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 Fungi 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

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 CXR USS CT 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

Trocar Introduction

Insertion of a Seldinger Drain

Insertion of a Seldinger Drain

Other Treatment IV antibiotics Oral 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