Bronchographic Contrast Mediums

HOWARD F. MARTIN, M.D., Palo Alto. and LLOYD F. O'NEIL, M.D., Aurora. Illinois

THE BISMUTH subcarbonate insufflation techniquesdevised by Jackson and Clerf and the barium sulfatein mineral oil method of Lynah were generallydiscarded soon after Forestier in 1925 summarizedhis experiences with iodized peanut oil (Lipiodoll)for bronchography. But iodized peanut oil andiodized poppyseed oil (Iodochlorols) have well-recognized shortcomings, which has led to the trialof a number of radiopaque materials for bronchog-raphy, with variable success.

Insufflated powder is good for demonstration ofthe trachea and major bronchi, but it rarely showsanything not seen with less risk by bronchoscopy.Barium sulfate in oil is not readily eliminated fromthe tracheobronchial tree, frequently acts as a for-eign body and occasionally produces oil pneumo-nitis. Other combinations of barium with iodizedoils or as collodial suspension (Celobar®*)24 stillentail this possibility. Iodized peanut and poppyseedoils are simple to use and usually result in adequatebronchograms, but both tend to enter the alveoliand require months or even years for completeelimination. Oil pneumonitis is rare, but it has beenreported 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 satisfactorythan Lipiodol and Iodochlorol due to low viscosityand rapid alveolar filling. Other agents such ascesium chloride22 entered the alveoli so rapidly as tobe useless unless mixed with carboxymethylcellulose,but then became so irritating as to cause severeinjury to bronchial mucosa. Thorium dioxide (Thor-otrast®) ' and Joduron B®8 also seem too irri-tating. Some of the newer agents such as Bayer1238 (Broncho-abrodil®) 5,13 iodized benzoic esterin 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 the91st Annual Session of the California Medical Association, SanFrancisco, 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 purposesof comparing the contrast medium Visciodol® (amixture of iodized peanut oil and powdered sul-fanilamide) with lodochlorol® (an iodized poppy-seed oil), it was observed that Visciodol is morereadily administered, produces better broncho-grams with less alveolar filling and clears fromthe lungs far more rapidly and completely thandoes lodochlorol.

Certain even newer highly promising agentsare available but specific results with them arenot included with this report.

Bronchography is a diagnostic procedure thatis contraindicated when the infornation to begained does not exceed the probable risk.

conclusions. These newest agents all seem to giveexcellent 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 intocommon use. Each gives good bronchograms, butnot without definite drawbacks. The present litera-ture usually discusses these agents: the propyl esterof diodone in aqueous solution with sodium car-boxymethylcellulose to increase viscosity (AqueousDionosil®), the same ester in peanut oil (Oily Di-onosil®), and a suspension of finely powderedsulfanilamide in iodized poppyseed oil (Visciodol®) -

Varying ratios of Lipiodol® and sulfanilamide havebeen studied7 and Oily Dionosil has been mixed withsulfanilamide-neohydriol mixtures,14 but only theroutine 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 assuredand the agent quickly loses radiopacity. It appearsto be faster in bronchial filling, fills alveoli less andradiographically clears faster than the other agents.However, acute bronchitis or post-bronchogram py-rexia is frequently reported with this agent.12'18"9Experimental studies of this material in rabbit lungsshow parenchymatous changes even four monthsafter its instillation for a bronchogram.2 The authorsof that study attributed the parenchymatous damageto irritation by the carboxymethylcellulose vehicle.

Oily Dionosil. The peanut oil vehicle used in thispreparation 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 HoursMedium 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 3poor ...... 16 much ...... 28 0 0 2 21 5inadequate ....... 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 0poor .------0 much ......... 0 0 0 0 0einadequate ....... 0 very much ...... 0 0 0 0 0 0

tion of expectoration, swallowing and partial en-zymatic hydrolysis.9"19 It seems less irritating thanAqueous Dionosil, and pathologic studies have dem-onstrated less tendency to granuloma formationsuch as has been observed with plain Lipiodol.12However, even when post-bronchogram x-ray filmsshow clearing of the radiopaque material, surgi-cal specimens often reveal mucosal inflammatorychanges, free oil in the alveoli and intracellular oildroplets.6'25 Studies with rabbit lungs showed oilresidua three months after instillation in 80 per centand after six months in 70 per cent of the rabbits,with foreign body granuloma formation in most ofthe animals. Despite these irritating properties,this agent has been quite widely adopted because itis relatively easy to use.

Visciodol. Since the radiopaque component ofVisciodol is oily and therefore is the relativelynon-absorbable portion of this material,3 and theviscosity-increasing portion of the mixture-sulfa-nilamide is absorbable and then is excreted, it canbe assumed that radiographic clearing representselimination of sulfanilamide. There is the danger ofallergic reaction to sulfonamide as well as to iodineand in certain cases the sulfanilamide has beenthought to have caused partial methemoglobi-nemia.11 Nevertheless, as early as 1953, one groupof investigators reported over seven thousand Vis-ciodol bronchograms without complication.21 Thisagent has approximately three times the viscosity ofLipiodol,4 and it rarely enters the alveoli except inbronchiectatic regions. In general, it seems to' be lesstoxic than most other agents.'1023

Since some physicians still use the same Lipiodolmethed described in 1925, it was deemed worth whileto review the experiments which were the basis forour changes five years ago. In this study, Visciodolwas compared with Iodochlorol as to adequacy ofdemonstration of the tracheobronchial tree, ease ofemployment, alveolar filling and post-bronchogramresidua. Technical errors also were analyzed interms of possible improvement of technique witheach agent.

