RESPIRATORY DISEASES by bhavya kelavadiya

The Children are very vulnerable to get affected with respiratory disease.
In our country, the respiratory Disease conditions are consider as major cause for mortality and Morbidity in Child.

1. RESPIRATORY DISEASES in pediatrics BY, BHAVYA N KELAVADIYA NURSING TUTOR

2. Introduction: Respiratory diseases are very often found in children, especially the respiratory infections. It is one of the leading cause of morbidity and mortality among young children. The important risk factors associated with respiratory disease include mal-nutrition, LBW, climatic variation especially in winter and rainy season, overcrowding houses, poor ventilation, air pollution, lack of ENV sanitation and poor socioeconomic condition.

3. The common C/F related to respiratory diseases are cough, dyspnea, expectoration, chest indrawing , chest pain, cyanosis and respiratory sound like wheezing, stridor, grunting and snoring. Apnea, air hunger and flaring of alae nasi may also present. In chronic cases hemoptysis, clubbing and associated cardiac or neurological symptoms may be found. Special diagnostic procedures in the patients with respiratory diseases can be done to confirm the diagnosis. They include ABG analysis, blood examination, examination of body secretion, radiology, MRI, USG, direct laryngoscopy, pulmonary function test, bronchoscopy, lung biopsy, sweat chloride in cystic fibrosis etc.

4. Acute Respiratory Infections

5. ARI and its complications are most frequent conditions of acute illness in infants and children. In india , ARI is one of the major cause of childhood death. It is also one of the major reason for which children are brought to the hospitals and health facilities. About 13% of inpatient death in pediatric wards is due to ARI. The proportion of death due to ARI in community is much higher as many children die at home. Most children have 3-5 attacks of ARI in each year. Many of these infections run their natural course without specific treatment and without complication.

6. DEFINITION : ARI are an acute infection of any part of the respiratory tract and related structures including para -nasal sinuses, middle ear and pleural cavity. It may cause inflammation of respiratory tract anywhere from nose to alveoli with wide range of combination of symptoms and signs. It include all infections of less than 30 days duration, except the infection of ear lasting less than 14 days. The incidence of ARI is highest in young children, especially below 5 yr of age and decreases with the increasing age.

7. Classification: Depending upon the site of infection: Acute upper respiratory infections: These include common cold, rhinitis, nasopharyngitis , pharyngitis and otitis media. Acute lower respiratory infections: these include epiglottitis, laryngitis, bronchitis, bronchiolitis and pneumonia. Depending upon the anatomical involvement: Broncho pneumonia: patchy involvement of lungs Lobar pneumonia: one or more lobes of lungs involved Pneumonitis or interstitial pneumonia : alveoli or interstitial tissue between them affected.

8. Depending upon the severity of infection( WHO recommendation): a) For the infant below 2 month: No pneumonia Severe pneumonia Very severe disease b) For the child aged 2 month upto 5 years: No pneumonia Pneumonia(not severe) Severe pneumonia Very severe disease

9. Etiological factors Bacterial: pneumococcus, staphylococcus, streptococcus. , Klebsiella , E-coli, M.tuberculie Viral: influenza, measels , chickenpox Mycoplasma: mycoplasma pneumoniae Fungal: candidiasis, blastomiosis Protozoal : pneumocystis carinii , toxoplasma gondi Rickettsial : typhus Miscellaneous:

10. There are several different causes of acute respiratory infection. a) Causes of upper respiratory infection: acute pharyngitis acute ear infection common cold b)Causes of lower respiratory infection: bronchitis pneumonia bronchiolitis

11. Clinical manifestations:

12. WHO recommendation, the features of lower respiratory infections can be grouped as follows: Only cough and cold indicates no pneumonia . Fast breathing: increased RR with the presence of cough and cold 40 b/m or more- 1-5yr 50 b/m or more- 2- 12 month 60b/m or more – less than 2 month Chest indrawing with or without fast breathing indicates severe pneumonia. (other sign with severe pneumonia include nasal flaring, cyanosis, grunting or wheezing sound) Very severe disease is indicated by the presence of danger sign like inability to drink, excessive drowsiness, stridor in calm child, apnea, fever, convulsion.

