2. Lung gangrene
▪ Gangrene of the lung is a purulent-putrefactive
decay of a necrotic lobe or the entire lung, not
separated from the surrounding tissue by a
restrictive capsule and having a tendency to
progress, which usually causes an extremely
severe general condition of the patient.
▪ Gangrenous abscess is less extensive and more
prone to limitation than in gangrene, the process
of necrosis of the lung tissue.
3. Abscess
▪ Lung abscess is a cavity in the lung, filled
with pus and bounded from the surrounding
tissues by a pyogenic membrane formed
from granulation tissue and a layer of fibrous
fibers.
▪ Mortality in acute abscesses varies from 7 to
28%.
4. Etiology
Acute abscesses and gangrene of the lungs are most often
caused by:
Staphylococcus aureus - hemolytic and Staphylococcus
aureus
Gram-negative microbial flora - Klebsiella, E. Coli, Proteus,
Pseudomonas aerugenosa, Legionella pneumonia.
Non-clostridial forms of anaerobic infection -
Peptostreptococcus, Bacteroids melaningenicus, Bac.
Fragilis, Fusobacterium nucleatum and necrophorum;
Protozoa Paragonimus westermani, Entamoeba histolytica,
Mycobacterium tuberculosis.
5. Pathogenesis
Infection routes:
-Bronchogenic (aspiration, post-pneumonic and
obstructive)
-Hematogenous-embolic
-Traumatic
-Others, associated with the transition of suppuration from
other organs and tissues (empyema of the pleura, liver
abscess)
Factors in the formation of purulent fusion:
1. Acute infectious inflammatory process in the pulmonary
parenchyma;
2. Violation of blood supply and necrosis of the lung
tissue;
3. Violation of bronchial patency in the area of
inflammation and necrosis.
6. Epidemilogy
Risk factors
• Alcoholism
• Drug overdose
• General anesthesia for surgical procedures
• Prolonged vomiting
• ACVA, myasthenia gravis
• Epilepsy
• Neoplasms in the lungs
• Foreign bodies in the airways
• GERD
• Diabetes
Acute pulmonary suppuration often occurs mainly in men aged 20-50
years, who are sick 3-5 times more often than in the general
population, which is explained by alcohol abuse, smoking, greater
susceptibility to hypothermia, and occupational hazards.
In 60%, the right lung is affected, in 34% - the left, and in 6% the
lesion is bilateral.
7. Clinic
The phase of abscess formation
Lasts 10-12 days
The clinical picture resembles pneumonia - weakness, chills,
fever, cough with scanty sputum, sometimes hemoptysis,
chest pain.
The patient's condition immediately becomes serious.
Determined by tachycardia and tachypnea, hyperemia of the
skin of the face, weight loss, the appearance and growth of
anemia, putrid breath.
Shortening of percussion sound over the affected area of the
lung, weakening of respiratory sounds and crepitant
wheezing. In blood tests, neutrophilic leukocytosis appears, a
shift in the leukocyte formula to the left and an increase in
ESR.
The patient takes a forced position on his side
Soreness of the intercostal spaces on the affected side
8. Abscess forming phase
▪ Localization of the
abscess mainly in the
posterior segment of
the upper lobe of the
lung and the upper
segment of the lower
lobe
▪ Segments II, VI, VIII,
IX, X.
9. Abscess emptying phase
▪ The leading clinical symptom of this period is the
discharge of purulent or putrid sputum, which may
contain an admixture of blood. In cases of the
formation of a large purulent-destructive focus, up
to 400-500 ml of sputum can be discharged at
once and can even reach 1000-1500 ml per day.
▪ The patient's condition improves: body
temperature decreases, appetite appears,
leukocytosis decreases.
▪ Physical data change: the area of shortening of
the percussion sound decreases, symptoms of the
presence of a cavity in the lung appear.
10. Abscess emptying phase
▪ X-ray examination the
abscess cavity with a
horizontal fluid level is
usually clearly visible.
11. Lung gangrene
▪ Clinical signs of lung gangrene are distinguished
by a significantly greater severity of symptoms of
general intoxication. Gangrene of the lung, as a
rule, is characterized by a rapid onset of a sharp
decrease in body weight, a rapid increase in
anemia, severe signs of purulent intoxication and
pulmonary heart failure, which cause an extremely
serious condition of the patient.
15. Sputum examination
▪ When settling in a glass, the sputum is divided into
three layers. Dense detritus accumulates at the
bottom, above it is a layer of turbid liquid (pus), and
foamy mucus is located on the surface. In sputum,
small pulmonary sequesters can be seen, and
microscopic examination reveals a large number of:
▪ leukocytes,
▪ elastic fibers,
▪ cholesterol, fatty acids
▪ and diverse microflora.
