Help for medical students about topic Suppurative lung diseases - Abscess and gangrene of the lungs, Pneumothorax, Hematorax, Purulent pleurisy. And useful material as required by students. Everything is inserted as per outlines of topics.

1. Suppurative lung diseases – Abscess and
gangrene of the lungs, Pneumothorax,
Hemotorax, Purulent pleurisy
Made by – Piyush Singhania
Group – GM19-066

2. Introduction
• Suppurative lung diseases are a group of disorders which result in
chronic lung infection, with pus in the lungs. Individuals with
suppurative lung diseases present with chronic purulent sputum
and recurrent respiratory tract infections. The aetiology of these
conditions is variable.

3. Content of File
• Abscess and gangrene of the lungs,
• Pneumothorax,
• Hemotorax,
• Purulent pleurisy

4. Outline
• Definition
• Etiology
• Pathogenesis
• Pathophysiology
• Classification
• Symptoms
• Diagnosis
• Treatment

5. Abscess and gangrene of the lungs
• Lung abscess is a type of liquefactive necrosis of the lung tissue
and formation of cavities (more than 2 cm) containing necrotic
debris or fluid caused by microbial infection. It can be caused by
aspiration, which may occur during altered consciousness and it
usually causes a pus-filled cavity.
• Pulmonary gangrene is a severe life threatening complication of
pulmonary infection in which a part of lung tissue is devitalized. It
can occur rarely after bacterial pneumonia, and may require
surgical removal of dead tissue.

6. Etiology
• Contributing factors for lung abscess are: elderly, dental/peridental
infections (gingivitis-with bacterial concentration >1011/mL),
alcoholism, drug abuse, diabetes mellitus, coma, artificial ventilation,
convulsions, neuromuscular disorders with bulbar dis functions,
malnutrition, therapy with corticosteroids, cytostatics or
immunosuppressants, mental retardation, gastro-oesophageal reflux
disease, bronchial obstruction, inability to cough, sepsis.
• Pulmonary gangrene is a rare complication of severe lung infection with
devitalization of lung parenchyma and secondary infection. If untreated,
gangrene of the lung leads to sepsis, multiple-organ failure, and death.
Resection of all gangrenous tissue is mandatory and is lifesaving.

7. Pathogenesis
• Lung abscess is a type of liquefactive necrosis of the lung tissue
and formation of cavities (more than 2 cm) containing necrotic
debris or fluid caused by microbial infection. It can be caused by
aspiration, which may occur during altered consciousness and it
usually causes a pus-filled cavity.
• Gangrene occurs when blood flow to a certain area of the body is
interrupted. The lack of blood flow causes tissue to die. Gangrene
often affects the fingers or toes.

8. Pathophysiology
• The pathophysiology of lung abscess is bacterial inoculum from the
gingival crevice reaches the lower airways and infection is initiated
because the bacteria are not cleared by the patient’s host defense
mechanism.
• The pathophysiology of gangrene depends on the type of gangrene. In
gangrene that occurs due to infection, bacteria initially infect a tissue.
The bacteria then release a number of toxins that damage nearby
tissues, resulting in the beginning of a gangrenous wound. In other forms
of gangrene, the pressure within the arteries is decreased which
eventually results in compressed circulatory pathways. This results in
poor oxygen delivery to tissue, which begins the formation of necrotic
and gangrenous tissue.

9. Classification
• Based on duration of symptoms
• Acute: If the duration of symptoms is less than 4-6 weeks before presenting to medical care.
• Chronic: If the symptoms persist for more than 6 weeks.
• Based on Etiology
• Primary: When the abscess develops after lung infection in previously healthy persons or in patients prone to aspiration.
• Secondary: Abscess formation in patients due to complications of a co-existing lung disease such as post obstructive process (bronchial obstruction due to
tumor, foreign body or enlarged lymphnodes) and systemic process resulting in decreased immune response like HIV, and patients on immunosuppressants and
corticosteroids.
• Based on mode of spread
• Bronchiogenic: Abscess formation is due to aspiration and inhalation.
• Aspiration of oropharyngeal secretions.
• Bronchial obstruction by a tumor.
• Foreign body, congenital malformations, and enlarged lymph nodes.
• Hematogenic: Abscess formation due to dissemination of causative agents from other infected sites
• Infective endocarditis.
• Abdominal sepsis.
• Septic thromboembolism.

