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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 67  |  Issue : 1  |  Page : 38-45

The role of ultrasound-guided nephrostomy catheter drainage in the management of peripheral pyogenic lung abscess


1 Zagazig Chest Hospital, Zagazig University, Zagazig, Egypt
2 Department of Chest, Faculty of Medicine, Zagazig University, Zagazig, Egypt
3 Department of Neurology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission07-Aug-2017
Date of Acceptance18-Sep-2017
Date of Web Publication21-Mar-2018

Correspondence Address:
Alaa Eldin M Elgazzar
Assistant Professor of Chest Disease and Tuberculosis, Faculty of Medicine, Zagazig University, 1 Abdullah Elnagdy , Street, Aleshara, Zagazig, Alsharkia, 11525
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejcdt.ejcdt_17_17

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  Abstract 

Introduction Mortality from lung abscesses continue to be substantial, even with surgical therapy, ranging from 15 to 20%. Image-guided percutaneous transthoracic drainage (PTD) improved lung abscess management and avoid complications of prolonged conservative treatment.
Aim The aim of the study was to assess the outcome of nephrostomy catheter ultrasound (US)-guided PTD on lung abscess treatment in comparison to postural drainage in addition to medical treatment.
Patients and methods A total of 30 patients with peripheral lung abscess were randomly assigned into two groups, the interventional group where US-guided percutaneous nephrostomy catheter was inserted in addition to medical treatment and the control group where postural drainage was done in addition to medical treatment. The following was done for all patients: thorough medical examination, neurological examination, routine laboratory investigations, radiological investigations (chest radiography, chest computed tomography, chest US), sputum culture and sensitivity.
Results The study included 30 patients with lung abscess 18 men, and 12 women with a mean age of 44.6±9.5 years, (P>0.05). Regarding the outcome, success was higher among patients treated with catheter drainage 13/15 (86.6%) versus 8/15 (53.3%) patients in the control group (P<0.001), failure rate was less in the interventional group two (13.3%) versus seven (46.7%) patients in the control group (P<0.001); the treatment duration in the interventional group was significantly shorter 14.4±2.8 versus 26.9±3.8 days in the control group (P<0.001). Both groups were comparable regarding age, sex, abscess size, smoking, comorbidities and the distance between the abscess and chest wall. There were no reported major complications in the interventional group.
Conclusion US-guided PTD using nephrostomy catheter for peripheral lung abscess is safe and effective; it can improve the outcome, shorten the duration and reduce the need for surgery in lung abscess treatment with less complications.

Keywords: lung abscess, nephrostomy catheter, percutaneous drainage


How to cite this article:
Gaballah AA, Elgazzar AM, Elshahat HM, Yusuf AI, Takwa H. The role of ultrasound-guided nephrostomy catheter drainage in the management of peripheral pyogenic lung abscess. Egypt J Chest Dis Tuberc 2018;67:38-45

How to cite this URL:
Gaballah AA, Elgazzar AM, Elshahat HM, Yusuf AI, Takwa H. The role of ultrasound-guided nephrostomy catheter drainage in the management of peripheral pyogenic lung abscess. Egypt J Chest Dis Tuberc [serial online] 2018 [cited 2018 Aug 16];67:38-45. Available from: http://www.ejcdt.eg.net/text.asp?2018/67/1/38/228130


  Introduction Top


Lung abscess-related mortality is still significant in spite of development of advanced antibiotics; it ranges from 15 to 20%. Medical treatment with antibiotics alone, even with the advancement of antibiotics in the last decades is still inadequate as a treatment for lung abscess [1].

Surgical pulmonary resection is advised when medical treatment and physiotherapy fail. However, mortality from lung abscesses continue to be significant, even with surgical treatment. Currently, percutaneous transthoracic drainage (PTD) is available for patients with lung abscess, the PTD as a line of management of lung abscess remains controversial [2].

Recently, image-guided PTD of lung abscesses resulted in reduced morbidity and mortality and reduced the length of hospital stay and cost. Lung abscess may be drained or guided by fluoroscopy, ultrasonography (US) or computed tomography (CT) [3],[4]. We hypothesized that PTD may improve the outcome of lung abscess management and may reduce the duration of lung abscess treatment.

The aim of this study was to assess the outcome of US-guided PTD of large peripheral pyogenic lung abscess by nephrostomy catheter in comparison to postural drainage.


  Patients and methods Top
[5]

A prospective randomised, controlled clinical trial was carried out at the Chest Department of Zagazig University Hospitals and Zagazig Chest Hospital in the period from December 2012 to December 2013. The study protocol was approved by Zagazig University Institutional Review Board (IRB), all patients signed an informed consent.