16. External respiration function
examination
▪ Patients have
mixed or restrictive
ventilation
disorders
▪ Hemoptysis is a
contraindication for
the study of
respiratory function
17. Complications
▪ Pyopneumothorax (in 9.1 - 38.5% of cases)
▪ Hemoptysis or pulmonary hemorrhage (6-
12%)
▪ Bacteria - with the development of sepsis,
meningitis, brain abscess
▪ Respiratory distress syndrome
▪ Empyema of the pleura
▪ Pericarditis
▪ Acute renal failure
18. Differential dx
▪ Differential diagnosis of acute abscesses and
gangrene of the lungs is carried out with
▪ lung cancer
▪ tuberculosis
▪ festering cysts
▪ echinococcus
▪ limited empyema of the pleura
19. Differential diagnosis
▪ Central lung cancer, causing a violation of bronchial
patency and atelectasis, often manifests itself in the area of
atelectasis by foci of purulent-necrotic fusion with signs of
a lung abscess. In these cases, bronchoscopy allows
detecting obstruction of the main bronchus by the tumor,
and biopsy - to clarify the morphological nature of the
formation, since with an abscess of a lung granulation can
be mistaken for tumor tissue. With cancer - the age of
patients over 50 years old, sputum scarcity, lack of smell.
▪ A lung abscess must be differentiated from a disintegrating
peripheral cancer. The "cancerous" cavity usually has thick
walls with irregular bulging inner contours. Transthoracic
puncture biopsy allows to verify the diagnosis in such
cases.
20. D/D
▪ The tuberculous cavity and lung abscess radiographically
have many common features. Often an acute tuberculous
process that has arisen is clinically very similar to a picture
of an abscess or gangrene of the lung. In this case,
differential diagnosis is based on data from anamnesis,
dynamic X-ray examination, in which, in the case of a
specific lesion, signs of dissemination are revealed at 2-3
weeks.
▪ The diagnosis of tuberculosis becomes unquestionable
when mycobacterium tuberculosis is found in the sputum
or bronchial washings. Combined lesions with tuberculosis
and nonspecific suppuration are possible.
21. D/D
▪ Suppurative cysts of the lung (often congenital) are
manifested by typical clinical and radiological symptoms of
an acute lung abscess. A characteristic radiological sign of
a festering cyst is the detection of a thin-walled, clearly
delineated cavity with a slightly pronounced perifocal
infiltration of the lung tissue after the cyst has broken
through into the bronchus. However, the final diagnosis is
not always possible even after a qualified histological
examination.
▪ Echinococcal cyst in the stage of primary suppuration is
practically indistinguishable from an abscess. Only after
the cyst breaks through the bronchus with phlegm,
elements of the chitinous membrane can leave. To clarify
the diagnosis, the history of the disease is very important.
22. D/D
▪ Acute lung abscess should be differentiated
from interlobar limited empyema of the
pleura, especially in cases of its
breakthrough into the bronchus. The main
methods of differential diagnosis is a
thorough X-ray examination.
24. Treatment principles
▪ A diet with an energy value of up to 3000 calories per day,
with a high protein content of up to (110 - 120 g / day).
Increase in vitamin-rich foods. Limiting table salt to 6-8 g /
day. Drink plenty of fluids.
▪ Drug therapy
▪ Antibiotic therapy
▪ Infusion therapy
▪ Symptomatic (pain reliever, antipyretic, expectorant)
▪ Transbronchial drainage for bronchoscopy
▪ Ultrasound-guided percutaneous puncture of an abscess
▪ Inhalation of antiseptics, proteolytic enzymes, bronchodilators
▪ Endotracheal administration of antiseptic drugs and enzymes
▪ Surgery
▪ Physiotherapy (vibration massage, postural drainage)
25. Antibiotics
The choice of the drug is carried out according to the results of
bacteriological examination of sputum.
The empirical choice of an antibiotic for a lung abscess is based
on knowledge of the most common causative agents of the
disease (anaerobes Bacteroides, Peptostreptococcus, etc.,
often in combination with enterobacteria or Staphylococcus
aureus).
The drugs of choice are: amoxicillin + clavulanic acid, ampicillin
+ sulbactam, ticarcillin + clavulanic acid, cefoperazone +
sulbactam.
Alternative drugs include lincosamides in combination with
aminoglycosides or cephalosporins of III-IV generations,
fluoroquinolones in combination with metronidazole, and
monotherapy with carbapenems.
27. Surgical treatment
Methods applied
"minor" surgery - drainage of the purulent cavity using one or more
drains (depending on the size of the cavity) and the introduction
of antibiotics and other antiseptics through the drainages.
Thoracic "large" surgery - if it is impossible to exclude lung cancer,
the size of the abscess is more than 6 cm, the development of
empyema:
- Lobectomy; - Bilobectomy; - Pulmonectomy
Pleuropulmonectomy
Pleurectomy
depending on the prevalence of the process.
