longer in the trachea.

Autopsy showed patchy collapse of both lowerlobes, with scattered areas of inflammation. There wassome degree of cerebral oedema.

(5) A twin, this child was the elder brother of caseno. 6. He was admitted one day later and followedthe same downhill course, until, collapsed, cyanosedand with totally inadequate tidal ventilation and poorair entry in all areas of both lungs, he requiredintubation and suction.

He responded well. The mucous membranes becamepink, and he coughed on the tube. Respirationsremained periodic in character, however, and it wasconsidered wise to retain the tube in position and con-trol respiration when required.

The tube was changed at frequent intervals andsuction applied as required. Unfortunately, again ata period when we were unable to provide instant

attention, the tube became blocked by secretions andthe child died from asphyxia before they could beremoved.

Of these five deaths, at least three are primarilydue to respiratory obstruction. It is to be hopedthat, when these cases are concentrated in a singleunit where expert attention is instantly availableat all times, such deaths will prove to be avoid-able.

DANGERS AND COMPLICATIONS

That many difficulties may be encountered in themanagement of these cases may be clear from thecase histories above. Constant detailed supervisionis essential to avoid and overcome the many pos-sible complications.

The greatest danger, even with an endotrachealtube in place, still comes from respiratory obstruc-tion, due to the accumulation of secretions orblockage of the tube from various causes.

Laryngeal Oedema.It is held in some quarters that intubation of

the infant's larynx frequently results in oedemawhich may require tracheotomy for relief. Duringthe past five years 35,000 children of all ages havebeen intubated for surgical purposes at Alder Heyand Royal Liverpool Children's Hospitals. Thisnumber has included many hundreds of infants.No such case has yet required tracheotomy as aresult of laryngeal trauma.

Where respiratory infection exists, however,laryngeal oedema must be accounted more likely.Case no. 11 already had marked laryngeal oedemabefore intubation, which undoubtedly aggravatedthe condition and necessitated tracheotomy. Caseno. 4 similarly had a moderate degree of laryngealoedema prior to intubation and tracheotomy wasrequired after the procedure had been repeatednine times. It may be thought inevitable that acertain proportion of cases will require tracheo-tomy where such methods of treatment are essen-tial to overcome respiratory obstruction.

In these cases without marked primary oedema,however, repeated and prolonged intubation haveresulted in remarkably little damage to the larynx.Several additional cases of neonatal respiratorydistress, not primarily of an infective nature, havebeen treated with endotracheal tubes in positionfor several days without harmful results to the


larynx. In one remarkable case of neonataltetanus, Rees and his colleagues retained an endo-tracheal tube in position for 34 days and per-formed bronchoscopy twice daily without markedlaryngeal oedema.

With these facts in view, we consider that theadvantages offered by intubation by far outweighthe possible disadvantage of laryngeal oedema.

Bronchopleural Fistula.Spontaneous rupture of a lung abscess may

occur into a bronchus or into the pleural cavity,or both. If the bronchial tree is flooded by secre-tions, intubation and suction may be required toprevent asphyxia. That the use of positive pres-sure may produce a pneumothorax in these casesis well shown in case no. 3.

It follows that such a possibility must be cons-tantly kept in mind, especially where the infectingorganism is the staph. pyogenes, and carefulwatch maintained on the response of the lungsand mediastinum to positive pressure.

Where such a condition is known to exist andintubation and suction are indicated, it is wise torefrain from using positive pressure until prepara-tions for pleural drainage are complete.

SUMMARY

In spite of modern advances in treatment, thereis still a significant rate of mortality in infants whosuffer from acute respiratory infections.

Failure to clear secretions from the air passagesresults in severe respiratory obstruction and in-creasing hypoxia. Oxygen demand is increased byvirtue of the increased respiratory effort, whileoxygen supply is diminished because of the defec-tive ventilation.

When such a state of respiratory insufficiencyexists, antibiotics are of little value unless the air-way can be maintained until such time as theycan exert their .beneficial effect. Similarly, anobstructed airway must reduce the value of oxy-gen therapy.

Methods by which this state of respiratoryinsufficiency may be alleviated are discussed.These include the use of endotracheal intubation,suction, bronchoscopy, tracheotomy, posture andhumidity; and of controlled respiration where theinfant is too weak to maintain adequate ventila-tion by its own unaided efforts.

A series of eighteen cases treated by suchmethods is described. Thirteen of these infantssurvived. Several case histories are presented insome detail while others are included in tabularform.

The five deaths which occurred in this seriesare discussed. In certain of these cases the pres-ence of associated lesions rendered survival un-likely.

Some complications which may arise arementioned, in particular those arising fromendotracheal intubation in infants. While theseproblems exist, they should not be held to contra-indicate this procedure, especially in cases whereintubation and suction are essential for relief ofrespiratory obstruction and the re-establishmentof adequate ventilation.

ACKNOWLEDGMENTS

We wish to thank Dr. T. Cecil Gray for his adviceand criticism during the preparation of this paper.We are grateful to Dr. G. Jackson Rees and Dr. AlanL. Stead for their encouragement and advice, bothin the preparation of this paper and in the treat-ment of these cases.

Our thanks are also due to Mr. A. Rutana for hisvaluable' advice in the management of those caseswhich required tracheotomy. We are indebted to theConsultant Physicians of Alder Hey Hospital, whoallowed us to treat these cases, and to the JuniorMedical and the Nursing Staffs for the continuous carewhich they devoted to these infants.

We also thank Mr. R. Rodney Green for the photo-graphs and Miss E. A. Kidd for her patience and helpin the preparation of the manuscript.

