Purulent diseases of lungs and pleura

Lung abscesses
• Lung abscess - necrosis of the pulmonary
tissue and formation of cavities containing
necrotic debris or fluid caused by microbial
infection.
• Necrotizing pneumonia
• Lung gangrene
 Factors contributing to lung abscess

• Oral cavity disease

• ·        Periodontal disease
• ·        Gingivitis
• Altered consciousness
• ·        Alcoholism
• ·        Coma
• ·        Drug abuse
• ·        Anesthesia
• ·        Seizures
 Factors contributing to lung abscess
-2
• Immunocompromised host
• ·        Steroid therapy
• ·        Chemotherapy
• ·        Malnutrition
• ·        Multiple trauma
• Esophageal disease
• ·        Achalasia
• ·        Reflux disease
• ·        Depressed cough and gag reflex
• ·        Esophageal obstruction
• Bronchial obstruction
• ·        Tumor
• ·        Foreign body
• ·        Stricture
 Lung abscessess classification
Duration:
• Chronic
• Acute (4-6 weeks)
Etiology (Anaerobic bacteria)
Origin:
• Primary (infection +aspiration or pneumonia)
• Secondary (obstruction, spread from
extrapulmonary site, immunocomprimized
 Classification According to the character of
purulent process:
• single purulent abscesses;
• -         multiple purulent abscesses;
• -         bilateral purulent abscesses;
• -         gangrenous abscesses (single, multiple,
uni- and bilateral);
• -         limited gangrene;
• -         wide-spread gangrene.
•  
 Classification According to stages:

• -         1 stage - necrotic pneumonia;

• -         2 stages - destruction and rejection;
• -         3 stages - cleaning and cicatrization.
 Classification Complications:
-      
•    pulmonary bleeding;
-         pyopneumothorax;
-         pleural empyema;
-         sepsis;
-         bronchogenic dissemination.
 Symptomatology

• Depends on:
• on the size of the focus and
• character of destruction,
• reactivity of the organism and
• stage of the disease,
• peculiarities of the drainage of purulent
cavities and
• complications.
 Clinical manifistation of the first stage of
acute abscess
• general weakness,
• headache,
• malaise,
• suppressed appetite,
• moderate chest pain,
• dyspnea,
• subfebrile temperature
Clinical manifistation of the second stage

• Condition is worsening (intoxication)

• The fever rises to as high as 39-40°С and has a
hectic character.
• the chest pain increases
• troubling cough and dyspnea.
• a foul-smelling from the mouth at cough
• The amount of sputum is small, after draining
can reach to 500 ml
Clinical manifestation at the third stage

• Further in favourable cases there is a

considerable improvement of state of the
patients.
• The body temperature falls,
• the signs of intoxication reduce and
• the appetite increases.
 Diagnostic procedures
• By palpation – weakened vocal fremitus.
• At percussion – a blunted sound over the site
of the purulent focus and perifocal infiltration
(at subpleural location of the abscess).
• By auscultation – tubular sound with a moist
rales in the zone of purulent focus
 Instrumental methods
• X-ray
• Computed tomography
• Examination of the sputum (bacteriological,
cytological)
• General blood and urine analyses
• Biochemical blood analysis (protein and its
fractions).
• Fibrobronchoscopy.
X-ray examination
X-ray –frontal and lateral exam
(2 plains)
 Chronic abscesses
• Chronic abscess of lungs occurs at 12-15 % of cases.
It is considered to be chronic at existence of a
pulmonary abscess more than 6-8 weeks. It is
characterized by a cyclic course. In the stage of
remission the patients complain of a moderate
dyspnea, cough with expectoration of a mucous or
mucopurulent discharge. The exacerbation
manifests by coughing up of 250-500 ml of a
purulent foul sputum, chest pain, dyspnea, hectic
temperature with the difference in 1,5-2°С
X-Ray chronic abscess
Lung gangrene
Differential diagnosis with Lung Carcinoma
The tactics in acute pulmonary destruction
• mainly conservative
• The adequate antibacterial, antiinflammatory therapy
consists of intravenous introduction of antibiotics of a wide
spectrum activity
• Injection of antibiotics in the vessels of a pulmonary
circulation by means of catheterization of central veins,
pulmonary artery;
• into respiratory tracts (in the second stage) – through the
endotracheal microirrigator, nasogastric tube, during
bronchoscopies, endoscopic catheterization of the abscess
cavity through the draining bronchus, in aerosolic inhalations.
 Tactics:
• Evacuation of purulent content of the cavities
• Homeostatic correction (oxygenotherapy,
correction of anemia, hypoproteinemia,
acidosis, microcirculatory disturbance)
• Correction of dysfunction of the vital organs
and systems, prevention of complications,
symptomatic therapy.
 Surgery, indications
• Pulmonary bleeding of ІІ- ІІІ degree;
• -         Progression of the process on the
background of active and appropriate therapy;
• -         Tense pyopneumothorax, which is failed
to liquidate by the draining of pleural space;
• -         Impossibility to rule out the suspicion on
a malignant tumour.
 Operations
• Operational incisions – anterolateral, lateral
and posterolateral thoracotomy.
• The operation suggests segmental,
polysegmental resection, lobectomy,
bilobectomy combined intervention (with the
decortication, pleurectomy).
Lateral thoracotomy
Posterolateral thoracotomy
Anterior thoracotomy
 Pleural empyema

