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Indwelling Transbronchial Catheter Drainage of Pulmonary Abscess
Indwelling Transbronchial Catheter Drainage of Pulmonary Abscess Gregory S. Schmitt, M.D., Jill M. Ohar, M.D., Kirk R. Kanter, M.D., and Keith S. Naunheim, M.D.
ABSTRACT Adequate cavitary drainage is of paramount importance in the treatment of pulmonary abscesses. Occasionally this cannot be achieved despite vigorous chest physical therapy and the utilization of bronchoscopy. Intermittent transbronchial catheterization under fluoroscopic guidance has been suggested as a method to facilitate drainage. We have modified this technique by placing an indwelling intracavitary catheter, which allows irrigation and drainage over a prolonged period. This report describes this technique and our experience with 3 patients managed in this fashion. The appropriate treatment of lung abscess entails adequate drainage coupled with appropriate antibiotic therapy. Drainage of the infected cavity is a critical component of management and often is achieved with chest physical therapy and postural drainage. In some instances, bronchoscopy can establish drainage of the abscess cavity, but frequently this drainage is not maintained and repeated bronchoscopies are necessary when fluid reaccumulates. To avoid this problem, we recently modified our approach by using an indwelling intracavitary catheter placed through the nose. It allows intermittent imgation and continuous drainage of the abscess cavity, thus eliminating the need for repeated bronchoscopy. This report describes our technique and experience with 3 patients managed in this fashion.
Material and Methods
Technique The patient is premedicated (meperidine hydrochloride, 50 mg, and atropine, 0.4 mg, intramuscularly) and positioned on the fluoroscopy table in a supine position with the head elevated 30 degrees. Oversedation is assiduously avoided to minimize the risk of contralateral aspiration of the abscess contents. Nebulized 4% Xylocaine (lidocaine hydrochloride) is used to anesthetize the nasopharynx, vocal cords, and tracheobronchial tree. An Olympus BF-10 bronchoscope is advanced in the standard fashion through the nasopharynx and the From the Departments of Surgery and Medicine, St. Louis University Medical Center, St. Louis, MO. Accepted for publication Aug 24, 1987. Address reprint requests to Dr. Naunheim, Department of Surgery, St. Louis University Medical Center, 1325 S Grand Blvd, St. Louis, MO 63104.
43
vocal cords and into the trachea. After examination of the nonaffected segmental orifices, the bronchus of the involved pulmonary segment is visualized. It is usually a slitlike opening occluded by inflamed and edematous mucosa. The flexible straight end of a guidewire 145 cm long and 0.875 mm (0.035 inches) long (C.R. Bard, Inc., Billerica, MA) is advanced through the instrument channel of the bronchoscope, and then guided under direct bronchoscopic visualization through the segmental orifice and into the abscess cavity. To shrink the mucosa, inhibit local bleeding, and facilitate passage of the guidewire, 0.1% epinephrine can be applied topically. Confirmation of the intracavity position of the guidewire is obtained using biplane fluoroscopy. When the wire is properly positioned, it is held stationary and the bronchoscope is withdrawn. During this maneuver, fluoroscopy is used to ensure that the guidewire remains within the cavity. A pigtail catheter is then advanced over the wire, through the nares, the nasopharynx, and the tracheobronchial tree, and into the abscess cavity. When the pigtail is in place within the abscess cavity, the guidewire is withdrawn and the catheter is taped in place as with a nasogastric tube. Initially, an 8F angiographic pigtail catheter 55 cm long was used. However, the small lumen of this catheter was thought to cause some resistance to aspiration of the viscous, purulent cavitary contents. Our current technique employs a 10F modified pigtail nephrostomy tube 55 cm long with an end hole and multiple side-holes (Cook Company, Bloomington, IN). A syringe is attached to the catheter, and gentle suction is applied to aspirate the contents of the abscess cavity. This material is then sent for Gram stain and culture. When no further material can easily be aspirated from the cavity, irrigation is begun to clear the cavity of residual necrotic debris. Aliquots of 25 to 50 ml of normal saline solution are injected into the cavity and then aspirated through the catheter. This irrigation is performed three times daily, each time followed by a session of vigorous chest percussion and postural drainage, usually resulting in the expectoration of purulent material. Because this imgation can result in the expectoration of large amounts of material, it should be done only in patients with an intact cough reflex, which would enable them to protect the contralateral lung from soilage. The catheter is left in place until the air-fluid level has resolved and shrinkage of the cavity is documented by serial chest roentgenograms. When the cavity is 4 cm or smaller and the patient has symptomatically improved, the catheter is removed.
