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Pneumonia, lung abscess and empyema

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

Left lung abscess

  • 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

Empyema

  • 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.

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