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Lung Abscess: A Study of 148 Cases Due to Aspiration
Lung Abscess: A Study of 148 Cases Due to Aspiration* W . F. BERNHARD, M.D.,** J. A . MALC >LM, M . D . * * * AND R . H . WYLIE, M.D.F New
C
URRENT
MANAGEMENT
OF
York, New
PULMO-
nary abscess has evolved with the introduction of antimicrobial agents. During this period, it became evident that prompt administration of penicillin or a broad spectrum antibiotic could produce resolution of the exudative phase of pneumonitis and abort abscess formation. These agents markedly reduced mortalitv from lung abscess, increased the complete cure rate to some extent, and permitted the surgeon to show greater resolve in extirpating the acute focus or its residual. However, the successful management of lung abscess today remains both a medical and a surgical problem of considerable magnitude. The present study is concerned primarily with the effectiveness of current therapy. However, for purposes of clarity and completeness, comments on etiology, pathogenesis, and anatomy of abscess are included. Two hundred and ten patients form the basis of this report. All were treated at the Columbia-Presbyterian Medical Center or on the Chest Service of Bellevue Hospital Center, New York City, during the eightyear period, 1950 to 1958. Pulmonary excavations of congenital, tuberculous, mycotic, and parasitic etiology were excluded, as was a case of septic embolism secondary to pyemia. M E T H O D OF STUDY
It was suspected as this study developed that differing etiologies of abscesses had *From the Chest Service, Bellevue Hospital Center and Presbyterian Medical Center, and the Department of Surgery, College of Physicians and Surgeons, Columbia University. # *Clinical Associate in Surgery, Harvard Medical School. ## * C h i e f , Thoracic Surgery, Veterans Administration Hospital, New York City. fClinical Professor of Surgery, College of Physicians and Surgeons, Columbia University.
York
more than a little bearing on therapeutic outcome. Accordingly, the cases were divided into six groups for e v a l u a t i o n (Table 1). T A B L E 1 — 2 1 0 C A S E S OF PULMONARY A B S C E S S TREATED AT BELLEVUE AND PRESBYTERIAN HOSPITALS
Group I. Group II.
Aspiration abscess Abscess of unknown etiology Group III. Abscess in bland pulmonary infarct Group IV. Abscess secondary to pneumonía Group V. Carcinomatous abscess
Cases
Per cent
100
47.6
44
20.9
4
1.9
43 19
20.5 9.1
We shall consider for discussion Groups I, II, and III which we feel have most in common etiologically and pathogenetically. Group IV cases aróse from infection by specific organisms frequently associated with abscess formation and were not, so far as is known, dependent upon aspiration of foreign material or bronchial obstruction. Group V being due to cáncer is quite out of a discussion which involves the effectiveness of medical therapy. Groups IV and V are discussed in separate communications.4'5 ETIOLOGY
There seems to be little doubt that the majority of benign lung abscesses have one thing in common, namely, aspiration of infected material. Early writers pointed out tonsillectomy15 and oral sepsis" as consistent precursors of lung abscess. While tonsillectomy has declined as a cause, oral sepsis has remained a continued factor.2'3'*3'"'*0 Also, conditions featuring loss of consciousness with or without a tendency to vomit and aspírate such as alcoholism,11'13'23'"'32 epilepsy,11'12'" coma from anesthesia or any other cause,2'6'23'" loss of gag reflex due to age,1 immersion1* have more recently been
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indicted as predisposing to lung abscess formation. From the large number of reports on the subject, two factors rise above all others predisposing to aspiration abscess : alcoholism and oral sepsis. Our Group I (100 cases) refleets etiologically the series of others during the past 20 years. M a l e s were c o m m o n e r than females by 3:1 ( 4 : 1 is the usual ratio) .12'13'29 Seventy per cent of the patients were white and 27 per cent Negro. A history of acute alcoholic stupor two to four weeks prior to onset of the illness was extracted from 70 of the patients. Eleven had had general anesthesia recently. Nine were epileptics with frequent grand mal seizures. Ten others had a variety of causes for aspiration. Eightysix had foul teeth, and in 56, the abscesses were foul. Etiologic mechanisms in Group I are summarized in Table 2. 2—GROUP 100 CASES
I . ETIOLOGIC M E C H A N I S M S OF A S P I R A T I O N A B S C E S S
1. Alcoholic stupor 2. Aspiration associated with anesthesia and surgery 3. Diabetic coma 4. Brain concussion 5. Epileptic seizures 6. Aspiration secondary to obstructing esophageal carcinoma 7. Massive epistaxis with syncope Total
IN
M 4) cti U 0 £
Foul bsce
TABLE
70
48
22
1
10 2 4 3
11 2 4 9 3 1 100
m
fl ¿3 C Vi O o)
<
¿<
tn
— —
6
3
—
1 56
—
44
As we suggested earlier, etiology was less clear cut in Group II (44 cases), but aspiration was strongly suspected. In spite of the fact that neither careful review of antecedent history ñor bacteriology of the abscess was helpful, 18 (40.9 per cent) were admitted alcoholics and 38 (86.4 per cent) had foul teeth, a defective gag reflex, or both. In Group III, we have no clear cut reasons to suspect aspiration except to point out that these four patients were quite debilitated. The most important feature they
621
ABSCESS
had in common was a necrotic area of lung, a fertile field for organisms aspirated with foreign material. Several authors4'10' 18,29 indicate that infection of an ordinary pulmonary infarct is not a rarity, and must be presumed to be due to aspiration in the presence of pre-existing nonviable lung tissue. PATHOGENESIS
Numerous authors have pointed out the necessary conditions for lung abscess formation. These appear to be bronchial obstruction with atelectasis and localized necrosis. The necrosis is due to a combination of small vessel thrombosis and the necrotizing potential of organisms contained within the material obstructing the bronchus.9'12' 13.33 c u t j e r a n ( j Schluetter9 demonstrated in dogs that neither bronchial embolism ñor infarction alone could cause lung abscess. Amberson1 points out that in silicosis, which is characterized by múltiple areas of ischemia, lung abscess is a rarity. Brock7 has noted that simple foreign body aspiration is more frequently followed by atelectasis alone rather than by abscess. In the case of abscess in bland pulmonary infarct (Group I I I ) , one is forced to invoke aspiration as an additional factor. This phenomenon appears to occur in only 4.9 per cent of infarets, or 4.8 per cent of all pulmonary abscesses.18 In the collected cases, size of infarcted area, nearness of atelectatic lung, and the presence of pathogenic bacteria in the upper respiratory tract seem to have been additional pathogenetic factors. Whether or not one chooses to invoke local infarction and necrosis in the pathogenesis of abscess, one cannot ignore the role of bronchial occlusion (or embolism), and thus implícate some mechanism of a s p i r a t i o n as being chiefly causative. Brock7'8 has contributed much to our understanding of this process. By clinical observation and by repetition of the radiopaque oil studies of Quinn and Meyer,22 he has shown that localization of abscess can be adequately explained by analyzing the position of the most dependent portions of
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Diseases of the Chest
lung. He is able to explain readily, therefore, the predilection of abscesses for the posterior segment of the right upper lobe and the superior segments of both lower lobes. The proclivity of persons with either oral sepsis or chronic sinus infection to develop abscesses in these locations is thus explained (even in the absence of a history of pathologic insensibilitv), since the passage of material from upper to lower respiratory tract can be demonstrated to occur in ordinary sleep.
