1. traction bronchiectasis is a finding of abnormal airway dilation due to lung fibrosis. It is
typically seen on high resolution computed tomography (CT) scan.[1]
It is classically seen in idiopathic pulmonary fibrosis.
Bronchiectasis is a disease state defined by localized, irreversible dilation of part of the
bronchial tree. It is classified as an obstructive lung disease, along with bronchitis and
cystic fibrosis. Involved bronchi are dilated, inflamed, and easily collapsible, resulting in
airflow obstruction and impaired clearance of secretions. Bronchiectasis is associated
with a wide range of disorders, but it usually results from necrotizing bacterial infections,
such as infections caused by the Staphylococcus or Klebsiella species or Bordetella
pertussis.[1]
Causes
There are both congenital and acquired causes of bronchiectasis. Kartagener syndrome,
which affects the mobility of cilia in the lungs[4], aids in the development of the disease.
Another common genetic cause is cystic fibrosis, in which a small number of patients
develop severe localized bronchiectasis[5]. Young's syndrome, which is clinically similar
to cystic fibrosis, is thought to significantly contribute to the development of
bronchiectasis. This is due to the occurrence of chronic, sinopulmonary infections.[6]
Patients with alpha 1-antitrypsin deficiency have been found to be particularly
susceptible to bronchiectasis, for unknown reasons.[7] Other less-common congenital
causes include primary immunodeficiencies, due to the weakened or nonexistent immune
system response to severe, recurrent infections that commonly affect the lung.[8]
Acquired bronchiectasis occurs more frequently, with one of the biggest causes being
tuberculosis. Endobronchial tuberculosis commonly leads to bronchiectasis, either from
bronchial stenosis or secondary traction from fibrosis.[9] An especially common cause of
the disease in children is acquired immune deficiency syndrome, stemming from the
human immunodeficiency virus. This disease predisposes patients to a variety of
pulmonary ailments, such as pneumonia and other opportunistic infections.[10].
Bronchiectasis can sometimes be an unusual complication of inflammatory bowel
disease, especially ulcerative colitis. It can occur in Crohn's disease as well, but does so
less frequently. Bronchiectasis in this situation usually stems from various allergic
responses to inhaled fungus spores.[11] Recent evidence has shown an increased risk of
bronchiectasis in patients with rheumatoid arthritis who smoke. One study stated a
tenfold increased prevalence of the disease in this cohort[12]. Still, it is unclear as to
whether or not cigarette smoke is a specific primary cause of bronchiectasis.
Other acquired causes of bronchiectasis involving environmental exposures include
respiratory infections, obstructions, inhalation and aspiration of ammonia and other toxic
gases, pulmonary aspiration, alcoholism, heroin (drug use), and various allergies.[13]
[edit] Diagnosis

2. The diagnosis of bronchiectasis is based on the review of clinical history and
characteristic patterns in high-resolution CT scan findings. Such patterns include "tree-in-
bud" abnormalities and cysts with definable borders. In one small study, CT findings of
bronchiectasis and multiple small nodules were reported to have a sensitivity of 80%,
specificity of 87%, and accuracy of 80% for the detection of bronchiectasis.
Bronchiectasis may also be diagnosed without CT scan confirmation if clinical history
clearly demonstrates frequent, respiratory infections, as well confirmation of an
underlying problem via blood work and sputum culture samples.[14]
[edit] Treatment
Treatment of bronchiectasis is aimed at controlling infections and bronchial secretions,
relieving airway obstruction, and preventing complications. This includes the prolonged
usage of antibiotics to prevent detrimental infections[15], as well as eliminating
accumulated fluid with postural drainage and chest physiotherapy. Surgery may also be
used to treat localized bronchiectasis, removing obstructions that could cause progression
of the disease.[16]
Inhaled steroid therapy that is consistently adhered to can reduce sputum production and
decrease airway constriction over a period of time, and help prevent progression of
bronchiectasis. One commonly used therapy is beclometasone dipropionate, which is also
used in asthma treatment.[17] Use of inhalers such as albuterol (salbutamol), fluticasone
(Flovent/Flixotide) and ipratropium (Atrovent) may help reduce likelihood of infection
by clearing the airways and decreasing inflammation.[18]
Although not approved for use in any country, Mannitol dry inhalation powder, under the
name Bronchitol, has been granted orphan drug status by the FDA for use in patients with
bronchiectasis and with cystic fibrosis.[19]
Combination therapies, long acting bronchodilators and inhaled corticosteroids such as
Symbicort and Advair Diskus are also commonly used inhaled medicines which has in
many cases been effective in clearing the airways, reducing sputum and reducing
inflammation.
[edit] Prevention
In order to prevent future development of bronchiectasis, an x-ray of the chest should be
taken after any severe attack of measles, whooping cough or other acute respiratory
infection in childhood. While smoking has not been found to be a direct cause of
bronchiectasis, it is certainly an irritant that all patients should avoid in order to prevent
the development of infections (such as bronchitis) and further complications.[20]
A healthy body mass index, vaccination (especially against pneumonia and influenza)
and regular doctor visits may have beneficial effects on the prevention of progressing

