Percutaneous Drainage of Lung Abscess1 BERNARDO VAINRUB, DANIEL M. MUSHER, GENE A. GUINN, EDWARD J. YOUNG, EDWARD J. SEPTIMUS, and LEWIE L. TRAVIS
SUMMARY The availability of effective antimicrobial agents has greatly decreased the need for surgical intervention in patients who have a pyogenic lung abscess. We describe 3 patients with lung abscesses caused by gram-negative bacteria who failed to respond to medical treatment and who were believed to be unable to withstand lobectomy. Percutaneous insertion of a drainage tube directly into the abscess brought about a dramatic clinical response, with prompt closure of the cavity. This procedure provides an alternative to thoracotomy and lobectomy in treating lung abscesses that fail to respond to medical therapy.
Introduction T h e availability of effective antimicrobial agents has greatly decreased the need for surgical intervention in patients who have a pyogenic lung abscess. Occasionally, patients with lung abscesses do not respond to medical treatment, yet are believed to be unsuitable candidates for lobectomy. In this paper we describe 3 such patients, in whom percutaneous transthoracic drainage resulted in complete closure of large cavities and rapid clinical recovery. Case Report Case 1. A 59-year-old retired man was admitted with a 1-week history of anorexia, malaise, and productive cough. The patient had long-standing chronic obstructive pulmonary disease with a 1-sec forced expiratory volume of 0.3 liter per sec. A chest roentgenogram revealed multiple cavities in the right upper lobe. Cultures of sputum and bronchial washings yielded Staphylococcus aureus, and 12 g of cefazolin per day and 240 mg of gentamicin per day were begun, with only transient clinical improvement. After 3 weeks the small cavities had coalesced, producing a single large abscess with a fluid level. (Received in original form July 21, 1977 and in revised form October 11,1977) l From the Departments of Medicine (Infectious Disease Section) and Surgery, Baylor College of Medicine, and the Veterans Administration Hospital, Houston, Tx. 77211.
Repeat sputum culture yielded Candida species and Pseudomonas fluorescens. A needle was inserted into the cavity for diagnostic purposes, and purulent material was aspirated. Gram stain revealed polymorphonuclear leukocytes and many gram-negative rods of a single morphologic type. Cultures yielded only P. fluorescens sensitive to carbenicillin, gentamicin, tobramycin, and polymyxin. The patient was treated with 32 g of carbenicillin per day and 240 mg of tobramycin per day for 1 week without clinical or radiographic improvement. Because of poor pulmonary reserve, he was believed to be an unsuitable candidate for surgery. A no. 16 French catheter was inserted into the cavity for drainage. Within 1 week he had improved clinically, and roentgenograms showed marked clearing. Further improvement was noted at 3 weeks, and subsequent roentgenograms showed complete resolution of the cavity. Case 2. A 61-year-old diabetic and alcoholic man was hospitalized for fever and nonproductive cough of 3 days' duration and an infiltrate in the posterior segment of the right upper lobe. He had atherosclerotic heart disease and severe chronic obstructive pulmonary disease with cor pulmonale and was taking 30 mg of prednisone per day. By the sixth hospital day the infiltrate had cavitated (figure 1). Cultures of the sputum yielded only mouth flora. Despite serial bronchoscopies, postural drainage, and treatment with cefazolin and gentamicin, there was no improvement, and the cavity increased in size (figure 2). Because of severe pulmonary disease, the patient was judged to be an unsuitable candidate for a
AMERICAN REVIEW OF RESPIRATORY DISEASE, VOLUME 117, 1978
153
154
VAINRUB, MUSHER, GUINN, YOUNG, SEPTIMUS, AND TRAVIS
Fig. 1. Case 2. Chest roentgenogram obtained on the patient's sixth hospital day shows a large abscess in the right upper lobe. lobectomy. A chest tube inserted into the abscess cavity yielded a large amount of brown, foul-smelling material. Gram stain showed a mixture of gramnegative bacilli of 2 morphologic types, suggesting both aerobic and anaerobic flora. Despite attempts to culture anaerobes, only Pseudomonas aeruginosa and Proteus rettgeri were recovered; both were sensitive to gentamicin and carbenicillin and resistant to cefazolin. T h e patient was treated for 2 weeks with 32 g of carbenicillin per day and 2.4 g of clindamycin per day, with good clinical and radiographic response (figure 3). Five months later, there was no radiographic evidence of a lung abscess (figure 4). Case 3. A 62-year-old diabetic man was hospitalized for recurrent chest pain 1 month after an acute myocardial infarction. He had been treated in the past for pulmonary tuberculosis and was taking 20 mg prednisone daily for severe obstructive pulmonary disease. A myocardial infarction was excluded. On the ninth hospital day he developed shortness of breath, fever, and a cough productive of purulent, blood-tinged sputum. A roentgenogram of the chest showed a right upper lobe infiltrate. T h e sputum contained many polymorphonuclear leuko-