When bleeding occurs, produce:
Bronchial obstruction of the draining bronchus
Embolization of bronchial arteries
Lung resection
Embolization of bronchial arteries
28. Prognosis
▪ Complete recovery, characterized by cavity scarring, is observed in 25-
40% of patients. Rapid elimination of the cavity is possible with small
(less than 6 cm) initial sizes of necrosis and destructionof lung tissue.
▪ The most frequent outcome of conservative treatment of acute lung
abscesses is the formation of a so-called dry residual cavity at the site
of the abscess (about 35-50%), which is accompanied by clinical
recovery.
▪ In the majority of patients, it proceeds sharply in the future, and only in
15-20% it can turn into a chronic form.
▪ The mortality rate of patients with acute lung abscesses is 5-10%. With
widespread gangrene of the lung, it remains very high and amounts to
30-40%.
29. Prophylaxis
▪ Prevention of acute pulmonary suppuration is
associated with extensive measures to combat
influenza, acute respiratory diseases, alcoholism,
improvement of working and living conditions,
adherence to the rules of personal hygiene, early
hospitalization of patients with pneumonia and
vigorous antibiotic treatment.
30. Empyema of pleura
▪ Empyema, an infected parapneumonic pleural effusion, is a rare but
severe complication of bacterial community-acquired pneumonia.
▪ Pleural effusion occurs in about 40% of cases of community-
acquired pneumonia, but in most cases, infection does not occur
and the effusion resolves on its own.
▪ Mortality in pleural empyema is, according to different authors, from
2 to 50%, with the most serious prognosis observed in elderly and
immunocompromised patients. The prognosis is also significantly
worse in the case of isolation of resistant strains of pathogens and
with delayed initiation of intensive therapy and adequate antibiotic
therapy.
31. Etiology
▪ If a lung abscess is caused by microorganisms that can
lead to destruction and necrosis of lung tissue, then pleural
empyema can be caused by any microorganism that has
penetrated into the pleural cavity.
▪ It should be noted that in most cases of the disease, two or
more microorganisms are isolated from the pleural cavity,
which allows us to consider the empyema of polymicrobial
infections.
▪ In almost half of cases, this complication is caused by the
association of aerobic and anaerobic microorganisms.
32. Dx
Empyema of the pleura is
characterized by a typical X-
ray picture, which, however,
is detected with a
widespread lesion.
A more sensitive method is
computed tomography.
33. Dx
▪ A mandatory research method is pleural puncture with analysis of
pleural effusion and its bacteriological examination.
▪ The most important for the prognosis and determination of patient
management tactics are the pH of the pleural effusion and microscopy
of the stained specimen. At pH values <7.1 and the detection of
bacteria in the stained preparation, it is necessary to drain the pleural
cavity.
▪ Given the serious prognosis in pleural empyema, it is advisable to carry
out diagnostic pleural puncture in all patients with pneumonia
complicated by significant pleural effusion. This test is mandatory for
suspectedpleural effusion infection and empyema.
34. Dx
When carrying out a pleural puncture, it is necessary
to collect material in three tubes:
1) for clinical and biochemical research and
microscopy of a stained preparation;
2) a sterile test tube for microbiological research;
3) for research on mycobacteria.
35. Pleural punture dx
1st test tube
Biochemical and
microscopic lab
tests
2nd test tube
Microbiological test
3rd test tube
Test for
mycobacterias
pH
Protein
LDG
Glucose
Leukocytes
Sowing environment
Isolation of pure
culture
Determination of
sensitivity
Polymerase chain
reaction
36. Clinical features of pleural effusion
• Persistence of fever> 38 ° C or recurrence of fever with antibiotic therapy.
• The appearance or intensification of chest pain when breathing.
• Increased shortness of breath.
• Persistent leukocytosis.
• Increasing the zone of dullness during percussion.
• The appearance of anemia.
37. Distinguishing signs of an infected pleural effusion
from an uninfected one:
• Purulent nature of the exudate.
• An increased number of leukocytes (more than 15,000 in 1 ml) with a
predominance of neutrophils.
• The glucose content is less than 40 g / l, with uninfected exudate - 40-
60 g / l.
• pH <7.1.
• The presence of bacteria on microscopy or a positive culture result.
38. Treatment
▪ Antibiotic therapy for pleural empyema presents
significant difficulties.
▪ It should be emphasized that antibiotics are of decisive
importance only at the earliest stages of the
development of this complication.
▪ In the future, only a timely comprehensive approach to
treatment can give a positive effect: drainage + surgical
treatment + antibiotics + fibrinolytic therapy.
