2. DefinitionDefinition
• Necrosis of pulmonary tissueNecrosis of pulmonary tissue
caused by severe infection,caused by severe infection,
characterized clinically by highcharacterized clinically by high
fever, cough with large quantity offever, cough with large quantity of
purulent sputum, porosis, which inpurulent sputum, porosis, which in
X-ray presents as one or severalX-ray presents as one or several
cavity with liquid planecavity with liquid plane
3. PathogensPathogens
• Bacteria located in oral cavity or upper respiratoryBacteria located in oral cavity or upper respiratory
tract, including aerobic, anaerobic or facultativetract, including aerobic, anaerobic or facultative
anaerobic bacteriumanaerobic bacterium
• Common pathogens, e.g., staphylococcus,Common pathogens, e.g., staphylococcus,
klebsiella, pseudomonas aeruginosa, suppurativeklebsiella, pseudomonas aeruginosa, suppurative
streptococcusstreptococcus
• 90% cases accompanied with anaerobic infection90% cases accompanied with anaerobic infection
4. • Aspirated lung abscessAspirated lung abscess
• Existence of local infectious loci in oral, nasal orExistence of local infectious loci in oral, nasal or
pharyngeal cavity, pathogen aspiratedpharyngeal cavity, pathogen aspirated
• Right lung is easily involved because right mainRight lung is easily involved because right main
branch is steeper and widerbranch is steeper and wider
• Anaerobes more oftenAnaerobes more often
Mechanisms
5. • Secondary lung abscessSecondary lung abscess
• To bacterial pneumonia, bronchiectasis,To bacterial pneumonia, bronchiectasis,
bronchial cyst, lung cancer, pulmonary TB cavitybronchial cyst, lung cancer, pulmonary TB cavity
• Obstructed by foreign body, esp. for childrenObstructed by foreign body, esp. for children
• Infiltrated by suppurative D in neighboringInfiltrated by suppurative D in neighboring
organsorgans
6. • Hematogenous lung abscessHematogenous lung abscess
• Toxic infection Caused by skin injury orToxic infection Caused by skin injury or
infection, furuncle or carbuncle (anthracia,infection, furuncle or carbuncle (anthracia,
痈痈 ), bacterial emboli disseminated to), bacterial emboli disseminated to
lunglung→ thrombosis of small veins,→ thrombosis of small veins,
inflammation and necrosisinflammation and necrosis
7. PathologyPathology
• Incomplete treatment or unsuccessfulIncomplete treatment or unsuccessful
bronchial drainagebronchial drainage →large amount of→large amount of
necrotized tissue remnant in cavitynecrotized tissue remnant in cavity
→persistent over 3 months, termed as→persistent over 3 months, termed as
chronic lung abscesschronic lung abscess..
• Hyperplasia of fibroblast, formation ofHyperplasia of fibroblast, formation of
granulation tissuegranulation tissue →cavity wall thicker→cavity wall thicker
→the peripheral bronchi or bronchioles→the peripheral bronchi or bronchioles
involved, deformity, or distentioninvolved, deformity, or distention
8. Clinical manifestationClinical manifestation
• HistoryHistory
1.1. Surgery in oral cavity, local infectious loci,Surgery in oral cavity, local infectious loci,
drunkenness, fatigue, coma, etcdrunkenness, fatigue, coma, etc
2.2. Other pulmonary DOther pulmonary D
3.3. Skin injury, furuncle, carbuncleSkin injury, furuncle, carbuncle
9. • SymptomsSymptoms
• Abrupt onsetAbrupt onset
• High fever with rigor, 39~40ºCHigh fever with rigor, 39~40ºC
• Cough with exuberant purulent sputum,Cough with exuberant purulent sputum,
300~500ml/day, 3 layers after deposition300~500ml/day, 3 layers after deposition
• Hemoptysis in 1/3 casesHemoptysis in 1/3 cases
