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A Hole New Kind of COPD Exacerbation
October 2013, Vol 144, No. 4_MeetingAbstracts Chest Infections | October 2013
A Hole New Kind of COPD Exacerbation Joshua Smith, MD; W. Graham Carlos, MD Indiana University, Indianapolis, IN Chest. 2013;144(4_MeetingAbstracts):170A. doi:10.1378/chest.1701997
Abstract SESSION TITLE: Infectious Disease Case Report Posters I SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM INTRODUCTION: Pneumatoceles are thin walled cystic lesions in the lungs. They are more commonly seen in neonates and children and are relatively rare in adults. We present a case of an infected pneumatocele in an adult treated with percutaneous drainage. CASE PRESENTATION: A 76-year-old male with history of chronic obstructive pulmonary disease presented with worsening dyspnea and chest pain of one-day duration. Given his respiratory distress on arrival to our hospital, he was placed on non-invasive positive pressure ventilation (Bipap). Initial chest x-ray showed no focal infiltrates and no cardiopulmonary abnormalities. Patient was treated with nebulized albuterol-ipratroprium, methylprednisolone, and doxycycline for his COPD exacerbation. Twelve hours after admission, a chest CT was performed which demonstrated a right middle lobe pneumatocele with compressive atelectasis (image 1). The patient’s clinical status worsened over 48 hours with increasing leukocytosis, and respiratory failure. Broad-spectrum antibiotics were started at this time and mechanical ventilation was instituted. On hospital day (HD) 3, a chest x-ray showed increased consolidation of the right lung base and a repeat chest CT showed a new fluid level and debris within the pneumatocele (image 2). A 12F percutaneous drainage catheter was placed by interventional radiology without complication on HD 4. The catheter was placed to continuous suction and purulent serosanguinous fluid was drained over the subsequent days. Sputum cultures collected at time of intubation showed pan-sensitive Pseudomonas aeruginosa, while the fluid culture showed no growth. A pneumothorax developed while patient was mechanically ventilated on HD 7 and a 7F pneumothorax catheter placed with resolution of the pneumothorax. The patient was successfully extubated on HD 13. The pneumothorax catheter was removed on HD 17 and patient transitioned to long-term acute care facility. Percutaneous drain was removed one month after initial presentation.
DISCUSSION: Pneumatoceles have been associated with trauma and hydrocarbon ingestion. They may form in setting of infection, particularly Staphylococcus aureus, due to a ball-valve effect related to secretions in the bronchus. They usually resolve spontaneously over weeks or months, though can enlarge resulting in cardiopulmonary collapse. CONCLUSIONS: Infected pneumatoceles are uncommon in the adult population. There is a lack of consensus to the most appropriate treatment for this condition. Few case reports do exist for treatment of infected pneumatoceles with percutaneous drainage, which was successful in the management of our patient. Reference #1: Dibardino et. al. Management of Complicated Pneumatocele. The Journal of Thoracic and Cardiovascular Surgery. 2005; 126 (3): 859 DISCLOSURE: The following authors have nothing to disclose: Joshua Smith, W. Graham Carlos No Product/Research Disclosure Information
A Hole New Kind of COPD Exacerbation Joshua Smith, MD; W. Graham Carlos, MD Indiana University, Indianapolis, IN Chest. 2013;144(4_MeetingAbstracts):170A. doi:10.1378/chest.1701997
Abstract SESSION TITLE: Infectious Disease Case Report Posters I SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM INTRODUCTION: Pneumatoceles are thin walled cystic lesions in the lungs. They are more commonly seen in neonates and children and are relatively rare in adults. We present a case of an infected pneumatocele in an adult treated with percutaneous drainage. CASE PRESENTATION: A 76-year-old male with history of chronic obstructive pulmonary disease presented with worsening dyspnea and chest pain of one-day duration. Given his respiratory distress on arrival to our hospital, he was placed on non-invasive positive pressure ventilation (Bipap). Initial chest x-ray showed no focal infiltrates and no cardiopulmonary abnormalities. Patient was treated with nebulized albuterol-ipratroprium, methylprednisolone, and doxycycline for his COPD exacerbation. Twelve hours after admission, a chest CT was performed which demonstrated a right middle lobe pneumatocele with compressive atelectasis (image 1). The patient’s clinical status worsened over 48 hours with increasing leukocytosis, and respiratory failure. Broad-spectrum antibiotics were started at this time and mechanical ventilation was instituted. On hospital day (HD) 3, a chest x-ray showed increased consolidation of the right lung base and a repeat chest CT showed a new fluid level and debris within the pneumatocele (image 2). A 12F percutaneous drainage catheter was placed by interventional radiology without complication on HD 4. The catheter was placed to continuous suction and purulent serosanguinous fluid was drained over the subsequent days. Sputum cultures collected at time of intubation showed pan-sensitive Pseudomonas aeruginosa, while the fluid culture showed no growth. A pneumothorax developed while patient was mechanically ventilated on HD 7 and a 7F pneumothorax catheter placed with resolution of the pneumothorax. The patient was successfully extubated on HD 13. The pneumothorax catheter was removed on HD 17 and patient transitioned to long-term acute care facility. Percutaneous drain was removed one month after initial presentation.
DISCUSSION: Pneumatoceles have been associated with trauma and hydrocarbon ingestion. They may form in setting of infection, particularly Staphylococcus aureus, due to a ball-valve effect related to secretions in the bronchus. They usually resolve spontaneously over weeks or months, though can enlarge resulting in cardiopulmonary collapse. CONCLUSIONS: Infected pneumatoceles are uncommon in the adult population. There is a lack of consensus to the most appropriate treatment for this condition. Few case reports do exist for treatment of infected pneumatoceles with percutaneous drainage, which was successful in the management of our patient. Reference #1: Dibardino et. al. Management of Complicated Pneumatocele. The Journal of Thoracic and Cardiovascular Surgery. 2005; 126 (3): 859 DISCLOSURE: The following authors have nothing to disclose: Joshua Smith, W. Graham Carlos No Product/Research Disclosure Information