Bronchiectasis, lung abcess, empyema

1. Dr. Prasoon Rastogi
MD Med.

2. Case 1 :
A 54-year-old woman presented with chronic cough with thick
greenish sputum that has worsened over a period of 6–12
months. Over the course of the day, she estimates that she
produces as much as 100 ml of sputum daily. Bilateral coarse
crackles are heard in the lower lung zones. Pulmonary function
tests demonstrate FEV1/FVC ratio of 56%. A chest radiograph is
unremarkable. What would you recommend as the next step in
the evaluation and management of this patient?

3. Case 2:
A 48-year-old man(chronic alcoholic) presented with fever and
cough. He has fever, fatigue and generalized malaise for about 8
weeks. During this period, he has been having increasing cough
with foul smelling dark sputum production at least 3 tablespoons
daily that has been blood streaked at times. He has evidence of
temporal wasting with very poor dentition. A foul odor is present
on his breath. Amphoric breath sounds are heard posteriorly in
the right lower lung field. What is the best initial choice for
therapy in this patient and investigations to be planned ?

4. At the end of this presentation we would be able to:
1. Know the different types of suppurative lung diseases.
2. Describe the etiology and pathogenesis of each type.
3. Describe the clinical features of each disease.
4. Interpret the specific investigations.
5. Discuss the different complications.
6. Discuss the treatment modalities including surgery.

5. The term suppurative lung diseases implies the following:
 Bronchiectasis
 Lung abscess
 Empyema thoracis

6. History
Fever, persistent cough with copious sputum production
Weeks to months
+
Risk of aspiration
GERD
Tooth infections (bad breath)
Months to years
+
h/o recurrent/long standing infections
Postural increase in sputum production
Congenital defects
Autoimmune disorder
Rhinosinusitis

7. Examination
Auscultation:
Wheezing + coarse
crepts
General : mouth
for decaying teeth,
gag reflex may be
absent.
Palpation :
increased vocal
fremitus
Percussion :
dullness
Auscultation :
Amphoric or
cavernous sounds
General: mouth for
decaying teeth
Inspection : restricted
movement, Crowding
of ribs
Palpation :
tracheal shift ± shifting
of apex beat
Decreased Vocal
fremitus
Reduced chest
expansion
Auscultation
Decreased/absent
breath sounds
Decreased/ absent
vocal resonance

9. Bronchiectasis
 Abnormal irreversible dilatation of the bronchi (medium sized
bronchioles).
 Not a disease per se but end stage of a variety of pathological
processes.
 Extent may focal (localized to an area distal to mechanical
bronchial obstruction) or diffuse (systemic pathology).

11. Etiology:
I. Post infectious
II. Mucociliary abnormalities
III. Immunological disorders
IV. Mechanical Obstruction

12. Post infectious
Bacterial
Viral
Fungi

13. Mucociliary
abnormalities
Kartagener’s
Syndrome
Young’s Syndrome
Cystic Fibrosis

14. Immunological
disorders
Immunodeficiency
Autoimmune
disorders
Hyper-immune
response (ABPA)

15. Clinical Features:
Symptoms:
1. Persistent cough with expectoration
2. Copious thick sputum associated with postural change.
3. Haemoptysis (30%)
4. Dyspnea
5. Chest pain

16. Signs:
1. Crepitations (78%)
2. Wheezes (20%)
3. Signs of pulmonary hypertension or corpulmonale.
4. General: Cyanosis, clubbing(5%)

17. Associated findings supporting the diagnosis
Signs and Symptoms suggestive of -
 Rhinosinusitis
 Gastro-esophageal reflux Disease
 Depressed sensorium
 Autoimmune disease
 Mucociliary defect
 ABPA (Allergic Brochopulmonary Aspergillosis)
 Primary immunodeficiency

18. Diagnosis and investigations:
 Sputum – culture & sensitivity
Common organisms:
H.Infleunza.
S.Pneumoniae.
Pseudomonas aeruginosa
S.Aureus.
Mycobacterium sp.

19. Chest X ray

20. HRCT(High Resolution Computed Tomography)

21. Radiological clues to etiology –
 Chronic recurrent aspirations – lower lung fields
 MAC infection - middle lung fields
 Congenital cilliary defects – middle lung field
 Allergic Bronchopulmonary Aspergillosis – central bronchioles
 Cystic fibrosis & radiation – upper lung fields

22. Tests for Detecting Specific Aetiologies of
Bronchiectasis
 Paranasal sinus disease (X-ray or CT paranasal sinuses)
 Gastro-oesophageal reflux (barium swallow, esophageal manometry)
 Immune deficiency [Total levels of IgG, IgM, IgE and IgA]
 ABPA [serum precipitins and sputum for Aspergillus fumigatus]
 Connective tissue disorders ( ANA and rheumatoid factor)
 α1-antitrypsin deficiency (serum α1-antitrypsin levels)
 Cystic fibrosis (sweat chloride analysis, genotyping)
 Endobronchial abnormalities (Fibre-optic bronchoscopy)
 Ciliary dyskinesias (semen analysis, saccharine test)

23.  Functional impairment :
1. Measurement of ventilatory capacity
 Airway obstruction.
 Lung volumes and compliance.
2. Gas exchange studies
 Decreased DLCO.
 Abnormal V/P scan.