abscess starts as a segment al affliction.7 Nevertheless, past studies have specified only the lobes involved by the process. The reports of six investigators3'6'12'13'23'29 describing 501 cases have indicated the following distribution:
BACTERIOLOGY
In similar analysis our series of 100 aspiration abscesses is as follows:
Much has been written about the bacteriology of lung abscess. In a large percentage of cases, this has been established as specific for putrid and non-putrid abscesses alike.,'11,l3'21'23'27'"'3í Smith27 firmly established symbiotic fusospirochetes and streptococci as pathogens in putrid abscess. Others later have shown the great frequency of "non-pathogens" as the only recoverable organisms in both putrid and non-putrid abscesses.2,11,23'32'33 Again, we exclude abscesses due to highlv specific pneumonías, namelv, Staphylococcus aureus, Streptococcus hemolyticus, and Klebsiella pneumoniae. Our bacteriologic findings in both putrid and non-putrid abscesses were, at best, inconclusive. The bulk cultured "non-pathogens." Conceivably, c a r e f u l anaerobic culture techniques might well have uncovered fusospirochetes and elusive micro-aerophilic streptococci. On the other hand, many of our patients were received having been previously treated with penicillin or a broad-spectrum antibiotic. In fact, this was the case in 50 per cent of Group I cases appearing with non-putrid abscesses. Of the other 50 per cent, it may be said that their abscesses may have been putrid at one time; but with re-established drainage and recovery of aerobic conditions, the abscesses became non-putrid and thus dispersed their original pathogens. LOCALIZATION OF
ABSCESS
If the specific pneumonías are excluded, one finds that in the majority of cases, lung
Per cent Right upper lobe Right middle lobe Right lower lobe Left upper lobe Left lower lobe
35.2 8.4 25.6 17.3 13.5
Per cent Right upper lobe Right middle lobe Right lower lobe Left upper lobe Left lower lobe
36.8 1.0 20.4 12.2 29.6
In the 100 cases, 98 single and two múltiple abscesses were encountered. Broadly speaking, involvement of superior segments of lower lobes was encountered in 45 per cent, and the posterior segment of the right upper lobe was noted in 29 per cent. The segmental localization in these 100 cases (that is, in the 98 per cent with single abscesses) may be visualized in Fig. 1. As can be seen, the difference in the distribution of our aspiration abscess cases and the distribution in other abscess series is not remarkable. Our Group II, however, bears another look. While the superior segments and posterior segment of right upper lobe account for 22 (50.0 per cent) of the single abscesses (40 cases), 16 (36.4 per cent) had statistically atypical locations. No fewer than nine (20.5 per cent) had right middle lobe cavities, which location is atypical, but is consistent with vomiting (bent forward) or immersion as etiology.7 Anterior segments were involved in seven cases (15.9 per cent) which suggests aspiration while lying on one side tipped toward the prone position.8 Basal segments were involved in six (13.6 per cent), which is unusual. This
Volume 43, No. 6 June 1963
L U N G A B S C E S S 61
suggests that we may be in error classifying these cases as being caused by aspiration unless they occurred in patients with chronic esophageal obstruction, which often causes small, repeated aspirations in the erect position, or unless they occurred in patients who had recently undergone laparotomy.7 Basilar abscesses more often suggest bronchiectasis or prior pneumonía. THERAPY
Sixty-nine patients of Group I were managed medically. The therapy consisted of antibiotics (penicillin plus another antibiotic indicated by sputum culture and m i c r o b i a l sensitivities), bronchodilators, postural drainage, and occasional bronchoscopic aspiration. A complete clinical and radiologic cure was obtained in 22 (31.9 per cent) immediately, and 19 (27.5 per cent) in follow-up of six months or more. Twenty-two (31.9 per cent) were clinically cured, but retained cavities demonstrable by x-ray. Of this group, only four proceeded to complete cure, while four developed active tuberculosis, four had symp-
LOCATION OF SC
623
tomatic bronchiectasis, four were asymptomatic, and eight were untraced. Seventeen patients who were medical treatment failures were advised to have surgery but refused. Of the 17 cases, seven who could be followed retained their open cavities and productive cough. Table 3 summarizes the fate of Group I patients, all of whom started on medical therapy when first admitted. The surgical cases in Group I were all medical treatment failures. These numbered 31 cases, and nine of them had preliminary drainage. Of the nine, three eventually required pulmonary resection. Of 25 pulmonary resections, one patient died and three others had major complications. All of the 13 traced had complete cures (Table 3 ) . The surgically treated cases in Group I are also summarized in Table 3. A summary of the deaths in Group I is available in Table 4. Group II seemed not to differ much in outeome from Group I. Early resection was felt to be indicated in six cases of this group because of the possibility of bronchogenic carcinoma. None of these patients was con-
TARY CAVITIES
LATERAL VIEW
The location and frequeney of solitary abscess formation in 9 8 patients of Group I is indicated. The majority of cavities involved the dependent segments: posterior segment of the right upper lobe (29 cases), superior segment of the right lower lobe (19 cases), superior segment of the left lower lobe (26 cases). FIGURE
1:
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Diseases of the Chest
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TABLE 3 — T H E R A P E U T I C OUTCOME IN GROUP I PATIENTS
100 CASES (all started on medical regimen) Surgical Therapy - 3 1 . /medical failures)
Med. Therapy Alone - 69.
I
1
Died
8
(2 died of
abscess)
i
1
Clinical Cure Clinical inical Cure Residual Cavity N o Cavity 22 22
1
I
I
Resection
Drainage, Lung Drainage, or Pleura 9 3-
1 _ 1 Cough c Asymptomatic Sputum 2 Cavity 7 Untraced Untraced 10 7
Asymptomatic 15
Untraced
8
O tu
Surgery Surgery Refused 17
Died
25-
-H
—Major—^ Complication 3
T~ 1 Asympto- Residual Active matic B'ectasis Tuberc. 4 4 6
cu 5 W > o IS > UD H O , 2
~ ~
—r—
Active Tuberc. 2
r
Asymptomatic 13
Untraced 2
Untraced
11
Complete cure (clinical and x-ray) of presenting cases—34% (by med. therapy alone 1 9 % ) . Complete cure of medically treated cases—19/69 or 27.5% (25 untraced). Complete cure of combined medical an dsurgically treated cases—15/31 or 48.8% (13 untraced ).
sidered medically cured if a residual cavity or bronchiectasis was present. Twenty-five cases had medical therapy alone. Eleven (44 per cent) were pronounced clinicallv and radiologically cured, but 14 (56 per cent) were advised to have surgery and all refused. The five of these traced beyond a period of six months had productive cough and a cavity demonstrabie by x-ray. They became, in other words, cases of chronic lung abscess. Thirteen medical therapy failures were subjected to surgery. All abscesses eventuallv were resected. Of the 19 (including six primary resections) who were resected, two died as a result of surTABLE
gical complications. Eleven of the 17 surviving surgery were cured as of follow-up exceeding six months. Six cases were untraced. A summarv of Group II treatment may be seen in Table 5. Group III contained unusual cases complicated by associated diseases. Apart from pulmonary infarction, these patients had the following disabilities: 2 cases — terminal gastrointestinal cáncer. 1 case — diffuse cerebral atrophy. 1 case — arteriosclerotic heart disease in failure.
Only the cardiac case survived, and following medical therapy, his lung abscess was successfullv resected.
4 — G R O U P I. ANALYSIS OF N I N E
D E A T H S IN 1 0 0
Duration of Treatment
Size of Cavity
Clinical Response to Antibiotic Therapy
1. 10 Days 2. 10 Days 3. 2 Months 4. 1 Day 5. 2 Weeks 6. 1 Month 7. 1 Month
Unchanged Unchanged Decreased Unchanged Unchanged Decreased Decreased
None None None None None Satisfactory Satisfactory
8. 9.
Unchanged (Resected)
Satisfactory Medical failure, underwent lobectomy
1 Week 8 Days
PATIENTS
Primary Cause of Death Myocardial infarct Myocardial infarct Carcinoma of the esophagus Acute pulmonary abscess Carcinoma of the larynx Myocardial infarct Gastrointestinal hemorrhage from duodenal ulcer Acute pulmonary abscess Arteriosclerotic heart disease with failure
Volume 43, N o . 6 June 1963
LUNG
ABSCESS
THERAPEUTIC OUTCOME IN GROUP
44
6 2 5
II
PATIENTS
CASES
_Resected because of possible carcinoma
6
. Medical Therapy Alone - 25, Clinical Cure N o Cavity 11
Clinical Cure Residual Cavity 0
1
Surgical Therapy - 13 _ (Med. failure) |
Surgery Rib Resection Refused Pneumonotomy 14 2 2-
-13
I
Died.
Died
Resected
2
0
Major Complication 1
Cough c Sputum Cavity 5
Asymptomatic 7 Untraced 4 o, £
W
>co H O , 2 O Cu
S
Asymptomatic 11 Untraced
Untraced 9
6
Cured by medical and/or surgical therapy—18/44 or 41 per cent. Cured by medical therapy alone—7/25 or 28 per cent (untraced 13). Cured by medical-surgical therapy—11/19 or 57.9 per cent (untraced 6)
DISCUSSION
The original purpose of this paper was to ascertain the present role of surgery in the treatment of lung abscess. Our clinical observations had convinced us that medical therapy alone in our hands did not vield the 85 to 90 per cent cure rate of Fox et al.14 or Gittens and Mihaly.18 Our medical therapy was sound, being based upon: 1. Intensive modern antibiotic therapy which included penicillin and most of the broad spectrum antibiotics still principally used at this time. 2. Bronchodilator therapy with or without intermittent positive pressure breathing (IPPB). 3. Postural drainage. 4. Intermittent bronchoscopy, both diagnostic and therapeutic. (We did not, however, employ manipulations with bronchial catheters and local antibiotics described by Metras and Charpin*0 with which they apparently obtained a 72.5 per cent clinical cure rate over a two year follow-up.)