13. Diagnostic evaluation: Examination of clinical features Detailed history taking Auscultation of chest sound X-rays Spirometry ABG analysis Blood analysis Sputum test

14. Complications: Pleural effusion Emphysema Atelectasis Empyema Lung abscess Bronchiectasis pneumothorax

15. Management : Rx depends upon type of illness, severity of infections and associated complications. The standard treatment for childhood ARI is recommended by National ARI Control Program especially for primary health care setting. The child with NO PNUEMONIA can be treated at home with home remedies for symptomatic treatment and does not require antibiotic therapy. The child with PNUEMONIA can be treated in OPD with antibiotics and other symptomatic Rx like antipyretic and bronchodilators. The child with SEVERE PNEUMONIA should be hospitalized urgently and requires parenteral antibiotics with symptomatic treatment. The child with VERY SEVERE PNEUMONIA needs immediate hospitalization , antibiotic theraphy and O2 therapy.

16. Nursing management ASSESSMENT Assessment of respiratory dysfunction in children includes health history, physical examination, and laboratory or diagnostic testing. Health History Physical Examination Physical examination of the respiratory system includes inspection and observation, auscultation, percussion, and palpation.  Inspection and Observation Color. Observe the child’s color, noting pallor or cyanosis ( circumoral or central). Pallor (pale appearance) occurs as a result of peripheral vasoconstriction in an effort to conserve oxygen for vital functions. Cyanosis (a bluish tinge to the skin) occurs as a result of hypoxia

17. Note the rate and depth of respiration as well as work of breathing. Often the first sign of respiratory illness in infants and children is tachypnea . Auscultation Assess lung sounds via auscultation. Evaluate breath sounds over the anterior and posterior chest, as well as in the axillary areas. Breath sounds should be equal bilaterally. The intensity and pitch should be equal throughout the lungs. Prolonged expiration is a sign of bronchial or bron - chiolar obstruction. Wheezing, a high-pitched sound that usually occurs on expiration, results from obstruction in the lower trachea or bronchioles. Wheezing that clears with coughing is most likely a result of secretions in the lower trachea.

18. Wheezing resulting from obstruction of the bronchioles, as in bronchiolitis, asthma, chronic lung disease, or cystic fibro- sis, that does not clear with coughing. Rales (crackling sounds) result when the alveoli become fluid-filled, such as in pneumonia. Interventions: Position with airway open (sniffing position if supine): open airway allows adequate ventilation. Humidify oxygen or room air and ensure adequate fluid intake (intravenous or oral) to help liquefy secretions for ease in clearance. .

19. Suction with bulb syringe or via nasopharyngeal catheter as needed, particularly prior to bottle-feeding to promote clearance of secretions. If tachypneic , maintain NPO status to avoid risk of aspiration. In older child, encourage expectoration of sputum with coughing to promote airway clearance. Perform chest physiotherapy if ordered to mobilize secretions. Ensure emergency equipment is readily availa ble to avoid delay should airway become unmaintainable

20. SINUSITIS Sinusitis is an infection of the sinuses. The infection usually occurs after a cold or after allergic inflammation.

21. Nasopharyngitis It is also known as common cold or rhinosinusitis . it is an inflammation of nasopharynx . It is usually caused by virus that inflammes the membrane lining of nose and throat.

22. Stridor It is high pitched sound that usually heard when a child breathes in. It usually cause by obstruction or narrowing of child’s upper respiratory path.

23. Pharyngitis and Tonsillitis Pharyngitis and tonsillitis are common co-morbidities that occurs due to infection and inflammation of the throat. If the throat is primarily affected, it is called PHARYNGITIS and if mainly the tonsils are affected, it is known as TONSILITIS . If both throat and tonsils are infected and inflammed , the condition is known as PHARYNGOTONSILITIS .

