PNEUMOTHORAX

PNEUMOTHORAX

Definition of Pneumothorax

Pneumothorax is a collection of air or gas in the pleural space of the lung, causing the lung to collapse. Pneumothorax may be the result of an open chest wound that permits the entrance of air, the rupture of an emphysematous vesicle on the surface of the lung, a severe bout of coughing, or it may occur spontaneously without evident cause.

Pneumothorax is a lung disorder in which air in the lungs leaks out through holes in the lung tissue into the spaces outside the lung airways. Pneumothorax is one type of lung disorders called air leak syndrome. A baby can have more than one form of air leak. Types of air leaks include the following:

· Pneumothorax - air leaks into the space between the chest wall and the outer tissues of the lungs.

· Pneumomediastinum - air leaks into the mediastinum (the space in the thoracic cavity behind the sternum and between the two pleural sacs containing the lungs).

· Pneumopericardium - air leaks into the sac surrounding the heart.

· Pulmonary interstitial emphysema (PIE) - air leaks and becomes trapped between the alveoli, the tiny air sacs of the lungs.

Air leaks may occur suddenly or may develop gradually. The degree of illness depends on the location of the leak and the amount of air.

Right-sided pneumothorax on CT scan of the chest or abdomen. A chest tube is in place--side of chest, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white). The heart can be seen in the centre.

In medicine (pulmonology), a pneumothorax is a potential medical emergency wherein air or gas is present in the pleural cavity. A pneumothorax can occur spontaneously. It can also occur as the result of disease or injury to the lung, or due to a puncture to the chest wall. A pneumothorax can result in a collapsed lung, or can be created therapeutically to collapse a lung.

Etiology

It most commonly arises:

· Spontaneously (most commonly in tall slim young males and in Marfan syndrome)

· Following a penetrating chest wound

· Following Barotrauma to the lungs

· It may also be due to:

· Chronic lung pathologies including emphysema, asthma

· Acute infections

· Chronic infections, such as tuberculosis

· Lung aggravation caused by Cystic Fibrosis

· Cancer

Pneumothoraces are divided into tension and non-tension pneumathoraces. A tension pneumothorax is a medical emergency as air accumulates in the pleural space with each breath. The increase in intrathoracic pressure results in massive shifts of the mediastinum away from the affected lung compressing intrathoracic vessels. A non-tension pneumothorax by contrast is of lesser concern because there is no ongoing accumulation of air and hence no increasing pressure on the organs within the chest.

The accumulation of blood in the thoracic cavity (hem thorax) exacerbates the problem, creating a hemopneumothorax

The following babies are most at risk for pneumothorax:

· babies with other lung diseases such as hyaline membrane disease (HMD)

· babies on mechanical ventilators

· premature babies whose lung tissues are more fragile

· babies with me conium aspiration because the me conium plugs the airways and can weaken the tissues

What causes pneumothorax?

Air leaks occur when the alveoli (tiny air sacs) become overdistended and burst. Pressure of the air delivered by mechanical ventilators (breathing machines) is the most common cause. Meconium aspiration (inhalation of the first stools passed in utero) can also trap air and lead to overdistention (the lungs expand too much) and air leaks. Air leaks often occur in the first 24 to 36 hours when lung disease is at its peak. Some otherwise healthy babies can develop a "spontaneous" air leak that does not cause symptoms or distress.

Description of Pneumothorax

The major types of pneumothorax are:

v Open pneumothorax results when a penetrating chest wound enables air to rush in and cause the lungs to collapse.

v Closed pneumothorax results when the chest wall is punctured or air leaks from a ruptured bronchus (or a perforated esophagus) and eventually ruptures into the pleural space.

v Spontaneous pneumothorax occurs in a previously healthy individual with no prior trauma. This is thought to be due to rupture of a bleb (a blister containing air) on the surface of the lung. This spontaneous pneumothorax is most frequent in people under the age of 40.

v Pulmonary Barotrauma occurs when a patient whose lung function is being maintained mechanically may have air forced into the lungs, which may rupture the pleural space.