Altogether, 103 of 148 patients (69.5 per cent) left the hospital relieved of the acute symptoms of their lung abscess. Of this number, 55 of 148 (37.1 per cent) succeeded on medical treatment alone as outlined above. Six had surgery without adequate medical therapy on suspicion of cáncer. Forty-five (30.4 per cent) were obliged to undergo surgery in addition to medical treatment. Of these, 42 were discharged free of their symptoms. However, an additional 31 (20.9 per cent) were advised to have surgery because medical therapy was proving a failure. These patients refused surgery and were ultimately discharged. We could follow 12 of them. All were cases of frank chronic lung abscess. Thus, if 51.3 per cent of the series had or were advised to have surgery, more of the series required operation than did not, modern antibiotics notwithstanding. Now, 55 of 148 cases left the hospital well after medical therapy alone; but in follow-up of six to 84 months, only 26 (17.6
626
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per cent) received a clean bilí of health while ten (6.8 per cent) languished with either symptomatic bronchiectasis or tuberculosis. Nineteen (12.8 per cent) were untraced. Thus, among 148 presenting cases, the following medical failures are tabulated (base of 142 when six immediate resections for possible carcinoma are excluded): Residual bronchiectasis Active tuberculosis Chronic abscess Referred to surgery Total
(59.8 per cent)
4 6 31 44 85
The medical failure rate is therefore 59.8 per cent of all patients attempting to undergo conservative therapy alone. The medical successes amount to 40.2 per cent provided we ignore cases lost to follow-up. If, in addition, those untraced patients are long term medical failures, the medical success rate is only 18.3 per cent. Let us now consider the mortality statistics within our series. Fourteen cases died, 11 undergoing medical therapy and three undergoing medical-surgical therapy. Five of these were directly attributable to lung abscess or the treatment thereof (in surgery this was due to bronchopleural fístula in two and to coronary sclerosis in one). Regardless of the role of surgery, the five deaths are directly attributable to medical treatment failure, since all the patients were referred to surgery following unsuccessful medical treatment. The remaining cases were probably beyond hope by any form of therapy. Comparison of our series with those of other authors has been anything but easy for the following reasons: 1. Few workers employ statistics extending into a follow-up period. 2. Most authors concern themselves with either medically or surgically treated groups. 3. Definitions of "cure," "improved," "good result," "poor result," etc., are maddeningly inexact. In short, only "died" is universal in its interpretaron.
AND
Diseases of the Chest
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4. We are often not discussing the same abscesses, as various authors deal separately with "acute" and "chronic" or include etiologies such as the specific pneumonías,2,29,31 bronchiectasis,25 and 23,31
carcinoma. For historie purposes, we may consider two different impressions of lung abscess prior to the modern antibiotic era. Smith27 surveyed 2166 published cases prior to 1945, and noted that on medical therapy (principallv sulfonamides) 34.7 per cent died, 31.3 per cent were cured, and 34.0 per cent became chronic. Schweppe et al.™ recall Massachusetts General Hospital series from 1909 to 1942 which chart the decline of lung abscess mortality from 75 per cent to 18.3 per cent. Their a n t i b i o t i c era ( 1 9 4 3 - 5 6 ) mortality was 8.7 per cent. Neuhof and associates in 1941 (cited by 17) are noteworthy for having reduced the mortality of acute lung abscess and "suppurative pneumonía" to 5 per cent by early open drainage. No one since has been able to match this mortality rate by similar methods. In the antibiotic era, which we define as 1945 to the present, we find the spectrum of medical cures or "good" results ranging from 35 per cent to 90 per cent, with an average of 62.5 per cent.2'3,11'13'14'16, 2o.2i.23,25,2« p r o m t h e s e numerous authors, we extract from the work of four2'13'20,í5 a breakdown of the medical and surgical cases or follow-up studies. Anderson and McDonald 2 discuss 90 cases treated between 1949 and 1958. They had complete resolution by medical therapy in 35 per cent with a mortality of 23 per cent (of which half were due to abscess per se). Forty-two per cent rsquired operation as medical failures, with 25 per cent of the surgical cases dying of postoperative complications. Fifer et al.13 reported 55 cases with 51 undergoing medical therapy. Forty-three per cent were classified as poor results because of persistent or recurrent abscess, death, chronic atelectasis, bronchiectasis or pulmonar)' fibrosis. Nineteen patients were discharged with cavity, 12
628
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generally been considered to have a better prognosis. 7 5. While the prognosis in all abscess may be somewhat worse because of the increase of those due to cáncer,31'33 antibiotics have at least made resection of cancerous abscesses safer. There comes a point in the treatment of lung abscess, however, when medical therapy should be abandoned. This point may be difficult to recognize, especially when temperatures are normal, sputum decreases, and patients are beginning to demand discharge from the hospital. Some prognostic hints may therefore be welcome: 1. Chronicity. Duration of over eight weeks bodes ill in terms of the liklihood of a medical cure.2'3,13'14'27,32 It is principally the late abscesses that require surgery these days.23 2. Size of cavity. A diameter of 6 cm. appears to be the máximum size above which a cavity cannot be expected to cióse under medical therapy alone.2,13,30 As a corollary, a cavity which is thickwalled resists closure by conservative means. 3. Fever. Failure of temperature to return to normal in two weeks is a bad sign.13 4. Signs of malignancy. Increase in cavity size, assumption of irregular configuration, and continued weight loss while under intensive medical treatment suggest cáncer and should hasten surgical intervention. 5. Signs of established chronicity.19,33 a. Satellite abscesses. b. Chronic pneumonitis with tasis and fibrosis. c. Bronchiectasis. d. Encapsulated empyema. e. Thick abscess walls. f. Repeated or uncontrolled nary hemorrhage. All are associated with bad prognosis and are indications sectional surgery.
atelec-
pulmomedical for re-
AND
Diseases of the Chest
WYLIE
Su M MARY 1. O n e hundred and forty-éight cases of known or suspected aspiration lung abscess were admitted to Bellevue and Presbyterian Hospitals, New York City during the years 1950 to 1958. 2. Of this number, 55 (37 per cent) left the hospital relieved of the acute symptoms of their lung abscess by medical treatment alone. However, in a follow-up period of six to 84 months, only 26 (18 per cent) remained entirely well, while ten (7 per cent) languished with either symptomatic bronchiectasis or tuberculosis. Nineteen cases (13 per cent) were untraced. 3. Forty-five (30 per cent) were obliged to undergo surgery in addition to medical treatment. Of these, 42 were discharged free of their symptoms. An additional 31 (21 per cent) were advised to have surgery because medical therapy was proving inadequate. These patients refused treatment and were ultimately discharged. Thus, if 51 per cent of the series had or were advised to have surgery, more of the patients required operations than did not, modern antibiotic therapy notwithstanding. 4. There were 14 deaths among the 148 cases, 11 undergoing medical therapy alone, and three others receiving medical-surgical treatment. Five deaths were directly attributable to the lung abscess or treatment thereof (in surgery, this was due to broncho-pleural fístula in two, and to coronary sclerosis in one). Regardless of the role of surgery, the five deaths were directly attributable to medical failure, since all patients were referred to surgery following unsuccessful medical treatment. The remaining nine cases were considered beyond hope by any form of therapy. 5. In the group of patients treated by resection following intensive medical therapy, there was a mortality rate of 6 per cent, and major pleuropulmonary complications in an additional 8 per cent. The surviving p a t i e n t s w e r e c u r e d of their lung abscess, and represent the true result of combined medical-surgical therapy in the modern sense.
Volume 43, No. 6 June1963
LUNG RESUMEN
1. Durante los años de 1950 a 1958 ingresaron 148 casos conocidos o sospechosos de absceso por aspiración, a los hospitales Bellevue y Presbiteriano, de Nueva York. 2. Se aliviaron de los síntomas agudos pulmonares 55 (37 por ciento), solamente con tratamiento médico. Sin embargo, al observarlos durante 6 a 84 meses sólo 26 (18 por ciento), se mantuvieron bien mientras que 10 (7 por ciento) marcharon hacia la bronquiectasia o la tuberculosis. Diecinueve casos (13 por ciento) se perdieron de vista. 3. Cuarenta y cinco ( 3 0 por ciento) se vieron obligados a sufrir operaciones además del tratamiento médico. D e éstos, 42 fueron dados de alta, libres de síntomas. A otros 31 (21 por ciento) se les aconsejó que se operaran porque la medicación no había sido adecuada. Estos rehusaron la cirugía y se dieron de alta. Así si el 51 por ciento de esta serie sufrieron o se les aconsejó operarse, fueron más los enfermos que requerían la operación que los que no la necesitaban, a pesar de la terapéutica moderna de antibióticos. 4. En estos casos hubo 14 muertes, II de los tratados solamente con medicación y tres que recibieron tratamiento medicoquirúgico. Cinco muertes fueron atribuibles directamente al absceso pulmonar o ai tratamiento de él (en cirugía, dos se debieron a fístula bronquial y uno a esclerosis coronaria). Fuera del papel de la cirugía, las cinco muertes fueron atribuibles a fracaso médico puesto que todos los enviados a cirugía, lo fueron después de tratamiento médico infructuoxis. Los otros nueve casos se consideraron c o m o fuera de cualquier recurso. 5. En el grupo de enfermos tratados por resección después de tratamiento médico intenso hubo una mortalidad de 6 por ciento o complicaciones pleuropulmonares mayores en un 8 por ciento adicional. Los supervivientes se curaron de sus ibscesos y representan los verdaderos resultados del tratamiento medicoquirúrgico moderno. RESUMÍ: 1. 148 cas d'abcés du poumon par aspiration, eonnus ou soup^onnés, furent admis & l'Hópital de Bellevue et á PHópital Presbytérien, á a New-York pendant les années 1950 á 1958. 2. Sur ce nombre, 55 ( 3 7 % ) quittérent l'hópital soulagés des symptómes aigus de leur abcés du poumon par le seul traitement medical. CePendant, pour une période de surveillance allant de six á 84 mois, 26 malades seulement ( 1 8 % ) restérent tout á fait en bonne santé, tandis que ( 7 % ) souffraient d'une bronchiectatic symptomatique ou d'une tuberculose. 19 cas ( 1 3 % ) forent perdus de vue.
