1. Chronic Lung Sepsis
Dr. Arun Nair

2. Includes
Lung Abscess
Empyema
Bronchiectasis

3. Lung Abscess

5. Lung Abscess

6. Definition & overview
Cavitating, infected, necrotic lesion of lung parenchyma
Several possible causes
Single or Multiple
Small <2cm or large
Most secondary to aspiration of oropharyngeal secretions
Mixed growth of organisms, including anaerobes

7. Causes Aspiration Bronchial obstruction {Tumour / Foreign Body}
Pneumonia
Blood borne infection
Transdiaphragmatic spread

8. Differential Diagnosis
Cavitating tumour
Infected bronchial cyst/bulla
Localised saccular bronchiectasis
Aspergilloma
Wegeners granulomatosis
Hydatid cyst
Gas-fluid level in oesophagus, stomach or bowel

9. Microbiology
Anaerobes: Peptostreptococcus, Prevotella, Bacteroides spp (usually not B. fragilis), and Fusobacterium spp.
Staph Aureus, Klebsiella, Strep Milleri
Strep Pneumonia, gram negative bacilli
M.Tuberculosis
Fungi

10. Clinical Features Most patients present over several weeks
Malaise, weight loss, fever
Cough with copious purulent sputum
Can be associated with haemoptysis
Toxic features prominent in patients with pneumonia or blood borne infection
Clubbing often seen

11. Investigations CXR: PA & Lateral CT Thorax Sputum & Blood Cultures
FBC, CRP, ESR, Serological tests

12. Treatment AUGMENTIN AMOXIXCILLIN & METRONIDAZOLE CLINDAMYCIN
Physiotherapy & postural drainage
Trans Thoracic/ endoscopic drainage for large abscess
Duration of ABx:
3- 4 weeks

13. Empyema Pus in pleural space
Sequelae of a complicated parapneumonic infection, when bacteria invade pleural space
Uncomplicated
Complicated
Frank Empyema

14. Pathogenesis Uncomplicated parapneumonic effusion —
occurs when the lung interstitial fluid increases during pneumonia, and is characterized by "exudative" pleural fluid chemistries and an influx of neutrophils into the pleural space.
resolve with resolution of the pneumonia.

15. Complicated Parapneumonic effusion
occurs when there is persistent bacterial invasion of the pleural space.
Results in pleural fluid acidosis (anaerobic utilization). Lysis of neutrophils increases the LDH concentration in the pleural fluid to values often in excess of 1000 IU/L.
Complicated parapneumonic effusions are often sterile because bacteria can be cleared rapidly from the pleural space. (Loculation )

16. Thoracic Empyema
Formation of empyema is the third stage and is characterized by bacterial organisms seen on gram stain or the aspiration of pus on thoracentesis.
A positive culture is not required for diagnosis.

17. Bacteriology Mixed bacterial flora Anaerobic bacteria in 36-76%
Streptococcus milleri, Staphylococcus aureus, and Enterobacteriaceae.
Patients with diabetes mellitus are at increased risk of empyema secondary to Klebsiella pneumoniae.
S. pneumoniae and S. aureus (including methicillin-resistant organisms) are the leading causative bacteria in children with empyema.

18. Pleural fluid analysis
Pus
Ph <7.2
Glucose < 60 mg/dl
LDH>1000 IU/L
WBC>15/nl

19. Imaging
CXR CT
USG

20. Signs favouring empyema
Evidence of lung compression
Smooth margins
Blunt angle with chest wall
Dissection of thickened visceral and parietal pleura

21. Treatment Pleural drainage Chest Drain Thoracoscopy Antibiotics
Fibrinolytics: No convincing benefit

22. Bronchiectasis Abnormal permanent dilatation of one or more bronchi
Poor mucous clearance
Chronic bacterial infection & inflammation
Long term lung damage

23. Types
Saccular /Cystic
Cylindrical
Varicose

24. Saccular Bronchiectasis
Large baloon like dilatation from severe loss of bronchial wall
Assoc with severe lung infections, large sputum volumes, finger clubbing

25. Cylindrical Bronchiectasis

26. Varicose Bronchiectasis

27. Causes Congenital {defective bronch wall/ sequesteration}
Post infective {TB, Pertussis, NTM, ABPA}
Airway obstruction (eg, foreign body aspiration)
Defective host defenses{ CVID, HIV, phagaocyte dysfn
Inflammatory pneumonitis {gastric aspiration, toxic gas inhalation}
Abnormal mucociliary clearance {Primary Ciliary Dyskinesia, cystic fibrosis, Young's syndrome
Rheumatic and systemic diseases, cigarette smoking, Chronic Bronchitis.

28. Symptoms Cough (98 percent of patients)
Daily sputum production (78 percent)
Dyspnoea (62 percent),
Rhinosinusitis (73 percent)
Hemoptysis (27 percent)
and recurrent pleurisy (20 percent).

29. Physical Findings Crackles (75 percent)
Wheezing (22 percent) were common,
Digital clubbing occurred in only 2 percent of patients.

30. Pathophysiology Induction of bronchiectasis requires two factors
An infectious insult
Impaired drainage, airway obstruction, or a defect in host defense
Recurrent infection leads to further scarring, obstruction, and distortion of the airways, as well as temporary or permanent damage to the lung parenchyma.

31. Diagnostic workup
The following LAB studies should be part of the initial evaluation of a patient with bronchiectasis:
A complete blood count with differential
Immunoglobulin quantitation to measure the levels of the immunoglobulins IgG, IgM, and IgA
Sputum culture and smear for bacteria, mycobacteria, and fungi

32. Imaging
CXR radiographic findings include linear atelectasis, dilated and thickened airways (ie, tram or parallel lines, ring shadows on cross section) and irregular peripheral opacities that may represent mucopurulent plugs.

33. High Resolution CT Thorax
Airway dilatation
Bronchial wall thickening
Lack of tapering
mucopurulent plugs or debris accompanied by post-obstructive air trapping (tree-in-bud)

34. Distribution A central (perihilar) distribution is suggestive of ABPA.
predominant upper lobe distribution is characteristic of cystic fibrosis
middle and lower lobe distribution is consistent with PCD
lower lobe involvement is typical of idiopathic bronchiectasi

35. Spirometry Obstructive picture common
Frequently isolated pathogens on CULTURE include Hemophilus influenzae, Pseudomonas aeruginosa (especially mucoid types), and, less frequently, Streptococcus pneumoniae

36. Treatment Postural drainage Based on sputum culture & sensitivity
Non-Pseudomonas organism:
Amoxicillin: 1gm TID 14 days
Augmentin 625 mg TID 14 days
Doxycyline 100mg BD 14 days
Ciprofloxacin 750 mg BD 14 days (Pseudomonas)
Ceftazidime 2gm TID 7-14 days (Pseudomonas)
Nebulised Tobramycin (Pseudomonas)

37. END

38. Signs favouring lung abscess
Spherical shape with irregular and thick wall
Absence of lung compression
Sharp angle with chest wall
Vasculature around abscess