24. Croup Croup is the syndrome characterized by BARKING COUGH, inspiratory stridor, horseness and sign of respiratory distress which occurs due to varying degree of laryngeal obstruction .

25. Acute Bronchitis Inflammation of the lining of bronchial tubes, which carry air to and from the lungs. Acute bronchitis is often caused by a viral respiratory infection and improves by itself. In children less than 4 yr of age

26. Etiology

27. Clinical features Runny nose( before the cough starts) Malaise Chills Fever Back and muscle pain Sore throat Wheezing In earlier stages of condition, the child may experiences a dry non-productive cough which progresses to excessive mucous filled cough.

28. Diagnostic evaluation History Physical examination X-ray Ct- scan Sputum test

29. Management It include administration of: Antibiotics Cough expectorants Antipyretic medicines Steam inhalation

30. Bronchiolitis Bronchiolitis is a serious illness characterized by inflammation of bronchioles, causing severe dyspnea. Bronchiolitis is almost always caused by a virus. Typically, the peak time for bronchiolitis is during the winter months

31. Incidences and Etiology Bronchiolitis is common in infant under the age of 6 month. It is common in winter and early spring days. The exact etiology is not clear. Etiologic agent may be viruses such as respiratory syncytial virus, adenovirus and influenza virus. Certain bacteria- pneumococcus, streptococcus

32. Clinical features Respiratory: fast breathing, shortness of breath, wheezing, difficulty breathing, or shallow breathing Whole body: dehydration, fever, loss of appetite, or malaise Also common: coughing or nasal congestion

33. Diagnostic evaluation X-ray x-ray of chest shows emphysema, prominent broncho -vascular markings and small areas of collaps . Lungs are characteristically overinflated and intercostal space are wide.

34. Management O2 administration Maintaining atmosphere more saturated with water vapour Mild sedation and postural drainage IV therapy Antibiotics Aerosol therapy

35. Bronchiectasis Bronchiectasis is a chronic and permanent dilation of the bronchi and bronchioles. It develops due to complete obstruction by inflammation , infection or inhalation of foreign body. Incomplete obstruction of bronchi may result in obstructive emphysema. Obstruction may develop due to collection of thick mucus in case of chronic bronchitis, bronchial asthma and cystic fibrosis.

36. Infection and obstruction lead to damage of the bronchial wall as formation of cultivation and tissue destruction. It causes segmental areas of collapse, which exert negative pressure on the damaged bronchi leading them to dilation. Collapse, emphysema and pneumonia usually accompany bronchiectasis. The most common site of dilation is left lower lobe. Right lower lobe may be affected due to foreign body and middle lobe due to tuberculosis. History of bronchial occlusion and inflammation for a prolonged period leads to the development of the condition.

37. Clinical Features

38. Diagnosis History taking Physical examination X-ray= honeycomb appearance of affected part Bronchoscopy Broncho-graphy CT-scan Bacteriological study Sputum analysis

39. Management Appropriate systematic antibiotic therapy especially in acute exacerbation Clearing secretion and exudates from air passage with postural drainage Bronchodilators Expectorants Breathing exercise

40. Nursing intervention Assessing respiratory status, signs of complications, general health and ABG analysis Providing rest, comfort and warm comfortable env . O2 therapy Removal of secretion Oral care

41. Pneumonia Pneumonia is defined as an acute inflammation and consolidation of lung parenchyma. It is 2 nd leading cause of death in children under 5yr of age.