629
ABSCESS
3. 45 cas ( 3 0 % ) furent obligés de subir une operation chirurgicale en plus du traitement médical. Parmi ceux-ci, 42 sortirent de PHópital indemnes de symptómes. 31 malades supplcmcntaires ( 2 1 % ) requrent le conseil de se faire opérer parce que le traitement médical s'était montré inactif. Ces malades refusérent le traitement et sortirent définitivement de Thopital. Ainsi,si 5 1 % des malades du groupe subirent ou re^urent le conseil de subir une opération, la proportion de malades qui eurent besoin d'une opération fut plus grande que celle des malades qui purent s'en passer, á cause de Timpossibilité de supporter le traitement antibotique moderne. 4. II y c m 14 décés parmi les cas, 11 étant soumis au scul traitement médical, et trois autres au traitement médico-chirurgical. Cinq décés furent directement imputables b l'abcfcs du poumon ou á son traitement (en chirurgie, cela fut imputable á une fistulc broncho-pleurale pour deux cas et á une sclérose coronarienne pour un cas). Sans considérer le role de la chirurgie, les cinq décés furent directement imputables a Péchec médical, puisque tous les malades furent renvoyes á la chirurgie aprés traitement médical infructueux. Les neuf cas restants furent considérés c o m m e désespérés quelle que soit la forme de traitement. 5. Dans le groupe des malades traités par réscction aprés traitement médical intensif, il y eut un taux de mortalité de 6 % et des complications pleuro-pulmonaires majeures d'un pourcentage supplémcntairc de 8%. Les malades ayant survécu furent guéris de leur abcés pulmonaire et représentent le résultat réel du traitement combiné médico-chirurgical au se ns moderne. ZlíSAMMF.N FASS U NG 1. 148 Falle von erkannten oder vermuteten Lungenabszess durch Aspiration wurden in die Bellevue und Presbyterian Krankenháuser der Stadt N e w York wahrend der Jahre 1950 bis 1958 aufgenommcn. 2. V o n dieser Zahl verlicssen 55 ( 3 7 % ) das Krankenhaus nach Behebung der akuten Symptome ihres Lungenabszesses und zwar ausschliesslich bei internistischer Behandlung. Bei einer Nachkontrolle jcdoch wahrend eines Zeicraumes von 6 bis 84 Monaten ergab sich, dap nur 26 ( 1 8 % ) bei voller Gesundheit verblieben waren, wahrend 19 ( 7 % ) erncut erkrankten und zwar entweder unter symptornatischen Bronchiektasen oder an Tuberkulose. 19 Falle ( 1 3 % ) blieben unbehandelt. 3. 45 ( 3 0 % ) waren genótigt, sich einer chirurgischen Behandlung zu unterziehen zusatzüch zur internistischen Therapie. Von diesen wurden 42 frei von alien Symptomen entlassen. Weitere 31 ( 2 1 % ) erhielten den dringenden Rat, sich op-
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BERNHARD,
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erieren zu lassen, weil sich die konservative Behandlung ais unzureichend erwiessen hatte. D i e s e Kranken verweigerten j e d o c h die B e h a n d l u n g und wurden schliesslich auch entlassen. So war bei mehr Patienten operatives V o r g e h e n erforderlich ais konservative M a P n a h m e n , w e n n 51 % aus dieser R e i h e eine Operation oder den R a t dazu b e k o m m e n hatten, U n b e s c h a d e t der m o d e r n e n antibiotischen Therapie. 4. D i e Zahl des T o d e s f á l l e betrug 14, davon 11 bei konservativer Behandlung allein und drei weitere, die internistisch u n d chirurgisch kombiniert behandelt worden waren. 5 T o d e s f á l l e m u f k e n direkt auf den Lungenabszess oder dessen Behandlung bezogen werden (bei der Operation war dies auf bronchopleurale Fisteln in 2 Fallen und auf Coronarsklerose in e i n e m Fall zurückzuf ü h r e n ) . U n b e s c h a d e t der R o l l e der Chirurgie waren die 5 T o d e s f á l l e direkt auf das Versagen der internistischen B e h a n d l u n g zurückzuführen, denn alie Patienten waren d e m Chirurgen zugeführt w o r d e n nach erfolgloser interner Behandlung. D i e übrigen 9 Fálle m u p t e n für jede Form v o n Therapie ais hoffnungslos angesehen werden. 5. Bei der Gruppe von Patienten, die mit R e sektion behandelt w u r d e n im Anschluft an intensive internistische T h e r a p i e betrug die Mortalitát 6% und nennenswerte pleuro-pulmonale K o m p l i kationen wurden v o n ihrem Lungenabszess geheit und stellen das echte Endergebnis kombinierter internistischer und chirurgischer Behandlung i m modernen Sinne dar.
2 ANDERSON,
M.
N.
AND
MCDONALD,
K.
E.:
"Prognostic Factors and Results of Treatment in Pyogenic Pulmonary Abscess," / . Thor. Cardiov. Surg., 3 9 : 5 7 3 , 1960. 3 BAN, B.: "Lung Abscess in India," / . Thor. Surg., 3 2 : 2 5 4 , 1956.
1962. 5 BERNHARD, W . F . , MALCOLM, J . A . AND WYLIE,
6 7 8 9 10
R. H . : "Pneumonía with Abscess Formation: Results of Medical and Surgical Treatment in 43 Cases," (In Preparation). BOSHER, L. H., JR. : "A Review of Surgically Treated Lung Abscesses," J. Thor. Surg., 21: 370, 1951. BROCK, R. C.: Lung Abscess, Blackwell Scientific Publications, Oxford, 1952. BROCK, R. C.: The Anatomy of the Bronchial Tree, Oxford University Press, London, 2nd Ed., 1954. CuTLER, E. C. AND SCHLUETTER, S. A . : Antl. Surg., 8 4 : 2 5 6 , 1926. Cited by Brock, R. C. in Lung Abscess, p. 8. DAVISON, K . : "Lung Abscess following Aseptic Pulmonary Embolism," Brit. J. Tuberc. and
Dis. Chest, 5 2 : 1 4 9 , 1958. 11 D E J A N N E Y , N . H . AND BIGMAN, O . :
Pulmonary Suppuration," Dis. 1959.
Chest,
"Chronic
36:602,
"Man-
agement of Lung Abscess with Special Reference to Place of Antibiotics in Therapy," Ann. Int. Med., 3 5 : 1 2 1 8 , 1951. 1 3 FIFER,
W.
R.,
BUSEBYE,
K.,
GHEDISTER, C.
AND MILLER, N . : "Primary Lung Abscess. Analysis of Therapy and Results in 55 Cases," A.M.A. Arch. Int. Med., 1 0 7 : 6 6 8 , 1961. 1 4 F o x , J . R . , JR., H U G H E S , F . A . , JR. AND SUT-
LIFF, W. D . : "Nonputrid Lung Abscess; Experience with Fifty-five Consecutive Cases," ]. Thor. Surg., 2 7 : 2 5 5 , 1954. 15 FREEDMAN, L. M . : "Etiology of Lung Abscess: Clinical Analysis of 477 Cases Occurring at Boston City Hospital from 1926 to 1935, Inclusive," New Engl. J. Med., 218:663, 1938. 1 6 G I T T E N S , S . A . AND M I H A L Y , J . P . :
Management
of
Acute
Lung
"Medical
Abscess," Am.
Rev. Tuberc., 6 9 : 6 7 3 , 1954. 1 7 GLOVER, R . P . AND CLAGETT, O . T . :
"Pulmo-
nary Resection for Abscess of the Lung," Surg., Gynec. and Obst., 8 6 : 3 8 5 , 1948. 1 8 LEVIN, L . , K E R N C H A N , J . W .
AND MOERSCH,
H. J.: "Pulmonary Abscess Secondary to Bland Pulmonary Infarction," Dis. Chest, 14:218, 1948.
19 LINDSKOG, G. E.: "Surgical Treatment of Chronic Pulmonary Abscess," Surgery, 15:783, 1944. 2 0 METRAS,
H.
