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Chronic Pulmonary Infection Dr Tom Fardon Respiratory SpR.

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Presentation on theme: "Chronic Pulmonary Infection Dr Tom Fardon Respiratory SpR."— Presentation transcript:

1 Chronic Pulmonary Infection Dr Tom Fardon Respiratory SpR

2 Diagnosis? Shadow on CXR Weight loss Persistent sputum production Chest pain Increasing shortness of breath

3 Differential Diagnosis Lung Cancer –Not unreasonable Intrapulmonary abscess Empyema Bronchiectasis Cystic Fibrosis

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7 Intrapulmonary Abscess Indolent presentation Weight loss common Lethargy, tiredness, weakness Cough ± sputum High mortality if not treated Usually a preceding illness of some sort

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12 Preceding Illnesses Pneumonia Aspiration pneumonia –Vomiting –Lowered conscious level –Pharyngeal pouch Poor host immune response –Hypogammaglobulinaemia

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15 Pathogens Bacteria –Streptococcus –Staphylococcus (Particularly post flu) –E-Coli –Gram Negatives Fungi –Aspergillus

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23 Empyema

24 Pus in the pleural space 57 % of all patients with pneumonia develop pleural fluid Remainder are Primary Empyema, usually iatrogenic High mortality –As high as severe pneumonia –> 20 % of all patients with empyema die

25 Progression of Effusion to Empyema Simple Parapneumonic Effusion –Clear fluid –pH > 7.2 –LDH < 1000 –Glucose > 2.2 Complicated Parapneumonic Effusion –pH < 7.2 –LDH > 1000 –Glucose < 2.2 –Requires Chest Tube Drainage Emyema –Frank pus –No other tests required –Requires Chest Tube Drainage

26 Bacteriology Aerobic organisms most frequently Gram Positive –Strep Milleri –Staph Aureus Usually post operative, or nosocmial Immunocomprimised Gram Negatives –E-Coli –Pseudomonas –Haemophilus Influenzae –Kelbsiellae Anaerobes in 13 % of cases –Usually in severe pneumonia, or poor dental hygiene

27 Diagnosis Clinical suspicion –The slow to resolve pneumonia –Dont forget the lateral chest film CXR –Persisting effusion, particularly if loculations visible USS –The preferred investigation –Simple, bedside test –Targetted sampling CT –Differentiation between Empyema and Abscess

28 CXR Some obvious Not always this large Look for D sign As always, better x- rays increase sensitivity, and specificity

29 CXR - D Sign

30 Lateral CXR Particularly useful in small retro- diaphragmatic collections Not straightforward in ICU

31 USS

32 USS in Empyema

33 CT Examination of Pleural Space

34 Empyema CT

35 Use USS or CT to position the drain site

36 Insertion of a Surgical Drain

37 Trocar Introduction

38 Insertion of a Seldinger Drain

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40 Other Treatment IV antibiotics –Broad spectrum –Co-amoxyclav initially Oral antibiotics –Directed towards cultured bacteria –At least 14 days

41 Summary Empyema is bad, and best avoided Detection of complicated pleural effusion requires sampling of the effusion Ultrasound guidance is preferred, but not always needed –Any body cavity can be reached with a green needle and a good strong arm Small bore seldinger type drains are preferred initially

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53 Treatment Options Stop smoking Flu vaccine Pneumococcal vaccine Reactive antibiotics –Send sputum sample –Give antibiotics appropriate to most recent positive culture

54 Treatment When colonised with persistent bacteria –Prophylactic antibiotics –Nebulised colomycin –Pulsed IV abx –Alternating oral antibiotics

55 Anti-inflammatory Treatment Low dose macrolide antibiotics have been shown to reduce exacerbation rates in bronchiectasis –Clarithromycin 250 mg OD

56 Prognosis Recurrent infection Abscesses and empyema Colonisation

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59 Cystic Fibrosis Congenital cause of bronchiectasis And much more

60 CF Incidence, Prevalence and Survival Carrier rate of 1 in 25 Incidence of 1 in 2,500 live births By 2002 the number of adult patients exceeded the number of children Carrier screening may influence numbers (Cunningham & Marshall 1998) Those born in the 1990s have a predicted survival into the 40s

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62 Tayside Caseload (annual report 4/00 - 3/01) 36 patients registered 3 patients on active transplant list 3 patients not suitable for transplant 2 deaths

63 Case Study Diagnosed at 10 months with steatorrhea and LRTI Stable until 13 when she required increasingly frequent IVs Pregnancy weeks Since 1998 she has suffered more frequent exacerbations and now requires IVs monthly

64 Oxygen dependent Abnormal liver function Occasional episodes of DIOS Button gastrostomy inserted Transplant assessment Dec 2000 Overnight BiPAP from June 2001 Difficulty in controlling pain and nausea

65 Bi-lateral lung transplant Sept 2001 June severe pneumonia Admitted to ICU Large blood clot extracted from right main bronchus –Organising pneumonia

66 Still an in patient in ward 3 Colonised with 3 distinct varieties of pseudomonas and MRSA Ongoing IV antibiotics

67 Specialities Involved Respiratory Gastro-Intestinal Obs & Gynae GP/DN Surgery Transplant team Child & Family Psychiatry ICU Anaesthesia

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80 Summary Chronic infection can mimic malignancy Chronic infection can have a similar prognosis if untreated Have a high index of suspicion, particularly when simple infection is not clearing

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