42. Classification It can be classified on anatomical and etiologic basis. Classification on ANATOMICAL BASIS: Lobar/lobular pneumonia: 1 or more lobes of lungs are involved Interstitial pneumonia: interstitial tissues of lungs are affected Bronchopneumonia : patchy consolidation of lungs

43. B) Classification on an etiological basis: Bacterial pneumonia: it may be cause by pneumococcus, streptococcus, staphylococcus Viral pneumonia: it is caused by viruses like influenza, measles, respiratory syncytial virus Fungal pneumonia: it may be caused by histoplasmosis and coccidiomycosis Protozoal pneumonia: it is caused by pneumocystis carnii , toxoplasma gondii

44. C) Miscellaneous types: Aspiration pneumonia: it is caused by aspiration of food, nasal drops, amniotic fluid by newborn, water(drowning), and chemicals like kerosene oil etc. Loffler’s pneumonia: it is condition in which eosinophils accumulate in lungs, in to parasitic infection. Hypersensitivity pneumonitis: it is an inflammation of alveoli within lungs caused by hypersensitivity to inhaled dust. Hypostatic pneumonia: it results from collection of fluid in dorsal region of lungs and occurs especially in those confined to bed for long time( bedridden)

45. Clinical features: Sudden onset High fever with chills Cough with thick sputum Increased respiratory rate Grunting respiration Nasal flaring Runny nose Irritability Malaise Sore throat Anorexia Late symptoms include: Convulsion Drowsiness Inability to drink from mouth Chest indrowing Wheezing Horseness of voice Cyanosis Pleural pain which may be increased by deep breathing and referred to shoulder or abdomen

46. Pathogenesis Infectious agent foreign substances aspiration of gastric contents Inflammatory reaction of pulmonary tissues Edema of alveolar membrane Alveoli fill with exudate from inflammation Gases cannot cross edematous alveolar membrane Air cannot enter fluid-filled alveolar Hypoxia, Shortness of breathing Fatigue

47. Diagnosis evaluation History taking Chest X-ray= X-ray finding suggesting bronchopneumonia include diffuse patchy consolidation in lungs. Consolidation is seen as homogenous opacity occupying the anatomic area of a lobe, usually in one lungs. Nasopharynx or throat culture Blood test

48. Management Antibiotics- penicillin, amoxicillin and clavulanic acid and macrolides including erythromycin, azythromycin and clorithromycin . Antiviral therapy Antifungal- fluconazole

49. Nursing management Make continuing assessment: - respiratory rate/patterns - observe the sign for distress Facilitate respiratory effort - maintain airway and provide high humidity atmosphere - place child in semi-fowlers position - change the positions frequently to prevent pooling of secretion into the lungs - adm. Cough suppressants and bronchodilators Control fever Maintain fluid electrolyte balance along with nutritional status of the child Promote rest and sleep

50. Emphysema Emphysema results from distension and rupture of the alveoli due to the loss of elasticity of the lungs tissue with resultant air trapping.

51. Risk factors/ causes Babies with a greater risk of are those with the following conditions: Preterm birth, which often leads to respiratory disease The lungs don't develop correctly (pulmonary hypoplasia) Breathing in the first intestinal discharge (meconium) at birth A lung infection (pneumonia) Very fast breathing right after birth (transient tachypnea of the newborn)

52. Classification Obstructive emphysema : it occurs due to partial occlusion of bronchus or a bronchiole in case of atelectasis, bronchial asthma, lung infection etc Compensatory emphysema: it occurs when normal lung tissue expands to fill up the areas of collapsed lung segments. Congenital lobar emphysema: it is found in neonates and young children resulting from severe RD Familial emphysema: it is found especially in female young child as progressive dyspnea, which is inherited as autosomal recessive trait .

53. Clinical manifestation: Common features are: Dyspnea Tachypnea Cough Wheeze Chest retraction cyanosis

54. Management Rx is depends upon the cause of the condition. Symptomatic Rx is important with, O2 adm Bronchodilators Mucolytic agents and antibiotics. Conservative treatment Lobectomy

55. Empyema

56. Empyema is the collection of thick pus in the pleural cavity. Empyema is the medical term for  pockets of pus that have collected inside a body cavity . It also termed as PYOTHORAX. It developed directly from lungs or from neighboring structure or through blood. It is fair common in infancy.