cytes and gram-negative rods; cultures of sputum and blood yielded P. aeruginosa sensitive to gentamicin and carbenicillin. He was treated with 32 g of carbenicillin per day and 240 mg of gentamicin per day, and his prednisone dosage was decreased. After 1 week his condition had not improved, and a repeat roentgenogram showed a cavity with an air-fluid level in the posterior segment of the right upper lobe (figure 5). Postural drainage and serial bronchoscopies brought about no improvement. Pseudomonas aeruginosa was continually cultured from the sputum and had become resistant to gentamicin. Anaerobic cultures of bronchial washings were repeatedly negative. After 4 weeks of systemic antimicrobial drugs; there was no improvement and the cavity was larger. Because of the patient's poor cardiopulmonary reserve, he was deemed an unsuitable candidate for lobectomy. Under fluoroscopic guidance, the abscess cavity was localized with a fine needle, and a no. 18 French trocar-tipped chest tube was inserted percutaneously; a large amount of pus was aspirated (figure 6). Within 24 hours the patient became afebrile and showed clinical improvement. Aerobic cultures of aspirated pus were nega-
PERCUTANEOUS DRAINAGE OF LUNG ABSCESS
Fig. 2. Case 2. Chest roentgenogram obtained 1 week after that shown in figure 1 shows that the cavity had increased in size.
155
156
VAINRUB, MUSHER, GUINN, YOUNG, SEPTIMUS, AND TRAVIS
Fig. 3. Case 2. Chest roentgenogram 18 days after insertion of the chest tube. The tube is still in place, and residual infiltration is seen without fluid. the, but anaerobic cultures yielded Bacterioides fragilis and Bacterioides melaninogenicus. Although improvement had already occurred, 1,200 mg of clindamycin per day was subsequently added. This treatment was continued for 2 weeks. Five weeks later, the patient was asymptomatic and the cavity could not be detected on roentgenogram. Discussion
Three patients developed lung abscess due to infection with gram-negative bacilli. These patients had multiple risk factors that predispose to lung abscess. All 3 had severe chronic obstructive pulmonary disease (1,2) for which 2 were taking daily prednisone (1). In addition, 2 were diabetic and one was alcoholic (1-4). Two cases were hospital acquired (table 1); Patient 1 developed Pseudomonas superinfection of a staphylococcal pneumonia, and Patient 3 acquired necrotizing pneumonia while being evaluated for a possible myocardial infarction. All 3 patients failed to respond to medical therapy that included an antimicrobial agent to which the causative organism was susceptible in vitro, postural drainage, and one or more bron-
choscopies (5). Although Patient 3 had 2 species of bacteroides isolated from the cavity itself, these had not been identified on previous anaerobic cultures and should have been susceptible in vitro to carbenicillin (6). Large abscess cavities persisted and, in fact, enlarged in 2 cases. The condition of Patients 1 and 2 had steadily deteriorated, and Patient 3 remained febrile, without signs of improvement. The failure of these patients to respond to medical treatment might have been related, in part, to abscess size (1, 3, 4) and location. One study has suggested that abscesses located in the posterior segment of the right upper lobe have a higher incidence of delayed closure (7), although other studies do not substantiate such a relationship (2, 3). Aerobic gram-negative bacillary pneumonias, particularly those due to Pseudomonas and Klebsiella, (8, 9) are said to have a high incidence of necrosis with abscess formation. It is interesting that Pseudomonas was implicated in our 3 cases. Abscesses due to these organisms have been shown to persist despite appropriate antimicrobial drug therapy (10, 11). A poor response
PERCUTANEOUS DRAINAGE OF LUNG ABSCESS
Fig. 4. Case 2. Chest roentgenogram 5 months a abscess.