• Less sputum in hematogenous cases,Less sputum in hematogenous cases,
hemoptysis is rarehemoptysis is rare
10. • In chronic cases, recurrent cough,In chronic cases, recurrent cough,
sputum, fever and hemoptysis,sputum, fever and hemoptysis,
persistent over 3 months; anemia ispersistent over 3 months; anemia is
not rarenot rare
• Other signs: loss of body weightOther signs: loss of body weight
11. • SignsSigns
• Associated with the size and site ofAssociated with the size and site of
lung abscesslung abscess
13. X-ray examinationX-ray examination
• In early stage, lump of dense foggyIn early stage, lump of dense foggy
shadow without clear marginshadow without clear margin
• After porosis, circular transparentAfter porosis, circular transparent
shadow with liquid plane, around whichshadow with liquid plane, around which
is dense inflammatory infiltrationis dense inflammatory infiltration
• In chronic lung abscess, cavity wallIn chronic lung abscess, cavity wall
thicker, irregular form, or collapsedthicker, irregular form, or collapsed
16. Diagnostic EssentialsDiagnostic Essentials
1.1. History of surgery in oral cavity, vomiting inHistory of surgery in oral cavity, vomiting in
coma status, or aspiration of foreign, orcoma status, or aspiration of foreign, or historyhistory
of skin injury, carbuncle or furuncle,of skin injury, carbuncle or furuncle,
endocarditisendocarditis
2.2. Abrupt onset of rigor, fever, cough withAbrupt onset of rigor, fever, cough with
exuberant purulent sputumexuberant purulent sputum
3.3. In Blood RT, WBC counting, NIn Blood RT, WBC counting, N↑↑
4.4. X-ray: cavity with liquid plane in denseX-ray: cavity with liquid plane in dense
inflammatory shadow (acute),inflammatory shadow (acute), Multiple loci inMultiple loci in
bilateral lungs indicates hematogenous lungbilateral lungs indicates hematogenous lung
abscessabscess
5.5. Pathogen examinationPathogen examination
17. Differentiation DiagnosisDifferentiation Diagnosis
1.1. Bacterial pneumoniaBacterial pneumonia
2.2. Infection secondary from pulmonary TBInfection secondary from pulmonary TB
cavitycavity
3.3. Bronchial carcinoma with obstructiveBronchial carcinoma with obstructive
bronchitisbronchitis
4.4. Infection secondary from pulmonaryInfection secondary from pulmonary
cystcyst
18. • Distinguish inflammatory cavityDistinguish inflammatory cavity
from cancerous onefrom cancerous one
1.1. Longer historyLonger history
2.2. Slight toxic symptomsSlight toxic symptoms
3.3. Less purulent sputumLess purulent sputum
4.4. X-ray: centrifugal cavity, the wall isX-ray: centrifugal cavity, the wall is
thicker with irregular marginthicker with irregular margin
5.5. Enlarged hilar LN is quite helpfulEnlarged hilar LN is quite helpful
21. TreatmentTreatment
• AntibioticsAntibiotics
1.1. Aspirated or secondary:Aspirated or secondary: anaerobicanaerobic
bacterium, most sensitive to penicillinbacterium, most sensitive to penicillin
2.2. Hematogenous:Hematogenous: staphylococcus orstaphylococcus or
streptococcus, primary antibiotics arestreptococcus, primary antibiotics are ββ--
lactamase resistant penicillins orlactamase resistant penicillins or
cephalosporinscephalosporins
3.3. Course:Course: 8~12 weeks till the disappearance8~12 weeks till the disappearance
of cavity and symptoms, or only little remnantof cavity and symptoms, or only little remnant
fibrosis leftfibrosis left
22. • Drainage of grassery juiceDrainage of grassery juice
1.1. Position drainage: based onPosition drainage: based on
administration of expectorant oradministration of expectorant or
