8 lung abscess

internal medicine

1. Lung abscessLung abscess

2. DefinitionDefinition
•Necrosis of pulmonary tissue Necrosis of pulmonary tissue
caused by severe infection, caused by severe infection,
characterized clinically by high characterized clinically by high
fever, cough with large quantity of fever, cough with large quantity of
purulent sputum, porosis, which in purulent sputum, porosis, which in
X-ray presents as one or several X-ray presents as one or several
cavity with liquid planecavity with liquid plane

3. PathogensPathogens
•Bacteria located in oral cavity or upper respiratory Bacteria located in oral cavity or upper respiratory
tract, including aerobic, anaerobic or facultative tract, including aerobic, anaerobic or facultative
anaerobic bacteriumanaerobic bacterium
•Common pathogens, e.g., staphylococcus, Common pathogens, e.g., staphylococcus,
klebsiella, pseudomonas aeruginosa, suppurative klebsiella, pseudomonas aeruginosa, suppurative
streptococcusstreptococcus
•90% cases accompanied with anaerobic infection90% cases accompanied with anaerobic infection

4. •Aspirated lung abscessAspirated lung abscess
•Existence of local infectious loci in oral, nasal or Existence of local infectious loci in oral, nasal or
pharyngeal cavity, pathogen aspiratedpharyngeal cavity, pathogen aspirated
•Right lung is easily involved because right main Right lung is easily involved because right main
branch is steeper and widerbranch is steeper and wider
•Anaerobes more oftenAnaerobes more often
Mechanisms

5. •Secondary lung abscessSecondary lung abscess
•To bacterial pneumonia, bronchiectasis, To bacterial pneumonia, bronchiectasis,
bronchial cyst, lung cancer, pulmonary TB cavitybronchial cyst, lung cancer, pulmonary TB cavity
•Obstructed by foreign body, esp. for childrenObstructed by foreign body, esp. for children
•Infiltrated by suppurative D in neighboring Infiltrated by suppurative D in neighboring
organsorgans

6. •Hematogenous lung abscessHematogenous lung abscess
•Toxic infection Caused by skin injury or Toxic infection Caused by skin injury or
infection, furuncle or carbuncle (anthracia, infection, furuncle or carbuncle (anthracia,
痈痈), bacterial emboli disseminated to ), bacterial emboli disseminated to
lunglung→ thrombosis of small veins, → thrombosis of small veins,
inflammation and necrosisinflammation and necrosis

7. PathologyPathology
•Incomplete treatment or unsuccessful Incomplete treatment or unsuccessful
bronchial drainage bronchial drainage →large amount of →large amount of
necrotized tissue remnant in cavity necrotized tissue remnant in cavity
→persistent over 3 months, termed as →persistent over 3 months, termed as
chronic lung abscesschronic lung abscess..
•Hyperplasia of fibroblast, formation of Hyperplasia of fibroblast, formation of
granulation tissue granulation tissue →cavity wall thicker →cavity wall thicker
→the peripheral bronchi or bronchioles →the peripheral bronchi or bronchioles
involved, deformity, or distentioninvolved, deformity, or distention

8. Clinical manifestationClinical manifestation
•HistoryHistory
1.1.Surgery in oral cavity, local infectious loci, Surgery in oral cavity, local infectious loci,
drunkenness, fatigue, coma, etcdrunkenness, fatigue, coma, etc
2.2.Other pulmonary DOther pulmonary D
3.3.Skin injury, furuncle, carbuncleSkin injury, furuncle, carbuncle

9. •SymptomsSymptoms
•Abrupt onsetAbrupt onset
•High fever with rigor, 39~40ºCHigh fever with rigor, 39~40ºC
•Cough with exuberant purulent sputum, Cough with exuberant purulent sputum,
300~500ml/day, 3 layers after deposition300~500ml/day, 3 layers after deposition
•Hemoptysis in 1/3 casesHemoptysis in 1/3 cases
•Less sputum in hematogenous cases, Less sputum in hematogenous cases,
hemoptysis is rarehemoptysis is rare

10. •In chronic cases, recurrent cough, In chronic cases, recurrent cough,
sputum, fever and hemoptysis, sputum, fever and hemoptysis,
persistent over 3 months; anemia is persistent over 3 months; anemia is
not rarenot rare
•Other signs: loss of body weightOther signs: loss of body weight

11. •SignsSigns
•Associated with the size and site of Associated with the size and site of
lung abscesslung abscess

