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Surgical Management of Necrotizing Pneumonia

Karmy-Jones, Riyad MD*; Vallières, Eric MD*; Harrington, Robert MD

Colleagues In Respiratory Medicine
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Necrotizing pneumonia is a rare but highly lethal process that is characterized by patchy areas of necrosis. Surgery is indicated primarily for complications, specifically hemoptysis, empyema, lung abscess, or lung gangrene. This latter condition can be detected by chest computed tomography, which demonstrates progressive loss of perfusion or obstruction of the bronchus. These findings also predict failure of medical management. Surgical intervention can be difficult, however, because patients often require high degrees of ventilatory and circulatory support. We reviewed our experience with 15 patients who underwent surgical resection for lung gangrene. Streptococcus pneumoniae was the responsible organism in nine cases. Twelve patients presented with rapidly progressive respiratory failure or radiographic evidence of gangrene over a 3 to 5 day course. Of the four patients with diffuse bilateral disease at the time of surgery, one died and one remains ventilator dependent. Resections included cavitary debridement (three), large wedge resection (one), bisegementectomy (one), lobectomy (six), bilobectomy (one), and pneumonectomy (three). There were three deaths (20%). Postoperative empyema occurred in three of seven patients who did not have an irrigation system placed intraoperatively. Two patients remain chronically ventilator dependent. These results demonstrate that lung resection is feasable. Attempts must be made to deal with the risk of postoperative empyema and residual space, including the use of irrigation systems. In patients who cannot tolerate resection, lung debridement is an option. Ultimately, outcome is affected by the extent of underlying disease.

From the *Divisions of Cardiothoracic Surgery and †Infectious Diseases, University of Washington, Seattle, WA, USA.

Address correspondence to: Riyad Karmy-Jones, MD, Division of Thoracic Surgery, University of Washington Medical Center, BOX 356310, 1959 NE Pacific St, Seattle, WA 98195. Address e-mail to karmy@u.washington.edu

© 2003 Lippincott Williams & Wilkins, Inc.