Death associated with bronchography. Question role of heating the contrast agent.

A young woman died following bronchography. The bilateral bronchogram done under general anesthesia without fluoroscopic control was associated with extensive small airway filling or "alveolarization" of the contrast medium. The oily Dionosil used had been heated in an autoclave. Experiments showed that the viscosity of oily Dionosil decreases with heating. The lowered viscosity could have contributed to the increased "alveolarization" of the contrast agent and death of the patient.