2. DEFINITION:
Lung abscess: A localized cavity with pus, resulting from
necrosis of lung tissue, with surrounding pneumonitis. A lung
abscess may be putrid (due to anaerobic bacteria) or
nonputrid (due to anaerobes or aerobes). "Gangrene of the
lung" denotes a similar though morediffuse and extensive
process in which necrosis predominates.
In acute lung abscess the duration is less than weeks and pus
has thin wall
Acute lung abscess
4. Clinical feature of acute lung abscess
1st period – before opening an abscess
(it lasts from 3-4 days to 2-4 weeks)
2nd period – after opening (when
abscess perforates a bronchus)
5. General inspection: diffuse cyanosis, clubbed
fingernails, forced posture lying on the affected side.
Inspection of chest: lagging of the affected side of chest;
dyspnea, tachypnoe.
Palpation of the chest: chest pain on the affected side,
intensified vocal fremitus.
Percussion of the lung - dull sound.
Auscultation: bronchial or diminished vesicular
breathing.
Bronchophony: intensified.
Egophony - heard a phonetic "ā" ('ay').
1st period clinial signs
6. 2nd period clinical signs
Complaints:
- cough with purulent sputum in large amounts «full
mouth» - till 2 liters per day (purulent sputum, three
layers, hemoptysis or streaked with blood, may be
expectorate over a few hours or several days);
- putrid odor;
- inspiratory dyspnea;
- chest pain on the affected side (in involving the
pleura);
- general complaint: weakness.
8. CLASSIFIATION ACCORDING TO PATHOGENISIS;
• suction abscesses (including obstructive);
• pneumonic abscesses;
• embolic hematogenous abscesses;
• Post-traumatic abscesses;
• lymph node abscesses.
CLASSIFIATION ACCORDING TO LOCALIZATION:
• abscess central (basal);
• abscess peripheral (cortical, subpleural)
dAcute lung abscess
9. Classification:
PRIMARY ABSCESS:
which develops as a result of primary infection of the lung. They most
commonly arise from aspiration, necrotising pneumonia or chronic
pneumonia (pulmonary TB).
SECONDARY ABSCESS:
In lung tissue affected by: existing lung disease, metastatic tumors, lung
carcinoma, foreign body, infarction,emphysema.
Acute lung abscess
11. Total blood count: neutrophylic hyperleukocytosis, shift
to the left, to the myelocytes, significantly ↑ ESR,
possible anemia.
Sputum examination
Macroscopically: large amounts, three layers, unpleasant
odor, purulent sputum, may be mixed with blood.
Microscopically: contains a large number of leucocytes,
neutrophils, erythrocytes, can be elastic fibers.
Dietrich's plugs (composed of cellular decomposition
various bacteria, droplets of fat, fatty acid crystals)
Laboratory diagnosis
12. Instrumental diagnosis
Chest X-ray :
a cavity in the lung tissue horizontal level of the
liquid, the connection with the bronchi, infiltration of
tissue around the cavity.
14. Instrumental diagnosis
Spirometry:
decrease of the vital capacity, total lungs
capacity;
forced expiratory volume in the first second
(FEV1), Tifno index (FEV1/FVC) and flow
rate of gases during breathing
(pneumotachometer) unchanged.
15. Conservative treatment :
Antibiotics based on drug sensitivity-
6-8 weeks
Supported by chest physiotherapy and
bronchoscopic aspiration
Acute lung abscess
16. THERAPY:
It is thought that lung abscess in its early stage can regress
spontaneously in approximately 20-30% of cases.
If conservative treatment is ineffective or complications are observed
adequate invasive or surgical treatment should be initiated.
It is estimated that invasive treatment by intercostal tube drainage or
surgery is indispensable in 11-12% of patients in whom antibiotic
therapy was ineffective.