10. Symptoms
• Chest pain, especially when you breathe in.
• Cough.
• Fatigue.
• Fever.
• Loss of appetite.
• Night sweats.
• Sputum (a mixture of saliva and mucus) with pus that’s often sour-
tasting, foul-smelling, or streaked with blood.
• Weight loss.

11. Diagnosis
• A lung abscess is typically diagnosed in two ways:
• Chest X-ray: This shows your doctor where the abscess is.
• CT scan of the chest: Your doctor is looking for an air- and fluid-filled cavity in the middle of your lung.
• Tests used to help diagnose gangrene include:
• Blood tests. A high white blood cell count is often a sign of infection. Other blood tests can be done to
check for the presence of specific bacteria and other germs.
• Fluid or tissue culture. Tests can be done to look for bacteria in fluid sample from a skin blister. A sample
of tissue can be examined under a microscope for signs of cell death.
• Imaging tests. X-rays, computerized tomography (CT) scans and magnetic resonance imaging (MRI) scans
can show the organs, blood vessels and bones. These tests can help show how far gangrene has spread
through the body.
• Surgery. Surgery may be done to get a better look inside the body and learn how much tissue is infected.

12. Treatment
• Tissue that has been damaged by gangrene can’t be saved. But treatment is available to help prevent gangrene from
getting worse. The faster you get treatment, the better your chance for recovery.
• Treatment for gangrene may include one or more of the following:
• Medication
• Surgery
• Hyperbaric oxygen therapy

13. Pneumothorax
• An abnormal collection of air in the space between the thin layer
of tissue that covers the lungs and the chest cavity. This can cause
all or part of the lung to collapse. A pneumothorax may be caused
by a chest injury, certain medical procedures, lung disease, or
other damage to lung tissue.

14. Etiology
• A pneumothorax can be caused by a blunt or penetrating chest
injury, certain medical procedures, or damage from underlying
lung disease. Or it may occur for no obvious reason. Symptoms
usually include sudden chest pain and shortness of breath. On
some occasions, a collapsed lung can be a life-threatening event.

15. Pathogenesis
• Tension pneumothorax occurs anytime a disruption involves the
visceral pleura, parietal pleura, or the tracheobronchial tree. This
condition develops when injured tissue forms a one-way valve,
allowing air inflow with inhalation into the pleural space and
prohibiting air outflow.

16. Pathophysiology
• Spontaneous pneumothorax
Spontaneous pneumothorax in most patients occurs from the rupture of blebs and bullae. Although PSP is defined as occurring
in patients without underlying pulmonary disease, these patients have asymptomatic blebs and bullae detected on computed
tomography scans or during thoracotomy. PSP is typically observed in tall, young people without parenchymal lung disease and
is thought to be related to increased shear forces in the apex.
• Tension pneumothorax
Tension pneumothorax occurs anytime a disruption involves the visceral pleura, parietal pleura, or the tracheobronchial tree.
This condition develops when injured tissue forms a one-way valve, allowing air inflow with inhalation into the pleural space
and prohibiting air outflow. The volume of this nonabsorbable intrapleural air increases with each inspiration because of the
one-way valve effect. As a result, pressure rises within the affected hemithorax. In addition to this mechanism, the positive
pressure used with mechanical ventilation therapy can cause air trapping.
• Pneumomediastinum
With pneumomediastinum, excessive intra-alveolar pressures lead to rupture of alveoli bordering the mediastinum. Air
escapes into the surrounding connective tissue and dissects further into the mediastinum. Esophageal trauma or elevated
airway pressures may also allow air to dissect into the mediastinum. Air may then travel superiorly into the visceral,
retropharyngeal, and subcutaneous spaces of the neck. From the neck, the subcutaneous compartment is continuous
throughout the body; thus, air can diffuse widely.