to antimicrobial drugs alone may be due, in part, to the difficulty in achieving adequate concentrations of antimicrobial drugs within the abscess cavity (10). Severe underlying lung disease with structural abnormalities and decreased compliance might also have played a role in failure of abscess cavities to drain spontaneously. The recommended treatment of lung abscesses that do not respond to medical management is lobectomy (11-14). Recommendations for patients who are poor surgical risks because of inadequate pulmonary reserve include limited wedge resection, with an emphasis on retaining uninvolved lung, and thoracostomy with or without partial rib resection to allow external drainage (12-15). Morbidity from both of these procedures is high. Our patients were believed to be unable to withstand resection of the abscess cavity. All 3 had chronic lung disease, one had severe atherosclerotic heart disease, and one
157
discharge shows scarring, with no evidence of an
was recovering from a myocardial infarction. As an alternative to lobectomy, a tube was inserted percutaneously into the abscess cavity under fluoroscopic control and was left in place for drainage. This simple procedure was described in 1938 in the treatment of tuberculous cavities and was later adapted for treating pyogenic lung abscesses (16). It has not received widespread application in the United States, and we were able to find only one report (17) in which tube thoracostomy was used in the treatment of pyogenic lung abscess. Insertion of a tube for drainage resulted in prompt clinical response in each of our patients, with closure of the abscess cavity within 4 to 5 weeks. Previous reports have described little if any associated morbidity with this procedure (16), although the potential for pneumothorax and intrabronchial hemorrhage is inherent in this technique. Our patients showed no deteri-
Fig. 5. Case 3. Chest roentgenogram taken on the sixteenth hospital day shows a large abscess in the right upper lobe.
**&$&"
Fig. 6. Case 3. Chest roentgenogram showing drainage of abscess with chest tube still in place.
62
3
RUL
RUL
RUL
Abscess Location
8:
P. aeruginosa, fragilis, B. melanin ogenicus
disease; OM
= diabetes mellitus;
CH F = congestive heart failure; M I = myocardial infarction; TB
= 0.31 literl
Recent MI, CHF, COPO
ASHO, CHF, COPO
min
FEV 1 ,
Contraindication to Surgery
Asp i rate from cavity yielded 2 species of Bacteroides, but patient had received carbenicillin without response th rough out, and he defervesced after insertion of tu be and before cI indamycin was added.
and cefazolin given without response. Cavity found to contain Ps. aeruginosa and P. rettgeri both sensitive to gentamicin and carbenicillin. Gram stain and foul odor suggested anaerobes.
I nitial culture of sputum and bronchial washing revealed "normal flora." Gentamicin
Comment
= tuberculosis.
FEV 1 = 1-sec forced expiratory volume; ASHO = atherosclerotic heart
Repeated bronchoscopies, postural drainage
Bronchoscopy, postural drainage
= right upper lobe;
day), gentamicin (240 mg/day), c1indamycin (1.2 g/day) added after insertion of tube.