Basic TechniqueRegardless of the material used, the technique

was constant. Premedication and local anesthesiawere the same as for bronchoscopy. A Stitt broncho-graphic catheter was inserted through the larynxunder indirect laryngoscopy, using a curved catheterguide to facilitate control. Using a syringe connectedto the catheter by an appropriate adapter, thebronchographic agent was injected under fluoro-scopic control. During the injection, both the oto-laryngologist and the radiologist were engaged inobserving the fluoroscopic screen so that the injec-tion rate and the patient's position were adjustedto assure the filling without overfilling of eachbronchial segment. Inadequate anesthesia, delaysallowing loss of the effectiveness of anesthesia, lackof cooperation by the patient and backflow of theagent through the larynx were the major causes ofuncontrolled cough. This usually resulted in a poorbronchogram and, with relatively free-flowing agents,in excessive alveolar filling. Spot films were usuallytaken during the fluoroscopy with the patient erectand 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 thisstudy.

PrecautionsEven more than with bronchoscopy, bronchogra-

phy is contraindicated if the potential dangers equalor exceed the probable benefits of this solely diag-nostic procedure. The respiratory reserve must beadequate. Severe dyspnea practically always presentsan undue risk. Sensitivity to the agents to be usedis a contraindication. Pulmonary secretions mustnot be enough to prevent adequate anesthesia andcontrol of cough, to prevent adequate filling of thetracheobronchial tree by the bronchographic agentor to prevent adequate filling without causing dysp-nea. Since the medical management of severesuppurative bronchitis is essentially the same as forbronchiectasis, the risk of bronchogram is notentirely justified if suppuration is bilateral and notamenable to surgical treatment.

CALIFORNIA MEDICINE294

Figure 1.-Upper left, bronchograph taken with Iodochlorol as contrast medium. Upper right, 24 hours afterinjection of lodochlorol. Below, left and right, corresponding films (same patient) with Visciodol as contrast medium.

ResultsThe present study includes all bronchograms per-

formed by the authors using Iodochlorol or Visci-odol in adult patients at the University of IllinoisHospitals during the two-year period from June 6,1956, through June 4, 1958. This includes 102bronchograms with Iodochlorol and 38 broncho-grams with Visciodol. In 11 patients, for the purposeof this study, the bronchogram was performed usingone of the two agents, and then, after an intervalsufficient for radiographic clearing of the agent fromthe lungs as demonstrated by a new preoperativex-ray film, another bronchogram was made, usingthe other agent.The general results are summarized in Table 1.

The judgments as to adequacy of tracheobronchialdemonstration, relative amount of alveolar fillingand radiopaque material residual after 24 hours,were made by the authors, assisted by one of the

radiology staff. These judgments were made withoutknowledge of the agent employed in any individualbronchogram. Every effort was made to be objec-tive, although admittedly this is at times difficult.The illustrations (Figures 1 and 2) are from twoof the patients who had a second bronchogram withthe alternate contrast agent for comparison withtheir first bronchograms.

Avoidable technical shortcomings brought to lightincluded:* Inadequate demonstration of anterior segmentsof lingula or of upper lobe segments due to inade-quate attention to these areas during positioning ofthe patient under fluoroscopic control.* Inadequate anesthesia due to delay between an-esthesia and carrying out of the procedure.* Poor patient cooperation due to lack of explana-tion of the procedure to the patient.

VOL. 97, NO. 5 * NOVEMBER 1962 295

* si.: :Z ^ .c. ...........................~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.. ...

:;rff. t'' ...................~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.......*jX||_ jW s$ as1i _ Er r~~~~~~~~~~~~~~~~~~~~~~~~~~11....

.o:_f_$:............b_:b..............>_L~~~~~~~~~~~~~~~~~~~~~~~~~~......

Figure 2.-The bronchograph at upper left was taken with Iodochlorol and that at upper right was taken 24hours later. In the lower films (same patient as above)Visciodol was used and the interval was the same.

* Language difficulties making communication im-possible.* Incessant cough by one patient upon whom theprocedure probably should have been avoided inview of this tendency.

In this series we noted no instance in whichVisciodol when employed according to directionssupplied by the manufacturer is any more difficultto use than any other agent. On the contrary, itsslower rate of flow allowed better fluoroscopic con-trol. An interesting observation with Visciodol wasthat it appeared to clear in one or two days, withthe notable exception of areas of saccular bronchi-ectasis, which often appeared prominently on the24-hour follow-up films. It might be an interestingpoint for further research to observe if residualVisciodol in any other areas could possibly repre-sent malfunction of ciliary activity.No matter what agent is used, one of the com-

monest reasons for excessive alveolar filling appearsto be overfilling of the main bronchi. Twenty-fivecubic milliliters of Iodochlorol or 30 ml. of Visci-odol is adequate for a bilateral bronchogram in theaverage adult male, except where a large amount ofthe agent enters saccular of cystic areas.

