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Bronchographic Contrast Mediums HOWARD F. MARTIN, M.D., Palo Alto. and LLOYD F. O'NEIL, M.D., Aurora. Illinois
THE BISMUTH subcarbonate insufflation techniques devised by Jackson and Clerf and the barium sulfate in mineral oil method of Lynah were generally discarded soon after Forestier in 1925 summarized his experiences with iodized peanut oil (Lipiodoll) for bronchography. But iodized peanut oil and iodized poppyseed oil (Iodochlorols) have well- recognized shortcomings, which has led to the trial of a number of radiopaque materials for bronchog- raphy, with variable success.
Insufflated powder is good for demonstration of the trachea and major bronchi, but it rarely shows anything not seen with less risk by bronchoscopy. Barium sulfate in oil is not readily eliminated from the tracheobronchial tree, frequently acts as a for- eign body and occasionally produces oil pneumo- nitis. Other combinations of barium with iodized oils or as collodial suspension (Celobar®*)24 still entail this possibility. Iodized peanut and poppyseed oils are simple to use and usually result in adequate bronchograms, but both tend to enter the alveoli and require months or even years for complete elimination. Oil pneumonitis is rare, but it has been reported with these agents, particularly after over- filling of a segmental bronchus.
Certain experimental agents such as Xumbra- dil®t20 and Acmiodol®tl5 have been less satisfactory than Lipiodol and Iodochlorol due to low viscosity and rapid alveolar filling. Other agents such as cesium chloride22 entered the alveoli so rapidly as to be useless unless mixed with carboxymethylcellulose, but then became so irritating as to cause severe injury to bronchial mucosa. Thorium dioxide (Thor- otrast®) ' and Joduron B®8 also seem too irri- tating. Some of the newer agents such as Bayer 1238 (Broncho-abrodil®) 5,13 iodized benzoic ester in peanut oil (Pulmidol®) ,16 and the aqueous sus- pension of propyl-diol-diiodopyridone and diiodo- pyridone (Hytrast®)17 seem quite promising, al- though present reports are insufficient for dependable
Presented before the Section on Ear, Nose and Throat at the 91st Annual Session of the California Medical Association, San Francisco, April 15-18, 1962.
Celobar® is: Barium Sulfate (65.3 gm. per cent), Methylcellulose (0.8 gm. per cent) in physiological saline. tXumbradil® is: Solution of Diodon® (diethanolamine salt of
diiodo-9yriden-N-acetic acid) and sodium salt of cellulose glycolicacid et er. lAcmiodol® is 2-(2,4,6-Triiodophenoxy) propane, 27.0 per cent,
1-( 2,4,6-Triiodophenoxy) hexane, 29.2 per cent, Cottonseed oil, 43.8 per cent.
* In a study of 102 bronchograms for purposes of comparing the contrast medium Visciodol® (a mixture of iodized peanut oil and powdered sul- fanilamide) with lodochlorol® (an iodized poppy- seed oil), it was observed that Visciodol is more readily administered, produces better broncho- grams with less alveolar filling and clears from the lungs far more rapidly and completely than does lodochlorol.
Certain even newer highly promising agents are available but specific results with them are not included with this report.
Bronchography is a diagnostic procedure that is contraindicated when the infornation to be gained does not exceed the probable risk.
conclusions. These newest agents all seem to give excellent contrast and are currently under investiga- tion as to safety, route and rate of elimination, alveolar fill and other important factors.
In the past ten years, three agents have come into common use. Each gives good bronchograms, but not without definite drawbacks. The present litera- ture usually discusses these agents: the propyl ester of diodone in aqueous solution with sodium car- boxymethylcellulose to increase viscosity (Aqueous Dionosil®), the same ester in peanut oil (Oily Di- onosil®), and a suspension of finely powdered sulfanilamide in iodized poppyseed oil (Visciodol®) - Varying ratios of Lipiodol® and sulfanilamide have been studied7 and Oily Dionosil has been mixed with sulfanilamide-neohydriol mixtures,14 but only the routine forms of Dionosil and Visciodol are per- tinent to the present discussion.
Aqueous Dionosil. This material is water soluble, the rapid elimination of the contrast dye is assured and the agent quickly loses radiopacity. It appears to be faster in bronchial filling, fills alveoli less and radiographically clears faster than the other agents. However, acute bronchitis or post-bronchogram py- rexia is frequently reported with this agent.12'18"9 Experimental studies of this material in rabbit lungs show parenchymatous changes even four months after its instillation for a bronchogram.2 The authors of that study attributed the parenchymatous damage to irritation by the carboxymethylcellulose vehicle.
