[Umbilical sepsis with pylephlebitis, multiple liver abscesses, lung abscesses and osteomyelitis; cure].
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Lung abscess was diagnosed during a complex examination in 115 patients. All the patients had local treatment through the bronchoscope. Cleansing of the abscess cavity takes place 1,3 times quicker in the patients who were given laser irradiation in addition to sanitation bronchoscopy or to whom immunomodulators and antibiotics were introduced lymphotropically intrabronchially, than in those with usual sanitation. The administration of 20 ml of glycerol in the abscess cavity allowed cleansing of the cavity to be 2-3 times quicker.
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Most lung abscesses are successfully treated with antibiotics. However, occasional patients with lung abscesses that drain poorly, causing persistent fever and toxic symptoms, may require surgical intervention. Lobectomy is the most frequent surgical procedure. Some patients are debilitated and have underlying medical conditions such as heart disease, chronic pulmonary disease, or liver disease that may render surgical intervention risky. Recently there have been reports of percutaneous drainage of lung abscess with good results. We have successfully carried out percutaneous drainage of lung abscess in 4 patients and an infected bulla in 1. All patients had failed to respond to therapy with antibiotics and postural drainage. There was prompt disappearance of the fluid level in the cavity, decline in temperature, and abatement of toxic symptoms with drainage. The cavities closed gradually over the next 6-12 weeks. The patients tolerated the chest tube well and there were no side effects from the tube drainage. Percutaneous tube drainage is the surgical treatment of choice in the medically complicated patient with a poorly draining lung abscess.
Although lung abscesses are successfully treated with antibiotics in 80-90% of cases, this conservative approach may occasionally fail. In cases of failure, pulmonary resection is usually advised. Although it remains controversial, an alternative therapy in such situations is percutaneous transthoracic tube drainage (PTTD). Herein we review the medical literature on PTTD from the last 25 y, focusing on its efficacy, indications, technique, complications and mortality. We conclude that PTTD is a safe, simple and efficacious tool for the management of refractory lung abscess. Complications relating to the procedure occurred in 9.7% of cases and included catheter occlusion, chest pain, pneumothorax and hemothorax. The overall mortality rate secondary to lung abscess was acceptable (4.8%).
Two hundred and seventy-six consecutive patients with small cell carcinoma of the lung (SCCL) treated with combination chemotherapy and in 79 cases with "high-dose" steroids (greater than 40 mg of prednisone per day) were reviewed for the presence of lung abscess. This was diagnosed in 17 patients, in 4 (1.5%) at the time of their malignant diagnosis and 13 (4.9%) during chemotherapy. Five of 79 patients receiving "high-dose" glucocorticoid therapy and 8 of 184 patients not receiving steroids developed lung abscess (no statistical difference, P greater than 0.05). "High-dose" steroids do not facilitate the development of lung abscess. Eleven patients presented with a lung abscess within a month of initiation of chemotherapy. Median survival of these patients was 182 days and not significantly different from a median survival of 224 days (P greater than 0.05) observed in 31 compatible patients without lung abscess. Lung abscess per se in patients with SCCL should not prevent the use of intensive combination chemotherapy and "high-dose" steroid therapy.
A 51 year-old man fitted with a dental prosthesis was hospitalized with buccal swelling, fever and chest pain. Laboratory data showed marked inflammatory changes, and chest radiography and CT scanning revealed small nodular shadows within the lung. A diagnosis of multiple lung abscesses secondary to a buccal abscess possibly caused by the prosthesis was made from needle aspiration biopsies of the lung nodules and of a buccal lesion. Klebsiella pneumoniae was isolated from these lesions and from a blood culture. The patient was successfully treated with antibiotics and by surgical drainage of the buccal abscess. It is important to note that the patient was immunodeficient at the time as a result of diabetes and alcohol intoxication.
