CAZURI CLINICE CASE PRESENTATION ENDOBRONCHIAL ...

CAZURI CLINICE

CASE PRESENTATION

ENDOBRONCHIAL TREATMENT OF LUNG SUPPURATIONS WITH METRAS PROBE Pallai Vasile1, Pallai Ildiko Rita2 1

Pneumology Hospital, Satu Mare, 2Public Health Department, Satu Mare, Bureau of Health Promotion Correspondence Address/Adresa de corespondenţă: Pallai Vasile, MD, PUD TB Hospital, Satu Mare, III Department, Bixad, 497, Principala St email: [email protected] Received: 10.08.2010 Accepted: 15.11.2010 Med Con December 2010 Vol 5, No 4, Abstract By presenting two clinical cases, I wish to remind this method of treatment that may significantly improve the treatment outcomes. The base of the method is the introduction of antibiotics and antiinflammatory medication in bronchial drainage or at least near them, with the help of Metras radiopaque probe. In the treatment with Metras probe after probe placement and verification, the patient with probe lies down properly, and only then the medicine will be entered. The patient remains in that position so medicine also remains exactly where it was applied. We can say that, in some cases, endobronchial treatment may be applied in therapy of pulmonar suppuration. Keywords:

pulmonary

suppuration,

Metras

probe,

X-ray

examination,

bronchoscopy,

antibiotherapy This paper does not aim a reviewing of the knowledge on the causes, methods of developing and complex treatment of lung abscesses and necrotizing pneumonia. By presenting of two clinical cases, I wish to recall this method of treatment that seems to be forgotten, although in some cases – of course combined with general antibiotic therapy -can greatly improve treatment outcomes. In the treaties of Internal Medicine published in 1956, 1968 is still recalled; in the treaty of internal diseases occurred in 1995 under the editorship of Professor Gherasim, no longer appears. At the courses of specialization of the young colleagues the metod has not been taught anymore. In cities near Satu Mare, Zalau, Baia Mare, this method is not practiced, at the TB Clinic in Cluj, the local treatment of lung abscesses and necrotizing pneumonia is by fibrobrohoscopie (FBS), once a week. In what follows, I try to recap my experience over the years by presenting two cases last treated. The summary of the method is the introduction of antibiotics and anti-inflammatory drug in bronchial drainage or at least near them, with Metras probe - after local anesthesia with 1% xilin solution. Metras radiopaque probe is inserted into the airways and guided by a wire under bent (Fig.1). After checking the site of the probe by radioscopy, the patient is lying in a proper position, so the place

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of suppuration to be under the tip of probe. We introduce the selected drugs, then we remove the probe. The patient must remain at least 30 minutes in this position. Perhaps the question is: by applying this method, we do not irradiate the patient too much? We must know that the radioscopies are done as soon as possible (sometimes just 4-5 seconds), and the disadvantage represented by irradiation is incomparably lower than the benefit, meaning the possibility of treatment, cure the sick, by avoiding surgery. Although local treatment can also be achieved through the bronchoscope, is not as effective because the bronchoscopy is done in seating poition and the patient is positioned properly in decubitus just after the introduction of the drug. Thus, changing the position, only part of the product will remain exactly where you want. In contrast, treatment with Metras probe, after probe placement and verification, the patient with probe is placed properly in the lie down position, and only then is introduced the product. So the patient remains in this position, and the medicine remains exactly where it was applied.

Fig.1. Metras probe and the wire used for introduction In both cases that will be presented, this procedure was repeated three times a week, a total of 10 sessions. Chloramphenicol was used earlier, because penicillin can cause allergic reactions and Streptomycin blocks the movement of the cilia of the bronchial mucosa cells. In practice it was found that Ciprofloxacin gives good results in suppurations in general administration, it can be administered intravenously, which is why I assumed that the endobronchial administration will not create problems. Currently we use 1% Ciprofloxacin 6-7 ml associated with Haemisuccinat Hydrocortisone 25 mg. For applicability of this method, certain conditions must be met:

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- the physician to have dexterity - the patient to be patient, to cooperate, to open the mouth, vocal cords to be clearly visible in the laryngeal mirror, - by fibrobronchoscopy we need to verify that bronchial drainage are permeable. Disinfection of wire is done by flaming, and of probe in a disinfecting solution (as well as FBS). The end of probes is straight or have bends of different shapes, that can be fixed at the hole of upper lobar bronchia. In both cases presented, the discharge was located in the left lower lobe, which is why we used a probe with stright end, which I cut obliquely, to ease its introduction. I inserted in the probe 1-2 drops of paraffin oil, and when I pulled it on the wire, I applied also on her outside, to make it slip better. Case no. 1 Male of 51 years old, living in rural area, was admitted to our hospital between 8 November and 15 December 2009. In history: in 2000 left pleural effusion; left coxarthrosis prosthetic in 2003. Current illness began in late September 2009, suddenly, with fever, chills, cough with fetid mucopurulent sputum. For two weeks he was treated at the internal diseases department of the Carei Municipal Hospital. The condition has not improved, which is why he was transferred to the department of thoracic surgery at The Pulmonary Disease Hospital of Baia Mare. There he received targeted antibiotics, systemic and on aerosols. The pleural puncture attempt failed (later to us too). The general condition was much improved, became without fever, sputum quantity in 24 hours was reduced to 10-15 ml and was not fetid. He was transferred to us for further treatment. At the admission he was feverish, eliminated unfetide purulent sputum, he accused effort dyspnea, numbness and pain in the legs, appetite was back. He was anemic (haematocrite 23.7%), creatinine and urea were slightly higher than normal. The chest radiography at admission: right hilum enlarged, infiltrative confluent opacities, left supradiafragmatic: left posterior encysted fluid 4 fingers wide (Fig.2).