39. Treatment
▪ Adequate antibiotic therapy for empyema can be
considered if the prescribed drug (s) has reliable
activity against all groups of major pathogens: S.
aureus + S. pneumoniae + Enterobacteriaceae +
Bacteroides spp. + PeptoStreptococcus spp. +
Fusobacterium spp.
40. Treatment
▪ From these positions, carbapenems and inhibitor-protected
antipseudomonal penicillins are the most reliable in
monotherapy, but the level of resistance of gram-negative
bacteria to the latter drugs has significantly increased in
recent years.
▪ Cephalosporins of the third-fourth generation and
fluoroquinolones are also potentially highly effective, but all
of them require a combined appointment with clindamycin.
▪ As with a lung abscess, the effectiveness of
aminoglycoside antibiotics is questionable.
41. ABT for empyema of pleura
Most reliable Alternative
Imipenem
Meropenem
Cefepime + metronidazole
Cefoperazone / sulbactam
Amoxicillin / clavulanate +
amikacin
Levofloxacin + metronidazole
Moxifloxacin
Ticarcillin / clavulanate +
amikacin
Ceftriaxone + clindamycin
Ciprofloxacin + clindamycin
Ertapenem
69. It is a chronic and necrotizing condition of bronchi
and bronchioles leading to their abnormal dilatations.
OR
Bronchiectasis is anatomicallydefined as abnormal,
irreversible dilatation and distortion of bronchi caused
by inflammatory destruction of the muscularand
elastic components of bronchi.
73. COUGH & SPUTUM:
Cough and mucopurulent sputum
Cough is invariably present and in many patients cough is
the only symptom for initial few years.
Sputum is Purulent, Tenacious and Foul smelling , more in
morning.
HEMOPTYSIS:
Present in 40-70 % of patients and may vary from blood
streaks to large clots or significant fresh bleed.
DRY BRONCHIECTASIS:
Cough with scanty sputum with or without hemoptysis.
75. Chest auscultation:
Prolonged expiration
Coarsecrackles
Diffuse Rhonchi
Bronchial breathing in selected cases in pneumonias.
Digital clubbing
Hypertrophic pulmonaryosteoarthropathy
Cor pulmonale
76.
77. History
Physical examination
X-ray Chest
Sputum cultures for bacteria, fungi and mycobacteria.
78. Cough
Fever
Copiousamount of foul smelling sputum
Dilatation is permanent
Reversibledilatation occurs in viral and bacterial
pneumonia.
79. Affect lower lobes more
Often bilateral
More in air passageswhich are vertical
In tumor or foreign body impaction it is localizedor
segmental
If more distal bronchi are involved more severe
Airwaysare usually four times dilated than normal
80. Cylindrical-most common, tube like, increased in
diameter
Fusiform – spindle shaped dilatation
Saccular -sac like dilatation, like grapes.
Varicose- irregular bronchial dilatations and
tortuosities of bronchial passages. Imagine varicose
veins.
Cut sections show Honey Comb appearance
81.
82.
83.
84.
85.
86.
87.
88. It is distortion of the airwayssecondary to mechanical
traction on the bronchi from fibrosis of the
surrounding lung parenchyma.
for exampleafter toxic gas exposure like bychlorine
gas and ammonia, leads to irreversible damage to
airways.
89. Increased pulmonarymarkings
Ring like structures
Atelectasis
Dilated and thickened airways (Tram lines)
Mucus plugging (Finger in glove appearance)
90.
91.
92.
93.
94.
95.
96.
97.
98. Controlling infection
Reducing inflammations
Improving bronchial hygiene
Surgical resection of affected segment in selected
patients.
99. Antibiotics for acute exacerbations
Prophylactic in few cases
Oral Flouroquinolonesare commonest. Mostly for 10-
14 days.
101. In case of lack of response to treatment culture and
sensitivity tests for sputum are done for better
selection of antibiotics.
May need injectible treatments
May need hospitalization
102. Mucus hypersecretion is a prominent feature of
bronchiectasis.
Maintenance of adequate hydration by oral or
intravenous fluids is helpful to avoid tenacious
inspissated sputum retention.
Humidificationof air or oxygen is used as an adjunct to
chest physiotherapy.
Nebulizationof normal or hypertonic saline
Use of acetylecystine or other mucolyticagents
103. As there is airway obstruction and mucosal
hyperreactivity so bronchodilators are often used.
104. Persistent endobronchial inflammation is known to be
play a significant role in pathophysiologyof
bronchiectasis so anti-inflammatorytreatment may be
beneficial.
105. For
Symptoms control
Control of bleeding
Reduction of tenacious sputum production
Reduction of acute exacerbations
Improved quality of life
Surgery of selected segments is indicated in :
Most severely affected segments
Recurrent bleeding segments
Segments harboring resistant tuberculosis or
other micro-organisms
106. LUNG TRANSPLANT:
A viable option in selected cases
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