We describe 3 critically ill patients with pneumonia complicated by lu
ng abscesses and contralateral pneumonia due to spill of purulent secr
etions into the healthy lung. Although the clinical picture of lung ab
scess often runs an indolent course, this was not observed in these cr
itically ill patients, who all died from this complication. Diagnosis
was delayed as chest X-ray underestimated lung pathology compared to c
omputed tomography (CT) scan. Therefore percutaneous chest tube draina
ge and placement of a double-lumen endobronchial tube to protect the h
ealthy lung were delayed and spill of purulent secretions into the con
tralateral lung occurred. These cases show the importance of rapid eva
luation by CT scan of the chest in mechanically ventilated patients wi
th slowly resolving infiltrates on chest X-ray.