- FNAB can change treatment plan in cases of non-responsive pulmonary infections
- Determination of fungal or bacterial DNA/RNA in the sample obtained by percutaneous FNAB can be helpful in immunocompromised patients
Fig. 1 Fig. 2
Nodular lung infections
- In some cases,
pulmonary infections can manifest as solitary or multiple nodules
- Percutaneous image-guided biopsy can be helpful in these cases
- It is indicated to perform more than one sample to increase the accuracy of the procedure
Pyogenic pulmonary abscess
- In the modern medical era is a less frequent entity and most cases are successfully treated with antibiotics.
- When resistant to conservative treatment surgical resection was the primary election.
- Percutaneous transthoracic tube drainage became the treatment of choice in cases of conservative treatment failure.
- Success rate above 83.9%.
- Complication rate 16,1 %
- Mortality rate: 4%.
Less than with surgical treatment.
- Previously rule out central endobronchial obstructive tumour (bronchoscopy should be performed)
- Size itself: greater than 4 cm,
- Ineffective antibiotic therapy (after 10-14 days),
- No delay in debilitated patients with poorly effective cough (e.g.
in intensive care setting) – mechanical ventilation is not a contraindication
- It is important to distinguish between lung abscess and necrotizing pneumonia,
as the drainage of a pneumonia could lead to a bronchopleural fistula
- US or CT guidance with Seldinger technique
- Puncture of normal lung should be avoided if possible
- Tube size: 6-12 F (optimal: 8F)
- After catheter placement and fluid evacuation,
irrigation with normal saline until fluid clearance and periodic irrigation with saline (5-15 ml) should be performed daily
- The effectiveness of intracavitary fibrinolytic agents in context of pulmonary abscess has not been confirmed yet.
- Single percutaneous aspiration and cultures of abscess content can be diagnostic and informative.
Fig. 4 , Fig. 5
- Reduction in abscess size with cessation of purulent drainage for at least 3 days
- Absence of clinical signs of sepsis
Complications and their management:
- Clogging of the catheter – catheter exchange
- Pneumothorax – chest tube insertion
- Haemoptysis / haemothorax – embolization
- Bronchopleural fistula – bronchoscopy / surgery after resolution of the infection (avoid the drainage of necrotizing pneumonia or rapidly increasing air component)
- During the post-chemotherapeutic aplastic period of hematologic malignancies
- After bone marrow or solid organ transplants
- Cultures results are often negative or late
- BAL (bronchoalveolar lavage) sensitivity to detect aspergillosis is 50%
The role is to:
- confirm fungal infection
- differentiate between Aspergillus spp.
- rule out other aetiology (tuberculosis,
Prior to biopsy a high resolution CT should be performed in order to
- detect findings of probable fungal infection
- locate target lesion for percutaneous biopsy
- guide fibroscopy and transbronchial biopsy in case of central lesions
- detect GGO consolidations – higher sensitivity of BAL
Fungal infections – Biopsy
- Prolonged febrile neutropenia with negative BAL and cultures
- No response to antifungal therapy
Sensitivity of FNAB or lung biopsy: 70,6% with 100% PPV.
- Biopsy needle of 18 G if possible to obtain sufficient material
- Obtain at least 3 samples (culture,
specific histological study of fungal infection and general HE stain)
– fresh sample in dry tube for culture
– fixed in 10% formaldehyde for histological and immunhistochemical study
- Fixed in AFA for HES stain to rule out lesion of other aetiology.
