lung abscess literally means a collection of pus within a destroyed portion of the lung .
therefore , the basic treatment of lung abscess consists of drainage and antibiotic therapy , which are the cornerstones of appropriate nonoperative management , with surgery reserved for special circumstances .
bronchoscopy has proved a most valuable adjunct in the diagnosis and treatment of pulmonary cavitary disease . in 1936 ,
goldman , and a few years later jackson and judd reiterated the value of bronchoscopy in the treatment of lung abscess .
they , using a rigid bronchoscope , showed that bronchoscopic measures were considered to play an indispensible role in diagnosis and to constitute an integral part of both the nonsurgical and surgical treatment of pulmonary abscess .
allen and blackman , in a collective review of 1086 cases of medically treated abscesses , found some 650 cases treated primarily by repeated bronchoscopic aspirations with a cure rate of 61% .
metras and chapin reported a 72.5% success rate with frequent bronchoscopic drainage and direct antibiotic instillation into the abscess cavity .
the methods of bronchoscopic drainage in lung abscess have been either simple conventional aspiration through a connecting bronchus or the recently introduced transbronchial catheter drainage via a rigid bronchoscope .
there have been debates on the usefulness and potential hazard of performing fiberoptic bronchoscopy in lung abscess , but the application of fiberoptic bronchoscopy is widened by virtue of improved skill and instrumentation .
we have recently adopted a technique which involves the introduction of a flexible polyethylene catheter through a fiberoptic bronchoscope into the bronchus of the involved bronchial segment .
the aim of this article is to review the technique , to evaluate the therapeutic efficacy in clinical practice and to determine its safety .
among 39 patients in whom fiberoptic bronchoscopy was performed from march 1986 through october 1988 , with cavitary pulmonary lesions on roentgenograms and a discharge diagnosis of lung abscess at seoul national university hospital , 11 patients were analyzed in this article .
those abscesses occurring in potential spaces of the pleural cavity , such as blebs or bullae , and in congenitally sequestered lung were excluded .
similary , cavitary carcinoma ( lung carcinoma with central necrosis ) and lung abscess occurring distal to an obstructing endobronchial tumor or foreign body were also excluded . on admission to the hospital , all patients had chest roentgenograms ( posteroanterior and lateral ) and cultures of expectorated sputum for bacteria , fungi and acid - fast bacilli were performed .
after cultures , various antimicrobial combination therapies with penicillin , clindamycin , aminoglycoside or cephalosporin were empirically started with postural drainage and chest physiotherapy according to the location of lung abscess by chest roentgenograms .
subsequently , the selection of antibiotics was optimally changed on the basis of the identification of the offending organism and its in vitro antibiotic susceptibility patterns .
the body temperature and other clinical manifestations were checked daily and chest roentgenograms were followed at 24 or 48 hour intervals . among 39 patients , we tried transbronchial catheterization in 11 patients with intractable lung abscess .
intractable lung abscess was arbitrarily defined as a cavitary lesion with poor clinical and radiological response in spite of aggressive attempts at postural drainage , chest physiotherpy and adequate antibiotic therapy for a week or more .
the remaining 28 patients underwent bronchoscopy after clinical and radiological improvements for the purpose of ruling out malignancy or associated tuberculosis . following local anesthesia by spraying the nasal mucosa and oropharynx with 4% lidocaine , transnasal insertion of a two - channeled olympus bf-2t10 bronchoscope
was introduced into each subsegment of the involved segment which was determined by radiological localization before the procedure , two patients needed biplane fluoroscopy for the confirmation of correct catheter position , but 8 did not . then , aspiration by a 30cc syringe attached to the external opening of the catheter was done .
if aspiration was inadequate , we tried the catheterization repeatedly up to three or four times with to and fro movements .
the aspirated material was sent to the laboratories for cultures of bacterial and acid - fast bacilli , and for cytology .
after the bronchoscopy , chest roentgenograms were checked within 12 hours and the patients were carefully observed as to whether hemoptysis or respiratory failure occurred as a complication of the bronchoscopic procedure .
the antimicrobial therapy was continued until radiographic changes were cleared or there was only a small stable lesion .
the cavity sizes of these patients were more than 8 cm in diameter while those of the others were less than 6 cm .
the air - fluid levels in the former were higher than two - thirds of the cavity .
age and the location of abscess were not related to the efficacy of this procedure .
