1 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 16 Lung Abscess

2 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure Lung abscess. A, Cross-sectional view of lung abscess. B, Consolidation and (C) excessive bronchial secretions are common secondary anatomic alterations of the lungs. AFC, Air-fluid cavity; EDA, early development of abscess; PM, pyogenic membrane; RB, ruptured bronchus (and drainage of the liquefied contents of the cavity). A AFC RB EDA PM B C

3 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Anatomic Alterations of the Lungs  Alveolar consolidation  Alveolar-capillary and bronchial wall destruction  Tissue necrosis  Cavity formation  Fibrosis and calcification of the lung parenchyma  Bronchopleural fistulae and empyema  Atelectasis  Excessive airway secretions and empyema

4 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Etiology  Predisposing factors for aspiration  Alcohol abuse  Seizure disorders  General anesthesia  Head trauma  Cerebrovascular accident  Swallowing disorders

5 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 16-1 Organisms Known to Cause Lung Abscess  Common Organisms Aspirations  Anaerobic gram positive cocci Peptococci Peptococci Peptostreptococci Peptostreptococci  Anaerobic gram negative bacilli Bacteroides fragilis Bacteroides fragilis Prevotella melaninogenica Prevotella melaninogenica Fusobacterium sp Fusobacterium sp

6 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 16-1 Organisms Known to Cause Lung Abscess (Cont’d)  Less Common Organisms  Klebsiella  Staphylococcus  Mycobacterium tuberculosis  Histoplasma capsulatum  Coccidioides immitis  Blastomyces  Aspergillus fumigatus

7 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 16-1 Organisms Known to Cause Lung Abscess (Cont’d)  Some Parasites  Paragonimus  Echinococcus  Entamoeba histolytica  On rare occasions  Streptococcus pneumonia  Pseudomonas aeruginosa  Legionella pneumophila

8 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Overview of the Cardiopulmonary Clinical Manifestations Associated with Lung Abscess The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by  Alveolar Consolidation  Excessive Bronchial Secretions

9 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

10 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

11 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Data Obtained at the Patient’s Bedside

12 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination  Vital Signs  Increased Respiratory rate (tachypnea) Heart rate (pulse) Blood pressure

13 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination (Cont’d)  Chest pain/decreased chest expansion  Cyanosis  Cough, sputum production, and hemoptysis

14 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination (Cont’d)  Chest Assessment Findings  Increased tactile and vocal fremitus  Crackles and rhonchi  The following may be noted directly over the abscess: Dull percussion note Bronchial breath sounds Diminished breath sounds Whispered pectoriloquy Pleural friction rub (if abscess is near pleural surface)

15 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Data Obtained from Laboratory Tests and Special Procedures

16 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pulmonary Function Test Findings Severe and Extensive Cases (Restrictive Lung Pathophysiology) Forced Expiratory Flow Rate Findings FVC FEV T FEV 1 /FVC ratio FEF 25%-75  N or  N or  * N or  FEF 50% FEF PEFR MVV N or  N or  ______ * May be down when airway obstruction is present

17 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pulmonary Function Test Findings Moderate to Severe (Restrictive Lung Pathophysiology) Lung Volume & Capacity Findings VT IRV ERV RV VC N or      IC FRC TLC RV/TLC ratio    N

18 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases Mild to Moderate Lung Abscess Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis) pH PaC0 2 HCO 3 Pa0 2    (slightly) 

19 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute alveolar hyperventilation.

20 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases Severe Lung Abscess Acute Ventilatory Failure with Hypoxemia (Acute Respiratory Acidosis) pH PaC0 2 HCO 3 Pa0 2    (Slightly) 

21 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute or chronic ventilatory failure.

22 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Oxygenation Indices Q S /Q T D02 V02 C(a-v)02 02ER Sv02   N N  

23 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Abnormal Laboratory Tests and Procedures  )  Abnormal sputum examination (see Overview section)

24 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Radiologic Findings  Chest Radiograph  Increased opacity  Cavity formation  Cavities with air-fluid levels  Fibrosis and calcification  Pleural effusion

25 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure Reactivation tuberculosis with a large cavitary lesion containing an air-fluid level in the right lower lobe. Smaller cavitary lesions are seen in other lobes.

26 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. General Management of Lung Abscess   Antibiotics are the primary treatment for a lung abscess—see Appendix III.

27 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Respiratory Care Treatment Protocols   Oxygen Therapy Protocol   Bronchopulmonary Hygiene Therapy Protocol   Lung Expansion Therapy Protocol