nebulization normal salinenebulization normal saline
2.2. Flush and aspiration UnderFlush and aspiration Under
bronchoscopybronchoscopy
23. Surgery indicationsSurgery indications
1.1. Medical treatment over 3 Months, cavityMedical treatment over 3 Months, cavity
not smallernot smaller
2.2. Cavity >Cavity >5cm5cm
3.3. Large amount of hemoptysis, life isLarge amount of hemoptysis, life is
EndangeredEndangered
4.4. Accompanied with bronchopleuralAccompanied with bronchopleural
fistulafistula
5.5. Pyemia, ineffective to aspiration andPyemia, ineffective to aspiration and
flushingflushing
6.6. Obstruction of airway,Obstruction of airway, e.g. cancerouse.g. cancerous
obstructionobstruction
24. BronchiectasisBronchiectasis
• Definition:Definition: distention of distal bronchi (distention of distal bronchi (φφ>>
2mm), caused by destruction of muscular &2mm), caused by destruction of muscular &
elastic tissue of bronchial wallelastic tissue of bronchial wall
• CharacterizedCharacterized by chronic cough, exuberant
purulent sputum or recurrent hemoptysis
• History:History: mumps in childhood, pertussis, or
bronchial pneumonia
• Etiology & Mechanism:Etiology & Mechanism: bronchopulmonarybronchopulmonary
infection and bronchial obstructioninfection and bronchial obstruction
25. EtiologyEtiology
• Bronchopulmonary infection –Bronchopulmonary infection – most common inmost common in
childhoodchildhood
• Common pathogens: pseudomonas aeruginosa,
staphylococcus, hemophilia influenzae, streptococcus
pneumoniae, etc
• Bronchial obstruction –Bronchial obstruction – tumor, foreign body ortumor, foreign body or
infection. Intraluminal obstruction or extraluminalinfection. Intraluminal obstruction or extraluminal
oppression.oppression. Middle lobe syndromeMiddle lobe syndrome : atelectasis of: atelectasis of
middle lobe caused by bronchial obstructionmiddle lobe caused by bronchial obstruction
• Genetic bronchial developmental abnormalityGenetic bronchial developmental abnormality
• Systemic D: rheumatoid arthritis, Crhon’s D, ulcericSystemic D: rheumatoid arthritis, Crhon’s D, ulceric
colitis, systemic lupus erythma, AIDS, yellow nailcolitis, systemic lupus erythma, AIDS, yellow nail
syndromesyndrome
26. • Kartagener syndrome:Kartagener syndrome:
bronchiectasis caused by geneticbronchiectasis caused by genetic
abnormal development of bronchialabnormal development of bronchial
cartilage and elastic tissue, oftencartilage and elastic tissue, often
accompanied with sinusitis andaccompanied with sinusitis and
visceral rotation (dextrocardia)visceral rotation (dextrocardia)
27. PathologyPathology
• Styloid (columnar) or cystic distention, may beStyloid (columnar) or cystic distention, may be
coexistentcoexistent
• Accompanied with distention of capillary,Accompanied with distention of capillary,
distension & anastomose of terminal branchesdistension & anastomose of terminal branches
of bronchial & pulmonary arteryof bronchial & pulmonary artery →angioma→angioma
• Recurrent hemoptysisRecurrent hemoptysis
• More common in inferior field, more common inMore common in inferior field, more common in
left I fieldleft I field
28. Clinical manifestationClinical manifestation
• SymptomsSymptoms
1. Chronic cough with exuberant purulent sputum.
2. Recurrent hemoptysis: sometimes, this is the
only symptom
3. Recurrent pulmonary infection: in the same
segment, almost incurable
4. Toxic symptoms: fever, anemia and emaciation
29. • SignsSigns
• Fixed, persistent, and localized coarseFixed, persistent, and localized coarse
moist rales in inferior field.moist rales in inferior field.
