Suppurative Lung DIsease

8/13/2019 Suppurative Lung DIsease

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By

Dr. Eman Arram


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Bronchiectasis is an abnormal

permanent dilatation of the mediumsized cartilagenous bronchi,

accompanied by variable destruction of

muscular and elastic components of

the bronchial walls. It may be

congenital or acquired. It may be focalor diffuse.


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It is a syndrome & characterized by

cough and expectoration that is

usually copious and related to

posture and time

It includes:

Bronchiectasis

Lung abscess

Empyema with bronchopleural fistula

Infected cystic lung


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Dilatation of medium sized

subsegmental bronchi from about the

4th to 9th generations and filling with

purulent secretions or mucus plugs.

Bronchial wall inflammation and

destruction and replacement of the all

components of the wall by fibrous

tissue.


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Pathogenesis:

Initiating factors for bronchiectasis:

Infection

Bronchial obstruction

Fibrosis


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Site: Bilateral in 30% of patients.

Left lower lobe > Rt lower lobe (>3 times). Left LL posterior basal segments is almost

always affected then lingula then Rt LL thenmiddle lobe.

The particular lobes affected may sometimesbear a relationship to underlyingpredisposition:

Upper lobe bronchiectasis is often 2ry to TB,lung abscess or cystic fibrosis.

Middle lobe bronchiectasis in TB.

Central bronchiectasis in ABPA.

Bronchiectasis due to FB aspiration is more inthe Rt LL or in post segment of UL.


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Classification (Reids classification) Cylindrical (tubular)

Cystic (saccular)

Varicose

Fusiform


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A) Congenital and hereditary disorders: Primary ciliary dyskinesia syndromes (PCD).

Cystic fibrosis

Alpha1 anti-trypsin deficiency

Tracheomalacia

Tracheobronchomegally Intralobar bronchopulmonary sequestration

Immunodeficiency syndromes

Yellow nail syndrome

Aetiology of Bronchiectasis


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Kartagners syndrome:

Bronchiectasis. Sinusitis or absent frontal air

sinuses

Situs inversus

Youngs syndrome:

Recurrent pulmonary infections

predisposing to bronchiectasis

Sinusitis

Infertility (obstructive azospermia)


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B) Acquired bronchiectasis:

1- Post-infection:

Bacterial: klebsiela pneumonia, S.

aureus, B. pertussis.

Mycobacteria.

Mycoplasma.

Viruses as infleunza, adenoviruses,

herpes simplex, measless and HIV.

Fungi eg histoplasmosis.


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2- Bronchial obstruction:

Endobronchial: FB, tumor, mucoid impaction.

Extrabronchial compression: LN, tumor, aneurysm.

Bronchial stenosis.

3- Chronic obstructive pulmonary disease.

4- Inhalation / Aspiration injury:

Inhalation of irritants such as ammonia, NO2, smoke

and toxic fumes.

Heroin use. Aspiration of gastric contents.

Recurrent aspiration pneumonias, alcoholism,

neurologic disorders, lipoid pneumonia.


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5- Autoimmune diseases:

Inflammatory bowel disease. Coeliac disease.

SLE.

Rheumatoid arthritis. Cryptogenic fibrosing alveolitis.

Primary biliary cirrhosis.

Thyroiditis.

Pernicious anemia.

.


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Clinical presentation of

bronchiectasis: Chronic cough with copious amount

of foul-smelling sputum more in the

morning and on leaning forwards with

characteristic winter exacerbations.

Dyspnea.

Chest pain.

Haemoptysis.


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Wheezy chest.

Concomitant sinusitis in some cases.

General manifestations: fever, weight

loss, growth retardation, GIT troubles.

Clubbing of the fingers and may be

HPOA.

Oedema LL.


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Complications of bronchiectasis:

Recurrent haemoptysis, pneumoniaand pleurisy are common.

Lung abscess and metastatic brain

abscess.

Amyloidosis.

Cor pulmonale and respiratoryfailure.


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1) Chest radiography:

Investigations

Tooth past or gloved finger

appearance.

Tramlines appearance. Honeycoomb or soap bubble

appearance in cystic bronchiectasis.


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2) Bronchography:

It was the investigation of choice.

3) HRCT chest:

Is now the favored investigation of

establishing the diagnosis ofbronchiectasis.

Cylindrical bronchiectasis appears as

uniformly dilated airways.

Signet ring sign: dilated bronchi appear

as ring structures with internal diameters

greater than those of their accompanying

pulmonary artery branches.


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Bronchogram showing cystic

bronchiectasis


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4) Fiberoptic bronchoscopy:

Evaluation of patients with recurrenthaemoptysis.

Perform more selective segmental

bronchography.

5) Sputum culture and sensitivity:

H.influenza, S.pneumoniae, moraxella

catarrhalis, staphyloccocus aureus,

klebsiella pneumonia, pseudomonas

aeruginosa, adenovirus and anaerobes.


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6) Pulmonary function tests:

Obstructive ventilatory defect is the

predominant defect usually mild.

Preoperative evaluation of patients.

7) Other investigations: Sweat chloride test in CF.

Serum immunoglobulins.

ECG evidence of cor pulmonale inadvanced disease.

CBC anaemia and leucocytosis.


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A) Medical treatment:

1) Postural drainage:

Gravitational drainage of accumulated sputum in

the bronchiectatic area facilitated by directpercussion, mechanical percussors and vibrators.

Treatment


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2) Antimicrobial therapy:

Amoxycelline 250mg TDS for 2 weeks may be

increased to 3 gm twice daily in severe cases.

Ofloxacin 200 mg twice daily for 10-15 days.

Clarithramycin 250 mg twice daily for 10 days.

Tetracyclines.

B lactam antibiotics e.g. amoxycelline

clavulinic acid.

Antistaph, antipseudomonal antibiotics.

Nebulized antibiotics for pseudomonas

aeruginosa.


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3) Expectorants and mucolytics.

4) Bronchodilators.

5) Corticosteroids: when there is failure

to obtain an adequate response to

bronchodilators.6) Human gamma globulin: IM 25 mg/kg

weekly or 2 weekly intervals in patients

with immunodeficiency syndromes.7) Vaccination: by influenza and

pneumoccocal vaccine specially in

children.


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B) Surgical treatment:

Indications: The diagnosis has been confirmed with

bilateral bronchogram or HRCT.

Localized disease to one lung or part ofthe lung.

Significantly disturbed patient by

recurrent infective exacerbation orhaemoptysis despite medical treatment

over a period of at least 12 months.


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Good pulmonary function. No systemic causal factor.

Patient is less than 40 years.

Surgical maneuvers include either

segmentectomy, lobectomy or even

pneumonectomy.


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C) Embolotherapy:

Bronchial artery embolization to control

massive or recurrent haemoptysis for

patient not candidates for surgery.


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Thank you forattention

Suppurative Lung DIsease

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