Complications of FNAB of fungal infections
- Pneumothorax: 17-60%,
0,5-5 % require thoracic drain insertion: ↑number of passes through the pleural cavity
- Bleeding: 5,3 – 30 %,
to minimize risk:
– correct INR if exceeds 1,5 (0,8-1,2)
– correct platelet level with transfusion below 50 000/microl
– suspend acetylsalicylic acid and clopidogrel 5 days before intervention if possible
– stop LMWH 24h before intervention
Fig. 2 , Fig. 7
- Pleural infections are increasing despite of modern medical therapy
- Increased morbidity and mortality associated with pulmonary infections
- Sampling of parapneumonic effusion with thickness greater than 10 mm (20 mm) is recommended
- Chest X-Ray may miss 10 % of effusions with recommendation of sampling
- Fluid pH can vary in cases of loculated effusions
Pleural space anatomy
Pleural fluid bacteriology
Pleural fluid chemistry
free-flowing effusion (<10 mm on lateral decubitus)
Bx: culture Gram stain results unknown
Cx: pH unknown
A1:Small to moderate free-flowing effusion (>10 mm and < one-half hemithorax)
B0: negative culture and Gram stain
C0: pH ≥ 7.20
free-flowing effusion (≥ one-half hemithorax),
or effusion with thickened parietal pleura
B1: positive culture and Gram stain
C1: pH < 7.20
- If possible,
initial thoracentesis should be therapeutic as well.•Always image guided drainage: CT or US? •US guidance permits comparison with initial findings and evaluate prognosis according to US appearance:
- Anechoic: success rate (92,3 %),
- Complex non-septated: (80-81,54%),
Probably exudative stage
- Complex septated: (50,6- 62,5%) fibrinopurulent (fibrinous adhesions and septae)
- organizational stages (fibrin clots,
multiple septations with thick pleural peel): higher ICU admission rate and increased mortality rate
- Drainage is recommended before worsening of US findings.
Small bore tube (6-14 F) or Large ( >20 F)?
- Small tubes (SBCT) are as effective as large ones with the exception of acute haemothorax (or complex empyema)
- Less complication rate with SBCT
- Insert multiple tubes in loculated pleural effusion
- Always with image guidance to avoid malposition (preferably US)
- Point of insertion should be anterior to the anterior superior iliac spine line
- LBCT in the fifth intercostal space mid axillary line with tube thoracostomy
- SBCT typically in second intercostal space along the anterior axillary line,
especially in pneumothorax
- Place tube in dependent position for fluid drainage
Intrapleural fibrinolytic agents:
- The aim is to improve the drainage of loculated pleural effusions based on observational studies.
- Not recommended for all patients,
needs to be studied in larger series.
- Various options: Urokinase,
t-PA (tissue plasminogen activator),
- Recent trial shows effectivity of the use of intrapleural t-PA in combination with DNase (x3 daily) but not alone:
- improves drainage with reduction of hospital stay and minor surgical rate.
- Specially indicated in suspected pleural tuberculosis
- Definite diagnosis of pleural tuberculosis depends on the demonstration of Mycobacterium tuberculosis in the sputum,
or pleural biopsy specimens.
- Image-guided pleural needle biopsy can be used as the primary method of diagnosis in patients with pleural thickening.
- Head and neck descendent infections,
and post-operative abscess (gastro-oesophageal anastomotic leaks,
- High rate of morbidity and mortality (20-40%),
risk of re-operation
- Few cases published,
no clear guidelines for heterogeneous patient group and aetiology
- CT guided drainage can be vital in cases of abscess formation to avoid re-operation due to its high mortality
- Patient positioning and route planning prior to intervention is essential.
If there is no pathway without passing through pulmonary parenchyma,
artificial hydrothorax or pneumothorax can be useful.
tandem trocar technique,
fluoroscopically- guided tube drainage of the abscess
Fig. 14 , Fig. 15 , Fig. 16 Fig. 19
- Only with image guidance (pericardiocentesis or tube pericardiostomy)
- Purulent effusion
Approach according to the distribution of pericardial effusion:
- Left lateral
- Arrhythmias: need for patient monitoring and catheter removal
- Pneumothorax / pneumomediastinum
- Atrial and ventricular wall puncture ∗
- Epicardial laceration∗
- Coronary artery injury∗
∗minimize risk with continuous image guidance
Fig. 17 , Fig. 18