Bacterial destruction of the lungs can lead to serious complications like lung abscesses and pleural effusions. Lung abscesses form when bacteria destroy lung tissue, causing necrosis and pus-filled cavities. Left untreated, the abscess can drain into the pleural cavity, causing a pleural effusion. Pleural effusions are accumulations of fluid in the pleural space that can become infected (pyothorax) or allow air to enter (pyopneumothorax), requiring drainage to prevent respiratory distress. Proper treatment involves identifying the underlying infection through testing of pleural fluid, administering antibiotics, and draining excess fluid or air in the pleural cavity through chest tubes or thoracentesis.

1. Done by: Shavkatxudjaev Hasan (419- II)

2. Bacterial destruction of the lungs. Pyothorax,
pneumotorax.
Bacterial destruction of the lungs occupy one of
the leading places among all causes of the
pediatric morbidity and mortality. The most
frequent pulmonary disease is a pneumonia. The
majority of the patients with pneumonia are
treated by pediatrics, but sometimes the course of
pneumonia are followed with complications,
required the surgical interventions.

3. Classification of the BDP:
Route of infection:
 1. Primary – by an aerogenous route through the
bronchi
 2. Secondary - by hematogenous route from other
purulent focus.
Infecting agent:
 1. Gram-negative.
 2. Gram-positive.
 3. Aerobe
 4.Anaerobe
 5.Mixed flora.

4. Complications:
1. Pulmonary:
a) abscess,
b) blebs (residual cavities).
2. Pleural:
a) exudative pleuritis,
b) pyothorax – local and total,
c) pneumothorax – tension and non-tension,
d) pyopneumothorax – tension and non-tension.
 3. Emphysema of mediastinum.

5. Microbes, reaching the
pulmonary tissue, begin to
produce the different toxins (one
of them – necrotoxin) and
proteolytic ferments, which cause
the tissue necrosis and
formations of the purulent
cavities. These cavities join and
form the pulmonary abscess.

6. The clinical course of the abscess
has two stages. The first one
(formation of abscess or undrained
abscess) is followed with severe
clinical symptoms of the respiratory
insufficiency and intoxication:
shortness of breath, tachypnea,
cyanosis, tachycardia, high
temperature, raised white blood
cells (WBC) level and erythrocyte
sedimentation rate (ESR).

7. The X-ray shows the round shadow,
that occupies a few segments or
entire pulmonary lobe. If
conservative treatment
(antibiotherapy, disintoxication) is
ineffective, the puncture of the
undrained abscess is indicated.

8. Lung abscess. The X-ray findings the round shadow,
that occupies a few segments or entire pulmonary
lobe.

9. The second stage of the abscess is a
drained abscess. Usually the abscess
drains into the bronchi, what is
followed with the violent cough with
pus, decreased temperature and
improvement of the patient
condition.

10. If the bronchial fistula within the
bronchus and abscess cavity is wide
and the pus leaves the cavity rapidly
the conservative treatment is used.
This includes the antibiotherapy,
bronchiolitic inhalation, expectorants,
postural drainage. Adequate drainage
of the lung abscess often is achieved
through postural drainage and chest
physiotherapy. The use of
bronchoscopy to drain an abscess is
controversial.

11. After the successful treatment of
the pulmonary abscesses the
residual air-filled cavities (blebs)
are present into the lung. These
cavities need no special
treatment and usually disappear
in 3 – 4 months.

12. The pneumonia almost always is
followed with a serous exudate
accumulation in pleural cavity. In
case of the destructive
pneumonia the suppuration of
the exudate happens and it
becomes purulent. This is a
pyothorax (the pus accumulation
in the pleural cavity).

13. The pyothorax is most frequent
complication of the bacterial
destructive pneumonia. In
auscultating a child with severe
pneumonia (respiratory
insufficiency, fever, intoxication) can
be founded the weak or absent
breath sounds and don't hear the
moist rales, this usually means a
presence of the pus in the pleural
cavity.

14. Pyothorax roentrenograms
At the X-ray the lung
field shadow (local or
total) is visible. This
shadow closes the
pleural sinus and has
an oblique upper
line. In case of the
total pyothorax the
upper line reaches
the pleural top.

15. To confirm the diagnosis the pleural
puncture at the 6th or 7th intercostal
space by linia axillaris media or
posterior should be done. Presence of
the pus in the pleural cavity confirms
the diagnosis of pyothorax, what
indicates a necessity for the pleural
tube insertion (drainage of the pleural
cavity).

16. Pleural puncture

17. Sometimes the abscess cavity empties
into the pleural cavity with formation
of the bronchial fistula between the
bronchus and pleural cavity. This
situation leads to pus and air
accumulation in the pleural cavity. This
complication is known as
pyopneumothorax. This is
complication is more severe than the
pyothorax.

18. In this case the severe condition of the patient
with pneumonia deteriorates significantly and
may be life-threatening. The dyspnea increases,
cyanosis and apprehension appear, the
additional muscles help to breathe. The
auscultation reveal the absence of breath
sounds, although a few hours before the moist
rales and coarse breath sounds will be heard.
During the percussion the tympanic sound,
which indicates presence of the air, is found. The
tension pyopneumothrax is followed with
progressive air accumulation in the pleural
cavity, what causes the mediastinum and heart
moved to the opposite side.

19. The tension pyopneumothrax is followed
with progressive air accumulation in the
pleural cavity, what causes the mediastinum
and heart shift to the opposite side. The
tension pyopneumothorax is life-
threatening condition, causing the acute
cardiac and respiratory insufficiency. The X-
ray shows the air and pus presence into the
pleural cavity with a clear horizontal line
between them. The lung is compressed.