Ann Thorac Surg 45:43-47, Jan 1988. Copyright 0 1988 by The Society of Thoracic Surgeons
44 The Annals of Thoracic Surgery Vol 45 No 1 January 1988
Fig 1 . (Patient 1 .) Chest roentgenogram shows abscess cavity with air-fluid level in mediobasal segment of right lower lobe.
Case Reports 1. A previously healthy 29-year-old man had been treated for several days at another hospital for a neck infection. Intravenous administration of antibiotics had produced no improvement. He was transferred to University Hospital for management of fever and right neck swelling. On admission, the condition of the patient was severely toxic. There was marked swelling, erythema, and tenderness of the anterior neck bilaterally with extension onto the chest. A computed tomographic scan revealed air in the superior mediastinurn and a large right pleural effusion. The patient was taken to the operating room for bilateral exploration of the neck, drainage of the superior mediastinum, and tracheostomy. A right thoracentesis yielded purulent fluid with a pH of 6.9 and many leukocytes. A right thoracostomy tube was placed. Intraoperative samples were taken for culture and yielded Staphylococcus aureus and Hemophilus influenzae. Despite appropriate antibiotics, the patient continued to have fever and leukocytosis. On the seventh postoperative day, the chest roentgenogram showed an air-fluid level in the right lower lobe where an infiltrate had previously been (Fig 1). At bronchoscopy, the endobronchial anatomy was normal except for a slitlike orifice in the mediobasal segment of the right lower lobe. Under fluoroscopic control, a flexible guidewire was placed into the abscess cavity, and a pigtail catheter was threaded over it (Fig 2). Sixty milliliters of purulent material was aspirated, cultures of which eventually yielded S. aureus. The patient’s fever resolved within 36 hours of catheter placement. The catheter remained in the cavity for one week, during which time the cavity was irrigated three times daily with normal saline solution, followed by chest percussion and postural drainage. By the seventh day of drainage, the abscess cavity had radiographically diminished (Fig 3), and the catheter was removed. The patient was discharged one week later. Fol-
Fig 2 . (Patient 1.) Pigtail drainage catheter in position within abscess cavity.
PATIENT
Fig 3 . (Patient 1 .) Chest roentgenogram made immediately prior to removal of the drainage catheter demonstrates resolution of the abscess cavity.
low-up examination in a month showed radiographic resolution of the abscess (Fig 4). PATIENT 2. A 59-year-old man with senile dementia and unresectable adenocarcinoma of the right lower lobe was seen with a 3-day history of fever, rigors, and cough productive of purulent sputum. The admission chest roentgenogram showed a cavitary lesion in the right lower lobe with an air-fluid level. Sputum samples were obtained for culture, and a regimen of intravenous antibiotics and chest percussion with postural drainage was begun. After 9 days of treatment, the patient’s symptoms had not improved and the air-fluid level within the cavity was unchanged. On the tenth day of hospitalization, fiberoptic bron-
45
Schmitt
et al:
Catheter Drainage of Pulmonary Abscess
Fig.4. (Patient 1 .) Chest roentgenogram made one month after discharge shows minimal residual from abscess cavity.
choscopy was performed. The basilar segmental orifices were noted to be occluded by inflamed, edematous mucosa. Attempts to enter the abscess cavity with the bronchoscope were unsuccessful, and a transbronchial drainage catheter was placed into the cavity over a guidewire. When the catheter entered the abscess cavity, the patient expectorated 250 ml of purulent material. The catheter was left in place for 48 hours during which time saline irrigation and chest percussion with postural drainage were performed. After 2 days of drainage, the catheter was inadvertently dislodged. However, with appropriate intravenous antibiotics and continued chest physical therapy, the patient remained afebrile and the air-fluid level in the cavity continued to resolve. Fourteen days after transbronchial d.rainage, the patient was discharged for outpatient radiation therapy. PATIENT 3. A 65-year-old woman was admitted to the hospital with an adhesive small-bowel obstruction. She was known to have cavitating squamous cell carcinoma of the right upper lobe, previously determined to be unresectable because of inadequate pulmonary reserve. After lysis of adhesions, spiking temperatures occurred and an air-fluid level developed in the previously noted cavity (Fig 5). Despite treatment with intravenous antibiotics and vigorous chest physical therapy, the fever persisted. After 4 days of treatment, bronchoscopy was performed and an occluded anterior segmental orifice was visualized; the bronchoscope could not be passed into the abscess cavity. A transbronchial drainage catheter was placed into the cavity over a guidewire, and 20 ml of purulent material was aspirated and sent for culture. When the patient sat upright, she expectorated 200 ml of similar fluid. The catheter remained in place for 4 days while intravenous antibiotics, chest physical therapy,
Fig 5 . (Patient 3 . ) Air-fluid level in the cavitary squamous cell carcinoma of the right upper lobe.