• The pleural empyema is a purulent

inflammation of its visceral and parietal
membranes, which is associated with
accumulation of pus in a pleural space.
 Etiology and pathogenesis

• inflammatory, or purulent and destructive

processes of lungs,
• abscesses of abdominal cavity (secondary
pleural empyema),
• open and closed damages of chest,
• in some cases, operative approaches on
thoracic organs (primary pleural empyema).
 Classification (1)

• According to the etiological factor:

• 1.     Specific.
• 2.     Nonspecific.
• According to the pathogenic factor:
• 1.     Primary.
• 2.     Secondary.
 Classification (2)
• According to the clinical course:
• 1.     Acute.
• 2.     Chronic.
• According to extension of the process:
• 1.     Focal.
• 2.     Wide-spread.
 Classification (3)
• According to the presence of lung destruction:
• 1.     Empyema with destruction of pulmonary
tissue.
• 2.     Empyema without destruction of
pulmonary tissue.
• 3.     Pyopneumothorax.
 Classification (4)
• According to communication with
environment:
• 1.     Closed pleural empyema;
• 2.     Open pleural empyema:
• ·        bronchopleural fistula;
• ·        thoracopleural fistula;
• ·        thoracopleurobronchial fistula;
• ·        cribrate lung.
 Symptomatology

• depends on
• extension of the process,
• reactivity of organism and
• presence of complications
 Symptoms-1
• The pain is the sign, which denote the
involvement of pleural membranes in the
process. Its intensity increases depending on
depth of respiration and body position.
• The dyspnea arises from accumulation of a
purulent content in a pleural space and
exception of particular volume of a pulmonary
tissue from respiration
 Symptoms-2
• The cough is manifestation of inflammation or
purulent and destructive process in a pulmonary
tissue.
• Fever to 39-40°C,
• headache,
• sleeplessness,
• general malaise, and
• anorexia – all these are manifestations of
intoxication.
 Examination
• By palpation – diminished vocal fremitus on the
part of lesion.
• At percussion - over the exudate it is possible
to reveal short sound with oblique upper
contour. Above the exudate – tympanic sound
resulting from consolidation of pulmonary
tissue.
• By auscultation – diminished or absent sound in
a great amount of exudate.
 X-ray examination
• roentgenological sign of a focal or wide-spread
empyema – the presence of exudate
• The wide-spread pleural empyema manifests
by intensive homogeneous shadow in a basal
parts with oblique upper contour (Damuaso'
line).
• The diaphragmatic dome is failed to observe
 The diagnostic program

1.Complaints and history of the disease.

