lungs abscess and bronchitis

Lungs Abscess And Bronchitis

Chanak Trikhatri

http://en.wikipedia.org/wiki/File:Abscess.jpg

Lungs Abscess • Introduction and Definition lungs abscess • Epidemiology• Etiology and risk factor • Pathophysiology • Clinical Feature • Diagnosis and investigation• Management

– Medical – Surgical – Nursing

• Prognosis • Complication • Prevention • Recent Research

Introduction

• Lungs abscess is a collection of pus within the lung tissue. In its early stages, the abscess resembles a localized pneumonia. If a lung abscess remains unidentified and untreated, tissue necrosis may occur. Lung abscesses are become more rare as result of improved treatment of pneumonia and effective preventive care clients at high risk for aspiration.

Introduction contd…..

Single lung abscesses usually occur distal to a bronchial obstruction. Most of the time they creates putrid material. The obstruction may be due to following

• Aspirated foreign material • Benign and malignant tumors

multiple lungs abscesses can follow pneumonia caused by necrotizing bacteria

Definition

Lung Abscess is the localized suppurative necrosis of lung tissue due to infection, commonly by staphylococci, streptococci, numerous gram-negative species, and anaerobes. A lung abscess is a localized necrotic lesion of the lung parenchyma containing purulent material that collapses and forms a cavity.

Definition Contd….

It is generally caused by aspiration of anaerobic bacteria. By definition, the chest x-ray will demonstrate a cavity of at least 2 cm. Lung abscess is considered

• Primary :- when it results from existing lung parenchymal process.

• Secondary:- when it complicates another process e.g. vascular emboli or follows rupture of extra-pulmonary abscess into lung.

Lesions

• Abscesses vary in number (single or multiple) and size (microscopic to many centimeters in diameter).

• Single abscess usually occur distal to a bronchial obstruction, commonly from aspirated foreign material or tumors.

• Multiple abscesses can follow pneumonia caused by necrotizing bacteria(s. aureus),which creates necrotic lung tissue.

Lesions• Aspiration abscesses are common on the right due to

more vertical right bronchus. • Contain variable mixtures of pus and air, depending on

available drainage through airways.• Abscesses due to pneumonia or bronchietasis are

usually, multiple, basal, and diffusely scattered.• Septic emboli and pyemic abscesses are multiple and

seen in any part of the lungs.• Chronic abscesses are often surrounded by reactive

fibrous wall.

Cause • Aspiration of infected material such as:– In oropharyngial surgery– Dental sepsis– Aspiration secondary to diminished consciousness from

coma, drugs, anesthesia and seizures.• Organisms– Anaerobic bacteria: Peptostreptococcus, Bacteroides,

species,– streptococcus: Streptococcus milleri– Aerobic bacteria: Staphylococcus, Klebsiella,

Haemophilus, Pseudomonas, Escherichia coli, – Fungi: Candida, Aspergillus

Cause contd…

• Previous primary bacterial infection (Example: Post-pneumonic abscess).

• Septic embolism from infected emboli, or vegetations of infective bacterial endocarditis on the right side of the heart.

• Primary or metastatic tumors may cause obstruction of the bronchopulmonary segment leading to infection and abscess formation.

• Direct traumatic puncture of the lungs

Risk Factor

• Person who impaired cough reflexes • Cannot close the glottis• Swallowing difficulties• Central nervous system disorders (seizure,

stroke)• Drug addiction• Alcoholism

Risk Factor Contd…

• Esophageal disease• Bacterial pneumonia • Compromised immune function• Those without teeth• nasogastric tube feedings• altered state of consciousness from

anesthesia.

Pathophysiology

Alveolar macrophages initiates the inflammatory response to bolster lower respiratory tract defense

Causative organism and factor invade the pulmonary tissues

Due to etiology/ risk factor

Pathophysiology contd….

release neutrophils and esionophils

These mediators start to necrotize the tissue

Chemokines (IL-8) and granulocyte colony stimulating factor (Fever)

Release of inflammatory mediators, such as interleukin(IL-1) and TNF(Tumor necrosis factor)

Impaired gas exchange and appearance of clinical features

Consolidation in the lung

leukocytosis increase purulent secretion and form lesions

alveolar capillary leak

Pathophysiology contd….

Pathophysiology

Initially, the cavity in the lung may or may not extend directly into a bronchus. Eventually the abscess becomes surrounded, or encapsulated, by a wall of fibrous tissue. The necrotic process may extend until it reaches the lumen of a bronchus or the pleural space and establishes communication with the respiratory tract, the pleural cavity, or both. If the bronchus is involved, the purulent contents are expectorated continuously in the form of sputum. If the pleura is involved, an empyema results. A communication or connection between the bronchus and pleura is known as a bronchopleural fistula.