AND
CHARPIN,
J.:
"Lung
Ab-
scess and Bronchial Catheterization," / . Thor. 21
Surg., 27:157, PICKER, D . N .
1954. AND R U O F F ,
W.
F.:
"Pulmo-
nary Abscess: A Study of 70 Cases," / . Thor. Surg., 3 7 : 4 5 2 , 1959. 2 2 Q U I N N , L . H . AND M E Y E R , O . O . : Arch.
Oto-
laryng., 1 0 : 1 5 2 , 1929. Cited by Brock, R. C., in Anatomy of the Bronchial Tree, p. 20. 2 3 S C H W E P P E , H . I . , K N O W L E S , J . H . AND KANE,
L.: "Lung Abscess: An Analysis of the Massachusetts General Hospital Cases from 1943 t h r o u g h 1 9 5 6 , " New Engl ] . Med., 265:1039, 1961. 2 4 S H A W , R . R . AND P A U L S O N , D . L . : "Pulmo-
nary Resection for Chronic Abscess of the Lung," J. Thor. Surg., 1 7 : 5 1 4 , 1948. 25 SHINOI, K . : "Lung Abscess in Japan," ]. Thor. Cardiov. Surg., 4 0 : 4 6 1 , 1960. 2 6 SHOEMAKER, H .
E.,
YEW,
E.
M.
AND BYRD,
W. C.: "Antibiotic Therapy in Primary Pulmonary Abscess," A.M.A. Arch. Int. Med.,
4 BERNHARD, W . F . , MALCOLM, J . A . AND W Y L I E ,
R. H . : "The Carcinomatous Abscess: A Clinical Paradox," New Engl. J. Med., 266:914,
Diseases of the Chest
WYLIE
1 2 D R A K E , E . H . AND S O N E S , F . M . , J R . :
REFERENCES
1 AMBERSON, J. B.: "Clinical Consideration of Abscesses and Cavities of Lung," Bull. Johns Hopkins Hosp., 9 4 : 2 2 7 , 1954.
AND
96:68,
1955.
27 SMITH, D . T . : "Medical Treatment of Acute and Chronic Pulmonary Abscesses," / . Thor. Surg.,
17:72,
1948.
28 STERN, L.: "Etiologic Factors in Pathogenesis of Putrid Abscess of Lung," / . Thor. Surg., 6 : 2 0 2 , 1936. 2 9 TABER, R . E . AND E H R E N H A F T , J . L . :
"Chron-
ic Lung Abscess: Fifteen Years of Change," Arch. Surg., 6 7 : 2 5 9 , 1953. 3 0 TOUROFF,
A.
S.
W.,
NABATOFF,
R.
A . AND
NEUHOFF, H . : "Acute Putrid Abscess of the Lung: V I . T h e Late Results of Surgical Treatment," / . Thor. Surg., 2 0 : 2 6 6 , 1950. 31
WATERMAN, D . H . AND D O M M , S . E . :
"Chang-
ing Trends in the Treatment of Lung Abscess," Dis. Chest, 2 5 : 4 0 , 1954. 3 2 WOLCOTT, M . W . AND M U R P H Y , J . D . :
"The
Changing Picture of Lung Abscess Therapy," Dis. Chest, 3 2 : 6 2 , 1957. 3 3 WOLCOTT, M . W . , COURY, O . H . AND BAUM.
G. L.: "Changing Concepts in the Therapy of Lung Abscess: A Twenty Year Survey," Dis. Chest, 4 0 : 1 , 1961
C
URRENT
MANAGEMENT
OF
York, New
PULMO-
nary abscess has evolved with the introduction of antimicrobial agents. During this period, it became evident that prompt administration of penicillin or a broad spectrum antibiotic could produce resolution of the exudative phase of pneumonitis and abort abscess formation. These agents markedly reduced mortalitv from lung abscess, increased the complete cure rate to some extent, and permitted the surgeon to show greater resolve in extirpating the acute focus or its residual. However, the successful management of lung abscess today remains both a medical and a surgical problem of considerable magnitude. The present study is concerned primarily with the effectiveness of current therapy. However, for purposes of clarity and completeness, comments on etiology, pathogenesis, and anatomy of abscess are included. Two hundred and ten patients form the basis of this report. All were treated at the Columbia-Presbyterian Medical Center or on the Chest Service of Bellevue Hospital Center, New York City, during the eightyear period, 1950 to 1958. Pulmonary excavations of congenital, tuberculous, mycotic, and parasitic etiology were excluded, as was a case of septic embolism secondary to pyemia. M E T H O D OF STUDY
It was suspected as this study developed that differing etiologies of abscesses had *From the Chest Service, Bellevue Hospital Center and Presbyterian Medical Center, and the Department of Surgery, College of Physicians and Surgeons, Columbia University. # *Clinical Associate in Surgery, Harvard Medical School. ## * C h i e f , Thoracic Surgery, Veterans Administration Hospital, New York City. fClinical Professor of Surgery, College of Physicians and Surgeons, Columbia University.
York
more than a little bearing on therapeutic outcome. Accordingly, the cases were divided into six groups for e v a l u a t i o n (Table 1). T A B L E 1 — 2 1 0 C A S E S OF PULMONARY A B S C E S S TREATED AT BELLEVUE AND PRESBYTERIAN HOSPITALS
Group I. Group II.
Aspiration abscess Abscess of unknown etiology Group III. Abscess in bland pulmonary infarct Group IV. Abscess secondary to pneumonía Group V. Carcinomatous abscess
Cases
Per cent
100
47.6
44
20.9
4
1.9
43 19
20.5 9.1
We shall consider for discussion Groups I, II, and III which we feel have most in common etiologically and pathogenetically. Group IV cases aróse from infection by specific organisms frequently associated with abscess formation and were not, so far as is known, dependent upon aspiration of foreign material or bronchial obstruction. Group V being due to cáncer is quite out of a discussion which involves the effectiveness of medical therapy. Groups IV and V are discussed in separate communications.4'5 ETIOLOGY
There seems to be little doubt that the majority of benign lung abscesses have one thing in common, namely, aspiration of infected material. Early writers pointed out tonsillectomy15 and oral sepsis" as consistent precursors of lung abscess. While tonsillectomy has declined as a cause, oral sepsis has remained a continued factor.2'3'*3'"'*0 Also, conditions featuring loss of consciousness with or without a tendency to vomit and aspírate such as alcoholism,11'13'23'"'32 epilepsy,11'12'" coma from anesthesia or any other cause,2'6'23'" loss of gag reflex due to age,1 immersion1* have more recently been
620
Volume 43, N o . 6 June 1963
LUNG
indicted as predisposing to lung abscess formation. From the large number of reports on the subject, two factors rise above all others predisposing to aspiration abscess : alcoholism and oral sepsis. Our Group I (100 cases) refleets etiologically the series of others during the past 20 years. M a l e s were c o m m o n e r than females by 3:1 ( 4 : 1 is the usual ratio) .12'13'29 Seventy per cent of the patients were white and 27 per cent Negro. A history of acute alcoholic stupor two to four weeks prior to onset of the illness was extracted from 70 of the patients. Eleven had had general anesthesia recently. Nine were epileptics with frequent grand mal seizures. Ten others had a variety of causes for aspiration. Eightysix had foul teeth, and in 56, the abscesses were foul. Etiologic mechanisms in Group I are summarized in Table 2. 2—GROUP 100 CASES
I . ETIOLOGIC M E C H A N I S M S OF A S P I R A T I O N A B S C E S S
1. Alcoholic stupor 2. Aspiration associated with anesthesia and surgery 3. Diabetic coma 4. Brain concussion 5. Epileptic seizures 6. Aspiration secondary to obstructing esophageal carcinoma 7. Massive epistaxis with syncope Total
IN
M 4) cti U 0 £
Foul bsce
TABLE
70
48
22
1
10 2 4 3
11 2 4 9 3 1 100
m
fl ¿3 C Vi O o)
<
¿<
tn
— —
6
3
—
1 56
—
44
As we suggested earlier, etiology was less clear cut in Group II (44 cases), but aspiration was strongly suspected. In spite of the fact that neither careful review of antecedent history ñor bacteriology of the abscess was helpful, 18 (40.9 per cent) were admitted alcoholics and 38 (86.4 per cent) had foul teeth, a defective gag reflex, or both. In Group III, we have no clear cut reasons to suspect aspiration except to point out that these four patients were quite debilitated. The most important feature they
621
ABSCESS
had in common was a necrotic area of lung, a fertile field for organisms aspirated with foreign material. Several authors4'10' 18,29 indicate that infection of an ordinary pulmonary infarct is not a rarity, and must be presumed to be due to aspiration in the presence of pre-existing nonviable lung tissue. PATHOGENESIS
Numerous authors have pointed out the necessary conditions for lung abscess formation. These appear to be bronchial obstruction with atelectasis and localized necrosis. The necrosis is due to a combination of small vessel thrombosis and the necrotizing potential of organisms contained within the material obstructing the bronchus.9'12' 13.33 c u t j e r a n ( j Schluetter9 demonstrated in dogs that neither bronchial embolism ñor infarction alone could cause lung abscess. Amberson1 points out that in silicosis, which is characterized by múltiple areas of ischemia, lung abscess is a rarity. Brock7 has noted that simple foreign body aspiration is more frequently followed by atelectasis alone rather than by abscess. In the case of abscess in bland pulmonary infarct (Group I I I ) , one is forced to invoke aspiration as an additional factor. This phenomenon appears to occur in only 4.9 per cent of infarets, or 4.8 per cent of all pulmonary abscesses.18 In the collected cases, size of infarcted area, nearness of atelectatic lung, and the presence of pathogenic bacteria in the upper respiratory tract seem to have been additional pathogenetic factors. Whether or not one chooses to invoke local infarction and necrosis in the pathogenesis of abscess, one cannot ignore the role of bronchial occlusion (or embolism), and thus implícate some mechanism of a s p i r a t i o n as being chiefly causative. Brock7'8 has contributed much to our understanding of this process. By clinical observation and by repetition of the radiopaque oil studies of Quinn and Meyer,22 he has shown that localization of abscess can be adequately explained by analyzing the position of the most dependent portions of
622
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AND
WYLIE
Diseases of the Chest
lung. He is able to explain readily, therefore, the predilection of abscesses for the posterior segment of the right upper lobe and the superior segments of both lower lobes. The proclivity of persons with either oral sepsis or chronic sinus infection to develop abscesses in these locations is thus explained (even in the absence of a history of pathologic insensibilitv), since the passage of material from upper to lower respiratory tract can be demonstrated to occur in ordinary sleep.
