대 한 방 사 선 의 학 회 지 1993 ; 29 (5) : 923~929

Journal of Korean Radiological Society, September, 1993

Percutaneous Catheter Drainage of Lung Abscess *

Young Shin Kim, M.D., Kyung Ah Chun, M.D., Hyo Sun Choi, M.D. Hyun Kown Ha, M.D., Kyung Sub Shinn, M.D.

Dφa1τment 0/ Radiology, Catholic University Medical College

- Abstract-

From March 1987 to July 1989, six patients (five dadults and one child) with lung abscess (size, 5- 13cm in

diameter) were treated with percutaneous aspiration and drainage. In each case , the puncture was made where

the wall of the abscess was in contact with the pleura1 surface. An 8 to 10 Fr catheter was inserted for drain­

age. Five of 6 had a dramatic clinica1 response within 24 hours of the drainage. Percutaneous drainage was

successful with complete abscess resolution in four and partial res이ution in one patient. No response was seen

in the rest one. The duration of drainage ranged from 7 to 18 days (average , 15.5days) in successful cases.

One case of the fai lure in drainage was due to persistent aspiration of the neurologically impaired patient. In

one patient, the abscess resolved after drainage but recurred after inadvertent removal of the catheter 7 days

after insertion. In two patients, concurrent pleura1 empyema was resolved completely by the drainage. Comput­

ed tomography provided anatomic details necessaη for choosing the puncture site and avoiding a puncture of

the lung parenchyma. Percutaneous catheter drainage is a safe and effective method for treating patient with

lung abscess.

Index Words: Lung, Abscess 60.216

Abscess, Percutaneous drainage

INTRODUCTION

Despite the wide availability of antibiotics

and advances in medical technology, lung

abscess continues to be a serious medical prob­

lem, particularly in the debilitated patients

such as those with alcoholism, diabetes mellitus, and medical conditions requiring steroid thera­

py. The mortality rates for lung abscess ranged

from 17 to 75% (1, 2). Although the admini­

stration of appropriate antibiotics has proved to

be an effective treatment for most of acute

lung abscesses , medical therapy could fail in

chronic cases that formed a thick fibrotic wall

or bronchial stenosis. Because delay in the

treatment of a lung abscess may result in irre­

versible parenchymal damage , surgical interven­

tion was used in the management of patients

with chronic lung abscesses unresponsive to

medical therapy. Surgical intervention is also

warranted when the abscess is associated with

hemoptysis, empyema, or bronchopleural fistu­

la. Percutaneous drainage of lung abscess is an

effective alternative to open surgery. Percutane­

ous aspiration and drainage were reported to

be safe and effective in management of patients

with intra-abdominal, pulmonary, and mediasti-

* 이 논문은 1992년 가톨릭중앙의료원 연구보조비로 이루어진것임 이 논문은 1992년 6월 22일 접수하여 1993년 4월 20일에 채택되었음.

Received June 22, 1992, Accepted April 20 , 1993

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Journal of Korean Radi이 ogical Society 1993; 29 (5) : 923~929

nal abscesses (3-5). The purpose of this report

is to present our experience of percutaneous

catheter drainage in six patients with lung

abscess.

MATERIALS AND METHODS

Six patients (3 women and 3 men, aged 6-

66) underwent percutaneous aspiration and

drainage of lung abscesses at St. Maη’ s Hospi­

tal of Catholoic University Medical college in

Seoul, Korea between March 1987 and June

1989. The predisposing causes of the abscesses

were diabetes mellitus (n = 2) , complicated

bronchoscopic biopsy (n = 1) , aspiration pneu­

monia (n = 1), and unknown etiology (n = 2).

Clinically, all patients presented with productive

cough, chest pain, and feve r. One patient with

whom the abscess was in the right middle lobe

presented with dyspnea, tachycardia, and cardi­

ac arrythmia additionally. The locations of the

abscesses were the superior segment of the

right lower lobe (n = 2) and left lower lobe (n =

2) , the right middle lobe (n = 1) , and the pos­

terior segment of thr right upper lobe (n = 1).

