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A lecture on a common disease which is lung abscess, for undergraduate students

A lecture on a common disease which is lung abscess, for undergraduate students

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  • 1. بسم الله الرحمن الرحيم " والله أخرجكم من بطون أمهاتكم لا تعلمون شيئا وجعل لكم السمع والأبصار والأفئدة لعلكم تشكرون " صدق الله العظيم النحل (78)
  • 2. Suppurative lung diseases RAMADAN M BAKR MBBcH, MSc, DM, DC, DHA, DIS, MD. Ass. Prof. Of Chest Diseases, MINOUFIYA UNIVERSITY.
  • 3.
    • Suppuration means pus formation.
    • According to the site of pus formation, suppurative lung diseases (syndromes) will comprise;
    • 1- Lung parenchyma (= lung
    • abscess).
    • 2- Bronchi (= bronchiectasis).
    • 3- Pleura (= empyema).
  • 4.
    • The three diseases are clinically characterized by;
    • 1- Fever (mild, moderate, high).
    • 2- Toxemia (mild, moderate,
    • severe).
    • 3- Purulent sputum production (for short or long periods).
  • 5. Lung abscess
    • Definition; Pulmonary abscess is a localized area of liquefactive necrosis of the lung . This
    • would then include necrotizing gram
    • negative and gram positive pneumonias eg . Klebsiella, Staph, Pseudomonas etc .
    • However, by convention we reserve the
    • term lung abscess for necrotizing
    • anaerobic pneumonia.
  • 6. predisposing conditions & Causes
    • I - Aspiration
    • II- Necrotizing Pneumonia;
    • 1- Staphylococcal 2- Streptococcal
    • 3- Klebsiella 4- Pseudomonas
    • III-Blood spread from distant site;
    • 1- UTI 2- Abdominal sepsis
    • 3- Infective endocarditis 4- IV canulas
    • 5- IV drug abuse 6- Septic pulmonary
    • embolism
  • 7.
    • IV- Preexisting lung disease;
    • 1- Bronchiectasis 2- CF 3- Infarction
    • 4- Congenital abnormality 5- Trauma
    • 6- Bronchial obstruction ( FB, tumor,
    • infection, mucous plug, stenosis )
    • V- Diseases of immunodefeciency;
    • 1- Primary ( e.g. B or T cell defects )
    • 2- Acquired ( AIDS )
  • 8. Aspiration
    • The most important and common cause for lung abscess.
    • The aspirated material may be saliva, teeth, blood, gastric contents, food, FB, septic material........etc.
    • Each 1 ml of saliva normally contains 100 millions bacterium of 350 different species ( x 1000 in dental & peridontal sepsis ).
  • 9.
    • During sleep, aspiration occurs in 45% of healthy subjects.
    • Aspiration occurs in 75% of patients with decreased conscious level states.
    • Development of lung abscess after aspiration depends upon;
    • 1- The material aspirated ( amount,
    • bacterial content & PH ) and
    • 2- The host defenses .
  • 10.
    • The site of lung abscess depends upon the body position at the time of aspiration;
    • 1- Supine -> posterior segments of UL
    • or apical segments of LL ( the
    • commonest site).
    • 2- Prone -> middle lobe
    • 3- On one side -> to the dependent side
    • upper or lower lobe.
  • 11.
    • Causes of aspiration of oropharyngeal flora;
    • 1- Depressed cons. Level ( brain causes )
    • e.g. drugs, alcohol, anaesthesia,
    • epilepsy, CVS, head injury, coma or any
    • prostrating illness.
    • 2- Paranasal sinus infection, dental &
    • peridontal sepsis ( upper airways ).
    • 3- Impaired laryngeal closure e.g. RLN
    • palsy, endotracheal & tracheostomy
    • tubes.
  • 12.