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Fig.2. Case no 1. Radiological appearance before and after treatment FBS: On the right: moderate congestion of the mucosa, free holes. In the left: primitive bronchia is deformed, it drains the abundant purulent discharge. Mucosa is heavily congested, bleed to the touch, which hampers further visibility. The holes appear to be free. Were administered: Moxifloxacin, Metronidazole, Gentamicin, Ciprofloxacin, associated with antiinflammatories, vitamins, hepatoprotective, anti-anemic. The improvement was not satisfactory, so we started endobronchial treatment with Ciprofloxacin and Hydrocortisone haemisuccinat, at the last meeting, the tenth, we have introduced the drugs by FBS. At the end of treatment, the mucosa was much less congested, free holes, and the secretion reduced pusfilled. Radiological: both infiltrative opacity and fluid opacity were reduced, anemia has improved, the patient was discharged. At the radiological control conducted in January 18, 2010 it was observed only issue of fibrosis at left basal, left lateral and basal pahipleuritis with symphysis of rib and diaphragm sinus. It had no subjective complaints. Case no. 2 Male 59 years old, living in rural areas, retired. He was admitted to our hospital between May 30 and July 21, 2010. The disease started about two weeks before admission, with fever, chills, cough, for which he received treatment from family physician. The condition has not improved, so that he was presented to the emergency room and he was sent for admission in our hospital.

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On admission he presented: modified general condition, low grade fever, purulent sputum, fatigue, poor nutritional status. Stetacustic were heard crackles rales on left basal. He stopped smoking for a month, occasionally consumed alcohol. Radiography pulmonary: annular image about 6x6 cm, with thick walls parahilar left rear, with infiltrative opacities around (Fig.3). After 10 days of treatment with penicillin, gentamicin, metronidazole infusion associated with vitamins, hepatoprotective, expectorants, the control radiography showed an slight increase of ring image.

Fig.3. Case no 2. Radiological appearance before and after treatment In order to confirm or rule out neoplastic etiology, in 17 June 2010 was performed fibrobronchoscopy: we found diffuse congestion of the lining of the bilaterally bronchial tree, with cloudy mucus secretion. The bronchial orifice of left Fowler segment was circular narrowed by infiltrated mucosa, and it was taken an inside sample. The remaining holes were free. Cytological examination of bronchial aspirate were negative for tumor cells. On 28 June 2010 the first meeting of Metras probe treatment was held, continuing with sessions three times a week with Ciprofloxacin and Hydrocortisone Haemisuccinat. There have been a total of 10 treatment sessions. Associated systemic medication consisted of: Ciprofloxacin, Cefaclor, Trimethoprim + Sulfometoxazol, Metronidazole. Radiographs performed during treatment showed continues radiographic improvement, in parallel with clinical improvement. Last radiography (performed on 16.7.2010, before discharge) showed a band-shaped opacity 18 mm wide of the left side of the heart, with a 5x20 mm excavated inside, and left infrahilar trabecular fibrosis. The patient was discharged with good general condition, without subjective complaints. It was proposed to continue outpatient treatment with ciprofloxacin.

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He returned to radiographic inspection in 17 August 2010. Radiography showed a fibrosis in band, 5-8 mm wide with a 5 mm excavated residual and left infrahilar trabecular fibrosis. He feels good, he gain weight, no longer require treatment. In conclusion we can say that in some cases, endobronchial treatment can be usefully applied in the therapy of lung suppuration. Referencies (Referinţe) 1. Gherasim, L: Tratat de Medicină Internă, Ed. Medicală, Bucureşti, 1995, vol. I, pp. 100-103 2. Magyar, I, Petrányi, G: A belgyógyászat alapvonalai. Ed. Művelt Nép, Budapesta, 1956, vol. II, pp. 701-704 3. Magyar, P, Hutás, I, Vastag, E: Pulmonológia. Ed. Medicina, Budapesta, 1998, pp. 303-304, 308-310 4. Moga, A, Teodorescu, P, Viorel, G: Manual de Medicină Internă, Ed. Medicală, Bucureşti, 1968, vol. II, pp. 91-99