Suppurative Lung Diseases

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Bronchiectasis, Lung Abscess, Empyema with BPF

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Suppurative Lung Diseases:

Suppurative Lung Diseases Dr/ Riham Hazem Raafat Lecturer of Chest Diseases Ainshams University

Bronchiectasis:

Bronchiectasis

Definition :

Definition Irreversible dilatation of the cartilage containing airways - Bronkos + Ectasia = Bronchi + Dilatation

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colonization Pathogenesis

Types of bronchiectasis :

Types of bronchiectasis

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Causes - AI Toxic gas inhalation Congenital (metabolic gross structure, ultrastructure) - Acquired

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Diagnostic Approach

Clinical Features::

Clinical Features: Cough Daily sputum production: green/yellow sputum (patients with bronchiectasis may produce 240ml (8 oz) of sputum daily).  Dyspnea Wheezing Hemoptysis Bluish skin color Recurrent pleurisy Dry Bronchiectasis: Breath odor Clubbing of fingers Fatigue Paleness Weight loss Acute exacerbation: purulence, amount of Sputum & Dyspnea Late: RF, Corpulmonale

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Complications : Recurrent hemoptysis, pneumonia and pleurisy Lung abscess and metastatic brain abscess Empyema Amyloidosis Cor pulmonale and respiratory failure

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CXR : Suspicious but not diagnostic radiographic findings include: focal pneumonitis, scattered irregular opacities that may represent mucopurulent plugs, linear or plate-like atelectasis , dilated and thickened airways that appear as ring-like shadows (of airways that are seen on end) or tram lines (airways that are perpendicular to the x-ray beam) HRCT: Major features on HRCT include AW dilatation & bronchial wall thickening Bronchoscopy: For diagnosis of tumor, foreign body, localize site of hemoptysis. PFTs Blood (including serology) & Sputum Examination

Sputum Organisms:

Sputum Organisms Typical offending organisms: Klebsiella species, Staphylococcus aureus, Mycobacterium tuberculosis, Mycoplasma pneumoniae, Non-tuberculous mycobacteria, Once a patient develops bronchiectasis: - Many of these same organisms colonize the damaged bronchi and may result in ongoing damage and episodic infectious exacerbations. - The organisms found most typically include Haemophilus species and Pseudomonas species (Staph Aureus in CF) Measles virus, Pertussis virus, Influenza virus, Herpes simplex virus, and Certain types of adenovirus. Aspergillus fumigatus

Plain radiographic signs :

Plain radiographic signs

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Chest radiography showing a) cystic bronchiectasis with multiple cystic airspaces and b) cylindrical bronchiectasis and tram track opacities in a cystic fibrosis patient. (a) (b)

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Cystic bronchiectasis with air-fluid levels.

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Mucoid Impaction

CT signs :

CT signs *Cause can be seen as well

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SIGNET RING SIGN. Chest CT shows small bronchiectasis .

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High-resolution computed tomography image showing non tapering bronchi, in keeping with bronchiectasis.

Visibility of peripheral air ways within 1cm from the costal pleura:

Visibility of peripheral air ways within 1cm from the costal pleura

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Categories of bronchiectasis. Normal bronchus (arrow) (A), cylindrical bronchiectasis with lack of bronchial tapering (arrow) (B), varicose bronchiectasis with string-of-pearls appearance (arrow) (C), and cystic bronchiectasis (arrow) (D). B A C D Abnormal bronchial contour.

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* High-resolution computed tomography image demonstrating bronchiectasis with bronchial wall thickening (asterisk) and mucous plugging (arrow) in the right lower lobe . Bronchial wall thickening

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Inspiratory high-resolution computed tomography image showing bronchiectasis and widespread areas of low attenuation, representing air-trapping. Air-trapping Sign.

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High-resolution computed tomography showing a) proximal bronchiectasis affecting segmental airways and b) high attenuation mucous plugs in patients with allergic bronchopulmonary aspergillosis. No intravenous contrast medium was used in (b). a) b) Mucous plugs Impaction.