In none of the patients in the series was any localor systemic reaction observed. In none was therebronchial fistula or postoperative delay of healingthat could be attributed to the bronchogram.

1101 Welch Road, Palo Alto (Martin).

REFERENCES

1. Bickerman, H. A.: Exsufflation with negative pressure:Elimination of radiopaque material and foreign bodies frombronchi of anesthetized dogs, Arch. Int. Med., 93:698-704,May 1954.

2. Bjoirk, L., and Lodin, H.: Pulmonary changes follow-ing bronchography with Dionosil Oily, Acta Radiol., 47:177-80, March 1957.

296 CALIFORNIA MEDICINE

3. Bovornkitti, S., Pantasuwan, P., Kangsadal, P.: Post-bronchographic protein-bound iodine concentration: A studyof five contrast media, Amer. Rev. Resp. Dis., 84:386-98,Sept. 1961.

4. Cohen, S., Perlberg, H. J., and Larde-Arthez, C. R.:The use of Visciodol in bronchography, Radiology, 68:197-203, Feb. 1957.

5. Distelmaier, A., Gloxhuber, C., Hecht, G., Scholtan,W., Vieten, H., and Willman, K. H.: A new contrast me-dium for bronchography, 'Broncho-abrodil' (in German),Forschr. Roentgenstr., 95:155-65, Aug. 1961.

6. Grabiger, R.: On retention of contrast medium afterbronchography with propyliodone Cilag, Fortschr. Roent-genstr., 93:801-03, Dec. 1960 (in German).

7. Gudbjerg, C. E.: Technique and choice of contrastmedia, Acta Radiol., 42:367-73, Nov. 1954.

8. Hellstrom, B. E.: Reaction of lung on bronchographywith water soluble contrast media in rats, comparison be-tween two media, Acta Radiol., 40:371-82, Oct. 1953.

9. Hyde, L., and Bodfish, R. E.: Effect of Propyliodone(Dionosil) bronchograms on blood iodine and radioiodineuptake, Dis. Chest, 39:407-11, April 1961.

10. Johnson, P. M., Benson, W. R., Sprunt, W. H., III,and Dunnagan, W. A.: Toxicity of bronchographic contrastmedia: an experimental investigation, Ann. Otol., 69:1102-13, Dec. 1960.

11. Johnson, P. M., and Irwin, G. L.: An evaluation ofthe pharmacological hazards resulting from use of Visciodolin bronchography, Radiology, 72:816-28, June 1959.

12. Joyne, G. H. C., and Harnick, L. R.: Bronchographywith Dionosil, S. G. and O., 101:425-30, Oct., 1955.

13. Koester, E., and Meyer, H. J.: Bronchography with anew type of contrast medium (in German), Forschr. Roent-genstr., 95:166-72, Aug. 1961.

14. Lecutier, E. R.: Approach to bronchography, Brit. J.Tuberc., 48:184-87, July 1954.

15. Lloyd, M. S., Galler, W., and O'Connor, P.: Experi-mental study in nebulization bronchography, Quart. Bull.Sea View Hosp., 15:83-92, April 1954.

16. Maxwell, D. R., Reid, L., and Simon, G.: Propertiesof a new contrast medium for bronchography: n-propyl2,4,6-triiodo-3-diacetamidobenzoate (propyl docetrizoate),Brit. J. Radiol., 34:744-47, Nov. 1961.

17. Mounts, R. J., and Molnar, W.: The clinical evalua-tion of a new bronchographic contrast medium, Radiology,78:231-33, Feb. 1962.

18. Nice, B., and Azad, M.: The use of Dionosil in bron-chography, a preliminary report, Radiol., 66:1-8, Jan. 1956.

19. Norris, C. M., and Stauffer, H. M.: Bronchographywith Dionosil, Ann. Otol. Rhin. and Laryng., 63:520-31,June 1954.

20. Rengarts, R. T.: Bronchography with water solublemedia, Dis. Chest, 28:558-67, Nov. 1955.

21. Salinger, P. L., and Houghton, H. G. H.: Bronchog-raphy: a plea for the use of suspension of sulphanilamide iniodized oil, Brit. J. Tuberc., 47:225-26, Oct. 1953.

22. Shapiro, R.: A preliminary report on the use of Ce-sium chloride in contrast radiography, Acta radiol., 46:635-39, Nov. 1956.

23. Smith, L. C., and Harrill, J. A.: Observations onaqueous and oily media in lungs of experimental animals,Ann. Otol. Rhin. and Laryng., 64:588-98, June 1955.

24. Teixeira, J., and Teixeira, L. C.: Bronchography with-out oil and iodine: the use of barium as a contrast medium,Dis. Chest, 36:256.64, Sept. 1959.

25. Wisoff, C. P., and Felson, B.: Bronchography withoily Dionosil, J. Thor. Surg., 29:435-46, April 1955.

:

4'4',

VOL. 97, NO. 5 * NOVEMBER 1962 297