Dr.Ahmed Al-AzzawiM.B.Ch.B,F.I.C.M.SCardiothoracic&Vascular SurgeonUniversity of SulaimaniCollege of Medicine

Suppurative Lung Diseases

Suppurative Lung Diseases

1- Bronchiectasis

2- Lung abscess

3- Empyema with broncho-pleural fistula

 

Bronchiectasis

Definition

Bronchiectasis is abnormal permanent dilatation of one or more bronchi or bronchioles, caused by destruction of muscular and elastic components of the bronchial walls. Most often secondary to an infectious process.  

Causes of BronchiectasisI) Congenital syndromesa) Cystic fibrosis b) Immotile Cilia Syndrome e.g. Kartagener’s Syndromec) Alpha-1 antitrypsin deficiencyd) Primary Hypogamma-globulinemia II) Acquired a)   Post infection b) Airway obstruction c) Traction Bronchiectasis is idiopathic in more than 50% of adults

despite aggressive investigations 

Diagnosis of Bronchiectasis

I) Clinical Diagnosis

► History and symptoms

► Clinical examination

 Symptoms

☉Chronic expectoration of (usually) large quantities of offensive, postural, purulent sputum production lasting months to years is the most often characterize bronchiectasis.

☉Less specific symptoms include dyspnea, recurrent pleuritic chest pain, wheezing, hemoptysis, fever, weakness, and weight loss.

Physical Examination▶ General findings may include digital clubbing,

cyanosis, wasting, and weight loss.▶ Chest examination are nonspecific and may be

normal if there is no secretions in bronchiectatic airways.▶ Most commonly, crackles and rhonchi, may be

heard on auscultation (may be unilateral or bilateral).▶ in advanced disease, the physical signs of

corpulmonale and signs of other complications may be observed.

Investigations

► Laboratory investigations

► Pulmonary function tests

► Radiological Images

◘ Chest X-Ray

◘ Bronchography

◘ Computed tomography

 

 

Chest X-Ray► Chest x-ray may be normal (about 10% 0f

cases).► It can show thickened bronchial walls,

multiple cystic spaces with fluid level (mucus) ► Honeycombing infiltrates in advanced cases► Associated complications e.g.Pneumonia,

pneumothorax, cor pulmonale and collapse.

Chest Computed Tomography (CT)

►Recently, High-resolution CT (HRCT) scanning of the chest has replaced bronchography as the “gold standard” for detecting bronchiectasis.

► Bronchiectasis is characterized by dilated bronchi with thickened walls on HRCT

► HRCT has a sensitivity of 97% and a specificity of 93% - 100% in diagnosing bronchiectasis.

 Differential Diagnosis

I) Other causes of chronic airway diseases:

◘ Bronchial asthma

◘ COPD

◘ Chronic bronchitis

II) Other causes of suppurative lung syndromes:◘ Empyema with bronchopleural fistula ◘ Chronic lung abscess

 III) Other causes of hemoptysis Complications1- Acute exacerbation2- Recurrent pneumonia3- Suppurative complications e.g.

► Empyema► Lung abscess► Brain abscess

4- Massive hemoptysis5- Respiratory failure6- Cor pulmonale 

Treatment of Bronchiectasis1- Treatment of pulmonary Infections

(Antibiotics)2- Anti-inflammatory therapy3- Clearance of airway secretions◘ Bronchodilators ◘ Mucolytics ◘ Mobilization of secretions: Postural drainage and Chest physiotherapy 

4- Surgery

◘ Resection

◘ Transplantation

 Lung Abscess

 

Definition

It is a localized suppurative lesion of lung parenchyma causing a rounded cavity with an air-fluid level in the chest X-ray.

Causes of lung abscess1- Post-pneumonia (commonest)

It occurs after necrotizing pneumonia e.g. staphylococcal pneumonia or klebsiella pneumonia

 2- Aspiration

It occurs secondary to aspirated foreign bodies. It is important to ask the patient about disturbances in his conscious state which may predispose to aspiration of any foreign body.

 3- Post-traumatic lung abscess This can occur in an infected hematoma of the lung4- Malignant lung abscess

► Presence of the central bronchial obstruction will impair drainage of secretions and ends in distal infection which leads to formation of peripheral lung abscess. ► Central necrosis in the tumor can result in formation of lung abscess.

 5- Septic pulmonary embolization 6- Amoebic lung abscessIt usually spreads to the lung from amoebic liver abscess 

Clinical picture► History of one of etiologic factors may be

present.► Characteristically, there is a history of

sudden expectoration of a big amount of sputum when the abscess communicates with a bronchus.

► Sputum is usually purulent and foul odor.►Patient usually looks ill and feverish►Clubbing may be present in chronic abscess► Clinical signs of consolidation e.g. bronchial

breathing or crepitations may be present.

Investigations

► Blood picture: increase in white cell count

► Sputum examination: culture and sensitivity to different antibiotics.

► Chest X-ray: reveals rounded hydro-aerial shadow with fluid level.

► Computed tomography demonstrates the abscess and shows any central masses.

► Bronchoscopy: it is used when there is suspicion of foreign body inhalation or endo-bronchial tumour causing bronchial obstruction

Treatment● Antibiotic therapy as described in the

treatment of pneumonia is given according to the results of culture and sensitivities for about 6-8 wks.

● Surgical excision may be required In chronic lung abscess

●Treatment of any underlying causes e.g. Removal of aspirated foreign body or malignant tumour causing central endobronchial obstruction

Empyema

Definition

It is pus in the pleural space or infected pleural fluid. The isolated organism may or may not be isolated from the pus.

Microscopically, neutrophil leucocytes are present in large number (>15. 000/ml).

Types

Empyema is either:

► Acute or chronic (> three months)

► Loculated or free in the pleural space

► Closed or opened (bronchopleural fistula)

Causes of empyema

► Direct spread from adjacent bacterial pneumonia or tuberculous infection.

► Rupture of a lung abscess into the pleural space.

► Invasion from subphrenic abscess

► Traumatic penetration (infected haemothorax)

► Blood or lymphatic seeding of the pleura in systemic infection.

Diagnosis of Empyema1- Chest X-ray► It reveals evidence of pleural effusion. ► This may be free or loculated pleural effusion or hydropneumothorax.  2- Thoracentesis (Pleural taping)►The pleural aspirate is usually purulent, foul-smelling in anaerobic infection.

► It is usually done using wide bored needle. 3- Laboratory investigations leucocytosis High ESR High C-reactive protein (CRP)  4- Ultrasound and C T chest .They are usually needed to define:          5- Pleural biopsyMay be needed to differentiate between tuberculous and non-tuberculous infections

PULMONARY HYDATID DISEASE

Echinococcus Egg in Feces

Appearance of a typical cyst at removal

The hydatid cyst in the lung composed of three layers.

The outer layer formed of atelectatic alveoli and fibrous tissue(pericyst).

Acellular white laminated memberane(ectocyst).

A nucleated thin germinal layer (endocyst) which secretes the hydatid fluid into its cavity

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