The size of abscess ranged from 5 to 13cm in

diameter.

In each patient, the chest radiographs and

computed tomographic scans or ultrasonograms

were reviewed before the drainage procedure

to localize the nearest skin puncture site from

the wall of the abscess. An 18 gauge needle was

inserted into the abscess cavity under a fluoro­

scopic (five patients) or CT (one patient) guid­

ance while respiration was suspended. Once the

needle tip was located within the abscess cavity,

fluid was withdrawn and then an O.035-inch, J ­

shaped guide wire was introduced into the cavi­

ty. After aspiration of pus, the abscess cavity

was irrigated with small aliquots of normal sa­

line solution until they became clear of pus . We

used 8 .3Fr catheters with a "pigtail " configura­

tion in three , 8Fr polyethylene catheters with a

"cobra head" configuration in two and a 10Fr

924

Malecot catheter in one patient. The choice of

catheter was made on the availability of cathe­

ter at the time of drainage.

In each patient, culture and antibiotic sensi­

tivity studies for the aspirated fluid were per­

formed. An appropriate antibiotic regimen was

administered according to the results of the

bacteriologic study.

In all patients irrigation was performed

twice a day. Body temperature was recorded

and white blood cell (WBC) counts were mea­

sured before and selially after the placement of

a catheter. The size of abscess was measured on

the chest radiographs . Volume of the drained

material was recorded daily. The catheter was

removed when the abscess resolved and drain­

age stopped. Abscess drainage was not attempt­

ed when the abscess wall did not touch the

pleura because of possibility of inducing pyo­

thorax or pneumothorax.

RESULTS

Five of the six patients had dramatic clinical

response after drainage. In these patients fever

dropped rapidly and their WBC counts de­

creased to normal or near normal value within

two days of drainage. The size of the abscesses

decreased gradually during the first week of

drainage , remained unchanged afterward in

four patients, and continued to decrease in one

patient by the time of catheter removal. The

duration of drainage in four patients showed

complete resolution of abscesses rangd from 11

to 18 days (caverage, 15.5 days) in two patients

it took 11 days , and in the other two patients

12 days and 18 days were required, respec­

tively.

In four of the six patients, the abscess

resolved completely without recurrence of any

pulmonary infection. In one patient who initial­

ly responded favorably after drainage (.vith an

8Fr polyethylene catheter with a "cobra head "

configuration) , the abscess recurred after an in-

a

b

c

Young Shin Kim , et al : Percutaneous Catheter Drainage of Lung Abscess

Fig. 1. Lung abscess associated with right pleural empyema in a 6-year-old girl who had staphylococal pneumoma a. Adrrússion chest radiograph shows a 10cm abscess 씨th an air- f1 uid in the right rrúddle lobe (arrow) and pleural effusion (smaller arrow). b. Follow-up chest radiograph 1 day after drainage shows a decrease in the size of the abscess and the drainage catheter (arrow) c. Chest radiograph obtained after 12 days of drain­age shows complete resolution of the abscess end empyema

advertent removal of the catheter 7 days after

the insertion. The patient refused the reinser­

tion of the catheter and drainage catheter sub­

sequently withdrew form the patient who left

the hospital 4 days Jater against medical advice.

1n the rest one patien t who was in comatous

state for six months due to traumatic brain con­

tusion and right putaminal hematoma, an

abscess with a thick wall, measuring 10cm in di­

ameter, was developed in the right upper lobe

Ultrasonograhy confirmed the thick wall of the

abscess at the time of drainage. The amount of

drained pus was scanty throughout the entire

drainage period revealing only a minimal de­

crease in size of the absess inspite of several at­

tempts of catheter repositioning. Therefore; the

catheter was removed 9 days after the inser­

tion. The failure of the drainage was thought to

be attributed to the thick abscess wall and re­

current aspiration pneumonia due to dimin­

ished cough reflex. The bacteriologic study

showed Proteus , Klebsiella and Peptostrepto­

coccus . The patient eventually succumbed to

respiratory failure 3 months later.

