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![Causes…
E)Haematogenous spread from a distal site [from
other infection as septic emboli]
Urinary tract infection
Abdominal sepsis
Pelvic sepsis
Infective endocarditis (right-sided)
Intravenous drug abuse
Infected IV cannulae
Septic thrombophlebitis
Salpingitis
Appendicitis
Pyaemia/ Septicaemia](https://image.slidesharecdn.com/lungabscess-230525155641-ad794246/85/LUNG-ABSCESS-pptx-40-320.jpg)
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LUNG ABSCESS.pptx
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- 3. Riskfactorand etiologylung abscess Clinical Manifestationlung abscess CMDlungAbscess Managementlung abscess 06 07 0910 Tableofcontents 08 Pathophysiology lungabscess
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- 6. Definition • Pneumonia isan acute infectionofthe parenchyma of the lung, caused by bacteria, fungi,virus,parasite etc. • Pneumoniamayalsobe causedby otherfactors including X-ray, chemical,allergen
- 7. Classification • Classification ofanatomy • Classification of pathogen • Classification of acquired environment
- 8. Ⅰ.Classificationbypathogen Pathogen classification is the mostuseful to treat the patients by choosing effective antimicrobial agents
- 9. Bacterialpneumonia (1) Aerobic Gram-positivebacteria,such as streptococcus pneumoniae, staphy- lococcus aureus, Group A hemolytic streptococci (2) Aerobic Gram-negative bacteria, such as klebsiella pneumoniae, Hemophilus influenzae, Escherichia coli (3) Anaerobicbacteria
- 10. Atypical pneumonia Including Legionnaiespneumonia , Mycoplasmal pneumonia ,chlamydia pneumonia. Fungal pneumonia Fungal pneumonia is commonly caused by candida and aspergilosis
- 11. Viral pneumonia Viral pneumoniamay be caused by adenoviruses, respiratory syncytial virus , influenza, cytomegalovirus, herpes simplex
- 12. Ⅱ.Classification by anatomy 1.Lobar: Involvement of an entire lobe 2. Lobular: Involvement of parts of the lobe only, segmental or of alveoli contiguous to bronchi (bronchopneumonia). 3. Interstitial
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- 15. Classificationbyacquired environment ◆Community acquired pneumonia，CAP ◆Hospital acquired pneumonia ，HAP ， NP ◆Nursing home acquired pneumonia, NHAP ◆Immunocompromised host pneumonia, ICAP
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- 17. Overview ◆ Pneumonia canresult from a variety of causes, including infection with bacteria, viruses, fungi, parasites, and chemical or physical injury to the lungs ◆ Source of Infection ◆ Aerosol ◆ Aspiration of amniotic fluid ◆ Blood-borne infection across the placenta
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- 20. Overview ◆ The riskfactors for pneumonia include: smoking, age>65, immuno-suppression, exposure to chemicals, and underlying lung disease.
- 21. Risk Factors ◆ AirwayObstruction ◆When part of the airway (bronchi)leading to the alveoli is obstructed, lead to infection of the fluid resulting in community-acquired pneumonia (CAP) ◆ Another cause of obstruction is lungcancer ◆ LungDisease ◆ Smoking, and diseases such as emphysema, result in more frequent and severe bouts of CAP ◆ ImmuneCompromise ◆ more likely to get CAP ◆ active malignancy,immuno-suppression, neurological disease, congestive heart failure, coronaryartery disease, and diabetes mellitus
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- 23. Clinicalmanifestations(1) • Many patientshave had an upperrespiratoryinfectionfor several days before the onset of pneumonia • Onset usually is sudden, half caseswith a shaking chill • The temperature rises during the first few hours to 39- 40℃
- 24. Clinicalmanifestations(2) • Typically, patientshave the symptoms of high fever , shaking chill, sharp chest pain, cough, dyspnea and blood-flecked sputum. • But in some cases, especially those at age extremes symptoms may be more insidious.
