471
Ped iulrics
VOLUME 44 OCTOBER 1969 NuMR 4
COMMENTARIES
DIAGNOSTIC
LUNG
PUNCTURE
T
HE normal lower respiratory tract isfree of viable bacteria,1,S whereas the
throat and nasopharynx become colonized
by several common species of bacteria soon
after birth.3’4 Moreover, in patients with
physical and roentgenographic signs of
lower respiratory tract pathology, there
often are great discrepancies between the
organisms seen in smears or grown in
cul-tures of exudates obtained from the
af-fected sites in the lungs and in those of
sputum or secretions from the throat or
na-sopharynx when similarly examined. In
in-fants and children, and even in many
adults, particularly women, sputum
repre-sentative of exudate from the lower
respira-tory tract often is not available or, when
raised, is mixed with secretions from the
upper respiratory tract. In an era when
therapy to be effective must be specifically directed against the susceptible organism
that is causing the infection in the patient,
failure to identify the causative organism may be a source of considerable difficulty.
The diagnostic lung puncture, never
ac-cepted as a routine procedure, has been
used only for circumscribed periods by a
few physicians responsible for large
num-bers of patients with pneumonias, in
cir-cumstances allowing proper studies of the
material obtained. The purpose of such
punctures was thus to achieve more
accu-rate diagnosis and more rational therapy.
Most physicians have continued to prefer
other methods for obtaining culture
mate-rial-the raising of sputum by gagging or
other procedures, such as direct laryngos-copy5 or tracheal intubation, both of which
may also be uncomfortable and sometimes
traumatic to the patient.
There is a natural reluctance to subject-ing the sick patient, especially an infant or
young child, to the trauma of lung
punc-ture,6 to say nothing of the risks of such
complications as hemoptysis or
pneumo-thorax (usually benign) and, though very
rare, even sudden death.7 Thus, some
au-thors have expressed the view that lung
puncture, if it is to be practiced, must be
shown to be simple, safe, and productive of
information. The expected benefits must
far outweigh the potential risk. Most
au-thors who have employed the procedure in
any large numbers of patients have
con-cluded that it meets these requirements.8’9
This issue of PEDIATRICS contains two
contributionslO,h1 on diagnostic lung
punc-tures in selected pediatric patients of two
quite different hospitals. Each paper
pre-sents rationale, methods, indications, and
results, as vel1 as a brief review of the
ex-perience of others, put into perspective.
The impression given by both
communica-tions is that, in such patients, the value of
lung puncture warrants the risks.
The indications for lung puncture have
changed with our increased knowledge
con-ceming the causative agents of pulmonary
lesions, the methods for their identification, and the wider selection of suitable therapy.
Under these newer circumstances, lung
puncture also contributes to more reliable
472 LUNG PUNCTURE
prognosis. The first, and still the most
widely accepted indication, is in relation to
the exploration of the pleural space for
fluid, a procedure that may be at once
diag-nostic and therapeutic. When fluid was not
thus obtained but inflammation of the
un-derlying lung was anticipated, the
exten-sion of the procedure, puncture into the un-denying lung with examination of aspirated “lung juice,” was a natural extension. When
pathogenic bacteria were thus obtained,
even before specific remedies were
avail-able, the possibility of defining etiology and offering useful prognosis led early
investi-gators to employ the procedure more
exten-sively.
With subsequent use of type-specific
pneumococcus antisera, and especially as
the succession of antibiotics for susceptible
organisms was introduced, rapid and
accu-rate diagnosis of etiology became still more imperative. Moreover, as KJein11 points out, changes in the flora of the respiratory tract during therapy and the possibility of
secon-dary infections by new and resistant
orga-nisms offer further reasons for diagnostic
lung puncture as the most accurate means
of differentiating between benign “coloniza-tion” of the upper respiratory tract and true “superinfection” of the lower. Such
superin-fection, potentially fatal, may require
a change in therapy as soon as it is recog-nized.