57. Etiological factors infections Pneumococcus Streptococcus H. Influenza, etc It may develop following pneumonia, lung abscess, pulmonary tuberculosis, chest injury, suppurative lung disease, septicemia and due to metastatic spread of suppurative foci from distant lesions such as osteomyelitis

58. Clinical feature Many children do not have any symptoms of empyema, but they may have growth failure and some nonspecific symptoms like, Fever Cough Respiratory distress Chest pain Diarrhea Weight loss Clubbing Anemia Other feature malnutrition Chest signs are found as diminished movement of the affected side, mediastinal shift to opposite healthy side, widening and dullness of the intercostal spaces, dull percussion note and diminished air entry .

59. Diagnostic evaluation History taking Physical examination Pleural aspiration for biochemical and bacteriological examination . Complications: Bronchopleural fistulas Pyopneumothorax Lung abscess Purulent pericarditis Osteomyelitis of rib Septicemia Meningitis arthiritis

60. Management Management of empyema should be done with appropriate antibiotic therapy, inter-coastal drainage and symptomatic measures. Antibiotic therapy should be started as early as possible and to be continued for 3-4 weeks. Commonly used antibiotics are penicillin, cloxacillin , ampicillin, chloramphenicol, cephalexin etc. Continuous closed intercoastal drainage is strongly recommended for management of empyema rather than the multiple aspiration of the pleural cavity. Surgical drainage after thoracotomy may be needed to remove the collection, in case of severe respiratory difficulty. Antipyretic Analgesics Nutritional supplementation

61. Bronchial asthma

62. The word “asthma” means Struggling For Breath. Asthma is a chronic inflammatory disease, characterized by airway obstruction( which is reversible either spontaneously or with medication), airway inflammation and an increased responsiveness of trachea and bronchi due to various stimuli. It is chronic inflammatory disorder of lower airway due to temporary narrowing of bronchi by bronchospasm, mucosal edema and thick secretion.

63. Etiological factors Bronchial asthma is the multifactorial. There are some predisposing and excitatory factors. A. Predisposing factors: Heredity, with a family history of asthma and some other allergic disorders Labile and over conscientious nature B. Excitatory factors: Allergy to foreign substance produces allergic or extrinsic asthma Inhalation of pollen, wool, feather, animal hair, smoke, dust Ingestion of food, like egg , chocolate, some vegetables Drugs

64. Respiratory infections Worm infestation Change in climate Emotional disturbance due to anxiety, tension, fear and conflict Excessive fatigue, exhaustion

65. It is produced by a hyper-immune ( IgE ) response to inhalation of specific allergen. The children usually have positive skin test to the offending allergen and positive family history of allergy. It is produced in response to unidentified or nonspecific factors of the environment. No hyper-immune response is produced. Inhalation of irritants like cigarette, odor, air pollution

66. Pathophysiology Exposure to allergens or triggers(dust, pollen, smoke) Inflammatory response ( increased IgE ) Bronchoconstriction Airway edema and increased mucous production Airway obstruction Hypoxia, wheezing, dyspnea, hyperventilation

67. Clinical features: The clinical feature of asthma have sudden onset and often occur at night. Occasionally, asthma attack is preceded by asthmatic aura which is characterized by feeling of tightness in chest, restlessness, polyuria or coughing spell. A typical asthmatic attack is manifested by: Severe dyspnea Bouts of cough Wheezing Cyanosis Pallor Sweating Restlessness Excessive use of accessory muscle of respiration Extreme fatigue

68. Severe attack of asthma results in hypoxia, cyanosis and cardiac arrhythmias In chronic cases the chest of the child becomes barrel shaped.

69. Diagnostic evaluation History Physical examination Pulmonary function test Blood examination Chest X-ray Allergy test

70. Management During acute attack, management aims at controlling bronchospasm and relieve inflammation. The medical management include: Fast acting drugs: Salbutamol are 1 st line Rx for bronchial asthma. Anticholinergic medications, such as Ipratropium bromide. Long term control: Fluticasone oral inhalation is used to prevent difficulty breathing, chest tightness, wheezing, and coughing caused by asthma in adults and children. It is in a class of medications called corticosteroids. Fluticasone works by  decreasing swelling and irritation in the airways to allow for easier breathing . Other drugs: O2 therapy Magnesium sulfate- in severe asthma attack HOLIX, a mixture of helium and O2 may also be considered in severe unresponsive case.

71. Nursing management Providing emotional support and education Administering adequate fluids Provide rest and comfortable Evaluate respiratory status and facilitate breathing

72. Pneumothorax

73. A  pneumothorax  is an abnormal collection of air in the pleural space between the lung and the chest wall. It may be develop due to rupture of sub-pleural or mediastinal nodes through the parietal pleura. Pneumothorax usually occurs with fluid- Hydro pneumothorax With blood- Hemo pneumothorax With purulent material- pyo pneumothorax It may occur spontaneously as spontaneous pneumothorax (due to trauma or pathological process) or be introduced deliberately as artificial pneumothorax.

74. Etiological factors: The causes of pneumothorax in neonates are mainly the vigorous resuscitative procedures and staphylococcal infections. In infancy, the common causes are infections (staphylococcal, pertussis) and iatrogenic problems ( thoracocentesis , tracheostomy). In older children, the common causes of pneumothorax are tuberculosis, empyema and foreign bodies.

75. Clinical manifestations Dyspnea Cyanosis Chest pain Mediastinal shift to healthy side Hyper-resonant percussion note Flat percussion indicate presence of fluid

76. Management Management of pneumothorax should be done promptly after the confirmation of diagnosis. Symptomatic and supportive care should be provided

77. Pleural effusion Pleural effusion is the collection of fluid in the thoracic cavity, between visceral and perietal pleura. It is less common in children below 5 years.

78. Small effusion rarely produces symptoms or definite physical signs and usually detected by X-ray. Large effusion may cause respiratory distress, chest pain and fever. The fluid accumulates in pleural cavity may be transudate, exudate, serous, sanguineous, sterile, purulent or chylous . Serous pleural effusion is commonly developed due to tuberculosis. Hemothorax may result from trauma, malignancy or hemorrhagic diseases. Chylothorax usually rare, it may occur due to injury of thoracic duct.

79. Clinical manifestation High fever Cough Chest pain on affected side that worsen on deep breathing and coughing Abdominal pain Weight loss On examination, decreased chest movement on affected side, mediastinal shift to the opposite side, fullness of inter-coastal space, pleural rub, decreased breath sound, dull percussion note, decreased vocal resonance are usually found.

80. Diagnostic evaluation History of illness Physical examination Chest X-ray X- ray = it shows a uniform opacity with curved upper border of fluid line.

81. Management Pleural effusion should be done according to the specific cause. Specific chemotherapy along with symptomatic and supportive measures should be provided. Relief of respiratory distress can be done by therapeutic thoracentesis for removal of collected fluid .

82. Cystic fibrosis

83. Cystic fibrosis is an inherited disease characterized by an abnormality in the body’s salt, water and mucous making cells. It is chronic, progressive and usually fatal condition. Children with cystic fibrosis have an abnormality in the function of a cell protein called Cystic Fibrosis Transmembrane Regulator (CFTR). This cell protein controls the flow of water and certain salts in and out of body’s cells. As the movement of salt and water in and out of cells is altered, mucous becomes thickened. Thick mucous can affect many organs and body system including: Respiratory system: sinuses and lungs Digestive system: pancreas, liver, gallbladder and intestines Reproductive system: in males, sperm- carrying ducts become clogged Sweat glands

