thought to be the tumor wall. No obvious echographic evidence of primary cardiac disease was seen, but the diminished anterior mitral valve diastolic closure rate was consistent with impaired left atrial emptying. This may be seen with decreased left ventricular compliance. 1 "·20 The postmortem findings confirmed the echocardiographic interpretation by revealing a extracardiac mass. An additional explanation for the restrictive picture may have been due to vena cava compression by tumor, which resulted in decreased venous return and diminished ventricular filling. Our third patient had an echocardiogram performed for evaluation of cardiac enlargement thought to be due to pericardia! disease 1 R· 19 or myocardiopathy. 13 • 20 - 2 2 Because of her marked obesity, the echocardiogram was technically difficult but was of sufficient clarity to allow recognition of an unusual strong echo behind the posterior left ventricular wall, apparently extracardiac in origin, instead of the lung tissue normally seen in this area. When the prominent echo behind the heart was seen and no primary cardiac disease was discovered, further study retrospectively of the chest x-ray films disclosed the posterior mediastinal mass, which was found to be a fibrolipoma at surgery. Whether the mass caused the patient's symptoms of shortness of breath by cardiac compression is questionable.
Circulation 46:897-904, 1972 14 Ostrum BJ, Goldberg BB, Isard HJ: A-mode ultrasound differentiation of soft-tissue masses. Radiology 88:745749, 1967 15 Blum M, Goldman AB, Herskovic A, et al: Clinical applications of thyroid echography. N Eng! J Med 287: ll64-1169, 1972 16 Freimanis AK, Asher WM: Echographic study of abdominal lesions. Am J Roentgen 108:747-755, 1970 17 McDonald DC, Leopold GR: Ultrasound B-scanning in the differentiation of Baker's cyst and thrombophlebitis. Br J Radiol45:729-732, 1972 18 Feigenbaum H: Echocardiographic diagnosis of pericardia! effusion. Am J Cardiol26:475-479, 1970 19 Abbasi AS, Flynn JM: The use of modified echocardiographic M-scan technique in the diagnosis of pericardia! effusion. Proceedings of the Scientific Sessions of the American Institute of Ultrasound in Medicine, Philadelphia, October 1972 20 Shah PM, Gramiak R, Kramer DH: Ultrasound localiza·· tion of left ventricular outflow obstruction in hypertrophic obstructive myocardiopathy. Circulation 40:3-11, 1969 21 Abbasi AS, Chahine RA, MacAipin RN, eta!: Ultrasound in the diagnosis of primary congestive cardiomyopathy. Chest 63:937-942, 1973 22 Abbasi AS, MacAlpin RN, Eber LM, eta!: Left ventricular hypertrophy diagnosed by echocardiography. N Eng) J Med 289:118-121, 1973
REFERENCES
1 Schattenberg TT: Echocardiographic diagnosis of left atrial myxoma. Mayo Clin Proc 43:620-627, 1968 2 Wolfe SB, Popp RL, Feigenbaum H: Diagnosis of atrial tumors by ultrasound. Circulation 39:615-622, 1969 3 Popp RL, Harrison DC: Ultrasound for the diagnosis of atrial tumor. Ann Intern Med 71:785-787, 1969 4 Finegan RE, Harrison DC: Diagnosis of left atrial myxoma by echocardiography. N Eng] J Med 282:10221023, 1970 5 Kostis JB, Moghadam AN: Echocardiographic diagnosis of left atrial myxoma. Chest 58:550-552, 1970 6 Allee G, Logue B, Mansour K: Thymic cyst simulating multiple cardiovascular abnormalities and presenting with pericarditis and pericardia! tamponade. Am J Cardiol 31:377-380, 1973 7 Coulshed N, Jones EW, Temple LJ: Cyst of the thymus: report of a case presenting as idiopathic cardiomegaly. Br J Radio! 31:95-99, 1958 8 Podolsky S, Ehrlich EW, Howard JM: Congenital thymic cyst attached to the pericardium. Dis Chest 42:642-644, 1962 9 Schlurger J, Scarpa WJ, Rosenblum DJ, et al: Thymic cyst simulating massive cardiomegaly. Report of a case and review of the literature. Dis Chest 53:365-368, 1968 10 Oldham HN, Sahiston DC: Primary tumors and cysts of the mediastinum presenting as cardiovascular abnormalities. Arch Surg (Chicago) 96:71-75, 1968 11 Shaver VC, Bailey WR, Marrangoni AG: Acquired pulmonic stenosis due to external cardiac compression. Am J Cardiol 16:256-261, 1965 12 Seltzer ItA, Mills DS, Baddocl;: SS. et al: ~fediastinal . thymic cyst. Dis Chest 53:186-196, 1968 .. 13 Abbasi AS, }.lacAipin R};, Eber LM, et al: Echocardiographic diagnosb of idiopathic hypertrophic cardiomyopathy without left ventricular outflow obstruction.