Other things can cause pneumothorax. Air can enter the mediastinum (the space in the center of the chest between the lungs), especially during an asthmatic attack, and then rupture into the pleural space, causing a pneumothorax. When a lung biopsy specimen is taken at the time of bronchoscopy or during thoracentesis (removal of fluid from the pleural space), the pleura lining the lung may be penetrated, causing a leak of air which may then cause a pneumothorax.

Signs and symptoms

The following are the most common symptoms of pneumothorax. However, each baby may experience symptoms differently. Symptoms may include:

· Increasing respiratory distress, including rapid breathing, grunting, nostril flaring, and chest wall retractions

· Difficulty hearing breath sounds when listening with a stethoscope

· Change in the location of heart or lung sounds when the organs are moved by the presence of air

· Changes in arterial blood gas levels

The symptoms of pneumothorax may resemble other conditions or medical problems. Always consult your baby's physician for a diagnosis.

There may be no symptoms if the pneumothorax is small (a small amount of air in the pleural space) or there may be shortness of breath if a large amount of air is in that space. If a physician suspects a pneumothorax, a chest x-ray may be taken to confirm the diagnosis and to determine the amount of air present.

Pneumothorax presents mainly as a sudden shortness of breath, dry coughs, cyanosis (turning blue) and pain felt in the chest, back and/or arms. In penetrating chest wounds, the sound of air flowing through the puncture hole may indicate pneumothorax, hence the term "sucking" chest wound. The flopping sound of a punctured lung is also occasionally heard. Subcutaneous emphysema is another symptom.

If untreated, hypoxia may lead to loss of consciousness and coma. In addition, shifting of the mediastinum away from the site of the injury can obstruct the superior and inferior vena cava resulting in reduced cardiac preload and decreased cardiac output. Untreated, a severe pneumothorax can lead to death within several minutes

Spontaneous Pneumothoraces are reported in young people with a tall, skinny stature. There is a preponderance among men, possibly because men are in general taller than women. The reason for this association, while unknown, is hypothesized to be the presence of subtle abnormalities in connective tissue. Some spontaneous Pneumothoraces, however, are results of "blebs", blister like structures on the surface of the lung, that rupture allowing the escape of air into the pleural cave

Pneumothorax can also occur as part of medical procedures, such as the insertion of a central venous catheter (an intravenous catheter) in the subclavian vein or jugular While rare, it is considered a serious complication and needs immediate treatment. Other causes include mechanical ventilation, emphysema and quite rarely other lung diseases (p Tuberculosis

· Pneumonia

· Asthma

· Cystic fibrosis

· Lung cancer

· Interstitial lung disease

· Marfan syndrome

· Lymphangioleiomyomatosis

Investigations

In addition to a complete medical history and physical examination, diagnostic procedures for pneumothorax may include:

· Chest x-rays - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. X-rays may show the following:

o air in places outside the normal lung airways

o collapse of the lung

o movement or shifting of other organs in the chest away from the air leak sick

· Tran illumination - a fiber optic light probe placed on the baby's chest wall (the side of the chest with the air leak transmits brighter light). This procedure is often used in an emergency.

AEM: Emergency Bedside Ultrasound to Detect Pneumothorax

A relatively new application of emergency ultrasound is its use in the diagnosis of pneumothorax. In patients with major trauma, early detection and treatment of pneumothorax are vital.

Diagnosis

The absence of audible breath sounds through a stethoscope can indicate that the lung is not unfolded in the pleural cavity. This accompanied by hyper resonance (higher pitched sounds than normal) to percussion of the chest wall is suggestive of the diagnosis. The "coin test" may be positive. Two coins when tapped on the affected side, produce a tinkling resonant sound which is audible on auscultation.

If the signs and symptoms are doubtful, an X-ray of the chest can be performed, but in severe hypoxia, or evidence of tension pneumothorax emergency treatment has to be administered first.

