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)

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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