(Chest. 2001;120:847-851.)
© 2001
American College of Chest Physicians
Late Complications of Collapse Therapy for Pulmonary Tuberculosis*
Dov Weissberg, MD, FCCP and
Dorit Weissberg, MD
*
From the Department of Thoracic Surgery, Tel Aviv University Sackler School of Medicine, Tel Aviv, and E. Wolfson Medical Center, Holon, Israel.
Correspondence to: Dov Weissberg, MD, FCCP, Department of Thoracic Surgery, E. Wolfson Medical Center, Holon 58100, Israel; e-mail: dovw{at}ccsg.tau.ac.il
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Abstract
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Study objectives: Collapse therapy for pulmonary
tuberculosis involved placement of various materials to occupy space
and keep the lung collapsed. Complications are encountered decades
later.
Patients and methods: Between 1980 and 1997, we
treated 31 patients with a history of pulmonary tuberculosis in whom
collapse therapy had been used and who later developed complications
related to their treatment. Pyogenic empyema was present in 24
patients, pleural calcifications with bronchopleural fistula was
present in 3 patients, pleural calcification with nonresolvable
pneumothorax was present in 1 patient, and migration of a foreign body
with formation of subcutaneous mass occurred in 3 patients. All
patients with empyema were treated with antibiotics and tube drainage
of pus. In addition, Lucite balls were extracted in 4 patients, lung
decortication was performed in 6 patients, thoracoplasty was performed
in 2 patients, and fenestration was performed in 16 patients.
Bronchopleural fistulas were closed with sutures and reinforced with
intercostal muscle flap in three patients; in one patient with pleural
calcification and nonresolvable pneumothorax, tube drainage was
attempted. In three patients with subcutaneous mass due to paraffin
migration, paraffin was extracted.
Results: Pulmonary
decortication (six patients) and thoracoplasty (two patients) resulted
in elimination of empyema. Extraction of Lucite balls resulted in lung
expansion and elimination of empyema in three of four patients;
draining sinus remains in one patient. Fenestration resulted in
elimination of empyema in 12 of 16 patients, with 3 patients with
residual draining sinuses and 1 patient with remaining empyema. All
bronchopleural fistulas closed with intercostal muscle flap remained
closed. Following extraction of paraffin blocks, infection developed in
one patient. During the follow-up period, three patients died, all of
unrelated causes.
Conclusions: Delayed complications
of collapse therapy for tuberculosis should be treated without delay.
Pressure on adjacent structures or their erosion presents danger and
mandates immediate extraction; however, there is no need for routine
removal of every residual plombe. Further increase in the number of
multiple-drug resistant strains may force the return of collapse
therapy.
Key Words: collapse therapy • complications of collapse therapy • tuberculosis
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Introduction
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Collapse
therapy was used widely in the treatment of pulmonary tuberculosis in
the 1930s, 1040s, and 1950s. It involved therapeutic pneumothorax with
multiple refills and extrapleural placement of various materials intended to occupy space and prevent expansion
of the lung, thus keeping the tuberculous cavity collapsed. With time,
presence of these materials and refills of pneumothorax, sometimes
under less than sterile conditions, led to complications.1
During the past 18 years, we treated 31 such patients.
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Materials and Methods
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Between 1980 and 1997, we admitted 31 patients with a history of
pulmonary tuberculosis. These patients had been treated in the 1930s
through 1950s with a range of invasive methods, such as artificial
pneumothorax and various forms of plombage. Although no effective
chemotherapy was available at that time, the disease was arrested in
all patients. However, the invasive therapeutic procedures and the
materials used for plombage resulted in a variety of complications.
There were 21 men and 10 women, ranging in age from 48 to 73 years
(mean age, 57 years). The preceding therapeutic procedure was
artificial pneumothorax in 22 patients, extrapleural oleothorax in 2
patients (Fig 1
), Lucite ball plombage in 4 patients (Fig 2
), and paraffin wax plombage in 3 patients. Because many more patients
were treated with pneumothorax than with plombage, complications of
pneumothorax were more common.
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Figure 1.. Oleothorax in a 61-year-old woman treated for
tuberculosis at the age of 18 years. During the 43-year interval, the
oil shifted down from its initial position over the apex of the lung.
Top: Posteroanterior radiograph. Bottom:
Lateral linear tomography.