- 25. • The pulseaccelerates • Sharp pain in the involved hemi thorax • The cough is initially dry with pinkish or blood-flecked sputum • Gastrointestinal symptoms such as, anorexia, nausea, vomiting abdominal pain, diarrhea may be mistaken as acute abdominal inflammation Clinicalmanifestations(3)
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- 29. • A lungabscess is a localized area of destruction of lung parenchyma (usually >2 cm in diameter) • Infection by pyogenic organisms results in tissue necrosis • Manifested radiologically as a cavity with air fluid level Definition
- 30. Classification Lung abscess maybe single or multiple and they frequently containair-fluid levels Lung abscesses can be classified based on the duration & the likely etiology Acute abscess Chronic abscess
- 31. Acute patient presents withsymptoms of <2weeks duration more likely to have an infection caused by a virulent aerobic bacterial agent (e.g. S. aureus)
- 32. Acute Lung Abscess CXRof a patient who had foul-smelling & bad tasting sputum, an almost diagnostic feature of anaerobic lung abscess
- 33. Classification… Clinically useful duringinitial evaluation Chronic: A chronic lung abscess is defined by symptoms lasting for > 4 to 6 weeks. Patients more like to have an underlying neoplasm or infection with a less virulentanaerobicagent
- 34. Primary abscess caused byaspirationor pneumonia in the healthy host Mostly result from necrosis in an existing parenchymal process, usually untreated or aspiration pneumonia
- 35. Classification… Secondary abscess iscaused by Pre-existing condition eg bronchiectasis Bronchial obstruction (eg- aspirated foreign body) An immuno-compromised state Spread from an extra-pulmonary site Abscess that complicates either a septic vascular embolus (eg- right sided endocarditis)
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- 37. Causes of Lungabscess (A) Aspiration A) Aspiration of infected material containing oropharyngeal flora (commonest cause) Organisms are anaerobic and aerobic May be due to Dental/ periodontal sepsis esp following tooth extraction, tonsillectomy and nasal operation Paranasal sinus infection
- 38. Causes… B) Necrotizing Pneumonia/ Inadequately Treated Pneumonia Aerobic bacteria (eg- Staphylococcus aureus, Strepto. Pneumoniae, Streptococcus milleri/intermedius, Klebsiella pneumoniae, Pseudomonas aeruginosa ) Anaerobic bacteria Others: Mycobacteria Fungal Parasites
- 39. Causes… C) Mechanical Bronchialobstruction by Tumour (Bronchial carcinoma/ Adenoma) Foreign body Enlarged lymph nodes Congenital abnormality – bronchial stenosis D) Pre-existing lung disease Bronchiectasis Cystic fibrosis
- 40. Causes… E)Haematogenous spread froma distal site [from other infection as septic emboli] Urinary tract infection Abdominal sepsis Pelvic sepsis Infective endocarditis (right-sided) Intravenous drug abuse Infected IV cannulae Septic thrombophlebitis Salpingitis Appendicitis Pyaemia/ Septicaemia
- 41. Causes… F) Extension fromextra-pulmonary abscess/( transdiaphragmatic spread) liver abscess subphrenic abscess Mediastinal abscess G) Trauma/ Post traumatic Infected pulmonary haematoma Contaminated foreign body H) Immunodeficiency Primary or Acquired
- 42. RISK FACTORS FOR GRAMNEGATIVE COLONIZATION 1. Malnutrition 2. Severe illness 3. Coma 4. Intubation 5. Diabetes 6. Prior surgery 7. Lung disease 1. Lung disease 2. Renal failure 3. Prior antibiotic uses 4. Hypotension 5. Cigarette smoking 6. Prolonged hospitalization
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- 44. Symptoms … Patients presentwith Severe cough with Profuse foul smelling sputum, may be foetid There may be large amounts of purulent sputum once a bronchial communication has been established Putrid sputum is a highly specific symptoms pathognomonic for anaerobic infection although present in only 50-60% of patients that is Haemoptysis (25% of patients) – not uncommon and may be life- threatening
- 45. Symptoms … Chest pain(pleuritic or deep-seated aching discomfort) – 60% of patients Fever – usually high with chill & rigor, profuse night sweating Constitutional upset like- malaise, weakness Weight loss (60% of patients) – with an average loss of between 15 & 20 lbs Anorexia Symptoms of associated disease process eg- Bronchial obstruction due to lung cancer Oesophageal obstruction due to achalasia Right-sided endocarditis Dyspnoea
- 46. Symptoms … In mostpatients, presentation is insidious with symptoms lasting at least 2 weeks before presentation History Includes risk factors for aspiration, eg- Alcoholism Drug overdose Seizures Head injury Stroke Absence of such risk factors should prompt a search for a diagnosis other than primary lung abscess
- 47. Signs There is nosigns specific for lung abscess Patient is toxic with high temperature & Halitosis Clubbing may develop within few weeks if treatment is inadequate usually in 10% cases after 3 weeks
- 48. Signs… On chest exam Evidence of consolidation Dullness to percussion and diminished breath sounds, if the abscess is large and situated near the surface of the lung The ‘amorphic’ or ‘cavernous’ breath sound traditionally associated with lung cavities are rarely elicited in modern practice