Inclusion criteria

The patients were enrolled to the study when they fulfill clinical and radiological diagnosis of peripheral large pyogenic lung abscess [5]:
  1. Symptoms suggestive of lung abscess which include cough, production of excessive purulent sputum and fever higher than 38.5°C.
  2. Lung abscess size greater than 4–8 cm in transverse diameter, peripherally located, with a distance between lung abscess and chest wall being less than or equal to 2 cm as assessed by CT chest.
  3. Patients who are fit for interventional treatment of lung abscess.
  4. Patients with adequate cough and gag reflex.


Exclusion criteria

  1. Bleeding disorders.
  2. Haemodynamically unstable patients (blood pressure of <90/60).
  3. Patients with skin lesions and diffuse cutaneous infiltration with malignancy.
  4. Inability of the patient to cooperate with, or to be positioned for, the procedure [6].
  5. Patients with past history of neurological disease either as a cause of lung abscess or disease affecting the cough reflex integrity.


Thirty patients with peripheral large pyogenic lung abscess who fulfilled the criteria were assigned systematically into two groups:
  1. Interventional group: it included 15 patients subjected to US-guided nephrostomy catheter drainage [3] (Percutaneous Nephrostomy Set, M.O.H Registration No. 99/2010/2, 14 F/25 cm; Access Pigtail Design Dawi Medical Co. Ltd, Assiut, Egypt) in addition to unified empirical medical treatment regimen [7] which is modified by the culture results later on.
  2. Control group: it included 15 patients treated with postural drainage [8] in addition to a unified empirical medical treatment regimen [7] which is modified by the culture results later on.


The following was done for all patients:
  1. Thorough medical history and examination for signs and symptoms suggestive of diagnosis of pyogenic lung abscess [5]:
    1. Fever higher than 38.5°C.
    2. Cough with production of excessive purulent sputum or less frequently with blood.
    3. Shortness of breath, chest pain, lethargy, and other features of chronic illness.
    4. Evidence of gingival disease.
  2. Neurological assessment: patients were examined by a qualified neurologist for exclusion of active or hidden neurologic disease and assessment of muscle power and the integrity of cough reflex in all patients.
  3. Full laboratory investigations, which include:
    1. Hematological evaluation: complete blood count, erythrocyte sedimentation rate for diagnosis and follow-up of response to treatment applied.
    2. Bleeding profile: including bleeding time, clotting time, partial thromboplastin time for assessment bleeding tendency.
    3. Kidney functions tests. Liver function tests, including serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, and serum albumin.
  4. Sputum culture and Gram stain was done to determine the causative organisms and sensitivity to define suitable antibiotics.
  5. Radiological examination, which include:
    1. Plain chest radiography (CXR) (posterioanterior and lateral views): which was done initially for the diagnosis of lung abscess according to the Moreira et al. [9] criteria and for follow-up thereafter.
    2. Chest contrast-enhanced CT: it was done for all patients to determine the size of lung abscess and the distance between the chest wall and the abscess and to exclude other aetiologies.
    3. Chest US: which was done initially for diagnosis and for visualization of the site and size of abscess and for guidance of nephrostomy catheter insertion.


Technique

First the CXR was reviewed as a guide for US. We used the direct approach to examine the chest with US. The direct approach utilizes the intercostal spaces. Curved array transducers with frequencies of 5.0–7.5 MHz were used [10].

Lung abscess in US appear as an echogenic, irregularly thickened wall cavity that may be filled with fluid, inflammatory or necrotic debris, or air, or as a rounded hypoechoic lesion with an outer margin. To differentiate between lung abscess and empyema; during inspiration the entire circumference of the abscess cavity expands, whereas with empyema only the lung-bordered portion of the loculated fluid collection moves with respiration [10]. After proper localization of the abscess by US proper site nephrostomy catheter was inserted for drainage.

Nephrostomy catheter insertion technique

Drainage catheter insertion was performed under local anesthesia with complete aseptic condition. We used the Seldinger technique, access is gained using a 20–22 G needle, and localization is confirmed by US and then aspiration of purulent contents was performed. Subsequently, a 0.018-inch wire is advanced into the cavity; a coaxial dilator is used for transition from 0.018–0.035-inch wire. Serial fascial dilatation is performed to accommodate the size of the drainage catheter (at least one French size larger than the catheter), and a locking-loop nephrostomy catheter with a metal or plastic stiffener is advanced over the wire into the collection. The stiffener and wire are removed and the catheter was connected to an underwater seal; CXR was repeated to confirm proper localization of the catheter [11].

