Physiotherapy and Research, São Paulo, v .17, n .4, p. 362-5, Oct. / Dec.

2010 ISSN 1809-2950

Safety and effectiveness of chest physiotherapy on lung abscess:

Case Study
Safety and effectiveness of chest physiotherapy in lung abscess: a two-case study

Josy Davidson Patricia Teodoro Teixeira Paula Ferreira dos Santos Peixoto Carla Martins Crivellaro Marcele Assisi Marques
1, 2, 2, 2, 2

Study developed in the course of
Pulmonology, Department. Medical
Unifesp
- Federal University of São Paulo,
São Paulo, SP, Brazil
1 Physiotherapist; Prof.. Dra.'S
Specialization in Respiratory
Therapy from Unifesp
2 Physiotherapists specialists
Respiratory fisioterapy
Resume: This is a lung abscess due to necrotic lesion generally pyogenic bacteria. Respiratory therapy
(FR) is indicated, but there are few reports in the literature, there is no consensus as to the use and RF
techniques to this case. The objective of this study two cases was to determine the safety and
effectiveness of the FR in the treatment of lung abscess. Case 1 was a 30 year old patient hospitalized; the
therapy was to position it in Trendelenburg semi-lateral ventral right for 30 minutes three times a day, with
great amount of discharge outlet. After 5 days, the chest X-ray showed a 90% reduction of the fluid level,
verifying the complete emptying of the abscess after 14 days of hospitalization. Case 2 was a 28-year-old
patient also diagnosed with lung abscess, also treated with postural drainage, and positioning the same
frequency as the case 1, draining large amount of yellow and fluid secretion. After 7 days of treatment
revealed significant reduction in the liquid level of the lung abscess. It follows that postural drainage
isolation is an effective and safe therapy technique to treat lung abscess.

TO ADDRESS
CORRESPONDENCE:
Key words: Lung abscess / rehabilitation; effectiveness evaluation
Josy Davidson intervention; postural drainage
R. Volunteers of the Homeland 2505 c.11
02401-000 Sao Paulo SP
Abstract: Lung abscess is a necrotic lesion mostly Caused by pyogenic germs. Chest physical therapy
email: josydavidson@yahoo.com.br
(CPT) is Indicated, but there are few studies available and no consensus on TLC and use techniques for
theses cases. The purpose of this study was to assess safety and effectiveness of postural drainage in
treating lung abscess in two cases. Patient 1, male, 30 years old, was laid in Trendelenburg, in semi-lateral
to the ventral decubitus for 30 minutes, three times a day. After five days of therapy, X-ray Showed 90%
decrease of sputum, and on the 14th day full drainage was achieved. Case 2 was a female patient, 28
years old, treated at the same frequency position and the case 1. After seven days of therapy, exams
Showed a great decrease of pus from the abscess.

PRESENTATION
in October 2009

ACCEPTED FOR PUBLICATION Key words: Drainage, postural; Evaluation of the effectiveness of interventions; Lung
June 2010 abscess / rehabilitation