Fig 6 . (Patient 3.) Chest roentgenogram made after 4 days of continuous indwelling-catheter drainage. The air-fluid level has resolved, and the catheter was subsequently removed.
and catheter irrigation and drainage were continued. Within 48 hours of drainage, the fever had resolved, although the patient continued to produce copious amounts of purulent sputum. By the fourth day of catheter drainage, the sputum production diminished and the air-fluid level resolved (Fig 6). The catheter was removed. Intravenous adminis-
46 The Annals of Thoracic Surgery Vol 45 No 1 January 1988
tration of antibiotics was continued for 4 additional days before the patient was discharged on a regimen of oral administration of antibiotics. Outpatient radiation therapy was then begun.
Comment Prior to the era of antibiotics, patients with lung abscess had a dismal prognosis. Surgical intervention usually entailed a localized drainage procedure, limited to those patients in whom the abscess cavity abutted the chest wall. Drainage was often not performed until the patient was severely debilitated and in the terminal stage of the disease. Results were understandably discouraging. In the 19409, the introduction of antibiotics greatly changed the results of treatment. Pneumonia, if diagnosed early, could be effectively treated, thus preventing progression to abscess formation. In those patients in whom a lung abscess did develop, intensive antibiotic treatment combined with postural drainage was frequently successful. However, medical management of lung abscess does have a substantial failure rate with a reported mortality of 10 to 27% [l-31. We believe the reasons for this are twofold. First, some physicians may rely on excessively prolonged courses of intensive antibiotic therapy in hopes of avoiding surgical intervention. More importantly, a different population of patients with lung abscess has now emerged. These patients have received broad-spectrum antibiotics, antimetabolites, immunosuppressive agents, or corticosteroids, and subsequently have had opportunistic lung infections [4, 51. These patients are at a higher risk of dying not only because of the unusual organisms involved, but also because of their underlying disease and immunosuppression, Surgical intervention is the accepted treatment for patients not responding to antibiotics and postural drainage. Patients treated by lung resection have a reported survival ranging from 89 to 95% [l-31. However, there are several disadvantages to surgical resection. With lobectomy, the loss of functioning pulmonary parenchyma adjacent to an abscess may have serious implications for the critically ill patient with marginal pulmonary reserve. In addition, inadvertent contamination of the pleural space can occur and may result in empyema in patients with persistent postoperative air spaces. Some patients are too debilitated to tolerate thoracotomy and pulmonary resection. It has been recommended that these patients undergo a Monaldi procedure, a twostage operation involving rib resection with delayed pneumonotomy and external drainage [ 6 ] . Although satisfactory results have been obtained with this approach [7, 81, there are several drawbacks, including the need for general anesthesia and the requirement that abscesses managed in this fashion be situated peripherally, adjacent to the chest wall. The introduction of the fiberoptic bronchoscope has added a new dimension to the diagnosis and treatment of pulmonary abscess, and has become an essential step
in the evaluation of every patient with this disease. Flexible bronchoscopy may be used to obtain representative culture material for accurate diagnosis, and often allows drainage of the abscess cavity, thereby effecting resolution of the disease process. Effective bronchoscopic drainage is not achieved in all patients, usually for one of two reasons. First, it is often impossible to introduce the bronchoscope through an edematous bronchial orifice into the abscess cavity. Second, even after successful bronchoscopic drainage, the communication created between the cavity and the bronchus may not remain patent, thus resulting in recurrent symptoms and the need for repeated bronchoscopy. Several authors have demonstrated that a transbronchial drainage catheter may be placed under fluoroscopic guidance into an abscess cavity otherwise unreachable with the bronchoscope [9]. This can be accomplished using a flexible or rigid bronchoscope, or through an endotracheal tube while the patient is under general anesthesia [9, lo]. These techniques are useful both for obtaining adequate diagnostic material and for achieving initial drainage of the cavity. However, once the drainage catheter is removed, the communication between the abscess cavity and the bronchial tree can occlude and lead to recurrent symptoms. To overcome this problem, we utilize an indwelling catheter for continuous drainage. The 3 patients reported here were carefully selected. Two of these patients had obstructing, unresectable lung carcinoma. The other patient had widespread suppurative disease including empyema, which would have increased the morbidity of pulmonary resection. All 3 patients were discharged from the hospital after 2 to 10 days of indwelling catheter drainage. None required