chronic pulmonary infection dr tom fardon respiratory spr
TRANSCRIPT
Chronic Pulmonary Infection
Dr Tom Fardon
Respiratory SpR
Diagnosis?
• Shadow on CXR
• Weight loss
• Persistent sputum production
• Chest pain
• Increasing shortness of breath
Differential Diagnosis
• Lung Cancer– Not unreasonable
• Intrapulmonary abscess
• Empyema
• Bronchiectasis
• Cystic Fibrosis
Intrapulmonary Abscess
• 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 x-rays increase sensitivity, and specificity
CXR - D Sign
Lateral CXR
• Particularly useful in small retro-diaphragmatic 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
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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
• 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)
• 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
• 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
• 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