A Simplified Method for Measuring Helium Closing Volume* Kirk McClelland 00 and Charles Mittman, M.D., F.C.C.P.t
A simple method for delivering a constant volume of helium for the measurement of airway closing volume is described. Using a standard fiveway valve and PVC plastic irrigation pipe, a device was constructed which permits the delivery of a uniform volume of helium and avoids the troublesome valve change during inspiration. Results obtained when using this device were comparable to those with the use of a conventional bag to contain the he6um.
T
he measurement of the volume at which small airways in dependent lung zones cease to ventilate (closing volume) has been proposed as a valuable means to detect early disease. Numerous investigators'- 3 use a technique similar to that first reported by Dollfuss and co-workers. • A subject first exhales to residual volume and then inhales slowly to total lung capacity. The initial portion of the inspiration consists of a bolus of some
°From the Respiratory Disease Department, City of Hope Medical Center, Duarte, Ca. ••supervisor, Pulmonary Physiology Laboratory. tJ)ire~r, Department of ltespiratory Piseases . This work was supported' by grants from the National Heart and Lung lnstitute ( l{El2833) and tlte ~ouncil for Tobacco Research. ·· Reprint requests: Mr. McClelland, City of Hope Medical Center, Dtwrte~ California fHOIO ~I:I~ST,
67: 1,
JA~YAij¥,
1975
tracer gas ( 133xenon, Ar, He); the remainder of the inspiration is air. The subject then exhales completely while maintaining a slow, steady flow rate. During expiration the concentration of the tracer gas and expired volume are measured and plotted on opposite axes of an X-Y recorder. From the plot of concentration versus volume the subject's closing volume is determined. 1 • 5 Problems were encountered delivering the bolus of tracer gas from a small rubber bag, the method commonly employed. Variations in the volume of tracer delivered interfered with achieving accurate replicate studies. In addition, some subjects are annoyed by the inspiratory pause occasioned if valve switching is delayed on evacuation of the tracer bag. We constructed a simple device to overcome these problems. When helium is used as the tracer gas (Fig 1), polyvinyl chloride (PVC) irrigation pipe of ~ inch diameter and sufficient length to contain the desired gas volume is attached to the right angle opening of the five-way valve (Collins) and oriented vertically. A small hole is drilled in the valve to allow connection of small diameter tubing for filling the PVC pipe with helium. A second small opening is drilled at the base of the mouthpiece to receive the sampling tube of a Mead-Collier helium analyzer. 6 For performance of the test, the valve is turned to the room air position and a suitable mouthpiece is attached. The PVC pipe is overfilled with helium. Due to the low density of helium the air will be entirely displaced from the pipe; helium will fill the internal volume and remain there for a prolonged period while the excess helium will disperse from the lower end of the pipe. During testing, the pipe was found to contain helium for time periods up to ten minutes without appreciable loss. The test subject is instructed to take the mouthpiece in his mouth and a noseclip is attached. After several normal breaths through a port open to the room, the subject is asked to exhale slowly and completely. At end expiration the valve is turned to the port connected to the PVC pipe and the subject is asked to inspire slowly and completely. The bolus of helium enters the subject's lungs first. When all the helium has been inspired the subject will breathe the room air which flows unimpeded through COLLINS 5-WAY MODULAR VALVE (CAT. NO. P-314)
Opening For Connect ion To Mead-Collier Analyzer
Smell Diameter Tubing To He Cylinder
Not
Used
. FIGURE
CHEST, 67: 1, JANUARY, 1975
1
tP.VC. Plastic Pipe (Length determined by size of He bolus des~red.l
--~--~ECT--J:A.i--
'
---. ·-·-
SUBJECT- K.M.: EXPIRED VOLUME FIGURE 2. Test results on two subjects using both conventional bag and pipe as a container for the helium bolus. Arrows indicate closing volume.
