Lung Lung abscessabscess

DefinitionDefinition

• Necrosis of pulmonary tissue Necrosis of pulmonary tissue caused by severe infection, caused by severe infection, characterized clinically by high characterized clinically by high fever, cough with large quantity fever, cough with large quantity of purulent sputum, porosis, of purulent sputum, porosis, which in X-ray presents as one or which in X-ray presents as one or several cavity with liquid planeseveral cavity with liquid plane

PathogensPathogens

• Bacteria located in oral cavity or upper Bacteria located in oral cavity or upper respiratory tract, including aerobic, anaerobic or respiratory tract, including aerobic, anaerobic or facultative anaerobic bacteriumfacultative anaerobic bacterium

• Common pathogens, e.g., staphylococcus, Common pathogens, e.g., staphylococcus, klebsiella, pseudomonas aeruginosa, suppurative klebsiella, pseudomonas aeruginosa, suppurative streptococcus streptococcus

• 90% cases accompanied with anaerobic infection90% cases accompanied with anaerobic infection

• Aspirated lung abscessAspirated lung abscess• Existence of local infectious loci in oral, Existence of local infectious loci in oral,

nasal or pharyngeal cavity, pathogen nasal or pharyngeal cavity, pathogen aspiratedaspirated

• Right lung is easily involved because right Right lung is easily involved because right main branch is steeper and widermain branch is steeper and wider

• Anaerobes more oftenAnaerobes more often

Mechanisms

• Secondary lung abscessSecondary lung abscess• To bacterial pneumonia, bronchiectasis, To bacterial pneumonia, bronchiectasis,

bronchial cyst, lung cancer, pulmonary TB bronchial cyst, lung cancer, pulmonary TB cavitycavity

• Obstructed by foreign body, esp. for Obstructed by foreign body, esp. for childrenchildren

• Infiltrated by suppurative D in neighboring Infiltrated by suppurative D in neighboring organsorgans

• Hematogenous lung abscessHematogenous lung abscess• Toxic infection Caused by skin injury Toxic infection Caused by skin injury

or infection, furuncle or carbuncle or infection, furuncle or carbuncle (anthracia, (anthracia, 痈痈 ), bacterial emboli ), bacterial emboli disseminated to lungdisseminated to lung→ thrombosis of → thrombosis of small veins, inflammation and necrosissmall veins, inflammation and necrosis

PathologyPathology• Incomplete treatment or unsuccessful Incomplete treatment or unsuccessful

bronchial drainage bronchial drainage →large amount of →large amount of necrotized tissue remnant in cavity necrotized tissue remnant in cavity →persistent over 3 months, termed as →persistent over 3 months, termed as chronic lung abscesschronic lung abscess..

• Hyperplasia of fibroblast, formation of Hyperplasia of fibroblast, formation of granulation tissue granulation tissue →cavity wall thicker →cavity wall thicker →the peripheral bronchi or bronchioles →the peripheral bronchi or bronchioles involved, deformity, or distentioninvolved, deformity, or distention

Clinical manifestationClinical manifestation• HistoryHistory1.1. Surgery in oral cavity, local infectious Surgery in oral cavity, local infectious

loci, drunkenness, fatigue, coma, etcloci, drunkenness, fatigue, coma, etc2.2. Other pulmonary DOther pulmonary D3.3. Skin injury, furuncle, carbuncleSkin injury, furuncle, carbuncle

• SymptomsSymptoms• Abrupt onsetAbrupt onset• High fever with rigor, 39~40ºCHigh fever with rigor, 39~40ºC• Cough with exuberant purulent sputum, Cough with exuberant purulent sputum,

300~500ml/day, 3 layers after deposition300~500ml/day, 3 layers after deposition• Hemoptysis in 1/3 casesHemoptysis in 1/3 cases• Less sputum in hematogenous cases, Less sputum in hematogenous cases,

hemoptysis is rarehemoptysis is rare

• In chronic cases, recurrent In chronic cases, recurrent cough, sputum, fever and cough, sputum, fever and hemoptysis, persistent over 3 hemoptysis, persistent over 3 months; anemia is not raremonths; anemia is not rare

• Other signs: loss of body weightOther signs: loss of body weight

• SignsSigns• Associated with the size and site Associated with the size and site

of lung abscessof lung abscess

Laboratory testingLaboratory testing

• Blood RT: Blood RT: WBC counting 20~30WBC counting 20~30××101099/L, /L, NN>>90%90% ，， hyposegmentation, toxic hyposegmentation, toxic granulesgranules