3. bronchiectasis. The presence of hypoxemia, hypercapnia, dyspnea level and radiographic
extent can greatly affect the mortality rate from this disease.[21]
Bronchiectasis is an abnormal destruction and dilation (permanent or abnormal widening)
of the large airways. This injury is the beginning of a cycle in which your airways slowly
lose their ability to clear out mucus. The mucus builds up and creates an environment in
which bacteria can grow. This leads to repeated serious lung infections.
Bronchiectasis is many a times caused by recurrent inflammation or infection of the
airways. It may be present at birth, but most often begins in childhood as a complication
from infection or inhaling a foreign object. Prior to the widespread use of immunizations,
bronchiectasis was often the result of a serious infection with either measles or
whooping cough. Now, viruses that cause influenza (flu) or influenza-like syndromes,
may lead to development of bronchiectasis.
Some other Causes of Bronchiectasis may be:
• Respiratory syncytial virus can cause bronchiectasis in some childs.
• Some inherited conditions. For example, a condition called primary ciliary dyskinesia affects the cilia so they do not
'beat' correctly to clear the mucus. Cystic fibrosis is another condition that affects the lungs and causes 'bronchiectatic'
airways.
• Inhaled objects, such as peanuts, can become stuck and block an airway. This may lead to local damage to that airway.
Acid from the stomach that is regurgitated and inhaled can also damage airways. Inhaling poisonous gases may also
cause damage.
• Some rare immune problems can also cause lung infections and damage to airways thereby causing bronchiectasis.
• Severe lung infections such as tuberculosis (TB), whooping cough, pneumonia or measles can damage the airways at
the time of infection. Ongoing bronchiectasis may then develop.
• Less commonly, bronchiectasis may be caused by cystic fibrosis, an inhaled foreign body such as a peanut, following
tuberculosis, or lung infection in Aids.
• Other causes include inhalation of damaging gases, dust or smoke. The condition is worsened by smoking.
• It is also seen in later life after severe lung infections such as pneumonia in childhood, and it is sometimes present from
birth if the baby's lungs have not developed properly in the womb.
Symptoms of Bronchiectasis
Bronchiectasis can develop at any age and to any person. But, is most commonly seen in
early childhood. Symptom severity varies widely from patient to patient and sometimes
the patient may be even asymptomatic. In other people, symptoms begin gradually,
usually after a respiratory infection, and tend to worsen over the years. The classic
symptom, however, is a chronic cough that produces foul-smelling, mucopurulent
secretions in amounts ranging from less than 10 ml/day to more than 150 ml/day. This
finding is observed in more than 90% of bronchiectasis patients. There may be coughing

4. spells - these are most common in the early morning and late in the day. Other
characteristic findings include coarse crackles during inspiration over involved lobes or
segments, dyspnea, sinusitis, anemia, malaise, clubbing, and other signs of infection.
Some other Symptoms of Bronchiectasis may be:
• Cough worsened by lying on one side
• Shortness of breath worsened by exercise
• Weight loss.
• Coughing up of blood is also common.
• Fatigue.
• Wheezing.
• recurrent fever, chills,
• Skin discoloration, bluish.
• Paleness.
• Abnormal chest sounds.
• Breath odor.
• There may be frequent bouts of pneumonia or hemoptysis.
Treatment for Bronchiectasis
Treatment of bronchiectasis is aimed at controlling infections and bronchial secretions,
relieving airway obstruction, and preventing complications. Some of the Treatment
options are given below:
• Antibiotics may be given to the patient - orally or intravenously, for at least 7 - 10 days or until sputum production
decreases. Long term antibiotic therapy is not appropriate because it may predispose the patient to serious Gram-
negative infections.
• Bronchodilators, combined with postural drainage and chest percussion, help remove secretions if the patient has
bronchospasm and thick, tenacious sputum.
• Bronchoscopy may be used to help mobilize secretions.
• Hypoxia requires oxygen therapy; severe hemoptysis commonly requires lobectomy, segmental resection, or bronchial
artery embolization if pulmonary function is poor.
Lung abscess is necrosis of the pulmonary tissue and formation of cavities (more than 2
cm)[1] containing necrotic debris or fluid caused by microbial infection.
This pus-filled cavity is often caused by aspiration, which may occur during altered
consciousness. Alcoholism is the most common condition predisposing to lung abscesses.
Lung Abscess is considered primary(60%[2]) when it results from existing lung
parenchymal process and is termed secondary when it complicates another process e.g.
vascular emboli or follows rupture of extrapulmonary abscess into lung.
Conditions contributing to lung abscess
• Aspiration of oropharyngeal or gastric secretion
• Septic emboli
• Necrotizing pneumonia