Management of the catheter

The catheter is secured to the skin with a suture, sterilely dressed, and daily monitored for assessment of the function drainage amount, complications and to detect accidental withdrawal up to the point of catheter removal [11]. Normal catheter function is indicated by a gradual tapering of fluid output on a daily basis, if the output has precipitously diminished or ceased over a 24 h period, the catheter was flushed with minimal (3–5 ml) saline to ensure patency. Cessation of output may necessitate further imaging, followed by catheter flushing, exchanging, or upsizing if a fluid collection remains [12]. Radiological follow-up was done every 3 days for assessment of response to treatment and for detection of complications.

Timing of catheter removal: the catheter was removed when the following criteria were fulfilled [2],[4]:
  1. Remarkable reduction in abscess size with no more than 20 ml of daily drain output for 3 days.
  2. Absence of clinical signs of abscess even before the abscess cavity is completely resolved.


Endpoint of the study

  1. For control group: until fever and putrid sputum have resolved and complete radiological resolution or stabilization to a small residual lesion [13], after that oral antibiotics was ensued.
  2. For interventional group: until fever and putrid sputum have resolved and complete radiological resolution or stabilization to a small residual lesion, no more than 20 ml of daily drain output for 3 days, that is absence of clinical signs of abscess even before the abscess cavity is completely resolved [3],[4].


Outcome of the catheter drainage were classified into [3],[4]
  1. Success which was defined as complete closure of the abscess cavity with clinical improvement.
  2. Failure was defined as failure of closure of the abscess cavity without clinical improvement and with need for more surgical procedures.


Those who failed in both groups were referred to the Cardiothoracic Surgery Department for further surgical treatment.

Statistical analysis of data collected

All data were collected (including demographic data, radiological characteristics, duration of medical treatment, reduction of cavity size, duration of tube drainage), and was tabulated and reformed for statistical analysis using statistical package for social sciences Epi-Info version 6 and SPSS for Windows version 11.0 (SPSS, Chicago, IL, USA). According to the type of data, the following tests were used to test differences for significance. Differences between frequencies (qualitative variables) in groups were compared by χ2-test. Differences between mean (quantitative variables) in two groups were compared by Student’s t-test. The P value was set at less than 0.05 for significant results, less than 0.01 for highly significant values and less than 0.001 was very highly significant.


  Results Top


The study included 30 patients with lung abscess: 18 men and 12 women with an age range of 27–75 years (mean: 44.6±9.5 years), with no significant difference between both groups regarding the age, sex, and incidence of comorbidities (P>0.05).

Thirteen patients succeeded to reach the clinical endpoint of the study, whereas two patients failed within the nephrostomy catheter group; in the control group eight patients succeeded to reach the clinical endpoint of the study.

The transverse diameter of lung abscess ranged from 4.5 to 7.4 cm for all patients (mean: 5.8±1.2 cm); the mean diameter for the interventional group was 5.4±1.5 cm and for the control group was 6.2±1.7 cm without significant difference between both groups (P>0.05). The distance between the chest wall and the lung abscess ranged from 0.5 to 1 cm for all patients (mean: 0.8±0.2 cm), whereas the mean distance for the interventional group was 0.8±0.2 cm and for the control group was 0.7±0.3 cm) without significant difference between both groups (P>0.05) ([Table 1]).
Table 1 Demographic, radiological, and comorbidities in both groups of the study

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Regarding the anatomical localization of lung abscess, 24 (80%) patients had right-sided lung abscess, most of those were in the lower lobe 14 (58.3%), eight in the middle lobe, two in the upper lobe. While six (20%) patients had left-sided lung abscess, five of them were in the left lower lobe; but there was no significant difference as regards the site of lung abscess in both the groups (P>0.05) ([Table 2]).
Table 2 Anatomical locations of lung abscess in both the groups

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Regarding the outcome, success was significantly higher among patients treated with catheter drainage, 13/15 (86.6%) patients in comparison to 8/15 (53.3%) patients in the control group. Failure rate was less in the interventional group (13.3%) whereas seven (46.7%) patients were reported in the control group (P<0.001). The average duration of catheter drainage of lung abscess was 8–15 days with a mean of 11.7±3.3 days. The duration of treatment in the interventional group was shorter with a range of 11–21 days and a mean of 14.4±2.8 days in comparison to 20–35 days, mean 26.9±3.8 days in the control group with high significance (P<0.001) ([Table 3]).
Table 3 Outcome and duration of treatment in both the groups