the open bottom of the pipe. At full inspiration the valve is turned to the port connected to a recording spirometer and the subject expires completely while maintaining a slow, steady How rate (
Circulation 46:897-904, 1972 14 Ostrum BJ, Goldberg BB, Isard HJ: A-mode ultrasound differentiation of soft-tissue masses. Radiology 88:745749, 1967 15 Blum M, Goldman AB, Herskovic A, et al: Clinical applications of thyroid echography. N Eng! J Med 287: ll64-1169, 1972 16 Freimanis AK, Asher WM: Echographic study of abdominal lesions. Am J Roentgen 108:747-755, 1970 17 McDonald DC, Leopold GR: Ultrasound B-scanning in the differentiation of Baker's cyst and thrombophlebitis. Br J Radiol45:729-732, 1972 18 Feigenbaum H: Echocardiographic diagnosis of pericardia! effusion. Am J Cardiol26:475-479, 1970 19 Abbasi AS, Flynn JM: The use of modified echocardiographic M-scan technique in the diagnosis of pericardia! effusion. Proceedings of the Scientific Sessions of the American Institute of Ultrasound in Medicine, Philadelphia, October 1972 20 Shah PM, Gramiak R, Kramer DH: Ultrasound localiza·· tion of left ventricular outflow obstruction in hypertrophic obstructive myocardiopathy. Circulation 40:3-11, 1969 21 Abbasi AS, Chahine RA, MacAipin RN, eta!: Ultrasound in the diagnosis of primary congestive cardiomyopathy. Chest 63:937-942, 1973 22 Abbasi AS, MacAlpin RN, Eber LM, eta!: Left ventricular hypertrophy diagnosed by echocardiography. N Eng) J Med 289:118-121, 1973
REFERENCES
1 Schattenberg TT: Echocardiographic diagnosis of left atrial myxoma. Mayo Clin Proc 43:620-627, 1968 2 Wolfe SB, Popp RL, Feigenbaum H: Diagnosis of atrial tumors by ultrasound. Circulation 39:615-622, 1969 3 Popp RL, Harrison DC: Ultrasound for the diagnosis of atrial tumor. Ann Intern Med 71:785-787, 1969 4 Finegan RE, Harrison DC: Diagnosis of left atrial myxoma by echocardiography. N Eng] J Med 282:10221023, 1970 5 Kostis JB, Moghadam AN: Echocardiographic diagnosis of left atrial myxoma. Chest 58:550-552, 1970 6 Allee G, Logue B, Mansour K: Thymic cyst simulating multiple cardiovascular abnormalities and presenting with pericarditis and pericardia! tamponade. Am J Cardiol 31:377-380, 1973 7 Coulshed N, Jones EW, Temple LJ: Cyst of the thymus: report of a case presenting as idiopathic cardiomegaly. Br J Radio! 31:95-99, 1958 8 Podolsky S, Ehrlich EW, Howard JM: Congenital thymic cyst attached to the pericardium. Dis Chest 42:642-644, 1962 9 Schlurger J, Scarpa WJ, Rosenblum DJ, et al: Thymic cyst simulating massive cardiomegaly. Report of a case and review of the literature. Dis Chest 53:365-368, 1968 10 Oldham HN, Sahiston DC: Primary tumors and cysts of the mediastinum presenting as cardiovascular abnormalities. Arch Surg (Chicago) 96:71-75, 1968 11 Shaver VC, Bailey WR, Marrangoni AG: Acquired pulmonic stenosis due to external cardiac compression. Am J Cardiol 16:256-261, 1965 12 Seltzer ItA, Mills DS, Baddocl;: SS. et al: ~fediastinal . thymic cyst. Dis Chest 53:186-196, 1968 .. 13 Abbasi AS, }.lacAipin R};, Eber LM, et al: Echocardiographic diagnosb of idiopathic hypertrophic cardiomyopathy without left ventricular outflow obstruction.
