(Chest. 2005;127:1378-1381.)
© 2005
American College of Chest Physicians
Endoscopic Drainage of Lung Abscesses*
Technique and Outcome
Felix Herth, MD, FCCP;
Armin Ernst, MD, FCCP and
Heinrich D. Becker, MD, FCCP
* From the Department of Interdisciplinary Endoscopy (Drs. Herth and Becker), Thoraxklinik, Heidelberg, Germany; and Interventional Pulmonology (Dr. Ernst), Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
Correspondence to: Armin Ernst, MD, FCCP, Director, Interventional Pulmonology, Pulmonary and Critical Care Division, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Rd, Boston, MA 02115; e-mail: aernst{at}bidmc.harvard.edu
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Abstract
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Background: Lung abscesses commonly respond well to antibiotic therapy. In patients in whom conventional therapy fails, either percutaneous catheter drainage or surgical resection are usually considered, but are frequently problematic. This study describes our experience with endoscopic lung abscess drainage in patients in whom antibiotic therapy fails.
Methods: Patients in whom antibiotic therapy for lung abscess (enlarging cavity or lack of improvement of clinical status) was unsuccessful were considered candidates if an airway connection to the cavity was present. Treatment decisions were made in a multidisciplinary chest conference. Pigtail catheters were placed via a guidewire approach into the cavities. The abscesses were flushed twice daily with gentamycin solution. If fungal infection was suspected, once-daily amphotericin B was added to the regimen.
Results: Forty-two patients, from January 2000 to May 2002 (17 woman and 25 men) were included in this study (mean age, 48.9 years). Catheter placement was successful in 38 patients and led to successful therapy after a mean of 6.2 days of treatment (range, 3 to 21 days). Two patients required transient ventilation after catheter placement; there were no other complications.
Conclusions: Endoscopic lung abscess drainage in selected patients in whom antibiotic therapy fails is feasible and successful in experienced hands. This treatment represents an additional option for the chest physician other than percutaneous catheter drainage or surgical resection.
Key Words: bronchoscopy • drainage • lung abscess • treatment
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Introduction
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Lung abscesses are associated with a wide variety of disorders. A primary abscess most frequently results from aspiration of oropharyngeal secretions or aspiration of gastric contents. Other etiologies include infectious agents such as tuberculosis and pneumocystis pneumonia, septic emboli, vasculitis, necrotizing pneumonia, and necrotizing tumors among others.12
Bronchoscopy is usually performed for sampling purposes as well as to exclude obstructive lesions within the airways. If airway abnormalities associated with the abscess are present, bronchoscopy can also be undertaken therapeutically for relief of the stenosis. The most common therapeutic approach to infectious abscesses of the lung is the administration of prolonged courses of systemic antibiotics. Antibiotic therapy in combination with diagnostic bronchoscopy and postural drainage where indicated is curative in most cases. If this regimen fails, drainage or resection options are usually considered. Pneumonostomy or cavernostomy with direct drainage (Monaldi procedure) can achieve this goal but is only possible when the pleural space is obliterated. Lung resection as the definitive procedure cannot be frequently performed because of septic complications. These surgical procedures achieved cure rates of 90%, but with concomitant mortality rates of 11 to 28%. In the past 2 decades, percutaneous catheter drainage has proven effective in appropriately selected adult and pediatric patients.3
Endoscopic abscess drainage is commonly performed in other organs such as the pancreas, but rarely in the lungs. In this report, we wish to present our technique for endoscopic abscess drainage, as well as the outcomes in our patient population.
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Materials and Methods
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All patients admitted to our institutions with lung abscesses are discussed in a multidisciplinary setting. When conventional therapy failed as noted, treatment options are discussed and decided in this forum. In this report, we included all patients in whom conventional therapy failed and were believed to be candidates for endoscopic drainage. Patients were included between January 2000 and May 2002, and observed prospectively.
Failure of antibiotic therapy was assumed for the following reasons: (1) if the abscess cavity grew in size during appropriate antibiotic treatment, (2) if the WBC count rose with therapy, or (3) if the general status of the patient deteriorated without any other identifiable reason. Patients were believed to be good candidates if a connection of the abscess to the bronchial tree was visualized. The Institutional Review Board approved the data collection.
Endoscopic Procedure
Patients underwent flexible bronchoscopy through a nasal approach in a standard fashion.4 Under fluoroscopic control, a guidewire was introduced into the cavity through the working channel of a flexible bronchoscope (Excera 160 and T40; Olympus; Tokyo, Japan). In some patients, selective bronchography was performed first to identify the airway leading into the cavity. In those patients, the guidewire was directly introduced through the bronchography catheter. When the guidewire was confirmed to be in place, the catheter and bronchoscope were removed. A pigtail catheter of 90 cm in length (Cordis; Miami, FL) of at least 7F was slipped over the wire into the cavity (Fig 1, 2
). The correct position was checked with an application of contrast medium (Isovist-300; Schering; Berlin, Germany) through the pigtail catheter, followed by the removal of the guidewire. The catheter was secured at the nose (Fig 3
).
