Suppurative lung diseases & lung cancer

1. Suppurative
Lung Diseases
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-
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Dr. Wondwossen M.

2. Introduction
• ↓ incidence after 1940s……..Penicillin
• Resurgence of lung abscess &
empyema
 Antibiotics resistant organisms
 ↑ immunosuppressed individuals
 Dv’t of drug abuse culture
 ↑ aging population

3. BRONCHIECTASIS

4. BRONCHIECTASIS
Abnormal & permanent dilatation of bronchi
• Classification
• Focal / Diffuse
• Cylindrical / Varicose / Saccular
Cylindrical bronchiectasis - bronchi appear as uniformly
dilated tubes
Varicose bronchiectasis – bronchi have irregular pattern
of dilatation
Saccular bronchiectasis - bronchi have a ballooned
appearance

6. INFECTIOUS
Viral
Bacterial
Mycobacterial
NON- INFECTIOUS
Inhalation of toxic
gas
Aspiration
Immune response
Congenital
Etiology

7. Pathogenesis
Is a consequence of inflammation & destruction of
of bronchial wall (major & minor bronchi)
INFLAMMATION (INFECTION)
 release of toxins & proteases
 bronchial wall damage
 impaired clearance of micro
organisms
 further chronic infection
more inflammation
 more airway destruction

8. • Persistent recurrent cough
• Copious production of foul smelling sputum
• Haemoptysis (50-70%)
• Halitosis
• P/E –crackles ,ronchi , wheezes reflect
damaged airways containing significant secretions
• - clubbing
- cor- pulmonale - pts with diffuse severe
disease particularly those with chronic hypoxemia
Clinical manifestations

9. • CBC
• Chest x-ray
• CT- scan
• Broncoscopy
• determine the specific segmental location of secretions
• detect foreign body, bronchial stenosis or neoplasm
• Sputum exam, staining & culture – may guide
antibiotic Rx
• Measurement of sweat chloride levels for cystic
fibrosis
Investigations

11. TREATMENT
1. Medical Rx
 Antibiotics
 Pulmonary toilet (postural drainage)
 Bronchodilators & steroids
 In patients with airflow obstruction, to enhance
airway patency
2. Surgical Rx
 Indicated for pts wit
 Localized (focal) bronchiectasis
 Proximal obstructive lesion
 Massive hemoptysis
 Recurrent infections
 Involves segmental resection of affected
area

12. THORACIC
EMPYEMA

13. THORACIC EMPYEMA
Defn-
 Presence of infected fluid or frank pus in
pleural cavity
 If not treated early
- pleural thickening surrounding the
walled of cavity + restricted lung mov’t
as a result of fibrosis

14. Etiology
1.Spread of infection from contagious
organs(2/3rd )
- Lungs-unresolved pneumonia, bronchiectasis, TB &
lung abscess
- Esophagus- perforations , post esophagectomy
- Spine & ribs – osteomyelitis
- Subdiaphragmatic – subphrenic & paracolic
abscesses
2. Direct inoculation (1/3rd )
- penetrating injuries of chest
- Iatrogenic infections – chest drains, post surgical

15. Bacteriology
Adults
- usually monomicrobial.
S. aureus, Strept. pneumonia, & Strept
pyogens
- In immunocompromised
Polymicobial & fungal infxn
children
<6 mths S. aureus
6/12 to 2 yrs S aureus, strept pneumonia & H. Inf
2 – 5yrs H. INFLUENZAE

16. Stages of Empyema
stage Main feature
I- Exudative phase Turbid thin fluid , minimal
pleural thickening &
mobile underlying lung
II- Fibropurulent Bacterial invasion of
effusion
Deposition of fibrin on
pleural surfaces
Loculation begins
III- Organizing Fibroblast proliferation &
scar formn. → lung
entrapment

17. Diagnosis
Assessment Finding
Clinical •Swinging pyrexia
•Cough, Dyspnoea
•chest pain
•Clubing & wt loss
•Signs of fluid
•Pus discharge
Laboratory Leukocytosis
↑ CRP & ESR
Radiology Abnormal PA & lateral CXR
U/S , CT

19. Treatment
Principle of Rx
> Control of infection – appropriate antibiotics
> Drainage of pus → lung expansion
Depends on the stage of Empyema
 Exudative phase  Antibiotic + thoracentesis
 Fibropurulent phase Chest tube + Antibiotic
 Organizing Phase Decortication

20. LUNG ABSCESS

21. LUNG ABSCESS
Defn:- A localized area of suppuration &
cavitation in the lung wit parenchyma
necrosis.
- Commonly affect
 Posterior segment of the
upper lobe
 Superior segment of lower
lobe

22. Risk factors
Dental caries & periodontal disease
Decreased state of consciousness
• Anesthesia
• Alcohol abuse
• Coma
• Convulsive disorders
Immunosupression
• Steroid Rx
• Malnutrition
• AIDS

23. Bacteriology
 Primary (aspiration, putrid, anaerobic)
Staphylococcus, peptococci, Bacteroides fragilis
 Immunocompromised
- Pseudomonas aeruginosa
- Proteus
- Aerobacter
- E Coli
- C albicans
- Legionella pneumophilia

24. Diagnosis
C/f - Sudden onset of cough, chest pain & fever
- Foul smelling sputum + haemoptysis
- Presence of contributing factor
Investigation
1. Sputum for gm stain/culture
2. CXR – cavitating shadow with air fluid level
3. CT–scan…… cavitation within an area of
consolidation
4. Bronchoscopy

