The document discusses the management of suppurative lung diseases, specifically bronchiectasis and lung abscess, highlighting their definitions, etiologies, clinical features, and treatment options. It covers various management strategies including medical interventions, surgical options, and diagnostic imaging methods for effective disease management. The document emphasizes the importance of a multidisciplinary approach and outlines prognostic factors associated with these lung conditions.

1. Mgt of suppurative Lung Disease
(Bronchiectasis,lung Abscess)
Addis Ababa University,
black lion hospital
Presentor:- Doti G.( GSRlll)
Moderator:-Dr Samuel(CTSF2)
Oct 5,2021
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2.  Outline
 Introduction
 Bronchiectasis
 lung Abscess
2

3.  Objectives
 To know different types of SLD
 To describe the etiology & pathogenesis of
each ds
 To understand clinical features & DX of each
SLD
 To discuss the management modalities of
each SLD
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4.  Introduction
Anatomy of lungs
4

5.  Bronchopulmonary
segment-largest fxnal unit of anatomic
lobe
5
10 BPS 8-9 BPS
-main bronchus
-lobar bronchus
-segmental bronchus

6.  Intro---
SLD=Definition
 Suppuration:- ''pus forming''
 Suppurative lung diseases:-are disorders
associated with puss formation within the
lungs & are named according to site;
 Bronchi---------------Bronchiectasis
 lung parenchyma--- Lung abscess
 pleural space--------Empyema Thoracis
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7.  Bronchiectasis
 DEFINITION
 EPIDEMIOLOGY
 CLASSIFICATION
 AETIOLOGY
 PATHOPHYSIOLOGY
 CLINICAL FEATURES
 DIAGNOSIS/INVESTIGATIONS
 DDX
 MANAGEMENT OPTIONS
 CX'S & PROGNOSIS
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8.  Bronchiectasis
 This is an abnormal irreversible dilatation
of one or more bronchi or bronchioles,large
or small sized airways,with destruction of
their elastic and muscular components
 pseudobronchiectasis-temporary(wks-mo)
cylinderical dilatation of bronchi due acute
pneumonic process=No surgical implications
 Usually due to acute or chronic infection
resulting in recurent inflammation, airflow
obstruction & impaired clearance of secretions
 classified as an obstructive airway disease
 May be focal or diffused
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9.  EPIDEMIOLOGY
 Currently there are no estimates of
incidence but prevalence varies by
country,region and underlying aetiology.
 recent study in USA shows:-HRCT identified
bronchiectasis in 50% of pt Dx to have Chronic
Bronchitis or COPD by GP previously
 There is decline in its prevalence in
developed countries with emergence of
vaccines & antibiotics in the 20th century.
 still prevalent in developing country due to
emergency of drug-resistant microrg/MDR.TB
 Overall it increases with age
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10.  CLASSIFICATION
Pathological/radiologic
classification
1.cylinderical/Tubular
-Bronchi is dilated &
non-tapering
-Bronchi directly
communicate with lung
parenchymawithout tapering
-usually post TB infection
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11.  CLASSIFICATION----
2.Cystic/ Saccular
 Progressive dilation of
the airway which end in
saclike Cystic structure
 Resemble cluster of
grapes
 common in bacterial
pulmonary infection,
FB obstruction &
bronchial stricture
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12.  CLASSIFI------
 3.Varicose /Mixed
Bronchiectasis
-Areas of Dilatation
& Constriction
-Resembles
varicose vein
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13.  AETIOLOGY-
BRONCHIECTASIS
- in 50% of cases there is no initiating events
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 Congenital causes
 Cystic Fibrosis-chronic
resp.infection
 primary Ciliary
Dyskinesia
 alpha1-antitrypsin
deficiency
 Hypogammaglobunemia
 Tendency to have
Diffuse & Bilateral
distribution
 Acquired causes
 post infections
 Bacterial
-H.infleunza=1/3
-Mycobacterial TB-scarring
-MAC
 Viral
-measles,influenza

