2. Diseases of the lungs occupy one of the leading
places among all causes of the pediatric
morbidity and mortality. The most frequent
pulmonary disease is a pneumonia. The majority
of the patients with pneumonia are treated by
pediatrics, but sometimes the course of
pneumonia are followed with
complications, required the surgical
interventions. This is a bacterial destructive
pneumonia.

3. Route of infection:
 1. Primary – by an aerogenous route
through the bronchi
 2. Secondary - by hematogenous route
from other purulent focus.
Infecting agent:
 1. Gram-negative.
 2. Gram-positive.
 3. Mixed flora.

4. 1. Pulmonary:
a) abscess,
b) blebs (residual cavities).
2. Pleural:
a) exudative pleuratis,
b) pyothorax – local and total,
c) pneumothorax – tension and non-
tension,
d) pyopneumothorax – tension and non-
tension.
 3. Emphysema of mediastinum.

5. Microbes, reaching the
pulmonary tissue, begin to
produce the different toxins
(one of them – necrotoxin) and
proteolytic ferments, which
cause the tissue necrosis and
formations of the purulent
cavities. These cavities join and
form the pulmonary abscess.

6. The clinical course of the abscess
has two stages. The first one
(formation of abscess or
undrained abscess) is followed
with severe clinical symptoms of
the respiratory insufficiency and
intoxication: shortness of
breath, tachypnea, cyanosis, tac
hycardia, high temperature, raised
white blood cells (WBC) level and
erythrocyte sedimentation rate
(ESR).

7. The X-ray shows the round
shadow, that occupies a few
segments or entire pulmonary
lobe. If conservative treatment
(antibiotherapy, disintoxication) is
ineffective, the puncture of the
undrained abscess is indicated.

9. The second stage of the
abscess is a drained abscess.
Usually the abscess drains into
the bronchi, what is followed
with the violent cough with pus,
decreased temperature and
improvement of the patient
condition.

10. If the bronchial fistula within the
bronchus and abscess cavity is
wide and the pus leaves the cavity
rapidly the conservative treatment
is used. This includes the
antibiotherapy, bronchiolitic
inhalation, expectorants, postural
drainage. Adequate drainage of
the lung abscess often is achieved
through postural drainage and
chest physiotherapy. The use of
bronchoscopy to drain an abscess
is controversial.

11. After the successful
treatment of the pulmonary
abscesses the residual air-
filled cavities (blebs) are
present into the lung. These
cavities need no special
treatment and usually
disappear in 3 – 4 months.

12. The pneumonia almost always
is followed with a serous
exudate accumulation in
pleural cavity. In case of the
destructive pneumonia the
suppuration of the exudate
happens and it becomes
purulent. This is a pyothorax
(the pus accumulation in the
pleural cavity).

13. The pyothorax is most frequent
complication of the bacterial
destructive pneumonia. If
auscultating a child with severe
pneumonia (respiratory
insufficiency, fever, intoxication)
you found the weak or absent
breath sounds and don't
hear the moist rales, this usually
means a presence of the pus
into pleural cavity.

14. At the roentrenograms
the lung field
shadow (local or
total) is visible. This
shadow closes the
pleural sinus and has
an oblique upper
line. In case of the
total pyothorax the
upper line reaches
the pleural top.

15. To confirm the diagnosis the
pleural puncture at the 6th or 7th
intercostal space by linia axillaris
media or posterior should be
done. Presence of the pus in the
pleural cavity confirms the
diagnosis of pyothorax, what
indicates a necessity for the
pleural tube insertion (drainage of
the pleural cavity).

17. Sometimes the abscess cavity
empties into the pleural cavity
with formation of the bronchial
fistula between the bronchus and
pleural cavity. This situation leads
to pus and air accumulation into
the pleural condition. This
complication is known as
pyopneumothorax. This is
complication is more severe than
the pyothorax.

18. In this case the severe condition of the
patient with pneumonia deteriorates
significantly and may be life-threatening. The
dyspnea increases, cyanosis and
apprehension appear, the accessory muscle
help to breathe. The auscultation reveal the
absence of breath sounds, although a few
hours before the moist rales and coarse
breath sounds were heard. During the
percussion the tympanic sound, which
indicates presence of the air, is found. The
tension pyopneumothrax is followed with
progressive air accumulation in the pleural
cavity, what causes the mediastinum and
heart shift to the opposite side.

19. The tension pyopneumothrax is followed
with progressive air accumulation in the
pleural cavity, what causes the
mediastinum and heart shift to the
opposite side. The tension
pyopneumothorax is life-threatening
condition, causing the acute cardiac
and respiratory insufficiency. The X-ray
shows the the air and pus presence into
the pleural cavity with a clear horizontal
line between them. The lung is
compressed.

21. In the case of the tension
pyopneumothorax the shift of
the mediastinum and heart to
the healthy side is visible. The
treatment in this case is
emergency and includes the
pleural tube insertion. The
system of the passive aspiration
should be applied.

22. In case of the pneumothorax the
air accumulates it the pleural
cavity. Like the pyopneumothorax
it may be tension and non-tension
and requires the puncture of the
pleural cavity to remove the air.
The puncture is done at the 2nd or
3rd intercostal space by linia
subclavia media. Sometimes a few
puncture should be done.

