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Quick to the Draw: Utilizing Percutaneous Tube Drainage as First Line for Pulmonary Abscess
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A3600 - Quick to the Draw: Utilizing Percutaneous Tube Drainage as First Line for Pulmonary Abscess
Author Block: R. Hilton, S. B. Weibel; Pulmonary Critical Care, Thomas Jefferson University, Philadelphia, PA, United States.
BACKGROUND: Percutaneous tube drainage (PTD) of pulmonary abscess is considered a second line or alternative treatment option given failure of medical treatment or non viability of surgery. There is a significant literature on PTD pre-dating the antibiotic era, but more recently there have been case series and reviews of those series evaluating the efficacy of PTD. However in these cases PTD is a second line treatment following medical failure. We present a case of massive pulmonary abscess successfully treated with PTD as first line therapy in conjunction with antibiotics.
CASE: A 51 year old male with a past medical history of type 2 diabetes presented with two weeks of cough and 3-4 days of fevers. On admission, vital signs were remarkable for a fever, and an exam revealed foul breath and decreased breath sounds on the right. Chest X ray showed opacification within the right lung, and subsequent CT scan of the chest revealed a 16cm fluid filled pulmonary abscess. While this was a healthy individual, who had not failed antibiotics, given the size and dense appearance of the abscess, it was determined drainage required mechanical facilitation. Within 12 hours of admission to the hospital, a small bore pigtail catheter was placed into the abscess. Output from the chest tube was feculent, slurry-like material that was “milked” from the tube every 6 hours. This was continued for 3 days, at which point the output decreased and the tube was removed. The patient was able to be discharged after four hospital days. Follow up confirmed resolution of the pulmonary abscess on imaging along with clinical improvement.
DISCUSSION: This case represents a rare approach to management of a not-uncommon disease. Utilizing PTD as first line treatment for pulmonary abscess in tandem with antibiotics, rather than awaiting medical failure, is not standard. However, the evidence for practice is not clear. A 2012 review of 21 cases/case series of PTD reported successful treatment in 83.9%, with a 16% complication rate and 4% mortality. However 20/21 studies were prior to the year 2000, well before modern interventional radiology technology. In addition, four studies made up 100% of the collective complications and mortality. As modern PTD techniques improve, and we are increasingly eager to identify alternatives to surgery, cases such as this reflect a new norm for safe and effective abscess drainage of large pulmonary abscess.
Author Block: R. Hilton, S. B. Weibel; Pulmonary Critical Care, Thomas Jefferson University, Philadelphia, PA, United States.
BACKGROUND: Percutaneous tube drainage (PTD) of pulmonary abscess is considered a second line or alternative treatment option given failure of medical treatment or non viability of surgery. There is a significant literature on PTD pre-dating the antibiotic era, but more recently there have been case series and reviews of those series evaluating the efficacy of PTD. However in these cases PTD is a second line treatment following medical failure. We present a case of massive pulmonary abscess successfully treated with PTD as first line therapy in conjunction with antibiotics.
CASE: A 51 year old male with a past medical history of type 2 diabetes presented with two weeks of cough and 3-4 days of fevers. On admission, vital signs were remarkable for a fever, and an exam revealed foul breath and decreased breath sounds on the right. Chest X ray showed opacification within the right lung, and subsequent CT scan of the chest revealed a 16cm fluid filled pulmonary abscess. While this was a healthy individual, who had not failed antibiotics, given the size and dense appearance of the abscess, it was determined drainage required mechanical facilitation. Within 12 hours of admission to the hospital, a small bore pigtail catheter was placed into the abscess. Output from the chest tube was feculent, slurry-like material that was “milked” from the tube every 6 hours. This was continued for 3 days, at which point the output decreased and the tube was removed. The patient was able to be discharged after four hospital days. Follow up confirmed resolution of the pulmonary abscess on imaging along with clinical improvement.
DISCUSSION: This case represents a rare approach to management of a not-uncommon disease. Utilizing PTD as first line treatment for pulmonary abscess in tandem with antibiotics, rather than awaiting medical failure, is not standard. However, the evidence for practice is not clear. A 2012 review of 21 cases/case series of PTD reported successful treatment in 83.9%, with a 16% complication rate and 4% mortality. However 20/21 studies were prior to the year 2000, well before modern interventional radiology technology. In addition, four studies made up 100% of the collective complications and mortality. As modern PTD techniques improve, and we are increasingly eager to identify alternatives to surgery, cases such as this reflect a new norm for safe and effective abscess drainage of large pulmonary abscess.
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