Chronic Lung Chronic Lung Sepsis Sepsis Dr. Arun Nair Dr. Arun Nair
Mar 26, 2015
Chronic Lung Chronic Lung SepsisSepsisDr. Arun NairDr. Arun Nair
IncludesIncludes
Lung AbscessLung Abscess
EmpyemaEmpyema
BronchiectasisBronchiectasis
Lung AbscessLung Abscess
Lung Abscess
Definition & overviewDefinition & overview Cavitating, infected, necrotic lesion of lung parenchymaCavitating, infected, necrotic lesion of lung parenchyma
Several possible causesSeveral possible causes
Single or MultipleSingle or Multiple
Small <2cm or largeSmall <2cm or large
Most secondary to aspiration of oropharyngeal secretionsMost secondary to aspiration of oropharyngeal secretions
Mixed growth of organisms, including anaerobesMixed growth of organisms, including anaerobes
CausesCauses AspirationAspiration
Bronchial obstruction {Tumour / Foreign Bronchial obstruction {Tumour / Foreign Body}Body}
PneumoniaPneumonia
Blood borne infectionBlood borne infection
Transdiaphragmatic spreadTransdiaphragmatic spread
Differential DiagnosisDifferential Diagnosis
Cavitating tumourCavitating tumour Infected bronchial cyst/bullaInfected bronchial cyst/bulla Localised saccular bronchiectasisLocalised saccular bronchiectasis AspergillomaAspergilloma Wegeners granulomatosisWegeners granulomatosis Hydatid cystHydatid cyst Gas-fluid level in oesophagus, Gas-fluid level in oesophagus,
stomach or bowelstomach or bowel
MicrobiologyMicrobiology Anaerobes: Peptostreptococcus, Anaerobes: Peptostreptococcus,
Prevotella, Bacteroides spp (usually not B. Prevotella, Bacteroides spp (usually not B. fragilis), and Fusobacterium spp. fragilis), and Fusobacterium spp.
Staph Aureus, Klebsiella, Strep MilleriStaph Aureus, Klebsiella, Strep Milleri
Strep Pneumonia, gram negative bacilliStrep Pneumonia, gram negative bacilli
M.TuberculosisM.Tuberculosis
FungiFungi
Clinical FeaturesClinical Features Most patients present over several weeksMost patients present over several weeks
Malaise, weight loss, feverMalaise, weight loss, fever
Cough with copious purulent sputumCough with copious purulent sputum
Can be associated with haemoptysisCan be associated with haemoptysis
Toxic features prominent in patients with Toxic features prominent in patients with pneumonia or blood borne infectionpneumonia or blood borne infection
Clubbing often seenClubbing often seen
InvestigationsInvestigations
CXR: PA & LateralCXR: PA & Lateral
CT ThoraxCT Thorax
Sputum & Blood CulturesSputum & Blood Cultures
FBC, CRP, ESR, Serological testsFBC, CRP, ESR, Serological tests
TreatmentTreatment
AUGMENTINAUGMENTIN AMOXIXCILLIN & AMOXIXCILLIN &
METRONIDAZOLEMETRONIDAZOLE CLINDAMYCINCLINDAMYCIN Physiotherapy & postural drainagePhysiotherapy & postural drainage Trans Thoracic/ endoscopic Trans Thoracic/ endoscopic
drainage for large abscessdrainage for large abscessDuration of ABx:Duration of ABx: 3- 4 weeks3- 4 weeks
EmpyemaEmpyema
Pus in pleural spacePus in pleural space
Sequelae of a complicated Sequelae of a complicated parapneumonic infection, when parapneumonic infection, when bacteria invade pleural spacebacteria invade pleural space
UncomplicatedUncomplicated ComplicatedComplicated Frank EmpyemaFrank Empyema
PathogenesisPathogenesis
Uncomplicated parapneumonic effusion — Uncomplicated parapneumonic effusion —
occurs when the lung interstitial fluid occurs when the lung interstitial fluid increases during pneumonia, and is increases during pneumonia, and is characterized by "exudative" pleural fluid characterized by "exudative" pleural fluid chemistries and an influx of neutrophils chemistries and an influx of neutrophils into the pleural space. into the pleural space.
resolve with resolution of the pneumonia. resolve with resolution of the pneumonia.