abscess starts as a segment al affliction.7 Nevertheless, past studies have specified only the lobes involved by the process. The reports of six investigators3'6'12'13'23'29 describing 501 cases have indicated the following distribution:
BACTERIOLOGY
In similar analysis our series of 100 aspiration abscesses is as follows:
Much has been written about the bacteriology of lung abscess. In a large percentage of cases, this has been established as specific for putrid and non-putrid abscesses alike.,'11,l3'21'23'27'"'3í Smith27 firmly established symbiotic fusospirochetes and streptococci as pathogens in putrid abscess. Others later have shown the great frequency of "non-pathogens" as the only recoverable organisms in both putrid and non-putrid abscesses.2,11,23'32'33 Again, we exclude abscesses due to highlv specific pneumonías, namelv, Staphylococcus aureus, Streptococcus hemolyticus, and Klebsiella pneumoniae. Our bacteriologic findings in both putrid and non-putrid abscesses were, at best, inconclusive. The bulk cultured "non-pathogens." Conceivably, c a r e f u l anaerobic culture techniques might well have uncovered fusospirochetes and elusive micro-aerophilic streptococci. On the other hand, many of our patients were received having been previously treated with penicillin or a broad-spectrum antibiotic. In fact, this was the case in 50 per cent of Group I cases appearing with non-putrid abscesses. Of the other 50 per cent, it may be said that their abscesses may have been putrid at one time; but with re-established drainage and recovery of aerobic conditions, the abscesses became non-putrid and thus dispersed their original pathogens. LOCALIZATION OF
ABSCESS
If the specific pneumonías are excluded, one finds that in the majority of cases, lung
Per cent Right upper lobe Right middle lobe Right lower lobe Left upper lobe Left lower lobe
35.2 8.4 25.6 17.3 13.5
Per cent Right upper lobe Right middle lobe Right lower lobe Left upper lobe Left lower lobe
36.8 1.0 20.4 12.2 29.6
In the 100 cases, 98 single and two múltiple abscesses were encountered. Broadly speaking, involvement of superior segments of lower lobes was encountered in 45 per cent, and the posterior segment of the right upper lobe was noted in 29 per cent. The segmental localization in these 100 cases (that is, in the 98 per cent with single abscesses) may be visualized in Fig. 1. As can be seen, the difference in the distribution of our aspiration abscess cases and the distribution in other abscess series is not remarkable. Our Group II, however, bears another look. While the superior segments and posterior segment of right upper lobe account for 22 (50.0 per cent) of the single abscesses (40 cases), 16 (36.4 per cent) had statistically atypical locations. No fewer than nine (20.5 per cent) had right middle lobe cavities, which location is atypical, but is consistent with vomiting (bent forward) or immersion as etiology.7 Anterior segments were involved in seven cases (15.9 per cent) which suggests aspiration while lying on one side tipped toward the prone position.8 Basal segments were involved in six (13.6 per cent), which is unusual. This
Volume 43, No. 6 June 1963
L U N G A B S C E S S 61
suggests that we may be in error classifying these cases as being caused by aspiration unless they occurred in patients with chronic esophageal obstruction, which often causes small, repeated aspirations in the erect position, or unless they occurred in patients who had recently undergone laparotomy.7 Basilar abscesses more often suggest bronchiectasis or prior pneumonía. THERAPY
Sixty-nine patients of Group I were managed medically. The therapy consisted of antibiotics (penicillin plus another antibiotic indicated by sputum culture and m i c r o b i a l sensitivities), bronchodilators, postural drainage, and occasional bronchoscopic aspiration. A complete clinical and radiologic cure was obtained in 22 (31.9 per cent) immediately, and 19 (27.5 per cent) in follow-up of six months or more. Twenty-two (31.9 per cent) were clinically cured, but retained cavities demonstrable by x-ray. Of this group, only four proceeded to complete cure, while four developed active tuberculosis, four had symp-
LOCATION OF SC
623
tomatic bronchiectasis, four were asymptomatic, and eight were untraced. Seventeen patients who were medical treatment failures were advised to have surgery but refused. Of the 17 cases, seven who could be followed retained their open cavities and productive cough. Table 3 summarizes the fate of Group I patients, all of whom started on medical therapy when first admitted. The surgical cases in Group I were all medical treatment failures. These numbered 31 cases, and nine of them had preliminary drainage. Of the nine, three eventually required pulmonary resection. Of 25 pulmonary resections, one patient died and three others had major complications. All of the 13 traced had complete cures (Table 3 ) . The surgically treated cases in Group I are also summarized in Table 3. A summary of the deaths in Group I is available in Table 4. Group II seemed not to differ much in outeome from Group I. Early resection was felt to be indicated in six cases of this group because of the possibility of bronchogenic carcinoma. None of these patients was con-
TARY CAVITIES
LATERAL VIEW
The location and frequeney of solitary abscess formation in 9 8 patients of Group I is indicated. The majority of cavities involved the dependent segments: posterior segment of the right upper lobe (29 cases), superior segment of the right lower lobe (19 cases), superior segment of the left lower lobe (26 cases). FIGURE
1:
624
BERNHARD,
MALCOLM
AND
Diseases of the Chest
WYLIE
TABLE 3 — T H E R A P E U T I C OUTCOME IN GROUP I PATIENTS
100 CASES (all started on medical regimen) Surgical Therapy - 3 1 . /medical failures)
Med. Therapy Alone - 69.
I
1
Died
8
(2 died of
abscess)
i
1
Clinical Cure Clinical inical Cure Residual Cavity N o Cavity 22 22
1
I
I
Resection
Drainage, Lung Drainage, or Pleura 9 3-
1 _ 1 Cough c Asymptomatic Sputum 2 Cavity 7 Untraced Untraced 10 7
Asymptomatic 15
Untraced
8
O tu
Surgery Surgery Refused 17
Died
25-
-H
—Major—^ Complication 3
T~ 1 Asympto- Residual Active matic B'ectasis Tuberc. 4 4 6
cu 5 W > o IS > UD H O , 2
~ ~
—r—
Active Tuberc. 2
r
Asymptomatic 13
Untraced 2
Untraced
11
Complete cure (clinical and x-ray) of presenting cases—34% (by med. therapy alone 1 9 % ) . Complete cure of medically treated cases—19/69 or 27.5% (25 untraced). Complete cure of combined medical an dsurgically treated cases—15/31 or 48.8% (13 untraced ).
sidered medically cured if a residual cavity or bronchiectasis was present. Twenty-five cases had medical therapy alone. Eleven (44 per cent) were pronounced clinicallv and radiologically cured, but 14 (56 per cent) were advised to have surgery and all refused. The five of these traced beyond a period of six months had productive cough and a cavity demonstrabie by x-ray. They became, in other words, cases of chronic lung abscess. Thirteen medical therapy failures were subjected to surgery. All abscesses eventuallv were resected. Of the 19 (including six primary resections) who were resected, two died as a result of surTABLE
gical complications. Eleven of the 17 surviving surgery were cured as of follow-up exceeding six months. Six cases were untraced. A summarv of Group II treatment may be seen in Table 5. Group III contained unusual cases complicated by associated diseases. Apart from pulmonary infarction, these patients had the following disabilities: 2 cases — terminal gastrointestinal cáncer. 1 case — diffuse cerebral atrophy. 1 case — arteriosclerotic heart disease in failure.
