1. Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 16 Lung Abscess Figure 16-1. Lung abscess. A, Cross-sectional view of lung abscess. AFC, Air-fluid cavity; RB, ruptured bronchus (and drainage of the liquified contents of the cavity); EDA, early development of abscess; PM, pyogenic membrane. Consolidation (B) and excessive bronchial secretions (C) are common secondary anatomic alterations of the lungs. A AFC RB EDA PM B C

2. Copyright © 2006 by Mosby, Inc. Slide 2 Anatomic Alterations of the Lungs  Alveolar consolidation  Alveolar-capillary and bronchial wall destruction  Tissue necrosis  Cavity formation  Fibrosis and calcification of the lung parenchyma  Bronchopleural fistulae  Atelectasis  Excessive airway secretions and empyema

3. Copyright © 2006 by Mosby, Inc. Slide 3 Etiology  Pneumonia caused by aspiration (most common)  Klebsiella  Staphylococcus  Predisposing factors for aspiration  Alcohol abuse  Seizure disorders  General anesthesia  Head trauma  Cerebrovascular accident  Swallowing disorders

4. Copyright © 2006 by Mosby, Inc. Slide 4 Etiology (Less frequent causes)  Aerobic organisms  Streptococcus pyogenes  Klebsiella pneumoniae  Escherichia coli  On rare occasions  Streptococcus pneumoniae  Pseudomonas aeruginosa  Legionella pneumophila

5. Copyright © 2006 by Mosby, Inc. Slide 5 Etiology (Other organisms that may lead to a lung abscess)  Mycobacterium tuberculosis  Fungal organisms  Histoplasma capsulatum  Coccidioides immitis  Blastomyces  Aspergillus fumigatus  Parasites  Paragonimus westermani  Echinococcus  Entamoeba histolytica

6. Copyright © 2006 by Mosby, Inc. Slide 6 Etiology Lung abscess may also develop from:  Bronchial obstruction  Vascular obstruction  Interstitial lung disease  Bullae or cysts  Penetrating chest wounds

7. Copyright © 2006 by Mosby, Inc. Slide 7 Overview of the Cardiopulmonary Clinical Manifestations Associated with LUNG ABSCESS The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Alveolar Consolidation (see Figure 9-8), and when the abscess is draining, by Excessive Bronchial Secretions (see Figure 9-8)—the major anatomic alterations of the lungs associated with chronic bronchitis (see Figure 16-1).

8. Copyright © 2006 by Mosby, Inc. Slide 8 Clinical Data Obtained at the Patient’s Bedside Clinical Data Obtained at the Patient’s Bedside Vital signs  Increased respiratory rate  Increased heart rate, cardiac output, blood pressure

9. Copyright © 2006 by Mosby, Inc. Slide 9 Clinical Data Obtained at the Patient’s Bedside  Chest pain/decreased chest expansion  Cyanosis  Cough, sputum production, and hemoptysis  Chest assessment findings  Increased tactile and vocal fremitus  Dull percussion note  Bronchial breath sounds  Diminished breath sounds  Whispered pectoriloquy  Pleural friction rub

10. Copyright © 2006 by Mosby, Inc. Slide 10 Figure 2-11. A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.

11. Copyright © 2006 by Mosby, Inc. Slide 11 Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung unit.

12. Copyright © 2006 by Mosby, Inc. Slide 12 Figure 2-19. Whispered voice sounds auscultated over a normal lung are usually faint and unintelligible.

13. Copyright © 2006 by Mosby, Inc. Slide 13 Clinical Data Obtained from Laboratory Tests and Special Procedures

14. Copyright © 2006 by Mosby, Inc. Slide 14 Pulmonary Function Study: Expiratory Maneuver Findings FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N PEFR MVV FEF 50% FEV 1% N N or  N N or  FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N PEFR MVV FEF 50% FEV 1% N N or  N N or 

15. Copyright © 2006 by Mosby, Inc. Slide 15 Pulmonary Function Study: Lung Volume and Capacity Findings V T RV FRC TLC N or     VC IC ERV RV/TLC%    N V T RV FRC TLC N or     VC IC ERV RV/TLC%    N

16. Copyright © 2006 by Mosby, Inc. Slide 16 Arterial Blood Gases Mild to Moderate Lung Abscess  Acute alveolar hyperventilation with hypoxemia pH PaCO 2 HCO 3 - PaO 2    (Slightly)  pH PaCO 2 HCO 3 - PaO 2    (Slightly) 

17. Copyright © 2006 by Mosby, Inc. Slide 17 Time and Progression of Disease 100 50 30 80 0 Pa CO 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa O 2 Disease Onset Pa O 2 or Pa CO 2 Figure 4-2. PaO 2 and PaC0 2 trends during acute alveolar hyperventilation.

18. Copyright © 2006 by Mosby, Inc. Slide 18 Arterial Blood Gases Severe Lung Abscess  Acute ventilatory failure with hypoxemia pH PaCO 2 HCO 3 - PaO 2    (Slightly)  pH PaCO 2 HCO 3 - PaO 2    (Slightly) 

19. Copyright © 2006 by Mosby, Inc. Slide 19 Time and Progression of Disease 100 50 30 80 0 Pa O 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa CO 2 Acute Ventilatory Failure Disease Onset Point at which disease becomes severe and patient begins to become fatigued Pa 0 2 or Pa C0 2 Figure 4-7. PaO 2 and PaCO 2 trends during acute ventilatory failure.

20. Copyright © 2006 by Mosby, Inc. Slide 20 Oxygenation Indices Q S /Q T D O 2 V O 2 C(a-v) O 2   Normal Normal O 2 ER Sv O 2   Q S /Q T D O 2 V O 2 C(a-v) O 2   Normal Normal O 2 ER Sv O 2  

21. Copyright © 2006 by Mosby, Inc. Slide 21 Abnormal Laboratory Tests and Procedures Sputum examination  Gram-positive organism  Streptococcus  Anaerobic organisms  Peptococcus  Peptostreptococcus  Bacteroides  Fusobacterium

22. Copyright © 2006 by Mosby, Inc. Slide 22 Radiologic Findings Chest radiograph  Increased density  Cavity formation  Cavity with air-fluid levels  Fibrosis  Pleural effusion

23. Copyright © 2006 by Mosby, Inc. Slide 23 Figure 16-2. Reactivation tuberculosis with a large cavitary lesion containing an air-fluid level in the right lower lobe. Smaller cavitary lesions are seen in other lobes. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)

24. Copyright © 2006 by Mosby, Inc. Slide 24 General Management of Lung Abscess Respiratory care treatment protocols  Oxygen therapy protocol  Bronchopulmonary hygiene therapy protocol  Hyperinflation therapy protocol

25. Copyright © 2006 by Mosby, Inc. Slide 25 General Management of Lung Abscess Medications and procedures commonly prescribed by the physician  Antibiotics  Surgery

26. Copyright © 2006 by Mosby, Inc. Slide 26 Classroom Discussion Case Study: Lung Abscess