REFERENCES V

Altschule, M. D., and Sulzbach, W. M. (1947). Toler-ance of human heart to acidosis; reversiblechanges in RS-T interval during severe acidosiscaused by administration of carbon dioxide. Amer.

. Heart J., 33, 458.Attinger, E. O., Herschfus, J. A., and Segal, S. J. (1956).

The mechanics of breathing in different bodypositions. II: In cardiopulmonary disease. /. clin.Invest., 35, 912.

Ayre, P. (1956). The T-piece technique. Brit. J.Anaesth., 28, 520.

Cook, C. D., Sutherland, J. M., Segal, S., Cherry,R. B., Mead, J., Mcllroy, M. B., and Smith, C. A.(1957). Studies of respiratory physiology in thenewborn infant. HI: Measurements of mechanicsof respiration. J. clin. Invest., 36, 440.

Freier, S., Neal, B. W., Nisbet, H. I. A., Rees, G. J.,and Wilson, F. (1957). Salicylate intoxicationtreated with intermittent positive pressure respira-tion. Brit. med. J., 1, 1333.

Gaisford, W., and Lightwood, R. 0953). Paediatricsfor the Practitioner. London: Butterworth.


Goodman, L. S., and Gillman, A. (1955). The Phar-macological Basis of Therapeutics, pp. 39, 920.New York: McMillan.

Goodwin, T. C. (1934). Lipoid cell pneumonia. Amer.J. Dis. Child., 48, 309.

James, V., Brimblecombe, F. S. W., and Weston Wells,J. (1952). The natural history of pulmonarycollapse in childhood. Quart. J. Med., 25, 121.

MacDonald, F. M., and Simonson, E. (1953). Humanelectrocardiogram during and after inhalation of30 per cent carbon dioxide. J. appl. Physiol., 6,304.

Marshall, J., and Spalding, J. M. K. (1953). Humidi-fication in positive pressure respiration for bul-bospinal paralysis. Lancet, 2, 1022.

Mcllroy, M. B., Marshall, R., and Christie, R. V.(1954). The work of breathing in normal subjects.Clin. Sci., 13, 127.

McLaurin, J. G. (1935). A review of the inter-relation-ship of paranasal sinus disease and certain chestconditions, with special consideration of bron-chietasis and asthma. Ann. Otol. (St. Louis), 44,344.

Otis, A. B., Fenn, W. O., and Rahn, H. (1950).Mechanics of breathing in man. J. appl. Physiol.,2, 592.

Pitman, R. G.. and Wilson, F. (1955). Tracheotomy inacute respiratory embarrassment. Lancet, 2, 523.

Quinn, L.H., and Mayer, O. O. (1929). The relation-ship of sinusitis and bronchiectasis. Arch. Oto-laryng. (Chicago), 10, 152.

Rees, G. J. (1954). Neonatal respiration Brit. J.Anaesth., 27, 154.

(1958). Neonatal anaesthesia. Brit. med. Bull,14, 38.

Rickham, P. P. (1957). The surgery of premature in-fants. Arch. Dis. Childh., 32, 508.(1957). Metabolic Response to Neo-natal Sur-

gery, p. 64. Cambridge, Massachusetts: HarvardUniversity Press.

Wilson, F. (1958). Modified tracheotomy tube. Lancet,1, 569.

Woolmer. R. (1956). Management of respiratoryinsufficiency. Anaesthesia, 11, 281.

CORRESPONDENCE

HALOTHANE AND THE ROWBOTHAM'S BOTTLE

Sir,—A few weeks before publication of my paper"Halothane concentration from a Rowbotham'sbottle in a circle absorption system" (Brit. J.Anaesth. (1958), 30, 312) there appeared on themarket a modified Rowbotham's bottle producedby the British Oxygen Company; this version iswickless and has downward facing ports and alarger liquid container. The company claims thatit delivers trichloroethylene vapour in similar con-centrations to the old pattern (B.O.C. andM. & I. E. makes); this may or may not be so,but when used in a circle absorber with halothaneI find that concentrations in excess of the figuresstated in my paper are obtainable. Actual read-ings cannot at the present time be given untilfurther more accurate estimations have beenmade; however, as a rough and safe clinical guide,half to three-quarters "ON" with the new bottleis equivalent to "FULL ON" in the old, forvaporization of the first 10-15 ml of halothane,i.e. for the first hour.

A new vaporizer, offering minimal resistance torespiration, has been designed and is in the pro-cess of manufacture, testing and calibration, butthis will not be available for purchase for some

months, meanwhile it seems advisable to warnwould-be users of the newly introduced B.O.C.'sRowbotham's bottle of the possibility of now pro-ducing concentrations of halothane in a circlesystem in excess of 3.5 per cent.

It was reassuring to see confirmatory clinicalevidence by Brown and Woods (Brit. J. Anaesth.(1958), 30, 333 and 338) for a lack in build-upof concentration of halothane with a circle ab-sorber but I feel it is a pity that they should advo-cate disembowelling and relining an otherwisesatisfactory piece of apparatus when they alreadypossess an adequate alternative.

P. J. C. BURTONSouthlands Hospital,

Shoreham-by-Sea

ERRATUM

The following correction should be made to thepaper on "Halothane concentration from a Row-botham's bottle in a circle absorption system" byP. J. C. Burton in the July 1958 issue (Brit. J.Anaesth., 30, 312):

Page 312, column 2, line 21, should read:". . . Atropine 0.6 mg"

the treatment of acute respiratory infection in infants · the removal of these secretions by...

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