Late Complications of Collapse Therapy for Pulmonary Tuberculosis*

Late Complications of Collapse Therapy
for Pulmonary Tuberculosis*
Dov Weissberg, MD, FCCP; and Dorit Weissberg, MD
Study objectives: Collapse therapy for pulmonary tuberculosis involved placement of various
materials to occupy space and keep the lung collapsed. Complications are encountered decades
later.
Patients and methods: Between 1980 and 1997, we treated 31 patients with a history of pulmonary
tuberculosis in whom collapse therapy had been used and who later developed complications
related to their treatment. Pyogenic empyema was present in 24 patients, pleural calcifications
with bronchopleural fistula was present in 3 patients, pleural calcification with nonresolvable
pneumothorax was present in 1 patient, and migration of a foreign body with formation of
subcutaneous mass occurred in 3 patients. All patients with empyema were treated with
antibiotics and tube drainage of pus. In addition, Lucite balls were extracted in 4 patients, lung
decortication was performed in 6 patients, thoracoplasty was performed in 2 patients, and
fenestration was performed in 16 patients. Bronchopleural fistulas were closed with sutures and
reinforced with intercostal muscle flap in three patients; in one patient with pleural calcification
and nonresolvable pneumothorax, tube drainage was attempted. In three patients with subcutaneous mass due to paraffin migration, paraffin was extracted.
Results: Pulmonary decortication (six patients) and thoracoplasty (two patients) resulted in
elimination of empyema. Extraction of Lucite balls resulted in lung expansion and elimination of
empyema in three of four patients; draining sinus remains in one patient. Fenestration resulted
in elimination of empyema in 12 of 16 patients, with 3 patients with residual draining sinuses and
1 patient with remaining empyema. All bronchopleural fistulas closed with intercostal muscle flap
remained closed. Following extraction of paraffin blocks, infection developed in one patient.
During the follow-up period, three patients died, all of unrelated causes.
Conclusions: Delayed complications of collapse therapy for tuberculosis should be treated
without delay. Pressure on adjacent structures or their erosion presents danger and mandates
immediate extraction; however, there is no need for routine removal of every residual plombe.
Further increase in the number of multiple-drug resistant strains may force the return of collapse
therapy.
(CHEST 2001; 120:847– 851)
Key words: collapse therapy; complications of collapse therapy; tuberculosis
therapy was used widely in the treatment
C ofollapse
pulmonary tuberculosis in the 1930s, 1040s,
and 1950s. It involved therapeutic pneumothorax
with multiple refills and extrapleural placement of
these materials and refills of pneumothorax, sometimes under less than sterile conditions, led to
complications.1 During the past 18 years, we treated
31 such patients.
For editorial comment see page 696
Materials and Methods
various materials intended to occupy space and
prevent expansion of the lung, thus keeping the
tuberculous cavity collapsed. With time, presence of
*From the Department of Thoracic Surgery, Tel Aviv University
Sackler School of Medicine, Tel Aviv, and E. Wolfson Medical
Center, Holon, Israel.
Manuscript received October 16, 2000; revision accepted March
5, 2001.
Correspondence to: Dov Weissberg, MD, FCCP, Department of
Thoracic Surgery, E. Wolfson Medical Center, Holon 58100,
Israel; e-mail: [email protected]
Between 1980 and 1997, we admitted 31 patients with a history
of pulmonary tuberculosis. These patients had been treated in
the 1930s through 1950s with a range of invasive methods, such
as artificial pneumothorax and various forms of plombage. Although no effective chemotherapy was available at that time, the
disease was arrested in all patients. However, the invasive
therapeutic procedures and the materials used for plombage
resulted in a variety of complications. There were 21 men and 10
women, ranging in age from 48 to 73 years (mean age, 57 years).
The preceding therapeutic procedure was artificial pneumothorax in 22 patients, extrapleural oleothorax in 2 patients (Fig 1),
Lucite ball plombage in 4 patients (Fig 2), and paraffin wax
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Figure 1. Oleothorax in a 61-year-old woman treated for
tuberculosis at the age of 18 years. During the 43-year interval,
the oil shifted down from its initial position over the apex of the
lung. Top: Posteroanterior radiograph. Bottom: Lateral linear
tomography.
plombage in 3 patients. Because many more patients were
treated with pneumothorax than with plombage, complications of
pneumothorax were more common.
