Chronic Pulmonary Infection Dr Tom Fardon Respiratory SpR.

Chronic Pulmonary Infection

Dr Tom Fardon

Respiratory SpR

Diagnosis?

• Shadow on CXR

• Weight loss

• Persistent sputum production

• Chest pain

• Increasing shortness of breath

Differential Diagnosis

• Lung Cancer– Not unreasonable

• Intrapulmonary abscess

• Empyema

• Bronchiectasis

• Cystic Fibrosis

Intrapulmonary Abscess

• Indolent presentation

• Weight loss common

• Lethargy, tiredness, weakness

• Cough ± sputum

• High mortality if not treated

• Usually a preceding illness of some sort

Preceding Illnesses

• Pneumonia• Aspiration pneumonia

– Vomiting– Lowered conscious level– Pharyngeal pouch

• Poor host immune response– Hypogammaglobulinaemia

Pathogens

• Bacteria– Streptococcus– Staphylococcus (Particularly post ‘flu)– E-Coli– Gram Negatives

• Fungi– Aspergillus

Empyema

Empyema

• 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

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

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

Diagnosis

• Clinical suspicion–The slow to resolve pneumonia–Don’t 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

CXR

• Some obvious• Not always this large• Look for D sign

• As always, better x-rays increase sensitivity, and specificity

CXR - D Sign

Lateral CXR

• Particularly useful in small retro-diaphragmatic collections

• Not straightforward in ICU

USS

USS in Empyema

CT Examination of Pleural Space

Empyema CT

Use USS or CT to position the drain site

Insertion of a Surgical Drain

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Trocar Introduction

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Insertion of a Seldinger

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Insertion of a Seldinger Drain

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Other Treatment

• IV antibiotics– Broad spectrum– Co-amoxyclav initially

• Oral antibiotics– Directed towards cultured bacteria– At least 14 days

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

Treatment Options

• Stop smoking

• ‘Flu vaccine

• Pneumococcal vaccine

• Reactive antibiotics– Send sputum sample– Give antibiotics appropriate to most recent

positive culture

Treatment

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

Anti-inflammatory Treatment

• Low dose macrolide antibiotics have been shown to reduce exacerbation rates in bronchiectasis– Clarithromycin 250 mg OD

Prognosis

• Recurrent infection

• Abscesses and empyema

• Colonisation

Cystic Fibrosis

• Congenital cause of bronchiectasis

• And much more

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 1990’s have a predicted

survival into the 40’s

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

Case Study

• Diagnosed at 10 months with steatorrhea and LRTI

• Stable until 13 when she required increasingly frequent IV’s

• Pregnancy 1996 - TOP @ 16 weeks• Since 1998 she has suffered more

frequent exacerbations and now requires IV’s monthly

• 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

• Bi-lateral lung transplant Sept 2001

• June 2006 - severe pneumonia

• Admitted to ICU

• Large blood clot extracted from right main bronchus– Organising pneumonia

• Still an in patient in ward 3

• Colonised with 3 distinct varieties of pseudomonas and MRSA

• Ongoing IV antibiotics

Specialities Involved

• Respiratory• Gastro-Intestinal• Obs & Gynae• GP/DN• Surgery• Transplant team• Child & Family

Psychiatry

• ICU• Anaesthesia

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