14.  AETIOLOGY-
BRONCHIECTASIS----
 fungi- Aspergillosis
 Mechanica obstruction
 intrinsic-FB Aspiration,tumor,mucus plug
 Extrinsic-lymph node,tumor
 Immune mediated diseases- post transplant
 Autoimmune /rheumatologic ds
 Toxic gas exposure-chlorine,ammonia gas
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15.  Pathogenesis
1.viscious cycle hypothesis
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-start with impaired defense Mzm
Bronchopulmonary
manifestations

16. 2.Atelectasis
-repeated inflammation increased mucus pxn
airway compression lung collapse airway obst-
Bronchopulmonary manifestations
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AIRWAY OBSTRUCTION Bronchopulmonary symptoms

17.  clinical presentations
 A typical patient has classical symptoms of
daily purulent, mucopurulent or mucoid
sputum discharge, cough, fatigue,
 Haemoptysis
 Recurrent pneumonia
 Dyspnea,exercise intolerance
 fever
 wheezing
 pleuritic chest pain
17

18.  clinical features---
 Non-specific signs
 pallor
 clubbing- Chronic hypoxia
 cyanosis
 tachycardia
 crackles/rales
 cor-pulmonale
 respiratory failure
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19.  Diagnosis
Imaging- CXR
 first imaging examination
 posterobasal segment of
lower lobes is mostly
involved
 bronchial wall thickening
 lobar collapse
 airway dilatation
 tram-track sign-parallel line
opacities-Cylinderical BE
 Heart displacement
 normal-mild cases
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20.  HRCT
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 Gold standard modality
 Confirms all cases
 97%sensitivity
 93-100% specificity
 airway dilatations
 signet ring( airway diameter
>1.5 times adjacent vessels)
 mediastinal shifting-the
same side

21. BRONCHOSCOPE
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 not routine, there
are indications
 Rigid bronchoscope
is prefered
-allows large sample

22. bronchography
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-Nowdays largely
replaced by HRCT
-Disadv=Contrast
associated S/E
=Cost

23.  Other investigations:-
to identify underlying causes
 PFT=FEV1 should 1.5L for lobectomy
 CBC
 Sweat chloride test->60meq/l & genetic
testing= CFTR protein-chloride channel-CysticFibrosis
 Sputum- Gram stain & culture for AFB,
bacteria & Fungi growth
 immunological tests
 Quantitative IgA,IgG & IgM levels
 Quantitative alpha1-antitrypsin levels
 Autoimmune serologic markers
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24.  Mgt- Bronchiectasis
MDT Approach
surgeon,pediatrician,physiotherapist involved
 Goals:-
 Eradication of infection
 RX of underlying causes
 Improve secretion clearance
 Relieving airway obstruction
 Reducing complications
 prevent exacerbations & improve quality of
life
 curative- in strictly localized ds
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25.  Mgt-Bronchiectasis
 Medical mgt
1.Antibiotics:- for post infectious causes
 Imperical broad spectrum against most
suspicious pathogens
 start with B-lactam ABC's-Amoxacilline
 can be modified according to CST
 7-14days IV ABC's for acute exacerbations
-Monitor clinical & radiologic response
 Anti-TB =mycobacterial tuberculosis
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26.  Mgt----
2. Bronchial Hygiene/Airway clearance
-Hydration-improves mucociliary activities
-Mucolytics- eg Guafinosine
-bronchodilators:-alph2 agonist
-Hyperosmolar agents-eg.saline salt
-chest physiotherapy
-postural drainage
-active breath cycles-ballon inflation
-manual techniques-eg chest clapping/blow
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27.  Mgt-----
3.Supportive Measures
-Anti-inflammatory drugs-Halt ds progression
-Smoking cessation=improve mucociliary fxn
-Nutritional supplements=eg,vitamines
-Oxygen therapy for severe cases
 Allergic Bronchopulmonary Aspergillosis
-oral corticosteroid + AZOLE antifungal
 -Immunoglobulin def-= IV Immunoglobulin
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28.  Surgical mgt
 options:-
1. Thoracoscopic/ VATS Lung Resection
2. Open Thoracotomy + Lung resection
(lobectomy or segementectomy)
indications:-
 refractory to optimal medical therapy
 Massive Haemoptsis- eg,post TB
bronchiectasis( pulmonary artery laceration)
 unilateral-segmental or lobar distribution
 bilateral-not more than one lobe in each lung
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29.  Surgical techniques
 Preoperative planning
 Po Antibiotics for 10 days before surgery
 chest physiotherapy should started 10d pre-op
-Smokers- should stop smoking for 6-8wks
- FEV1 >1.5L for lobectomy
> 2l for pneumonectomy
 position:- lateral decubitus position
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30.  Surgical techniques
Left lower Lobectomy
 Posterolateral incision
prefered:-
-Bcoz it provide bird's
eye view of fissure b/n
lul & lower lobe
Disadv=muscle
resection
landmarks-
30
4th-6th ICS