12. Laboratory testingLaboratory testing
•Blood RT: Blood RT: WBC counting 20~30WBC counting 20~30××1010
99
/L, /L,
NN>>90%90%，，hyposegmentation, toxic granuleshyposegmentation, toxic granules
•CytologyCytology
1.1.Sputum film preparation + Gram stainingSputum film preparation + Gram staining
2.2.Sputum, pleural effusion, blood cultureSputum, pleural effusion, blood culture
3.3.CultureCulture

13. X-ray examinationX-ray examination
•In early stage, lump of dense foggy In early stage, lump of dense foggy
shadow without clear marginshadow without clear margin
•After porosis, circular transparent After porosis, circular transparent
shadow with liquid plane, around which shadow with liquid plane, around which
is dense inflammatory infiltrationis dense inflammatory infiltration
•In chronic lung abscess, cavity wall In chronic lung abscess, cavity wall
thicker, irregular form, or collapsedthicker, irregular form, or collapsed

14. 图图72-72-肺
脓疡
肺
脓疡
右肺下叶大 状病 ，
块 灶
其内密度不均 ，可
匀 见
更低密度的坏死区， CT
值约18Hu

15. 图图73-73-肺
脓疡
肺
脓疡
病 部分
灶实质
CT值60Hu
（ 描）， 部分
增强扫 边缘
欠清， 球菌性肺
为隐 脓疡

16. Diagnostic EssentialsDiagnostic Essentials
1.1.History of surgery in oral cavity, vomiting in History of surgery in oral cavity, vomiting in
coma status, or aspiration of foreign, or coma status, or aspiration of foreign, or history history
of skin injury, carbuncle or furuncle, of skin injury, carbuncle or furuncle,
endocarditisendocarditis
2.2.Abrupt onset of rigor, fever, cough with Abrupt onset of rigor, fever, cough with
exuberant purulent sputumexuberant purulent sputum
3.3.In Blood RT, WBC counting, NIn Blood RT, WBC counting, N­­
4.4.X-ray: cavity with liquid plane in dense X-ray: cavity with liquid plane in dense
inflammatory shadow (acute), inflammatory shadow (acute), Multiple loci in Multiple loci in
bilateral lungs indicates hematogenous lung bilateral lungs indicates hematogenous lung
abscessabscess
5.5.Pathogen examinationPathogen examination

17. Differentiation DiagnosisDifferentiation Diagnosis
1.1.Bacterial pneumoniaBacterial pneumonia
2.2.Infection secondary from pulmonary TB Infection secondary from pulmonary TB
cavitycavity
3.3.Bronchial carcinoma with obstructive Bronchial carcinoma with obstructive
bronchitisbronchitis
4.4.Infection secondary from pulmonary Infection secondary from pulmonary
cystcyst

18. •Distinguish inflammatory cavity Distinguish inflammatory cavity
from cancerous onefrom cancerous one
1.1.Longer historyLonger history
2.2.Slight toxic symptomsSlight toxic symptoms
3.3.Less purulent sputumLess purulent sputum
4.4.X-ray: centrifugal cavity, the wall is X-ray: centrifugal cavity, the wall is
thicker with irregular marginthicker with irregular margin
5.5.Enlarged hilar LN is quite helpfulEnlarged hilar LN is quite helpful

19. 图图75-75-肺癌肺癌
左下肺 ，向 隔内
肿块灶 纵
生 ， 描：左心房
长 增强扫
（LA）内 低密度充盈缺
见
损

20. 图图76-76-肺癌肺癌
左肺下叶癌，左心房
内癌栓形成

21. TreatmentTreatment
•AntibioticsAntibiotics
1.1.Aspirated or secondary: Aspirated or secondary: anaerobic anaerobic
bacterium, most sensitive to penicillin bacterium, most sensitive to penicillin
2.2.Hematogenous: Hematogenous: staphylococcus or staphylococcus or
streptococcus, primary antibiotics are streptococcus, primary antibiotics are bb--
lactamase resistant penicillins or lactamase resistant penicillins or
cephalosporinscephalosporins
3.3.Course: Course: 8~12 weeks till the disappearance 8~12 weeks till the disappearance
of cavity and symptoms, or only little remnant of cavity and symptoms, or only little remnant
fibrosis leftfibrosis left

22. •Drainage of grassery juiceDrainage of grassery juice
1.1.Position drainage: based on Position drainage: based on
administration of expectorant or administration of expectorant or
nebulization normal salinenebulization normal saline
2.2.Flush and aspiration Under Flush and aspiration Under
bronchoscopybronchoscopy