A Simplified Method for Measuring Helium Closing Volume* Kirk McClelland 00 and Charles Mittman, M.D., F.C.C.P.t
A simple method for delivering a constant volume of helium for the measurement of airway closing volume is described. Using a standard fiveway valve and PVC plastic irrigation pipe, a device was constructed which permits the delivery of a uniform volume of helium and avoids the troublesome valve change during inspiration. Results obtained when using this device were comparable to those with the use of a conventional bag to contain the he6um.
T
he measurement of the volume at which small airways in dependent lung zones cease to ventilate (closing volume) has been proposed as a valuable means to detect early disease. Numerous investigators'- 3 use a technique similar to that first reported by Dollfuss and co-workers. • A subject first exhales to residual volume and then inhales slowly to total lung capacity. The initial portion of the inspiration consists of a bolus of some
°From the Respiratory Disease Department, City of Hope Medical Center, Duarte, Ca. ••supervisor, Pulmonary Physiology Laboratory. tJ)ire~r, Department of ltespiratory Piseases . This work was supported' by grants from the National Heart and Lung lnstitute ( l{El2833) and tlte ~ouncil for Tobacco Research. ·· Reprint requests: Mr. McClelland, City of Hope Medical Center, Dtwrte~ California fHOIO ~I:I~ST,
67: 1,
JA~YAij¥,
1975
tracer gas ( 133xenon, Ar, He); the remainder of the inspiration is air. The subject then exhales completely while maintaining a slow, steady flow rate. During expiration the concentration of the tracer gas and expired volume are measured and plotted on opposite axes of an X-Y recorder. From the plot of concentration versus volume the subject's closing volume is determined. 1 • 5 Problems were encountered delivering the bolus of tracer gas from a small rubber bag, the method commonly employed. Variations in the volume of tracer delivered interfered with achieving accurate replicate studies. In addition, some subjects are annoyed by the inspiratory pause occasioned if valve switching is delayed on evacuation of the tracer bag. We constructed a simple device to overcome these problems. When helium is used as the tracer gas (Fig 1), polyvinyl chloride (PVC) irrigation pipe of ~ inch diameter and sufficient length to contain the desired gas volume is attached to the right angle opening of the five-way valve (Collins) and oriented vertically. A small hole is drilled in the valve to allow connection of small diameter tubing for filling the PVC pipe with helium. A second small opening is drilled at the base of the mouthpiece to receive the sampling tube of a Mead-Collier helium analyzer. 6 For performance of the test, the valve is turned to the room air position and a suitable mouthpiece is attached. The PVC pipe is overfilled with helium. Due to the low density of helium the air will be entirely displaced from the pipe; helium will fill the internal volume and remain there for a prolonged period while the excess helium will disperse from the lower end of the pipe. During testing, the pipe was found to contain helium for time periods up to ten minutes without appreciable loss. The test subject is instructed to take the mouthpiece in his mouth and a noseclip is attached. After several normal breaths through a port open to the room, the subject is asked to exhale slowly and completely. At end expiration the valve is turned to the port connected to the PVC pipe and the subject is asked to inspire slowly and completely. The bolus of helium enters the subject's lungs first. When all the helium has been inspired the subject will breathe the room air which flows unimpeded through COLLINS 5-WAY MODULAR VALVE (CAT. NO. P-314)
Opening For Connect ion To Mead-Collier Analyzer
Smell Diameter Tubing To He Cylinder
Not
Used
. FIGURE
CHEST, 67: 1, JANUARY, 1975
1
tP.VC. Plastic Pipe (Length determined by size of He bolus des~red.l
--~--~ECT--J:A.i--
'
---. ·-·-
SUBJECT- K.M.: EXPIRED VOLUME FIGURE 2. Test results on two subjects using both conventional bag and pipe as a container for the helium bolus. Arrows indicate closing volume.
the open bottom of the pipe. At full inspiration the valve is turned to the port connected to a recording spirometer and the subject expires completely while maintaining a slow, steady How rate (
