suppurative lung diseases.Group of diseases characterized clinically by presence of excessive purulent sputum, usually foetid and often related to postureppt

Definition: Group of diseases characterized clinically by presence of excessive purulent sputum, usually foetid and often related to posture.
They include:
1- Lung abscess
2- Bronchiectasis
3- Infected cystic lung
4- Empyema with broncho-pleural fistula
Bronchiectasis
Definition
Bronchiectasis means abnormal dilatation of the bronchi due to chronic airway inflammation and infection. It is usually acquired but may result from an underlying genetic or congenital defect of airway defenses.

1. SUPPURATIVE LUNG SUPPURATIVE LUNG
DISEASES (SLD)DISEASES (SLD)

2. Definition: Group of diseases characterized clinically
by presence of excessive purulent sputum, usually
foetid and often related to posture.
They include:
1- Lung abscess
2- Bronchiectasis
3- Infected cystic lung
4- Empyema with broncho-pleural fistula

3. BronchiectasisBronchiectasis

4. Bronchiectasis
Definition
Bronchiectasis means abnormal dilatation of the
bronchi due to chronic airway inflammation and
infection. It is usually acquired but may result
from an underlying genetic or congenital defect
of airway defenses.
 

7. Causes of bronchiectasis
Congenital
• Cystic fibrosis
• Primary ciliary dyskinesia
• Kartagener’s syndrome (sinusitis and
transposition of the viscera)
• Primary hypogammaglobulinemia
• Younge’s syndrome

8. Associated developmental pulmonary Associated developmental pulmonary
anomalies:anomalies:
aa) Parti pulmonary agenesis
b) Tracheo-bronehomegaly (Mounier-kuhn
syndeome) (enlarged cartilaginous rings)
c) William’s – cambell syndrome (bronchomalacia)
(defective or completely absence of cartilage) )

9. Acquired
• Pneumonia (complicating whooping cough or
measles)
• Inhaled foreign body
• Suppurative pneumonia
• Pulmonary TB
• Allergic bronchopulmonary aspergillosis
complicating asthma
• Bronchial tumors
 

10. Clinical features
A) Symptoms:
- Cough + expectoration of mucopurulent sputum related to
posture .
- Hemoptysis → may be massive.
- Recurrent infection especially with “wet” bronchiectasis →
large volume + purulent sputum.
- dyspnoea → late symptom → in wide spread disease with
extensive fibrosis + destruction.
-Halitosis
Other coexisting symptoms → upper respiratory infection +
sinusitis .

11. B) Signs:
- Early crackles – (Inspiratory & expiratory – Coarse –
Not affected by coughing).
- Clubbing → commonly with cystic fibrosis.
- Signs of collapse and fibrosis: in advanced cases with
cyanosis.
- May signs of complications (pulmonary hypertension,
right heart failure.
 

12. Investigations
Sputum: Testing may reveal common respiratory pathogens.
Most common organisms 1) Haemophilus influenza
2) streptococcus pneumonia.
As disease progresses, Pseudomonas aeruginosa and less
commonly Klebsiella or fungi such as Aspergillus and various
mycobacteria may be seen. Frequent cultures assist
appropriate antibiotic selection.

13. Radiology: x-ray:
a) May → No abnormalities.
b) Evidence of dilated bronchi : ring shadows (honey comb lung)
if large (0.5 – 2 cm) diffuse → cystic lung.
c) Parallel lines (may called tram lines).
d) Solid tubular shadows → gloved finger shadows.
e) Volume loss : In one or more lobe or segments due to long
standing shrinkage due to atelectasis ± fibrosis.
CT is much more sensitive and shows thickened dilated airways.