23. Surgery indicationsSurgery indications
1.1.Medical treatment over 3 Months, cavity Medical treatment over 3 Months, cavity
not smallernot smaller
2.2.Cavity >Cavity >5cm5cm
3.3.Large amount of hemoptysis, life is Large amount of hemoptysis, life is
EndangeredEndangered
4.4.Accompanied with bronchopleural Accompanied with bronchopleural
fistulafistula
5.5.Pyemia, ineffective to aspiration and Pyemia, ineffective to aspiration and
flushingflushing
6.6.Obstruction of airway, Obstruction of airway, e.g. cancerous e.g. cancerous
obstructionobstruction

24. BronchiectasisBronchiectasis
•Definition: Definition: distention of distal bronchi (distention of distal bronchi (φφ>>
2mm), caused by destruction of muscular & 2mm), caused by destruction of muscular &
elastic tissue of bronchial wallelastic tissue of bronchial wall
•Characterized Characterized by chronic cough, exuberant
purulent sputum or recurrent hemoptysis
•History: History: mumps in childhood, pertussis, or
bronchial pneumonia
•Etiology & Mechanism: Etiology & Mechanism: bronchopulmonary bronchopulmonary
infection and bronchial obstructioninfection and bronchial obstruction

25. EtiologyEtiology
•Bronchopulmonary infection – Bronchopulmonary infection – most common in most common in
childhoodchildhood
•Common pathogens: pseudomonas aeruginosa,
staphylococcus, hemophilia influenzae, streptococcus
pneumoniae, etc
•Bronchial obstruction – Bronchial obstruction – tumor, foreign body or tumor, foreign body or
infection. Intraluminal obstruction or extraluminal infection. Intraluminal obstruction or extraluminal
oppression. oppression. Middle lobe syndromeMiddle lobe syndrome: atelectasis of : atelectasis of
middle lobe caused by bronchial obstructionmiddle lobe caused by bronchial obstruction
•Genetic bronchial developmental abnormalityGenetic bronchial developmental abnormality
•Systemic D: rheumatoid arthritis, Crhon’s D, ulceric Systemic D: rheumatoid arthritis, Crhon’s D, ulceric
colitis, systemic lupus erythma, AIDS, yellow nail colitis, systemic lupus erythma, AIDS, yellow nail
syndromesyndrome

26. •Kartagener syndrome: Kartagener syndrome:
bronchiectasis caused by genetic bronchiectasis caused by genetic
abnormal development of bronchial abnormal development of bronchial
cartilage and elastic tissue, often cartilage and elastic tissue, often
accompanied with sinusitis and accompanied with sinusitis and
visceral rotation (dextrocardia)visceral rotation (dextrocardia)

27. PathologyPathology
•Styloid (columnar) or cystic distention, may be Styloid (columnar) or cystic distention, may be
coexistentcoexistent
•Accompanied with distention of capillary, Accompanied with distention of capillary,
distension & anastomose of terminal branches distension & anastomose of terminal branches
of bronchial & pulmonary artery of bronchial & pulmonary artery →angioma→angioma
•Recurrent hemoptysisRecurrent hemoptysis
•More common in inferior field, more common in More common in inferior field, more common in
left I fieldleft I field

28. Clinical manifestationClinical manifestation
•SymptomsSymptoms
1.Chronic cough with exuberant purulent sputum.
2.Recurrent hemoptysis: sometimes, this is the
only symptom
3.Recurrent pulmonary infection: in the same
segment, almost incurable
4.Toxic symptoms: fever, anemia and emaciation

29. •SignsSigns
•Fixed, persistent, and localized coarse Fixed, persistent, and localized coarse
moist rales in inferior field.moist rales in inferior field.
•Wheezing is not rareWheezing is not rare
•Acropachy in some patients have Acropachy in some patients have

30. ImagingImaging
•X-rayX-ray
•Typical changes– tract sign, reflex the shadow of Typical changes– tract sign, reflex the shadow of
thickened bronchial wallthickened bronchial wall
•Cystic distention in X-ray: typical imaging is curled Cystic distention in X-ray: typical imaging is curled
shadow or multiple cellular transparent shadow, shadow or multiple cellular transparent shadow,
liquid plane appears if accompanied with infectionliquid plane appears if accompanied with infection

31. •CTCT
•Columnar distention: Columnar distention: bronchial wall thickenedbronchial wall thickened
•Cystic distention: Cystic distention: clusters of cystic shadowclusters of cystic shadow
•High resolution CT (HRCT): High resolution CT (HRCT): show lobule show lobule
structures, replace bronchography in most structures, replace bronchography in most
situationssituations
•Bronchography: Bronchography: determine the site of determine the site of
bronchiectasis, only used before surgerybronchiectasis, only used before surgery