84. Clinical features Each child may experience symptoms differently. Infants born with cystic fibrosis usually show symptoms within the first year. some children may not show symptoms until later in life. The following symptoms may indicate cystic fibrosis- Abnormalities in the glands that produce sweat and mucous Thick mucous that accumulates in the lungs and intestines may lead to poor growth, frequent respiratory infections Diarrhea may occur Frequent episode of wheezing/ pneumonia Persistent cough Skin tastes like salt Abdominal pain Gas in intestines

85. Other medical problems: Sinusitis Nasal polyps Clubbing of finger and toes Pneumothorax Hemoptysis Cor pulmonale Rectal prolapse Liver disease Diabetes Pancreatitis gallstones

86. Diagnostic evaluation Physical examination History taking Genetic test Sweat (chloride) test Chest X ray Pulmonary function test Sputum cultures Stool evaluation

87. Management At present there is no cure for cystic fibrosis. However, researches in gene therapy are being performed. The gene that causes cystic fibrosis has been identified and there is hope that will lead to an increased understanding of the disease. Also being researched are different drug regimens, to help treat cystic fibrosis. The goal of treatment are to ease severity of symptoms and slow the progress of the disease. Treatment may include:

88. Management of respiratory problems: Chest physiotherapy ( to help loosen and clear lung secretion, it may include postural drainage and devices, such as a percussor or flutter, which vibrate the chest wall and loosen the secretion.) Exercise (it help to loosen mucous, stimulate coughing and improve overall physical condition) Medications (bronchodilators and anti- inflammatory medication) Antibiotics ( to treat infection)

89. Management of digestive problems: Appropriate diet Pancreatic enzymes to aid digestion Vitamin supplement Psychosocial support is required to help the child and family to deal with issues such as independence, health, quality of life, finances and relationships. Newer therapies include lung transplantation for patient with end-stage lung disease.

90. Lung abscess

91. Lung abscess is a sever, localized suppurative infection in the lung, associated with necrotic cavity formation. The cavity is surrounded by a fibrous reaction, forming the abscess wall. Multiple small abscess formation may occur and sometimes referred to as “Necrotizing pneumonia”. It may develop single abscess or multiple abscesses.

92. Etiology and risk factors The most frequent cause of lung abscess is aspiration of anaerobic organism from mouth, in those predisposed to pulmonary aspiration and having impaired immune defenses and cough reflex. A pneumonitis develops which progresses to abscess formation over a period of days or weeks. Mechanisms precipitating abscess formation include: Inhalation of foreign body Bacterial colonization in the lungs Tricuspid endocarditis leading to septic pulmonary embolus Extension of hepatic abscess Bronchial carcinoma Severe or incompletely treated pneumonia Penetrating pulmonary trauma

93. Post general anesthesia Pneumonia Diabetes mellitus Choking/ near-drowning/ aspiration Severe periodontal disease Stroke/cerebral palsy/cognitive impairment Immunosuppression Congenital heart disease Chronic lung disease Bacteremia

94. Types of lung abscess

95. Diagnostic evaluation Blood and sputum cultures ESR and C-reactive protein, which are usually elevated Chest-X-ray shows walled cavity, usually with a fluid level. There may also be presence of an empyema or effusion. CT-scan Fibreoptic bronchoscopy Trans-thoracic biopsy

96. Management The management of lung abscess includes: IV antibiotics are given usually about 2-3 weeks, followed by oral antibiotics for a further 4-8 weeks. Recommended first line therapy includes beta-lactamase inhibitor or cephalosporin plus clindamycin, an alternative regimen is to begin with a broad spectrum cephalosporin and flucloxacillin .

97. If the condition fails to resolve, bronchoscopy/ trans-thoracic drainage/cardiothoracic surgical intervention may be considered. Surgery may be necessary when reinfection of large cavitary lesion occur or there is evidence of underlying neoplasm. The usual procedure done is lobectomy or pneumonectomy . Supportive measure include: Analgesics O2 if required Rehydration, if indicated Postural drainage with chest physiotherapy