1n all patients chest radiographs were

checked after removal of the catheters: one pa­

tient had complete resolution of the abscess

(Fig. 1), three had small residual cavities with­

out any air-fluid level (Fig. 2) , one had

reaccumulation of f1uid after an inadvertent re­

moval of the catheter, and in the rest one pa­

tient, the residual cavities that were noted at

the time of catheter removal were completely

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Journal of Korean Radiological Society 1993; 29 (5) : 923~929

a b

c

resolved. In the second patient, a chest rad io­

graph taken 2 months later showed coJlapse of

the cavity to be col1apsed with focaJ fibrosis. In

the third patient, the residual cystic cavity re­

mained unchanged, however, a recurrent pneu­

monia was developed around the thin wal1ed

cystic residua 3 years later. This reinfection

might have been related to the underlying

chronic paranasal sinus disease

Before the drainage , al1 patients received

antibiotic therapy for 1 to 14 days. Cefazolin

and a combination of cefazolin and gentamicin

were common types of initial drug therapy.

These regimens were changed later according

to bacte rial susceptibiJity during drainage and

d

Fig. 2. Lung abscess in a 62-year-old womaen who had streptococcal pneumonia. a. admission chest radiograph shows a 8cm diameter, thick walled abscess in the right middle lobe (arrow). b. Chest radiograph after placement of a Malecot catheter within the abscess cavity shows the proper position of the catheter tip in the cavity (arrow) c. CT scan of chest sh。、vs the entJγ of the catheter into the cavity ‘vhich is in contact with the pleural surface (arrow) d. Upright chest radiograph obtained after removal of the catheter shows residual cavity

continued for average of 5 days after removal

of catheters. In two patient concurrent pleural

empyema (proved by pleurocentesis) resolved

after percutaneous drainage of the abscess (Fgi.

1). There were no complications related to the

proceudre.

The causative organismjorganisms on the

bacteriolo멍c studies of the abscess fluid wasj

were Staphylococcus (n = 1), Streptococcus (n =

1), Streptococcus and Citrobacter (n = 1),

Streptococcus, Staphylococcus and Veillone l1a

(n= 1), Proteus , Klebsiella, and Peptostrepto­

coccus (n = 1).

In one patient showed recurrent abscess , no

microorganism was isolated from aspirated pus.

Therefore appropriate antibiotics could not be

selected and this was considered to be the rea-

926

Young Shin Kim , et al : Percutaneous Catheter Drainage of Lung Abscess

son that the abscess recurred in spite of contin­

ued antibiotic therapy after inadvertent removal

of catheter.

DISCUSSION

The initial therapy of lung abscess has been

medical with the administration of appropriate

antimicrobial agents and supportive measures

with cure rates of 40 to 90 percent (6). It was

considered that medical therapy was often inef­

fective in the treatment of abscesses with a

thick wall or bronchial obstruction (7) . Thus ,

surgical intervention (lobectomy, wedged lung

resection , or external drainage through thora­

cotomy) is required to avoid the development

of bronchiectasis and pulmonary fibrosis . Sur­

gery is also indicated for patients with lung

abscess associated with empyema, broncho­

pleural fistula, or suspected malignancy (8).

The mortality rate of surgery for lung abscess

was low but the incidence of empyema after

pulmonary resection for abscess ranged from

10 to 28.8 percent (6 , 9).

Surgeη of the lung abscesses necessitates

sacrifice of lung volume and creates a resultant

contamination of the pleural space, which if not

obliterated, may develop and empyema. Percu­

taneous drainage of lung abscesses may avoid

some shortcomings. However, the major draw­

back is that a bronchial deforrnity persists after

drainage and the the patient will experience a

recurrence. Secondly, the tube or packing may

erode pulmonaη vessels and cause exsanguina­

ting hemorrhage.