In a supine chest X-ray the deep sulcus sign is diagnostic^[, which is characterized by a low lateral costophrenic angle on the affected side. In layman's terms, the place where rib and diaphragm meet appears lower on an X-ray with a deep sulcus sign and suggests the diagnosis of pneumothorax.

Differential diagnosis

When presented with this clinical picture, other possible causes include:

· Acute Myocardial Infarction: presents with shortness of breath and chest pain, though MI chest pain is characteristically crushing, central and radiating to the jaw, left arm or stomach. Whilst not a lung condition, patients having an MI often happen to also have lung disease.

· Emphysema: here, delicate functional lung tissue is lost and replaced with air spaces, giving shortness of breath, and decreased air entry and increased resonance on examination. However, it is usually a chronic condition, and signs are diffuse (not localized as in pneumothorax).

Careful history taking and examination and a chest X-ray will allow accurate diagnosis.

Pathophysiology

Mechanics of a sucking chest wound. A. Air enters the chest through the opening in the chest wall during inspiration (a). The lung collapses on the affected side (b), air passes out of affected bronchus. Air enters the bronchus from the collapsed lung (c) and passes to the intact lung. The mediastinum shifts toward the uninvolved side (d), and hemothorax occurs (e). B. During expiration, air escapes through the wound (a). The collapsed lung expands (b). Air passes from the uninvolved side to the lung on involved side and out the trachea (c). The mediastinum shifts to the involved side (d), and hemothorax occurs (e).

The lungs are located inside the chest cavity, which is a hollow space. Air is drawn into the lungs by the diaphragm (a powerful abdominal muscle). The pleural cavity is the region between the chest wall and the lungs. If air enters the pleural cavity, either from the outside (open pneumothorax) or from the lung (closed pneumothorax), the lung collapses and it becomes mechanically impossible for the injured person to breathe, even with an open airway. If a piece of tissue forms a one-way valve that allows air to enter the pleural cavity from the lung but not to escape, overpressure can build up with every breath; this is known as tension pneumothorax. It may lead to severe shortness of breath as well as circulatory collapse, both life-threatening conditions. This condition requires urgent intervent

FIRST AID

Chest wound

Wounds (also known as 'sucking chest wounds') require immediate coverage with an occlusive dressing, field dressing, or pressure bandage made air-tight with petroleum jelly or clean plastic sheeting. The sterile inside of a plastic bandage packaging is good for this purpose; however in an emergency situation any airtight material, even the cellophane of a cigarette pack, can be used. A small opening, known as a flutter valve, may be left open so the air can escape while the lung reinflates. Any patient with a penetrating chest wound must be closely watched at all times and may develop a tension pneumothorax or other immediately life-threatening respiratory emergency at any moment. They cannot be left alone.

Blast injury or tension

If the air in the pleural cavity is due to a tear in the lung tissue (in the case of a blast injury or tension pneumothorax), it needs to be released. A thin needle can be used for this purpose, to relieve the pressure and allow the lung to reinflate.

Pre-hospital care

Many paramedics can perform needle thoracocentesis to relieve intrathoracic pressure. Incubation may be required, even of a conscious patient, if the situation deteriorates. Advanced medical care and immediate evacuation are strongly indicated.

An untreated pneumothorax is an absolute contraindication of evacuation or transportation by flight.

Clinical treatment

If the lung is less than 20 to 25 percent collapsed, the physician may choose to watch the progress by a series of chest x-rays until the air is completely absorbed or the lung completely re-expands.

If collapse of the lung exceeds 25 percent or if you are short of breath at rest, the physician may recommend removing the air through your chest wall. This can be done with a needle, but is better performed by inserting a tube and applying constant suction for 24 hours or more. The latter procedure also helps to prevent recurrence of pneumothorax

Small Pneumothoraces are often managed conservatively as they will resolve on their own. Repeat observation via chest X-rays and oxygen administered to speed the resolution is often carried out. Pneumothoraces which are too small to require tube thoracostomy and too large to leave untreated, have been aspirated with a needle.