20. Pyopneumothorax
roentrenograms

21. The treatment in this case is
emergency and includes the pleural
tube insertion. The system of the
passive aspiration should be
applied.

22. In case of the pneumothorax the air
accumulates it the pleural cavity. Like
the pyopneumothorax it may be tension
and non-tension and requires the
puncture of the pleural cavity to remove
the air. The puncture is done at the 2nd
or 3rd intercostal space by linia
clavicularis media. Sometimes a few
puncture should be done.

23. The emphysema of mediastinum is a rare
complication of the bacterial destructive
pneumonia. The presence of the air in the
mediastinum is always followed with its
spread to neck, where the subcutaneous
emphysema is visible. This symptom and X-
ray, which shows the presence of air in the
mediastinum, allow to make a correct
diagnosis. The local treatment of the
emphysema is a suprajugular
mediastinotomy and drainage of the
mediastinum.

24. X-ray symptom,
which shows the
presence of air
in the
mediastinum

25. All these complication of the pneumonia require a
general treatment as well, as mentioned above local
treatment. The general treatment includes the
antibiotherapy, infusion therapy, symptomatic therapy.
The antibiotherapy is begun with wide-spread
antibiotics, then this therapy is adjusted due to results
of the microbial sensitivity. The intravenous route for
antibiotherapy is preferable. Quite often the children
with bacterial destructive pneumonia need the oxygen.
The nasal cannulas or oxygen tent are used for this
purpose. The severe cases may require the ventilator
support.

26. Pleural effusion
Pleural effusion, a collection of fluid in
the pleural space, is rarely a primary
disease process ,it is usually secondary
to other diseases. Normally, the pleural
space may contain a small amount of
fluid (5 to 15 ml) acting as a lubricant
that allows the visceral and parietal
surfaces to move without friction.

27. In certain intrathoracic and systemic
diseases, fluid may accumulate in the
pleural space to the point where it
becomes clinically evident, and it is
almost always of pathologic
significance. The effusion can be a
relatively clear fluid, which may be a
transudate or an exudate, or it can be
blood, pus, or chyle.

28. The secondary bacterial destruction of
the lungs develops as a complication of
other purulent diseases. The most
common among these diseases is an
osteomyelitis. Usually the bacterias
reach the lungs through the
hematogenous route. Such pneumonia
have a double-side localization and may
be followed with any above-mentioned
complication (pyothorax,
pyopneumothorax)

29. A transudate (filtration of plasma that
move across intact capillary walls)
occurs when factors influencing
formation and reabsorption of pleural
fluid are altered, usually by imbalances
in hydrostatic or oncotic pressures. A
transudate indicates that a condition
such as ascites or a systemic disease
such as congestive heart failure or
renal failure underlies the fluid
accumulation.

30. An exudate (extravasation of fluid into
tissues/ cavity) usually results from
inflammation by bacterial products or
tumors involving the pleural surfaces.

31. Pleural effusion may be a complication
of tuberculosis, pneumonia, congestive
heart failure, pulmonary viral
infections, and neoplastic tumors.
Bronchogenic carcinoma is the most
common malignancy associated with a
pleural effusion.

32. Clinical Manifestations
Usually the clinical manifestations are those
caused by the underlying disease, pneumonia
will cause fever, chills, and pleuritic chest pain,
whereas malignant effusion may result in
dyspnea and coughing. A large quantity of
pleural effusion will cause shortness of breath
with dullness or flatness to percussion over
areas of fluid with minimal or absence of breath
sounds.

33. The presence of fluid is confirmed by
chest X-ray, ultrasound, physical
examination, and thoracentesis.
Pleural fluid is analyzed by bacterial
cultures, Gram stain, acid-fast bacillus
stain (for tuberculosis), red and white
blood сell counts, blood chemistry
studies (glucose, amylase, lactic
dehydrogenase, protein), and pH.

34. Pleural effusion Pleural empyema

35. The objectives of treatment are to
discover the underlying cause to
prevent fluid collection from recurring,
and to relieve discomfort and dyspnea.
Specific treatment is directed to the
underlying cause.

36. Thoracentesis is performed to remove fluid, to collect a
specimen for analysis, and to relieve dyspnea. If the
underlying cause is a malignancy, however, the
effusion may recur within a few days or weeks. Can be
repeated thoracentesis if there is pain, depletion of
protein and electrolytes, and sometimes
pneumothorax. In this event the patient may be
treated with chest tube drainage connected to a water-
seal drainage system or suction to evacuate the pleural
space and re-expand the lung. Sometimes tetracycline,
radioactive isotopes, or cytotoxic or other chemically
irritating drugs are instilled in the pleural space to
obliterate the pleural space and prevent further
accumulation of fluid.

37. After drug instillation, the chest tube is clamped
and the patient is assisted to assume various
positions to ensure uniform drug distribution and
to maximize drug contact with the pleural surfaces.
The tube is unclamped chest drainage is usually
continued several days longer to prevent
accumulation of fluid and to facilitate obliteration
of the pleural space by formation of adhesions
between the visceral and parietal pleurae. Other
modalities of treatment for malignant pleural
effusions include radiation of the chest wall,
surgical pleurectomy, and diuretic therapy. If the
pleural fluid is an exudate, more extensive
diagnostic procedures are performed to determine
the cause.

38. Spontaneous
pneumothorax
Pyopneumothorax

39. Pulmonary bulla

40. Let’s put the diagnose