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When comparing success and failure patients within the catheter group, those who failed were of older age (70±7.07 vs. 48.7±7.4 years, P<0.05), abscess size was larger (7.2±0.035 vs. 5.1±1.29 cm, P<0.05) and the duration of treatment was longer (23±5.23 vs. 14.5±4.8 days, P<0.05), without significant difference regarding the distance between lung abscess and chest wall, sex, smoking habit and comorbidities ([Table 4]). A similar comparison done between success and failure patients within the control group showed no significant difference except that failure patients were of older age (44.1 vs. 39.1 years, P=0.01); data not shown.
Table 4 Comparison between success and failure patients within the catheter group

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Regarding the complications reported in the catheter group, local dermatitis occurred in two patients, surgical emphysema in three patients and wound infection in one patient ([Figure 1],[Figure 2],[Figure 3]).
Figure 1 Chest radiography before catheter insertion.

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Figure 2 Chest radiography, catheter inside the abscess cavity.

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Figure 3 Chest radiography after removal of the catheter.

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  Discussion Top


The available evidence regarding the efficacy of PTD is of level 5, that is uncontrolled case series, emphasizing the need for randomized trials to further confirm the role of PTD in the management of lung abscess [2]. The design selected for the current study was a comparative, randomized, controlled clinical trial for better evidence-based assessment of PTD in the treatment of pyogenic lung abscess. The aim of this study was to assess the outcome of US-guided PTD of large peripheral pyogenic lung abscess by nephrostomy catheter in comparison to postural drainage.

Mortality rates from lung abscesses continue to be substantial, even with surgical therapy, ranging from 15 to 20% [14]. Considering the advantages of image-guided PTD and the failure of medical treatment which raise the need for pulmonary resection, we hypothesized that PTD may improve the outcome of lung abscess management and may reduce the duration of lung abscess treatment.

Wali et al. [2] have reviewed many studies that reported timing for PTD. It is not known for how long PTD should be delayed. A 10–14 days period of conservative medical therapy without clinical improvement has been suggested to be a suitable delay in some studies; successful drainage was performed in patients with giant abscesses within 24 h from the time of presentation with no complications, death or recurrence. Accordingly in the present study, we decided to use nephrostomy catheter for draining lung abscess early at the start of management, in addition to antibiotics, and not after failure of medical treatment aiming to reduce the need for surgical treatment.

In this study, PTD was done using US as the method of guidance for catheter drainage of lung abscess. Advantages of US over other methods of image guidance are discussed in this work. US is relatively inexpensive, does not entail exposure to radiation, does not restrict image direction and can be performed at the bedside in critically ill patients.

There is a wide variation in the ideal size of the percutaneous tube. However, it is well established that a small tube (10–14 French) can adequately and effectively drain pus [15]. The nephrostomy catheter is easy to track, has good kink resistance, durable enough to use for more than 2 weeks and has a locking-pigtail keeping it in its place. Its low cost makes it ideal for short-term drainage procedures in cooperative patients [16]. This is why the nephrostomy catheter with a small size (14 F) was utilized in the current study. In the current study, catheter removal was considered when there is remarkable reduction in abscess size with no more than 20 ml of daily drain output for 3 days with absence of clinical signs of abscess even before the abscess cavity is completely resolved [4].

This study was carried out on 30 patients with peripheral lung abscess more than 4 cm in transverse diameter. They were 18 men and 12 women with an age range of 27–75 years, mean of 44.6±9.5 years. They were randomly assigned into two groups: interventional group (15 patients) where nephrostomy catheter drainage was inserted early at the start of management in addition to medical treatment and control group (15 patients) maintained on medical treatment and postural drainage; all patients were matched regarding age, sex, smoking, size of the abscess, and the distance between the abscess and chest wall (P>0.05) ([Table 1]). Matching of patient case studies as regards the age and all other clinical and radiological parameters allowed for better comparison and fair evaluation of the performed interventional maneuver.

The treatment outcome in the present study revealed a high significant success rate in the interventional group (86.8%) in comparison to a success rate of 53.3% (P<0.001) in the control group ([Table 3]), with a drainage duration range of 8–15 days (mean: 11.7±3.3 days). A similar success rate (83.3%) was achieved by Kelogrigoris et al. [4] with a 4-week period for complete closure of the abscess. Van Sonnenberg et al. [15] reported a 100% success rate for pigtail drainage of lung abscess, where the average duration of drainage was 9.8 days. On the other hand, the current study success rate was higher than the following studies. Ha et al. [17] reported abscess resolution in 4/6 (66.7%) patients treated with small-size catheters with a mean drainage duration of 15.5 days. This result may be due to the fact that some cases were pyogenic lung abscess and others cases were tuberculous.