Larger Pneumothoraces may require tube thoracostomy, also known as chest tube placement. If a thorough anesthetizing of the parietal pleura and the intercostals muscles is performed, the only major pain experienced should be either the injury that caused the pneumothorax or the re-expanding of the lung. Proper anesthetizing will come about by the following procedure: the needle should be inserted into the chest cavity and a negative pressure created in the syringe. While air bubbles rise into the syringe, the needle should be slowly pulled out of the cavity until the bubbles cease. The tip of the syringe that contains the anesthetic is now in the intercostals muscles. A proper and sizable injection should ensue. This will allow the patient to be fairly comfortable despite a hemostat or finger being inserted into the chest cavity. A tube is then inserted into the chest wall outside the lung and air is extracted using a simple one way valve or vacuum and a water valve device, depending on severity. This allows the lung to re-expand within the chest cavity. This re-expansion usually lasts for approximately 15–30 seconds depending on the size of the pneumothorax and feels as if your breath has been taken away. This response is normal and should pass fairly quickly. The pneumothorax is followed up with repeated X-rays. If the pneumothorax has resolved and there is no further air leak, the chest tube removed. If, during the time that the tube is still in the chest, the lung manages to sustain the re-expansion once suction is turned off, but the lung still diminishes if actually clamped off, a Heimlich valve may be used. This flutter valve allows air and fluid in the pleural cavity to escape the pleura into a drainage bag while not letting any air or fluid back in. This method was developed by the military in order to get soldiers with lung injuries stable and out of the battle field faster. It is a rarely used medical device in the treatment of patients these days, but may be used in order to allow the patient to leave the hospital.

It is critical that the chest tube be managed in such a way that it does not become occluded with clot or other fibrinous material. Chest tube clogging can result in build up of air in the pleural space. At the very least, this will lead to a recurrent pneumothorax. In the worse case, the patient can have a tension pneumothorax if the air builds up under pressure and impairs venous return to the heart. This can be fatal. The tubes have a tendency to form clot from blood and other fibrinous material that can occlude them. To keep them open they must be stripped, milked or even replaced if they totally occlude. Smaller tubes are more prone to clogging, although this can occur with larger tubes. One sign the chest tube is clogged is subcutaneous emphysema. Another is a loss of respiratory variation in the fluid in the tube to the drainage canister.

In the situation that the chest tube does not seem to be helping (for example a continued air leak despite chest tube drainage) the healing of the lung or if CAT scans show the presence of "blebs" on the surface of the lung thoracoscopic surgery, or video assisted thorascopic surgery (VATS), may be done in order to staple the leak shut. Two small incisions are made in the back, one for a small camera and one for the tool used to seal the lung. When finished the wound is covered with a steri-strip and bandaged up.

In case of penetrating wounds, these require attention, but generally only after the airway has been secured and a chest drain inserted. Supportive therapy may include mechanical ventilation.

Recurrent pneumothorax may require further corrective and/or preventive measures such as pleurodesis. If the pneumothorax is the result of bullae, then bullectomy (the removal or stapling of bullae or other faults in the lung) is preferred. Chemical pleurodesis is the injection of a chemical irritant that triggers an inflammatory reaction, leading to adhesion of the visceral pleura, which is in contact with the lung, to the parietal pleura. Substances used for pleurodesis include talc, blood, tetracycline and bleomycin. Mechanical pleurodesis does not use chemicals. The surgeon "roughs" up the inside chest wall ("parietal pleura") so the lung attaches to the wall with scar tissue. This can also include a "parietal" pleurectomy, which is the removal of the "parietal" pleura; "parietal" pleura is the serous membrane lining the inner surface of the thoracic cage and facing the "visceral" pleura, which lies all over the lung surface. Both operations can be performed using keyhole surgery to minimize discomfort to the patient. Sometimes pneumothorax occurs bilaterally in sequence or, more rarely, simultaneously; that is often associated to bilateral apical blebs and obviously requires bilateral treatment.