- 49. Features Of SevereAspiration Pneumonia Chest radiographic findings 50% increase in the infiltrate in 48 hours Respiratory rate >30 breaths/min SIRS (systemic inflammatory Presence of shock Urine output <<20 mL/h Bilateral multilobar involvement Severe lung injury (PaO2/FIO2 response syndrome) or need for vasopressors to support blood pressure ratio <<250 mm Hg) Acute renal failure requiring dialysis
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- 54. Investigations 1.CBC 2.X-ray chest P/Aview & lateral view 3.Sputum examination : Gram staining C/S (aerobic & anaerobic) AFB, fungus & malignant cells 4.FOB 5.CT scan of chest in some cases 6.Blood sugar
- 55. Investigations CBC Neutrophilic Leukocytosis WBC count may exceed 20,000 Elevated ESR Anaemia of chronic inflammation
- 56. Imaging Studies… X-ray chest Radiographicabnormality may start with a pneumonic infiltrate followed by the development of one or more spherical areas of more homogeneous density in which air-fluid levels often arise indicating the formation of a bronchial communication
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- 59. Treatment Principles: Sputum is sentfor C/S & broad-spectrum antibiotic should be started Postural drainage & chest physiotherapy Surgery Treatment of the cause if any
- 60. Treatment… Antimicrobials Currently the mainstayof therapy is antimicrobial therapy Antibiotics should be given according to the culture & sensitivity for prolonged period Commonly sputum is sent for C/S and a broad-spectrum antibiotic should be started
- 61. Treatment… The majority ofpatients are treated empirically Most lung abscess pathogens are sensitive to conventional antimicrobial therapy Majority of lung abscesses are related to aspiration and are caused by anaerobes About 90% of patients with anaerobic lung abscess responds to medical treatment
- 62. Treatment… Clindamycin associated withfewer treatment failure & a shorter time to symptom resolution than penicillin May be preferable to other agents. Dose is 600 mg IV every 6-8 hourly Switching to oral therapy at a dose of 300 mg every 6-8 hourly when the patient improves
- 63. Treatment… Antibiotic Regimen ForAspiration Pneumonia Clindamycin + fluoroquinolone Clindamycin + aminoglycosides Clindamycin + third/fourth generation cepalosporin Imipenem/meropenem
- 64. Treatment… Antimicrobial options forcommon infecting bacteria Organism Antimicrobial options Staph. aureus Flucloxacillin, clindamycin Pseudomonas aeruginosa Ciprofloxacin, piperacillin- tazobactam, aztreonam, meropenem, aminoglycosides, ceftazidime/cefepime Enterobacter spp. Ciprofloxacin, meropenem, aminoglycosides
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- 66. Differential diagnosis/Clinically Consolidation (duringresolution stage), usually no clubbing Bronchiectasis Bronchial carcinoma, usually Squamous cell carcinoma Pulmonary tuberculosis (without causing abscess) Rare infections, including – Actinomycosis, Nocardiasis, Fungal pneumonia
- 67. Differential diagnosis (Contd) InLung abscess Fever, systemic complaints purulent sputum and WBC count >11x109/L more likely to be found Response to antibiotic therapy
- 68. Differential diagnosis…/Radiologically Necrosis ina lung tumour Age more than 50 years No history suggestive of aspiration Lesions need not be situated in a typically dependent segment of the lung In CXR: an eccentric cavity with thick irregular walls
- 69. Lung abscess Empyema Fever,systemic complaints Purulent infection ,confined to pleural space Purulent sputum Can developed as a complication, or be a cause, of a lung abscess WBC count >11x109/L If an empyema contains an air-fluid level, then a broncho-pleural fistula is likely to be present Response to antibiotic therapy Often difficult to distinguish radiographically between a localized empyema with a bronchopleural fistula and a lung abscess. In CT - wall is of varying thickness with an irregular itraluminal margin and exterior surface. Seen on the lateral Chest X-ray as a D- shaped opacity with the convexity projecting Anteriorly from the Posterior Chest wall. Differential diagnosis…/Radiologically
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- 71. Prevention Prevention of aspirationis important to minimize the risk of lung abscess Vomiting patients should be placed on their sides Improving oral hygiene and dental care in elderly and debilitated patients Positioning the supine patient at a 30° reclined angle minimizes the risk of aspiration Early intubation in patients who have diminished ability to protect the airway from massive aspiration (cough, gag reflexes), should be considered
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- 73. Reference: 1. Gutierrez G.Baum's Textbook of Pulmonary Diseases, 7th Edition. Crit Care. 2005;9(5):E15. doi: 10.1186/cc3717. Epub 2005 May 12. PMCID: PMC4082226. 2. TATTERSFIELD A. Crofton and Douglas's respiratory diseases, 5th edition. Occup Environ Med. 2001 Feb;58(2):137. doi: 10.1136/oem.58.2.137a. PMCID: PMC1740100. 3. Longo, Dan; Fauci, Anthony; Kasper, Dennis; Hauser, Stephen; Jameson, J.; and Loscalzo, Joseph. Harrisons Manual of Medicine, 18th Edition. US: McGraw-Hill Professional, 2012.