further bronchoscopy to enhance drainage, and all exhibited prompt defervescence within 48 hours. The length of hospitalization for these patients ranged from 5 to 23 days, far below the usual hospital stay of four to six weeks reported to be necessary for lung abscess not drained bronchoscopically [ll]. We believe that the efficacy of this technique is due not only to persisent drainage through the indwelling catheter, but also to the catheter serving as a stent to maintain a patent route for drainage from the abscess cavity to the bronchial tree. As the purulent fluid is drained and the cavity shrinks, the inflammation and compression of the bronchus and surrounding parenchyma resolves. Once this has occurred, the bronchial communication with the cavity probably widens, allowing drainage around the catheter. This would explain why postural drainage following intracavitary instillation of saline solution frequently results in expectoration of copious amounts of purulent material. The vigorous instillation of saline solution may also aid in removing suppurative debris from the abscess wall, thus speeding the healing process. The limited clinical experience with this technique does not allow us to recommend its routine use in all patients with lung abscess. However, we do believe that
47 Schmitt et al: Catheter Drainage of Pulmonary Abscess
it should be strongly considered as a therapeutic alternative in those patients in whom medical management has failed and prompt drainage cannot be achieved with chest physical therapy or bronchoscopy. The advantages are the ease of catheter placement and the maintenance of continuous drainage over extended periods. It is conceivable that broader application of continuous transbronchial drainage in patients with primary lung abscess could shorten the duration of medical treatment and dbviate the need for more extensive surgical intervention in many. This could result in increased survival, shorter hospital stay, and substantially reduced medical costs. In addition, there may be particular subsets of patients who may benefit from early transbronchial catheter drainage. Patients with large abscess cavities are known to respond poorly to medical treatment alone and might benefit from early use of this technique. Immunosuppressed patients might also benefit, since the trahsbronchial catheter will not only provide samples for representative cultures of opportunistic pathogens, but will also establish prompt, effective, and lasting drainage in the compromised host. Finally, patients in whom infection develops within cavitating neoplasms can undergo effective drainage prior to institution of other treatments.
References 1. Delarue NC, Pearson FG, Nelems JM, Cooper J D Lung abscess: surgical implications. Can J Surg 23:297, 1980 2. CMdi CC, Mendelsofi HJ: Lung abscess: a study of the results of treatment based on 90 consecutive cases. J Thorac Cardiovasc Surg 68:168, 1974 3. Estera AS, Platt MR, Mills LJ, Shaw RR: Primary lung abscess. J Thorac Cardiovasc Surg 79275, 1980 4. Perlman LV, Lemer E, DEsopa N: Clinical classification and analysis of 97 cases of lung abscess. Am Rev Respir Dis 99.390, 1969 5. Pappas G, Shroter G, Brettschneider L, et al: Pulmonary surgery in immunosuppressed patients. J Thorac Cardiovasc Surg 59:882, 1970 6. Monaldi V. Endocavitaryaspiration in the treatment of lung abscess. Chest 29:193, 1956 7. Snow N, Lucas A, Homgan TI? Utility of pneumonotomy in the treatment of cavitary lung disease. Chest 87731,1985 8. Lawrence GH, Rubin SL Management of giant lung abscess. Am J Surg 1x134, 1978 9. Connors JP, Roper CL, Ferguson TB: Transbronchial catherization of pulmonary abscesses. Ann Thorac Surg 19254, 1975 10. Groff DB, Marquis J: Transtracheal drainage of lung abscesses in children. J Pediatr Surg 12:303, 1977 11. Gopalakrishna KV, Lemer PI: Primary lung abscess: analysis of 66 cases. Cleve Clin Q 42:3, 1975
ABSTRACT Adequate cavitary drainage is of paramount importance in the treatment of pulmonary abscesses. Occasionally this cannot be achieved despite vigorous chest physical therapy and the utilization of bronchoscopy. Intermittent transbronchial catheterization under fluoroscopic guidance has been suggested as a method to facilitate drainage. We have modified this technique by placing an indwelling intracavitary catheter, which allows irrigation and drainage over a prolonged period. This report describes this technique and our experience with 3 patients managed in this fashion. The appropriate treatment of lung abscess entails adequate drainage coupled with appropriate antibiotic therapy. Drainage of the infected cavity is a critical component of management and often is achieved with chest physical therapy and postural drainage. In some instances, bronchoscopy can establish drainage of the abscess cavity, but frequently this drainage is not maintained and repeated bronchoscopies are necessary when fluid reaccumulates. To avoid this problem, we recently modified our approach by using an indwelling intracavitary catheter placed through the nose. It allows intermittent imgation and continuous drainage of the abscess cavity, thus eliminating the need for repeated bronchoscopy. This report describes our technique and experience with 3 patients managed in this fashion.