Carbenicillin (32 gl
Cefazolin (12 g/day), gentamicin (240 mg/day), carbenicillin (32 g/day), and clindamycin (2.4 g/day) after insertion of tube.
P. aeruginosa, Proteus rettgeri; anaerobes suspected
Gentamicin (240 mgl day), then carben icill in (30 g/day) and tobramycin (240 mg/day).
Other Bronchoscopy, postural drainage
Medical Management Antimicrobial Orug
P. fluorescens
Organism
Definition of abbreviations: COPO = chronic obstructive pulmonary disease; RU L
COPO, ASHO, OM, CHF, recent MI, inactive TB; on prednisone hospitalacquired infection
Severe ASHO, OM, alcohol ingestion; on prednisone
61
2
Underlying Condition
COPO, staphylococcal pneumonia (h ospi ta! acquired)
Age (years)
59
Case No.
TABLE 1 SUMMARY OF CLINICAL FINDINGS AND TREATMENT OF 3 MEN WITH PULMONARY ABSCESS
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160
VAINRUB, MUSHER, GUINN, YOUNG, SEPTIMUS, AND TRAVIS
o r a t i o n in p u l m o n a r y function or blood gases after tube thoracostomy. As has been noted repeatedly, prolonged antimicrobial d r u g therapy is usually successful in treating l u n g abscess (2, 10, 18) and, in o u r experience, it is u n u s u a l for this condition n o t to respond to conservative m a n a g e m e n t . I n the rare case in which medical therapy fails, percutaneous tube drainage should be considered as an alternative to thoracostomy a n d lobectomy. T h i s limited procedure is particularly useful in patients whose u n d e r l y i n g medical conditions are contraindications to surgical resection, b u t perh a p s should also be considered in those who are n o t such p o o r candidates for lobectomy.
7.
8.
9.
10.
11. Acknowledgment T h e writers are indebted to Ms. Mona Thomas for secretarial assistance.
12.
13. References 1. Chidi, C. C , and Mendelson, H. J.: Lung abscess: A study of the results of treatment based on 90 consecutive cases, J Thorac Cardiovasc Surg, 1974, 68,168. 2. Fifer, W. R., Husebye, K., Chedister, C , and Miller, M.: Primary lung abscess: Analysis of therapy and results of 55 cases, Arch Intern Med, 1961,107, 668. 3. Barnett, T. B., and Herring, C. L.: Lung abscess: Initial and late results of medical therapy, Arch Intern Med, 1971,127, 217. 4. Weiss, W.: Cavity behavior in acute, primary, nonspecific lung abscess, Am Rev Respir Dis, 1973,108,1273. 5. Wanner, A., Landa, J. F., Neiman, R. E., Jamsheed, V., and Deldago, I.: Bedside bronchofibroscopy for atelectasis and lung abscess, JAMA, 1973,224,1281. 6. Sutter, V. L., and Finegold, S. M.: Susceptibility
14.
15.
16. 17.
18.