17. Classification
• There are five main types of collapsed lung (Pneumothorax):
1. Primary spontaneous pneumothorax: Collapsed lung sometimes happens in people who don’t have
other lung problems. It can occur due to abnormal air sacs in the lungs that break apart and
release air.
2. Secondary spontaneous pneumothorax: Several lung diseases may cause a collapsed lung. These
include chronic obstructive pulmonary disease (COPD), cystic fibrosis and emphysema.
3. Injury-related pneumothorax: Injury to the chest can cause collapsed lung. Some people
experience a collapsed lung due to a fractured rib, a hard hit to the chest or a knife or gunshot
wound.
4. Iatrogenic pneumothorax: After certain medical procedures such as lung biopsy or a central
venous line insertion, some people can have complications that include a pneumothorax.
5. Catamenial pneumothorax: This rare condition affects women who have endometriosis.
Endometrial tissue lines the uterus. With endometriosis, it grows outside the uterus and attaches
to an area inside the chest. The endometrial tissue forms cysts that bleed into the pleural space,
causing the lung to collapse.

18. Symptoms
• Sudden onset of chest pain – sharp pain worse on inspiration[6]
• Dyspnoea – shortness of breath
• Tachycardia – increased heart rate
• Tachypnoea – increased respiration rate
• Dry cough
• Fatigue
• Signs of respiratory distress –nasal flaring, anxiety, use of accessory
muscles
• Hypotension
• Subcutaneous emphysema

19. Diagnosis
• Chest radiography, ultrasonography, or CT can be used for diagnosis, although
diagnosis from a chest x-ray is more common. Radiographic findings of 2.5 cm
air space are equivalent to a 30% pneumothorax. Occult pneumothoraces may
be diagnosed by CT but are usually clinically insignificant. The extended
focused abdominal sonography for trauma (E-FAST) exam has been a more
recent diagnostic tool for pneumothorax. The absence usually makes the
diagnosis of ultrasound of lung sliding, the absence of a comet-tails artifact,
and the presence of a lung point. Unfortunately, this diagnostic method is very
operator dependent and sensitivity, and specificity can vary. In skilled hands,
ultrasonography has up to a 94% sensitivity and 100% specificity (better than
chest x-ray). If a patient is hemodynamically unstable with suspected tension
pneumothorax, intervention is not withheld to await imaging. Needle
decompression can be performed if the patient is hemodynamically unstable
with a convincing history and physical exam, indicating tension pneumothorax.

20. Treatment
• There are a variety of treatment options for a spontaneous pneumothorax. It has been shown that
intervention has similar results to conservative management of pneumothorax including less days spent in
hospital.
• Conservative management with observation until the air is naturally resorbed by the body
• Simple aspiration.
• Chest drain placement – Simple chest drain placement alone has a very high rate of recurrence (about 65%)
in patients with LAM.
• Heimlich valve (HV) insertion – a lightweight one-way valve designed for the ambulatory treatment of
pneumothorax (with an intercostal catheter).
• Pleurodesis through a chest tube – a procedure which obliterates the pleural space to prevent future
pneumothoraces.
• Mechanical (using physical abrasion)
• Chemical (using talc, doxycycline, bleomycin or other agents). While chemical pleurodesis through a chest
tube can be successful, this may result in incomplete pleurodesis due to the uneven distribution of the
chemical.
• Surgery – Surgical treatment, using video-assisted thoracoscopy (VATS), is the preferred approach.

21. Hemotorax
• Hemothorax is a collection of blood in the space between the
visceral and parietal pleura (pleural space). The clinical findings
in such patients include respiratory distress and tachypnea.