Specific treatment for pneumothorax and air leak syndrome will be determined by your baby's physician based on:

· Your baby's gestational age, overall health, and medical history

· Extent of the condition

· Your baby's tolerance for specific medications, procedures, or therapies

· Expectations for the course of the condition

· Your opinion or preference

Treatment for pneumothorax may include:

· Supplemental oxygen

· Removal of the collected air by insertion of a chest tube (a needle or catheter placed through the chest wall into the air space). The air may be withdrawn with a syringe or the tube connected to a drainage system to help remove the air until the leak can seal.

Spontaneous air leaks that do not cause symptoms or distress may get better on their own without treatment. As the leak seals over, air is absorbed into the body.

There are no specific treatments for pneumomediastinum and pulmonary interstitial emphysema (PIE), as these air leaks are in spaces that cannot be treated with chest tubes. High frequency ventilation is sometimes used for babies with PIE.

Possible Complications

· Recurrent pneumothorax

· Tension pneumothorax with shock

Tension pneumothorax

tension pneumothorax is a life-threatening condition that results from a progressive deterioration and worsening of a simple pneumothorax, associated with the formation of a one-way valve at the point of a rupture in the lung. Air becomes trapped in the pleural cavity between the chest wall and the lung, and builds up, putting pressure on the lung and keeping it from inflating fully.

Upon inspiration, when the pressure inside the chest and pleural cavity falls as a result of the respiratory muscles increasing chest dimensions, air is sucked in through the one way valve, into the pleural space. Because exhalation is a passive process, there is an insignificant amount of pressure created to force the air back out of the pleural cavity. This condition over time results in a gradual accumulation of air to the degree that it begins to put pressure on the mediastinum, compressing the heart and decreasing cardiac output due to the reduced amount of diastolic filling of the ventricles, and also putting pressure against the trachea, causing it to move away from the midline (the center). Because of the increased thoracic pressure, venous return to the heart is decreased, causing a backup of blood into the venous system, as evidenced by distended jugular veins

Signs and Symptoms

· Decreased or absent breath sounds on the affected side

· Tracheal deviation towards unaffected side

· Hyper resonance on percussion

· Unequal chest rise

· Dyspnea (difficulty breathing)

· Tachypnea (rapid breathing)

· Tachycardia (rapid heart rate)

· Hypotension (low blood pressure)

· Hypoxia (deficiency in the amount of oxygen reaching the tissues)

· Pale, cool, clammy skin

· Subcutaneous emphysema (air trapped beneath the skin)

· Cyanosis (bluish color of skin)

· Jugular venous distension (enlarged jugular veins; late sign)

Treatment

Initial treatment involves the insertion of a large bore cannula or needle into the second intercostals space on the mid-clavicular line (known as "needle thoracostomy", or more commonly, "needle decompression"), thereby releasing the pressure in the pleural cavity and converting the tension pneumothorax to a simple pneumothorax, which is then treated at the earliest opportunity by inserting a chest tube.

Tension pneumothorax represents a medical emergency which cannot often accommodate the time spent waiting for the capture and interpretation of a chest radiograph. Consequently, the decision to proceed with needle decompression must be made clinically (i.e., "at the bedside") by observing the acute presentation and reviewing relevant history. There is some debate on the topic of needle thoracostomy. There are risks associated with the process such as lung laceration, especially if no tension pneumothorax condition is present, and that relieved tension may reaccumulate undetected if the needle thoracostomy becomes dislodged. There is also the possibility that the cannula will not reach the pleural cavity due to a thick chest wall, especially in overweight individuals. Traditionally needle decompression has been attempted using a 4.5cm (2") to 5cm catheter. However, previous studies have shown a failure rate of up to 40% using this technique. Based on the clinical findings and failure rates, it is recommended that a 3.25" 14 gauge needle should be used in order to address the issue of the needle not reaching the pleural space.

