Bronchoscopic washing in the treatment of lung abcess

INTRODUCTION
Lung abscess can be caused by numerous pathogenic and conditionally pathogenic bacteria. Th e most common causative agents are Staphylococcus aureus, Diplococcus
pneumoniae, Streptococcus pneumoniae, Escherichia coli, Pseudomonas aeruginosa, while anaerobes are rarely isolated. Th e infection is caused by inhalation of the causative agent and its spread from surrounding or distant purulent foci via blood or lymph. Th e diagnosis is made on the basis of history, clinical examination, lung x-ray, as well as bronchoscopy examination. Laboratory analyzes show leukocytosis with granulocytosis, accelerated sedimentation, an increase in nonspecific inflammatory markers, and often secondary anemia. Of particular importance is the cytological finding in the sputum. Causative agents are detected by direct bacilloscopic and culture. Treatment of lung abscess in clinical practice is a complex procedure due to the existence of multiple causative agents and is carried out by simultaneous administration of two antibiotics in maximum doses according to the sputum antibiogram. Postural
drainage, application of bronchodilators, secretolytics and expectorants can be useful for successful treatment, and endoscopic lavage should always be performed except in
severe cases where there are absolute contraindications for bronchoscopy. The tactics of treating a lung abscess directly depends on the severity of the disease, but it is always carried out in hospital conditions. Most patients are successfully cured within 6 to 8 weeks. An untreated abscess aft er 8 weeks is considered chronic and should undergo surgical treatment.
CASE REPORT
Case 1. GI, 40-year-old man, non-smoker, no comorbidities, negative personal and family history. Hospitalized at the Pulmonology Department in October 2023 due to an abscess of the left upper lobe (in the projection of the lingula). Th e symptoms
appeared 3 weeks previously: febrile up to 39C, mainly continuous type in the afternoon and evening, with occasional shivering, chills, night sweats, slight loss of
appetite, productive cough with copious expectoration of thick dark green discharge with a putrid odor that was very foul smelling (smell “rotten”). Antibiotic therapy
(cefixime 400 1x1) was administered for ten days without effect. A large, cavernous change (diameter of 10 cm) was seen on the chest X-ray in the projection of the lingula
with a level and pronounced peri cavernous infiltrate in connection with the heart and the shadow of the lateral thoracic wall. Laboratory analyzes showed an increase in nonspecific inflammatory markers (CRP over 200, ref value up to 5), increased SeErc 84 for the first hour, leukocytosis of 13.5/mm3 with a predominance of neutrophils of 95% and a slight increase in D-dimer (1090, ref <500). Bacteriological confirmation was not obtained from the broncho aspirate (cultures remained negative aft er 48 hours of incubation). CT of the chest showed a large abscess formation and consolidation in the lingula with an air bronchogram and reactively enlarged mediastinal lymph glands. Bronchoscopy showed regular passage to the subsegments, hyperemia of the
mucous membrane of the left bronchial tree with abundant whitish secretion coming from the basal segmental mouths. Aft er aspiration, lavage was performed with 500 ml of physiological solution 0.9% NaCl. The procedure was repeated 14 times during the 20-day hospitalization, the control chest X-ray at discharge showed resolution with a decrease in the thickness of the walls and peri cavernous infiltrates. X-ray (PA and lateral projection) before the start of therapy During the patient’s hospitalization, 14
bronchoscopies were performed with lavage of 500 to 750 ml of physiological solution 0.9% NaCl and aspiration of the contents (bronchoscopy lavage was performed once every 24 hours. Radiographs showed a reduction of the abscess cavity, so that in a period of 14 days a reduction by more than half (from 4 to about 1.5 cm) was observed. Th e patient’s condition improved significantly, the patient was afebrile for the entire time of hospitalization, his appetite returned to normal. Aft er discharge, the medical treatment was extended for the next three months with clindamycin at a dose of 600 mg/24 hours. The radiological picture showed complete normalization aft er three months. X-ray (PA and lateral projection) aft er three months from the beginning of therapy Case 2. SP, a 70-year-old man, without comorbidities, smokes 5 cigarettes a day, does not consume alcohol. Hospitalized due to cough with expectoration of
thick secretions with green purulent and bloody admixtures, high febrility with onset of fever. Symptoms appeared two weeks before admission. Th e antibiotic treatment
did not have a particular effect, which is why hospitalization is indicated. On the radiograph of the chest on the right at the level of the hilus, a round formation with a level and a suspicious view of the drainage bronchus was seen. Chest CT showed a cavitation lesion of approximate size 8.5x7.6 cm with air-liquid level and cellular
detritus. Reactively enlarged hilar and paratracheal lymph glands were also monitored. Laboratory analyzes showed an increase in non-specific inflammatory markers (CRP
184, ref value up to 5), an increased SeErc 106 for the first hour, a leukocytosis of 21.5/mm3 with a predominance of neutophils of 90% and an increase in D-dimer (3080,
ref <500). During hospitalization, dual antibiotic treatment (broad-spectrum and anti-anaerobic) with excessive supportive therapy was applied. Clinical improvement was achieved, and slow resolution was observed radiologically. Bronchoscopy showed normal patency to the subsegments. Bronchoscopy lavage was performed 8 times (no pathogens were isolated from the aspirate; bacteriological examination did not show an increase in cultures aft er incubation). Due to the persistence of radiological changes, a broncho biopsy and a transbronchial biopsy were performed on two occasions (the histopathological analysis of the samples did not detect malignancy, a specific process or other finding that would fi t into a certain clinical entity). Th e overall finding was consistent with a lung abscess, and repeated lavages helped speed up restitution. Clinical and laboratory improvement was monitored, and changes in the direction of adhesions were monitored X-ray. Aft er discharge, the patient was treated for 3 months with oral clindamycin and a temporary oral steroid regimen in decreasing doses. Th e
patient was monitored for one year aft er the end of the therapy. No occurrence of fever or any suspicion of recurrence was observed.
CONCLUSION
Cases with a lung abscess caused by a complication of pneumonia, in which no bacteriological confirmation was obtained, are presented. Treatment was empiric with
dual antibiotics. Bronchoscopy lavage and aspiration of secretions was performed daily within a reasonable range of tolerance. We obtained radiographic regression in
the expected time period, thereby confirming the impact and importance of repeated bronchoscopy lavages. By aggressive application of saline solution through the opening
of the bronchus of the anatomically affected segment and lobe, a direct washing of the mucous content and detritus was performed, which facilitated the tissue regeneration
of the affected part of the lung and achieved ad integrum restitution in the optimal time with reduced residue formation. With the ones shown, we got almost complete
radiological resolution. Th e patients tolerated the intervention and the entire treatment well. Repeated endoscopic lavages with physiological solution had a positive effect and significantly helped conservative treatment.
KEYWORDS
Lung abscess, bronchoscopy, bronchoscopic lavage, aspiration