Lung abscess
- Some patients with pneumonia develop focal necrosis and a lung
abscess
- Particularly occurs in patients with malignancy and malnutrition
- Can also occur following aspiration or inhalation of a foreign body
- Diagnosis can be difficult
Clinical features
- Usually clinical features of pneumonia that fails to improve with
antibiotics
- Patient develops pleuritic chest pain and haemoptysis
- Volume of sputum produced may increase
- Patients usually systemically unwell with swinging pyrexia
- Examination usually shows signs of pneumonia
- Commonest complication is an empyema
- Differential diagnosis includes:
- Primary lung neoplasm
- Tuberculosis
- Aspergillosis
- Lung cyst
Investigations
- Chest x-ray may show cavity with air / fluid level
- CT scanning will confirm diagnosis of chest x-ray inconclusive
- Bronchoscopy should be considered to exclude foreign body
Management
- Appropriate antibiotic therapy based on sputum culture result
- Percutaneous aspiration if fails to improve with antibiotics
- For abscesses greater than 5 cm diameter open drainage may be
required
- Thoracotomy and lung resection should be considered
Empyema
- Empyema = pus within a body cavity
- Lung empyema usually occurs secondary to pneumonia
- Collection is often multiloculated
- If diagnosis is delayed it will also have a thick, fibrous wall
- Also seen following:
- Oesophageal perforation or rupture
- Blunt or penetrating thoracic trauma
- Nasopharyngeal sepsis that has spread to chest
- Thoracic surgical procedures
Clinical features
- Usually clinical features of pneumonia that fails to improve with
antibiotics
- Pleuritic chest pain and breathlessness
- Examination may show clinical features of pleural fluid
- Chest x-ray will show fluid within the pleural cavity
- CT scanning will confirm diagnosis
- Percutaneous aspiration will provide microbiological sample for
culture
Management
- Appropriate antibiotic therapy based on sputum culture result
- If fails to resolve will require drainage
- Pleural drainage should be with adequate (28Fr) chest drain
- Thoracoscopy may be required to break down loculi
- Decortication of visceral and parietal pleura may be required to
allow lung expansion
- Post-operative adequate drainage is required
- Pneumothorax is not a risk due to resulting pleural scarring
Bronchiectasis
- Chronic bronchial dilatation with parenchymal infection and
inflammatory reaction
- Acquired infection is the most common cause, typically when
occurring in childhood
- Congenital causes include
- Cystic fibrosis
- Kartagener's syndrome
- Various immunodeficiency disorders
- Bronchopulmonary sequestration
- Other acquired causes include bronchial obstruction and scarring
- Typically affects the basal segments of the lower lobes
Clinical features
- Recurrent pneumonia
- Persistent cough
- Copious foul smelling sputum
- Haemoptysis is common in adults but rare in children
Diagnosis
- CXR may show a honeycomb pattern
- Bacteriologic studies typically show H. influenza, E. coli
or Klebsiella as the causative agents
- Chest CT with fine cuts has replaced bronchography as the test of
choice
- Bronchoscopy can rule out obstructing lesions and allow pulmonary
lavage
Management
- Medical therapy is the primary approach, using antibiotics,
humidification, bronchodilators
- Surgical intervention is indicated for
- Failure of medical management
- Persistent symptoms
- Recurrent pneumonias
- Haemoptysis
- The ideal surgical candidate has unilateral disease confined to one
lobe
- Most patients have bilateral disease
- Surgery should be reserved for localized disease, operating on the
worst side first
Bibliography
Heffner J E. Infections of the pleural space. Clin Chest Med
1999; 20:607-622.
King P, Holdsworth S, Freezer N et al.
Bronchiectasis. Intern Med J 2006; 36: 729-737.
Rowe S, Cheadle W G. Complications of nosocomial pneumonia in surgical
patients. Am J Surg 2000; 197 (Suppl 2A); S63-S68. |