Once the needle is placed, a chest tube is inserted. Almost always there is a rush of air released from the pleural space when the chest is entered, then the tube is slipped into the pleural space to drain the air and re-expand the lung. Nearly always, there will be a large air leak that will generally resolve over the subsequent days. If the chest tube becomes clogged or kinked, the tension pneumothorax will reoccur. This can be a life threatening event, especially when un recognized. Chest tubes are prone to clogging with fibrinous material or blood clot. Chest tube clogging can occur in the external portion of the chest tube, where it can be seen, at which point milking and stripping of the tubes can be carried out to try to re open or keep open the tubes. These techniques are controversial and of limited utility. Another option is to create a sterile field, open the chest tube and the connection to the drainage tubing, and introduce a external suction catheter to try to suck out the clogged chest tube. This has the disadvantage of breaking the sterile field, and air can be sucked back into the chest. If the chest tube clogging cannot be cleared, the tube has to be replaced. Often physicians will place large bore chest tubes or multiple chest tubes with the hope of minimizing the potential for chest tube clogging. Chest tube clogging can also occur in the non visible portion of the tube inside the chest, and go unrecognized. In the setting of ongoing air leak this can result in a return of the tension pneumothorax, which can be lethal if unrecognized.

Spontaneous Pneumothorax

Spontaneous Pneumothorax can be classified as primary spontaneous pneumothorax and secondary spontaneous pneumothorax. In primary spontaneous pneumothorax, it is usually characterized by a rupture of a bleb in the lung while secondary spontaneous pneumothorax mostly occurs due to chronic obstructive pulmonary disease (COPD).

Primary spontaneous pneumothorax

A primary spontaneous pneumothorax may occur without either trauma to the chest or any kind of blast injury. This type of pneumothorax is caused when a bleb (an imperfection in the lining of the lung) bursts causing the lung to deflate. The lung is reinflated by the surgical insertion of a chest tube. A minority of patients will suffer a second instance. In this case, thoracic surgeons often recommend thorascopic pleurodesis to improve the contact between the lung and the pleura. If multiple and/or bilateral occurrences continue, surgeons may opt for a far more invasive bullectomy and pleurectomy to permanently adhere the lung to the interior of the rib cage with scar tissue, making collapse of that lung physically impossible. Primary spontaneous pneumothorax is most common in tall, thin men between 17 and 40 years of age, without any history of lung disease. Though less common, it also occurs in women, usually of the same age and body type. The tendency for primary spontaneous pneumothorax sufferers to be tall and thin is not due to weight, diet or lifestyle, but because the genetic predisposition toward those traits often coincides with a genetic predisposition toward high volume lungs with large, burstable blebs. A small portion of primary spontaneous pneumothoraxes occur in persons outside the typical range of age and body type.

Secondary spontaneous pneumothorax

In secondary spontaneous pneumothorax, a known lung disease is the cause of the collapse The most common cause is chronic obstructive pulmonary disease (COPD). However, there are several other diseases that may also lead to spontaneous pneumothorax:

· Tuberculosis

· Pneumonia

· Asthma

· Cystic fibrosis

· Lung cancer

· Interstitial lung disease

· Marfan syndrome

· Lymphangioleiomyomatosis

Pneumothorax in the Newborn

Air leaks from the lungs into other parts of the chest cavity can occur in newborns, and it is a potentially serious problem. Small air leaks can occur in 1 to 2 percent of all births. Babies are normally born with collapsed lungs, and considerable pressure is generated as the newborn's body works to inflate them with the first few breaths. There is no problem whatsoever for 98 percent of all newborns, but in some babies, the lungs do not open completely at once, and the strong pressures generated to inflate the lung may cause small ruptures in the alveoli (the smallest, most plentiful breathing sacs). The leaked air may be removed from the chest cavity by the attending physician. Continuous removal of leaked air is necessary until the ruptures heal.