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Figure 1.. Chest radiograph of a 46-year-old man with a large abscess in the left upper lobe. Sputum was culture positive for Legionella pneumonia. Note the cavity size as well as the significant amount of abscess contents 4 weeks into appropriate systemic antibiotic therapy.
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Local Treatment Protocol
In the study subjects, the abscess cavity was flushed twice daily with 80 mg gentamycin in 20 mL of normal saline solution. In cases of documented fungal disease, the addition of 50 mg amphotericin B in 20 mL of normal saline solution was added to the flushes once a day. At all other times, the catheter was open to gravity. All patients continued with their previously established antibiotic therapy. A successful intervention was defined by a decrease in abscess size and drainage of the cavity contents. Systemic signs of infection, such as WBC count and fever, were closely observed.
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Results
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During the study period, 42 patients (17 women and 25 men; mean age, 48.9 years; range, 35 to 78 years) were identified as appropriate candidates (Table 1
). The underlying diseases were pneumonia (n = 19), lung cancer (n = 14), tuberculosis (n = 7), and aspergilloma (n = 2). The mean time of antibiotic therapy before drainage was 27.8 days (range, 14 to 51 days). The mean diameter of the abscess cavity before endoscopic drainage was 4.7 cm (range, 3.2 to 8.3 cm), increased from a mean of 3.7 cm (range, 1.7 to 8.3 cm) before initiation of systemic antibiotic therapy at the time of diagnosis. The locations of the abscesses included all parts of the lung: right upper lobe (n = 13), right middle lobe (n = 7), right lower lobe (n = 5), left upper lobe (n = 10), and left lower lobe (n = 7).
In 38 patients (90%), we were able to place a catheter into the lesion, and those patients underwent treatment per protocol. Two patients who had aspergillus species demonstrated on diagnostic specimens had amphotericin B added to the rinsing solution. In all of the 38 patients, the cavity could be cleaned, sterilized, and nearly obliterated. The mean diameter of the lesions at catheter removal was 2.3 cm (range, 1.8 to 3.2 cm), and in most cases it was mainly scar tissue. The mean duration of rinsing was 6.2 days (range, 3 to 21 days). Two patients needed transient mechanical ventilation after the placement of the catheter for 24 h; no other complications were observed. The mean time needed for the placement was 18.6 min (range, 9.5 to 28.9 min). In the four patients in whom no catheter could be placed, the following outcomes were observed: fatal hemoptysis (n = 1), death due to sepsis (n = 1), curative lobectomy (n = 1), and long-term percutaneous drainage (n = 1).
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Discussion
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Lung abscesses are generally successfully treated with prolonged systemic antibiotic therapy without the need for any interventional procedures. It has been estimated that drainage is required in 11 to 21% of patients with lung abscesses in whom medical therapy is unsuccessful.356 Commonly in these cases, the first consideration is for percutaneous drainage under CT guidance. This approach may be problematic in patients with coagulopathies, if a significant amount of lung tissue needs to be traversed and if other anatomic structures do not allow for unimpeded access to the cavity. Additionally, there is always a concern for soiling the pleural space with abscess contents.5 Another consideration if percutaneous drainage appears problematic is for surgical resection of the diseased lung and the abscess.7
Endoscopic drainage as described in this article may be a valuable minimally invasive addition to the armamentarium of the chest physician dealing with patients with a lung abscess. It can be considered in selected patients who have an airway connection to the abscess or in whom an endobronchial obstruction preventing drainage is present. It does not carry the risk of soiling the pleural space and is less invasive and not associated with the loss of lung parenchyma as in a surgical resection. It is noteworthy that all patients were selected in a multidisciplinary fashion and catheters were placed by experienced endoscopists.
Endoscopic drainage of parenchymal abscess cavities was first reported by Metras and Chapin8 in 1954. Three more reports have been published91011 between 1975 and 1988. Altogether, 16 cases with five failures of the endoscopic intervention have been described prior to this study. In contrast to our description, there was no documentation of an airway leading into the abnormality, and different types of catheters were used. Endobronchial spillage of abscess contents12 may be a concern when performing this intervention, but neither in the reports listed nor in our experience has this actually been a problem.
In summary, our experience with endoscopic abscess drainage is excellent in selected patients in whom conventional therapy fails. We consider it an alternative to percutaneous drainage in patients who are coagulopathic, have airway obstruction, or have a fairly central abscess, if an airway leading to the abscess can be demonstrated.
Received for publication December 15, 2003.
Accepted for publication September 15, 2004.
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References
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Abstract
Introduction