Clinical Feature

• Vary from a mild productive cough to acute illness

• fever with shivering and night sweating • Productive cough with moderate to copious

amounts of foul smelling, purulent cough• Blood in sputum • Leukocytosis• Pleurisy

Clinical Feature contd…

• Dull chest pain• Dyspnea, shortness of breath • Weakness, lethargy • Anorexia, and weight loss • Finger clubbing• On examination of chest there will be features

of consolidation such as localised dullness on percussion, bronchial breath sound

Diagnostic Findings• History taking:

– Dental problem, previous respiratory infection, trauma.• Physical examination:

– General examination reveals anemia, fever, finger clubbing.– Dullness on percussion and decreased or absent breath sounds with

an intermittent pleural friction rub (grating or rubbing sound) on auscultation, crackles may present.

• Chest x-ray: – To help diagnose and locate lesion ,often shows an opaque area of

consolidation.• Direct bronchoscopic:

– Visualization to exclude possibility of tumor or foreign body.

• Sputum culture and sensitivity tests: – To determine causative organisms and antimicrobial sensitivity

and cytological examination for malignant cells.• CT scan:

– To exclude the malignancies, scan of thorax can detect lung abscess with certainty.

• CBC:– anaemia, leucocytosis and raised ESR.

• Immunological test:– which detects microbial antigens in serum , sputum and urine.

Diagnostic Findings Cont….

Diagnostic Findings Cont….• Thoracentesis:– to obtain a specimen of pleural fluid for

examination• Ventilation–perfusion scan:– The test of choice and clinically important in

patients with suspected Pleural Effusion, hence it is done to exclude the Pleural effusion

• Arterial blood gas analysis:– May show hypoxemia and hypocapnia (from

tachypnea Peripheral vascular studies

Diagnostic Findings Cont…

• Pulmonary angiogram:– This test is invasive. A contrast agent is injected into

the pulmonary arterial system, allowing visualization of obstructions to blood flow and abnormalities.

• Peripheral vascular studies: – Test results confirm or exclude the diagnosis of PE.

• ECG• Biopsy • MRI

Management (Non-Pharmacological)

• According to the findings of the history, physical examination, chest x-ray, and sputum culture indicate the type of organism and the treatment required.

• Pulmonary physiotherapy and postural drainage are also important.

• Percutaneous chest catheter placed for long-term drainage of the abscess


• Therapeutic use of bronchoscopy to drain an abscess

• A diet high in protein and calories is necessary because chronic infection is associated with a catabolic state, necessitating increased intake of calories and protein to facilitate healing

• Fluid and electrolyte management

Management (Pharmacological)

• Most often ampicillin 500mg PO X QIDs or cotrimoxazole 1g PO X BD or clinadamycin

• On the basis of the result of the sputum culture and sensitivity IV antimicrobial therapy is administered Penicillin G or clindamycin (Cleocin) is the medication of choice with metronidazole added in serious cases. Penicillin G benzathine 1 Million U IM single dose, 400,000-600,000 U PO X q4-q6 h


• Metronidazole 400mg PO X TDS if there is foul smell of the sputum

• The intravenous dose is continued until there is evidence of symptom improvement.

• Long-term therapy with oral antibiotics replaces intravenous therapy after the patient shows signs of improvement

• Oral administration of antibiotic therapy is continued for an additional 4 to 8 weeks.

• If treatment stops too soon, a relapse may occur.

Management (Surgical)

• Surgical intervention is rare, but pulmonary resection (lobectomy) is Performed. And indication are:-

• Massive hemoptysis • No response medical management• Localized malignancy• Persistent abscess cavity

Nursing Management

• Assessment– History of food particle aspirations, previous respiratory

problem, trauma– Examine oral cavity because poor condition of teeth and

gums increases number of anaerobes in oral cavity– Perform chest examination, dullness on percussion and

decreased or absent breath sounds with an intermittent pleural friction rub (grating or rubbing sound) on auscultation. Crackles may be present.

– Monitor for foul-smelling sputum ,indicate an anaerobic pulmonary infection.