2. Physical findings.
3. Data of chest X-ray (in two planes, if necessary –
laterography).
4. Pleural puncture.
5. The microbiological investigation of the exudate for its
sensivity to antibiotics.
6. General blood and urine analyses.
7. Biochemical blood analysis.
8. Pleurography (in transferring of the process into chronic form).
Chest X-ray presentation of pleural empyema
Pleural puncture
Local anestesia
Needle Positioning
 Tactics and choice of treatment

• Pleural drainage
• Intensive antibacterial and antiinflammatory
therapy should be immediately instituted
• detoxication therapy (infusion of saline
solutions, hemotransfusion, transfusion of
proteins, solutions of dextran, haemodes,
forced diuresis, hemosorption if necessary),
therapy for rising up of immunological
resistance of the organism
Pleural drainage
 Tactics and choice of treatment
• During the empyema's sanation decreases the
amount of pus which discharges out through
the drainage. The optimal variant of such
course is the liquidation of empyema's cavity,
then the drainage must be removed.
• Transferring of the process into the chronic
form (10-12 weeks) results in formation of a
residual empyema's cavity
 surgery
• Operative approach is applied when the
process has transferred into the chronic form,
that is in case of residual empyema's cavity.
Volume of the operation – pleurectomy,
decortication of lung
 Mediastinitis
• Mediastinitis is an infection affecting the
mediastinum.
• It can be a life-threatening condition and
requires urgent surgical and medical
intervention
 Etiology
• Infection originating from structures within the
mediastinum.
• Infection descending from the oropharynx through
the fascial planes in the neck (eg the carotid space,
the prevertebral space). This descending infection is
known as descending necrotising mediastinitis.
• A rare fibrotic reaction to granulomatous diseases
such as histoplasmosis. This is known as fibrosing
mediastinitis.
Mediastinitis originating from structures within the mediastinum

• Oesophageal rupture is the most common cause of

mediastinitis.
• This may be due to:Foreign body ingestion.
• Spontaneous oesophageal rupture.
• Local neoplastic spread.
• Iatrogenic causes including:
– Endotracheal intubation.
– Bronchoscopy.
– Cardiothoracic surgery (most cases of mediastinitis in the
developed world follow cardiothoracic surgery).
– Upper gastrointestinal (GI) endoscopy.
 Descending necrotising mediastinitis

• This may originate from:

• Pharyngitis.
• Tonsillitis, peritonsillar abscess and
parapharyngeal abscess.
• Otitis media.
• Sinusitis.
• Dental abscess. Sialadenitis.
• Infection after head and neck surgery
 Symptoms

• Fever and/or rigors can occur.

• Shortness of breath may be present.
• Retrosternal chest pain, usually described as pleuritic,
may radiate to the neck or back.
• There may be a sensation of soreness or congestion in
the neck if the condition is due to descending infection.
• The patient may notice that their neck is swollen.
• Confusion or disorientation may be present due to the
onset of systemic sepsis.
 Investigations
• FBC: white cell count is usually elevated.
• Blood cultures should be taken.
• Swabs of any obvious sources of sepsis in the mouth or
neck tissues should be taken.
• X-ray of the neck and chest may show widening of the
pre-cervical, retropharyngeal and paratracheal soft
tissues. Pneumomediastinum and air-fluid levels may
be seen
• Mediastinal widening may be seen but is not a reliable
sign.
X-ray examination
CT scans
 Management
• Initial management should focus on
resuscitation, including protecting the airway,
maintaining adequate oxygenation with
supplementary oxygen,
• High-dose broad-spectrum intravenous
antibiotics should be started as soon as
possible.
 surgery
• Surgery usually consists of urgent
thoracotomy or access via a cervical approach.
• Drainage of pus and necrotic material with
tissue debridement is carried out
• as well as closure of any oesophageal rupture,
or drainage of any cervical infective focus
 Prognosis

• In the presence of comorbid conditions, the

mortality rate may be as high as 67%.
• descending necrotising mediastinitis in the last
decade indicate mortality rates ranging
between 11.1-34.9%.
• High clinical suspicion in susceptible individuals,
early diagnosis and prompt aggressive
management are the best way to reduce
morbidity and mortality