Scandinavian Journal of Infectious Diseases, 2010; 42: 65–68
SHORT COMMUNICATION
Endobronchial drainage of lung abscess: The use of laser
DEKEL SHLOMI, MORDICHAI R. KRAMER, LEONARDO FUKS, NIR PELED
& DAVID SHITRIT1
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From the 1Pulmonary Institute, Rabin Medical Center, Beilinson Campus, Petah Tiqwa, and 2Sackler Faculty of Medicine,
Tel Aviv University, Tel Aviv, Israel
Abstract
The management of lung abscess is usually conservative. However, in some cases drainage is necessary, commonly performed transcutaneously. Endobronchial catheter drainage is a potential alternative, though reported only sporadically.
Transbronchial pigtail catheter drainage was used in 3 patients with refractory lung abscesses at our centre. The catheter
was introduced endobronchially under bronchoscopic procedure. Laser was used to perforate the abscess wall through the
airway into the abscess in order to provide a pathway for catheter insertion. An improvement in clinical and radiological
parameters was noted immediately after catheter placement. The catheters were extracted after 4–6 days. All patients had
a complete clinical recovery. Endobronchial catheters with the use of laser appear to be relatively safe and effective for the
treatment of pulmonary abscess in selected patients in whom the abscess is adjacent to the central airway. When necessary,
a bulge in an adjacent airway can be perforated with laser. To the best of our knowledge, there have been no previous
reports of endobronchial drainage with the use of laser.
Introduction
Lung abscesses caused by infection commonly
respond well to prolonged antibiotic treatment and
chest physical therapy or postural drainage. If there
is no clinical improvement, bronchoscopy may be
performed to identify the culprit organism, drain
ﬂuid, or exclude or treat obstruction. Approximately
20% of abscesses fail to respond to conservative
treatment and require drainage. Surgical drainage or
pulmonary resection may be associated with serious
complications and lead to the loss of lung parenchyma; it is rarely performed in septic or high-risk
patients [1]. Percutaneous catheter drainage is effective, although difﬁcult to perform when the abscess
is not adjacent to the chest wall. Computed tomography (CT) guidance allows for more accurate placement of the catheter [2], but it may damage normal
lung parenchyma and cause haemothorax [3] or
uncontrolled bleeding [4].
Endoscopic drainage may offer another option.
However, its use has been reported only sporadically
in the past decades.
We describe 3 patients with lung abscesses whose
condition clinically deteriorated under antibiotic
treatment and who underwent transbronchial pigtail
catheter drainage with signiﬁcant improvement in
their clinical and radiological parameters.
Methods
Patients underwent ﬂexible bronchoscopy through a
nasal approach in a standard fashion. Under ﬂuoroscopic control, a guide wire was introduced into the
cavity through the working channel of a ﬂexible
bronchoscope (Excera 160 and T40; Olympus;Tokyo,
Japan). When the guide wire was conﬁrmed to be in
place, the catheter and bronchoscope were removed.
A pigtail catheter of 90 cm in length (Cordis; Miami,
FL, USA) of at least 6F was slipped over the wire
into the cavity. 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 guide wire.
The catheter was secured at the nose.
Correspondence: D. Shitrit, Pulmonary Institute, Rabin Medical Center, Petah Tiqwa, 49100, Israel. Tel: 972 3 9377221. Fax: 972 3 9242091. E-mail:
[email protected]
(Received 19 July 2009; accepted 24 August 2009)
ISSN 0036-5548 print/ISSN 1651-1980 online © 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.3109/00365540903292690
66
D. Shlomi et al.
Clinical summaries
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Patient 1
A 20-y-old male was transferred to our hospital after
sustaining a blast injury. Chest CT revealed pneumomediastinum, bilateral lung contusions, and a 3.6 cm
cavitary lesion in the right lung. The patient was
treated with a broad-spectrum empiric antibiotic.
Nevertheless, the patient’s condition worsened. Eight
days after admission, a 10F percutaneous pigtail catheter was placed inside the right upper lung abscess.
Imipenem-sensitive Enterobacter was isolated from
the purulent right pleural ﬂuid. One week later, the
patient showed signiﬁcant clinical improvement, and
the pigtail catheter was extracted.
On day 26 of hospitalization, however, high fever
with leukocytosis developed. A follow-up CT scan
demonstrated a growth in the cavitary lesion measuring 6.6 6.5 cm in greatest diameter. A second
ﬂexible bronchoscopy revealed a bulge in the subcarinal area of the right upper lobe. Laser was used
to perforate the right upper lobe bronchus and create
a pathway for insertion of the guide wire. A 6F
catheter was then placed in the cavity; its position was
conﬁrmed by injection of contrast medium. The catheter was extracted 4 days later after a few decilitres of
ﬂuid had been collected. A follow-up X-ray ﬁlm
showed complete disappearance of the abscess.
Patient 2
A 35-y-old woman with mild asthma was admitted
with a 1-week history of fever with rigors and productive cough with purulent sputum. A chest X-ray
ﬁlm demonstrated a large abscess in the right lower
lobe that was conﬁrmed on CT scan (Figure 1A).