Nursing Management • Nursing diagnosis– Ineffective breathing pattern related to presence

of supportive lung diseases.– Imbalance nutrition less than body requirement

related to catabolic state from chronic infection.– Acute pain related to congestion, possible lung

infraction.– Anxiety related to dyspnea ,pain and seriousness

of condition.– Knowledge deficit regarding home management of

diseases

Nursing Management

• Nursing Intervention– Improving respiratory status• Observe patient’s breathing pattern, and other vital

signs, for evidence of improvement or deterioration.• Monitor patient’s response to antimicrobial therapy:

take temperature at prescribed intervals.• administers antibiotics and intravenous therapies as

prescribed and monitors for adverse effects.• Chest physiotherapy is initiated as prescribed to

facilitate drainage of the abscess.

Nursing Management • Implement additional interventions as indicated:– Postural drainage may be recommended. – position to be assumed depend on location of abscess– improve the patient’s respiratory and vascular status.–Oxygen therapy is administered to correct the

hypoxemia, relieve the pulmonary vascular vasoconstriction, and reduce the pulmonary hypertension.– Carry out coughing and breathing exercises–Measure and record the volume of sputum to follow

patients clinical course – Give adequate fluids to enhance liquefying of

secretions

Nursing Management

• Nursing Intervention– Control of pain • Assess degree and characteristics of discomfort/pain.• Monitor vital signs, noting elevated temperature.• Position semi-Fowler’s position • Turning and reposition frequently• Administers opioid analgesics as prescribed for severe

pain.

Nursing Management

• Nursing intervention – Attaining comfort• Use nursing measure to generalized discomfort; oral

hygiene ,position of comfort .• monitor vital signs to determine the severity of infectious

process.• Encourage rest and limitation of physical activity.• Monitor chest tube functioning.• Evaluate signs of hypoxia, monitor pulse oximeter to know

oxygen level. ,• Administer analgesics as directed.

Nursing Management

• Nursing Intervention – Improved nutritional status• Provide a high protein ,calorie diet.• Offer liquid supplement for additional nutritional

support when anorexia limits patients intake.

Nursing Management

• Promoting Home and Community – Based Care– Teaching Patients Self-Care.

• How to monitor for signs and symptoms of infection• How to care for and maintain the drain or tube• Instructs the patient to perform deep-breathing and

coughing exercises every 2 hours during the day • Perform chest percussion and postural drainage to

facilitate expectoration of lung secretions • Importance of completing the antibiotic regimen • Suggestions for rest and appropriate activity

Nursing Management • Teach the patient how to contain airborne droplets and

secretions to reduce the risk of spreading the infection• Practice good hand hygiene techniques to reduce the risk of

spreading the infection• Explain disease transmission to the patient and the need

for prolonged therapy to help increase his compliance with the treatment plan• Encourage the patient to maintain adequate dietary intake

to maintain nutritional status, build strength, and improve the body’s defense mechanisms• Weigh the patient daily to assess nutritional status• Teach patient for the follow up visit

Nursing Management

• Evaluations/expected outcomes:– Cyanosis and dyspnea reduced; Sao2 improved.– Coughs effectively, and dullnesss absence of

crackles.– Appears more comfortable, free from pain.– Fever controlled, no signs of infection.– Understood the drug regime, self care activities

and nutritional support

Prognosis

Most cases respond to antibiotic and prognosis is usually excellent unless there is a debilitating underlying condition. Mortality from lung abscess alone is around 5% and is improving

Complication

• Bronchiectasis• Empyema• bacteraemia with metastatic infection such as

brain abscess• bronchopleural fistula• Pleuritis • Progressive damage of lungs tissues

Prevention

• Appropriate antibiotic therapy before any dental procedures in patients who must have teeth extracted while their gums and teeth are infected

• Adequate dental and oral hygiene, because anaerobic bacteria play a role in the pathogenesis of lung abscess

• Appropriate antimicrobial therapy for patients with pneumonia

Bronchitis

Bronchitis • Introduction and Definition Bronchitis • Epidemiology• Etiology and risk factor • Pathophysiology • Clinical Feature • Diagnosis and investigation• Management

– Medical – Surgical – Nursing

• Prognosis • Complication • Prevention • Recent Research

Introduction

A bronchitis, is an inflammation of the mucous membranes of the the bronchial tree, often follows infection of the upper respiratory tract. A patient with a viral infection has decreased resistance and can readily develop a secondary bacterial infection. Thus, adequate treatment of upper respiratory tract infection is one of the major factors in the prevention of bronchitis.

Introduction contd…..

