SUPPURATIVE LUNG DISEASES

DR FAISAL MOIDUNNY MAMMU

DEPARTMENT OF PAEDIATRICS
EMPYEMA

•Accumulation of pus in the pleural space.

Causative organisms- most commonly by
Streptococcus Pneumoniae ,
Staphylococcal aureus in developing
nations, Asia and Post traumatic empyema.
•Other causes- Rupture of lung absecess
into pleural space, contamination
introduced from trauma or thoracic
surgery, mediastinitis or extension of
intra-abdominal abscess.
•Less common organisms- Group A
Streptococcus, Gram-negative
organisms, tuberculosis, fungi.
 Epidemiology
Most commonly encountered in Infants
and Preschool children.
5-10% children with bacterial pneumonia
and 86% children with necrotizing
pneumonia.
 Pathology

3 stages

Stage 1-Exudative stage- fibrinous

exudate forms on pleural surfaces.
Stage 2- Fibrinopurulent stage- Fibrinous septa
form, causing loculation of fluid and thickening
of parietal pleura.
If pus not drained – dissect through pleura into
lung parenchyma producing bronchopleural
fistulas and pyopneumothorax or into
abdominal cavity. Rarely pus dissects through
chest wall ( i.e. Empyema necessitans)
 Stage 3- Organizational stage- Fibroblast
proliferation
Pockets of loculated pus may develop into
thick walled abscess cavities or the lung
may collapse and become surrounded by a
thick, inelastic envelope (peel)
 Clinical features
Initial signs and symptoms those of bacterial
pneumonia.
Children treated with antibiotic agents may
have an interval of few days between the
clinical pneumonia phase and the evidence of
empyema.
Most patients are febrile, develop increased
work of breathing or respiratory distress and
often appear more ill.
Physical findings similar to those for
serofibrinous pleurisy and the 2 conditions
are differentiated only by thoracocentesis
which should always be performed when
empyema is suspected.
 Lab findings

Radiographically all pleural effusions

appear similar , but absence of fluid shift
indicates loculated empyema.

Septa confirmed by USG or CT.

Maximal amount of fluid obtainable should
be withdrawn by thoracocentesis and
analysed.
Effusion is empyema if bacteria present on
Gram staining, pH <7.20, >100,000
neutrophils/microliter.
•Appearance of pus produced by
different organisms is not distinctive.
•Cultures of fluid must be performed.
•Blood cultures have higher yield than
cultures of pleural fluid.
Leukocytosis and elevated ESR found.
 COMPLICATIONS

Staphylococcal infections- bronchopleural

fistulas and pyopneumothorax
Others-Purulent Pericarditis
Pulmonary abscess
Peritonitis (extension through diaphragm)
Osteomyelitis of ribs
Septic complications- meningitis, arthritis,
osteomyelitis
Septicemia seen in H.Influenzae and
Pneumococcal infections.
Effusion organize into thick peel which may
restrict lung expansion and may be
associated with persistent fever and
scoliosis.
 Treatment
Aim- To sterilize pleural fluid and restore
normal lung function.
Systemic antibiotics
Thoracocentesis and chest tube drainage
initially with a fibrinolytic agent
If no improvement VATS
Open decortication if VATS and fibrinolysis fails
If empyema diagnosed early- antibiotic therapy
with thoracocentesis provides complete cure.
Clinical response in empyema is slow, even
with optimal treatment there may be little
improvement for as long as 2 weeks. With
staphylococcal infections resolution is very
slow and systemic antibiotic therapy required
for 3-4 weeks.
When pus obtained by thoracocentesis,
closed chest-tube drainage with
fibrinolytics is initial procedure followed by
VATS if there is no improvement.
If pleural fluid septa are detected on USG,
fibrinolysis is attempted followed by VATS if
no improvement.
Closed chest tube drainage is controlled by
an underwater seal or continuous suction;
sometimes more than one tube required to
drain loculated areas. Closed drainage
usually continued for 5-7 days. Chest tubes
that are no longer draining are removed.
Instillation of the fibrinolytic agents into
the pleural cavity via chest tube may
promote drainage, decrease fever, lessen
need for surgical intervention, and shorten
hospitalization; it does not shorten the
course of disease when used after VATS.
Streptokinase 15000 Units/ kg in 50 mL of
0.9% saline daily for 3-5 days and Urokinase
40000 units in 40ml saline every 12 hours
for 6 doses . Alteplase has also been used.

There is risk of anaphylaxis with

streptokinase and all 3 drugs can be
associated with hemorrhage and other
complications.
In the child who remains febrile and
dyspnoeic for more than 72 hours after
initiation of therapy with intravenous
antibiotics and thoracostomy tube
drainage, surgical decortication via VATS
or, less often, open thoracotomy may
speed recovery.
If pneumatocoeles form, no attempt
should be made to treat them surgically or
by aspiration, unless they reach sufficient
size to cause respiratory embarrassment or
become secondarily infected.

Pneumatocoeles usually respond

spontaneously over time.
 LUNG ABSCESS

Lung abscess is a thick-walled cavity in the

pulmonary parenchyma that contains
purulent material and is initiated or
complicated by infectious organisms.
Lung abscess is classified as primary or
secondary depending on underlying
conditions.
Primary lung abscess occurs in the absence
of a specific lung disease due to organisms
causing underlying pneumonia eg:
Streptococcus pneumonia, Staphylococcal
aureus, Klebsiella pneumoniae
 Secondary lung abscess occurs in the
presence of predisposing structural or
functional lung diseases including
congenital lung disorders, ciliary
dyskinesia, and cystic fibrosis, systemic
diseases such as neuro-developmental
abnormalities and congenital
immunodeficiencies that may lead to
aspiration or infection.
 Clinical features
Fever
Cough
Rhinorhoea
Dyspnoea
Chest pain
Abdominal pain
Lethargy
Investigations

Chest Xray,
USG and CT chest
Management

Two basic principles are involved, namely

adequate appropriate antibiotic therapy
and drainage of the abscess cavity
Antibiotic therapy-

Primary- 3 rd
gen Cephalosporin +
Vancomycin + Aminoglycoside

Secondary- CP + Chloramphenicol
Drainage

Endobronchial aspiration of the abscess

cavity by Bronchoscopy
Postural drainage and chest
physiotherapy

inhalation of an aerosol solution of 10%

propylene glycol, followed by percussion
of the chest wall to implement coughing
and drainage.