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Cystic Bronchiectasis. CT: Markedly dilated bronchi are seen, some with air-fluid levels (yellow arrows), mostly in the right lung. Cystic changes with air-fluid levels.

Tree in budd opacities:

Tree in budd opacities

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Mounier-Kuhn syndrome, also known as tracheobronchomegaly, is a rare congenital abnormality of the trachea and main bronchi characterized by cystic dilatation of the tracheobronchial tree and recurrent respiratory infections.  

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Treatment Goals: Controlling infections and bronchial secretions Relieving airway obstructions Removal of affected portions of lung by surgical removal or artery embolization Preventing complications. Treatment of bronchiectasis include: The prolonged usage of  Antibiotics  to prevent detrimental infections Eliminating accumulated fluid with  Bronchial Hygiene therapy + Humidification & Mucolytics (dornase, HS, ACC) +/- Anti-oxidants Inhaled Bronchodilators (in obst.) & Steroids (in exac., ABPA) Surgery is used to treat localized bronchiectasis, removing obstructions, recurrent hemoptysis & exacerbations  Transplantation Vaccination (S. pn, H. Inf., M., P.), IgG (25mg/kg /wk), O2, Smoke Cess Pulmonary Rehabilitation (add ADEK, Panc enz to CF)

Antibiotic Use:

Antibiotic Use During Exacerbation: Mild to Moderate Exacerbation (7-10 ds): Amoxacillin, Tetracycline, Trimethoprim-Sulfamethoxazole, New Macrolides, Cephalosporin, Quinolones Moderate to Severe Exacerbation (10-14 ds): Antipseudomonal IV (dual therapy) or MAC treatment if proved (clarithromycin, ethambutol, rifampicin, sterptomycin 18-14 Ms) Regular Treatment for Colonization: Intermittent courses are used for 7 days and Ab- free periods of 7 days each month can be used (oral previous drugs) or Long term antibiotics for 3 to 6 Ms (macrolides) Inhaled Antibiotics: Tobramycin, Colistin, Gentamycin, Astreonam

Bronchial Hygiene Techniques:

Postural drainage Percussion Directed cough: as Forced expiratory technique (huffing: small long (LL) or big short huff (UL) in cycle ; 10 mins twice /d ) Active cycle of breathing ( breathing control (hands on abd.) , deep breathing exercises e’ breath hold (ribs) & huffing +/- manual technique ) Autogenic drainage (self drainage: unstick, collect, evacuate) Positive expiratory pressure (behind mucus to push) Incentive Spirometry Bronchial Hygiene Techniques Can be associated with others

Diaphragmatic Breathing :

Diaphragmatic Breathing

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Vibratory PEP Flutter device Acapella

Lung Abscess:

Lung Abscess

Definition::

Definition: A lung abscess is a localized area of destruction of lung parenchyma in which infection by a Pyogenic organism results in tissue necrosis and suppuration and cavity formation.

Classification:

Classification Lung abscesses can be classified based on: - Duration : Acute abscesses are less than 4-6 wks old Chronic abscesses are of longer duration - Etiology : Primary Abscess is infectious in origin: caused by aspiration or pneumonia in the healthy host. Secondary Abscess - Pre-existing lung condition (obstruction, bronchiectasis, cyctic lung, c). - Hematogenous: Spread from an extra-pulmonary site (septic emboli) - Immuno-compromised state. - Inhalation of infected material - Necrotizing pneumonia (klebsiella, staph., pseudomonus, anearobic, nocardia, fungi) - Number: single or multiple

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Pathogenesis: Lung abscess begin as an area of pneumonia  necrosis or microabscess  coalesce to form a single or sometimes multiple areas of suppuration  reach a size > 1cm in diameter  lung abscess. Inflammation erodes adjacent bronchi  suppuration is expectorated  air finds its way to the abscess cavity  fluid air interface.