Lung abscess and empyema can often be distinguished on plain radiographs. Sometimes, oblique or decubitus views may be necessary in order to demonstrate the more specific conventional radiographic features--the shape of the lesion and its relationship to the chest wall. In seriously ill patients, special positioning may be impossible. CT may be easier to perform than special views in some ill patients. In many cases of suppurative disease, both lung and pleura may be involved, and pleural disease in the presence of lung disease is easily missed on plain radiographs. Furthermore, infections located at the periphery or at the apices of the thorax are difficult to define with conventional imaging. CT with cross-sectional images and unequalled density resolution delineates the lung-pleura interface and the periphery and apices of the lung. With CT, lung abscess and empyema show statistically significant differences in shape--round (abscess) or lenticular (empyema); the presence of separation of pleural layers (empyema); the presence of lung compression (empyema); the presence of acute (abscess) or obtuse (empyema) chest wall angles; and wall characteristics--thick, nonuniform, and irregular (abscess) or thin, uniform, and smooth (empyema). Few lesions demonstrate all of these features; however, sufficient information may be obtained from CT to permit a confident diagnosis of lung abscess or empyema. Thus, CT helps in the evaluation of suppurative diseases. CT provides diagnostic information not available from conventional radiographs in 47 per cent of cases, and in 34 per cent of cases, CT gives more accurate delineation of the extent of disease.(ABSTRACT TRUNCATED AT 250 WORDS)
Patients with primary lung abscess who do not respond to medical management are usually candidates for a lobectomy. Percutaneous tube drainage, used routinely and with good results before the antibiotic era, has nearly been forgotten. Seven patients with lung abscesses and severe sepsis were in critical condition, not permitting pulmonary resection. They were treated by tube drainage. Prompt clinical recovery occurred in all, with complete resolution of abscesses within 4 to 24 days. When medical therapy of lung abscess fails, tube drainage should be considered in preference to a lobectomy. It is safe and curative and avoids unnecessary loss of functioning lung parenchyma. Lobectomy should be considered in patients who have major life-threatening bleeding or massive pulmonary necrosis.
Three neonates with lung abscess unresponsive to antibiotic therapy underwent successful resection of infected lobes with the aid of one-lung anesthesia. This was accomplished by selective endobronchial intubation of the opposite lung and obstruction of the ipsilateral main bronchus with a Fogarty balloon-tipped catheter. This valuable technique provides protection against tracheobronchial spillage of purulent material and results in the rapid recovery of these seriously ill neonates.
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We describe the anaesthetic management of a patient undergoing lobectomy for cavitating lung abscess complicated by haemoptysis. Surgery for lung abscess is one of the absolute indications for the use of a double-lumen tube (DLT). Because pus or blood could impede fibreoptic-assisted DLT placement, a traditional, blind placement of the DLT was performed. To protect the uninvolved parts of the operated lung, ventilation of the lung with the abscess was not performed until the resection of the involved lobe had been completed.
Lung abscess was successfully treated with percutaneous drainage in 5 of 6 patients. Complete abscess resolution occurred in 4 patients, partial resolution in one, and no response in one. The duration of drainage ranged from 7 to 18 days (mean 15.5 days) in successful cases. The failure of drainage in one neurologically impaired patient was attributed to persistent aspiration. In 2 patients, concurrent pleural empyema was also cured. CT provided the anatomic details necessary for choosing the puncture site and avoiding puncture of the lung parenchyma. Percutaneous catheter drainage is a safe and effective method for treating lung abscess.
Lung abscesses were drained by means of catheters guided by computed tomography (CT) in 19 patients who still had sepsis despite standard medical therapy; all patients had received antibiotics for at least 5 days, and 11 of the 19 patients had undergone bronchoscopy. The abscess was cured (by clinical and radiographic criteria) in all 19 patients (100%), and surgery was avoided in 16 of the 19 patients (84%). Three patients underwent surgery for removal of organized tissue or decortication after the lung abscess was evacuated. Complications included a hemothorax that required a chest tube in one patient and three minor complications (a clogged catheter in two patients and transient elevation of intracerebral pressure in one patient). The hemothorax occurred in one of two patients in whom the catheter traversed normal lung. The percutaneous drainage catheters traversed juxtaposed abnormal pleura on route to the abscess in 17 of the patients. CT-guided drainage of lung abscess is an effective method to treat lung abscesses that are refractory to conventional therapy; the procedure should obviate major operation in most patients. A catheter route through abscess-pleural syndesis is preferable, and CT is useful for planning this route.
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