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Chronic Lung Sepsis

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  1. Chronic Lung Sepsis Dr. Arun Nair

  2. Includes • Lung Abscess • Empyema • Bronchiectasis

  3. Lung Abscess

  4. Lung Abscess

  5. Definition & overview • Cavitating, infected, necrotic lesion of lung parenchyma • Several possible causes • Single or Multiple • Small <2cm or large • Most secondary to aspiration of oropharyngeal secretions • Mixed growth of organisms, including anaerobes

  6. Causes • Aspiration • Bronchial obstruction {Tumour / Foreign Body} • Pneumonia • Blood borne infection • Transdiaphragmatic spread

  7. Differential Diagnosis • Cavitating tumour • Infected bronchial cyst/bulla • Localised saccular bronchiectasis • Aspergilloma • Wegeners granulomatosis • Hydatid cyst • Gas-fluid level in oesophagus, stomach or bowel

  8. Microbiology • Anaerobes: Peptostreptococcus, Prevotella, Bacteroides spp (usually not B. fragilis), and Fusobacterium spp. • Staph Aureus, Klebsiella, Strep Milleri • Strep Pneumonia, gram negative bacilli • M.Tuberculosis • Fungi

  9. Clinical Features • Most patients present over several weeks • Malaise, weight loss, fever • Cough with copious purulent sputum • Can be associated with haemoptysis • Toxic features prominent in patients with pneumonia or blood borne infection • Clubbing often seen

  10. Investigations • CXR: PA & Lateral • CT Thorax • Sputum & Blood Cultures • FBC, CRP, ESR, Serological tests

  11. Treatment • AUGMENTIN • AMOXIXCILLIN & METRONIDAZOLE • CLINDAMYCIN • Physiotherapy & postural drainage • Trans Thoracic/ endoscopic drainage for large abscess Duration of ABx: 3- 4 weeks

  12. Empyema • Pus in pleural space • Sequelae of a complicated parapneumonic infection, when bacteria invade pleural space • Uncomplicated • Complicated • Frank Empyema

  13. Pathogenesis • Uncomplicated parapneumonic effusion —  • occurs when the lung interstitial fluid increases during pneumonia, and is characterized by "exudative" pleural fluid chemistries and an influx of neutrophils into the pleural space. • resolve with resolution of the pneumonia.

  14. Complicated Parapneumonic effusion • occurs when there is persistent bacterial invasion of the pleural space. • Results in pleural fluid acidosis (anaerobic utilization). Lysis of neutrophils increases the LDH concentration in the pleural fluid to values often in excess of 1000 IU/L. • Complicated parapneumonic effusions are often sterile because bacteria can be cleared rapidly from the pleural space. (Loculation )

  15. Thoracic Empyema • Formation of empyema is the third stage and is characterized by bacterial organisms seen on gram stain or the aspiration of pus on thoracentesis. • A positive culture is not required for diagnosis.

  16. Bacteriology • Mixed bacterial flora • Anaerobic bacteria in 36-76% • Streptococcus milleri, Staphylococcus aureus, and Enterobacteriaceae. • Patients with diabetes mellitus are at increased risk of empyema secondary to Klebsiella pneumoniae. • S. pneumoniae and S. aureus (including methicillin-resistant organisms) are the leading causative bacteria in children with empyema.

  17. Pleural fluid analysis • Pus • Ph <7.2 • Glucose < 60 mg/dl • LDH>1000 IU/L • WBC>15/nl

  18. Imaging • CXR • CT • USG

  19. Signs favouring empyema • Evidence of lung compression • Smooth margins • Blunt angle with chest wall • Dissection of thickened visceral and parietal pleura

  20. Treatment • Pleural drainage • Chest Drain • Thoracoscopy • Antibiotics • Fibrinolytics: No convincing benefit

  21. Bronchiectasis • Abnormal permanent dilatation of one or more bronchi • Poor mucous clearance • Chronic bacterial infection & inflammation • Long term lung damage

  22. Types • Saccular /Cystic • Cylindrical • Varicose

  23. Saccular Bronchiectasis • Large baloon like dilatation from severe loss of bronchial wall • Assoc with severe lung infections, large sputum volumes, finger clubbing

  24. Cylindrical Bronchiectasis

  25. Varicose Bronchiectasis

  26. Causes • Congenital {defective bronch wall/ sequesteration} • Post infective {TB, Pertussis, NTM, ABPA} • Airway obstruction (eg, foreign body aspiration) • Defective host defenses{ CVID, HIV, phagaocyte dysfn • Inflammatory pneumonitis {gastric aspiration, toxic gas inhalation} • Abnormal mucociliary clearance {Primary Ciliary Dyskinesia, cystic fibrosis, Young's syndrome • Rheumatic and systemic diseases, cigarette smoking, Chronic Bronchitis.

  27. Symptoms • Cough (98 percent of patients) • Daily sputum production (78 percent) • Dyspnoea (62 percent), • Rhinosinusitis (73 percent) • Hemoptysis (27 percent) • and recurrent pleurisy (20 percent).

  28. Physical Findings • Crackles (75 percent) • Wheezing (22 percent) were common, • Digital clubbing occurred in only 2 percent of patients.

  29. Pathophysiology • Induction of bronchiectasis requires two factors • An infectious insult • Impaired drainage, airway obstruction, or a defect in host defense • Recurrent infection leads to further scarring, obstruction, and distortion of the airways, as well as temporary or permanent damage to the lung parenchyma.

  30. Diagnostic workup • The following LAB studies should be part of the initial evaluation of a patient with bronchiectasis: • A complete blood count with differential • Immunoglobulin quantitation to measure the levels of the immunoglobulins IgG, IgM, and IgA • Sputum culture and smear for bacteria, mycobacteria, and fungi

  31. Imaging • CXR radiographic findings include linear atelectasis, dilated and thickened airways (ie, tram or parallel lines, ring shadows on cross section) and irregular peripheral opacities that may represent mucopurulent plugs.

  32. High Resolution CT Thorax • Airway dilatation • Bronchial wall thickening • Lack of tapering • mucopurulent plugs or debris accompanied by post-obstructive air trapping (tree-in-bud)

  33. Distribution • A central (perihilar) distribution is suggestive of ABPA. • predominant upper lobe distribution is characteristic of cystic fibrosis • middle and lower lobe distribution is consistent with PCD • lower lobe involvement is typical of idiopathic bronchiectasi

  34. Spirometry • Obstructive picture common • Frequently isolated pathogens on CULTURE include Hemophilus influenzae, Pseudomonas aeruginosa (especially mucoid types), and, less frequently, Streptococcus pneumoniae

  35. Treatment • Postural drainage • Based on sputum culture & sensitivity • Non-Pseudomonas organism: • Amoxicillin: 1gm TID 14 days • Augmentin 625 mg TID 14 days • Doxycyline 100mg BD 14 days • Ciprofloxacin 750 mg BD 14 days (Pseudomonas) • Ceftazidime 2gm TID 7-14 days (Pseudomonas) • Nebulised Tobramycin (Pseudomonas)

  36. END

  37. Signs favouring lung abscess • Spherical shape with irregular and thick wall • Absence of lung compression • Sharp angle with chest wall • Vasculature around abscess