• CytologyCytology1.1. Sputum film preparation + Gram stainingSputum film preparation + Gram staining2.2. Sputum, pleural effusion, blood cultureSputum, pleural effusion, blood culture3.3. CultureCulture

X-ray examinationX-ray examination• In early stage, lump of dense foggy In early stage, lump of dense foggy

shadow without clear marginshadow without clear margin• After porosis, circular transparent After porosis, circular transparent

shadow with liquid plane, around which shadow with liquid plane, around which is dense inflammatory infiltrationis dense inflammatory infiltration

• In chronic lung abscess, cavity wall In chronic lung abscess, cavity wall thicker, irregular form, or collapsedthicker, irregular form, or collapsed

图图 72-72-肺脓疡肺脓疡

右肺下叶大块状病灶，其内密度不均匀，可见更低密度的坏死区， CT值约 18Hu

图图 73-73-肺脓疡肺脓疡

病灶实质部分 CT值 60Hu（增强扫描），边缘部分欠清，为隐球菌性肺脓疡

Diagnostic EssentialsDiagnostic Essentials1.1. History of surgery in oral cavity, vomiting in History of surgery in oral cavity, vomiting in

coma status, or aspiration of foreign, or coma status, or aspiration of foreign, or history history of skin injury, carbuncle or furuncle, of skin injury, carbuncle or furuncle, endocarditisendocarditis

2.2. Abrupt onset of rigor, fever, cough with Abrupt onset of rigor, fever, cough with exuberant purulent sputumexuberant purulent sputum

3.3. In Blood RT, WBC counting, NIn Blood RT, WBC counting, N 4.4. X-ray: cavity with liquid plane in dense X-ray: cavity with liquid plane in dense

inflammatory shadow (acute), inflammatory shadow (acute), Multiple loci in Multiple loci in bilateral lungs indicates hematogenous lung bilateral lungs indicates hematogenous lung abscessabscess

5.5. Pathogen examinationPathogen examination

Differentiation DiagnosisDifferentiation Diagnosis

1.1. Bacterial pneumoniaBacterial pneumonia2.2. Infection secondary from pulmonary Infection secondary from pulmonary

TB cavityTB cavity3.3. Bronchial carcinoma with obstructive Bronchial carcinoma with obstructive

bronchitisbronchitis4.4. Infection secondary from pulmonary Infection secondary from pulmonary

cystcyst

• Distinguish inflammatory cavity Distinguish inflammatory cavity from cancerous onefrom cancerous one

1.1. Longer historyLonger history2.2. Slight toxic symptomsSlight toxic symptoms3.3. Less purulent sputumLess purulent sputum4.4. X-ray: centrifugal cavity, the wall is X-ray: centrifugal cavity, the wall is

thicker with irregular marginthicker with irregular margin5.5. Enlarged hilar LN is quite helpfulEnlarged hilar LN is quite helpful

图图 75-75-肺癌肺癌

左下肺肿块灶，向纵隔内生长，增强扫描：左心房（ LA）内见低密度充盈缺损

图图 76-76-肺癌肺癌

左肺下叶癌，左心房内癌栓形成

TreatmentTreatment• AntibioticsAntibiotics1.1. Aspirated or secondary: Aspirated or secondary: anaerobic anaerobic

bacterium, most sensitive to penicillin bacterium, most sensitive to penicillin 2.2. Hematogenous: Hematogenous: staphylococcus or staphylococcus or

streptococcus, primary antibiotics are streptococcus, primary antibiotics are --lactamase resistant penicillins or lactamase resistant penicillins or cephalosporinscephalosporins

3.3. Course: Course: 8~12 weeks till the disappearance 8~12 weeks till the disappearance of cavity and symptoms, or only little of cavity and symptoms, or only little remnant fibrosis leftremnant fibrosis left

• Drainage of grassery juiceDrainage of grassery juice1.1. Position drainage: based on Position drainage: based on

administration of expectorant administration of expectorant or nebulization normal salineor nebulization normal saline

2.2. Flush and aspiration Under Flush and aspiration Under bronchoscopybronchoscopy

Surgery indicationsSurgery indications1.1. Medical treatment over 3 Months, Medical treatment over 3 Months,

cavity not smallercavity not smaller2.2. Cavity >Cavity >5cm5cm3.3. Large amount of hemoptysis, life is Large amount of hemoptysis, life is