33. Circular transparent shadow
Cellular, honeycombed

34. Cystic distention, 囊状支
扩

35. Columnar distention,
柱状支扩

36. 混合状支扩

37. 七、纤维支气管镜检查七、纤维支气管镜检查
有助于对引有助于对引
起局部支气管起局部支气管
扩张的管内肿扩张的管内肿
物、结核病灶物、结核病灶
和异物的诊断。和异物的诊断。
对咯血的定位对咯血的定位
诊断及判断感诊断及判断感
染情况也有重染情况也有重
要意义。要意义。

38. Normal Bronchiectasis

39. Bronchiectasis

40. Diagnostic EssentialsDiagnostic Essentials
1.1.Typical symptomsTypical symptoms
2.2.Signs of recurrent infection in a Signs of recurrent infection in a
fixed site, presented as fixed, fixed site, presented as fixed,
persistent coarse moist ralespersistent coarse moist rales
3.3.History of respiratory infection or History of respiratory infection or
systemic D in childhoodsystemic D in childhood
4.4.Confirmed by findings of HRCT & Confirmed by findings of HRCT &
bronchographybronchography

41. Differentiation DiagnosisDifferentiation Diagnosis
1.1.Chronic bronchitisChronic bronchitis
2.2.Lung abscessLung abscess
3.3.Pulmonary TBPulmonary TB
4.4.Congenital pulmonary cystCongenital pulmonary cyst
5.5.Disseminated bronchiolitisDisseminated bronchiolitis

42. •Congenital pulmonary cystCongenital pulmonary cyst
•Round or oval shadow with clear margin and Round or oval shadow with clear margin and
thin wall, without inflammatory infiltrationthin wall, without inflammatory infiltration

43. Principles in TreatmentPrinciples in Treatment
•Smooth airwaySmooth airway
1.1.ExpectorantExpectorant
2.Bronchodilator
3.Position drainage
4.Aspiration under bronchoscopy
•AntibioticsAntibiotics
•Surgery indicationsSurgery indications
1.1.Recurrent acute respiratory infection or large Recurrent acute respiratory infection or large
amount of hemoptysis, life is endangeredamount of hemoptysis, life is endangered
2.2.Ineffective by medical treatmentIneffective by medical treatment
3.3.Localized in one lobe or in one sideLocalized in one lobe or in one side
4.4.No severe basic DNo severe basic D

44. ALI & ARDSALI & ARDS
•Acute progressive respiratory Acute progressive respiratory
failure caused by extra-or failure caused by extra-or
intrapulmonary factors, excluding intrapulmonary factors, excluding
cardiac diseases.cardiac diseases.

45. •2 stage in one 2 stage in one dynamicdynamic process process
•ALI– acute lung injury; ARDS– acute ALI– acute lung injury; ARDS– acute
respiratory distress syndromerespiratory distress syndrome
•ALI represents the early moderate stage, while ALI represents the early moderate stage, while
ARDS represents the later severe stageARDS represents the later severe stage
•Conception of ALIConception of ALI
1.1.Early stage of ARDS. In this stage, pathogen directly or Early stage of ARDS. In this stage, pathogen directly or
indirectly via inflammatory response indirectly via inflammatory response →injury of →injury of
pulmonary capillary or epithelial cellspulmonary capillary or epithelial cells
2.2.Indicate that effective treatment may intervene in this Indicate that effective treatment may intervene in this
stagestage
3.3.Benefit for evaluation of efficacy Benefit for evaluation of efficacy

46. Pathology & PathophysiologyPathology & Pathophysiology
•PathologyPathology: : ­­Permeability of pulmonary Permeability of pulmonary
capillary capillary →→congestion, edema and formation of congestion, edema and formation of
hyaline membrane, accompanied with interstitial hyaline membrane, accompanied with interstitial
fibrosisfibrosis
•3 stages: 3 stages: exudation, hyperplasia and fibrosisexudation, hyperplasia and fibrosis, ,
which are always overlappedwhich are always overlapped

47. Etiology & pathogenesisEtiology & pathogenesis
•EtiologyEtiology
•Intrapulmonary: direct factorsIntrapulmonary: direct factors
1.1.PhysiochemicalPhysiochemical
2.2.Biological factors, etcBiological factors, etc
•Extrapulmonary: indirect factors Extrapulmonary: indirect factors
1.Shock, toxic syndrome caused by severe infection
2.Severe trauma (non-thoracic), or burning
3.Large amount of transfusion
4.Necrotic pancreatitis
5.Intoxication of drugs or anesthetics