22. Etiology
• By far the most common cause of hemothorax is trauma. Penetrating injuries of the lungs, heart, great vessels, or chest wall are
obvious causes of hemothorax; they may be accidental, deliberate, or iatrogenic in origin. In particular, central venous catheter and
thoracostomy tube placement are cited as primary iatrogenic causes.
• Blunt chest trauma can occasionally result in hemothorax by laceration of internal vessels. Because of the relatively more elastic
chest wall of infants and children, rib fractures may be absent in such cases.
• The causes of nontraumatic or spontaneous hemothorax include the following:
1. Neoplasia (primary or metastatic)
2. Blood dyscrasias, including complications of anticoagulation
3. Pulmonary embolism with infarction
4. Torn pleural adhesions in association with spontaneous pneumothorax
5. Bullous emphysema
6. Necrotizing infections
7. Tuberculosis
8. Pulmonary arteriovenous fistulae
9. Hereditary hemorrhagic telangiectasia [12]
10. Nonpulmonary intrathoracic vascular pathology (eg, thoracic aortic aneurysm or aneurysm of the internal mammary artery)
11. Intralobar and extralobar sequestration [4]
12. Abdominal pathology (eg, pancreatic pseudocyst, splenic artery aneurysm, or hemoperitoneum)
13. Catamenial

23. Pathogenesis
• The pathogenesis of large hemothoraces can involve progressive
organization and fibrosis leading to lung restriction, arguing for
the removal of this fibrotic encasement. Intrapleural thrombolytic
therapy is an alternative approach to address organizing
hemothoraces.

24. Pathophysiology
• Bleeding into the pleural space can occur with virtually any disruption of
the tissues of the chest wall and pleura or the intrathoracic structures.
The physiologic response to the development of a hemothorax is
manifested in two major areas: hemodynamic and respiratory. The
degree of hemodynamic response is determined by the amount and
rapidity of blood loss.
1. Hemodynamic response
2. Respiratory response
3. Physiologic resolution of hemothorax
4. Late physiologic sequelae of unresolved hemothorax

25. Classification
• Traumatic hemothorax due to penetrating or blunt trauma to chest
• Iatrogenic hemothorax due to complications of chest procedures
• Spontaneous hemothorax due to various underlying conditions

26. Symptoms
• The most common symptoms of hemothorax include:
1. pain or feeling of heaviness in your chest
2. feeling anxious or nervous
3. dyspnea, or having trouble breathing
4. breathing quickly
5. abnormally fast heartbeat
6. breaking out in cold sweats
7. skin turning pale
8. high fever over 100°F (38°C)

27. Diagnosis
• During a physical exam, doctors will listen for sounds of abnormal breathing through
a stethoscope. Doctors may also tap on the chest to listen for sounds of liquid.
• Other methods of diagnosis include:
1. X-rays: an X-ray image of the chest will quickly reveal if there is liquid in the
chest cavity. In an X-ray, the lungs will show up black, where the pleural fluid and
any blood in the chest cavity will show up white.
2. CT scans: this can give doctors a complete image of the lungs and pleural cavity,
which may be especially important in cases of injury. A full CT scan of the chest
can often reveal the cause of the hemothorax and the best treatment for the
individual.
3. Ultrasound: in emergency situations, ultrasound images provide a quick and
accurate look into the pleural space for potential damage and hemothorax.

28. Treatment
• The majority of haemothorax require the insertion of a surgical
chest drain, to evacuate the blood from the pleural cavity (Fig. 6).
Large bore (28-40Fr) tubes are recommended to reduce the risk of
blood clotting in the tube* and the volume from the chest drain
must be carefully recorded.
• Those patients with small haemothorax who are clinically stable
can be admitted for observation and repeat CXR performed after
24hrs for further assessment

29. Purulent Pleurisy
• Pleurisy is a symptom characterized by localized chest pain caused
by a disease-causing inflammation of the pleura. Pleurisy can be
caused by a primary pleural disease or secondary to a systemic
illness. It can lead to significant morbidity and mortality if not
treated expediently.

30. Etiology
• Pleurisy occurs when the pleural lining — two large, thin layers of
tissue that separate your lungs from your chest wall — becomes
inflamed, causing chest pain. Pleurisy (PLOOR-ih-see) is a
condition in which the pleura — two large, thin layers of tissue
that separate your lungs from your chest wall — becomes
inflamed.