The duration of medical treatment and postural drainage (control group) in this study (26.9±3.8 days) was longer than those treated with the nephrostomy catheter (14.4±2.8 days) (P<0.001) ([Table 3]). The short duration reported with the nephrostomy catheter insertion could be explained by the fact that drainage with nephrostomy catheter hastens the resolution of abscess cavity and the surrounding consolidation and inflammation, in other words it lessens the impact of inflammation on the general condition of the patient and toxic manifestations which are usually associated with the presence of trapped pus anywhere. Moreover, drainage of abscess offered by the nephrostomy catheter reduces the tension inside the abscess cavity and help in rapid resolution of the cavity which is reflected on the total duration of medical treatment with antimicrobials.

The mean age in the present study was 44.6±9.5 years which was in agreement with the observation of a case series from an urban center where they reported a mean age of 41 years for lung abscess patients [9]. Also Hsu et al. [1] reported a mean age of 54.69±17.91 years for lung abscess patients which is nearly similar to the present study. However, Kelogrigoris et al. [4] reported a mean age of 61 years for lung abscess patients, which is older to the mean age of the present study patient. Such difference may be attributed to the increased incidence of periodontal disease and the increased prevalence of dysphagia and aspiration which are predisposed to developing lung abscesses in elderly patients [18].

There was no significant male predominance (60%) versus (40%) female in the present study which was comparable to other studies, Hsu et al. [1] reported a male predominance of 80% versus 20% among his studied lung abscess cases. Kelogrigoris et al. [4] reported male predominance of 75% versus 25% female in their study [4].

Smokers in the current study were reported to be 66.7 versus 33.3% of nonsmokers. Smoking contributes for lung abscess by inducing poor oral hygiene and thus increases the amount of bacteria in the mouth. It suppresses the innate and adaptive immune response and reduces the activity of alveolar macrophages, dendritic cells, and natural killer cells which predispose to infection [19].

The maximum transverse diameter of lung abscess in the study (4.5–7 cm, [Table 1]) was comparable in both the studied groups; it being one of the selection criteria in addition to the random assignment of patients into the study groups, assisted in better evaluation of both treatment duration and outcome in the studied groups. Also anatomical location of lung abscess in the current work by plain CXR has shown that 24 cases out of total 30 (80%) had right-sided lung abscesses and 14 (58.3%) of them were in the lower lobe ([Table 2]). This finding can be attributed to the aspiration etiology in most of these cases.

Although Mwandumba and Beeching [14] had concluded that the coexisting medical condition might influence the mortality and outcome in the patients contracting lung abscess and might have worse outcome, the current study reported a nonsignificant difference between success and failed patients in both study groups, among the 13 who had achieved the clinical endpoint in the interventional group 11 (84.6%) were diabetic, whereas in the control group among the eight who achieved the clinical endpoint four (50%) were diabetic and six (85.7%) of the seven patients who failed were diabetics.Regarding the complications resulting from nephrostomy catheter in the interventional group, they were six out of 15 patients (40%). The reported complications were surgical emphysema (three cases), dermatitis (two cases), and wound infection (one case); no other major complications were reported.

Also, the complications reported in the present study were less severe than that reported in the study by Van Sonnenberg [15] which was done in 19 unresponsive patients treated with CT-guided pigtail catheter. They reported the complications as haemothorax, clogging of catheter, and transient elevation of intracerebral pressure. Yunus [6] in his study on 19 patients with lung abscess who were selected for CT-guided pigtail catheter drainage found that three patients out of them (15.78%) had mild pneumothorax, which resolved and needed no further management, whereas two (10.52%) patients developed moderate pneumothorax. These two patients were those who had deeply placed abscesses and normal lung tissue who had to be traversed to acquire access to the abscess cavity.

Failure of catheter drainage was reported in two patients. They were old (mean: 65 years), smokers, with an abscess of 7 cm in diameter, diabetic and hypertensive and with increased duration of treatment (20 days). Kamangar [18] stated that host factors associated with a poor prognosis include advanced age, large abscess size, debilitation, malnutrition, human immunodeficiency virus infection or other forms of immunosuppression, malignancy, and duration of symptoms for more than 8 weeks. There were no reported mortality in the present study. In conclusion, US-guided PTD using nephrostomy catheter for peripheral large pyogenic lung abscess is safe and effective with a high success rate. It can improve the outcome, shorten the duration and reduce the need for surgery in lung abscess treatment with less complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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