Only the cardiac case survived, and following medical therapy, his lung abscess was successfullv resected.
4 — G R O U P I. ANALYSIS OF N I N E
D E A T H S IN 1 0 0
Duration of Treatment
Size of Cavity
Clinical Response to Antibiotic Therapy
1. 10 Days 2. 10 Days 3. 2 Months 4. 1 Day 5. 2 Weeks 6. 1 Month 7. 1 Month
Unchanged Unchanged Decreased Unchanged Unchanged Decreased Decreased
None None None None None Satisfactory Satisfactory
8. 9.
Unchanged (Resected)
Satisfactory Medical failure, underwent lobectomy
1 Week 8 Days
PATIENTS
Primary Cause of Death Myocardial infarct Myocardial infarct Carcinoma of the esophagus Acute pulmonary abscess Carcinoma of the larynx Myocardial infarct Gastrointestinal hemorrhage from duodenal ulcer Acute pulmonary abscess Arteriosclerotic heart disease with failure
Volume 43, N o . 6 June 1963
LUNG
ABSCESS
THERAPEUTIC OUTCOME IN GROUP
44
6 2 5
II
PATIENTS
CASES
_Resected because of possible carcinoma
6
. Medical Therapy Alone - 25, Clinical Cure N o Cavity 11
Clinical Cure Residual Cavity 0
1
Surgical Therapy - 13 _ (Med. failure) |
Surgery Rib Resection Refused Pneumonotomy 14 2 2-
-13
I
Died.
Died
Resected
2
0
Major Complication 1
Cough c Sputum Cavity 5
Asymptomatic 7 Untraced 4 o, £
W
>co H O , 2 O Cu
S
Asymptomatic 11 Untraced
Untraced 9
6
Cured by medical and/or surgical therapy—18/44 or 41 per cent. Cured by medical therapy alone—7/25 or 28 per cent (untraced 13). Cured by medical-surgical therapy—11/19 or 57.9 per cent (untraced 6)
DISCUSSION
The original purpose of this paper was to ascertain the present role of surgery in the treatment of lung abscess. Our clinical observations had convinced us that medical therapy alone in our hands did not vield the 85 to 90 per cent cure rate of Fox et al.14 or Gittens and Mihaly.18 Our medical therapy was sound, being based upon: 1. Intensive modern antibiotic therapy which included penicillin and most of the broad spectrum antibiotics still principally used at this time. 2. Bronchodilator therapy with or without intermittent positive pressure breathing (IPPB). 3. Postural drainage. 4. Intermittent bronchoscopy, both diagnostic and therapeutic. (We did not, however, employ manipulations with bronchial catheters and local antibiotics described by Metras and Charpin*0 with which they apparently obtained a 72.5 per cent clinical cure rate over a two year follow-up.)
Altogether, 103 of 148 patients (69.5 per cent) left the hospital relieved of the acute symptoms of their lung abscess. Of this number, 55 of 148 (37.1 per cent) succeeded on medical treatment alone as outlined above. Six had surgery without adequate medical therapy on suspicion of cáncer. Forty-five (30.4 per cent) were obliged to undergo surgery in addition to medical treatment. Of these, 42 were discharged free of their symptoms. However, an additional 31 (20.9 per cent) were advised to have surgery because medical therapy was proving a failure. These patients refused surgery and were ultimately discharged. We could follow 12 of them. All were cases of frank chronic lung abscess. Thus, if 51.3 per cent of the series had or were advised to have surgery, more of the series required operation than did not, modern antibiotics notwithstanding. Now, 55 of 148 cases left the hospital well after medical therapy alone; but in follow-up of six to 84 months, only 26 (17.6
626
BERNHARD,
MALCOLM
per cent) received a clean bilí of health while ten (6.8 per cent) languished with either symptomatic bronchiectasis or tuberculosis. Nineteen (12.8 per cent) were untraced. Thus, among 148 presenting cases, the following medical failures are tabulated (base of 142 when six immediate resections for possible carcinoma are excluded): Residual bronchiectasis Active tuberculosis Chronic abscess Referred to surgery Total
(59.8 per cent)
4 6 31 44 85
The medical failure rate is therefore 59.8 per cent of all patients attempting to undergo conservative therapy alone. The medical successes amount to 40.2 per cent provided we ignore cases lost to follow-up. If, in addition, those untraced patients are long term medical failures, the medical success rate is only 18.3 per cent. Let us now consider the mortality statistics within our series. Fourteen cases died, 11 undergoing medical therapy and three undergoing medical-surgical therapy. Five of these were directly attributable to lung abscess or the treatment thereof (in surgery this was due to bronchopleural fístula in two and to coronary sclerosis in one). Regardless of the role of surgery, the five deaths are directly attributable to medical treatment failure, since all the patients were referred to surgery following unsuccessful medical treatment. The remaining cases were probably beyond hope by any form of therapy. Comparison of our series with those of other authors has been anything but easy for the following reasons: 1. Few workers employ statistics extending into a follow-up period. 2. Most authors concern themselves with either medically or surgically treated groups. 3. Definitions of "cure," "improved," "good result," "poor result," etc., are maddeningly inexact. In short, only "died" is universal in its interpretaron.
AND
Diseases of the Chest
WYLIE
4. We are often not discussing the same abscesses, as various authors deal separately with "acute" and "chronic" or include etiologies such as the specific pneumonías,2,29,31 bronchiectasis,25 and 23,31
carcinoma. For historie purposes, we may consider two different impressions of lung abscess prior to the modern antibiotic era. Smith27 surveyed 2166 published cases prior to 1945, and noted that on medical therapy (principallv sulfonamides) 34.7 per cent died, 31.3 per cent were cured, and 34.0 per cent became chronic. Schweppe et al.™ recall Massachusetts General Hospital series from 1909 to 1942 which chart the decline of lung abscess mortality from 75 per cent to 18.3 per cent. Their a n t i b i o t i c era ( 1 9 4 3 - 5 6 ) mortality was 8.7 per cent. Neuhof and associates in 1941 (cited by 17) are noteworthy for having reduced the mortality of acute lung abscess and "suppurative pneumonía" to 5 per cent by early open drainage. No one since has been able to match this mortality rate by similar methods. In the antibiotic era, which we define as 1945 to the present, we find the spectrum of medical cures or "good" results ranging from 35 per cent to 90 per cent, with an average of 62.5 per cent.2'3,11'13'14'16, 2o.2i.23,25,2« p r o m t h e s e numerous authors, we extract from the work of four2'13'20,í5 a breakdown of the medical and surgical cases or follow-up studies. Anderson and McDonald 2 discuss 90 cases treated between 1949 and 1958. They had complete resolution by medical therapy in 35 per cent with a mortality of 23 per cent (of which half were due to abscess per se). Forty-two per cent rsquired operation as medical failures, with 25 per cent of the surgical cases dying of postoperative complications. Fifer et al.13 reported 55 cases with 51 undergoing medical therapy. Forty-three per cent were classified as poor results because of persistent or recurrent abscess, death, chronic atelectasis, bronchiectasis or pulmonar)' fibrosis. Nineteen patients were discharged with cavity, 12
628
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generally been considered to have a better prognosis. 7 5. While the prognosis in all abscess may be somewhat worse because of the increase of those due to cáncer,31'33 antibiotics have at least made resection of cancerous abscesses safer. There comes a point in the treatment of lung abscess, however, when medical therapy should be abandoned. This point may be difficult to recognize, especially when temperatures are normal, sputum decreases, and patients are beginning to demand discharge from the hospital. Some prognostic hints may therefore be welcome: 1. Chronicity. Duration of over eight weeks bodes ill in terms of the liklihood of a medical cure.2'3,13'14'27,32 It is principally the late abscesses that require surgery these days.23 2. Size of cavity. A diameter of 6 cm. appears to be the máximum size above which a cavity cannot be expected to cióse under medical therapy alone.2,13,30 As a corollary, a cavity which is thickwalled resists closure by conservative means. 3. Fever. Failure of temperature to return to normal in two weeks is a bad sign.13 4. Signs of malignancy. Increase in cavity size, assumption of irregular configuration, and continued weight loss while under intensive medical treatment suggest cáncer and should hasten surgical intervention. 5. Signs of established chronicity.19,33 a. Satellite abscesses. b. Chronic pneumonitis with tasis and fibrosis. c. Bronchiectasis. d. Encapsulated empyema. e. Thick abscess walls. f. Repeated or uncontrolled nary hemorrhage. All are associated with bad prognosis and are indications sectional surgery.
