Respiration 32: 103-111 (1975)
Respiratory Function in Esophageal Hiatus Hernia II. Regional I.ung Function
J erzy Senyk, M ans A rborelius, jr. and Bo L iija Departments of Thoracic and Cardiovascular Surgery and Clinical Physiology, University of Lund, Malmö General Hospital, Malmö
Abstract. 64 subjects with hiatus hernia (34 sliding, Key Words 22 mixed, and 8 of paraesophageal variety) were divid Hiatus hernia ed into 3 groups according to the transverse diameter Radiospirometry of the thoracic loculus and examined by ,3sXe-radio- Xenon radioactive spirometry in the supine position. 48 subjects (22 sliding, Regional lung function 18 mixed, and 8 of paraesophageal variety) showed a significant reduction in the regional ventilation, perfusion or lung volume. Significant correlations were found between the diameter of the thoracic loculus and the reduction in these variables of the affected lung.
Introduction
Received: February 22, 1974; accepted: March 3, 1974.
Downloaded by: King's College London 137.73.144.138 - 3/6/2018 7:37:57 PM
Hiatus hernia may act as an intrathoracic space-occupying mass which can push into either or both sides of the thoracic cavity, compress the lower lobes of the lungs and interfere with diaphragmatic motility thus causing respiratory distress [8, 9, 13]. Apart from the work by M alm and Svanberg [12], no systematic studies on regional lung function in hiatus hernia have been found in accessible literature. The purpose of the present investigation was to study the effect of hiatus hernia of different sizes and types on the regional lung function measured with 133Xe-radiospiromctry [14].
104
Senyk/ Arboreuus /L iu a
Material and Methods 64 patients (26 males and 38 females) with X-ray-verified esophageal hiatus hernia were studied. The selection of the material, its distribution and partition according to the size and type of hernia has been described earlier [17]. ,33Xe-radiospirometry was performed as described previously with the patient in the su pine position [14]. Four pairs of scintillation detectors were placed symmetrically over the medial line of the sternum and over the fourth costal interspace at the sternum. The activity in one basal and one apical field of each lung was measured by one ventral and one opposing dorsal scintillation detector covering each field. The impulses from the ventral and dorsal detectors over each field were added and registered in one of four channels. After subtraction of the preceding background activity, the activities registered over the four fields were added, and the activities registered for each lung were expressed as a percentage of the sum as in bronchospirometry: L x 100
L+ R ’ L = left lung, R = right lung. The activity registered for each basal field was also expressed as percentage of the activities registered in the two basal fields: Lb x 100 Lb + Rb' Lb = left basal field, Rb = right basal field. The activity registered for each apical field was expressed in a corresponding way: L a x 100
La = left apical field, Ra = right apical field. The regional pulmonary circulation (Qr) was measured from an intravenous injection of 0.2 mCi Xenon-133 dissolved in saline which was injected through a polyethylene catheter (PE 160. Intramedic®, Clay Adams, New York, USA) with the tip placed in the right atrium under X-ray control. The injection was made af ter a slow exhalation to the normal end-exhalatory level at which the breath was held for 10 sec. The regional ventilation (Vr) was estimated after 3 normal inhala tions of the same gas (0.2 mCi/l) from a closed circuit spirometer (Lundia Spiro graph. Kifa AB, Stockholm. Sweden). The regional lung volume (FRCr) was mea sured after rebreathing in the spirometer system until the ,33Xe-concentration was the same throughout in the lung-spirometer system. The count rate at the endexpiratory level then represents the FRCr within the field [14]. The difference between the measured and the normal mean values [14] was an alyzed in the following way. The total number of subjects in the hernia and nor
Downloaded by: King's College London 137.73.144.138 - 3/6/2018 7:37:57 PM
La + Ra
Regional Lung Function in Hiatus Hernia
105
