Dr.

Ahmed Al-Azzawi Lec 3 #236

SUPPURATIVE LUNG DISEASES
The term suppurative lung diseases implies the following:

Bronchiectasis

Lung abscess

Empyema

Bronchiectasis
Definition

•Chronic disease of the lungs characterised by bronchial dilatation with associated infection
of bronchial walls and surrounding pulmonary parenchyma

AETIOLOGY

Congenital Acquired

Aetiology
Congenital lesions

•Congenital cystic bronchiectasis

•Kartagener’s syndrome (situs inversus, pansinusitis, bronchiectasis)

•Cystic fibrosis

•IgA deficiency

•Alpha 1-antitrypsin deficiency

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Acquired Lesions:

–Infection: Bacterial and viral

–Bronchial obstruction

–Intrinsic; neoplasm or foreign body

–Extrinsic; enlarged lymph node

–Tuberculosis

Pathology
•Upper lobe involvement is uncommon.

•Common area: basilar segments of lower lobes, the middle lobe and lingular segments

Gross

•Reduced volume of involved lobe/lung

•Pleural adhesions– numerous, dense & vascular

•Grossly dilated subsegmental (2 nd-4th) bronchi

•Saccular blind ending bronchial sacs surrounded by peribronchial consolidation

•Parenchyma is often airless, fibrosed ± pneumonitis and small abscesses

•Lobar and peribronchial lymphadenopathy

Clinical Features
•Recurrent episodes of chest infection: cough, fever, haemoptysis

•Copious offensive mucopurulent sputum

•Cyanosis

•Finger clubbing / pulmonary osteoarthropathy

•Anorexia, weight loss, anaemia

Surgery ｜ 2
•Dullness to percussion, rales & rhonchi

Symptoms:

.1Cough .4Wheezes

.2Haemoptysis .5History of recurrent URTI and sinusitis

.6Associated autoimmune diseases
.3Dyspnea 7- nfertility
8- Complications
Diagnosis
CXR

•Non specific abnormalities •Lung fibrosis

•Pleural thickening •Segmental atelectasis

Bronchoscopy

•Excludes foreign body •Excludes neoplasm

•Localises segmental involvement •Uncontaminated secretions for culture

CT Scan

•Virtually replaced bronchography for diagnosis

•Shows bronchial dilatation with peribronchial infiltration

•Determines the lobe(s) involved

•Enables assessment of lung parenchyma and pleural space

Medical Treatment
•Prevention and control of infection with •Postural drainage / Bronchoscopy with
appropriate antibiotics lavage

•Mucolytics •Humidification

•Non irritant expectorants •Bronchodilators

Surgery ｜ 3
 Dr. Ahmed Al-Azzawi
Surgical Treatment
•Failure of medical management after several months

•Frequent or massive haemoptysis

•Localised disease

• Surgical treatment involves complete resection of all involved segments

Double lumen endotracheal tube essential

Lung Abscess
Definition:

•Localised area of suppuration and usually accompanying cavitation in the lung

•A suppurative and destructive process occurring within the lung parenchyma caused by
pyogenic organisms

Classification
•Aspiration–related / Primary or non– •Carcinomatous
specific
–Cavitating carcinoma
•Abscess in pre-existing pulmonary lesions
•Abscess following trauma (blunt or
–Infected intrapulmonary bronchogenic penetrating)
cysts
–Intrapulmonary haematoma that becomes
–Infected bullae infected

•Others:

–Specific infections that cause pneumonia •Klebsiella, Pseudomonas, Proteus etc

•Staph aureus •Candida albicans

•β-haemolytic strept •Legionella pneumonia

•H. influenza

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 Dr. Ahmed Al-Azzawi
Contributing Factors
•Dental caries / periodontal disease

•Decreased state of consciousness

–Anaesthesia –Coma

–Alcohol abuse / drug abuse –CVA

–Seizure disorders

•Immunosuppression –Transplant

–Steroid Therapy –Malnutrition & debilitation

–Chemotherapy for malignancy –AIDS

•Neuromuscular & Oesophageal Disease

–Oesophageal obstruction –GERD

–Oesophageal motility disorders eg –Inability to cough

achalasia

•Bronchial obstruction

–Stricture –Neoplasm

–Foreign body –Bronchial compression

•Generalised septicaemia

Pathogenesis / Pathology
•Necrosis and suppuration extends unless limited by host defenses or appropriate therapy

•Extension may occur:

–Across fissures into adjacent lobes

–Into pleural cavity → empyema

–Via lymphatics into hilar and mediastinal nodes

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–Haemotogenously → metastatic abscess e.g. brain

•Microoganisms

–Anaerobic bacteria

–Staphyloccoci –E. Coli

–Streptoccoci –Klebsiella etc.

–Haemophilus

Clinical Features
•Look out for contributing factors

•Acute pneumonic process

–Fever –Chest pain, often pleuritic

–Cough; initially dry, later foul smelling –Dyspnoea

purulent sputum
–haemoptysis

Complications

•Rupture into pleural space → •Metastatic intracranial abscess

pyopneumothorax
•Bronchogenic spread to uninvolved areas
•Extension into chest wall – empyema of lung
necessitans
•Generalised septicaemia
•Haemoptysis

Radiographic Findings
CXR

•Early finding: localised extensive area of consolidation.

