risks of percutaneous lung abscess drainage.

1. Empyema as a complication of
lung abscess drainage
Star Ye MS 4
Jayanth H.Keshavamurthy
2/20/17

2. HPI
• 66 year old male was directly admitted from an outside
hospital for management of a cavitary lesion in his left
lung visualized on CT. The patient presented with a
chief complaint of cough that was productive for non-
bloody, copious, yellow sputum for “a few days.” The
patient also reported subjective fevers, left-sided chest
pain localized to left parasternal area under the nipple,
and unintentional weight loss of 20 pounds over 3-4
months. His chest pain had increased since onset and
was exacerbated by movement and cough. He had no
history of incarceration or homelessness. The patient
was living alone and denied known exposure to
tuberculosis and HIV.

3. PMH
• Past medical history was significant for “head
& neck cancer” s/p total laryngectomy,
radiation therapy, and tracheostomy. The
patient also has COPD, hypertension, seizure,
gout, hypothyroidism, and tobacco abuse
(discontinued 3 years ago).

4. Physical Exam
• afebrile, BP119/78, HR 90, RR 20, 100% O2 on
room air.
• Pertinent exam findings:
– Presence of tracheostomy tube, which had a
patent stoma and some yellow phlegm.
– Lungs were clear to auscultation and no abnormal
heart sounds were noted.
– Neurologic exam was normal.

5. Labs
• Total WBC 13,000 cells/mm3
• Quantiferon negative
• HIV antibody/antigen negative
• Sputum culture obtained

6. Initial CXR

7. Outside/initial CT

8. Impression
• Outside hospital thorax CT showed a 4.2 x 4.3
x 4.2 cm cavitary lesion with an air-fluid level
in the lingula.
• Several smaller loculated lesions were located
inferior to the primary cavitary lesion.
• No pathologically enlarged hilar or mediastinal
lymph nodes were noted.

9. Hospital course
• Sputum culture grew P. aueruginosa
• Patient was started on empiric pip/tazo

10. Learning points
• The majority of lung abscesses are caused by
polymicrobial infection, predominately anaerobes,
from bacteria that normally colonize the oropharynx
• patients with poor dentition, reduced consciousness,
and/or dysphagia are particularly susceptible to
development of lung abscesses
• Percutaneous transtracheal aspirates and transthoracic
needle aspirates yield are most likely to yield accurate
identification of causal bacteria in lung abscesses
• Sputum cultures less accurate in identifying causative
bacteria because these cultures can be contaminated
by other bacteria in the oropharynx

11. Hospital day 2
• Bronchoscopy was performed on hospital day
2 and was notable for mucopurulent discharge
predominantly at the left lingula.
• Bronchoaveolar lavage produced
predominately acute inflammatory cells
present and no cytologic features of
malignancy.
• The patient became febrile later that day, and
his white cell count remained elevated.

12. Hospital day 3
• The patient underwent CT-guided
percutaneous drainage of the abscess on
hospital day 3.
• The abscess drained 15 ml of frankly purulent
discharge, and percutaneous pig tail drainage
catheter was placed in the lung abscess.
• The abscess drainage was not cultured.

13. Hospital course
• The patient developed an empyema which
was likely secondary to percutaneous drainage
catheter placement and contamination of
pleural space from the abscess drainage

14. Repeat CXR s/p perc drainage

15. Repeat CT s/p perc drainage

16. Hospital course
• The patient underwent video assisted
thoracoscopic surgery (VATS) with
debridement of fluid collections and lung
decortication on hospital day 10.
• The patient improved clinically after the
procedure and was discharged on hospital day
18.

17. Repeat CXR s/p VATS

18. Learning points
• 80-90% of lung abscesses resolve with continued antibiotic treatment
• There is no consensus on duration of antibiotic therapy, and duration of
therapy is dependent upon clinical response and can range from 3-20
weeks.
• Patients are typically afebrile after 3-10 days.
• Bronchoscopy is may be useful if there is suspicion of an obstructive lesion
but otherwise poses a risk for aspiration of abscess contents.
• Pulmonary resection and/or drainage should only be considered in
complicated abscesses that fail medical management or are unlikely to
respond with conservative measures.
• Suspicion of malignancy, bronchial obstruction, massive tissue necrosis,
empyema, and multiloculated or poorly defined abscesses are indications
for resection.
• Percutaneous drainage is an alternative intervention that may have less
mortality compared to surgical intervention.
• Indications for percutaneous drainage include large abscesses of >4-8cm
or an inability to produce productive cough which prevents spontaneous
drainage.
• Complications of percutaneous drainage include pneumothorax,
hemothorax, and hemoptysis. Bronchopleural fistula and empyema may
result from contamination of drainage devices.