EndangeredEndangered4.4. Accompanied with bronchopleural Accompanied with bronchopleural

fistulafistula5.5. Pyemia, ineffective to aspiration and Pyemia, ineffective to aspiration and

flushingflushing6.6. Obstruction of airway, Obstruction of airway, e.g. cancerous e.g. cancerous

obstructionobstruction

BronchiectasisBronchiectasis • Definition: Definition: distention of distal bronchi (distention of distal bronchi (φφ>> 2m 2mm), caused by destruction of muscular & elastim), caused by destruction of muscular & elastic tissue of bronchial wallc tissue of bronchial wall • Characterized Characterized by chronic cough, exuberant purulent sputum or recurrent hemoptysis• History: History: mumps in childhood, pertussis, or bronchial pneumonia• Etiology & Mechanism: Etiology & Mechanism: bronchopulmonary inbronchopulmonary infection and bronchial obstructionfection and bronchial obstruction

EtiologyEtiology• Bronchopulmonary infection – Bronchopulmonary infection – most common in most common in

childhoodchildhood• Common pathogens: pseudomonas aeruginosa,

staphylococcus, hemophilia influenzae, streptococcus pneumoniae, etc

• Bronchial obstruction – Bronchial obstruction – tumor, foreign body or tumor, foreign body or infection. Intraluminal obstruction or extraluminal infection. Intraluminal obstruction or extraluminal oppression. oppression. Middle lobe syndromeMiddle lobe syndrome: atelectasis of : atelectasis of middle lobe caused by bronchial obstructionmiddle lobe caused by bronchial obstruction

• Genetic bronchial developmental Genetic bronchial developmental abnormalityabnormality

• Systemic D: rheumatoid arthritis, Crhon’s D, ulceric Systemic D: rheumatoid arthritis, Crhon’s D, ulceric colitis, systemic lupus erythma, AIDS, yellow nail colitis, systemic lupus erythma, AIDS, yellow nail syndromesyndrome

• Kartagener syndrome: Kartagener syndrome: bronchiectasis caused by genetic bronchiectasis caused by genetic abnormal development of abnormal development of bronchial cartilage and elastic bronchial cartilage and elastic tissue, often accompanied with tissue, often accompanied with sinusitis and visceral rotation sinusitis and visceral rotation (dextrocardia)(dextrocardia)

PathologyPathology

• Styloid (columnar) or cystic distention, may Styloid (columnar) or cystic distention, may be coexistentbe coexistent

• Accompanied with distention of capillary, Accompanied with distention of capillary, distension & anastomose of terminal branches distension & anastomose of terminal branches of bronchial & pulmonary artery of bronchial & pulmonary artery →angioma→angioma

• Recurrent hemoptysisRecurrent hemoptysis• More common in inferior field, more common More common in inferior field, more common

in left I fieldin left I field

Clinical manifestationClinical manifestation

• SymptomsSymptoms1. Chronic cough with exuberant purulent

sputum.2. Recurrent hemoptysis: sometimes, this is the

only symptom3. Recurrent pulmonary infection: in the same

segment, almost incurable 4. Toxic symptoms: fever, anemia and

emaciation

• SignsSigns• Fixed, persistent, and localized Fixed, persistent, and localized

coarse moist rales in inferior field.coarse moist rales in inferior field.• Wheezing is not rareWheezing is not rare• Acropachy in some patients have Acropachy in some patients have

ImagingImaging• X-rayX-ray• Typical changes– tract sign, reflex the shadow Typical changes– tract sign, reflex the shadow

of thickened bronchial wallof thickened bronchial wall• Cystic distention in X-ray: typical imaging is Cystic distention in X-ray: typical imaging is

curled shadow or multiple cellular transparent curled shadow or multiple cellular transparent shadow, liquid plane appears if accompanied shadow, liquid plane appears if accompanied with infectionwith infection

•CTCT• Columnar distention: Columnar distention: bronchial wall bronchial wall

thickenedthickened• Cystic distention: Cystic distention: clusters of cystic clusters of cystic

shadowshadow• High resolution CT (HRCT): High resolution CT (HRCT): show lobule show lobule

structures, replace bronchography in most structures, replace bronchography in most situationssituations

• Bronchography: Bronchography: determine the site of determine the site of bronchiectasis, only used before surgerybronchiectasis, only used before surgery