atelec-
pulmomedical for re-
AND
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Su M MARY 1. O n e hundred and forty-éight cases of known or suspected aspiration lung abscess were admitted to Bellevue and Presbyterian Hospitals, New York City during the years 1950 to 1958. 2. Of this number, 55 (37 per cent) left the hospital relieved of the acute symptoms of their lung abscess by medical treatment alone. However, in a follow-up period of six to 84 months, only 26 (18 per cent) remained entirely well, while ten (7 per cent) languished with either symptomatic bronchiectasis or tuberculosis. Nineteen cases (13 per cent) were untraced. 3. Forty-five (30 per cent) were obliged to undergo surgery in addition to medical treatment. Of these, 42 were discharged free of their symptoms. An additional 31 (21 per cent) were advised to have surgery because medical therapy was proving inadequate. These patients refused treatment and were ultimately discharged. Thus, if 51 per cent of the series had or were advised to have surgery, more of the patients required operations than did not, modern antibiotic therapy notwithstanding. 4. There were 14 deaths among the 148 cases, 11 undergoing medical therapy alone, and three others receiving medical-surgical treatment. Five deaths were directly attributable to the lung abscess or treatment thereof (in surgery, this was due to broncho-pleural fístula in two, and to coronary sclerosis in one). Regardless of the role of surgery, the five deaths were directly attributable to medical failure, since all patients were referred to surgery following unsuccessful medical treatment. The remaining nine cases were considered beyond hope by any form of therapy. 5. In the group of patients treated by resection following intensive medical therapy, there was a mortality rate of 6 per cent, and major pleuropulmonary complications in an additional 8 per cent. The surviving p a t i e n t s w e r e c u r e d of their lung abscess, and represent the true result of combined medical-surgical therapy in the modern sense.
Volume 43, No. 6 June1963
LUNG RESUMEN
1. Durante los años de 1950 a 1958 ingresaron 148 casos conocidos o sospechosos de absceso por aspiración, a los hospitales Bellevue y Presbiteriano, de Nueva York. 2. Se aliviaron de los síntomas agudos pulmonares 55 (37 por ciento), solamente con tratamiento médico. Sin embargo, al observarlos durante 6 a 84 meses sólo 26 (18 por ciento), se mantuvieron bien mientras que 10 (7 por ciento) marcharon hacia la bronquiectasia o la tuberculosis. Diecinueve casos (13 por ciento) se perdieron de vista. 3. Cuarenta y cinco ( 3 0 por ciento) se vieron obligados a sufrir operaciones además del tratamiento médico. D e éstos, 42 fueron dados de alta, libres de síntomas. A otros 31 (21 por ciento) se les aconsejó que se operaran porque la medicación no había sido adecuada. Estos rehusaron la cirugía y se dieron de alta. Así si el 51 por ciento de esta serie sufrieron o se les aconsejó operarse, fueron más los enfermos que requerían la operación que los que no la necesitaban, a pesar de la terapéutica moderna de antibióticos. 4. En estos casos hubo 14 muertes, II de los tratados solamente con medicación y tres que recibieron tratamiento medicoquirúgico. Cinco muertes fueron atribuibles directamente al absceso pulmonar o ai tratamiento de él (en cirugía, dos se debieron a fístula bronquial y uno a esclerosis coronaria). Fuera del papel de la cirugía, las cinco muertes fueron atribuibles a fracaso médico puesto que todos los enviados a cirugía, lo fueron después de tratamiento médico infructuoxis. Los otros nueve casos se consideraron c o m o fuera de cualquier recurso. 5. En el grupo de enfermos tratados por resección después de tratamiento médico intenso hubo una mortalidad de 6 por ciento o complicaciones pleuropulmonares mayores en un 8 por ciento adicional. Los supervivientes se curaron de sus ibscesos y representan los verdaderos resultados del tratamiento medicoquirúrgico moderno. RESUMÍ: 1. 148 cas d'abcés du poumon par aspiration, eonnus ou soup^onnés, furent admis & l'Hópital de Bellevue et á PHópital Presbytérien, á a New-York pendant les années 1950 á 1958. 2. Sur ce nombre, 55 ( 3 7 % ) quittérent l'hópital soulagés des symptómes aigus de leur abcés du poumon par le seul traitement medical. CePendant, pour une période de surveillance allant de six á 84 mois, 26 malades seulement ( 1 8 % ) restérent tout á fait en bonne santé, tandis que ( 7 % ) souffraient d'une bronchiectatic symptomatique ou d'une tuberculose. 19 cas ( 1 3 % ) forent perdus de vue.
629
ABSCESS
3. 45 cas ( 3 0 % ) furent obligés de subir une operation chirurgicale en plus du traitement médical. Parmi ceux-ci, 42 sortirent de PHópital indemnes de symptómes. 31 malades supplcmcntaires ( 2 1 % ) requrent le conseil de se faire opérer parce que le traitement médical s'était montré inactif. Ces malades refusérent le traitement et sortirent définitivement de Thopital. Ainsi,si 5 1 % des malades du groupe subirent ou re^urent le conseil de subir une opération, la proportion de malades qui eurent besoin d'une opération fut plus grande que celle des malades qui purent s'en passer, á cause de Timpossibilité de supporter le traitement antibotique moderne. 4. II y c m 14 décés parmi les cas, 11 étant soumis au scul traitement médical, et trois autres au traitement médico-chirurgical. Cinq décés furent directement imputables b l'abcfcs du poumon ou á son traitement (en chirurgie, cela fut imputable á une fistulc broncho-pleurale pour deux cas et á une sclérose coronarienne pour un cas). Sans considérer le role de la chirurgie, les cinq décés furent directement imputables a Péchec médical, puisque tous les malades furent renvoyes á la chirurgie aprés traitement médical infructueux. Les neuf cas restants furent considérés c o m m e désespérés quelle que soit la forme de traitement. 5. Dans le groupe des malades traités par réscction aprés traitement médical intensif, il y eut un taux de mortalité de 6 % et des complications pleuro-pulmonaires majeures d'un pourcentage supplémcntairc de 8%. Les malades ayant survécu furent guéris de leur abcés pulmonaire et représentent le résultat réel du traitement combiné médico-chirurgical au se ns moderne. ZlíSAMMF.N FASS U NG 1. 148 Falle von erkannten oder vermuteten Lungenabszess durch Aspiration wurden in die Bellevue und Presbyterian Krankenháuser der Stadt N e w York wahrend der Jahre 1950 bis 1958 aufgenommcn. 2. V o n dieser Zahl verlicssen 55 ( 3 7 % ) das Krankenhaus nach Behebung der akuten Symptome ihres Lungenabszesses und zwar ausschliesslich bei internistischer Behandlung. Bei einer Nachkontrolle jcdoch wahrend eines Zeicraumes von 6 bis 84 Monaten ergab sich, dap nur 26 ( 1 8 % ) bei voller Gesundheit verblieben waren, wahrend 19 ( 7 % ) erncut erkrankten und zwar entweder unter symptornatischen Bronchiektasen oder an Tuberkulose. 19 Falle ( 1 3 % ) blieben unbehandelt. 3. 45 ( 3 0 % ) waren genótigt, sich einer chirurgischen Behandlung zu unterziehen zusatzüch zur internistischen Therapie. Von diesen wurden 42 frei von alien Symptomen entlassen. Weitere 31 ( 2 1 % ) erhielten den dringenden Rat, sich op-
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erieren zu lassen, weil sich die konservative Behandlung ais unzureichend erwiessen hatte. D i e s e Kranken verweigerten j e d o c h die B e h a n d l u n g und wurden schliesslich auch entlassen. So war bei mehr Patienten operatives V o r g e h e n erforderlich ais konservative M a P n a h m e n , w e n n 51 % aus dieser R e i h e eine Operation oder den R a t dazu b e k o m m e n hatten, U n b e s c h a d e t der m o d e r n e n antibiotischen Therapie. 4. D i e Zahl des T o d e s f á l l e betrug 14, davon 11 bei konservativer Behandlung allein und drei weitere, die internistisch u n d chirurgisch kombiniert behandelt worden waren. 5 T o d e s f á l l e m u f k e n direkt auf den Lungenabszess oder dessen Behandlung bezogen werden (bei der Operation war dies auf bronchopleurale Fisteln in 2 Fallen und auf Coronarsklerose in e i n e m Fall zurückzuf ü h r e n ) . U n b e s c h a d e t der R o l l e der Chirurgie waren die 5 T o d e s f á l l e direkt auf das Versagen der internistischen B e h a n d l u n g zurückzuführen, denn alie Patienten waren d e m Chirurgen zugeführt w o r d e n nach erfolgloser interner Behandlung. D i e übrigen 9 Fálle m u p t e n für jede Form v o n Therapie ais hoffnungslos angesehen werden. 5. Bei der Gruppe von Patienten, die mit R e sektion behandelt w u r d e n im Anschluft an intensive internistische T h e r a p i e betrug die Mortalitát 6% und nennenswerte pleuro-pulmonale K o m p l i kationen wurden v o n ihrem Lungenabszess geheit und stellen das echte Endergebnis kombinierter internistischer und chirurgischer Behandlung i m modernen Sinne dar.
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