Lung Abscess & Spontaneous Pneumothorax
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Ananth Sai BadetiLung Abscess & Spontaneous Pneumothorax
Uploaded by
Ananth Sai BadetiASTANA Medical
University
Lung Abscess & Spontaneous pneumothorax
Prepared by: B.Ananth
Sai Roop Sagar
Group no: 485
Lung abscess
A localized collection of pus and necrotic tissue within lung parenchyma caused by
microbial infection
Risk factors
Predisposition to aspiration due to reduced level of consciousness (see risk factors for “Aspiration
pneumonia” above)
Bronchial obstruction (e.g., lung cancer, foreign body aspiration, bronchial stenosis)
Immunocompromised state
Pneumonia
Pathogens
Most commonly: mixed infections caused by anaerobic bacteria that colonize the oral cavity (e.g.,
Peptostreptococcus, Prevotella, Bacteroides, Fusobacterium spp.)
Less commonly: monomicrobial lung abscess caused by S. Aureus, Klebsiella pneumoniae,
Streptococcus pyogenes, Streptococcus anginosus
Clinical findings:
indolent presentation with symptoms that evolve over weeks to months
Fever
Cough with production of foul-smelling sputum
Anorexia, weight loss
Night sweats
Hemoptysis
Diagnosis
Gram stain, culture, and sensitivity of expectorated sputum
Radiologic imaging (x-ray or CT scan): irregular rounded cavity with an air-fluid level
that is dependent on body position (most commonly in the right lung)
Upright position: right lower lobe
Recumbent position: right upper or middle lobe
Management
Antibiotic treatment that covers anaerobes (e.g., ampicillin-sulbactam, carbapenems, or
clindamycin )
If medical therapy fails, percutaneous catheter drainage or surgical resection (e.g.,
segmentectomy or lobectomy) may be considered.
Spontaneous pneumothorax
Primary spontaneous pneumothorax: occurs in patients without clinically apparent
underlying lung disease.
Secondary spontaneous pneumothorax: occurs as a complication of underlying lung
disease
Recurrent pneumothorax: a second episode of spontaneous pneumothorax, either
ipsilateral or contralateral
Etiology
Primary (idiopathic or simple pneumothorax)
Caused by ruptured subpleural apical blebs
Risk factors
Family history
Male sex
Young age
Asthenic body habitus (slim, tall stature) (e.g., in Marfan syndrome)
Smoking (90% of cases): up to 20-fold increase in risk (risk increases with the cumulative number
of cigarettes smoked)
Homocystinuria
Secondary (pneumothorax as a complication of underlying lung disease)
COPD (smoking) → rupture of bullae in emphysema
Infections
Pulmonary tuberculosis
Pneumocystis pneumonia → alveolitis, rupture of a cavity
Cystic fibrosis → bronchiectasis with obstructive emphysema and bleb or cyst rupture
Marfan syndrome
Malignancy
Catamenial pneumothorax (thoracic endometriosis): extremely rare
Pathophysiology
Increased intrapleural pressure → alveolar collapse → decreased V/Q ratio and increased
right-to-left shunting.
Spontaneous pneumothorax: rupture of blebs and bullae → air moves into pleural
space with increasing positive pressure → ipsilateral lung is compressed and collapses
Clinical features
Patients range from being asymptomatic to having features of hemodynamic
compromise.
Sudden, severe, and/or stabbing, ipsilateral pleuritic chest pain and dyspnea
Reduced or absent breath sounds, hyperresonant percussion, decreased fremitus on the
ipsilateral side
Subcutaneous emphysema
Diagnostics
The diagnosis of pneumothorax is usually confirmed by chest x-ray.
Ultrasound is becoming an increasingly accepted modality for identifying pneumothorax
and is part of the eFAST. [ref][ref]
CT can provide information about the underlying cause (e.g., bullae in spontaneous
pneumothorax).
Imaging
Chest x-ray
Indications: all patients suspected of having pneumothorax
Procedure: Upright PA chest x-ray in inspiration is the modality of choice. [ref][ref]
Supportive findings of pneumothorax
Ipsilateral pleural line with reduced/absent lung markings (i.e., increased transparency)
Abrupt change in radiolucency
Deep sulcus sign
Decreased radiodensity and deep costophrenic angle on the ipsilateral side [ref]
The sign is a result of interpleural air that collects basally and anteriorly in the supine position.
Hemidiaphragm elevation on the ipsilateral side
If pulmonary disease is present: airway or parenchymal lesions
Ultrasound
Indications
Trauma (eFAST)
Quick bedside assessment
Supportive findings [ref]
Absence of pleural sliding
Absence of B-lines
Combination of prominent A-lines and absent B-lines
Chest CT
Indications
Uncertain diagnosis despite chest x-ray and complex cases
In suspected underlying lung disease, to determine the likelihood of recurrent
disease
Detailed assessment of bullae
Presurgical workup
Findings: similar to CXR
Laboratory studies
Laboratory analysis is generally not indicated.
Arterial blood gas analysis (ABG)
Indications
SpO2< 92% on room air
Evaluation for CO2 retention in patients with lung disease (e.g., COPD) receiving
supplemental O2
Findings: ↓ PaO2 may be present
Treatment
Assess patient stability
Provide respiratory support and treat dyspnea.
Stability criteria for spontaneous pneumothorax:
All of the following must be present for the patient to be considered stable:
Respiratory rate < 24 breaths/minute
SpO2 (room air): > 90%
Patient able to speak in complete sentences
HR 60–120/minute
Normal BP
All other patients are considered unstable.
Respiratory support:
Upright positioning
Provide supplemental high-flow oxygen as needed (target SpO2 ≥ 96%).
If a patient requires mechanical ventilation, emergency chest tube placement is indicated.
Positive pressure ventilation can turn a simple pneumothorax into a life-threatening tension
pneumothorax.
Decompression of a pneumothorax can sometimes rapidly improve dyspnea, making
mechanical ventilation unnecessary.
Airway management
Oxygen therapy
Primary spontaneous
pneumothorax (stable patient)
Apex-to-cupola distance < 3 cm
Usually resolves spontaneously within a few days (∼ 10 days)
Serial follow-up with repeat chest x-ray
Repeat CXR after observation for 3–6 hours to exclude progression prior to discharge.
Consider outpatient management with follow-up within 2 days.
Apex-to-cupola distance ≥ 3 cm
Chest tube placement typically recommended
Consider conservative management in otherwise healthy patients without
respiratory distress and no progress in repeat CXR after 4 hours. [ref][ref][ref]
Needle aspiration may also be considered.
Secondary spontaneous
pneumothorax (stable patient)
Apex-to-cupola distance < 3 cm: Consider observation or chest tube placement.
Apex-to-cupola distance ≥ 3 cm
Chest tube placement
ICU transfer and thoracic surgery consultation
Needle thoracostomy
Indication: tension pneumothorax
Procedure:
Immediate insertion of a large-bore needle
In adults: use the 2nd intercostal space at the midclavicular line or the 4th–5th intercostal
space between the anterior and midaxillary line (especially in muscular or obese patients)
In children: use the 2nd intercostal space at the midclavicular line
Typically followed by the insertion of a chest tube
Chest tube placement
Indications: see above
Procedure
Most commonly in the 4th–5th intercostal space (nipple line), between the anterior and
midaxillary line (safe triangle )
Rarely: second intercostal space, midclavicular line (Monaldi drain)
The intercostal space is very narrow at this site and the pectoralis muscle must be
penetrated.
Primarily used for emergency chest decompression
Connect tubing to water seal or suctioning .
Always check CXR after the procedure is complete.