mal control groups who deflected more than 2 standard deviations (SD) from the normal mean values [14] was calculated and statistically analyzed by use of X -square test with Yates’ correction [2]. The observed deviations in the regional function of the whole lung and basal fields, respectively, were correlated to the diameter of the thoracic loculus accord ing to the conventional methods for analysis of regression and correlation [7],
As seen from table I. the small hernia group (I) was significantly dif ferent from the normal group concerning Vr of the whole lung and the apical fields as well as Qr of the apical and basal fields. No significant difference was observed concerning FRCr. The medium-sized hernia group (11) was significantly different re garding Vr and Qr of the whole lung and of the apical and basal fields, respectively, but not regarding FRCr. The large hernia group (III) differed significantly from the normal group for V,. and Q, of the whole lung, apical and basal fields and for FRCr of the whole lung and the apical field. Independent of group, more subjects showed significant reduction in Q, and Vr than in FRCr. Regional lung function values within the normal were found only in 16 subjects, 11 in group I, 4 in group II, and 1 in group III. Of these patients 12 had sliding and 4 mixed type of hernia. Radiographic evaluation of the different locations and types of hiatus hernias is presented in table II. As seen from table III, in 34 subjects (53%), sliding variety was dis closed, and 22 of them showed significant radiospirometric abnormali ties. The mixed variety of hiatus hernia was found in 22 subjects, and only in 4 subjects, the regional lung function was normal. In 8 subjects, a paraesophageal type of hiatus hernia was revealed, and in all of them, a significant reduction in the regional lung function was registered. Independent of type or size of hernia, functional decreases occurred in all four lung regions. Exclusively left-sided location of the gastric pouch was found in 53 subjects (83°/o), while protrusion of the hernia also into the right thora cic cavity was noted in 11 subjects (17%().
Downloaded by: King's College London 137.73.144.138 - 3/6/2018 7:37:57 PM
Results
O OS Table I. ,33Xe-radiospirometry in 64 subjects divided into three groups according to the size of the hernia and compared by the X2-tesl with Miorner’s normal subjects (38). n = number of subjects in each group who deflected more than 2 SD from the normal mean. Within brack ets right sided deviation more than 2 SD. M = corresponding number of subjects from Miorner's normal material [Miorner 1968], p = probability. NS = not significant = p>0.05.
II (23)
III (13)
Total (64)
basal field
Ventilation (Vr) whole apical lung field
basal field
FRCr whole lung
apical field
basal field
KD 1 NS
5 (3) 2 NS
4 (I) 3 NS
n M P n M P n M P
4 (1) 1 NS
5 (1) I
Respiratory Function in Esophageal Hiatus Hernia II. Regional I.ung Function
J erzy Senyk, M ans A rborelius, jr. and Bo L iija Departments of Thoracic and Cardiovascular Surgery and Clinical Physiology, University of Lund, Malmö General Hospital, Malmö
Abstract. 64 subjects with hiatus hernia (34 sliding, Key Words 22 mixed, and 8 of paraesophageal variety) were divid Hiatus hernia ed into 3 groups according to the transverse diameter Radiospirometry of the thoracic loculus and examined by ,3sXe-radio- Xenon radioactive spirometry in the supine position. 48 subjects (22 sliding, Regional lung function 18 mixed, and 8 of paraesophageal variety) showed a significant reduction in the regional ventilation, perfusion or lung volume. Significant correlations were found between the diameter of the thoracic loculus and the reduction in these variables of the affected lung.
Introduction
Received: February 22, 1974; accepted: March 3, 1974.
Downloaded by: King's College London 137.73.144.138 - 3/6/2018 7:37:57 PM
Hiatus hernia may act as an intrathoracic space-occupying mass which can push into either or both sides of the thoracic cavity, compress the lower lobes of the lungs and interfere with diaphragmatic motility thus causing respiratory distress [8, 9, 13]. Apart from the work by M alm and Svanberg [12], no systematic studies on regional lung function in hiatus hernia have been found in accessible literature. The purpose of the present investigation was to study the effect of hiatus hernia of different sizes and types on the regional lung function measured with 133Xe-radiospiromctry [14].