• Wheezing is not rareWheezing is not rare
• Acropachy in some patients haveAcropachy in some patients have
30. ImagingImaging
• X-rayX-ray
• Typical changes– tract sign, reflex the shadow ofTypical changes– tract sign, reflex the shadow of
thickened bronchial wallthickened bronchial wall
• Cystic distention in X-ray: typical imaging is curledCystic distention in X-ray: typical imaging is curled
shadow or multiple cellular transparent shadow,shadow or multiple cellular transparent shadow,
liquid plane appears if accompanied with infectionliquid plane appears if accompanied with infection
31. • CTCT
• Columnar distention:Columnar distention: bronchial wall thickenedbronchial wall thickened
• Cystic distention:Cystic distention: clusters of cystic shadowclusters of cystic shadow
• High resolution CT (HRCT):High resolution CT (HRCT): show lobuleshow lobule
structures, replace bronchography in moststructures, replace bronchography in most
situationssituations
• Bronchography:Bronchography: determine the site ofdetermine the site of
bronchiectasis, only used before surgerybronchiectasis, only used before surgery
40. Diagnostic EssentialsDiagnostic Essentials
1.1. Typical symptomsTypical symptoms
2.2. Signs of recurrent infection in aSigns of recurrent infection in a
fixed site, presented as fixed,fixed site, presented as fixed,
persistent coarse moist ralespersistent coarse moist rales
3.3. History of respiratory infection orHistory of respiratory infection or
systemic D in childhoodsystemic D in childhood
4.4. Confirmed by findings of HRCT &Confirmed by findings of HRCT &
bronchographybronchography
42. • Congenital pulmonary cystCongenital pulmonary cyst
• Round or oval shadow with clear margin andRound or oval shadow with clear margin and
thin wall, without inflammatory infiltrationthin wall, without inflammatory infiltration
43. Principles in TreatmentPrinciples in Treatment
• Smooth airwaySmooth airway
1.1. ExpectorantExpectorant
2. Bronchodilator
3. Position drainage
4. Aspiration under bronchoscopy
• AntibioticsAntibiotics
• Surgery indicationsSurgery indications
1.1. Recurrent acute respiratory infection or largeRecurrent acute respiratory infection or large
amount of hemoptysis, life is endangeredamount of hemoptysis, life is endangered
2.2. Ineffective by medical treatmentIneffective by medical treatment
3.3. Localized in one lobe or in one sideLocalized in one lobe or in one side
4.4. No severe basic DNo severe basic D
44. ALI & ARDSALI & ARDS
• Acute progressive respiratoryAcute progressive respiratory
failure caused by extra-orfailure caused by extra-or
intrapulmonary factors, excludingintrapulmonary factors, excluding
cardiac diseases.cardiac diseases.
45. • 2 stage in one2 stage in one dynamicdynamic processprocess
• ALI– acute lung injury; ARDS– acuteALI– acute lung injury; ARDS– acute
respiratory distress syndromerespiratory distress syndrome
• ALI represents the early moderate stage, whileALI represents the early moderate stage, while
ARDS represents the later severe stageARDS represents the later severe stage
• Conception of ALIConception of ALI
1.1. Early stage of ARDS. In this stage, pathogen directly orEarly stage of ARDS. In this stage, pathogen directly or
indirectly via inflammatory responseindirectly via inflammatory response →injury of→injury of
pulmonary capillary or epithelial cellspulmonary capillary or epithelial cells
2.2. Indicate that effective treatment may intervene in thisIndicate that effective treatment may intervene in this
stagestage
3.3. Benefit for evaluation of efficacyBenefit for evaluation of efficacy
46. Pathology & PathophysiologyPathology & Pathophysiology
• PathologyPathology :: ↑↑Permeability of pulmonaryPermeability of pulmonary
capillarycapillary →→congestion, edema and formation ofcongestion, edema and formation of
hyaline membrane, accompanied with interstitialhyaline membrane, accompanied with interstitial
fibrosisfibrosis