of anaerobic bacteria to carbenicillin,.cefoxitin and related drugs, J Infect Dis, 1975, 131, 417. Weiss, W.: Delayed cavity closure in acute nonspecific primary lung abscess, Am J Med Sci, 1968,255,313. Pierce, A. K., and Sanford, J. P.: Aerobic gramnegative bacillary pneumonias, Am Rev Respir Dis, 1974,110,647. Renner, R. R., Coccaro, A. P., Heitzman, R. E., Dailey, E. T., and Markarian, B.: Pseudomonas pneumonia: A prototype of hospital-based infection, Radiology, 1972,105, 555. Finegold, S. M.: Necrotizing pneumonias and lung abscess, in Infectious Diseases, P. D. Hoeprich, ed., Harper and Row, Publishers, Hagerstown, Md., 1972, pp. 339-350. Shields, T. W.: General Thoracic Surgery, Lea and Febiger, Philadelphia, Pa., 1972, pp. 593595. Blades, B.: Surgical Diseases of the Chest, 3rd ed., T h e C. V. Mosby Co., St. Louis, Mo., 1974, p.123. Reed, W. A., and Allbritten, A., Jr.: T h e lungs: Suppurative and fungal diseases, in Surgery of the Chest, ed. 2, J. H. Gibbon, Jr., D. C. Sabiston, Jr., and F. C. Spencer, ed., W. B. Saunders Co., Philadelphia, Pa., 1969, pp. 341-415. Glover, R. P., and Clagett, O. T.: Pulmonary resection for abscess of lung, Surg Gynecol Obstet, 1948,86,385. Neuhof, H., Touroff, A. S. W., and Aufses, A. H.: T h e surgical treatment by drainage of subacute and chronic putrid abscess of lung, Ann Surg, 1941,113,209. Monaldi, V.: Endocavitary aspiration in treatment of lung abscess, Dis Chest, 1956, 29, 193. Morris, J. F., and Okies, J. E.: Enterococcal lung abscess: Medical and surgical therapy, Chest, 1974,65,688. Schweppe, H. I., Knowles, J. H., and Kane, L.: Lung abscess: An analysis of the Massachusetts General Hospital cases from 1943 through 1956, N Engl J Med, 1961,265,1039.
SUMMARY The availability of effective antimicrobial agents has greatly decreased the need for surgical intervention in patients who have a pyogenic lung abscess. We describe 3 patients with lung abscesses caused by gram-negative bacteria who failed to respond to medical treatment and who were believed to be unable to withstand lobectomy. Percutaneous insertion of a drainage tube directly into the abscess brought about a dramatic clinical response, with prompt closure of the cavity. This procedure provides an alternative to thoracotomy and lobectomy in treating lung abscesses that fail to respond to medical therapy.
Introduction T h e availability of effective antimicrobial agents has greatly decreased the need for surgical intervention in patients who have a pyogenic lung abscess. Occasionally, patients with lung abscesses do not respond to medical treatment, yet are believed to be unsuitable candidates for lobectomy. In this paper we describe 3 such patients, in whom percutaneous transthoracic drainage resulted in complete closure of large cavities and rapid clinical recovery. Case Report Case 1. A 59-year-old retired man was admitted with a 1-week history of anorexia, malaise, and productive cough. The patient had long-standing chronic obstructive pulmonary disease with a 1-sec forced expiratory volume of 0.3 liter per sec. A chest roentgenogram revealed multiple cavities in the right upper lobe. Cultures of sputum and bronchial washings yielded Staphylococcus aureus, and 12 g of cefazolin per day and 240 mg of gentamicin per day were begun, with only transient clinical improvement. After 3 weeks the small cavities had coalesced, producing a single large abscess with a fluid level. (Received in original form July 21, 1977 and in revised form October 11,1977) l From the Departments of Medicine (Infectious Disease Section) and Surgery, Baylor College of Medicine, and the Veterans Administration Hospital, Houston, Tx. 77211.
