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Chronic Lung Sepsis Dr. Arun Nair. Includes Lung Abscess Lung Abscess Empyema Empyema Bronchiectasis Bronchiectasis.

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Presentation on theme: "Chronic Lung Sepsis Dr. Arun Nair. Includes Lung Abscess Lung Abscess Empyema Empyema Bronchiectasis Bronchiectasis."— Presentation transcript:

1 Chronic Lung Sepsis Dr. Arun Nair

2 Includes Lung Abscess Lung Abscess Empyema Empyema Bronchiectasis Bronchiectasis

3 Lung Abscess

4

5

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

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

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

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

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

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

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

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

14 Pathogenesis Uncomplicated parapneumonic effusion 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. 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. resolve with resolution of the pneumonia.

15 Complicated Parapneumonic effusion occurs when there is persistent bacterial invasion of the pleural space. 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. 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 ) 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. 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. A positive culture is not required for diagnosis.

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

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

19 Imaging CXR CXR CT CT USG USG

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

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

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

23 Types Saccular /Cystic Saccular /Cystic Saccular /Cystic Saccular /Cystic Cylindrical Cylindrical Cylindrical Varicose Varicose Varicose

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

25 Cylindrical Bronchiectasis

26 Varicose Bronchiectasis

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

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

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

30 Pathophysiology Induction of bronchiectasis requires two factors Induction of bronchiectasis requires two factors An infectious insult An infectious insult Impaired drainage, airway obstruction, or a defect in host defense 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. 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: The following LAB studies should be part of the initial evaluation of a patient with bronchiectasis: A complete blood count with differential A complete blood count with differential Immunoglobulin quantitation to measure the levels of the immunoglobulins IgG, IgM, and IgA Immunoglobulin quantitation to measure the levels of the immunoglobulins IgG, IgM, and IgA Sputum culture and smear for bacteria, mycobacteria, and fungi 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. 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 Airway dilatation Bronchial wall thickening Bronchial wall thickening Lack of tapering Lack of tapering mucopurulent plugs or debris accompanied by post-obstructive air trapping (tree-in-bud) mucopurulent plugs or debris accompanied by post-obstructive air trapping (tree-in-bud)

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

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

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

37 END

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


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