• 3 stages:3 stages: exudation, hyperplasia and fibrosisexudation, hyperplasia and fibrosis,,
which are always overlappedwhich are always overlapped
47. Etiology & pathogenesisEtiology & pathogenesis
• EtiologyEtiology
• Intrapulmonary: direct factorsIntrapulmonary: direct factors
1.1. PhysiochemicalPhysiochemical
2.2. Biological factors, etcBiological factors, etc
• Extrapulmonary: indirect factorsExtrapulmonary: indirect factors
1. Shock, toxic syndrome caused by severe infection
2. Severe trauma (non-thoracic), or burning
3. Large amount of transfusion
4. Necrotic pancreatitis
5. Intoxication of drugs or anesthetics
48. • PathogenesisPathogenesis
• Not very clearNot very clear
1.1. Direct injury of alveolar membraneDirect injury of alveolar membrane
2.2. Inflammatory response: intermediates &Inflammatory response: intermediates &
cytokines released from inflammatory cellscytokines released from inflammatory cells
3333 or disappear of surfactantor disappear of surfactant →aggravate→aggravate
edema & atelectasisedema & atelectasis
3333 pulmonary compliance, intrapulmonarypulmonary compliance, intrapulmonary
shunt, abnormal ventilation and gas exchangeshunt, abnormal ventilation and gas exchange
5.5. Abnormal ratio of ventilation/blood flowAbnormal ratio of ventilation/blood flow
6.6. Dysfunction of Neuroendocrinal regulationDysfunction of Neuroendocrinal regulation
7.7. Obstinate hypoxemiaObstinate hypoxemia
49. Clinical manifestationClinical manifestation
• ALI/ARDS often occurs within 5 days afterALI/ARDS often occurs within 5 days after
onset of primary D, even within 24Hrsonset of primary D, even within 24Hrs
• Addition to manifestations of primary D, theAddition to manifestations of primary D, the
earliest symptom is tachypnea, progressivelyearliest symptom is tachypnea, progressively
aggravated with dyspnea and cyanosisaggravated with dyspnea and cyanosis
• Dyspnea is characterized by deep, rapid breathDyspnea is characterized by deep, rapid breath
with great effort, chest-stressed feeling, unablewith great effort, chest-stressed feeling, unable
to be corrected by oxygen inhalation, neitherto be corrected by oxygen inhalation, neither
interpreted by primary pulmonary Dinterpreted by primary pulmonary D
• Signs: none in early stage, or fine moist rales;Signs: none in early stage, or fine moist rales;
in the later stage, moist rales is common,in the later stage, moist rales is common,
bronchophony is not rarebronchophony is not rare
50. Laboratory & imagingLaboratory & imaging
examinationexamination
• Arterial gas analysis: typical changes:Arterial gas analysis: typical changes:
hypoxemia,hypoxemia, PaO2. in ALI, PaO2/ FiO2PaO2. in ALI, PaO2/ FiO2
(inspiratory O(inspiratory O22 fraction)fraction) ≤≤300; in ARDS,300; in ARDS,
PaO2/FiO2PaO2/FiO2 ≤≤ 200200
• PAOP (pulmonary artery occlusion pressure): NPAOP (pulmonary artery occlusion pressure): N
<12mmHg, if >18mmHg<12mmHg, if >18mmHg → left heart failure; 12-18→ left heart failure; 12-18
mmHgmmHg →ALI or ARDS→ALI or ARDS
• X-ray: N in early stage, or slight interstitialX-ray: N in early stage, or slight interstitial
changes–changes– ↑↑ pulmonary texture with foggypulmonary texture with foggy
margin; in late stage: flake or lamellar shadow,margin; in late stage: flake or lamellar shadow,
bronchial transparency in lamellar shadowbronchial transparency in lamellar shadow
51. DiagnosisDiagnosis
1.1. Existence of high risk factors: includingExistence of high risk factors: including
direct or indirect factorsdirect or indirect factors
2.2. Acute onset with typical dyspnea &Acute onset with typical dyspnea &
tachypneatachypnea
3.3. Bilateral infiltrated lamellar shadow inBilateral infiltrated lamellar shadow in
chest radiographychest radiography
4.4. in ALI, PaO2/ FiO2in ALI, PaO2/ FiO2 ≤≤300; in ARDS,300; in ARDS,
PaO2/FiO2PaO2/FiO2 ≤≤ 200200
5.5. PAWPPAWP≤≤18mmHg, or excluding cardiac18mmHg, or excluding cardiac
pulmonary edema clinicallypulmonary edema clinically