24. Treatment
Medical
Antibiotics Bronchial hygiene Corticosteroids Prevention
Surgical

25. Antibiotics
Indications:
1. Mucoid sputum  muco-purulent sputum.
2. Chronic muco-purulent or purulent sputum  ↑ amount or
purulence, change of color, systemic symptoms or
worsening of lung functions.

26. Antibiotic therapy
 Start with β lactum antibiotics preferably with pseudomonal
coverage.
 Add antibiotics according to culture and sensitivity.
 Duration – 7-10 days(acute exacerbations) upto 14 days.

27. Bronchial hygiene
Aim:
 Mobilization of secretions from the lung periphery (or
affected area)towards the more central unaffected segments
in which cough reflex is intact and mucociliary function is
preserved.
Approaches :
 Hydration and mucolytic administration
 Brochodilators
 Chest physiotherapy

28. Complications
1. Recurrent pneumonia.
2. Lung abscess.
3. Pneumothorax.
4. Cor pulmonale and pulmonary hypertension
5. Secondary Amyloidosis.

30. Lung Abscess
Localized area of destruction of lung parenchyma where
pyogenic infection is the cause of tissue necrosis and suppuration.
 Primary lung abscesses - arise from aspiration (anaerobic
bacteria), absence of an underlying pulmonary or systemic
condition.
 Secondary lung abscesses – underlying pulmonary
condition(postobstructive e.g. a bronchial foreign body or
tumor) or a systemic process (e.g., HIV infection or another
immunocompromising condition).

31. Primary lung abscess
1. Factors predisposing to aspiration
 Dental caries
 Impaired consciousness
 Anaesthesia (general)
 Stroke (cerebro-vascular accident)
 Seizures including post-ictal state
 Head trauma
 Alcohol intoxication
 Drug overdose or abuse (narcotics, sedatives)
 Metabolic encephalopathy
 Neuromuscular diseases

32. 2. Oesophageal disorders
 Achalasia and other dysmotility syndromes
 Gastro-oesophageal reflux
 Stricture (benign or malignant)
 Zenker’s diverticulum

33. Clinical features
Symptoms: chronic indolent course
1. Fever
2. Cough with expectoration(copious & foul smelling)
3. Chest pain.
4. Hemoptysis.
5. Dyspnea
6. Fatigue, night sweats and anemia.

34. Signs:
General: clubbing, mouth for decaying teeth, gag reflex may
be absent.
Palpation : increased vocal fremitus
Percussion : dullness
Auscultation :
 amphoric or cavernous sounds

35. Anaerobic organisms
Prevotella
spp.
Fusobacterium
nucleatum
Peptostreptococci
spp.
Common organisms

36. Aerobic
organisms
G +ve
Strep. melleri
Strep. pneum.
Staph aureus
G –ve
Pseudomonas
Klebsiella
E.coli
H.Infleunza

37. Investigations:
Microbiological studies:
1. Sputum
 Gram stain
 Culture
2. Blood culture
3. Specimens for anaerobic culture without oropharyngeal
contamination
 Transtracheal aspiration
 Percutaneus Needle Aspiration
 Brochoalveolar lavage

38. Chest X Ray

39. CECT Thorax

40.  Other investigations
1. Bronchoscopy
2. Upper GI endoscopy

41. Complications
1. Pneumatocoeles (persistent cystic changes)
2. Bronchiectasis
3. Empyema
4. Direct or haematogenous spread.
5. Massive hemoptysis

42. Treatment
1. Antibiotics
 Duration - 3-4 weeks( upto 14 weeks) – non tubercular
2. Bronchoscopy
3. Surgery
 Abscess > 6 – 8 cm in diameter
 Non responders to antibiotic treatment

43. Antibiotics
Community
acquired
Clindamycin Amoxicillin +
Clavulanic acid
Hospital
acquired
To cover:
G–ve, staph &
anaerobe

45. Empyema thoracis
 Definition:
Pus in the pleural cavity
 Etiology:
1.Thoracic & extrathoracic infection
2.Tumour
3.Trauma or iatrogenic

46. Infections
Thoracic
Pulmonary: TB,
Pneumonia,
Bronchiectasis
Mediastinitis
Extrathoracic
Liver or
subphrenic
abscess

47. Common organisms:
1. Anaerobes
2. Staph. aureus
3. β hemolytic streptococci
4. Pseudomonas, E. coli & Klebsiella spp.
5. Mixed.

48. Clinical picture:
Symptoms
1. Fever
2. Malaise
3. Pleuritic chest pain
4. Dyspnea
5. Cough  sputum

49. Signs
General: weight loss, clubbing, mouth for decaying teeth
Inspection : restricted movement, Crowding of ribs
Palpation :
 tracheal shift
shifting of apex beat
 Vocal fremitus
 Reduced chest expansion
Auscultation
 Decreased breadth sounds
 Decreased/ absent vocal resonance
 No added sounds

50. Investigations:
1. Blood and biochemical exam
2. Chest radiograph
3. CT scan
4. Sputum culture
5. Blood culture
6. Usg guided thoracocenthesis:
 Chemistry
 Bacteriology
 Cytology
8. Bronchoscopy

52. Management
(Antibiotics + Drainage)
Antibiotics
 Same as lung abscess
Drainage
 10 –20% require external drainage or surgery.

53. Drainage
Closed
Frank pus
ph < 7
Failure to improve
Bronchopleural fistula
Open drainage
with rib resection
Decortication

54. Complications
 Restrictive defect
 Pleural calcifications
 Brochopleural fistula
 Pleuro-cutaneous fistula
 Pleural thickening