Content area
Full Text
In Brief
A 69-year-old diabetic man developed a lung abscess that was refractory to standard antibiotic therapy. Surgical resection was not feasible because of severe lung function impairment. An unconventional bronchoscopic technique was successfully used for management.
Case Vignette
A 69-year-old male cigarette smoker with severe chronic obstructive pulmonary disease and uncontrolled diabetes mellitus presented after 3 weeks of productive cough, dyspnea, generalized weakness, and night sweats.
Physical examination was notable for tachycardia, tachypnea, normal blood pressure, and borderline oxygen saturation as measured by pulse oximetry while he breathed supplemental oxygen. Breath sounds were diminished over the right upper lung field.
The white blood cell count was elevated (13.9 3 103/mm3). A chest radiograph showed right upper lobe consolidation with a central cavity, ill-defined right perihilar density, and a clear left lung (Figure 1A). Computed tomographic (CT) imaging of the chest showed a large multiloculated cavitary lesion containing air-fluid levels replacing most or all of the right upper lobe. There was an associated mass effect on the trachea and mediastinum (Figures 2A and 2B). The patient was given intravenous antibiotics and admitted to the hospital for further management.
A sputum culture grew Pseudomonas aeruginosa. Given the size of the abscess, the mass effect on the mediastinum, and a lack of clinical response after several days of antibiotics, the pulmonary medicine and thoracic surgery consultants concurred that a procedure was indicated to drain the abscess. Because the patient was deemed high-risk for surgical intervention, we opted for bronchoscopy.
Flexible bronchoscopy was performed under general anesthesia through an 8.5 French endotracheal tube. Airway examination revealed mild extrinsic compression of the right tracheal wall. Purulent secretions were present in the trachea and right upper lobe bronchus.
A guide-sheath catheter (SG-201C; Olympus America Inc., Center Valley, PA) was passed under fluoroscopic guidance into the posterior segment of the right upper lobe (RB2) at the most dependent part of the abscess and suction was applied. A small quantity of thick, purulent secretions was drained slowly against considerable resistance. Suction was stopped temporarily. Using...