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بسم الله الرحمن الرحيم " والله أخرجكم من بطون أمهاتكم لا تعلمون شيئا وجعل لكم السمع والأبصار والأفئدة لعلكم تشكرون " صدق الله العظيم النحل (78)

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Suppurative lung diseases RAMADAN M BAKR MBBcH, MSc, DM, DC, DHA, DIS, MD. Ass. Prof. Of Chest Diseases, MINOUFIYA UNIVERSITY.

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<ul><li>Suppuration means pus formation. </li></ul><ul><li>According to the site of pus formation, suppurative lung diseases (syndromes) will comprise; </li></ul><ul><li>1- Lung parenchyma (= lung </li></ul><ul><li>abscess). </li></ul><ul><li>2- Bronchi (= bronchiectasis). </li></ul><ul><li>3- Pleura (= empyema). </li></ul>

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<ul><li>The three diseases are clinically characterized by; </li></ul><ul><li>1- Fever (mild, moderate, high). </li></ul><ul><li>2- Toxemia (mild, moderate, </li></ul><ul><li>severe). </li></ul><ul><li>3- Purulent sputum production (for short or long periods). </li></ul>

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Lung abscess <ul><li>Definition; Pulmonary abscess is a localized area of liquefactive necrosis of the lung . This </li></ul><ul><li>would then include necrotizing gram </li></ul><ul><li>negative and gram positive pneumonias eg . Klebsiella, Staph, Pseudomonas etc . </li></ul><ul><li>However, by convention we reserve the </li></ul><ul><li>term lung abscess for necrotizing </li></ul><ul><li>anaerobic pneumonia. </li></ul>

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predisposing conditions & Causes <ul><li>I - Aspiration </li></ul><ul><li>II- Necrotizing Pneumonia; </li></ul><ul><li>1- Staphylococcal 2- Streptococcal </li></ul><ul><li>3- Klebsiella 4- Pseudomonas </li></ul><ul><li>III-Blood spread from distant site; </li></ul><ul><li>1- UTI 2- Abdominal sepsis </li></ul><ul><li>3- Infective endocarditis 4- IV canulas </li></ul><ul><li>5- IV drug abuse 6- Septic pulmonary </li></ul><ul><li>embolism </li></ul>

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<ul><li>IV- Preexisting lung disease; </li></ul><ul><li>1- Bronchiectasis 2- CF 3- Infarction </li></ul><ul><li>4- Congenital abnormality 5- Trauma </li></ul><ul><li>6- Bronchial obstruction ( FB, tumor, </li></ul><ul><li>infection, mucous plug, stenosis ) </li></ul><ul><li>V- Diseases of immunodefeciency; </li></ul><ul><li>1- Primary ( e.g. B or T cell defects ) </li></ul><ul><li>2- Acquired ( AIDS ) </li></ul>

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Aspiration <ul><li>The most important and common cause for lung abscess. </li></ul><ul><li>The aspirated material may be saliva, teeth, blood, gastric contents, food, FB, septic material........etc. </li></ul><ul><li>Each 1 ml of saliva normally contains 100 millions bacterium of 350 different species ( x 1000 in dental & peridontal sepsis ). </li></ul>

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<ul><li>During sleep, aspiration occurs in 45% of healthy subjects. </li></ul><ul><li>Aspiration occurs in 75% of patients with decreased conscious level states. </li></ul><ul><li>Development of lung abscess after aspiration depends upon; </li></ul><ul><li>1- The material aspirated ( amount, </li></ul><ul><li>bacterial content & PH ) and </li></ul><ul><li>2- The host defenses . </li></ul>

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<ul><li>The site of lung abscess depends upon the body position at the time of aspiration; </li></ul><ul><li>1- Supine -> posterior segments of UL </li></ul><ul><li>or apical segments of LL ( the </li></ul><ul><li>commonest site). </li></ul><ul><li>2- Prone -> middle lobe </li></ul><ul><li>3- On one side -> to the dependent side </li></ul><ul><li>upper or lower lobe. </li></ul>

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<ul><li>Causes of aspiration of oropharyngeal flora; </li></ul><ul><li>1- Depressed cons. Level ( brain causes ) </li></ul><ul><li>e.g. drugs, alcohol, anaesthesia, </li></ul><ul><li>epilepsy, CVS, head injury, coma or any </li></ul><ul><li>prostrating illness. </li></ul><ul><li>2- Paranasal sinus infection, dental & </li></ul><ul><li>peridontal sepsis ( upper airways ). </li></ul><ul><li>3- Impaired laryngeal closure e.g. RLN </li></ul><ul><li>palsy, endotracheal & tracheostomy </li></ul><ul><li>tubes. </li></ul>

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<ul><li>4- Disturbed swallowing; </li></ul><ul><li>- Oesophageal sricture or motility </li></ul><ul><li>disorder, achalasia of the cardia </li></ul><ul><li>- Pharyngeal pouch, bulbar & </li></ul><ul><li>pseudobulbar palsy or neck surgery </li></ul><ul><li>5- Gastric causes e.g. vomitting, GOR or </li></ul><ul><li>delayed emptying </li></ul>