Persistence of infected pulmonary lesions
in spite of presumably proper therapy
based on the usual examinations of sputum
or tracheal secretions offers another
poten-tial use of lung puncture. Pathogenic
orga-nisms may not be shed into the sputum or
readily identified in that source. The recent
finding of cytomegaloviruses and of
Pneu-nwcystic
carinii
in lungs of patientsunder-going immunosuppressive treatment for
tap during life. This additional feature
should be encouraged. The physician
per-forming a lung puncture is obligated not
only to be prepared to cope with rare corn-plications of the procedure itself, but also to have at hand all technics for the greatest
possible use of the specimen obtained:
direct smears for bacteria and cytology, cul-ture in suitable media (including tissue Cul-tures for viruses
)
, and even animal inocula-tion when indicated. An appropriate diluentfor the small volume of lung fluid will be
required. Further requirements are
ade-quate diagnostic resources and vise
judg-ment as to which diagnostic procedures
should be done. Lung taps cannot and
should not be repeated as lightly as
veni-punctures, sputum examinations, or
naso-pharyngeal swabs and cultures merely
be-cause the physician was not adequately
prepared at the time of the first tap.
The desirability of extending or
modi-fying the procedure to include extraction of
pulmonary tissue for histologic as well as
microbiologic examination, in selected
pa-tients suspected of chronic granulomatous
lesions or tumors, should also be
consid-ered. Experienced thoracic surgeons, to
whom exploration of the thoracic cage with
excisional biopsies or wedge resections are
simple and commonplace procedures, may
argue that the risks of those procedures are relatively small, and their potential value
for accurate diagnosis, and possibly even
for therapy, are much greater than those of
needle biopsy by the inexperienced
inter-nist or pediatrician. Under some
circum-stances this is undoubtedly true, but in
many instances there is room for
contro-versy and, better still, for consultation and mutual agreement in the best interest of the patient.
COMMENTARIES 473
“normals” and chronic bronchitis. Lancet,
2:1112, 1950.
2. Laurenzi, C. A., Porter, R. T., and Kass, E.
H.: Bacteriologic flora of the lower
respira-tory tract. New Eng. J. Med., 265:1273,
1961.
3. Torrey, J. C., and Reese, M. K.: Initial aerobic
flora of newborn infants; selection and
toler-ance of upper respiratory tract bacteria.
Amer. J. Dis. Child., 69:208, 1945.
4. Gialdroni-Grassi, C., Pryles, C. V., and
Fin-land, M.: Controlled study of the use of
pro-phylactic anti.microbials in premature in-fants. PEDIATRICS, 18:899, 1956.
5. Butler, C. D., Shaw, N. C., Hoffman, S.
J.,
Ditkowsky, S., McVey, E., and Zeldes, M.:
Pneumonia in children: A review of seven
hundred and thirty-one cases. J.A.M.A., 117:
1840, 1941.
6. Lyons, A. B.: Bacteriologic studies of one
hun-dred and sixty-five cases of pneumonia and
postpneumonic empyema in infants and
children. Amer. J. Dis. Children, 23:72,
1922.
7. Exploratory puncture of the chest-Abuse of
the needle-A warning. Brit. J. Child. Dis.,
2:466, 1905.
8. Sappington, S. W., and Favorite, C. 0.: Lung
puncture in lobar pneumonia. Amer. J. Med.
Sci., 191:225, 1936.
9. Bullowa, J. C. M.: The Management of the
Pneumonias. New York: Oxford Medical
Publications, 1937.
10. Hughes, J. R., Sinha, D. P., Cooper, M. R.,
Shah, K. V., and Bose, S. K.: Lung tap in
childhood. PEDIATRICS, 44:477, 1969.
11. Klein, J. 0.: Diagnostic lung puncture in the
pneumonias of infants and children.
PEmAT-rucs, 44:486, 1969.
12. Tillotson, J. R., and Finland, M.: Bacterial
col-onization and clinical superinfection of the respiratory tract complicating antibiotic treatment of pneumonia. J. Infect. Dis., 119:
