lung-abscess. Dr ibrahimi md pulmonologist.ppt

Lung abscess

1. Lung abscess
Pleural empyema
Tuberculosis
Janusz Kowalewski, MD, PhD.
Department and Clinic of Thoracic Surgery
Faculty of Medicine
Nicolaus Copernicus University in Toruń

2. DEFINITION:
Lung abscess 
(Latin: 
abscessus) is a collection
of
 pus that has built up within the
lung tissue. 
This is usually caused by a
 bacterial infection
. .
Lung abscess

3. -Diabetes
-Neoplastic disease
Alcohol abuse
-Malnutrition
-Narcotics abuse
-Immunosupression
-HIV infection
-Older age
Lung absces: predisposing factors:

4. Lung abscess (chest X-ray)

5. Staphylococcus pneumoniaStaphylococcus pneumonia

6. ETIOLOGY:

Aerobic bacteria infection (streptococcus (streptococcus
pneumoniae, streptococcus pyogenes, staphylococus aereus, pneumoniae, streptococcus pyogenes, staphylococus aereus,
klebsiella pneumonie, pseodomonas aeruginosa, proteus klebsiella pneumonie, pseodomonas aeruginosa, proteus
vulgaris, escherichia coli, neisseria meningitidis, haemophillus vulgaris, escherichia coli, neisseria meningitidis, haemophillus
influenzae)influenzae)
Anaerobic bacteria infectionbacteria infection
(clostridium hystoliticum, bacteroides fragilis).(clostridium hystoliticum, bacteroides fragilis).
Mixed bacterial flora ( common) ( common)
Fungal infections

Protozoa infections Protozoa infections (entamoeba histolytica)
Lung abscess (abscessus pulmonis)
The most
common

7. Streptococcus pneumoniaeStreptococcus pneumoniae

8. Staphylococcus aureusStaphylococcus aureus

9. Classification:
PRIMARY ABSCESS:
In healthy lung parenchyma
(anaerobic aspiration,
specific pneumonia)
SECONDARY ABSCESS :
In lung tissue affected by: existing lung disease, metastatic
tumors, lung carcinoma, foreign body, infarction,emphysema.
Lung abscess (abscessus pulmonis)

10. Lung abscessLung abscess
•Clinical signs ?Clinical signs ?

11. CLINICAL SIGNS :
 Hectic fever, Hectic fever,
 chills, chills,
 cough, cough,
 expectoration, expectoration,
 chest pain, chest pain,
 weight loss, weight loss,
 dyspnoea dyspnoea
 hemoptysishemoptysis
Lung abscess (abscessus pulmonis)

12. Lung absces (diagnosis) ?Lung absces (diagnosis) ?

13. Diagnosis:
 clinical signs,

 chest X-ray,
 CT scan,
 bronchoscopy,
 sputum analysis
 (BAL)
 CRP, OB, WBC elevation
Lung absces (abscessus pulmonis)

15. Bad prognostic factors:
 big abscess,
 right lower lobe,
 bad general condition (anemia, hipoproteinemia,
alcohol abuse, narcotics abuse),
 pathogenic bacteria:
- Pseudomonas aeruginosa – mortality rate: app. 83%,
- Staphylococus aureus – mortality rate: app. 50%.
- Klebsiella pneumoniae -44%).
(Boaz Hirshberg,  Miri Sklair-Levi,  Ran Nir-Paz,  Liat Ben-Sira,  et
al. Factors predicting mortality of patients with lung abscess
Chest. Chicago: Mar 1999. Vol.115,  Iss. 3;  pg. 746, 5 pgs)
Lung abscess (abscessus pulmonis)

16. LOCAL COMPLICATIONS:
 Spread to the healthy lung tissue,
 Pleural empyema,
 Broncho-pleural fistula,
 Phlegmon of the chest wall,
 Major hemoptysis,
 Aspergilloma.
Lung abscess (abscessus pulmonis)

17. General complicatons:
 bacterial endocarditis,

 multifocal liver abscess,
 multifocal brain abscess,
 nephritis, amyloidosis,
 sepsis,
 multi-organ failure
Mortality rate: 15%-20%
(Bartlett JG. Lung abscess. In: Baum GL, Wolinsky E, eds. Textbook of pulmonary
diseases. 5th ed. Boston, MA: Little, Brown and Company, 2007; 607-620. )
Lung abscess (abscessus pulmonis)

18. Conservative treatment ???:
Antibiotics based on drug sensitivity-
6-8 weeks
Supported by chest physiotherapy and
bronchoscopic aspiration
Lung abscess (abscessus pulmonis)

19. THERAPY:
It is thought that lung abscess in its early stage can regress
spontaneously in approximately 20-30% of cases.
If conservative treatment is ineffective or complications are observed
adequate invasive or surgical treatment should be initiated.
It is estimated that invasive treatment by intercostal tube drainage or
surgery is indispensable in 11-12% of patients in whom antibiotic
therapy was ineffective.
(Estrera AS, Platt MR, Mills LJ, et al. Primary lung abscess. J
Thorac Cardiovasc Surg 1980; 79:275-282).
Lung abscess (abscessus pulmonis)

20. INVASIVE THERAPY:
INJECTION OF THERAPEUTIC AGENTS DIRECTLY INTO AN ABSCESS
CAVITY:
The abscess is punctured through the chest wall and antibiotics are injected directly
into its cavity. This method is suitable for large peripheral abscesses where the
visceral and parietal pleura are accreted. The method is burdened with a risk of
pneumothorax or empyema formation.
ENDOSCOPIC ABSCESS EVACUATION:
If lung abscess is a result of pathology of the bronchial tree with its obstruction and
retention of septic debris within bronchi distally to the level of obstruction
bronchoscopy is an effective technique for abscess evacuation. The abscess
evacuation can be completed by the injection of antibiotic into the abscess cavity.
Lung abscess (abscessus pulmonis)

21. INVASIVE MANAGEMENT:
CAVERNOSTOMY:
A method used in selected cases of lung abscess (Monaldi procedure). Obliteration
of the pleural cavity is an indispensable condition to perform this procedure. Short
fragments of two or three ribs are resected over a place where the distance between
an abscess capsule and the chest wall is the shortest. The surface of the lung is
visualized and the abscess cavity is opened. Then the abscess cavity is packed with
gauze saturated with an antiseptic solution. The gauze is changed regularly for
several weeks until the process of healing and contraction of a lung defect is
obtained.
PERCUTANEOUS CATHETER DRAINAGE
Percutaneous catheter drainage of lung abscess under fluoroscopic or computed
tomography guidance is a technique introduced into medical practice during last
three decades and brings relatively good results in selected cases. The limitation of
this method is a localization of an abscess near important anatomical structures that
makes an introduction of a catheter hazardous. The technique is burdened with some
serious complications such as pneumothorax accompanied by a brocho-pleural
fistula, pleural empyema, hemorrhage and cardiac arrest.
Lung abscess (abscessus pulmonis)

22. Lung abscess drainage Lung abscess drainage

23. INVASIVE MANAGEMENT:
ENDOSCOPIC DRAINAGE:
This technique is suitable for lung abscesses having a contact with the
bronchus. A flexible bronchoscope is introduced into the bronchial tree with its
end-part as close as possible to an abscess cavity. Then a guide-wire is inserted
through a bronchoscope tool channel under fluoroscopic guidance directly into
the abscess cavity. When fluoroscopy shows that the guide-wire is in a proper
position a 90 cm long 7F catheter (pigtail catheter - Cordis; Miami, FL) is
introduced along the guide-wire into the abscess cavity. To check a proper
position of the catheter a non-barite contrast medium ( Isovist-300) can be
injected into the abscess cavity through this catheter. The proximal end of the
catheter is brought out through the nostril. The method enables the evacuation
of liquid content of abscess and abscess cavity irrigation with antibiotic or
antifungal (Amphotericin B) solutions. The catheter is kept within the abscess
cavity from 3 to 21 days. The technique offers gradual sterilization and
obliteration of abscess .
Lung abscess (abscessus pulmonis)

24. Surgical treatment:
Method: RESECTION.
Indications: ???
Mortality rate: 11%-28%.
Lung abscess (abscessus pulmonis)

25. Surgicasl treatment - INDICATIONS:
 Massive hemoptysis,
 Pleural empyema,
 Bronchopleural fistula,
 Conservative treatment failure,
 Foreign body,
 Big abscess (big cavity, >6cm after 8 weeks of treatment),
 Cancer suspicion.
Lung abscess (abscessus pulmonis)

26. Surgical treatment:

METHODS:
Wedge resection:
Anatomical resections: (segmentectomy, lobectomy,
pneumonectomy)
Lung cancer (abscessus pulmonis)

27. METHODS OF SURGICAL TREATMENT:

A type of resection of pulmonary parenchyma is dependent on localization
and size of abscess and a patient’s general state.
NON-ANATOMICAL LUNG RESECTION
Marginal or wedge pulmonary parenchyma resection for abscesses using
linear staplers: TA and GIA type is effective for small lesions localized
peripherally.
ANATOMICAL LUNG RESECTION
Large lung abscesses, abscesses localized deeply in pulmonary parenchyma
and multiple lung abscesses are all indications for anatomical resections. The
most frequent procedures are resections of a pulmonary lobe (lobectomy) or
resection of two pulmonary lobes of the right lung (bilobectomy). In the cases
of solitary abscess or multiple abscesses with vast destruction of the lung the
resection of the whole lung (pneumonectomy) is sometimes necessary. Local
conditions rarely enable less extensive surgical procedures such as
semisegmentectomy or bisegmentectomy.
Lung abscess (abscessus pulmonis)

28. METHODS OF SURGICAL TREATMENT :

VATS (Video Assisted Thoracic Surgery)
A method that is a combination of minithoracotomy and videothoracoscopic
technique (video telescope and endoscopic instruments). It enables resection of
some small, peripherally localized abscesses.
DECORTICATION + LUNG RESECTION
A method used for the treatment of lung abscesses accompanied by pleural
empyema. Decortication consists in the removal of a thick fibrinopurulent
coat from the lung surface. Besides it the part of a pleural empyema capsule
that covers the internal surface of the chest wall is also resected along with the
parietal pleura. The procedure is completed by resection of pulmonary
parenchyma with abscess.
LUNG RESECTION + IRRIGATING DRAINAGE
A procedure used in the cases of lung abscess coexisting with acute pleural
empyema. When pulmonary parenchyma with lung abscess is resected two or
three tubes are introduced into the pleural cavity and continuous irrigating
drainage with antibiotic or antiseptic solution is carried out.
Lung abscess (abscessus pulmonis)

29. PLEURAL EMPYEMA (empyema pleurae)
Pleural empyema is a kind of exudative pleuritis caused by
Microorganisms (bacteria, fungi, some protozoa) that infected
the pleural cavity.
Inflammation of organs or anatomical structures localized within the chest
and out of its anatomical borders can caused a retention of effusion in the
pleural space (hydrothorax)
A reason for pleural effusions are also systemic diseases. Initially sterile
exudate can be resorbed by the pleura if a primary disease is treated effectively.
The infection of the exudate causes its transformation into purulent liquid that
fills the pleural cavity and forms pleural empyema (empyema pleurae).

30. PLEURAL EMPYEMA (empyema pleurae)
Pleural effusion infected by: bacteria,
fungi,
protozoa.

31. PLEURAL EMPYEMA (empyema pleurae)
CLINICAL CONDITIONS CAUSING LIQUID RETENTION IN THE
PLEURAL CAVITY :
 TRANSUDATE - circulatory insufficiency, hepatic cirrhosis, nephrotic
syndrome, superior vena caval obstruction.
 EXUDATE – malignancy, infection, pulmonary embolism, esophageal
perforation, pancreatitis, sarcoidosis, systemic diseases.
 LYMPH (chylothorax) – trauma, surgery, malignancy, subclavian vein
thrombosis.
 BLOOD (haemothorax) - trauma, malignancy
In a case when a liquid collected in the pleural space becomes infected
by virulent microorganisms it transforms into pus.
Pleural empyema can develop in any individual but it seems to be more
frequent in younger people in whom immune system is weakened.

32. Left pleural effusionLeft pleural effusion

33. Right hydro-pneumothoraxRight hydro-pneumothorax

34. Pleural empyemaPleural empyema
CTCT

35. Pleural empyema: causes
1OthersOthers
< 1Complications of parasitic infectionsComplications of parasitic infections
< 1Bronchopleural fistula (spontaneus Bronchopleural fistula (spontaneus
pneumothorax)pneumothorax)
8-11Intraabdominal abscessIntraabdominal abscess
25Surgical procedures: lungs, esophagus, Surgical procedures: lungs, esophagus,
mediastinummediastinum
3-5Thoracic traumaThoracic trauma
1MycosisMycosis
1TuberculosisTuberculosis
1-3SepsisSepsis
1-3Lung abscessLung abscess
50 PneumoniaPneumonia
%%Causes Causes

36. Pleural empyema (empyema pleurae)
Etiology:
 pneumococus
 staphylococus
 streptococus
 haemophilus influenzae
 Gram-negative bacteria (pseudomonas, klebsiella, enterobacteriace,
escherichia coli)
 anaerobes

37. Pleural empyema (empyema pleurae)
PATOPHYSIOLOGY – the way of contamination :
 Direct way (thoracic wall): trauma, pleural puncture, drainage
( 25% of all empyemas): FROM OUTSIDE
 FROM INSIDE – pneumonia,
lung abscess, bronchiectases, mediastinitis,
intraabdominal abscess.
 Hematogenic way
 Lymphagenic way

38. PLEURAL EMPYEMA (empyema pleurae)
PATHOPHYSIOLOGY
PHASES OF PLEURAL EMPYEMA FORMATION :
 Serous phase (exudative empyema): clear, straw-colored effusion
(pH>7.3, glucose concentration [GLU]>60 mg%, lactate
dehydrogenase activity [LDH] < 500 U/L )
 Fibrinopurulent phase (fibrinopurulent empyema): effusion contains
large numbers of bacteria and polymorphonuclear granulocytes,
intensification of clinical signs and symptoms of inflammation,
deposition of fibrin on both the visceral and parietal pleura
( pH < 7,1, GLU < 40mg%, LDH > 1000 U/L)
 Organizing empyema phase (organizing empyema) (fibrothorax) –
nonelastic, fibrinopurulent coat that imprisons the lung appears.
An empyema capsule contains pus.

39. Pleural empyema (empyema pleurae)
Classification :
Size :
 total empyema – entire pleural cavity
 partial empyema ( one compartment, many compartments)
Time :
 acute
 chronic
Iatrogenic:
 preserved lung parenchyma
 postpneumonectomy empyema
With or without broncho-
pleural fistula

40. Pleural empyema (empyema pleurae)
Clinical signs:
ACUTE PHASE:
 fever (hectic)
 chills
 dyspnoea
 toxememia
 chest pain
 tachypnoë
 weakness
 anorexia
 weight loss
 chst wall infiltration
 WBC elevation
 Anemia
 Expectoration (fistula)


CHRONIC PHASE:
 feverishness
 cachexia
 cough
 dyspnoea
 intercostal space
norrowing
 scoliosis
 chest pain

41. Pleural epmyemaPleural epmyema

42. Pleural empyema (empyema pleurae)
TREATMENT :
ACUTE PHASE:
 Antibiotics (IV),
 Pleural pucture,
 Pleural drainage,
 Antibiotics (inside the pleura).

43. PLEURAL EMPYEMA (empyema pleurae)
TREATMENT :
CHRONIC PHASE:
 Pleural drainage + antibiotics to the pleural cavity.
 Drainage flow
 Open drainage (chest window) after 14 days.
 Fibrinolitics ( streptokinase, streptodornase): local PE.
 VATS (debridement).

44. PLEURAL EMPYEMA (empyema pleurae)
SURGICAL TREATMENT:
 Thoracotomy and decortication of the lung -
 Decortication of the lung + lung resection
 Thoracostomy (fenestration) – chest window.

45. PLEURAL EMPYEMA (empyema pleurae)
COMPLICATIONS :
 atelectasis and respiratory insufficiency
 broncho-pleural fistula
 pleuro-cutaneous fistula
 esophageo-pleural fistula
 sepsis
 peritonitis
 metastatic abscesses in liver, kidneys, spleen and other organs.
 chest wall inflamatory infiltration
 progressing respiratory insufficiency

46. PLEURAL EMPYEMA (empyema pleurae)
PROGNOSIS :
Mortality rate in acute phase: app. 1-19%.
(sepsis).

Chronic phase : Mortality rate in patients with diabetes, cancer,
alcohol abuse is app. 40%.
(respiratory insufficiency, MOF).

47. BronchiectasisBronchiectasis
DefinitionDefinition: abnormal permanent dilatation of : abnormal permanent dilatation of
subsegmental airwayssubsegmental airways
..
The first description:LaThe first description:Laëënnec in 1819 .nnec in 1819 .
Term bronchiectasis: Hasse in 1846.Term bronchiectasis: Hasse in 1846.
The first successful surgical procedure for The first successful surgical procedure for
bronchiectasis (partial resection of the lung lobe)- bronchiectasis (partial resection of the lung lobe)-
Krause 1898.Krause 1898.

49. Bronchiectasis: classificationBronchiectasis: classification
Macroscopic picture Macroscopic picture (Reid)(Reid)

CylindricalCylindrical (27%) (27%)

SaccularSaccular (11%) (11%)

Varicose (Mixed)Varicose (Mixed) (62%) (62%)
{Reid L.M.: Reduction in bronchial subdivision in bronchiectases. Thorax 5:233, 1950}{Reid L.M.: Reduction in bronchial subdivision in bronchiectases. Thorax 5:233, 1950}
HoodHood’s classification’s classification

SaccullarSaccullar

CylindricalCylindrical

PseudoPseudobronchiectasesbronchiectases
{Hood R.M.: Bacterial infections of the lungs. General thoracic surgery. {Hood R.M.: Bacterial infections of the lungs. General thoracic surgery.
Baltimore, 1994;930}Baltimore, 1994;930}

50. Bronchiectases: autopsyBronchiectases: autopsy

51. Clinical signs and symptoms
 Early stage: no symptoms (20-30 y.)Early stage: no symptoms (20-30 y.)

Female / Male ratio - 2.5 : 1Female / Male ratio - 2.5 : 1

Cought with expectoration: the most common Cought with expectoration: the most common
symptom (75%).symptom (75%).

52. Clinical signs and symptoms
 Hemophtysis (50%), sometimes massive.Hemophtysis (50%), sometimes massive.

Late sign: clubbed fingers, cachexiaLate sign: clubbed fingers, cachexia

Repeated episodes of respiratory tract Repeated episodes of respiratory tract
infections(33%)infections(33%)

53. Clubbed fingersClubbed fingers

54. BronchographyBronchography

55. Diagnosis

CT: the gold standardCT: the gold standard

56. Bronchiectasis: CTBronchiectasis: CT

57. Bronchiectasis: treatmentBronchiectasis: treatment
Conservative: Conservative:
FIRST LINE TREATMENT!!!FIRST LINE TREATMENT!!!
- - AAntntiibiotbioticsics
- - Mucolitic agentsMucolitic agents
- - Postural drainagePostural drainage
- - Breathing exercisesBreathing exercises

58. Bronchiectasis: surgical treatmentBronchiectasis: surgical treatment
SurgerySurgery
-Indications: Indications:
•conservative treatment failure (reccurent conservative treatment failure (reccurent
symptoms or infection when medication is symptoms or infection when medication is
discontinued)discontinued)
• complications- recurrent hemoptysis, complications- recurrent hemoptysis,
haemorrhagehaemorrhage
- - Aim: resecton of all affected lung tissue, Aim: resecton of all affected lung tissue,
prevention of reccurence.prevention of reccurence.
- - Method: Method: wedge, segmentectomy, wedge, segmentectomy, lobelobecctomtomyy
(pneumone(pneumonecctomtomyy v. rarev. rare)), lung transplantation, lung transplantation

59. Mycobacterium TuberculosisMycobacterium Tuberculosis

60. 18821882
ROBERT KOCHROBERT KOCH

61. TuberculosisTuberculosis

62. TBC infectionTBC infection

63. Clinical pictureClinical picture
Non-characteristic- very oftenNon-characteristic- very often

Purulent coughPurulent cough

MalaiseMalaise

Weight lossWeight loss

HaemoptysisHaemoptysis

FeverFever

Night sweatsNight sweats

64. DiagnosisDiagnosis
Tuberculin skin testingTuberculin skin testing

Sputum smear (Ziehl- Neelsen)Sputum smear (Ziehl- Neelsen)

Sputum (bronchoalveolar lavage) culturesSputum (bronchoalveolar lavage) cultures

X-ray examinationX-ray examination

Nucleic acid assay (NAA)Nucleic acid assay (NAA)

PCRPCR

IFN-
Ɣ
IFN-
Ɣ

65. Tuberculosis: chest X-rayTuberculosis: chest X-ray

66. Cavernous tuberculosisCavernous tuberculosis

67. Pulmonary tuberculosis: autopsyPulmonary tuberculosis: autopsy

68. TREATMENTTREATMENT
Conservative treatment with Conservative treatment with
antitubercuolus drugsantitubercuolus drugs

Surgical treatment approx. Surgical treatment approx. 2%2% of of
casescases

2 million deaths annually worldwide2 million deaths annually worldwide

69. PHARMACOLOGYPHARMACOLOGY
IsoniazidIsoniazid

RifampinRifampin

PyrazinamidePyrazinamide

StreptomicinStreptomicin

EthambutolEthambutol

Time: 6-9 monthsTime: 6-9 months

Resistance for first line drugs (Isoniazid, Resistance for first line drugs (Isoniazid,
Rifampin, Ethambutol) is a serious problem.Rifampin, Ethambutol) is a serious problem.

70. SURGICAL TREATMENTSURGICAL TREATMENT
INDICATIONSINDICATIONS
UNEFFECTIVE PHARMACOLOGICAL UNEFFECTIVE PHARMACOLOGICAL
TREATMENT FOR 12 MONTHSTREATMENT FOR 12 MONTHS

COMPLICATIONS OF TUBERCULOSISCOMPLICATIONS OF TUBERCULOSIS

71. SURGICAL TREATMENT OF SURGICAL TREATMENT OF
COMPLICATIONSCOMPLICATIONS
ABSOLUTE INDICATIONSABSOLUTE INDICATIONS
- - HaemorrhageHaemorrhage
- Pleural empyema with bronchopleural fistula- Pleural empyema with bronchopleural fistula
- Aspergilloma in posttuberculous cavity- Aspergilloma in posttuberculous cavity
- Lymph node compression of the bronchi- Lymph node compression of the bronchi

72. SURGICAL TREATMENT OF SURGICAL TREATMENT OF
COMPLICATIONSCOMPLICATIONS
RELATIVE INDICATIONSRELATIVE INDICATIONS
- - Posttuberculous cavityPosttuberculous cavity
- - Tuberculoma (carcinoma suspicion, Tuberculoma (carcinoma suspicion,
potential source of tuberculosis potential source of tuberculosis
reactivation)reactivation)
- - Lung completely destroyed by tuberculosisLung completely destroyed by tuberculosis