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Pathology <ul><li>Lung abscess starts as an area of pneumonia </li></ul><ul><li>↓ </li></ul><ul><li>Small zones of necrosis </li></ul><ul><li>↓ </li></ul><ul><li>Coalesce together to form one </li></ul><ul><li>or more large cavities of 1-2 cm s </li></ul><ul><li>↓ </li></ul><ul><li>Progression & enlargement to form the abscess cavity </li></ul>

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<ul><li>The abscess cavity well erode a bronchus </li></ul><ul><li>↓ </li></ul><ul><li>Expectoration of purulent sputum with air fluid formation in the abscess cavity </li></ul><ul><li>↓ </li></ul><ul><li>Fate </li></ul><ul><li>1- Complete cure ( especially with good ttt ) </li></ul><ul><li>2- Chronicity </li></ul><ul><li>3- Infection of the other lung </li></ul><ul><li>4- Open into pleura -> pyopneumothorax </li></ul><ul><li>5- Haematogenous spread </li></ul>

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Clinical picture <ul><li>I- Of the underlying disease. </li></ul><ul><li>II- Of the lung abscess; </li></ul><ul><li>A- Symptoms: </li></ul><ul><li>1- General ; fever, malaise, chills, </li></ul><ul><li>anorexia, loss of wt. ......etc. </li></ul><ul><li>2- Local ; cough, dyspnea, chest pain & </li></ul><ul><li>tightness, haemoptysis and purulent </li></ul><ul><li>sputum of large amounts. </li></ul>

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<ul><li>B- Signs: </li></ul><ul><li>1- General ; fever, tachypnea, tachycardia, pallor, clubbing ........etc. </li></ul><ul><li>2- Local ; of pleurisy (rub), consolidation </li></ul><ul><li>(br br, ↑ TVF), effusion ( dullness, </li></ul><ul><li>↓ intensity of breath sounds & ↓ TVF ). </li></ul>

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Investigations <ul><li>I) Blood; CBC & ESR, blood culture & </li></ul><ul><li>sensetivity and serology (for hydatid, </li></ul><ul><li>amoeba.....etc.). </li></ul><ul><li>II) Radiology; CxR (PA & Lat), CT scan, US, MRI & radioactive indium </li></ul><ul><li>labelled leucocytes (IN 111 ). </li></ul>

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<ul><li>III) Microbiology; examination of : </li></ul><ul><li>1- Sputum (spont., or induced) for Gm </li></ul><ul><li>& ZN stains, C&S ( for aerobes, </li></ul><ul><li>anaerobes & fungi + quantitative C) </li></ul><ul><li>and GLC. </li></ul><ul><li>2- Transtracheal aspirate. </li></ul><ul><li>3- Percut. needle aspiration . </li></ul><ul><li>4- PSB biopsy. </li></ul>

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<ul><li>IV) F.O. Bronchoscopy; for PSB biopsy or to </li></ul><ul><li>exclude the presence of FB or tumor. </li></ul>

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Differential diagnosis <ul><li>1- Cavitating lung cancer. </li></ul><ul><li>2- Localized empyema. </li></ul><ul><li>3- Infected cyst, bulla, congenital lesion, </li></ul><ul><li>haematoma or infarction. </li></ul><ul><li>4- Cavitating pneumoconiotic or Wagner’s </li></ul><ul><li>nodules. </li></ul><ul><li>5- Hydatid or any other parasitic cyst. </li></ul><ul><li>6- Diaph. hernia, paralysis or eventration. </li></ul><ul><li>7- TB, fungus or actinomycotic lesions. </li></ul>

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Treatment <ul><li>I- Antibiotics; used in large doses, for </li></ul><ul><li>sufficient time, parentral, broadspectrum </li></ul><ul><li>for aerobes and anaerobes ( gm +ve & </li></ul><ul><li>gm –ve, cocci & bacilli ), and shift to oral </li></ul><ul><li>antibiotics after that. </li></ul><ul><li>Antibiotics of choice; penicillin, </li></ul><ul><li>metronidazole and clindamycin. Other beta lactams such as ampicillin & sulbactam, </li></ul><ul><li>ticarcillin or amoxicillin with clavulanate, </li></ul><ul><li>piperacillin with tazobactam, cefoxitin and cefotetan and imipenem. </li></ul>

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<ul><li>II- Drainage; </li></ul><ul><li>1- Postural drainage (physiotherapy). </li></ul><ul><li>2- Bronchoscopy, for drainage (tamponade, </li></ul><ul><li>or removal of FB ). </li></ul><ul><li>3- Transthoracic needle aspiration ( with </li></ul><ul><li>toilet and local antibiotic injection ). </li></ul><ul><li>III- Role of surgery; is very limited because </li></ul><ul><li>antibiotics & drainage is effective in most </li></ul><ul><li>cases. </li></ul>

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<ul><li>A-Typs of surgery; </li></ul><ul><li>1- Intercostal tube drainage or open </li></ul><ul><li>draniage via pneumonostomy. </li></ul><ul><li>2- Resective surgery. </li></ul><ul><li>B- Indications; </li></ul><ul><li>1- Poor response to antibiotics. </li></ul><ul><li>2- Suspicion of lung cancer. </li></ul><ul><li>3- Massive or recurrent life threatening </li></ul><ul><li>haemoptysis. </li></ul><ul><li>4- Complicating empyema. </li></ul>