Lung Abscess Sung Chul Hwang, M.D. Dept. of Pulmonary and Critical Care Medicine Ajou University School of Medicine

Definition Infection of the lung parenchyme consisting of one or more necrotic inflammatory cavities, containing fibropurulent exudates and gaseous materials

Etiology of Lung Abscess Aspiration : seizure, coma, surgery, DM, sedatives, alcohol, neurologic diseases Bronchial obstruction : malignancy, F.B. Septic emboli : SBE, catheters, prostheses, pelvic thrombophlebitis Direct Spread : subphrenic, hepatic Pneumonia complication : S. aureus, Klebsiella, pseudomonas, etc

Classifications Duration Acute < 4-6 week Chronic Causes Primary Secondary

Symptoms of Lung Abscess Cough : 77% Sputum : 65% Fever and chills : 40% Chest pain : 24% Hemoptysis : 16% Dyspnea : 15% Anorexia : 4% Night sweats : 1 %

Most common cause Tosillectomy, seizure, neurosurgery, alcoholism, etc Organism identification in only 30-40% Mostly Anarobic, mixed organisms “Putrid sputa” Dependent portions: Lowerlobe,posteior & lateral basal seg. Upper lobe, posterior seg. Usually single abscess cavity Aspiration Abscess

Necrotizing Pneumonia Community :Staph. Aureus or Klebsiella Hospital : Pseudomonas or Proteus Aspiration pneumonias cause necrotizing infections Klebsiella predominant in alcoholics or DM

Secondary to Malignancy Bronchogenic cancer : Squamous Ca Lymphoma Leukemia Multiple Myeloma Metastatic Malignancies

Diagnosis X-ray : Cavity with “air-fluid level” CBC : leukocytosis, Anemia, etc Cultures : Sputum & Blood Anaerobic culture is important Chest CT Sputum cytology Sputum AFB Bronchoscopy or NAB to Rule out malignancy

Treatment Medical treatment is the mainstay Pennicillin, Cephalosporin Clindamycin, chloramphenicol, Metronidazole to cover for the Anarobes Postural drainage Bronchoscopic drainage

Indications for Surgery Massive hemoptysis Refractory to Medical treatment Large cavity with thick walls Complicated by malignancy Empyema develops Chronicity, Recurrence Remaining residual cavity

Prognosis Relatively Favorable Underlying Disease is important Operation Rate : 15% Overall mortality rate : 10%

Empyema Mainly Surgical disease Presence of Pus or demonstrable Micro- organisms such as, Bacteria, mycobacterium, or fungus in pleural cavity Closed Drainage Pig-tail catheter insertion with intra-pleural urokinase instillation Surgical drainage with empymectomy : conventional surgery or VATS

Lung Abscess Cavity with “Air-Fluid level”

Lung Abscess Left Upper Lobe Posterior Segment

Lung Abscess Pseudomonas Lung Abscess

Lung Abscess Malignant Abcess Cavity

Septic Pneumonia multiplrmultiplr Multiple Bilateral Septic Emboli

Septic Emboli Septic Emboli in Pulmonary arteries : H & E

Empyema

diaphragm pus

Indication for Pneumococcal Vaccination (Polyvalent) > 65 years Chronic Cardiac conditions Chronic Lung Diseases Asplenia Chronic Liver Diseases Alcoholism DM Chronic Renal Failure Hodgkin ’ s Disease Leukemia, Multiple myeloma Chronic hemodialysis HIV Infection