104
Senyk/ Arboreuus /L iu a
Material and Methods 64 patients (26 males and 38 females) with X-ray-verified esophageal hiatus hernia were studied. The selection of the material, its distribution and partition according to the size and type of hernia has been described earlier [17]. ,33Xe-radiospirometry was performed as described previously with the patient in the su pine position [14]. Four pairs of scintillation detectors were placed symmetrically over the medial line of the sternum and over the fourth costal interspace at the sternum. The activity in one basal and one apical field of each lung was measured by one ventral and one opposing dorsal scintillation detector covering each field. The impulses from the ventral and dorsal detectors over each field were added and registered in one of four channels. After subtraction of the preceding background activity, the activities registered over the four fields were added, and the activities registered for each lung were expressed as a percentage of the sum as in bronchospirometry: L x 100
L+ R ’ L = left lung, R = right lung. The activity registered for each basal field was also expressed as percentage of the activities registered in the two basal fields: Lb x 100 Lb + Rb' Lb = left basal field, Rb = right basal field. The activity registered for each apical field was expressed in a corresponding way: L a x 100
La = left apical field, Ra = right apical field. The regional pulmonary circulation (Qr) was measured from an intravenous injection of 0.2 mCi Xenon-133 dissolved in saline which was injected through a polyethylene catheter (PE 160. Intramedic®, Clay Adams, New York, USA) with the tip placed in the right atrium under X-ray control. The injection was made af ter a slow exhalation to the normal end-exhalatory level at which the breath was held for 10 sec. The regional ventilation (Vr) was estimated after 3 normal inhala tions of the same gas (0.2 mCi/l) from a closed circuit spirometer (Lundia Spiro graph. Kifa AB, Stockholm. Sweden). The regional lung volume (FRCr) was mea sured after rebreathing in the spirometer system until the ,33Xe-concentration was the same throughout in the lung-spirometer system. The count rate at the endexpiratory level then represents the FRCr within the field [14]. The difference between the measured and the normal mean values [14] was an alyzed in the following way. The total number of subjects in the hernia and nor
Downloaded by: King's College London 137.73.144.138 - 3/6/2018 7:37:57 PM
La + Ra
Regional Lung Function in Hiatus Hernia
105
mal control groups who deflected more than 2 standard deviations (SD) from the normal mean values [14] was calculated and statistically analyzed by use of X -square test with Yates’ correction [2]. The observed deviations in the regional function of the whole lung and basal fields, respectively, were correlated to the diameter of the thoracic loculus accord ing to the conventional methods for analysis of regression and correlation [7],
As seen from table I. the small hernia group (I) was significantly dif ferent from the normal group concerning Vr of the whole lung and the apical fields as well as Qr of the apical and basal fields. No significant difference was observed concerning FRCr. The medium-sized hernia group (11) was significantly different re garding Vr and Qr of the whole lung and of the apical and basal fields, respectively, but not regarding FRCr. The large hernia group (III) differed significantly from the normal group for V,. and Q, of the whole lung, apical and basal fields and for FRCr of the whole lung and the apical field. Independent of group, more subjects showed significant reduction in Q, and Vr than in FRCr. Regional lung function values within the normal were found only in 16 subjects, 11 in group I, 4 in group II, and 1 in group III. Of these patients 12 had sliding and 4 mixed type of hernia. Radiographic evaluation of the different locations and types of hiatus hernias is presented in table II. As seen from table III, in 34 subjects (53%), sliding variety was dis closed, and 22 of them showed significant radiospirometric abnormali ties. The mixed variety of hiatus hernia was found in 22 subjects, and only in 4 subjects, the regional lung function was normal. In 8 subjects, a paraesophageal type of hiatus hernia was revealed, and in all of them, a significant reduction in the regional lung function was registered. Independent of type or size of hernia, functional decreases occurred in all four lung regions. Exclusively left-sided location of the gastric pouch was found in 53 subjects (83°/o), while protrusion of the hernia also into the right thora cic cavity was noted in 11 subjects (17%().
Downloaded by: King's College London 137.73.144.138 - 3/6/2018 7:37:57 PM
Results
O OS Table I. ,33Xe-radiospirometry in 64 subjects divided into three groups according to the size of the hernia and compared by the X2-tesl with Miorner’s normal subjects (38). n = number of subjects in each group who deflected more than 2 SD from the normal mean. Within brack ets right sided deviation more than 2 SD. M = corresponding number of subjects from Miorner's normal material [Miorner 1968], p = probability. NS = not significant = p>0.05.
II (23)
III (13)
Total (64)
basal field
Ventilation (Vr) whole apical lung field
basal field
FRCr whole lung
apical field
basal field
KD 1 NS
5 (3) 2 NS
4 (I) 3 NS
n M P n M P n M P
4 (1) 1 NS
5 (1) I
