1. Chronic Pulmonary Infection
Dr Tom Fardon
Respiratory SpR

2. Diagnosis? Shadow on CXR Weight loss Persistent sputum production
Chest pain
Increasing shortness of breath

3. Differential Diagnosis
Lung Cancer
Not unreasonable
Intrapulmonary abscess
Empyema
Bronchiectasis
Cystic Fibrosis

7. Intrapulmonary Abscess
Indolent presentation
Weight loss common
Lethargy, tiredness, weakness
Cough ± sputum
High mortality if not treated
Usually a preceding illness of some sort

12. Preceding Illnesses Pneumonia Aspiration pneumonia
Vomiting
Lowered conscious level
Pharyngeal pouch
Poor host immune response
Hypogammaglobulinaemia

15. Pathogens Bacteria Fungi Streptococcus
Staphylococcus (Particularly post ‘flu)
E-Coli
Gram Negatives
Fungi
Aspergillus

23. Empyema

24. 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

25. 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

26. 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

27. 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

28. CXR Some obvious Not always this large Look for D sign
As always, better x-rays increase sensitivity, and specificity

29. CXR - D Sign

30. Lateral CXR
Particularly useful in small retro-diaphragmatic collections
Not straightforward in ICU

31. USS

32. USS in Empyema

33. CT Examination of Pleural Space

34. Empyema CT

35. Use USS or CT to position the drain site

36. Insertion of a Surgical Drain

37. Trocar Introduction

38. Insertion of a Seldinger Drain

39. Insertion of a Seldinger Drain

40. Other Treatment IV antibiotics Oral antibiotics Broad spectrum
Co-amoxyclav initially
Oral antibiotics
Directed towards cultured bacteria
At least 14 days

41. 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

53. Treatment Options Stop smoking ‘Flu vaccine Pneumococcal vaccine
Reactive antibiotics
Send sputum sample
Give antibiotics appropriate to most recent positive culture

54. Treatment When colonised with persistent bacteria
Prophylactic antibiotics
Nebulised colomycin
Pulsed IV abx
Alternating oral antibiotics

55. Anti-inflammatory Treatment
Low dose macrolide antibiotics have been shown to reduce exacerbation rates in bronchiectasis
Clarithromycin 250 mg OD

56. Prognosis
Recurrent infection
Abscesses and empyema
Colonisation

59. Cystic Fibrosis
Congenital cause of bronchiectasis
And much more

60. 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

62. 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

63. Case Study Diagnosed at 10 months with steatorrhea and LRTI
Stable until 13 when she required increasingly frequent IV’s
Pregnancy weeks
Since 1998 she has suffered more frequent exacerbations and now requires IV’s monthly

64. 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

65. Bi-lateral lung transplant Sept 2001 June 2006 - severe pneumonia
Admitted to ICU
Large blood clot extracted from right main bronchus
Organising pneumonia

66. Still an in patient in ward 3
Colonised with 3 distinct varieties of pseudomonas and MRSA
Ongoing IV antibiotics

67. Specialities Involved
Respiratory
Gastro-Intestinal
Obs & Gynae
GP/DN
Surgery
Transplant team
Child & Family Psychiatry
ICU
Anaesthesia

80. 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