Oily Dionosil. The peanut oil vehicle used in this preparation seems to be eliminated by a combina-
VOL. 97, NO. 5 * NOVEMBER 1962 293
TABLE 1.- Study of Factors Affecting Adequacy of Two Contrast Media Used In Making Bronchograms
Contrast Tracheobronchial Alveolar Radiopaque Residua After 24 Hours Medium Demonstration Filling None Slight Moderate Much Very Much
Iodochlorol® very good ...... 21 none ...... 12 1 10 1 0 0 (102 patients) good .----- 31 slight ...... 26 0 11 11 4 0
fair .----- 28 moderate .----- 29 0 3 12 11 3 poor ...... 16 much ...... 28 0 0 2 21 5 inadequate ....... 6 very much ....... 7 0 0 0 1 6
Visciodolg very good ...... 20 none ...... 17 5 10 2 0 0 (38 patients) good .----- 12 slight .----- 17 0 12 5 0 0
fair .------ 6 moderate ....... 4 0 1 1 2 0 poor .------0 much ......... 0 0 0 0 0e inadequate ....... 0 very much ...... 0 0 0 0 0 0
tion of expectoration, swallowing and partial en- zymatic hydrolysis.9"19 It seems less irritating than Aqueous Dionosil, and pathologic studies have dem- onstrated less tendency to granuloma formation such as has been observed with plain Lipiodol.12 However, even when post-bronchogram x-ray films show clearing of the radiopaque material, surgi- cal specimens often reveal mucosal inflammatory changes, free oil in the alveoli and intracellular oil droplets.6'25 Studies with rabbit lungs showed oil residua three months after instillation in 80 per cent and after six months in 70 per cent of the rabbits, with foreign body granuloma formation in most of the animals. Despite these irritating properties, this agent has been quite widely adopted because it is relatively easy to use.
Visciodol. Since the radiopaque component of Visciodol is oily and therefore is the relatively non-absorbable portion of this material,3 and the viscosity-increasing portion of the mixture-sulfa- nilamide is absorbable and then is excreted, it can be assumed that radiographic clearing represents elimination of sulfanilamide. There is the danger of allergic reaction to sulfonamide as well as to iodine and in certain cases the sulfanilamide has been thought to have caused partial methemoglobi- nemia.11 Nevertheless, as early as 1953, one group of investigators reported over seven thousand Vis- ciodol bronchograms without complication.21 This agent has approximately three times the viscosity of Lipiodol,4 and it rarely enters the alveoli except in bronchiectatic regions. In general, it seems to' be less toxic than most other agents.'1023
Since some physicians still use the same Lipiodol methed described in 1925, it was deemed worth while to review the experiments which were the basis for our changes five years ago. In this study, Visciodol was compared with Iodochlorol as to adequacy of demonstration of the tracheobronchial tree, ease of employment, alveolar filling and post-bronchogram residua. Technical errors also were analyzed in terms of possible improvement of technique with each agent.
Basic Technique Regardless of the material used, the technique
was constant. Premedication and local anesthesia were the same as for bronchoscopy. A Stitt broncho- graphic catheter was inserted through the larynx under indirect laryngoscopy, using a curved catheter guide to facilitate control. Using a syringe connected to the catheter by an appropriate adapter, the bronchographic agent was injected under fluoro- scopic control. During the injection, both the oto- laryngologist and the radiologist were engaged in observing the fluoroscopic screen so that the injec- tion rate and the patient's position were adjusted to assure the filling without overfilling of each bronchial segment. Inadequate anesthesia, delays allowing loss of the effectiveness of anesthesia, lack of cooperation by the patient and backflow of the agent through the larynx were the major causes of uncontrolled cough. This usually resulted in a poor bronchogram and, with relatively free-flowing agents, in excessive alveolar filling. Spot films were usually taken during the fluoroscopy with the patient erect and the x-ray apparatus at the routine 6-foot dis- tance. Because the technique with children is some- what different, no children were included in this study.
Precautions Even more than with bronchoscopy, bronchogra-
phy is contraindicated if the potential dangers equal or exceed the probable benefits of this solely diag- nostic procedure. The respiratory reserve must be adequate. Severe dyspnea practically always presents an undue risk. Sensitivity to the agents to be used is a contraindication. Pulmonary secretions must not be enough to prevent adequate anesthesia and control of cough, to prevent adequate filling of the tracheobronchial tree by the bronchographic agent or to prevent adequate filling without causing dysp- nea. Since the medical management of severe suppurative bronchitis is essentially the same as for bronchiectasis, the risk of bronchogr