Aside from infection, inhalation of physical and chemical irritants, gases, and other air contaminants can also cause acute bronchial irritation. According to the length and severity there are two types of bronchitis

• Acute bronchitis • Chronic bronchitis

Acute Bronchitis

Bronchitis having short clinical course with cough, expectoration and fever often caused by the upper respiratory viral infection to the bronchi

Chronic Bronchitis

Chronic or recurrent excess mucus secreation in to the bronchial tree without a demonstrable cause either local or general occurring on most of the days at least three months of the year at least two successive year.

Epidemiology

Cause • Prolong exposure to the environmental pollution • Prolong use of cigarette• Occupation related to pollutant, allergens and fume • Prolong use of fire wood • Upper respiratory infection viral and bacterial • Ascending infection from the adjacent anatomy

Risk Factor Contd…

• Fire wood kitchen • Irritant gaseous pollutent

Pathophysiology

Inflammation features infiltration by neutrophils with fibrino-purulent exudation

Spread to the whole bronchus

The quantity of accumulated exudate from the inflammatory mediators

Inflammatory mediator release

Inflammatory response started accumulatoin of macrophage to phagocyte

Mircoorganism and polluent travel through the lungs tissue

Due to etiology and risk factor

Clinical Feature • Initially, the patient has a dry, irritating cough and

expectorates scanty amount of mucoid sputum. • Raw burning pain over the upper anterior chest wall

over the medisternm • Pain increase with exposure of cold environments,

ciggrette smoking, cough • Complains of sternal soreness from coughing • Cough related syncope • Fever or chills and night• Sweats, headache, and general malaise.

Clinical Feature contd…

• As the infection progresses, the patient may be short of breath

• Noisy inspiration and expiration (inspiratory stridor and expiratory wheeze),

• Produce purulent (pus-filled) sputum. • With severe bronchitis• blood-streaked secretions may be expectorated

as a result of the irritation of the mucosa of the airways.

Diagnostic Findings• History taking:

– Personal habits smoking, prolong use of fire wood, previous respiratory infection, trauma.

• Physical examination:– General examination reveals fever, pallor, weakness.– Dullness on percussion and decreased or absent breath sounds with an

intermittent pleural friction rub (grating or rubbing sound) on auscultation, crackles may present.

• Chest x-ray: – To help diagnose and locate lesion ,often shows an opaque area of

consolidation.• Direct bronchoscopic:

– Visualization to exclude possibility of tumor or foreign body.

• Sputum culture and sensitivity tests: – To determine causative organisms and antimicrobial sensitivity

and cytological examination for malignant cells.• CT scan:

– To exclude the malignancies, scan of thorax can detect lung abscess with certainty.

• CBC:– anaemia, leucocytosis and raised ESR.

• Immunological test:– which detects microbial antigens in serum , sputum and urine.

Diagnostic Findings Cont….

Diagnostic Findings Cont….• Thoracentesis:– to obtain a specimen of pleural fluid for

examination• Ventilation–perfusion scan:– The test of choice and clinically important in

patients with suspected Pleural Effusion, hence it is done to exclude the Pleural effusion

• Arterial blood gas analysis:– May show hypoxemia and hypocapnia (from

tachypnea Peripheral vascular studies

Diagnostic Findings Cont…

• Pulmonary angiogram:– This test is invasive. A contrast agent is injected into

the pulmonary arterial system, allowing visualization of obstructions to blood flow and abnormalities.

• Peripheral vascular studies: – Test results confirm or exclude the diagnosis of PE.

• ECG• Biopsy • MRI


• Therapeutic use of bronchoscopy to drain an secretion• The patient is advised to rest. • Avoid irritant, cold, and pollutant, stop smoking • Nutritional support • Promote airway clearance by encouraging coughing • Fluid and electrolyte management• Fluid intake is increased to thin the viscous and

tenacious secretions. • Changing position

Management (Pharmacological)• Treatment focus on cause of cough• Symptomatic treatment elimination of irritant and pain

relief analgesic and antipyretic • Antibiotic treatment may be indicated depending on the

symptoms, sputum purulence, and results of the sputum culture.

• Antihistamines are usually not prescribed because they may cause excessive drying and make secretions more difficult to expectorate.

• Expectorants may be prescribed, although their efficacy is questionable.


• Rarely, endotracheal intubation may be required in cases of bronchitis leading to acute respiratory failure.

• This may be necessary for patients who are severely debilitated or who have coexisting diseases that also impair the respiratory system.

• Humidified air increased through, aerosols • Cool vapor therapy or steam inhalations may help

relieve laryngeal and tracheal irritation. Moist heat to the chest may relieve the soreness and pain.