Necrosis of the pulmonary tissue caused by
microbial infection and the formation of cavities
containing necrotic debris or fluid.
• There may be continuity with the airway, with
partial drainage air fluid level on chest X-ray.
• If complicated with erosion into the pleural
space, empyema with bronchopleural fistula.
Etiology of lung abscess
A. Primary abscess :
Infectious in origin,
impaired consciousness (e.g. anesthesia, alcoholism,
poor oral hygiene,
ii. pneumonia in the healthy host.
B. Secondary abscess:
a preexisting condition (eg, obstruction with tumor, foreign body),
spread from an extrapulmonary site (e.g. subphrenic abscess),
an immunocompromised state.
• Acute lung abscess:
Duration of symptoms prior to presentation
for medical care < one month.
• Chronic lung abscess:
Duration of symptoms prior to presentation
for medical care > one month.
• Parenchymal involvement occurs in segmental distribution.
• What are the commonly affected segments?
Posterior segment of upper lobe and superior segment of
The right side more affected than left side.
As these segments are dependent when the patient is in
recumbent position so aspiration more to these segments.
The right side more affected as right bronchus more in line
with trachea so aspiration more to the right.
• Intermittent fever, cough, malaise, weight
loss, night sweats, and may be hemoptysis
• When cavitations occurs, putrid expectoration
and is usually pronounced in patient with
Clinical Picture, Cont.
• Physical examination:
a small area of dullness
suppressed breath sound (rather than
Fine or medium moist crackles may be
If the cavity is large, there may be tympany or
1. History, and physical examination.
2. Sputum should be examined by smear and
culture should be obtained.
4. Chest x ray show cavitary space within the
lung with an air fluid level .
5. CT scan: for better anatomic interpretation.
Medical therapy :
Successful in 85 – 90 % 0f cases.
• 1- Antibiotic:
Initial therapy should be intravenous unless the
patient is minimally symptomatic, for 6 -8 weeks.
• 2- Pulmonary clearance techniques :
The availability of effective antibiotic therapy for
primary lung abscess has diminished the role of
• External drainage:
i) Percutaneously under CT, or ultrasound
ii) Edoscopic drainage, or
iii) Video-assisted thoracoscopic (VATS) drainage.
• Surgical resection:
Required in less than 10% of cases.
Surgical therapy, cont.
Indications of surgical resection:
Failure of medical therapy for 8 weeks.
Bronchopheural frstula of empyema,
Massive or significant hemoptysis.
Persistence of cavity larger that 6cm after medical
Necrotizing infection associated with multiple abscesses.
Strong suspicion of carcinoma.
Lobectomy is usually required, as segmentectomy may
be inadequate and pneumonectomy is rarely
Definition: Abnormal, irreversible dilatation of part of
the bronchial tree.
• Due to an infections insult,
• Impairment of drainage,
• Airway obstruction
• Defect in host defense
• Infants and children
• Due to development arrest
of bronchial tree
• Include, cystic fibrosis,
congenital deficiency of
bronchial cartilage, IgA and
IgG deficiency and α1
• Regardless of the etiology, there is :
abnormal bronchial dilatation & bronchial wall
destruction & transmural inflammation,
vicious circle of bronchial damage and bronchial
dilatation with impaired clearance of secretions
and recurrent infection more bronchial
• Site: Typically involve basal segments of lower
lobes and it is bilateral in 30 – 50 % of patients.
• Regardless of the etiology,
there is :
Abnormal bronchial dilatation &
bronchial wall destruction &
circle of bronchial damage and
bronchial dilatation with
impaired clearance of
secretions and recurrent
Site: Typically involve basal segments of lower
lobes and it is bilateral in 30 – 50 % of
Bronchiectasis can present in two forms:
a.Local form, involve a lobe or segment of a lung
b. diffuse form, involving much of both lungs.
• History of cough, daily mucopurulent, tenacious
sputum production lasting months to years.
• Dyspnea, pleuritic chest pain, fever, wheezing.
• Hemoptysis occur in about 50% of adult but it is
not usually sever
Clinical Picture, cont.
• Non specific and may include, crackles,
• Manifestations of chronic illness:
Digital clubbing, cyanosis, plethora, wasting
and weight loss indicate the chronic nature of
• History and physical exam.
• Chest x Ray, suggestive not diagnostic
volume loss with crowding of pulmonary vasculature
areas of atelectasis and persistent infiltrate.
• High resolution CT:
The diagnostic tool of choice and replace bronchography
Shows bronchial dilatation and parenchymal disease,
"signet ring" sign (the abnormal dilated bronchi appears
much larger than adjacent pulmonary artery branch).
Helpful for both diagnostic and therapeutic purposes
Plain Chest x Ray P-A View
• Medical therapy:
the 1ry approach, and is focused on airway
secretion and control of recurrent infection and
include appropriate antibiotic, postural drainage,
humidifiers and bronchodilators as indicated.
• Surgical therapy:
Resection of the diseased lobe or segment.
The role of surgery has evolved from early
curative to more palliative.
Indications of pulmonary resection for
Persistent, recurrent infection following
discontinuation of medication.
Where removal of a foreign body or tumor is
• Ideal candidates:
Unilateral, segmental or labor distribution
disease or bilateral localized bronchiectasis.
Surgery for Pulmonary Tuberculosis
• Medical therapy is the standard management
for pulmonary tuberculosis.
• Also, Surgery plays a role in the treatment of
patients with TB
Indications of Surgery for pulmonary
Emergencies, almost exclusively for haemoptysis.
Those in whom there is a need to rule out cancer.
Surgery for complicatIon :
• destroyed lung
• cavitary disease, with or without positive sputum
• bronchopleural fistulas
• Resectional surgery in form of:
Segmentectomy, lobectomy or pneumonectomy
represents the majority of operations,
Operations on the pleura (as decortication).
Rarely, thoracoplasty may be done.