All patients with empyema were treated initially with tube
drainage of pus and of oleothorax (Fig 3). The organisms cultured
were Staphylococcus aureus in nine patients, Klebsiella pneumoniae in five patients, Streptococcus pneumoniae in three
patients, and Haemophilus influenzae in one patient. In seven of
these patients, two organisms were grown: Staphylococcus and
Klebsiella in four patients, and Streptococcus and Klebsiella in
three patients. In 13 instances, there was no growth. No mycobacterium was found in any of the patients with empyema.
Antibiotics were administered according to results of culture and
sensitivity studies. Lucite balls numbering from 16 to 36 per
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Figure 2. Lucite spheres compressing the apicoposterior and
anterior segments of the left upper lobe. Top: Posteroanterior
radiograph. Bottom: Lateral linear tomography.
Clinical Investigations
closure with an intercostal muscle flap in the three
patients, who had pleural calcifications and bronchopleural fistula, resulted in permanent obliteration of
the fistula in all. Nonresolvable pneumothorax in one
patient remained unchanged; however, its size is
small, and the patient is asymptomatic. Following
extraction of the paraffin blocks, infection developed
in one patient and the wound had to be drained.
During the follow-up period, three patients died of
unrelated causes: two deaths were caused by myocardial infarction and one death resulted from cancer
of the colon with metastases.
Discussion
Figure 3. Bronchogram of the same patient as in Figure 1,
following drainage of oil and pus. Note the presence of the
contrast medium (lipiodol) in the left bronchial tree.
plombage were extracted at muscle-sparing thoracotomy in 4
patients, decortication of the lung was performed in 6 patients
(including both patients with oleothorax), seven-rib thoracoplasty
was performed in 2 patients, and fenestration of the pleural cavity
was performed in 16 patients. In the three patients with pleural
calcifications and bronchopleural fistula, there was no pus. Partial
decortication was performed, and the fistulae were covered and
closed with suture and an intercostal muscle flap. In one patient
with pleural calcification and nonresolvable pneumothorax, tube
drainage was attempted without success and was discontinued,
and no other treatment was given. In three patients with
subcutaneous mass due to paraffin migration, all paraffin was
extracted.
Results
Pulmonary decortication resulted in complete expansion of the lung and return to normal activity in
all six patients. In both patients treated with thoracoplasty, the empyema was eliminated, and they did
well. Extraction of Lucite balls resulted in complete
lung expansion and elimination of empyema in three
of four patients; draining sinus remains in one
patient who also underwent fenestration. Fenestration resulted in obliteration of the pleural cavity by
granulation tissue and elimination of empyema in 12
of 16 patients. Three patients have residual draining
sinuses, including one patient who underwent an
earlier extraction of Lucite balls. In one patient, the
fenestration failed to eliminate empyema. Suture
Before the discovery of antimicrobial drugs and
development of techniques of pulmonary resection,
collapse therapy was the mainstream of treatment for
pulmonary tuberculosis. It evolved from the idea
that collapse of the lung would put the lung at rest
and thus promote the healing process.2 Also, it would
limit the spread of tuberculous infection by collapsing the diseased portion of the lung and so prevent
spread of tuberculous material to other, uninvolved
parts of both lungs. A successful treatment resulted
in formation of fibrosis with encapsulation of the
diseased portion and containment of infection.
Methods to achieve and to maintain the collapse
were many and included artificial pneumothorax
with air refills, phrenic nerve crush, thoracoplasty,
and extrapleural plombage. The method of plombage involved creation of extrapleural space by dissecting periosteum and intercostal muscles off the
ribs and filling the space with one of many available
materials, such as fat (omentum, fresh lipoma),
paraffin wax, bone, gauze sponge, silk, gelatin, rubber balloons, methyl-methacrylate (Lucite) balls, and
oil.1 Both vegetable and mineral oil were used to
produce oleothorax and were frequently rendered
aseptic by the addition of gomenol, a volatile product
of distillation of the leaves of the myrtle tree.3,4 The
advantages of plombage over thoracoplasty included
selective collapse of the diseased part of the lung
with less derangement of pulmonary function; also, it
could be carried out in one stage and was cosmetically more acceptable.2,5 However, the presence of a
foreign body for a prolonged period of time resulted
in complications, such as malignant tumors,6,7 erosion of major vessels with bleeding,8 and, most
commonly, infection and migration.1,2 In the survey
conducted by Shepherd1 involving 119 patients,
there were 16 infections, to which she added 3 of her
own. Three of the infections were caused by Mycobacterium tuberculosis; all others were pyogenic.