48. •PathogenesisPathogenesis
•Not very clearNot very clear
1.1.Direct injury of alveolar membraneDirect injury of alveolar membrane
2.2.Inflammatory response: intermediates & Inflammatory response: intermediates &
cytokines released from inflammatory cellscytokines released from inflammatory cells
3333 or disappear of surfactant or disappear of surfactant →aggravate →aggravate
edema & atelectasisedema & atelectasis
3333 pulmonary compliance, intrapulmonary pulmonary compliance, intrapulmonary
shunt, abnormal ventilation and gas exchangeshunt, abnormal ventilation and gas exchange
5.5.Abnormal ratio of ventilation/blood flowAbnormal ratio of ventilation/blood flow
6.6.Dysfunction of Neuroendocrinal regulationDysfunction of Neuroendocrinal regulation
7.7.Obstinate hypoxemiaObstinate hypoxemia

49. Clinical manifestationClinical manifestation
•ALI/ARDS often occurs within 5 days after ALI/ARDS often occurs within 5 days after
onset of primary D, even within 24Hrsonset of primary D, even within 24Hrs
•Addition to manifestations of primary D, the Addition to manifestations of primary D, the
earliest symptom is tachypnea, progressively earliest symptom is tachypnea, progressively
aggravated with dyspnea and cyanosisaggravated with dyspnea and cyanosis
•Dyspnea is characterized by deep, rapid breath Dyspnea is characterized by deep, rapid breath
with great effort, chest-stressed feeling, unable with great effort, chest-stressed feeling, unable
to be corrected by oxygen inhalation, neither to be corrected by oxygen inhalation, neither
interpreted by primary pulmonary Dinterpreted by primary pulmonary D
•Signs: none in early stage, or fine moist rales; Signs: none in early stage, or fine moist rales;
in the later stage, moist rales is common, in the later stage, moist rales is common,
bronchophony is not rarebronchophony is not rare

50. Laboratory & imaging Laboratory & imaging
examinationexamination
•Arterial gas analysis: typical changes: Arterial gas analysis: typical changes:
hypoxemia, hypoxemia, PaO2. in ALI, PaO2/ FiO2 PaO2. in ALI, PaO2/ FiO2
(inspiratory O(inspiratory O
22 fraction) fraction) ££300; in ARDS, 300; in ARDS,
PaO2/FiO2 PaO2/FiO2 ££ 200 200
•PAOP (pulmonary artery occlusion pressure): N PAOP (pulmonary artery occlusion pressure): N
<12mmHg, if >18mmHg <12mmHg, if >18mmHg → left heart failure; 12-18 → left heart failure; 12-18
mmHg mmHg →ALI or ARDS→ALI or ARDS
•X-ray: N in early stage, or slight interstitial X-ray: N in early stage, or slight interstitial
changes– changes– ­­ pulmonary texture with foggy pulmonary texture with foggy
margin; in late stage: flake or lamellar shadow, margin; in late stage: flake or lamellar shadow,
bronchial transparency in lamellar shadowbronchial transparency in lamellar shadow

51. DiagnosisDiagnosis
1.1.Existence of high risk factors: including Existence of high risk factors: including
direct or indirect factorsdirect or indirect factors
2.2.Acute onset with typical dyspnea & Acute onset with typical dyspnea &
tachypneatachypnea
3.3.Bilateral infiltrated lamellar shadow in Bilateral infiltrated lamellar shadow in
chest radiographychest radiography
4.4.in ALI, PaO2/ FiO2 in ALI, PaO2/ FiO2 ££300; in ARDS, 300; in ARDS,
PaO2/FiO2 PaO2/FiO2 ££ 200 200
5.5.PAWPPAWP££18mmHg, or excluding cardiac 18mmHg, or excluding cardiac
pulmonary edema clinicallypulmonary edema clinically

52. TreatmentTreatment
•AimAim
1.1.Improve oxygenation, correct Improve oxygenation, correct
hypoxemiahypoxemia
2.2.Protect pulmonary functionProtect pulmonary function
3.3.Prevent complicationsPrevent complications

53. •MeasurementsMeasurements
1.1.SurveillanceSurveillance
2.2.Treat primary systemic disorders– keyTreat primary systemic disorders– key
3.3.Oxygen therapy – mechanical ventilation PEEP Oxygen therapy – mechanical ventilation PEEP
(positive end-expiratory pressure), PaO2 (positive end-expiratory pressure), PaO2
≥

≥
60mmHg or SaO260mmHg or SaO2≥≥90%90%
4.4.Supportive: infusion managementSupportive: infusion management
5.5.Balance acid-base and electrolyte disorders,Balance acid-base and electrolyte disorders,