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Clinical features: Presence of the predisposing factors Symptoms of acute lung abscess: The onset may be abrupt or gradual. Fever with rigors , sweating , cough (dry cough at first which is followed by sudden onset of expectoration of large amounts of sputum after which fever drop). Sputum: foul-odor, purulent with relation to posture. Chest pain: it may be dull aching or severe pleuritic pain. Hemoptysis may occur and may be massive. Weight loss , anaemia and clubbing in chronic lung abscess (8-12 weeks).

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Complications: Local spread to the same or to the other lung. Prolonged fever and chronicity. Massive hemoptysis. Residual bronchiectasis or fibrosis  Trapped lung Extension to the pleura or skin  Empyema, BPF or PCF Metastatic brain abscess . Perinephric abscess. Amyloidosis.

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Investigations: Chest x-ray PA and lateral view In the acute abscess the wall is thin with surrounding consolidation, and the chronic abscess the wall is thick. 2. Laboratory: - Sputum examination: Gram- stain film and culture (85% anaerobes) Ziehl- Neelsen staining to exclude TB Sputum cytology for malignant cells Sputum culture for fungi and parasitic ova (if suspected) - Blood picture : leucocytosis (>30.000/mm3) and anemia.

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Irregularly shaped cavity with an air-fluid level inside posterior segments of the upper lobes or the superior segments of the lower lobes

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3. Bronchoscopy: - Diagnostic: foreign body, tumors, or inspissated secretions. - Therapeutic: Aspiration of secretions. Instillation of antibiotics. Foreign body extraction. Palliative treatment of bronchial carcinoma with laser or cryotherapy. 4. C-T chest: for suspected bronchial carcinoma.

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Treatment: Prophylactic: proper attention to the etiologic factors. Acute lung abscess: Medical treatment is usually sufficient: a) Antibiotics: 4 -6 wks  till resolution or small stable It is usually given empirically in the form of combined antibiotics to cover the spectrum of Gram positive, Gram negative and anaerobic organisms (Clindamycin).

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b) Postural drainage is an important item in the management of lung abscess. c) Bronchoscopic aspiration and instillation of antibiotics. d) Symptomatic treatment : Analgesics for pain. Expectorants. e) Rest, good nutrition with high protein diet.

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3 . Chronic lung abscess : Continue the medical treatment for another 6 wks. Surgical treatment (lobectomy or pneumonectomy) is indicated in chronic situation with: Serious hemoptysis. Failed medical treatment. Suspected neoplasm Congenital lung malformation

Empyema with Broncho-Pleural Fistula:

Empyema with Broncho-Pleural Fistula

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Definition Pus in the pleural space or infected pleural fluid with fistula (opening) between the pleural space and the bronchial tree.

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Causes: Direct spread from adjacent bacterial pneumonia. Rupture of a lung abscess into the pleural space. Invasion from subphrenic collection either pyogenic or amoebic. Traumatic penetration or Iatrogenic - It may be acute or chronic (> 3 months). It may be loculated or free. It may be post-operative (2/3) or non-operative (1/3)

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Clinical features Fever and chest pain. Dyspnea. Broncho-pleural fistula is characterized by postural cough and big amount of expectorated pus. Chronicity: pallor, malaise, weakness, easy fatigability, fever, anorexia and weight loss. Clubbing and pleural rub. Bubbling from chest tube

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Investigations Chest x-ray (air-fluid level, tension pnx) CT of the chest: the condition of the underlying lung, Pnx Thoracentesis : Foul - smelling aspirate (anaerobic infection). Gram stain and culture and sensitivity: identification of the causative organisms. Low PH (<7.2). Pleural fluid white cell count > 15.000/ mm 3 . Methylene blue test: injection of methylene blue 1% in the pleural space, it will be expectorated in the sputum. Inhalation of radioactive isotopes: detected in the pleural space. FOB: Methylene blue test and visualization of bubbles after bronchial wash

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Treatment : Appropriate antibiotic therapy. Intercostal tube drainage under water seal & pleurodesis Decortication Muscle flap closure of fistula Pleuropneumonectomy.

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