14. -Assessment of ciliary function: Saccharin test or
nasal biopsy may be used.
- PFT
Localized bronchiectasis: normal PFT
Diffuse bil. Bronchiectasis: obstructive pattern
Associated with atelectasis, parenchymal & pleural
scarring restrictive pattern
-Investigations of the cause

20. Management and prognosis

I -Antimicrobial chemotherapy.
Oral fluroquinolones are used as initial antibiotics, duration for
10-14 days.
In case of failure of response to treatment and frequent
exacerbation, sputum culture and sensitivity should be done.
Severe exacerbations due to Pseudomonas aeruginosa requires
I.V administration of two antipseudomonal antibiotics and
potential hospitalization.

21. II .Other lines of therapy in bronchiectasis :
•Prophylactic or suppressive antibiotics :
e.g. daily antibiotics for 1-2 weeks every month, twice or thrice
weekly use of azithromycin .
-Antibiotic aerosols : (chiefly tobramycin 300 mg neublized
twice daily is effective against pseudomonas infection), others
include ; aerosolized aztreonam, colistin and gentamycin .
- Allergic bronchopulmonary aspirgellosis (ABPA) is treated
with oral prednisolone 0.5 – 1 mg/kg/d + itraconazole 400 mg/d
for two months then 200 mg/d.

22. •Chest wall percussion and postural drainage
•Mechanical vibration with ultrasonic devices.
•Positive expiratory pressure
•Flutter valve use.
•Intra-pulmonary percussive ventilation device

23. III) Other medical treatment :
1- Mucus clearance ; via
- Maintenance of hydration with oral and I.V. fluids
- Humidification of inhaled air or oxygen.
- Neubulized normal or hypertonic saline and acetylcysteine.
- Aerosolized DNAse
2- Bronchodilators :
- As beta agonist, anticholinergics, or theophyllines.
3- Anti-inflammatory :
e.g., inhaled steroids (fulticasone) may play a role.
4- Treatment of complications
If no response → give corticosteroids 30- 40 mg/d for 7- 10
days, unless there is exacerbation of infection.

24. Surgical treatment:
Surgery is only indicated in a few cases where
bronchiectasis is unilateral and confined to a
single lobe/segment on CT.

The disease is progressive when associated with
ciliary dysfunction and cystic fibrosis, and
eventually causes respiratory failure

25. In other patients, the prognosis can be good with
regular physiotherapy and judicious use of
antibiotics. Bronchiectasis may be prevented by
prophylaxis or treatment of common causes, e.g.
measles, whooping cough, TB

26. Complications:
1) infective exacerbations.
2) Haemoptysis.
3) Chronic paranasal sinusitis.
4) Cor pulmonale.
5) Brain abscess .
6) Amyloidosis.
7) Disseminated aspergillosis.
8) Operative complications:
Haemorrhage, pneumonia – empyema – atelectasis –
bronchopleural fistula – pneumothorax.

27. Lung abscess

28. Lung abscess
Definition
This term is used to describe severe localized
suppuration within the lung associated with
cavity formation visible on the chest X-ray or
CT scan, often with a fluid level (which always
indicates an air-liquid interface).

29. There are several causes of lung abscess
Common causative organisms in lung abscess
Klebsiella pneumonia
Staphylococcus aureus
Gram-negative enteric bacilli
Mycobacterium tuberculosis
Streptococcus milleri
Anaerobic bacteria (post aspiration)
Haemophilus influenzae

30. Aspiration pneumonia: rarely, abscesses
develop as a complication of aspiration
pneumonia. A history of excessive alcohol
consumption or impaired swallowing in a
patient with pneumonia suggests aspiration.
Tuberculosis.
Pneumonia caused by certain species,
particularly Staphylococcus aureus or
Klebsiella pneumonia.

31. Septic emboli usually containing staphylococci:
these can cause multiple lung abscesses. The
presence of multiple lung abscesses in an injecting
drug user should
prompt investigation for infective endocarditis of the
tricuspid valves. Infarcted areas of lung (due to
pulmonary emboli) occasionally cavitate and become
infected.
 

32. Spread from an amoebic liver abscess:
amoebic lung abscesses occasionally develop
in the right lower lobe following
transdiaphragmatic spread.
Bronchial obstruction by an endoluminal
cancer
Foreign body inhalation.