31.  surgical steps
 The open LL lobectomy for bronchiectasis
involves 3 main steps:
 in contrast to lung ca lobectomy( vein 1st
principle), pA ligation preceeds vein.
 (1) ligation of the interlobar basal
pulmonary artery,
 (2) ligation of the inferior pulmonary vein
(IPV),
 (3) division of the lower lobe bronchus.
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32.  step1:- Division of
interlobar basal PA
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33. Step2:- Division of IPV 33
IPV

34.  step3:- Division of LLLB 34

35. postop care
 Aim:-To prevent common postop cx's
such as pain, atelectasis & pneumonia
 postop Analgesia
-essential to prevent postop resp cx's
-facilitate pt cough & walk ability
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36.  postop care----
 options
 Thoracic Epidural Anesthasia
-mixture of LA & Narcotics used
-Gold standard
 paravertabral catheter-LA
 paravertaberal blocks
 NSAID
 Narcotics-
 Neuroleptic- Gabapentin
- if intercostal nerve bundle compression is likely
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37.  Respiratory physiotherapy
 Lung expansion techniques :-includes
 incentive spirometry,
 deep breathing exercises,
 postural drainage, percussion & vibration,
coughing, suctioning,
 continuous positive airway pressure (CPAP).
 DVT prophylaxis-UFH/LMWH after 24hrs
 GI prophylaxis- stress gastritis= IV cimitidine
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38.  mgt----last option
lung Transplantation
-End stage ds-Disseminated BE
Bilateral, all lobes bronchiectasis
38

39.  prognosis(PX)
poor pxtic factors includes
 life threatening haemoptysis
 Bilateral lung involvement
 Associated lung abscess
 Malnutrition
 Chronic anemia
 frequency of exacerbation
 Specific pathogens:-
p.aeroginosa,Aspergillus ,MAC
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40.  LUNG ABSCESS
 INTRODUCTION
 CLASSIFICATION
 AETIOLOGY
 PATHOGENESIS
 CF
 DX
 MGT
40

41.  Lung Abscess
introduction
 lung Abscess is necrosis of pulmonary tissue
& formation of cavities( >2cm) containing
necrotic debris or pus caused by microbial
infection
 formation of multiple small(<2cm) abscesses
is called Necrotizing pneuminia or lung
gangrene
 More common in Male & older age
 in the pre-antibiotic era 1/3 of pt died
 Nowdays most of uncomplicated LA respond
to prolonged Antibiotic therapy
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42.  Classification
lung Abscess
 Duration:- Acute(<6wks),subacute(6-12wk)or
chronic(>12wks)
 Origins:primary LA=aspiration or pneumonia
Secondary LA- obstruction(FB,tumor)
-Bronchiectasis,BEF
-spread from Extra p.site
eg.perforated Appendix
 setup:-Community Acquired LA= Anaerobic oral flora
-Hospital Acquired LA= aerobic organisms. eg P.aerginosa
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43.  Aetiology
based on pathophysiology
 Aspiration pneumonia from oropharyngeal
flora
 Dental/periodontal sepsis
 paranasal sinus infection
 Depressed conscious level
-Alcohol/sedative abuse
-Anaesthesia
-Epilepsy
-Head injury/Coma
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44.  Aetiology----
 Impaired Larygeal Closure
-prolonged ET intubation
-recurrent laryngeal nerve palsy
 Disturbance of swallowing
-oesophageal stricture,Achalasia, GERD
 Haematogenous spread from a distal site
-UTI, Abdominal sepsis,Amebic liver Abscess
44

