Surgical therapy for necrotizing pneumonia and lung gangrene

Necrotizing Pneumonia Secondary to Pulmonary Blastomycosis: A Case Report

Necrotizing pneumonia is a rare but potentially life-threatening complication of pulmonary blastomycosis, a fungal infection caused by inhaling spores of the fungus Blastomyces dermatitidis. This case report describes a 56-year-old male who presented with worsening malaise, subjective fevers and chills, night sweats, and a productive cough. Further evaluation revealed a right upper lobe necrotizing pneumonia secondary to pulmonary blastomycosis.

Percutaneous transthoracic catheter drainage for lung abscess: a systematic review and meta-analysis

OBJECTIVES

To evaluate the outcomes of patients receiving image-guided percutaneous catheter drainage (PCD) for lung abscesses in terms of treatment success, major complications, and mortality as well as the predictors of those outcomes.

METHODS

Embase and OVID-MEDLINE databases were searched to identify studies on lung abscesses treated with PCD that had extractable outcomes. The outcomes were pooled using a random-intercept logistic regression model. Multivariate Firth's bias-reduced penalised-likelihood logistic regression analyses were performed to identify predictors of treatment success and complications. Methodological quality was assessed by summing scores of binary responses to items regarding selection, ascertainment of exposure and outcome, causality of follow-up duration, and reporting.

RESULTS

From 26 studies with acceptable methodological quality (median score, 4; range, 3-5), 194 patients were included. The pooled rates of treatment success and major complications were 86.5% (95% confidence interval [CI], 78.5-91.8%; I² = 23%) and 8.1% (95% CI, 4.1-15.3%; I² = 26%), respectively. Four patients eventually died from uncontrolled lung abscesses (pooled rate, 1.5%; 95% CI, 0.2-11.1%; I² = 36%). Malignancy-related abscess (odds ratio [OR], 0.129; 95% CI, 0.024-0.724; p = .022) and the occurrence of a major complication (OR, 0.065; 95% CI, 0.02-0.193; p < .001) were significant predictors of treatment failure. Traversing normal lung parenchyma was the only significant risk factor for major complications (OR, 27.69; 95% CI, 7.196-123.603; p < .001).

CONCLUSION

PCD under imaging guidance was effective for lung abscess treatment, with a low complication rate. Traversal of normal lung parenchyma was the sole risk factor for complications, and malignancy-related abscesses and the occurrence of major complications were predictors of treatment failure.

KEY POINTS

• The pooled treatment success rate of PCD for lung abscess was reasonably high (86.5%); malignancy-related abscesses and the occurrence of a major complication were predictors of treatment failure. • The pooled rate of percutaneous transthoracic catheter drainage-related major complications was 8.1% and traversing normal lung parenchyma by the catheter was the only risk factor. • The pooled mortality rate from uncontrolled lung abscesses with percutaneous transthoracic catheter drainage was low.

Spontaneous Pneumothorax After Rupture of the Cavity as the Initial Presentation of Tuberculosis in the Emergency Department

Patient: Male, 65-year-old

Final Diagnosis: Tuberculosis

Symptoms: Cough accompanied by greenish expectoration • chest pain • asthenia • weight loss

Medication: —

Clinical Procedure: Thoracic drainage tube and bronchoscopy

Specialty: Critical Care Medicine

Post-resection complications: abscesses, empyemas, bronchopleural fistulas

The role of thoracic surgeons in the management of pulmonary infection has evolved over time as the medical treatments have improved. We herein review historical and current management for surgically-treated pulmonary infections-lung abscesses, empyemas, and bronchopleural fistulas. In particular, we review when the surgeons need to be involved for infectious cases, our algorithm/approach to empyemas, and summary of post-operative bronchopleural fistula in tuberculosis cases.