as shown in table 2 , prolonged antibiotic therapy after the catheter drainage was necessary even in the successful group , suggesting that antibiotic therapy without drainage is ineffective in lung abscess . in regard to complications , minute hemoptysis occurred in 5 patients and stopped spontaneously within 48 hours .
hemoptysis was not related to the amount of aspirated pus but might have been due to irritation of the abscess wall by the catheter tip . aside from the therapeutic results ,
1 was chocolate - colored and he was diagnosed as having lung abscess secondary to the rupture of amebic liver abscess which had not been suspected .
although significant improvements in the curability rate have been achieved with the introduction of penicillin and other antibiotics , lung abscess still constitutes a serious illness with a significant morbidity and mortality rate , and therapeutic effects are lost unless the cavity is adequately evacuated .
the percutaneous needle drainage of lung abscess is now rarely used because it carries a risk of contaminating the pleural space , resulting in empyema .
however , it is probably indicated in an elderly debilitated patient who is unresponsive to the usual medical measures and is too acutely ill to withstand any other procedure .
accurate localization of the involved bronchial segment can be made , thereby assuring good postural drainage . in patients with hemoptysis
in addition , underlying obstructing lesions , such as tumors or foreign bodies , can be ruled out .
the advantage afforded by precise identification of the infectious agent followed by initiation of proper systemic antibiotic therapy makes bronchoscopy a vital component of the treatment regimen .
but , if drainage is not adequate with these maneuvers , the patient should be bronchoscoped .
both the fiberoptic and rigid bronchoscope are effective in the treatment of lung abscess . however , in spite of widespread use , there has been no well described report of successful drainage through a flexible fiberoptic bronchoscope in the patients with lung abscess
. the reason may be that the bronchoscopic procedure in lung abscess has been considered to be relatively contraindicated due to the risk of endobronchial dissemination of evacuated pus or life - threatening hemoptysis .
stated that patients with a very large abscess and those with hemoptysis ideaslly should be bronchoscoped with the rigid instrument because this assured satisfactory evacuation of a large amount of expectorated infected material and blood .
but , when compared with the flexible fiberoptic bronchoscope , the rigid bronchoscope has a number of significant disavantages including discomfort to the patient when performed under local anesthesia , increased cost and risk when a general anesthetic is employed , limited range of vision , and unusability in patients being mechanically ventilated or when disease or trauma involves the skull , jaw or cervical spine .
connors , groff , and their associates have utilized coronary angiocatheters threaded through the rigid bronchoscope into the involved bronchial segments under topical or general anesthesia . they suggested that it was particularly useful in occasional patients with edematous and deformed bronchial orifices which are difficult , or even impossible , to enter with suction apparatus .
connors had tried this technique with the use of a fiberoptic bronchoscope in pulmonary abscess , but he said it was disappointing .
not all of our trials were successful , but without great difficulty we could introduce the instrument through a fiberoptic bronchoscope into an appropriate site within the bronchus to provide satisfactory drainage .
except in 2 cases , we did not use fluoroscopy or portable chest roentgenograms routinely for confirmation of the correct catheter position .
however , both precise localization by chest roentgenograms prior to the bronchoscopy and the return of a large amount of purulent material on aspiration usually indicated that the catheter was correctly positioned .
our overall results show that transbronchial catheter drainage through a fiberoptic bronchoscope in lung abscess can be applied to cases of a ) persisting fever and significant toxicity without response to combined postural drainage and appropriate antibiotic therapy after at least 1 week , and b ) the very large and toxic lung abscess with a high air - fluid level in the cavity .
 the use of the fiberoptic bronchoscope as a drainage procedure for lung abscess has become more and more widespread . 
 we have recently adopted the technique of inserting a simple polyethylene catheter through the flexible fiberoptic bronchoscope into the abscess cavity of 11 patients with lung absess . 
 all cases had not responded to aggressive postural drainage and adequate antibiotic therapy for at least a week . 
 the results were as follows : 
 among 11 patients , the therapeutic response was dramatic in 6 patients.in the successful group , the abscess sizes were greater than 8 cm in diameter and the air - fluid levels were higher than two - thirds of the cavity.additional diagnoses , other than bacterial lung abscess , could be made in 2 cases when otherwise the diagnosis would have remained in doubt.the authors suggest that catheter drainage via fiberoptic bronchoscpope is an effective treatment modality in the large lung abscess with a high air - fluid level which is intractable to other medical approaches , and it is also a safe procedure . 
INTRODUCTION
PATIENTS AND METHODS
RESULTS
DISCUSSION