45.  pathognesis
bacteria reach lower airway
( not cleared by DEFENSE MZM)-mucociliary dfs
ASPIRATION PNEUMONITIS
7-14 days later
TISSUE NECROSIS EMPYEMA( BPF).
LUNG ABSCESS
45
Bacteremia(
haematogenous/septic emboli)
Impaired host defense mzm
Distant focus
eg.abdominal sepsis

46.  CF-LUNG ABSCESS
 The typical pt presents with a hx of an
antecedent event suspicious for aspiration,
pulmonary infection, or pneumonia.
 productive cough, foul breath,fever
rigors,fatigue,,dyspnea,hemoptysis
 absence of fever or leucocytosis suggest
non-infectious cause of LA
 95% of LA occur in posterior segment of Upper lobe
& superior segment of Lower lobes.
 DX is by IMAGING
 CXR,BRONCHOSCOPE & HRCT scan
46

47.  CXR
 Abscess is often
unilateral & single
involving posterior
segments of the
upper lobes & the
apical segment of
lower lobe due to
gravitywhile lying
down
 Air-fluid level
47
Air fluid level

48. CT-lung Abscess
48
 Absecss in lt upper
lobe thick & irregular
wall air -fluid level
 Does not cross
fissures

49. A)Multiple cavitation,Disseminated
infiltration & B)fistulization
49
bronchopleural fistula
causing empyema &
pneumothorax
sagital view
Axialview

50.  Microbiologic studies
 Samples: sputum, BAL,Transtracheal
aspiration,transthoracic needle aspiration
under CT guidance
 All above specimens for:-
-Gram stain
-CST
-cytology
 Bronchoscope- R/O obstructive lesions
- Bronchial drainage(Rx)
 CBC,ESR,CRP- non-specific
50

51.  Mgt
1.Medical Mgt
 ANTIBIOTICS
-Targeted & prolonged (6-8wks)ABC is Mainstay of Rx
- start with abc against suspected pathogens
-comminity Acquired LA- clindamycine/metr
-Hospt Acquired= ciprofloxacilline
@ 90% of pt (aerobic LA)respond to ABC alone
 Chest physiotherapy-aggressive
 Internal drainage- bronchoscopic lavage
51

52. if pt not respond to above
measures-sx's/cavity persist
 External drainage( Acute stage)
 Closed- tube thoracostomy
 CT-guided catheter drainage
 pneumonostomy(cavernostomy)
 open drainage(chronic stage)
-thoracotomy + drainage
 if no response to above measures
about 10% of pts require surgical
intervention as last option
52

53. 2.Surgical Mgt
 Surgical Indications
 Failed Medical Therapy
 abscess cavity >6cm after 8wk of RX
 Persistant endobronchial obstruction
 Formation of an EMPHYEMA
 Hemorrhage
 Bronchopleural fistula
 Inability to rule out Malignancy
53

54.  Surgical indications 54

55.  Surgical options
1.OPEN SURGERY/Thoracotomy
 Anatomic Lobectomy-prefered
 pneumonectomy- avoid if possible for benign
disease
Note:@All bronchial stump should be covered
-Intercostal Muscle, omentum,
pleural flap,pericardial fat pad
2.VATS Thoracotomy-less invasive
-less postop cx's
55

56.  Mgt Algorithm/Summary
Lung Abscess
56

57. References 57
MEDSCAPE.COM

58. THANK YOU
For your Attention
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