26. TREATMENT
1. Conservative
 IV Antibiotics: PCN & metronidazole
- effective in 90% of cases
- for 4 -12 wks
 Internal drainage (Postural percussion,
coughing)
2. SURGERY
Indications:
• Failure of antibiotic therapy
• Massive hemoptysis
• Inability to rule out carcinoma
• Giant abscess (> 6cm in diameter)
• Rupture with a resultant empyema

27. Complications
 Pyopneumothorax rupture into pleura
cavity
 Metastatic intracranial abscess
 Septicemia

28. LUNG CANCER

29. Accounts for 90-95% of all lung tumors.
Leading common cancer in men & women.
• Accounts for 32% in men & for 25% of all cancer deaths
in women.
1.04 million new cases every year world wide.
Incidence: Males:80/100,000,Females:
40/100,000
80-90% of cases are inoperable at diagnosis &
86% of them die in the first years.

30. Highest incidence > 75
years, peaking at 80.
Male : female ratio - 1.14 : 1
Incidence rate has been
declining for men due to
reduction in smoking
Incidence increasing for
women due to increase in
cigarette smoking

31. Risk factors
SMOKING !!!
Age-Older age
Asbestos,
arsenic, mustard
Pulmonary
scar
Family history

32. Cigarette smoking
• Tobacco contains at least 55
known carcinogens.
• The cause in as many as 90%
of patients
• RISK 13.3x than Never-smoker
• Once a person quits smoking
• Risk gradually decreases
• Never returns to never-
smoker level

33. • Duration of smoking
• Numbers smoked
• Pattern of smoking
• Active Vs Passive

34. Active Vs Passive
Smoker

35. 1 hr of hookah is equal to smoking 40-400
cigarettes.
1 hr of hookah exposes the smoker to 100-200x
the amount of smoke inhaled from 1 cigarette

38. WHO classification
Non-small cell carcinoma ~ 75%
• Adenocarcinoma
• Squamous cell carcinoma
• Large cell carcinoma
• Adeno-Squamous cell carcinoma
Small cell carcinoma ~ 25%
• Oat cell carcinoma
• Intermediate cell type
• Combined oat cell carcinoma

39. Adenocarcinoma
Accounts for 30-35% of
lung cancers
Most common type in
Non-smokers & Females
Often Peripheral Location
May arise from scars
“Scar carcinoma”

40. Squamous cell carcinoma
Accounts for 25-30%
of lung cancers
Essentially a
disease of Smokers
More common in
Males
Centrally Located

41. Small cell carcinoma
Accounts
for 15-25%
of lung
cancers
> 95% are
current or
past
Smokers
The Most
Malignant
type
Usually
central
Para-
neoplastic
syndrome

42. Clinical presentation
Manifestation depends on
1. Primary tumor location
• Peripheral
 Cough
 Dyspnea
 Pleural effusion
 Chest pain
• Endo –bronchial / Central
Cough, dyspnea
Hemoptysis
Atelectasis
Post-obstructive pneumonia
Wheezing

43. 2. Extension into adjacent structures
• Pleural
effusion……………….........
• Hoarseness…………………
……………
• Dysphagia……………………
………….
• Diaphragm
paralysis……………..
• Rib
destruction……………………
…
• SVC
 Spread to the pleura
 RLN invasion
 Esophageal invasion
 Phrenic nerve invasion
 Chest wall invasion
 SVC compression
 Sympathetic ganglia
 Pericardial invasion
 C8-T2 invasion

44. 3. Systemic effect due to hormonal
syndromes
• Typical for small cell cancers
 ADH…………………….Water Retention
 ACTH…………………..Cushing
Syndrome
 Parathyroid
Hormone………Hypercalcemia

45. 4. Presence of metastases
• Lymphogenous:
 To regional lymph nodes
• Haematogenous:
 Liver 40%, Bones 40%, Brain 15%
• Tracheobronchial spread: uncommon

46. Diagnostic work up:
CBC,RFT,LFT
CXR
Sputum Cytology
CT- scan
Bronchoscopy
Bone & Brain scan

47. Treatment
Non small cell Lung Ca
• Surgery
• Radiotherapy
• Chemotherapy
Small cell Lung Ca
• Chemo-radiation

48. Solitary Pulmonary Nodule(SPN)
• SPN is defined radiographically as an
intrapulmonary lung lesion < 3 cm in diameter
that is not associated with adenopathy or
atelectasis.
• A lesion larger than 3 cm is considered a
mass.
• SPN should be considered malignant until
proved otherwise.
• Malignancy rate increases with age.
• Most are asymptomatic

49. • Nodules are benign if they;
 Are unchanged on CXR over 2 years
 < 2cms
 Have symmetrical patterns of calcification
 Well-circumscribed smooth borders
 Have Central fat on chest CT.
• Nodules are malignant if they:
 Growing
 > 2 cms
 Spiculated & irregular border
 Irregular eccentric calcification
 Older patients
 Smoking history

50. Differential diagnosis
Benign
Hamartoma
Tuberculosis
Histoplasmosis
Coccidioidomycosis
Malignant
• Bronchogenic Ca.
• Pulmonary adenoma
• Carcinoid tumor
• Metastasis

51. Thank
you