Acute lung abscess
17. INVASIVE THERAPY:
INJECTION OF THERAPEUTIC AGENTS DIRECTLY INTO AN ABSCESS
CAVITY:
The abscess is punctured through the chest wall and antibiotics are injected directly
into its cavity. This method is suitable for large peripheral abscesses where the
visceral and parietal pleura are accreted. The method is burdened with a risk of
pneumothorax or empyema formation.
ENDOSCOPIC ABSCESS EVACUATION:
If lung abscess is a result of pathology of the bronchial tree with its obstruction and
retention of septic debris within bronchi distally to the level of obstruction
bronchoscopy is an effective technique for abscess evacuation. The abscess
evacuation can be completed by the injection of antibiotic into the abscess cavity.
Acute lung abscess
18. INVASIVE MANAGEMENT:
CAVERNOSTOMY:
A method used in selected cases of lung abscess (Monaldi procedure). Obliteration
of the pleural cavity is an indispensable condition to perform this procedure. Short
fragments of two or three ribs are resected over a place where the distance between
an abscess capsule and the chest wall is the shortest. The surface of the lung is
visualized and the abscess cavity is opened. Then the abscess cavity is packed with
gauze saturated with an antiseptic solution. The gauze is changed regularly for
several weeks until the process of healing and contraction of a lung defect is
obtained.
PERCUTANEOUS CATHETER DRAINAGE
Percutaneous catheter drainage of lung abscess under fluoroscopic or computed
tomography guidance is a technique introduced into medical practice during last
three decades and brings relatively good results in selected cases. The limitation of
this method is a localization of an abscess near important anatomical structures that
makes an introduction of a catheter hazardous. The technique is burdened with some
serious complications such as pneumothorax accompanied by a brocho-pleural
fistula, pleural empyema, hemorrhage and cardiac arrest.
Acute lung abscess
21. Surgical treatment:
METHODS OF SURGICAL TREATMENT:
A type of resection of pulmonary parenchyma is dependent on
localization and size of abscess and a patient’s general state
• Non-anatomical resection (wedge or marginal)
• Anatomical resections: (segmentectomy, lobectomy,
pneumonectomy)
Acute lung abscess
22. NON-ANATOMICAL LUNG RESECTION
Marginal or wedge pulmonary parenchyma resection for abscesses
using linear staplers: TA and GIA type is effective for small lesions
localized peripherally.
ANATOMICAL LUNG RESECTION
Large lung abscesses, abscesses localized deeply in pulmonary
parenchyma and multiple lung abscesses are all indications for
anatomical resections. The most frequent procedures are resections of
a pulmonary lobe (lobectomy) or resection of two pulmonary lobes
of the right lung (bilobectomy). In the cases of solitary abscess or
multiple abscesses with vast destruction of the lung the resection of
the whole lung (pneumonectomy) is sometimes necessary. Local
conditions rarely enable less extensive surgical procedures such as
semisegmentectomy or bisegmentectomy.
Acute lung abscess
23. METHODS OF SURGICAL TREATMENT :
VATS (Video Assisted Thoracic Surgery)
A method that is a combination of minithoracotomy and videothoracoscopic
technique (video telescope and endoscopic instruments). It enables resection of
some small, peripherally localized abscesses.
DECORTICATION + LUNG RESECTION
A method used for the treatment of lung abscesses accompanied by pleural
empyema. Decortication consists in the removal of a thick fibrinopurulent coat
from the lung surface. Besides it the part of a pleural empyema capsule that covers
the internal surface of the chest wall is also resected along with the parietal pleura.
The procedure is completed by resection of pulmonary parenchyma with abscess.
LUNG RESECTION + IRRIGATING DRAINAGE
A procedure used in the cases of lung abscess coexisting with acute pleural
empyema. When pulmonary parenchyma with lung abscess is resected two or three
tubes are introduced into the pleural cavity and continuous irrigating drainage with
antibiotic or antiseptic solution is carried out.
Acute lung abscess
