Chronic Pulmonary Infection
Dr Tom Fardon
Respiratory SpR
Diagnosis?
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Shadow on CXR
Weight loss
Persistent sputum production
Chest pain
Increasing shortness of breath
Differential Diagnosis
• Lung Cancer
– Not unreasonable
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Intrapulmonary abscess
Empyema
Bronchiectasis
Cystic Fibrosis
Intrapulmonary Abscess
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Indolent presentation
Weight loss common
Lethargy, tiredness, weakness
Cough ± sputum
High mortality if not treated
Usually a preceding illness of some sort
Preceding Illnesses
• Pneumonia
• Aspiration pneumonia
– Vomiting
– Lowered conscious level
– Pharyngeal pouch
• Poor host immune response
– Hypogammaglobulinaemia
Pathogens
• Bacteria
– Streptococcus
– Staphylococcus (Particularly post ‘flu)
– E-Coli
– Gram Negatives
• Fungi
– Aspergillus
Empyema
Empyema
• Pus in the pleural space
• 57 % of all patients with pneumonia
develop pleural fluid
• Remainder are “Primary Empyema”,
usually iatrogenic
• High mortality
– As high as severe pneumonia
– > 20 % of all patients with empyema die
Progression of Effusion to
Empyema
• Simple Parapneumonic Effusion
– Clear fluid
– pH > 7.2
– LDH < 1000
– Glucose > 2.2
• Complicated Parapneumonic Effusion
– pH < 7.2
– LDH > 1000
– Glucose < 2.2
– Requires Chest Tube Drainage
• Emyema
– Frank pus
– No other tests required
– Requires Chest Tube Drainage
Bacteriology
• Aerobic organisms most frequently
• Gram Positive
– Strep Milleri
– Staph Aureus
• Usually post operative, or nosocmial
• Immunocomprimised
• Gram Negatives
– E-Coli
– Pseudomonas
– Haemophilus Influenzae
– Kelbsiellae
• Anaerobes in 13 % of cases
– Usually in severe pneumonia, or poor dental hygiene
Diagnosis
• Clinical suspicion
–The slow to resolve pneumonia
–Don’t forget the lateral chest film
• CXR
–Persisting effusion, particularly if loculations visible
• USS
–The preferred investigation
–Simple, bedside test
–Targetted sampling
• CT
–Differentiation between Empyema and Abscess
CXR
• Some obvious
• Not always this large
• Look for D sign
• As always, better xrays increase
sensitivity, and
specificity
CXR - D Sign
Lateral CXR
• Particularly useful in
small retrodiaphragmatic
collections
• Not straightforward
in ICU
USS
USS in Empyema
CT Examination of Pleural Space
Empyema CT
Use USS or CT to position the
drain site
Insertion of a
Surgical Drain
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Trocar
Introduction
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Insertion of
a Seldinger
Drain
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Insertion of a Seldinger Drain
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Other Treatment
• IV antibiotics
– Broad spectrum
– Co-amoxyclav initially
• Oral antibiotics
– Directed towards cultured bacteria
– At least 14 days
Summary
• Empyema is bad, and best avoided
• Detection of complicated pleural effusion
requires sampling of the effusion
• Ultrasound guidance is preferred, but not
always needed
– “Any body cavity can be reached with a green
needle and a good strong arm”
• Small bore seldinger type drains are
preferred initially
Treatment Options
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Stop smoking
‘Flu vaccine
Pneumococcal vaccine
Reactive antibiotics
– Send sputum sample
– Give antibiotics appropriate to most recent
positive culture
Treatment
• When colonised with persistent
bacteria
– Prophylactic antibiotics
– Nebulised colomycin
– Pulsed IV abx
– Alternating oral antibiotics
Anti-inflammatory Treatment
• Low dose macrolide antibiotics have
been shown to reduce exacerbation
rates in bronchiectasis
– Clarithromycin 250 mg OD
Prognosis
• Recurrent infection
• Abscesses and empyema
• Colonisation
Cystic Fibrosis
• Congenital cause of bronchiectasis
• And much more
CF Incidence, Prevalence and
Survival
• Carrier rate of 1 in 25
• Incidence of 1 in 2,500 live births
• By 2002 the number of adult patients
exceeded the number of children
• Carrier screening may influence numbers
(Cunningham & Marshall 1998)
• Those born in the 1990’s have a predicted
survival into the 40’s
Tayside Caseload
(annual report 4/00 - 3/01)
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36 patients registered
3 patients on active transplant list
3 patients not suitable for transplant
2 deaths
Case Study
• Diagnosed at 10 months with
steatorrhea and LRTI
• Stable until 13 when she required
increasingly frequent IV’s
• Pregnancy 1996 - TOP @ 16 weeks
• Since 1998 she has suffered more
frequent exacerbations and now
requires IV’s monthly
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Oxygen dependent
Abnormal liver function
Occasional episodes of DIOS
Button gastrostomy inserted
Transplant assessment Dec 2000
Overnight BiPAP from June 2001
Difficulty in controlling pain and nausea
• Bi-lateral lung transplant Sept 2001
• June 2006 - severe pneumonia
• Admitted to ICU
• Large blood clot extracted from right
main bronchus
– Organising pneumonia
• Still an in patient in ward 3
• Colonised with 3 distinct varieties of
pseudomonas and MRSA
• Ongoing IV antibiotics
Specialities Involved
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Respiratory
Gastro-Intestinal
Obs & Gynae
GP/DN
Surgery
Transplant team
Child & Family
Psychiatry
• ICU
• Anaesthesia
Summary
• Chronic infection can mimic malignancy
• Chronic infection can have a similar
prognosis if untreated
• Have a high index of suspicion,
particularly when simple infection is not
clearing