Material and Methods
Technique The patient is premedicated (meperidine hydrochloride, 50 mg, and atropine, 0.4 mg, intramuscularly) and positioned on the fluoroscopy table in a supine position with the head elevated 30 degrees. Oversedation is assiduously avoided to minimize the risk of contralateral aspiration of the abscess contents. Nebulized 4% Xylocaine (lidocaine hydrochloride) is used to anesthetize the nasopharynx, vocal cords, and tracheobronchial tree. An Olympus BF-10 bronchoscope is advanced in the standard fashion through the nasopharynx and the From the Departments of Surgery and Medicine, St. Louis University Medical Center, St. Louis, MO. Accepted for publication Aug 24, 1987. Address reprint requests to Dr. Naunheim, Department of Surgery, St. Louis University Medical Center, 1325 S Grand Blvd, St. Louis, MO 63104.
43
vocal cords and into the trachea. After examination of the nonaffected segmental orifices, the bronchus of the involved pulmonary segment is visualized. It is usually a slitlike opening occluded by inflamed and edematous mucosa. The flexible straight end of a guidewire 145 cm long and 0.875 mm (0.035 inches) long (C.R. Bard, Inc., Billerica, MA) is advanced through the instrument channel of the bronchoscope, and then guided under direct bronchoscopic visualization through the segmental orifice and into the abscess cavity. To shrink the mucosa, inhibit local bleeding, and facilitate passage of the guidewire, 0.1% epinephrine can be applied topically. Confirmation of the intracavity position of the guidewire is obtained using biplane fluoroscopy. When the wire is properly positioned, it is held stationary and the bronchoscope is withdrawn. During this maneuver, fluoroscopy is used to ensure that the guidewire remains within the cavity. A pigtail catheter is then advanced over the wire, through the nares, the nasopharynx, and the tracheobronchial tree, and into the abscess cavity. When the pigtail is in place within the abscess cavity, the guidewire is withdrawn and the catheter is taped in place as with a nasogastric tube. Initially, an 8F angiographic pigtail catheter 55 cm long was used. However, the small lumen of this catheter was thought to cause some resistance to aspiration of the viscous, purulent cavitary contents. Our current technique employs a 10F modified pigtail nephrostomy tube 55 cm long with an end hole and multiple side-holes (Cook Company, Bloomington, IN). A syringe is attached to the catheter, and gentle suction is applied to aspirate the contents of the abscess cavity. This material is then sent for Gram stain and culture. When no further material can easily be aspirated from the cavity, irrigation is begun to clear the cavity of residual necrotic debris. Aliquots of 25 to 50 ml of normal saline solution are injected into the cavity and then aspirated through the catheter. This irrigation is performed three times daily, each time followed by a session of vigorous chest percussion and postural drainage, usually resulting in the expectoration of purulent material. Because this imgation can result in the expectoration of large amounts of material, it should be done only in patients with an intact cough reflex, which would enable them to protect the contralateral lung from soilage. The catheter is left in place until the air-fluid level has resolved and shrinkage of the cavity is documented by serial chest roentgenograms. When the cavity is 4 cm or smaller and the patient has symptomatically improved, the catheter is removed.