Repeat sputum culture yielded Candida species and Pseudomonas fluorescens. A needle was inserted into the cavity for diagnostic purposes, and purulent material was aspirated. Gram stain revealed polymorphonuclear leukocytes and many gram-negative rods of a single morphologic type. Cultures yielded only P. fluorescens sensitive to carbenicillin, gentamicin, tobramycin, and polymyxin. The patient was treated with 32 g of carbenicillin per day and 240 mg of tobramycin per day for 1 week without clinical or radiographic improvement. Because of poor pulmonary reserve, he was believed to be an unsuitable candidate for surgery. A no. 16 French catheter was inserted into the cavity for drainage. Within 1 week he had improved clinically, and roentgenograms showed marked clearing. Further improvement was noted at 3 weeks, and subsequent roentgenograms showed complete resolution of the cavity. Case 2. A 61-year-old diabetic and alcoholic man was hospitalized for fever and nonproductive cough of 3 days' duration and an infiltrate in the posterior segment of the right upper lobe. He had atherosclerotic heart disease and severe chronic obstructive pulmonary disease with cor pulmonale and was taking 30 mg of prednisone per day. By the sixth hospital day the infiltrate had cavitated (figure 1). Cultures of the sputum yielded only mouth flora. Despite serial bronchoscopies, postural drainage, and treatment with cefazolin and gentamicin, there was no improvement, and the cavity increased in size (figure 2). Because of severe pulmonary disease, the patient was judged to be an unsuitable candidate for a
AMERICAN REVIEW OF RESPIRATORY DISEASE, VOLUME 117, 1978
153
154
VAINRUB, MUSHER, GUINN, YOUNG, SEPTIMUS, AND TRAVIS
Fig. 1. Case 2. Chest roentgenogram obtained on the patient's sixth hospital day shows a large abscess in the right upper lobe. lobectomy. A chest tube inserted into the abscess cavity yielded a large amount of brown, foul-smelling material. Gram stain showed a mixture of gramnegative bacilli of 2 morphologic types, suggesting both aerobic and anaerobic flora. Despite attempts to culture anaerobes, only Pseudomonas aeruginosa and Proteus rettgeri were recovered; both were sensitive to gentamicin and carbenicillin and resistant to cefazolin. T h e patient was treated for 2 weeks with 32 g of carbenicillin per day and 2.4 g of clindamycin per day, with good clinical and radiographic response (figure 3). Five months later, there was no radiographic evidence of a lung abscess (figure 4). Case 3. A 62-year-old diabetic man was hospitalized for recurrent chest pain 1 month after an acute myocardial infarction. He had been treated in the past for pulmonary tuberculosis and was taking 20 mg prednisone daily for severe obstructive pulmonary disease. A myocardial infarction was excluded. On the ninth hospital day he developed shortness of breath, fever, and a cough productive of purulent, blood-tinged sputum. A roentgenogram of the chest showed a right upper lobe infiltrate. T h e sputum contained many polymorphonuclear leuko-
cytes and gram-negative rods; cultures of sputum and blood yielded P. aeruginosa sensitive to gentamicin and carbenicillin. He was treated with 32 g of carbenicillin per day and 240 mg of gentamicin per day, and his prednisone dosage was decreased. After 1 week his condition had not improved, and a repeat roentgenogram showed a cavity with an air-fluid level in the posterior segment of the right upper lobe (figure 5). Postural drainage and serial bronchoscopies brought about no improvement. Pseudomonas aeruginosa was continually cultured from the sputum and had become resistant to gentamicin. Anaerobic cultures of bronchial washings were repeatedly negative. After 4 weeks of systemic antimicrobial drugs; there was no improvement and the cavity was larger. Because of the patient's poor cardiopulmonary reserve, he was deemed an unsuitable candidate for lobectomy. Under fluoroscopic guidance, the abscess cavity was localized with a fine needle, and a no. 18 French trocar-tipped chest tube was inserted percutaneously; a large amount of pus was aspirated (figure 6). Within 24 hours the patient became afebrile and showed clinical improvement. Aerobic cultures of aspirated pus were nega-
PERCUTANEOUS DRAINAGE OF LUNG ABSCESS
Fig. 2. Case 2. Chest roentgenogram obtained 1 week after that shown in figure 1 shows that the cavity had increased in size.
