Wenckebach periods in posterior inferior division of left bundle.

chospasm and edema of the bronchial wall. The problem of plugs is compounded by the invariably present tachypnea, resulting in respiratory loss of fluids. Dehydration produces tenacious, inspissated plugs, which are difficult to remove via the cough mechanism. Messer et al,1° in a large autopsy series, reported a 97 percent incidence of abnormal bronchial contents (mucous, purulent exudate, or both) in 35 patients dying in status asthmaticus. Mucous plugs in the bronchi and focal areas of collapse were prominent features in another 20 cases of fatal status asthmaticus." In the present case, mucoid material was found at the four bronchoscopies. The degree of atelectasis is of interest in the present case, since reports of complete atelectasis of a lung are rare in the literature. However, there is no reason to believe that the mechanism responsible for the massive collapse in the present case is qualitatively different from the more frequent lobar or segmental atelectasis. Treatment in the present case was directed primarily to re-expansion of the right lung. In cases of segmental or lobar-asthmatic atelectasis, conservative management with fluids, chest percussion, administration of bronchodilators and antimicrobials, and intermittent positive pressure breathing, is usually successful. When these measures fail, bronchoscopy with removal of obstructing secretions is indicated. In this patient, bronchoscopy was performed at an early point in the hospitalization because of extensive atelectasis and was repeated until satisfactory expansion of the lung was appreciated. Careful and persistent suctioning and irrigation of the bronchi were performed during bronchoscopy, with improvement in the postbronchoscopy roentgenogram and clinical condition. As judged by pulmonary function studies, chest roentgenogram, lung scan, arterial blood gas determinations, and clinical status, this patient essentially made a complete recovery. Early and multiple bronchoscopies are indicated in patients with massive asthmatic atelectasis to re-expand the lung and prevent lung abscess and bronchiectasis. Multiple bronchoscopies in the present case preserved a functioning lung that otherwise might have remained collapsed, with resultant tissue destruction.