23. The emphysema of mediastinum is a
rare complication of the bacterial
destructive pneumonia. The presence
of the air in the mediastinum is always
followed with its spread to neck, where
the subcutaneous emphysema is
visible. This symptom and X-ray, which
shows the presence of air in the
mediastinum, allow to make a correct
diagnosis. The local treatment of the
emphysema is a suprajugular
mediastinotomy and drainage of the
mediastinum.

24. X-ray
symptom, which
shows the
presence of air
in the
mediastinum

25. All these complication of the pneumonia
require a general treatment as well, as
mentioned above local treatment. The
general treatment includes the
antibiotherapy, infusion therapy,
symptomatic therapy. The antibiotherapy
is begun with wide-spread antibiotics,
then this therapy is adjusted due to results
of the microbial sensitivity. The
intravenous route for antibiotherapy is
preferable. Quite often the children with
bacterial destructive pneumonia need
the oxygen. The nasal cannulas or oxygen
tent are used for this purpose. The severe
cases may require the ventilator support.

26. Pleural effusion, a collection of
fluid in the pleural space, is rarely
a primary disease process but is
usually secondary to other
diseases. Normally, the pleural
space may contain a small
amount of fluid (5 to 15 ml) acting
as a lubricant that allows the
visceral and parietal surfaces to
move without friction.

27. In certain intrathoracic and
systemic diseases, fluid may
accumulate in the pleural space
to a point where it becomes
clinically evident, and it is almost
always of pathologic significance.
The effusion can be a relatively
clear fluid, which may be a
transudate or an exudate, or it
can be blood, pus, or chyle.

28. The secondary pneumonia
develops as a complication of
other purulent diseases. The most
common among these diseases is
an osteomyelitis. Usually the
bacterias reach the lungs through
the hematogenous route. Such
pneumonia have a double-side
localization and may be followed
with any above-mentioned
complication
(pyothorax, pyopneumothorax)

29. A transudate (filtrates of plasma that
move across intact capillary walls)
occurs when factors influencing
formation and reabsorption of
pleural fluid are altered, usually by
imbalances in hydrostatic or oncotic
pressures. A transudate indicates
that a condition such as ascites or a
systemic disease such as congestive
heart failure or renal failure underlies
the fluid accumulation.

30. An exudate (extravasation of fluid
into tissues/ cavity) usually results
from inflammation by bacterial
products or tumors involving the
pleural surfaces.

31. Pleural effusion may be a
complication of
tuberculosis, pneumonia, congesti
ve heart failure, pulmonary viral
infections, and neoplastic tumors.
Bronchogenic carcinoma is the
most common malignancy
associated with a pleural effusion.

32. Usually the clinical manifestations are those
caused by the underlying disease, pneumonia
will cause fever, chills, and pleuritic chest
pain, whereas malignant effusion may result in
dyspnea and coughing. A large quantity of
pleural effusion will cause shortness of bread
with dullness or flatness to percussion over
areas of fluid with minimal or absence of
breath sounds.

33. Egophony will be present
above the effusion. Tracheal
deviation away from the
affected side may occur with
significant accumulation of
pleural fluid.

34. The presence of fluid is confirmed
by chest X-ray, ultrasound,
physical examination, and
thoracentesis. Pleural fluid is
analyzed by bacterial cultures,
Gram stain, acid-fast bacillus stain
(for tuberculosis), red and white
blood сell counts, blood
chemistry studies (glucose,
amylase, lactic dehydrogenase,
protein), and pH.

35. Pleural effusion Pleural empyema

36. The objectives of treatment are to
discover the underlying cause to
prevent fluid collection from
recurring, and to relieve
discomfort and dyspnea. Specific
treatment is directed to the
underlying cause.

37. Thoracentesis is performed to remove
fluid, to collect a specimen for analysis, and
to relieve dyspnea. If the underlying cause
is a malignancy, however, the effusion may
recur within a few days or weeks. Repeated
thoracenteses result in pain, depletion of
protein and electrolytes, and sometimes
pneumothorax. In this event the patient
may be treated with chest tube drainage
connected to a water-seal drainage system
or suction to evacuate the pleural space
and re-expand the lung. Sometimes
tetracycline, radioactive isotopes, or
cytotoxic or other chemically irritating drugs
are instilled in the pleural space to
obliterate the pleural space and prevent
further accumulation of fluid.

38. After drug instillation, the chest tube is
clamped and the patient is assisted to
assume various positions to ensure uniform
drug distribution and to maximize drug
contact with the pleural surfaces. The tube is
unclamped chest drainage is usually
continued several days longer to prevent
accumulation of fluid and to facilitate
obliteration of the pleural space by formation
of adhesions between the visceral and
parietal pleurae. Other modalities of
treatment for malignant pleural effusions
include radiation of the chest wall, surgical
pleurectomy, and diuretic therapy. If the
pleural fluid is an exudate, more extensive
diagnostic procedures are performed to
determine the cause.

39. Pyopneumothorax

40. The secondary pneumonia develops
as a complication of other purulent
diseases. The most common among
these diseases is an osteomyelitis.
Usually the bacterias reach the lungs
through the hematogenous route.
Such pneumonia have a double-side
localization and may be followed with
any above-mentioned complication
(pyothorax, pyopneumothorax).

43. Thank you for attention !!!