Ann Thorac Surg 45:43-47, Jan 1988. Copyright 0 1988 by The Society of Thoracic Surgeons
44 The Annals of Thoracic Surgery Vol 45 No 1 January 1988
Fig 1 . (Patient 1 .) Chest roentgenogram shows abscess cavity with air-fluid level in mediobasal segment of right lower lobe.
Case Reports 1. A previously healthy 29-year-old man had been treated for several days at another hospital for a neck infection. Intravenous administration of antibiotics had produced no improvement. He was transferred to University Hospital for management of fever and right neck swelling. On admission, the condition of the patient was severely toxic. There was marked swelling, erythema, and tenderness of the anterior neck bilaterally with extension onto the chest. A computed tomographic scan revealed air in the superior mediastinurn and a large right pleural effusion. The patient was taken to the operating room for bilateral exploration of the neck, drainage of the superior mediastinum, and tracheostomy. A right thoracentesis yielded purulent fluid with a pH of 6.9 and many leukocytes. A right thoracostomy tube was placed. Intraoperative samples were taken for culture and yielded Staphylococcus aureus and Hemophilus influenzae. Despite appropriate antibiotics, the patient continued to have fever and leukocytosis. On the seventh postoperative day, the chest roentgenogram showed an air-fluid level in the right lower lobe where an infiltrate had previously been (Fig 1). At bronchoscopy, the endobronchial anatomy was normal except for a slitlike orifice in the mediobasal segment of the right lower lobe. Under fluoroscopic control, a flexible guidewire was placed into the abscess cavity, and a pigtail catheter was threaded over it (Fig 2). Sixty milliliters of purulent material was aspirated, cultures of which eventually yielded S. aureus. The patient’s fever resolved within 36 hours of catheter placement. The catheter remained in the cavity for one week, during which time the cavity was irrigated three times daily with normal saline solution, followed by chest percussion and postural drainage. By the seventh day of drainage, the abscess cavity had radiographically diminished (Fig 3), and the catheter was removed. The patient was discharged one week later. Fol-
Fig 2 . (Patient 1.) Pigtail drainage catheter in position within abscess cavity.
PATIENT
Fig 3 . (Patient 1 .) Chest roentgenogram made immediately prior to removal of the drainage catheter demonstrates resolution of the abscess cavity.
low-up examination in a month showed radiographic resolution of the abscess (Fig 4). PATIENT 2. A 59-year-old man with senile dementia and unresectable adenocarcinoma of the right lower lobe was seen with a 3-day history of fever, rigors, and cough productive of purulent sputum. The admission chest roentgenogram showed a cavitary lesion in the right lower lobe with an air-fluid level. Sputum samples were obtained for culture, and a regimen of intravenous antibiotics and chest percussion with postural drainage was begun. After 9 days of treatment, the patient’s symptoms had not improved and the air-fluid level within the cavity was unchanged. On the tenth day of hospitalization, fiberoptic bron-
45
Schmitt
et al:
Catheter Drainage of Pulmonary Abscess
Fig.4. (Patient 1 .) Chest roentgenogram made one month after discharge shows minimal residual from abscess cavity.
choscopy was performed. The basilar segmental orifices were noted to be occluded by inflamed, edematous mucosa. Attempts to enter the abscess cavity with the bronchoscope were unsuccessful, and a transbronchial drainage catheter was placed into the cavity over a guidewire. When the catheter entered the abscess cavity, the patient expectorated 250 ml of purulent material. The catheter was left in place for 48 hours during which time saline irrigation and chest percussion with postural drainage were performed. After 2 days of drainage, the catheter was inadvertently dislodged. However, with appropriate intravenous antibiotics and continued chest physical therapy, the patient remained afebrile and the air-fluid level in the cavity continued to resolve. Fourteen days after transbronchial d.rainage, the patient was discharged for outpatient radiation therapy. PATIENT 3. A 65-year-old woman was admitted to the hospital with an adhesive small-bowel obstruction. She was known to have cavitating squamous cell carcinoma of the right upper lobe, previously determined to be unresectable because of inadequate pulmonary reserve. After lysis of adhesions, spiking temperatures occurred and an air-fluid level developed in the previously noted cavity (Fig 5). Despite treatment with intravenous antibiotics and vigorous chest physical therapy, the fever persisted. After 4 days of treatment, bronchoscopy was performed and an occluded anterior segmental orifice was visualized; the bronchoscope could not be passed into the abscess cavity. A transbronchial drainage catheter was placed into the cavity over a guidewire, and 20 ml of purulent material was aspirated and sent for culture. When the patient sat upright, she expectorated 200 ml of similar fluid. The catheter remained in place for 4 days while intravenous antibiotics, chest physical therapy,
Fig 5 . (Patient 3 . ) Air-fluid level in the cavitary squamous cell carcinoma of the right upper lobe.
