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Atelectasis in the postsurgical patient or patients on artificial ventilation problems is a frequently occurring complication. Bronchoscopy, local secretion removal by suction, lavage and vigorous positive pressure ventilation in many cases fail to re-expand the collapsed lung. Intubation after bronchoscopy by a double lumen tube permits systematic overinflation of the collapsed lung whereas the other lung is open to atmospheric pressure. In this manner the opening pressure of the collapsed lung can be overcome without overdistension of the other lung. The result is a marked improvement of oxygenation by reducing the venous admixture in lung.

Arrhythmias often complicate the course of patients with severe respiratory disease; the frequency of arrhythmias in patients with this condition approaches that seen with acute myocardial infarction. No one rhythm disturbance predominates, but rapid atrial and ventricular rhythms are characteristic. In the setting of acute respiratory failure, several conditions may predispose to arrhythmias. Hypoxemia, a serum pH that is too high or too low, and a low serum potassium may produce arrhythmias by disturbing the myocardial cellular milieu. Drugs such as digitalis, epinephrine, and theophylline may also act as myocardial irritants. The first step in therapy is to careful examination, it is helpful to note the specific effect of the arrhythmia on the patient. Some rhythm disturbances are well tolerated, while others are associated with serious problems in ventilation and perfusion. In many cases the control of respiration, correction of pH and electrolyte imbalance, and provision of bronchial hygiene will restore a normal sinus rhythm. Such measures are essential even when antiarrhythmic drugs or cardioversion are needed.

The neonatal pleural empyema, especially in its most serious form, following staphylococcal pneumonia, presents a surgical problem demanding immediate emergency treatment. In 1957, we proposed that after diagnosis the empyema should immediately by drained by intercostal suction although in those times drainage was only an attempt after numerous aspirations. Children treated for pleural suppuration in the past were subjected to follow-up studies over a period of 14 to 15 years. Two comparative groups of "early-drained" and "late-drained" empyema cases showed that after immediate drainage there was definite improvement. Careful study of all the data of our 273 cases (up to 1970) shows that immediate continuous suction drainage with specific antibiotic and general supportive treatment have been very successful.

Two patients who required ventilatory support for acute pulmonary disease failed to be weaned when they developed the Guillain-Barré syndrome. Respiratory muscle weakness was a major sign of their acute neuromuscular disease because the manifestations of critical illness obscured the progressive paralysis. Both cases illustrate the difficulty in diagnosing acute neuromuscular syndromes in critically ill patients.

Right middle lobe syndrome (RMLS) is characterized by a spectrum of diseases from recurrent atelectasis and pneumonitis to bronchiectasis of the middle lobe. It has been described among all age groups, although the diagnosis in pediatrics may be delayed or missed because of non-specific symptoms or findings. Twenty-one children with RMLS were evaluated during the past 10 years with particular attention to the history, bronchoscopic and pathologic findings. Most of these patients had asthma or a family history of atopic disorders; 3 patients had a family history of RMLS. Only two of the 21 patients had sufficient obstruction on bronchoscopy to account for their disease. Four had evidence of concomitant laryngeal pathology. The various theories of pathogenesis are discussed. In this series, the non-obstructive (impaired collateral ventilation) theory appeared to be most plausible. Bronchoscopy was performed in all instances to rule out obstruction due to foreign body or tumor. It was therapeutic in two-thirds of the cases. Resolution occurred promptly in one-third, and eventually in another third. Of the remaining patients, 4 required lobectomy and were cured; two have decreased but persistent symptoms. An aggressive medical management following bronchoscopy is warranted in all cases, especially when there is a possibility of asthma.

This work confirms the generally known decrease in arterial oxygen following surgery. On the basis of a more rapid restitution of pulmonary function the superiority of mobilization to the usual respiratory exercises is clearly shown.