Prevention of pneumothorax and other air leaks:

Despite careful regulation of the air pressure and the settings on mechanical ventilators, air leaks can still occur. Your baby's physician and other healthcare providers in the newborn intensive care unit (NICU) will watch your baby carefully for signs of air leak so that treatment can be started as quickly as possible.

HOMOEOPATHIC MANAGEMENT

Arsenicum Album

Unable to lie down; fears suffocation. Air-passages constricted. Asthma worse midnight. Burning in chest. Suffocative catarrh. Cough worse after midnight; worse lying on back. Expectoration scanty, frothy. Darting pain through upper third of right lung. Wheezing respiration. Hæmoptysis with pain between shoulders; burning heat all over. Cough dry, as from sulphur fumes; after drinking.

Aconitum Napellus

Constant pressure in left chest; oppressed breathing on least motion. Hoarse, dry, croupy cough; loud, labored breathing. Child grasps at throat every time he coughs. Very sensitive to inspired air. Shortness of breath. Larynx sensitive. Stitches through chest. Cough, dry, short, hacking; worse at night and after midnight. Hot feeling in lungs. Blood comes up with hawking. Tingling in chest after cough.

Ammonium Muriaticum

Hoarseness and burning in larynx. Dry, hacking, scraping cough; worse lying on back or right side. Stitches in chest. Cough loose in afternoon, with profuse expectoration and rattling of mucus. Oppression of chest. Burning at small spots in chest. Scanty secretion. Cough with profuse salivation.

Antimonium Tartaricum

Great rattling of mucus, but very little is expectorated. Velvety feeling in chest. Burning sensation in chest, which ascends to throat. Rapid, short, difficult breathing; seems as if he would suffocate; must sit up. Emphysema of the aged. Coughing and gaping consecutively. Bronchial tubes overloaded with mucus. Cough excited by eating, with pain in chest and larynx. Edema and impending paralysis of lungs. Much palpitation, with uncomfortable hot feeling. Pulse rapid, weak, trembling. Dizziness, with cough. Dyspnea relieved by eructation. Cough and Dyspnea better lying on right side

Bacillinum Burnett

Catarrhal Dyspnea. Humid asthma. Bubbling rales and muco-purulent expectoration. Note. This mucous-purulent expectoration of bronchitis patients is equally poly-bacillary; it is a mixture of diverse species and hence Bacillinum is truly indicated (Cartier). Often relieves congestion of the lungs, thus paving way for other remedies in Tuberculosis.

Drosera Rotundifolia

Spasmodic, dry irritative cough, like whooping-cough, the paroxysms following each other very rapidly; can scarcely breathe; chokes. Cough very deep and hoarse; worse, after midnight; yellow expectoration, with bleeding from nose and mouth; retching. Deep, hoarse voice; hoarseness; laryngitis. Rough, scraping sensation deep in the fauces and soft palate. Sensation as if crumbs were in the throat, of feather in larynx. Laryngeal phthisis, with rapid emaciation. Harassing and titillating cough in children-not at all through the day, but commences as soon as the head touches the pillow at night. Clergyman's sore throat, with rough, scraping, dry sensation deep in the fauces; voice hoarse, deep, toneless, cracked, requires exertion to speak. Asthma when talking, with contraction of the throat at every word uttered.

Grindelia Robusta

An efficacious remedy for wheezing and oppression in bronchitis patients. The sibilant rales are disseminated with foamy mucus, very difficult to detach. Acts on the pulmonary circulation. Asthma, with profuse tenacious expectoration, which relieves. Stops breathing when falling asleep; wakes with a star, and gasps for breath. Must sit up to breathe. Cannot breathe when lying down. Pertussis, with profuse mucous secretion (Coccus). Bronchorrhœa, with tough, whitish, mucous expectoration. Sibilant rales. Weak heart and respiration. Cannot breathe lying down. Cheyne-Stokes respiration.