Fig 6 . (Patient 3.) Chest roentgenogram made after 4 days of continuous indwelling-catheter drainage. The air-fluid level has resolved, and the catheter was subsequently removed.
and catheter irrigation and drainage were continued. Within 48 hours of drainage, the fever had resolved, although the patient continued to produce copious amounts of purulent sputum. By the fourth day of catheter drainage, the sputum production diminished and the air-fluid level resolved (Fig 6). The catheter was removed. Intravenous adminis-
46 The Annals of Thoracic Surgery Vol 45 No 1 January 1988
tration of antibiotics was continued for 4 additional days before the patient was discharged on a regimen of oral administration of antibiotics. Outpatient radiation therapy was then begun.
Comment Prior to the era of antibiotics, patients with lung abscess had a dismal prognosis. Surgical intervention usually entailed a localized drainage procedure, limited to those patients in whom the abscess cavity abutted the chest wall. Drainage was often not performed until the patient was severely debilitated and in the terminal stage of the disease. Results were understandably discouraging. In the 19409, the introduction of antibiotics greatly changed the results of treatment. Pneumonia, if diagnosed early, could be effectively treated, thus preventing progression to abscess formation. In those patients in whom a lung abscess did develop, intensive antibiotic treatment combined with postural drainage was frequently successful. However, medical management of lung abscess does have a substantial failure rate with a reported mortality of 10 to 27% [l-31. We believe the reasons for this are twofold. First, some physicians may rely on excessively prolonged courses of intensive antibiotic therapy in hopes of avoiding surgical intervention. More importantly, a different population of patients with lung abscess has now emerged. These patients have received broad-spectrum antibiotics, antimetabolites, immunosuppressive agents, or corticosteroids, and subsequently have had opportunistic lung infections [4, 51. These patients are at a higher risk of dying not only because of the unusual organisms involved, but also because of their underlying disease and immunosuppression, Surgical intervention is the accepted treatment for patients not responding to antibiotics and postural drainage. Patients treated by lung resection have a reported survival ranging from 89 to 95% [l-31. However, there are several disadvantages to surgical resection. With lobectomy, the loss of functioning pulmonary parenchyma adjacent to an abscess may have serious implications for the critically ill patient with marginal pulmonary reserve. In addition, inadvertent contamination of the pleural space can occur and may result in empyema in patients with persistent postoperative air spaces. Some patients are too debilitated to tolerate thoracotomy and pulmonary resection. It has been recommended that these patients undergo a Monaldi procedure, a twostage operation involving rib resection with delayed pneumonotomy and external drainage [ 6 ] . Although satisfactory results have been obtained with this approach [7, 81, there are several drawbacks, including the need for general anesthesia and the requirement that abscesses managed in this fashion be situated peripherally, adjacent to the chest wall. The introduction of the fiberoptic bronchoscope has added a new dimension to the diagnosis and treatment of pulmonary abscess, and has become an essential step
in the evaluation of every patient with this disease. Flexible bronchoscopy may be used to obtain representative culture material for accurate diagnosis, and often allows drainage of the abscess cavity, thereby effecting resolution of the disease process. Effective bronchoscopic drainage is not achieved in all patients, usually for one of two reasons. First, it is often impossible to introduce the bronchoscope through an edematous bronchial orifice into the abscess cavity. Second, even after successful bronchoscopic drainage, the communication created between the cavity and the bronchus may not remain patent, thus resulting in recurrent symptoms and the need for repeated bronchoscopy. Several authors have demonstrated that a transbronchial drainage catheter may be placed under fluoroscopic guidance into an abscess cavity otherwise unreachable with the bronchoscope [9]. This can be accomplished using a flexible or rigid bronchoscope, or through an endotracheal tube while the patient is under general anesthesia [9, lo]. These techniques are useful both for obtaining