Complicated Complicated Parapneumonic effusionParapneumonic effusion
occurs when there is persistent bacterial occurs when there is persistent bacterial invasion of the pleural space. invasion of the pleural space.
Results in pleural fluid acidosis (anaerobic Results in pleural fluid acidosis (anaerobic utilization). Lysis of neutrophils increases utilization). Lysis of neutrophils increases the LDH concentration in the pleural fluid the LDH concentration in the pleural fluid to values often in excess of 1000 IU/L. to values often in excess of 1000 IU/L.
Complicated parapneumonic effusions are Complicated parapneumonic effusions are often sterile because bacteria can be often sterile because bacteria can be cleared rapidly from the pleural space. cleared rapidly from the pleural space. (Loculation )(Loculation )
Thoracic EmpyemaThoracic Empyema
Formation of empyema is the third Formation of empyema is the third stage and is characterized by stage and is characterized by bacterial organisms seen on gram bacterial organisms seen on gram stain or the aspiration of pus on stain or the aspiration of pus on thoracentesis. thoracentesis.
A positive culture is not required for A positive culture is not required for diagnosis.diagnosis.
BacteriologyBacteriology
Mixed bacterial floraMixed bacterial flora Anaerobic bacteria in 36-76%Anaerobic bacteria in 36-76% Streptococcus milleri, Staphylococcus aureus, Streptococcus milleri, Staphylococcus aureus,
and Enterobacteriaceae.and Enterobacteriaceae. Patients with diabetes mellitus are at Patients with diabetes mellitus are at
increased risk of empyema secondary to increased risk of empyema secondary to Klebsiella pneumoniae.Klebsiella pneumoniae.
S. pneumoniae and S. aureus (including S. pneumoniae and S. aureus (including methicillin-resistant organisms) are the methicillin-resistant organisms) are the leading causative bacteria in children with leading causative bacteria in children with empyema.empyema.
Pleural fluid analysisPleural fluid analysis
PusPus Ph <7.2Ph <7.2 Glucose < 60 mg/dl Glucose < 60 mg/dl LDH>1000 IU/LLDH>1000 IU/L WBC>15/nlWBC>15/nl
ImagingImaging
CXRCXR
CTCT
USGUSG
Signs favouring Signs favouring empyemaempyema
Evidence of lung compressionEvidence of lung compression Smooth marginsSmooth margins Blunt angle with chest wallBlunt angle with chest wall Dissection of thickened visceral and Dissection of thickened visceral and
parietal pleuraparietal pleura
TreatmentTreatment Pleural drainagePleural drainage
Chest DrainChest Drain
ThoracoscopyThoracoscopy
AntibioticsAntibiotics
Fibrinolytics: No convincing benefitFibrinolytics: No convincing benefit
BronchiectasisBronchiectasis
Abnormal permanent dilatation of Abnormal permanent dilatation of one or more bronchione or more bronchi
Poor mucous clearancePoor mucous clearance
Chronic bacterial infection & Chronic bacterial infection & inflammationinflammation
Long term lung damageLong term lung damage
TypesTypes
Saccular /Cystic
Cylindrical
Varicose
Saccular BronchiectasisSaccular Bronchiectasis
Large baloon like Large baloon like dilatation from dilatation from severe loss of severe loss of bronchial wallbronchial wall
Assoc with severe Assoc with severe lung infections, lung infections, large sputum large sputum volumes, finger volumes, finger clubbingclubbing
Cylindrical Cylindrical BronchiectasisBronchiectasis
Varicose BronchiectasisVaricose Bronchiectasis
CausesCauses 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 dysfnDefective host defenses{ CVID, HIV, phagaocyte dysfn
Inflammatory pneumonitis {gastric aspiration, toxic gas Inflammatory pneumonitis {gastric aspiration, toxic gas inhalation}inhalation}
Abnormal mucociliary clearance {Primary Ciliary Abnormal mucociliary clearance {Primary Ciliary Dyskinesia, cystic fibrosis, Young's syndromeDyskinesia, cystic fibrosis, Young's syndrome
Rheumatic and systemic diseases, cigarette smoking, Rheumatic and systemic diseases, cigarette smoking, Chronic Bronchitis.Chronic Bronchitis.