33. In the latter two, a fiberoptic bronchoscopy and
CT scan are performed.
Chronic or subacute lung abscesses may follow
inadequate treatment of pneumonia.
 

34. Classification:
1- According to etiology;
-1ry (aspiration, pneumonia).
-2ry (obst., spread from extrapulmonary site,
infarction, immune suppression).
2- According to the duration;
- Acute <4-6 W.
- Chronic >6 W.
 

35. Clinical features
Symptoms: toxic &SLD symptoms
- Symptoms of any associated diseases as bronchial
obstruction, oesophageal stricture
- Fever, cough, purulent sputum related to posture and
begins with sudden gush of large amount, dyspnea,
chest pain (pleuritic or deep seated discomfort) and may
haemoptysis
 

36. N.B.
If sputum has putrid small (bad odour) →
anaerobic infection is the likely cause.
* In staphylococcal infection → symptoms are
acute and fulminating.

37. Signs:
- general → finger clubbing within some
weeks.
- Local → movement on affected side, may →
impaired percussion note and diminished
breath sounds ± added crepitations and pleural
rub.

38. •Site of abscess : varies according to the etiology;
A.Site of aspirational lung abscess:
- in supine position → posterior segment of right
upper lobe or apex of lower lobe
- Lateral decubitus → axillary subsegment
- Prone position → middle lobe.
B- Site of amoebic lung abscess:
anterior basal seg. of RT. lower lobe.
C- Site of pyemic abscess:
It is usually bilateral multiple and small in size

39. Investigations:
1.Chest radiography: Usually single cavity ≥ 2 cm in
diameter
- Cavities typically have: a thick-wall (which may become
thinner as the surrounding inflammation resolves),
smooth inner margin and air-fluid level (which has the
same length on both the PA & lateral projection)
- Complications as effusion or empyema, pneumothorax,
the abscess shadow may persists for 3 months even
with treatment with appropriate antibiotic.

40. 2. Microbiolgy:
Blood cultures in metastatic abscesses.
Sputum examination by:
* Gram stain.
* Culture.
* Z.N stain of direct smear
For anaerobic organism diagnosis : Gas liquid
chromatography
3. Bronchoscopy.

41. Differential diagnosis:
- Other SLDs.
- Cavitated bronchial carcinoma (Thick irregular wall,
abnormal site).
- TB & fungal infection.
- Encysted pyopneumothorax (The abscess shows irregular
wall with acute angle with the chest wall while empyema
shows smooth regular wall and froms obtuse angle with the
chest wall).
- Infected bulla containing a fluid level or infected hydatid
cyst.
- Hiatus hernia

42. Complications:
1-Hemoptysis
2- Extension of infection to;
* pleura
* other parts of the lung
* distant organs
3.Pyopneumothorax
4.Chronic abscess
* Cachexia
* Anemia
 

43. Treatment.
Lines of treatment
1-Postural drainage: In cases of bronchial communication.
2- Proper antibiotic chemotherapy. According to culture and
sensitivity testing if possible, but emperic antibiotic
therapy could be started using strong antibiotic with good
tissue penetration, e.g: new generations of quinolones as
moxifloxacin, gatifloxacin, levofloxacin (once daily),
ciprofloxacin, ofloxacin (twice daily).
3- Bronchoscopic or radiographically guided catheter
drainage of any fluid or necrotic debris.
4-Surgical resection of affected lung segments.
 

49. Infected Cystic Lung

50. - Etiology:
I-Congenital
•Bronchogenic cyst
•Cystic adenomatoid malformation,
• Lobar emphysema,
•Pulmonary sequestration.
II-Acquired from an
•infection
•injury, or
•as a complication of another disease.

52. Empyema with broncho-pleural fistula:
 

53. Definition: Presence of pus in the pleural space
(empyema) with presence of a communication
between the pleura and the bronchial tree
(fistula).

54. 5454Thank you for your attention!