adequate diagnostic material and for achieving initial drainage of the cavity. However, once the drainage catheter is removed, the communication between the abscess cavity and the bronchial tree can occlude and lead to recurrent symptoms. To overcome this problem, we utilize an indwelling catheter for continuous drainage. The 3 patients reported here were carefully selected. Two of these patients had obstructing, unresectable lung carcinoma. The other patient had widespread suppurative disease including empyema, which would have increased the morbidity of pulmonary resection. All 3 patients were discharged from the hospital after 2 to 10 days of indwelling catheter drainage. None required further bronchoscopy to enhance drainage, and all exhibited prompt defervescence within 48 hours. The length of hospitalization for these patients ranged from 5 to 23 days, far below the usual hospital stay of four to six weeks reported to be necessary for lung abscess not drained bronchoscopically [ll]. We believe that the efficacy of this technique is due not only to persisent drainage through the indwelling catheter, but also to the catheter serving as a stent to maintain a patent route for drainage from the abscess cavity to the bronchial tree. As the purulent fluid is drained and the cavity shrinks, the inflammation and compression of the bronchus and surrounding parenchyma resolves. Once this has occurred, the bronchial communication with the cavity probably widens, allowing drainage around the catheter. This would explain why postural drainage following intracavitary instillation of saline solution frequently results in expectoration of copious amounts of purulent material. The vigorous instillation of saline solution may also aid in removing suppurative debris from the abscess wall, thus speeding the healing process. The limited clinical experience with this technique does not allow us to recommend its routine use in all patients with lung abscess. However, we do believe that
47 Schmitt et al: Catheter Drainage of Pulmonary Abscess
it should be strongly considered as a therapeutic alternative in those patients in whom medical management has failed and prompt drainage cannot be achieved with chest physical therapy or bronchoscopy. The advantages are the ease of catheter placement and the maintenance of continuous drainage over extended periods. It is conceivable that broader application of continuous transbronchial drainage in patients with primary lung abscess could shorten the duration of medical treatment and dbviate the need for more extensive surgical intervention in many. This could result in increased survival, shorter hospital stay, and substantially reduced medical costs. In addition, there may be particular subsets of patients who may benefit from early transbronchial catheter drainage. Patients with large abscess cavities are known to respond poorly to medical treatment alone and might benefit from early use of this technique. Immunosuppressed patients might also benefit, since the trahsbronchial catheter will not only provide samples for representative cultures of opportunistic pathogens, but will also establish prompt, effective, and lasting drainage in the compromised host. Finally, patients in whom infection develops within cavitating neoplasms can undergo effective drainage prior to institution of other treatments.
References 1. Delarue NC, Pearson FG, Nelems JM, Cooper J D Lung abscess: surgical implications. Can J Surg 23:297, 1980 2. CMdi CC, Mendelsofi HJ: Lung abscess: a study of the results of treatment based on 90 consecutive cases. J Thorac Cardiovasc Surg 68:168, 1974 3. Estera AS, Platt MR, Mills LJ, Shaw RR: Primary lung abscess. J Thorac Cardiovasc Surg 79275, 1980 4. Perlman LV, Lemer E, DEsopa N: Clinical classification and analysis of 97 cases of lung abscess. Am Rev Respir Dis 99.390, 1969 5. Pappas G, Shroter G, Brettschneider L, et al: Pulmonary surgery in immunosuppressed patients. J Thorac Cardiovasc Surg 59:882, 1970 6. Monaldi V. Endocavitaryaspiration in the treatment of lung abscess. Chest 29:193, 1956 7. Snow N, Lucas A, Homgan TI? Utility of pneumonotomy in the treatment of cavitary lung disease. Chest 87731,1985 8. Lawrence GH, Rubin SL Management of giant lung abscess. Am J Surg 1x134, 1978 9. Connors JP, Roper CL, Ferguson TB: Transbronchial catherization of pulmonary abscesses. Ann Thorac Surg 19254, 1975 10. Groff DB, Marquis J: Transtracheal drainage of lung abscesses in children. J Pediatr Surg 12:303, 1977 11. Gopalakrishna KV, Lemer PI: Primary lung abscess: analysis of 66 cases. Cleve Clin Q 42:3, 1975