362 Fisioter Pesq. 2010; 17 (4): 362-5

362 revfisio.indd 14/02/2011 01:00:30

 Davidson et al.
INTRODUCTION
The lung abscess (AP) is a necrotic cavitary
lesion with more than two cm in diameter caused by
pyogenic bacteria most commonly anaerobic. which
destroy the lung parenchyma 1.2 With the main
causes of oropharyngeal secretion aspiration of
gastric contents, or 3.4 And preferably located in the
right lung, most often in the posterior segment of the
lower lobe and the posterior lateral lobe of the upper 5.6
.
As lung abscess treatment indicates the
association of antibiotic 2.7 and respiratory therapy
(FR) 8.9 and, in severe cases, surgical approach.
However, while the FR is prescribed, there are
disagreements about the best form of intervention,
because when done improperly, can aggravate the
condition of the patient, causing pleural empyema to
septicemia 10.11 , Questioning the safety and
effectiveness of physiotherapy intervention in these
patients.
The objective of this study was to assess the
safety and effectiveness of the FR in the treatment
of lung abscess.
CASE 1
Patient 1, male, 30 years old, born and living in
São Paulo, previously healthy, smoker 1 year /
pack, reported that about four months before had
presented cough with expectoration greenish, fluid
and fetid secretions. He sought health clinic that
referred to the hospital, where they were made
chest X-ray and CT scan and was diagnosed with
AP 2.2 cm in diameter and fluid level in about 80%
of the abscess (Figure 1A).
Front frame, the patient was hospitalized for
treatment with antibiotics (Clindamycin and
Clarithromycin) for 21 days. After physical therapy
assessment, it was decided to isolated postural
drainage and diaphragmatic breathing exercises in
therapy intervals. The patient was placed in the
Trendelenburg (bed tilted at 45 °), with the head in
the lower part on the right half side position to the
prone position for 30 minutes,
363 revfisio.indd
three times a day (morning, afternoon and evening).
Initially, the bed was inclined at 15 °, draining large
amount of green discharge, thick and
non-malodorous. After three days we have made
new chest X-ray, which showed reduction of the
fluid level, as observed decrease in amount of
sputum expectorated. Thus, the bed was increased
from the tilt angle to 30 to yield increased sputum,
yellow-green discharge and semi-
- thick. After five days of treatment initiation, a new
chest X-ray (Figure 1B) showed reduction of the
fluid level around 90% (from 1.8 cm to 0.2 cm). After
14 days of hospitalization the patient was
discharged with significant clinical improvement, we
were instructed to keep the respiratory therapy and
the use of antibiotics.
1.8 cm
BA
0.2 cm
Figure 1 - Chest radiograph prior to the
application of physical therapy;
and
B - after application of five days of
therapy in 1 patient; arrow on the left
shows the level of secretion; right, the
height of the cavity; It is the measure
of the fluid level height
lung abscess and physiotherapy
CASE 2
The second case is a 28 year old patient, born in
Paraná and resident in Sao Paulo for eight years.
Reported four episodes of childhood pneumonia
and lung abscess in the left hemithorax at 18, three
rhinosinusitis crises in the last 10 months.
Approximately six days before presented severe
pain at the base of the left hemithorax ventilatório-
- dependent, continuously and without irradiation.
THE
1.0 cm
B
0.4 cm
Figure 2 - Chest radiograph prior to the application of
physical therapy; and
B - seven days after application of
physiotherapy in Patient 2; arrow on the
left shows the level of secretion; right,
the height of the cavity; It is the measure
of the fluid level height
Fisioter Pesq. 2010; 17 (4): 362-5 363
14/02/2011 01:00:34
 The improved pain became worse and prone to
cough - production, bloody. In addition, reported
symptoms of fever (which improved with antipyretic)
for four days, chills, vomiting episodes of watery
yellowish and large volume of diarrhea. He also
mentioned appetite loss and general malaise, loss
of 2 kg last week. To the emergency room of
Pneumology and made the chest X-ray, was
hospitalized. lung abscess was diagnosed with
about 20% filling of the respective cavity (Figure
2A).
After evaluating started pharmacological
treatment with clindamycin and clarithromycin and
physical therapy with use of postural drainage in
Trendelenburg, prone and semilateralização left
hemithorax, also with diaphragmatic breathing
exercises in intervals of care. The patient remained
in position for 30 minutes three times a day. Initially,
the bed was positioned 30 degrees elevation,
draining large amount of yellow and fluid secretion.
After four days was made new chest X-ray, showing
decrease in fluid level. Due to the reduction in
abscess drainage efficiency, increased the
inclination posture to the bed 45, enhancing the
expectoration, with an average amount of yellow
and fluid secretion. After three more days, it was
carried out new chest X-ray,
DISCUSSION AND
CONCLUSION
In both cases there was favorable evolution of
abscess drainage only the association between
antibiotics and use of postural drainage,
demonstrating that a RF only technique is able to
assist in the resolution of the abscess in a short
period without risk of pulmonary complications.
364 Fisioter Pesq. 2010; 17 (4): 362-5
revfisio.indd 364
The etiological point of view, immunosuppressed
patients with a history of dental cavity lesions, poor
oral hygiene and alcohol dependent individuals are
at higher risk of developing lung abscesses 1.2 . In
one study 2 conducted with 252 patients with lung
abscess, it was observed that impaired general
condition (97.6%), and poorly kept teeth (82.5%)
were frequently associated with the onset of the AP.
In both cases presented, the patients had no such
record, which differentiates the features found in the
literature. Moreover, both were young and without
impairment of general condition, being able to
suspect a pulmonary malformations and / or rare
immunodeficiency 12 . The use of antibiotics is the
reference standard for the treatment of AP. Calls
the association of drugs that combat anaerobic
bacteria and other like
Staphylococcus aureus, that often cause cavitation
and purulence 2,6,11,13 . In both cases presented,
patients received the drug combination of
clindamycin and clarithromycin for 21 days, with
good evolution.
Besides the use of antibiotics, the application of
RF is cited by many studies as an adjuvant
treatment, there are controversies with regard to
best conduct these cases. Some studies report that
the performance of bronchial hygiene techniques
such as tapping, expiratory flow acceleration or
vibro assist the opening of the cavity to the airways,
and facilitate drainage of secretions 8.9 . However, it sequence.
is known that drainage of these cavitations occur
with the thinning of the walls of the abscess
and since it is thinner, there is possibility wall
rupture, which may cause leakage of secretion into
the pleural space, causing empyema 6.10 ; in turn,
this creates the need for chest drainage and
prolonged use of antibiotics, increasing the risk of
complications, as well as costs and hospital stay.
A study 8 specific about the performance of FR
1990s date and guides that patients should be kept
in the drain position as long as possible; adds that
the chest percussion maneuvers should be linked to
posture, to bring about the elimination of secretion,
thereby draining the abscess, avoiding the retention
and infection of the pulmonary parenchyma,
actually occurred in a case report in which the
application of FR with maneuvers bronchial hygiene
caused the spread of purulent content of AP
causing pneumonia, septicemia and significant
worsening of the patient gas exchange 14 . Faced
with the controversy surrounding the realization of
bronchial hygiene maneuvers in cases of AP, the
option of making the isolated postural drainage in
this study is justified mainly by to demonstrate
effective and safe, because patients have benefited
from this procedure, obtaining the complete
drainage of the abscess.
The fact of using different angula- tions of the
patient in the bed towards the achievement of
postural drainage was due to the lack of accurate
information from the AP location. Chest X-ray is a
little in- strument to check accurate location
targeting of an injury. Thus, they used basea-
postures of the region affected lobe, requeren-
changes in the angle of the bed for more effective
therapy based on clinical signs of the patient -
decreased sputum and fluid level in radiological
Few studies discuss the FR of action in such
cases. This study allows to conclude that postural
drainage can be a good technique to be used, as
there was good progress in both cases, with a total
drainage of secretions. However, there is need for
randomized studies with larger numbers of patients
to analyze the risks and the effectiveness of the use
of different physical therapy techniques for these
cases.
14/02/2011 01:00:34
 Davidson et al.
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