•Common sites of ‘aspiration abscess’

–Lateral aspect of posterior segment of RUL

Surgery ｜ 6
–Superior segment of RLL

•Air fluid levels later in consolidated area

CT Scan

•Valuable in demonstrating cavitation within area of consolidation

•Evaluates thickness and character of abscess wall

•Determines exact position with respect to chest wall and interlobar fissures

•Demonstrates bronchial occlusive disease

•Distinguishes lung abscess from loculated empyema

Differential Diagnosis
Cavitary Lesions Other Than Lung –Infected pulmonary infarct
Abscess
•Loculated empyema
•Infections
•Parasitic Diseases
–TB
–Amoebic abscess
–Mycoses
–Echinococcus cyst
•Coccidiodomycosis
•Cavitary squamous cell carcinoma
•Histoplasmosis

Differential Diagnosis
•Cystic pulmonary disease –Pulmonary sequestration

–Infected emphysematous bullus •Granulomatous disease

–Infected bronchogenic cyst –Wegener’s granulomas

Medical Treatment
•Appropriate antibiotics 4-12wks

Surgery ｜ 7
•Bronchoscopy :

–specimen for culture –Postural drainage

–Excludes presence of FB –Blood trasfusion

–Provides drainage –Correction of serious dental disease

•Supportive measures –Cessation of drug/alcohol abuse

–Nutritional rehabilitation

Surgical Treatment
Indications –Empyema

•Failed medical Rx –Bronchopleural fistula

•Giant abscess (>6cm cavity) •Significant haemoptysis

•Complications •Suspicion of carcinoma

Surgical Options
•Percutaneous tube drainage

•Resection of involved lobe

•External drainage for peripheral abscesses

•Anaesthetic management

–Double lumen endotracheal tube –Bronchial blockers

Massive Haemoptysis

•Bronchoscopy and tamponade of involved segment prior to resection

•Gel foam embolisation of affected bronchial artery

EMPYEMA THORACIS (pyothorax)

Definition: Accumulation of pus in the pleural space

Etiology:

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1.Traumatic •Parapneumonic – 50%

2.Non-traumatic •Post-surgical

Aetiology –Post-resectional

•Open lung biopsy or wedge resection •Gastric / Pancreatic / Splenic

•Post segmentectomy –Lung abscess rupture

•Post lobectomy –Pulmonary TB

•Post pneumonectomy –Pulmonary mycotic infections

–Secondary to other thoracic or intra- –Post traumatic (blunt or penetrating)

abdominal procedures
–BPF of spontaneous pneumothorax
•Oesophageal
–Extension from subphrenic suppuration;
•Cardiac liver abscesses, infected pancreatic
pseudocyst; subphrenic abscess.
•Mediastinal

Pathogenesis
Classified into 3 phases: American Thoracic Society

1.Exudative/Acute

2.Fibrinopurulent/ Transitional

3.Organizational/ Chronic

Bacteriology:

Strept pneumonia
E – coli
Staphylocci esp. in children
Pseudomonas
Anaerobic organisms

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Exudative or acute

–Acccumulation of small to moderate amount of pleural fluid

–Exudative fluid

–Sterile, contains a small number of polymorphonuclear leukocytes

–Low viscosity

–Pleural fluid glucose and pH are normal, LDH <1000IU/L

Fibrinopurulent or transitional phase

•More turbid fluid of increasing volume •Fibrin deposited in layers on pleural

and viscosity surfaces

•Lots of polymorphs and cellular debris •Less expandable lungs

•Bacteria may be identified on Gram stain •Pleural fluid glucose and pH fall

•LDH level increases

Chronic or organization phase

•Ingrowth of fibroblasts and capillaries •Very thick and viscous fluid; about 75%
into the deposited fibrin sediment

•Produces a firm inelastic membrane •Glucose level<40mg/dl, pH<7.0

termed pleural peel
•Lung is trapped

•Completed at 4-6 weeks

Clinical Features
•Fever, chest pain, cough, dyspnoea

•Failure of response to adequate antibiotic Rx

•Weight loss, anaemia

•Decreased breath sounds, restricted chest movements, dull PN, clubbing

Surgery ｜ 10
•Empyema necessitans

•Post surgical empyema – hx of operation

Diagnosis
•Thoracocentesis

•CXR – homogenous opacity, mediastinal shift in large effusions

•CT Scan – especially for loculated empyema

•Bronchoscopy – excludes a FB or endobronchial tumour

Management
Principles

•Evacuation of fluid –Nutritional support

•Obliteration of the pleural space •Control of the underlying disease

•Augmentation of host defenses •Restoration of normal mobility of the lung

if possible
–Appropriate antibiotics

Management options ( alone or in combination)

•Drainage: –Fibrinolytic enzymes:
Streptokinase/Urokinase) for loculated
–Thoracocentesis
empyemas
–Closed chest tube thoracostomy
–V.A.T.S. debridement and drainage
–Open drainage
•Surgical procedures
•Tube drainage
–Decortication
•Rib resection drainage (Eloesser flap)
–Empyemectomy

–Thoracoplasty

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 Dr. Ahmed Al-Azzawi
Management of incomplete lung expansion

•Omentoplasty

•Muscle flap closure

–Latissimus dorsi

–Pectoralis major

–Serratus anterior

–Rectus abdominis

•Thoracoplasty

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