Tuberculosis: mother of thoracic surgery then and now, past and prospectives: a review

Knowledge on ontogenesis of thoracic surgery is essential not only for understanding present concepts and debates on surgery for tuberculosis, but it also contributes to the further developments in operative treatment of lung cancer. Both diseases have been the leading cause of death in their respective ages. History of tuberculosis follows the classic algorithm: diagnostic, casuistic and therapeutical stages. Villemin followed by Virchow, and, finally, Koch revealed the pathoanatomy and the cause of tuberculosis. The therapeutic phase of lung cancer has been reached without identified cause of the disease. Chest surgery, eradication of the macroscopic focus by physical interference with the involved tissue mass, in both diseases preceded medical treatment. Identification of phenotypes of lung cancer-if it is a single disease at all-does not contravene the concept: the tumor mass should been eliminated. However, causation is not an absolute sine qua non of an effective treatment, as the tuberculosis-lung cancer analogy also proves. Surgical approach of both diseases suffered from the same paraoxon: eradication without direct interference with the causative factor. While lung cancer seems to be controlled by an emerging array of new drugs, tuberculosis poses a new challenge, as multidrug resistant and extensively drug resistant Koch bacteria are emerging and fragile societies' immunity is weakening. Thoracic surgery has a significant share in the fight against tuberculosis, when drugs and/or society fail. Palliative and radical adjuvant surgery multiplies the chance of cure in those cases, where not much hope is left. The jury is still out in a series of questions, but it is obvious, that surgery is only an option and not a panacea where medicines and their providers fail. Deeper understanding of our past and present failures with tuberculosis and its surgery might contribute to new concepts in coping with lung cancer as well.

Necrotising pneumonia caused by non-PVL Staphylococcus aureus with 2-year follow-up

Necrotising pneumonia (NP) is a rare but life-threatening complication of pulmonary infection. It is characterised by progressive necrosis of lung parenchyma with cavitating foci evident upon radiological investigation. This article reports the case of a 52-year-old woman, immunocompetent healthcare professional presenting to Accident and Emergency with NP and Staphylococcus aureus septicaemia. The cavitating lesion was not identified on initial chest X-ray leading to a delay in antimicrobial optimisation. However, the patient went on to achieve a full symptomatic recovery in 1 month and complete radiological recovery at 2-year follow-up. Long-term prognosis for adult cases of NP currently remains undocumented. This case serves as the first piece of published evidence documenting full physiological and radiological recovery following appropriate treatment of NP in an immunocompetent adult patient.

Demystifying the persistent pneumothorax: role of imaging

Evaluation for pneumothorax is an important indication for obtaining chest radiographs in patients who have had trauma, recent cardiothoracic surgery or are on ventilator support. By definition, a persistent pneumothorax constitutes ongoing bubbling of air from an in situ chest drain, 48 h after its insertion. Persistent pneumothorax remains a diagnostic dilemma and identification of potentially treatable aetiologies is important. These may be chest tube related (kinks or malposition), lung parenchymal disease, bronchopleural fistula, or rarely, oesophageal-pleural fistula. Although radiographs remain the mainstay for diagnosis and follow up of pneumothorax, computed tomography (CT) is increasingly being used for problem solving. Aetiology of persistent air leak determines the optimal treatment. For some, a simple repositioning of the chest tube/drain may suffice; others may require surgery. In this pictorial review, we will briefly describe the physiology of pneumothorax, discuss imaging features of identifiable causes for persistent pneumothorax and provide a brief overview of treatment options. Specific aetiology of a persistent air leak may often not be immediately discernible, and will need to be carefully sought. Accurate interpretation of imaging studies can expedite diagnosis and facilitate prompt treatment.

Key points

• Persistent pneumothorax is defined as a leak persisting for more than 2 days.

• Radiographs can identify chest-tube-related causes of pneumothorax.

• CT is the most useful test to identify other causes.

• Penetrating thoracic injury can cause fistulous communication resulting in a persistent pneumothorax.

• Discontinuity of visceral pleura identified by CT may indicate a bronchopleural fistula.