155
156
VAINRUB, MUSHER, GUINN, YOUNG, SEPTIMUS, AND TRAVIS
Fig. 3. Case 2. Chest roentgenogram 18 days after insertion of the chest tube. The tube is still in place, and residual infiltration is seen without fluid. the, but anaerobic cultures yielded Bacterioides fragilis and Bacterioides melaninogenicus. Although improvement had already occurred, 1,200 mg of clindamycin per day was subsequently added. This treatment was continued for 2 weeks. Five weeks later, the patient was asymptomatic and the cavity could not be detected on roentgenogram. Discussion
Three patients developed lung abscess due to infection with gram-negative bacilli. These patients had multiple risk factors that predispose to lung abscess. All 3 had severe chronic obstructive pulmonary disease (1,2) for which 2 were taking daily prednisone (1). In addition, 2 were diabetic and one was alcoholic (1-4). Two cases were hospital acquired (table 1); Patient 1 developed Pseudomonas superinfection of a staphylococcal pneumonia, and Patient 3 acquired necrotizing pneumonia while being evaluated for a possible myocardial infarction. All 3 patients failed to respond to medical therapy that included an antimicrobial agent to which the causative organism was susceptible in vitro, postural drainage, and one or more bron-
choscopies (5). Although Patient 3 had 2 species of bacteroides isolated from the cavity itself, these had not been identified on previous anaerobic cultures and should have been susceptible in vitro to carbenicillin (6). Large abscess cavities persisted and, in fact, enlarged in 2 cases. The condition of Patients 1 and 2 had steadily deteriorated, and Patient 3 remained febrile, without signs of improvement. The failure of these patients to respond to medical treatment might have been related, in part, to abscess size (1, 3, 4) and location. One study has suggested that abscesses located in the posterior segment of the right upper lobe have a higher incidence of delayed closure (7), although other studies do not substantiate such a relationship (2, 3). Aerobic gram-negative bacillary pneumonias, particularly those due to Pseudomonas and Klebsiella, (8, 9) are said to have a high incidence of necrosis with abscess formation. It is interesting that Pseudomonas was implicated in our 3 cases. Abscesses due to these organisms have been shown to persist despite appropriate antimicrobial drug therapy (10, 11). A poor response
PERCUTANEOUS DRAINAGE OF LUNG ABSCESS
Fig. 4. Case 2. Chest roentgenogram 5 months a abscess.
to antimicrobial drugs alone may be due, in part, to the difficulty in achieving adequate concentrations of antimicrobial drugs within the abscess cavity (10). Severe underlying lung disease with structural abnormalities and decreased compliance might also have played a role in failure of abscess cavities to drain spontaneously. The recommended treatment of lung abscesses that do not respond to medical management is lobectomy (11-14). Recommendations for patients who are poor surgical risks because of inadequate pulmonary reserve include limited wedge resection, with an emphasis on retaining uninvolved lung, and thoracostomy with or without partial rib resection to allow external drainage (12-15). Morbidity from both of these procedures is high. Our patients were believed to be unable to withstand resection of the abscess cavity. All 3 had chronic lung disease, one had severe atherosclerotic heart disease, and one
157
discharge shows scarring, with no evidence of an
was recovering from a myocardial infarction. As an alternative to lobectomy, a tube was inserted percutaneously into the abscess cavity under fluoroscopic control and was left in place for drainage. This simple procedure was described in 1938 in the treatment of tuberculous cavities and was later adapted for treating pyogenic lung abscesses (16). It has not received widespread application in the United States, and we were able to find only one report (17) in which tube thoracostomy was used in the treatment of pyogenic lung abscess. Insertion of a tube for drainage resulted in prompt clinical response in each of our patients, with closure of the abscess cavity within 4 to 5 weeks. Previous reports have described little if any associated morbidity with this procedure (16), although the potential for pneumothorax and intrabronchial hemorrhage is inherent in this technique. Our patients showed no deteri-
Fig. 5. Case 3. Chest roentgenogram taken on the sixteenth hospital day shows a large abscess in the right upper lobe.
**&$&"
Fig. 6. Case 3. Chest roentgenogram showing drainage of abscess with chest tube still in place.