    • 4- Disturbed swallowing;
    • - Oesophageal sricture or motility
    • disorder, achalasia of the cardia
    • - Pharyngeal pouch, bulbar &
    • pseudobulbar palsy or neck surgery
    • 5- Gastric causes e.g. vomitting, GOR or
    • delayed emptying
  • 13. Pathology
    • Lung abscess starts as an area of pneumonia
    • Small zones of necrosis
    • Coalesce together to form one
    • or more large cavities of 1-2 cm s
    • Progression & enlargement to form the abscess cavity
  • 14.
    • The abscess cavity well erode a bronchus
    • Expectoration of purulent sputum with air fluid formation in the abscess cavity
    • Fate
    • 1- Complete cure ( especially with good ttt )
    • 2- Chronicity
    • 3- Infection of the other lung
    • 4- Open into pleura -> pyopneumothorax
    • 5- Haematogenous spread
  • 15.  
  • 16.  
  • 17.  
  • 18. Clinical picture
    • I- Of the underlying disease.
    • II- Of the lung abscess;
    • A- Symptoms:
    • 1- General ; fever, malaise, chills,
    • anorexia, loss of wt. ......etc.
    • 2- Local ; cough, dyspnea, chest pain &
    • tightness, haemoptysis and purulent
    • sputum of large amounts.
  • 19.
    • B- Signs:
    • 1- General ; fever, tachypnea, tachycardia, pallor, clubbing ........etc.
    • 2- Local ; of pleurisy (rub), consolidation
    • (br br, ↑ TVF), effusion ( dullness,
    • ↓ intensity of breath sounds & ↓ TVF ).
  • 20. Investigations
    • I) Blood; CBC & ESR, blood culture &
    • sensetivity and serology (for hydatid,
    • amoeba.....etc.).
    • II) Radiology; CxR (PA & Lat), CT scan, US, MRI & radioactive indium
    • labelled leucocytes (IN 111 ).
  • 21.  
  • 22.  
  • 23.  
  • 24.  
  • 25.  
  • 26.  
  • 27.
    • III) Microbiology; examination of :
    • 1- Sputum (spont., or induced) for Gm
    • & ZN stains, C&S ( for aerobes,
    • anaerobes & fungi + quantitative C)
    • and GLC.
    • 2- Transtracheal aspirate.
    • 3- Percut. needle aspiration .
    • 4- PSB biopsy.
  • 28.  
  • 29.
    • IV) F.O. Bronchoscopy; for PSB biopsy or to
    • exclude the presence of FB or tumor.
  • 30. Differential diagnosis
    • 1- Cavitating lung cancer.
    • 2- Localized empyema.
    • 3- Infected cyst, bulla, congenital lesion,
    • haematoma or infarction.
    • 4- Cavitating pneumoconiotic or Wagner’s
    • nodules.
    • 5- Hydatid or any other parasitic cyst.
    • 6- Diaph. hernia, paralysis or eventration.
    • 7- TB, fungus or actinomycotic lesions.
  • 31. Treatment
    • I- Antibiotics; used in large doses, for
    • sufficient time, parentral, broadspectrum
    • for aerobes and anaerobes ( gm +ve &
    • gm –ve, cocci & bacilli ), and shift to oral
    • antibiotics after that.
    • Antibiotics of choice; penicillin,
    • metronidazole and clindamycin. Other beta lactams such as ampicillin & sulbactam,
    • ticarcillin or amoxicillin with clavulanate,
    • piperacillin with tazobactam, cefoxitin and cefotetan and imipenem.
  • 32.
    • II- Drainage;
    • 1- Postural drainage (physiotherapy).
    • 2- Bronchoscopy, for drainage (tamponade,
    • or removal of FB ).
    • 3- Transthoracic needle aspiration ( with
    • toilet and local antibiotic injection ).
    • III- Role of surgery; is very limited because
    • antibiotics & drainage is effective in most
    • cases.
  • 33.
    • A-Typs of surgery;
    • 1- Intercostal tube drainage or open
    • draniage via pneumonostomy.
    • 2- Resective surgery.
    • B- Indications;
    • 1- Poor response to antibiotics.
    • 2- Suspicion of lung cancer.
    • 3- Massive or recurrent life threatening
    • haemoptysis.
    • 4- Complicating empyema.