A1though the procedure of the percutane­

ous drainage of lung abscess was not described

in the 1940 s, it was not used clinically. Recent­

ly, to overcome the long duration of medial

treatment and the risk of surgery, intervention­

al technique within the thorax was designed

and applied. The majority of reports describe

their use in the drainage of pleural effusion or

empyema in adults (1 이 . Several authors also

reported good results with mediastinal, chest

wall , and intraparenchymal abscess (1, 6 , 11).

A1though our series is small, our results indi­

cate that percutaneous aspiration and drainage

are safe and effective in managing patients with

lund abscess except chronic lung abscess with

thick fibrotic wall. The drainage technique that

was used in our patients is the smae as used for

drainage of intra-abdominal and mediastinal

abscesses.

The indications of the percutaneous drain­

age method include persistent unremitting sep­

sis and toxicity from and abscess over 4cm in

diameter while receving an antibiotics , lack of

adequate cough mechanism, radiologic e、rid­

neces of developing contralateral lung pneumo­

nia, and increasing size or fluid content of the

abscess (1 2, 13).

Computed tomography will provide infor­

mations about the site and the distance be­

tween the skin and the wall of the abscess con­

tacting the pleural surface. A1 though we did

not encounter any complication in this series , the pU l1cture should be made where the wall of

abscess was in contact with the pleural surface

to avoid spillage of pus into the pleural cavity

and the development of pneumothorax. Until

more experiences are gained , those abscesses

that are surrounded by the lung parenchyma

and fail to respond to a medical therapy should

be subjected to a surgical intervention.

We used 8 or 10Fr catheters for drainage

of the abscesses in our patients. A larger bore­

catheter may be necessaη for drainage of the

abscess with thick fluid. Replacement of the

drainage catheter with a larger bore-catheter

after the tract was matured is a safe and simple

procedure and dose not cause pneumothorax

and bleeding. Continuous negative pressure

suction with catheter irrigation should be used

to facilitate drainage and reduce spillage of

abscess fluid into the pleural cavity.

It is important to check the patient clinically

with the amount of drainage, catheter position,

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Journal of Korean Radi이ogical Society 1993; 29 (5) : 923~929

and the size of the abscess by chest radiogra­

phy. We recomrnend administration of appro­

priate antibiotics before , during, and after

drainage. The optimal duration of catheter

drainage for lung abscess has not determined.

The average duration of drainage in our four

cured patients was 15.5 days (range , 11-18

days) , which were much shorter period than

those of the cases included in the report of Ball

(1 이. We removed the catheter when the size of

abscess decreased significantly and there was no

evidence of drainage for at least 3days. It is

possible to monitor recurrence of the abscess

by withdraqing the catheter gradually over a

period of a few days or replacing the catheter

with a smaller end-hole catheter and clamping

it. 1t was demonstrated that the residual abscess

cavity might continue to resolve after removal

of the catheter after drainage. We also ob­

served that the drainage catheter might be re­

moved before the abscess cavity completely

resolved radiographically. There is a concern

that infection is related to the persistence of

the predisposing cause of the original lung

abscess as in our case (1 4). 1n addition, imrne­

diate reinfection in the area of thin walled

residue of the lung absess could be easily

controled with antimicrobial drugs obtained

from bacteriologic study.

1n sumrnaη， percutaneous drainage is a safe

and effective method for management of pa­

tients with s이itary large lung abscess unrespon­

sive to medical therapy. 1t can be carried out

with minimal stress and risk to the patient and

results in a dramatic clinical response and rapid

resolution of the abscess. Further study is

reguired to determine whether the percutane­

ous method can be safely used to treat the lung

abscess surrounded by the lung parenchyma.

Until then, the method described heretofore

should be reserved for treatment of patients

with lung abscess unresponsive to medical ther­

apy.