Extracorporeal membrane oxygenation and toilet bronchoscopy as a bridge to pneumonectomy in severe community-acquired methicillin-resistant Staphylococcus aureus pneumonia

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) pneumonia is associated with very high mortality. Though surgical evacuation of necrotic tissue is desirable in patients unresponsive to antimicrobial therapy, most patients are acutely ill precluding surgical intervention. We utilized a combination of extracorporeal membrane oxygenation (ECMO) with frequent toilet bronchoscopies to salvage an unaffected right lung from spillage of necrotic pus from left lung cavitary CA-MRSA pneumonia in a 22-year-old patient. Our patient while on ECMO and after decannulation was positioned with the right lung up at all times with 1-2 toilet bronchoscopies every day for almost 30 days. This time was utilized for ventilator weaning and optimizing the nutritional status prior to extrapleural left pneumonectomy. Prevention of soilage of the unaffected right lung and mitigating volutrauma with ECMO support combined with the subsequent surgical evacuation of necrotic left lung tissue led to a favorable outcome in this case. This strategy could be of value in similar presentations of unilateral suppurative pneumonia, where the progressive disease occurs despite optimal medical therapy.

Awake video-assisted thoracic surgery in acute infectious pulmonary destruction

BACKGROUND

Many of thoracic minimally invasive interventions have been proven to be possible without general anesthesia. This article presents results of video-assisted thoracic surgery (VATS) application under local anesthesia in patients with lung abscesses and discusses its indications in detail.

METHODS

The study involved prospective analysis of treatment outcomes for all acute infectious pulmonary destruction (AIPD) patients undergoing VATS under local anesthesia and sedation since January 1, 2010, till December 31, 2013. Patients with pulmonary destruction cavity at periphery of large size (>5 cm) underwent non-intubated video abscessoscopy (NIVAS). Patients with pyopneumothorax (lung abscess penetration into pleural cavity) underwent non-intubated video thoracoscopy (NIVTS). Indications for NIVAS and NIVTS were as follows: cavity debridement and washing, necrotic sequestra removal, adhesion split, biopsy. All interventions were done under local anesthesia and sedation without trachea intubation and epidural anesthesia.

RESULTS

Sixty-five enrolled patients had 42 NIVAS and 32 NIVTS interventions, nine patients underwent two surgeries. None of the patients required trachea intubation or epidural anesthesia. In none of our cases with conversion to thoracotomy was required. Post-surgical complications developed after 11 interventions (13%): subcutaneous emphysema (five cases), chest wall phlegmon (three cases), pulmonary bleeding (two cases), and pneumothorax (one case). One patient died due to the main disease progression. In 50 patients NIVAS and NIVTS were done within 5 to 8 days after abscess/pleural cavity draining, while in other 15 patients-immediately prior to draining; both pulmonary bleeding episodes and all cases of chest wall phlegmon took place in the latter group.

CONCLUSIONS

NIVAS and NIVTS under local anesthesia and sedation are well tolerated by patients, safe and should be used more often in AIPD cases. Timing of NIVAS and NIVTS procedures was found to be of paramount importance for ensuring complete therapeutic effectiveness.

Management of necrotizing pneumonia and pulmonary gangrene: a case series and review of the literature

BACKGROUND

Necrotizing pneumonia is an uncommon but severe complication of bacterial pneumonia, associated with high morbidity and mortality. The availability of current data regarding the management of necrotizing pneumonia is limited to case reports and small retrospective observational cohort studies. Consequently, appropriate management for these patients remains unclear.

OBJECTIVE

To describe five cases and review the available literature to help guide management of necrotizing pneumonia.

METHODS

Cases involving five adults with respiratory failure due to necrotizing pneumonia admitted to a tertiary care centre and infected with Streptococcus pneumoniae (n=3), Klebsiella pneumoniae (n=1) and methicillin-resistant Staphylococcus aureus (n=1) were reviewed. All available literature was reviewed and encompassed case reports and retrospective reviews dating from 1975 to the present.

RESULTS

All five patients received aggressive medical management and consultation by thoracic surgery. Three patients underwent surgical procedures to debride necrotic lung parenchyma. Two of the five patients died in hospital.

CONCLUSIONS

Necrotizing pneumonia often leads to pulmonary gangrene. Computed tomography of the thorax with contrast is recommended to evaluate the pulmonary vascular supply. Further study is necessary to determine whether surgical intervention, in the absence of pulmonary gangrene, results in better outcomes.