31. Pathogenesis
• Pleurisy is a condition whereby inflammation of the pleura causes
the membranes to rub and grate against each other. Common
causes of pleurisy include bacterial and viral infections which can
lead to pneumonia. Other causes of pleurisy include a pulmonary
embolus, cancer and trauma to the chest wall.

32. Pathophysiology
• The visceral pleura does not contain any noci-ceptors or pain receptors.
The parietal pleura is innervated by somatic nerves that sense pain when
the parietal pleura is inflamed. Inflammation that occurs at the
periphery of the lung parenchyma can extend into the pleural space and
involve the parietal pleura, thereby activating the somatic pain
receptors and resulting in pleuritic pain. Parietal pleurae of the outer rib
cage and lateral aspect of each hemidiaphragm are innervated by
intercostal nerves. Pain is localized to the cutaneous distribution of
those nerves. The phrenic nerve supplies innervations to the central part
of each hemidiaphragm; when these fibers are activated, the sensation
of pain is referred to the ipsilateral neck or shoulder.

33. Classification
• A variety of conditions can cause pleurisy. Causes include:
1. Viral infection, such as the flu (influenza)
2. Bacterial infection, such as pneumonia
3. Fungal infection
4. Autoimmune disorder, such as rheumatoid arthritis or lupus
5. Lung cancer near the pleural surface
6. Pulmonary embolism
7. Tuberculosis (TB)
8. Rib fracture or trauma
9. Certain inherited diseases, such as sickle cell disease
10. Certain medications and recreational drugs

34. Symptoms
• Signs and symptoms of pleurisy might include:
1. Chest pain that worsens when you breathe, cough or sneeze
2. Shortness of breath — often from trying to limit breathing in and out
3. Cough — only in some cases
4. Fever — only in some cases
Pain caused by pleurisy might worsen with movement of your upper body and can spread to your shoulders or back.
Pleurisy can occur along with pleural effusion, atelectasis or empyema:
1. Pleural effusion. In some cases of pleurisy, fluid builds up in the small space between the two layers of tissue. This is called pleural effusion.
When there is a fair amount of fluid, pleuritic pain lessens or disappears because the two layers of pleura are no longer in contact and don’t
rub together.
2. Atelectasis. A large amount of fluid in the pleural space can create pressure. This can compress your lung to the point that it partially or
completely collapses (atelectasis). This makes breathing difficult and might cause coughing.
3. Empyema. The extra fluid in the pleural space can also become infected, resulting in a buildup of pus. This is called an empyema. Fever
often occurs along with an empyema.

35. Diagnosis
• Your healthcare provider uses tests to diagnose pleurisy and figure out the underlying cause.
Possible tests include:
1. Blood tests. Your provider looks at a sample of your blood for signs of infection or
autoimmune disorders.
2. Electrocardiogram (EKG or ECG). Your provider may use small electrodes on your body to
see how well your heart is working. This is to make sure a heart problem isn’t causing your
chest pain.
3. Imaging tests. Your provider takes pictures of your lungs using X-rays, CT scans and
ultrasounds to help them figure out what’s causing your pain.
4. Fluid testing (thoracentesis). Your provider inserts a small needle into the area around your
lungs and removes fluid. They examine the fluid for signs of infection or clues to other
causes of pleurisy.
5. Thoracoscopy. Your provider uses a small, lighted tube with a camera to look inside your
lungs and find any problems.

36. Treatment
• Treatment for pleurisy depends on what’s causing it. Your healthcare provider
will work with you to treat the underlying cause. They can also help you manage
your pain in the meantime.
• Your treatment options might include:
1. Medication for infection. If your pleurisy is caused by an infection, your
healthcare provider may prescribe antibiotics or antifungal medications.
2. Medication for symptom relief. You provider may suggest nonsteroidal anti-
inflammatory drugs (NSAIDs) or corticosteroids for your pain.
3. Fluid draining. Your provider may remove fluid from your lungs (thoracentesis)
to help ease your pain.