62
3
RUL
RUL
RUL
Abscess Location
8:
P. aeruginosa, fragilis, B. melanin ogenicus
disease; OM
= diabetes mellitus;
CH F = congestive heart failure; M I = myocardial infarction; TB
= 0.31 literl
Recent MI, CHF, COPO
ASHO, CHF, COPO
min
FEV 1 ,
Contraindication to Surgery
Asp i rate from cavity yielded 2 species of Bacteroides, but patient had received carbenicillin without response th rough out, and he defervesced after insertion of tu be and before cI indamycin was added.
and cefazolin given without response. Cavity found to contain Ps. aeruginosa and P. rettgeri both sensitive to gentamicin and carbenicillin. Gram stain and foul odor suggested anaerobes.
I nitial culture of sputum and bronchial washing revealed "normal flora." Gentamicin
Comment
= tuberculosis.
FEV 1 = 1-sec forced expiratory volume; ASHO = atherosclerotic heart
Repeated bronchoscopies, postural drainage
Bronchoscopy, postural drainage
= right upper lobe;
day), gentamicin (240 mg/day), c1indamycin (1.2 g/day) added after insertion of tube.
Carbenicillin (32 gl
Cefazolin (12 g/day), gentamicin (240 mg/day), carbenicillin (32 g/day), and clindamycin (2.4 g/day) after insertion of tube.
P. aeruginosa, Proteus rettgeri; anaerobes suspected
Gentamicin (240 mgl day), then carben icill in (30 g/day) and tobramycin (240 mg/day).
Other Bronchoscopy, postural drainage
Medical Management Antimicrobial Orug
P. fluorescens
Organism
Definition of abbreviations: COPO = chronic obstructive pulmonary disease; RU L
COPO, ASHO, OM, CHF, recent MI, inactive TB; on prednisone hospitalacquired infection
Severe ASHO, OM, alcohol ingestion; on prednisone
61
2
Underlying Condition
COPO, staphylococcal pneumonia (h ospi ta! acquired)
Age (years)
59
Case No.
TABLE 1 SUMMARY OF CLINICAL FINDINGS AND TREATMENT OF 3 MEN WITH PULMONARY ABSCESS
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VAINRUB, MUSHER, GUINN, YOUNG, SEPTIMUS, AND TRAVIS
o r a t i o n in p u l m o n a r y function or blood gases after tube thoracostomy. As has been noted repeatedly, prolonged antimicrobial d r u g therapy is usually successful in treating l u n g abscess (2, 10, 18) and, in o u r experience, it is u n u s u a l for this condition n o t to respond to conservative m a n a g e m e n t . I n the rare case in which medical therapy fails, percutaneous tube drainage should be considered as an alternative to thoracostomy a n d lobectomy. T h i s limited procedure is particularly useful in patients whose u n d e r l y i n g medical conditions are contraindications to surgical resection, b u t perh a p s should also be considered in those who are n o t such p o o r candidates for lobectomy.
7.
8.
9.
10.
11. Acknowledgment T h e writers are indebted to Ms. Mona Thomas for secretarial assistance.
12.
13. References 1. Chidi, C. C , and Mendelson, H. J.: Lung abscess: A study of the results of treatment based on 90 consecutive cases, J Thorac Cardiovasc Surg, 1974, 68,168. 2. Fifer, W. R., Husebye, K., Chedister, C , and Miller, M.: Primary lung abscess: Analysis of therapy and results of 55 cases, Arch Intern Med, 1961,107, 668. 3. Barnett, T. B., and Herring, C. L.: Lung abscess: Initial and late results of medical therapy, Arch Intern Med, 1971,127, 217. 4. Weiss, W.: Cavity behavior in acute, primary, nonspecific lung abscess, Am Rev Respir Dis, 1973,108,1273. 5. Wanner, A., Landa, J. F., Neiman, R. E., Jamsheed, V., and Deldago, I.: Bedside bronchofibroscopy for atelectasis and lung abscess, JAMA, 1973,224,1281. 6. Sutter, V. L., and Finegold, S. M.: Susceptibility
14.
15.
16. 17.
18.
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