Justicia Adhatoda

Dry cough from sternal region all over chest. Hoarseness, larynx painful. Paroxysmal cough, with suffocative obstruction of respiration. Cough with sneezing. Severe Dyspnea with cough. Tightness across chest. Asthmatic attacks, cannot endure a close, warm room. Whooping-cough.

Hepar Sulphur

Loses voice and coughs when exposed to dry, cold wind. Hoarseness, with loss of voice. Cough troublesome when walking. Dry, hoarse cough. Cough excited whenever any part of the body gets cold or uncovered, or from eating anything cold. Croup with loose, rattling cough; worse in morning. Choking cough. Rattling, croaking cough; suffocative attacks; has to rise up and bend head backwards. Anxious, wheezing, moist breathing, asthma worse in dry cold air; better in damp. Palpitation of heart.

Ipecacuanha

Dyspnea; constant constriction in chest. Asthma. Yearly attacks of difficult shortness of breathing. Continued sneezing; coryza; wheezing cough. Cough incessant and violent, with every breath. Chest seems full of phlegm, but does not yield to coughing. Bubbling rales. Suffocative cough; child becomes stiff, and blue in the face. Whooping-cough, with nosebleed, and from mouth. Bleeding from lungs, with nausea; feeling of constriction; rattling cough. Croup. Hæmoptysis from slightest exertion (Millef). Hoarseness, especially at end of a cold. Complete aphonia

Phosphoricum Acidum

Chest troubles develop after brain-fag. Hoarseness. Dry cough from tickling in chest. Salty expectoration. Difficult respiration. Weak feeling in chest from talking (Stann). Pressure behind the sternum, rendering breathing difficult. -Better, from keeping warm. Worse, exertion, from being talked to; loss of vital fluids; sexual excesses. Everything impeding circulation causes aggravation of symptoms.

Belladonna

Drying in nose, fauces, larynx, and trachea. Tickling, short, dry cough; worse at night. Larynx feels sore. Respiration oppressed, quick, unequal. Cheyne-Stokes respiration (Cocaine; Opium). Hoarse; loss of voice. Painless hoarseness. Cough with pain in left hip. Barking cough, whooping cough, with pain in stomach before attack, with expectoration of blood. Stitches in chest when coughing. Larynx very painful; feels as if a foreign body were in it, with cough. High, piping voice. Moaning at every breath

Cactus Grandiflorus

Oppressed breathing as from a weight on chest. Constriction in chest, as if bound, hindering respiration. Inflammation of diaphragm

Veratrum Viride

Congestion of lungs. Difficult breathing. Sensation of a heavy load on chest. Pneumonia, with faint feeling in stomach and violent congestion. Croup. Menstrual colic before the appearance of the discharge with strangury.

Ferrum Phosphoricum

First stage of all inflammatory affections. Congestions of lungs. Hæmoptysis. Short, painful tickling cough. Croup. Hard, dry cough, with sore chest. Hoarseness. Expectoration of pure blood in pneumonia (Millefol). Cough better at night.

Ammonium Carbonicum

Cough every morning about three o'clock, with dyspnœa, palpitation, burning in chest; worse ascending. Chest feels tired. Emphysema. Much oppression in breathing; worse after any effort, and entering warm room, or ascending even a few steps. Asthenic Pneumonia. Slow labored, stertorous breathing; bubbling sound. Winter catarrh, with slimy sputum and specks of blood. Pulmonary œdema.

Apis Mellifica

Hoarseness; dyspnœa, breathing hurried and difficult. Œdema of larynx. Feels as if he could not draw another breath. Suffocation; short, dry cough, suprasternal. Hydrothorax.

The very characteristic effects of the sting of the bee furnish unerring indications for its employment in disease. Swelling or puffing up of various parts, œdema, red rosy hue, stinging pains, soreness, intolerance of heat, and slightest touch, and afternoon aggravation are some of the general guiding symptoms. Erysipelatous inflammations, dropsical effusions and anasarca, acute, inflammation.