Circular transparent shadow Cellular, honeycombed

Cystic distention, 囊状支扩

Columnar distention, 柱状支扩

混合状支扩

七、纤维支气管镜检查七、纤维支气管镜检查 有助于对引起有助于对引起局部支气管扩局部支气管扩张的管内肿物、张的管内肿物、结核病灶和异结核病灶和异物的诊断。对物的诊断。对咯血的定位诊咯血的定位诊断及判断感染断及判断感染情况也有重要情况也有重要意义。意义。

Normal Bronchiectasis

Bronchiectasis

Diagnostic EssentialsDiagnostic Essentials1.1.Typical symptomsTypical symptoms2.2.Signs of recurrent infection in a Signs of recurrent infection in a

fixed site, presented as fixed, fixed site, presented as fixed, persistent coarse moist ralespersistent coarse moist rales

3.3.History of respiratory infection History of respiratory infection or systemic D in childhoodor systemic D in childhood

4.4.Confirmed by findings of HRCT & Confirmed by findings of HRCT & bronchographybronchography

Differentiation DiagnosisDifferentiation Diagnosis

1.1. Chronic bronchitisChronic bronchitis2.2. Lung abscessLung abscess3.3. Pulmonary TBPulmonary TB4.4. Congenital pulmonary cystCongenital pulmonary cyst5.5. Disseminated bronchiolitisDisseminated bronchiolitis

• Congenital pulmonary cystCongenital pulmonary cyst• Round or oval shadow with clear margin and Round or oval shadow with clear margin and

thin wall, without inflammatory infiltrationthin wall, without inflammatory infiltration

Principles in TreatmentPrinciples in Treatment• Smooth airwaySmooth airway1.1. ExpectorantExpectorant2. Bronchodilator3. Position drainage4. Aspiration under bronchoscopy• AntibioticsAntibiotics• Surgery indicationsSurgery indications1.1. Recurrent acute respiratory infection or large Recurrent acute respiratory infection or large

amount of hemoptysis, life is endangeredamount of hemoptysis, life is endangered2.2. Ineffective by medical treatmentIneffective by medical treatment3.3. Localized in one lobe or in one sideLocalized in one lobe or in one side4.4. No severe basic DNo severe basic D

ALI & ARDSALI & ARDS• Acute progressive respiratory failure Acute progressive respiratory failure

caused by extra-or intrapulmonary caused by extra-or intrapulmonary factors, excluding cardiac diseases.factors, excluding cardiac diseases.

• 2 stage in one 2 stage in one dynamicdynamic process process• ALI– acute lung injury; ARDS– acute ALI– acute lung injury; ARDS– acute

respiratory distress syndromerespiratory distress syndrome• ALI represents the early moderate stage, ALI represents the early moderate stage,

while ARDS represents the later severe stagewhile ARDS represents the later severe stage• Conception of ALIConception of ALI1.1. Early stage of ARDS. In this stage, pathogen Early stage of ARDS. In this stage, pathogen

directly or indirectly via inflammatory response directly or indirectly via inflammatory response →injury of pulmonary capillary or epithelial cells→injury of pulmonary capillary or epithelial cells

2.2. Indicate that effective treatment may intervene in Indicate that effective treatment may intervene in this stagethis stage

3.3. Benefit for evaluation of efficacy Benefit for evaluation of efficacy

Pathology & Pathology & PathophysiologyPathophysiology• PathologyPathology: : Permeability of pulmonary Permeability of pulmonary

capillary capillary →→congestion, edema and congestion, edema and formation of hyaline membrane, formation of hyaline membrane, accompanied with interstitial fibrosisaccompanied with interstitial fibrosis

• 3 stages: 3 stages: exudation, hyperplasia and exudation, hyperplasia and fibrosisfibrosis, which are always overlapped, which are always overlapped

Etiology & pathogenesisEtiology & pathogenesis• EtiologyEtiology• Intrapulmonary: direct factorsIntrapulmonary: direct factors1.1. PhysiochemicalPhysiochemical2.2. Biological factors, etcBiological factors, etc• Extrapulmonary: indirect factors Extrapulmonary: indirect factors 1. Shock, toxic syndrome caused by severe infection2. Severe trauma (non-thoracic), or burning3. Large amount of transfusion4. Necrotic pancreatitis5. Intoxication of drugs or anesthetics

