🎯 Background & Rationale
While 80% to 90% of lung abscesses resolve with medical management, refractory cases require intervention. Surgical resection and percutaneous catheter drainage (PCD) carry significant risks (such as pneumothorax, empyema, hemothorax, and bronchopleural fistula), particularly in frail or elderly patients. While bronchoscopic drainage offers a minimally invasive alternative, it has historically been limited by the stability and precision of conventional flexible bronchoscopes. This case addresses the clinical gap of managing refractory lung abscesses in a patient declining general anesthesia and surgery, exploring the novel application of shape-sensing robotic-assisted bronchoscopy (RAB) performed via the nasal route under monitored anesthesia care (MAC) to achieve targeted abscess drainage and indwelling catheter placement.
👥 Study Design & Population
- Publication Type: Case Report.
- Clinical Scenario: An 87-year-old woman with significant cardiovascular comorbidities (hypertension, diabetes, prior myocardial infarctions status post drug-eluting stents) presented with a large, progressive 7.7 × 5.0 cm left lower lobe cavitary lesion and necrotizing pneumonia that failed a 6-week course of antibiotics. She suffered from a debilitating nonproductive cough and worsening clinical status.
- Patient Preferences: The patient explicitly declined surgical management due to invasiveness, requested avoidance of endotracheal intubation, and refused nasal insertion of a standard, large-diameter linear endobronchial ultrasound (EBUS) scope (6.9-mm outer diameter) due to anticipated discomfort. She consented to an alternative approach utilizing the Ion robotic bronchoscopy system (3.5-mm outer diameter) via a nasal trumpet under MAC.
📈 Methodology & Rigor
- Diagnostic Workup & Preparation: Initial diagnostic workup included a chest CT and flexible bronchoscopy with bronchoalveolar lavage (BAL), which was non-diagnostic. Due to rapid radiographic progression and failure of medical therapy, multidisciplinary discussion preceded the intervention.
- Procedural Technique: Airway inspection under MAC and spontaneous ventilation was initially performed using a disposable aScope bronchoscope and an oral EBUS scope (BF-UC180F) to localize the abscess pocket and mark the optimal entry site under fluoroscopy. The Ion robotic catheter (3.5-mm OD) was then successfully inserted through a 30-French nasal trumpet into the distal left main stem bronchus. Guided by fluoroscopy, a 19-gauge robotic needle was advanced into the abscess cavity, confirming position with the aspiration of frank purulent material. A guidewire was passed through the catheter, allowing subsequent placement of a 6-French Impulse drainage catheter connected to a continuous chest drainage system.
🔬 Key Findings [or Planned Endpoints]
- Procedural Success: The procedure was completed successfully without immediate complications under MAC and spontaneous ventilation, avoiding general anesthesia and endotracheal intubation.
- Microbiological Yield: Aspiration cultures of the purulent fluid grew Klebsiella (Enterobacter) aerogenes (sensitive to quinolones), allowing for targeted antimicrobial therapy.
- Clinical & Radiographic Outcomes: The indwelling drainage catheter remained in place for 36 hours, evacuating an additional 60 mL of purulent fluid (beyond the initial 100 mL aspirated intraprocedurally). The patient tolerated the catheter comfortably. A follow-up chest CT 1 month later demonstrated near-complete drainage of the abscess cavity, and the patient remained asymptomatic, breathing comfortably on room air with resolved cough.
⚖️ Critical Appraisal
- Generalizability: As a single case report, the findings are inherently limited by a lack of generalizability. The success of this technique heavily depends on operator expertise, institutional availability of robotic platforms, and specific anatomical features (such as a viable bronchial pathway to the abscess).
- Technical Considerations: Utilizing a 3.5-mm outer diameter robotic catheter through a nasal trumpet under MAC successfully bypassed the patient’s aversion to large-bore transnasal scopes and general anesthesia; however, direct visualization of peripheral airways was limited by severe stenosis, necessitating reliance on EBUS and fluoroscopic coregistration.
💡 The Clinical Bottom Line
This case demonstrates the expanding utility of robotic-assisted bronchoscopy beyond routine diagnostic tissue acquisition into active therapeutic interventions. For carefully selected, high-risk, or frail patients who refuse or are poor candidates for general anesthesia and surgical or percutaneous drainage, performing nasal RAB under monitored anesthesia care with fluoroscopic and EBUS guidance is a technically feasible, minimally invasive strategy for targeted lung abscess drainage and catheter placement.