Bronchoscopic examination revealed a bulge in the
right lower lobe. Laser was used to perforate the
bronchus so that a guide wire could be inserted. The
guide wire was then replaced with a 6F pigtail catheter, and contrast medium was injected to conﬁrm
its correct placement. The patient was treated with
intravenous ceftriaxone and infusion of clindamycin
and gentamicin through the catheter directly into
the abscess cavity. Culture of the abscess ﬂuid was
positive for Peptostreptococcus micros. Several days
later, signiﬁcant clinical improvement was noted and
a third CT scan showed clearance of the abscess ﬂuid
(Figure 1B). The catheter was removed after 6 days.
Patient 3
A 38-y-old man was treated for a right upper lung
abscess with conservative treatment without success.
The patient was a recent immigrant from Russia and
had known insulin-dependent diabetes.
On admission, his temperature measured 38.5°C,
and he had marked leukocytosis. A chest CT performed
3 days after admission showed a large abscess with airﬂuid level occupying most of the right upper lobe ﬁeld.
A 6F pigtail catheter was inserted into the abscess cavity, and placement was conﬁrmed by injection of contrast medium (Figure 2). A chest X-ray performed 2
days later showed a marked reduction in the air-ﬂuid
level. The fever and leukocytosis resolved. The patient
self-extracted the pigtail catheter 4 days after insertion.
A CT scan performed the next day showed marked
clearance of the abscess ﬂuid. The patient was discharged from the hospital 10 days after admission.
Discussion
Although lung abscesses are successfully treated with
antibiotics in 80–90% of cases, this conservative
approach may occasionally fail. In cases of failure,
Figure 1. Patient 2, a 35-y-old woman with a giant abscess in the right lower lobe. (A) Chest CT scan 9 days after admission, showing
the abscess with air-ﬂuid level. (B) Chest CT scan showing the pigtail catheter inside the abscess cavity.
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Endobronchial drainage of lung abscess
Figure 2. Patient 3, a 38-y-old man with a right upper lobe abscess.
Chest X-ray ﬁlm showing the transbronchial pigtail catheter 2
days after pigtail insertion.
pulmonary resection is usually advised. Although
it remains controversial, an alternative therapy in
such situations is percutaneous transthoracic tube
drainage. The procedure is safe, simple and an efﬁcacious tool for the management of refractory lung
abscess. In one study, complications relating to the
procedure occurred in 9.7% of cases and included
catheter occlusion, chest pain, pneumothorax and
haemothorax. The overall mortality rate secondary to
lung abscess was acceptable (4.8%) [5].
Bronchoscopic abscess drainage may be considered in selected patients in whom the abscess wall is
adjacent to a major bronchus, especially when bulging of the bronchus is observed. It can be considered
in 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. Endobronchial spillage of abscess contents may
be a concern when performing this intervention, but
neither in the reports listed6 nor in our experience
has this actually been a problem.
This procedure appears to relatively safe and
causes only minor patient discomfort. Nevertheless,
only few reports on its use have appeared in the last
3 decades [1–7]. Jeong et al. [4] described 11 cases
of transbronchial catheter drainage. A dramatic
response was noted in 6 patients, all of whom had
abscesses larger than 8 cm in diameter and air-ﬂuid
levels higher than two-thirds of the cavity.
More recently, Herth et al. [6] used transbronchial drainage to treat 38 patients with lung
67
abscesses. From January 2000 to May 2002, 42
patients (17 women and 25 men) were included in
this study (mean age 48.9 y). Catheter placement
was successful in all patients and led to successful therapy after a mean of 6.2 days of treatment
(range 3–21 days). Two patients required transient
ventilation after catheter placement; there were no
other complications. They concluded that 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.
Although gentamicin would probably not be very
efﬁcacious in the acid environment of an abscess, we
used it in our patient 2 based on the data from Herth
et al. [6], who found this treatment effective in their
cases.
In the present series, clinical improvement was
observed in all patients with right lung abscesses
several days after transbronchial drainage. To our
knowledge, this is the ﬁrst description of catheter
placement following laser perforation of a bulging
airway adjacent to the abscess cavity in the absence
of an alternate pathway leading to the cavity.
Transbronchial catheter drainage of lung abscess
is a complex procedure and should be performed
in carefully selected patients by a physician highly
skilled in interventional pulmonology. This qualiﬁcation may explain the limited number of reported
cases. This method appears to be highly effective in
the treatment of patients with large central abscesses
that have failed to respond to conservative treatment
and of patients at high risk for other types of surgical
procedures. Percutaneous drainage is preferable only
in peripheral cavitations and therefore is not suitable
for central abscesses. It is necessary to manage airway
obstruction and the catheter can easily be inserted in
cases in which the abscess is accessible by patent
airways. In addition, it may be combined with laser
treatment in cases in which the abscess is blocked
and a bulge in the surrounding airway is identiﬁed.
Declaration of interest: The authors report no
conﬂicts of interest. The authors alone are responsible for the content and writing of the paper.
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