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tients, reported on eight instances of empyema: four
were pyogenic and four were tuberculous. They
theorized that tuberculous empyema can be expected in those patients treated previously without
any major antituberculous chemotherapy. These
findings contrast with our series, in which all infections were pyogenic; no mycobacterium was ever
isolated. This can be explained by the follow-up
conducted in our group. After their initial treatment
for tuberculosis in the 1940s and 1950s, most of our
patients remained under long-term observation and
often received antimicrobial therapy that included
isoniazid, para-amino salicylic acid, and some other
agent. Three successive negative culture findings of
mycobacterium were obtained before cessation of
treatment.
Compared with other series, ours is characterized
by a relatively large number of fenestrations
(n ⫽ 16), and only six instances of decortication. This
finding is not coincidental. It has been influenced by
our policy to avoid major surgery in these usually
severely ill and debilitated patients. Decortication
can be very tedious and time-consuming. As pointed
out by Shepherd,1 it would be particularly difficult in
the presence of heavy calcification, and thoracoplasty
also might be required. In contrast, fenestration is a
procedure for patients with empyema who cannot
tolerate decortication and closure of the bronchopleural fistula. Under general anesthesia, short segments of two or three ribs are resected together with
intercostal muscles, and the skin is folded in and
sutured to the parietal pleura. The procedure inflicts
very little trauma on the patient and leaves a large
opening through which the pleural cavity can be
mechanically cleansed and filled with gauze soaked
in antiseptic solution.10 Indeed, the results of fenestration in our series were excellent: in 15 of 16
patients, the empyema was eliminated, with minor
residual draining sinuses in 3 patients, and there
were no complications. The empyema persisted in
only one patient.
Pain is a rare symptom. When it occurs, it may be
caused by pressure of the plombe on adjacent structures or their erosion. Hemoptysis may be a sign of
erosion into the aorta and may be accompanied by
pain. The cause of both symptoms must be determined by emergency angiography and, if suspicion is
confirmed, immediate extraction of the plombe after
adequate preparation is mandatory.2,8 Any foreign
material that becomes a source of complication
should be extracted in order to prevent further
deterioration. However, we cannot concur with Massard and colleagues,9 who recommend routine ablation of any residual plombage material whenever
operative risk is acceptable, nor do we accept their
recommendation of routine thoracoplasty. As these
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patients were treated several decades ago in various
countries, it is impossible to determine what proportion of the total these complications represent.
However, there are many such patients who remain
asymptomatic while carrying residual “plombes.”
The addition of a major operative risk would be of no
obvious benefit to them, and thoracoplasty would
further add to respiratory embarrassment.11
As the number of living patients treated by plombage is attenuating rapidly, fewer and fewer will be
seen in the future, and no one is likely to accumulate
considerable experience with this problem. Careful
approach to these patients is, therefore, essential.
The discovery of drugs effective against M tuberculosis and development of techniques of pulmonary
resection in the 1940s and 1950s brought about a
great decline in the prevalence and severity of
tuberculosis. With the emergence of ethambutol in
1961 and rifampin in 1963, the disease seemed to
have been conquered.12,13 Collapse therapy appeared to have passed into history, leaving behind
only a diminishing residue of complications. However, over the past 15 years, a reverse trend has
occurred. A significant and steady worldwide increase in prevalence of tuberculosis has been noted,
including multiple-drug resistant organisms of
M tuberculosis and atypical strains. The reasons for
this change are many and are not likely to disappear
anytime soon. One might assume that both the
incidence of tuberculosis and the number of multiple-drug resistant strains will continue to increase.
How will these patients be treated? In absence of
adequate therapeutic agents, is it not possible that
collapse therapy will return? There are already many
patients for whom no combination of agents is of any
use. A review of results before the era of modern
therapy brings up some interesting data. According
to Strieder and associates,14 of ⬎ 300 patients at
Boston City Hospital treated with plombage and
thoracoplasty, at the 5-year follow-up, the disease
was inactive in 67%, while among the patients who
had no contralateral disease, 75% of patients were
reported as having inactive disease. This was considerably better than the present situation. For lack of
better means, the return to the old methods may
become justified. Should this happen, what materials
could be used for plombage? Of those available in
the past, Lucite spheres wrapped in a plastic bag
were probably the best. On the other hand, Silastic
prostheses filled with saline solution, such as those
used for breast implantation and in the treatment of
postpneumonectomy syndrome, would serve the
purpose equally well and with less danger of complications.15–17
Clinical Investigations
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