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All patients with empyema were treated initially with tube drainage of
pus and of oleothorax (Fig 3
). The organisms cultured were Staphylococcus aureus in nine
patients, Klebsiella pneumoniae in five patients,
Streptococcus pneumoniae in three patients, and
Haemophilus influenzae in one patient. In seven of these
patients, two organisms were grown: Staphylococcus and Klebsiella in
four patients, and Streptococcus and Klebsiella in three patients. In
13 instances, there was no growth. No mycobacterium was found in any of
the patients with empyema. Antibiotics were administered according to
results of culture and sensitivity studies. Lucite balls numbering from
16 to 36 per plombage were extracted at muscle-sparing thoracotomy in 4
patients, decortication of the lung was performed in 6 patients
(including both patients with oleothorax), seven-rib thoracoplasty was
performed in 2 patients, and fenestration of the pleural cavity was
performed in 16 patients. In the three patients with pleural
calcifications and bronchopleural fistula, there was no pus. Partial
decortication was performed, and the fistulae were covered and closed
with suture and an intercostal muscle flap. In one patient with pleural
calcification and nonresolvable pneumothorax, tube drainage was
attempted without success and was discontinued, and no other treatment
was given. In three patients with subcutaneous mass due to paraffin
migration, all paraffin was extracted.
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Results
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Pulmonary decortication resulted in complete expansion of the lung
and return to normal activity in all six patients. In both patients
treated with thoracoplasty, the empyema was eliminated, and they did
well. Extraction of Lucite balls resulted in complete lung expansion
and elimination of empyema in three of four patients; draining sinus
remains in one patient who also underwent fenestration. Fenestration
resulted in obliteration of the pleural cavity by granulation tissue
and elimination of empyema in 12 of 16 patients. Three patients have
residual draining sinuses, including one patient who underwent an
earlier extraction of Lucite balls. In one patient, the fenestration
failed to eliminate empyema. Suture closure with an intercostal muscle
flap in the three patients, who had pleural calcifications and
bronchopleural fistula, resulted in permanent obliteration of the
fistula in all. Nonresolvable pneumothorax in one patient remained
unchanged; however, its size is small, and the patient is asymptomatic.
Following extraction of the paraffin blocks, infection developed in one
patient and the wound had to be drained. During the follow-up period,
three patients died of unrelated causes: two deaths were caused by
myocardial infarction and one death resulted from cancer of the colon
with metastases.
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Discussion
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Before the discovery of antimicrobial drugs and development of
techniques of pulmonary resection, collapse therapy was the mainstream
of treatment for pulmonary tuberculosis. It evolved from the idea that
collapse of the lung would put the lung at rest and thus promote the
healing process.2
Also, it would limit the spread of
tuberculous infection by collapsing the diseased portion of the lung
and so prevent spread of tuberculous material to other, uninvolved
parts of both lungs. A successful treatment resulted in formation of
fibrosis with encapsulation of the diseased portion and containment of
infection. Methods to achieve and to maintain the collapse were many
and included artificial pneumothorax with air refills, phrenic nerve
crush, thoracoplasty, and extrapleural plombage. The method of plombage
involved creation of extrapleural space by dissecting periosteum and
intercostal muscles off the ribs and filling the space with one of many
available materials, such as fat (omentum, fresh lipoma), paraffin wax,
bone, gauze sponge, silk, gelatin, rubber balloons, methyl-methacrylate
(Lucite) balls, and oil.1
Both vegetable and mineral oil
were used to produce oleothorax and were frequently rendered aseptic by
the addition of gomenol, a volatile product of distillation of the
leaves of the myrtle tree.3
4
The advantages of plombage
over thoracoplasty included selective collapse of the diseased part of
the lung with less derangement of pulmonary function; also, it could be
carried out in one stage and was cosmetically more
acceptable.2
5
However, the presence of a foreign body for
a prolonged period of time resulted in complications, such as malignant
tumors,6
7
erosion of major vessels with
bleeding,8
and, most commonly, infection and
migration.1
2
In the survey conducted by
Shepherd1
involving 119 patients, there were 16
infections, to which she added 3 of her own. Three of the infections
were caused by Mycobacterium tuberculosis; all others were
pyogenic. Massard and associates,9
in their series of 14
patients, reported on eight instances of empyema: four were pyogenic
and four were tuberculous. They theorized that tuberculous empyema can
be expected in those patients treated previously without any major
antituberculous chemotherapy. These findings contrast with our series,
in which all infections were pyogenic; no mycobacterium was ever
isolated. This can be explained by the follow-up conducted in our
group. After their initial treatment for tuberculosis in the 1940s and
1950s, most of our patients remained under long-term observation and
often received antimicrobial therapy that included isoniazid,
para-amino salicylic acid, and some other agent. Three successive
negative culture findings of mycobacterium were obtained before
cessation of treatment.