REFERENCES

1. VanSonnenberg EM, Muller pr, Ferrucci JT J r.

Percutaneous drainage of 250 abdominal abs­

cesses and fluid collection. 1. Results, failure , and complications. Radiology 1984; 151:267-

277

2. VanSonnengerg E, Nakamoto SK, Muller PR, Casola G, Neff CC, FPJ , Ferruci JT Jr, Simeone

JF. CT and Ultrasound-guide catheter drainage

of empyemas after chest tube failure. Radiology

1984; 151:349-353

3. Vainrub B, Musher D, Guinn GA, Young EJ , Septimus EJ, Travis LL. Percutaneous drainage

of lung abscess. Am Rev of Respir Dis 1978;

117:153- 159

4. Aronberg DJ , Sagel SS, Jost RG , Lee J 1. Percu­

taneous drainage of lung abscess. AJR 1979; 132:282-288

5. Gobien RP , Stanley JH , Gobien BS , Vl~ic 1, Pass

HF. Percutaneous catheter aspiration and drain­

age of suspected mediastinal abscesses. Radiolo­gy1984;151 ’ 69-71

6. Estrera AS , Platt MR, Mills LJ , Shaw RR. Pri

maη lung abscess. J Thorac Cardiovascular sur­

gerγ 1980; 79:275-282

7. Fisher WR, Husebye K, Chedister C, Miller M.

Primaη lung abscess. Arch Intern Med 1961; 107-100-112

8. Delarue NC, Pearson FG , Nelems JM , Cooper

JD. Lung abscess: Surgical implications. Can J

Surg 1980; 23:297-302

9. Shaw RR, Pauson D1. Pulmonary resection for

chronic abscess of the lung. J Thoracic Surg 1948; 17:514

10. Ball WS , Bisset III GS Jr, Towbin RB. Percuta­

neous drainage of chest abscesses in children Radiology 1989; 171 :431 -434

11. Neff C, Lowson DW ‘ Boerhaave syndrom: inter­

ventional radiologic management. AJR 1985; 145:819-820

12. Eric VS , Horacio BD, Giovanna C, et al. Lung

abscess: CT -guided drainage. Radiology 1991;

178:347-351

13. Ricε πN， Ginsberg l\J, Todd TRJ. Tube drain-

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Yo ung Shin Kim , et al : Percutaneous Catheter Drainage of Lung Abscess

age of lung abscesses . Ann Thorac Surg 1987;

44:356-359

c1assfication and analysis of 97 cases‘ ung

abscess. Am Rev of Respir Dis 1969; 99:390-

398 14. Perlman LV, Lerner E , D ’esopo N. Clinical

〈국문 요약〉

폐 농양의 경피적 도관 배액술

가톨릭대학 의학부 방사선과학교실

김영신·천경아·최효선·하현권·신경섭

저자들은 6예의 폐 농양 환자를 대상으로 경피적 홉인과 도관 배액술을 시행하였다. 각예에서 늑막표면과 접촉하

고 있는 폐농양 벽에서 천자하여 8-10Fr 도관을 삽입하였다. 6명중 5명이 배액 24시간 내에 현저한 임상적 호전을

보였다. 농양은 배액술후 4명에서 완전히 농양이 없어졌고 한명은 부분적인 크기의 감소를 보였고 나머지 한명에서

는 농양의 변화가 없었다. 성공한 배액술의 기간은 7- 18일 이었고 평균 15. 5일 이었다. 신경학적 장애를 가진 한명

의 환자에서 배액이 실패한 이유는 계속적인 홉-인 때문이었다. 배액술후 초기에는 농양이 호전되었으나 부주의로 도

관이 빠진후 농양이 다시 커진 환자가 일례 있었다. 두맹의 환자에서 폐농양과 공존하던 늑막농흉이 배액후 완전히

없어졌다. 천자 위치를 결정하고 정상폐에 천자하는 것을 피하기 위하여， 정확한 해부학적 구조를 아는데 전산화단

층촬영이 유용하였다. 경피적 도관 배액술을 폐농양을 치료하는데 안전하고 효과적인 방법이다.

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