SymptomsSymptoms
Cough (98 percent of patients)Cough (98 percent of patients) Daily sputum production (78 Daily sputum production (78
percent)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).
Physical FindingsPhysical Findings
Crackles (75 percent)Crackles (75 percent) Wheezing (22 percent) were Wheezing (22 percent) were
common, common, Digital clubbing occurred in only 2 Digital clubbing occurred in only 2
percent of patients. percent of patients.
PathophysiologyPathophysiology
Induction of bronchiectasis requires two Induction of bronchiectasis requires two factors factors
An infectious insult An infectious insult Impaired drainage, airway obstruction, or Impaired drainage, airway obstruction, or
a defect in host defense a defect in host defense Recurrent infection leads to further Recurrent infection leads to further
scarring, obstruction, and distortion of scarring, obstruction, and distortion of the airways, as well as temporary or the airways, as well as temporary or permanent damage to the lung permanent damage to the lung parenchyma. parenchyma.
Diagnostic workupDiagnostic workup
The following LAB studies should be The following LAB studies should be part of the initial evaluation of a patient part of the initial evaluation of a patient with bronchiectasis:with bronchiectasis:
A complete blood count with differential A complete blood count with differential Immunoglobulin quantitation to Immunoglobulin quantitation to
measure the levels of the measure the levels of the immunoglobulins IgG, IgM, and IgA immunoglobulins IgG, IgM, and IgA
Sputum culture and smear for bacteria, Sputum culture and smear for bacteria, mycobacteria, and fungi mycobacteria, and fungi
ImagingImaging
CXR radiographic CXR radiographic findings include findings include linear atelectasis, linear atelectasis, dilated and thickened dilated and thickened airways (ie, tram or airways (ie, tram or parallel lines, ring parallel lines, ring shadows on cross shadows on cross section) and irregular section) and irregular peripheral opacities peripheral opacities that may represent that may represent mucopurulent plugs. mucopurulent plugs.
High Resolution CT High Resolution CT ThoraxThorax
Airway dilatation Airway dilatation Bronchial wall Bronchial wall
thickening thickening Lack of tapering Lack of tapering mucopurulent mucopurulent
plugs or debris plugs or debris accompanied by accompanied by post-obstructive post-obstructive air trapping (tree-air trapping (tree-in-bud)in-bud)
DistributionDistribution
A central (perihilar) distribution is A central (perihilar) distribution is suggestive of ABPA.suggestive of ABPA.
predominant upper lobe distribution predominant upper lobe distribution is characteristic of cystic fibrosisis characteristic of cystic fibrosis
middle and lower lobe distribution is middle and lower lobe distribution is consistent with PCDconsistent with PCD
lower lobe involvement is typical of lower lobe involvement is typical of idiopathic bronchiectasi idiopathic bronchiectasi
SpirometrySpirometry
Obstructive picture commonObstructive picture common
Frequently isolated pathogens on Frequently isolated pathogens on CULTURE include Hemophilus CULTURE include Hemophilus influenzae, Pseudomonas aeruginosa influenzae, Pseudomonas aeruginosa (especially mucoid types), and, less (especially mucoid types), and, less frequently, Streptococcus frequently, Streptococcus pneumoniae pneumoniae
TreatmentTreatment Postural drainagePostural drainage Based on sputum culture & sensitivityBased on sputum culture & sensitivity Non-Pseudomonas organism:Non-Pseudomonas organism: Amoxicillin: 1gm TID 14 daysAmoxicillin: 1gm TID 14 days Augmentin 625 mg TID 14 daysAugmentin 625 mg TID 14 days Doxycyline 100mg BD 14 daysDoxycyline 100mg BD 14 days Ciprofloxacin 750 mg BD 14 days Ciprofloxacin 750 mg BD 14 days
(Pseudomonas)(Pseudomonas) Ceftazidime 2gm TID 7-14 days Ceftazidime 2gm TID 7-14 days
(Pseudomonas)(Pseudomonas) Nebulised Tobramycin (Pseudomonas)Nebulised Tobramycin (Pseudomonas)
ENDEND
Signs favouring lung Signs favouring lung abscessabscess
Spherical shape with irregular and Spherical shape with irregular and thick wallthick wall
Absence of lung compressionAbsence of lung compression
Sharp angle with chest wallSharp angle with chest wall
Vasculature around abscessVasculature around abscess