Compared with other series, ours is characterized by a relatively large
number of fenestrations (n = 16), and only six instances of
decortication. This finding is not coincidental. It has been influenced
by our policy to avoid major surgery in these usually severely ill and
debilitated patients. Decortication can be very tedious and
time-consuming. As pointed out by Shepherd,1
it would be
particularly difficult in the presence of heavy calcification, and
thoracoplasty also might be required. In contrast, fenestration is a
procedure for patients with empyema who cannot tolerate decortication
and closure of the bronchopleural fistula. Under general anesthesia,
short segments of two or three ribs are resected together with
intercostal muscles, and the skin is folded in and sutured to the
parietal pleura. The procedure inflicts very little trauma on the
patient and leaves a large opening through which the pleural cavity can
be mechanically cleansed and filled with gauze soaked in antiseptic
solution.10
Indeed, the results of fenestration in our
series were excellent: in 15 of 16 patients, the empyema was
eliminated, with minor residual draining sinuses in 3 patients, and
there were no complications. The empyema persisted in only one patient.
Pain is a rare symptom. When it occurs, it may be caused by pressure of
the plombe on adjacent structures or their erosion. Hemoptysis may be a
sign of erosion into the aorta and may be accompanied by pain. The
cause of both symptoms must be determined by emergency angiography and,
if suspicion is confirmed, immediate extraction of the plombe after
adequate preparation is mandatory.2
8
Any foreign material
that becomes a source of complication should be extracted in order to
prevent further deterioration. However, we cannot concur with Massard
and colleagues,9
who recommend routine ablation of any
residual plombage material whenever operative risk is acceptable, nor
do we accept their recommendation of routine thoracoplasty. As these
patients were treated several decades ago in various countries, it is
impossible to determine what proportion of the total these
complications represent. However, there are many such patients who
remain asymptomatic while carrying residual "plombes." The addition
of a major operative risk would be of no obvious benefit to them, and
thoracoplasty would further add to respiratory
embarrassment.11
As the number of living patients treated by plombage is attenuating
rapidly, fewer and fewer will be seen in the future, and no one is
likely to accumulate considerable experience with this problem. Careful
approach to these patients is, therefore, essential.
The discovery of drugs effective against M tuberculosis and
development of techniques of pulmonary resection in the 1940s and 1950s
brought about a great decline in the prevalence and severity of
tuberculosis. With the emergence of ethambutol in 1961 and rifampin in
1963, the disease seemed to have been conquered.12
13
Collapse therapy appeared to have passed into history, leaving behind
only a diminishing residue of complications. However, over the past 15
years, a reverse trend has occurred. A significant and steady worldwide
increase in prevalence of tuberculosis has been noted,
including multiple-drug resistant organisms
ofM tuberculosis and atypical strains. The reasons
for this change are many and are not likely to disappear anytime soon.
One might assume that both the incidence of tuberculosis and the number
of multiple-drug resistant strains will continue to increase. How will
these patients be treated? In absence of adequate therapeutic agents,
is it not possible that collapse therapy will return? There are already
many patients for whom no combination of agents is of any use. A review
of results before the era of modern therapy brings up some interesting
data. According to Strieder and associates,14
of > 300
patients at Boston City Hospital treated with plombage and
thoracoplasty, at the 5-year follow-up, the disease was inactive in
67%, while among the patients who had no contralateral disease, 75%
of patients were reported as having inactive disease. This was
considerably better than the present situation. For lack of better
means, the return to the old methods may become justified. Should this
happen, what materials could be used for plombage? Of those available
in the past, Lucite spheres wrapped in a plastic bag were probably the
best. On the other hand, Silastic prostheses filled with saline
solution, such as those used for breast implantation and in the
treatment of postpneumonectomy syndrome, would serve the purpose
equally well and with less danger of complications.15
16
17
Received for publication October 16, 2000.
Accepted for publication March 5, 2001.
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TOP
Abstract
Introduction