• PathogenesisPathogenesis• Not very clearNot very clear1.1. Direct injury of alveolar membraneDirect injury of alveolar membrane2.2. Inflammatory response: intermediates & Inflammatory response: intermediates &

cytokines released from inflammatory cellscytokines released from inflammatory cells3333 or disappear of surfactant or disappear of surfactant →aggravate →aggravate

edema & atelectasisedema & atelectasis3333 pulmonary compliance, intrapulmonary pulmonary compliance, intrapulmonary

shunt, abnormal ventilation and gas shunt, abnormal ventilation and gas exchangeexchange

5.5. Abnormal ratio of ventilation/blood flowAbnormal ratio of ventilation/blood flow6.6. Dysfunction of Neuroendocrinal regulationDysfunction of Neuroendocrinal regulation7.7. Obstinate hypoxemiaObstinate hypoxemia

Clinical manifestationClinical manifestation• ALI/ARDS often occurs within 5 days after ALI/ARDS often occurs within 5 days after

onset of primary D, even within 24Hrsonset of primary D, even within 24Hrs• Addition to manifestations of primary D, the Addition to manifestations of primary D, the

earliest symptom is tachypnea, progressively earliest symptom is tachypnea, progressively aggravated with dyspnea and cyanosisaggravated with dyspnea and cyanosis

• Dyspnea is characterized by deep, rapid Dyspnea is characterized by deep, rapid breath with great effort, chest-stressed breath with great effort, chest-stressed feeling, unable to be corrected by oxygen feeling, unable to be corrected by oxygen inhalation, neither interpreted by primary inhalation, neither interpreted by primary pulmonary Dpulmonary D

• Signs: none in early stage, or fine moist Signs: none in early stage, or fine moist rales; in the later stage, moist rales is rales; in the later stage, moist rales is common, bronchophony is not rarecommon, bronchophony is not rare

Laboratory & imaging Laboratory & imaging examinationexamination• Arterial gas analysis: typical changes: Arterial gas analysis: typical changes:

hypoxemia, hypoxemia, PaO2. in ALI, PaO2/ FiO2 PaO2. in ALI, PaO2/ FiO2 (inspiratory O(inspiratory O22 fraction) fraction) 300; in ARDS, 300; in ARDS, PaO2/FiO2 PaO2/FiO2 200 200

• PAOP (pulmonary artery occlusion pressure): N PAOP (pulmonary artery occlusion pressure): N <12mmHg, if >18mmHg <12mmHg, if >18mmHg → left heart failure; 12-18 → left heart failure; 12-18 mmHg mmHg →ALI or ARDS→ALI or ARDS

• X-ray: N in early stage, or slight interstitial X-ray: N in early stage, or slight interstitial changes– changes– pulmonary texture with foggy pulmonary texture with foggy margin; in late stage: flake or lamellar shadow, margin; in late stage: flake or lamellar shadow, bronchial transparency in lamellar shadowbronchial transparency in lamellar shadow

DiagnosisDiagnosis1.1. Existence of high risk factors: Existence of high risk factors:

including direct or indirect factorsincluding direct or indirect factors2.2. Acute onset with typical dyspnea & Acute onset with typical dyspnea &

tachypneatachypnea3.3. Bilateral infiltrated lamellar shadow Bilateral infiltrated lamellar shadow

in chest radiographyin chest radiography4.4. in ALI, PaO2/ FiO2 in ALI, PaO2/ FiO2 300; in ARDS, 300; in ARDS,

PaO2/FiO2 PaO2/FiO2 200 2005.5. PAWPPAWP18mmHg, or excluding 18mmHg, or excluding

cardiac pulmonary edema clinicallycardiac pulmonary edema clinically

TreatmentTreatment• AimAim1.1. Improve oxygenation, correct Improve oxygenation, correct

hypoxemiahypoxemia2.2. Protect pulmonary functionProtect pulmonary function3.3. Prevent complicationsPrevent complications

• MeasurementsMeasurements1.1. SurveillanceSurveillance2.2. Treat primary systemic disorders– keyTreat primary systemic disorders– key3.3. Oxygen therapy – mechanical ventilation Oxygen therapy – mechanical ventilation

PEEP (positive end-expiratory pressure), PEEP (positive end-expiratory pressure), PaO2 PaO2 ≥ ≥ 60mmHg or SaO260mmHg or SaO2≥≥90%90%

4.4. Supportive: infusion managementSupportive: infusion management5.5. Balance acid-base and electrolyte Balance acid-base and electrolyte

disorders,disorders,