5. • Vasculitis: Wegener's granulomatosis
• Necrotizing tumors: 8% to 18% are due to neoplasms across all age groups,
higher in older people; primary squamous carcinoma of the lung is the
commonest.
Organisms
In the post-antibiotic era pattern of frequency is changing. In older studies anaerobes
were found in up to 90% cases but they are much less frequent now[3].
• Anaerobic bacteria: Peptostreptococcus, Bacteroides, Fusobacterium species,
• Microaerophilic streptococcus : Streptococcus milleri
• Aerobic bacteria: Staphylococcus, Klebsiella, Haemophilus,
Pseudomonas,Nocardia, Escherichia coli, Streptococcus, Mycobacteria[4]
• Fungi: Candida, Aspergillus
• Parasites: Entamoeba histolytica,
[edit] Signs and Symptoms
Onset of symptoms is often gradual, but in necrotizing staphylococcal or gram-negative
bacillary pneumonias patients can be acutely ill. Cough, fever with shivering and night
sweats are often present. Cough can be productive with foul smelling purulent sputum
(≈70%) or less frequently with blood (i.e. hemoptysis in one third cases) [5]. Affected
individuals may also complain of chest pain, shortness of breath, lethargy and other
features of chronic illness.
Patients are generally cachectic at presentation. Finger clubbing is present in one third of
patients[5]. Dental decay is common especially in alcoholics and children. On examination
of chest there will be features of consolidation such as localised dullness on percussion,
bronchial breath sound etc.
[edit] Diagnosis
Chest Xray and other imaging studies
Abscess is often unilateral and single involving posterior segments of the upper lobes and
the apical segments of the lower lobes as these areas are gravity dependent when lying
down. Presence of air-fluid levels implies rupture into the bronchial tree or rarely growth
of gas forming organism.
Laboratory studies
Raised inflammatory markers (high ESR, CRP) are usual but not specific. Examination of
sputum is important in any pulmonary infections and here often reveals mixed flora.
Transtracheal of Transbronchial (via bronchoscopy) aspirates can also be cultured. Fibre

6. optic bronchoscopy is often performed to exclude obstructive lesion; it also helps in
bronchial drainage of pus.
[edit] Management
Broadspectrum antibiotic to cover mixed flora is the mainstay of treatment. Pulmonary
physiotherapy and postural drainage are also important. Surgical procedures are required
in selective patients for drainage or pulmonary resection.
[edit] Complications
Rare nowadays but include spread of infection to other lung segments, bronchiectasis,
empyema, and bacteraemia with metastatic infection such as brain abscess[2].
[edit] Prognosis
Most cases respond to antibiotic and prognosis is usually excellent unless there is a
debilitating underlying condition. Mortality from lung abscess alone is around 5% and is
improving
Lung abscess is defined as necrosis of the pulmonary tissue and formation of cavities containing
necrotic debris or fluid caused by microbial infection. The formation of multiple small (<2 cm)
abscesses is occasionally referred to as necrotizing pneumonia or lung gangrene. Both lung abscess
and necrotizing pneumonia are manifestations of a similar pathologic process. Failure to recognize
and treat lung abscess is associated with poor clinical outcome.
Lung abscesses can be classified based on the duration and the likely etiology. Acute abscesses are
less than 4-6 weeks old, whereas chronic abscesses are of longer duration. Primary abscess is
infectious in origin, caused by aspiration or pneumonia in the healthy host; secondary abscess is
caused by a preexisting condition (eg, obstruction), spread from an extrapulmonary site,
bronchiectasis, and/or an immunocompromised state. Lung abscesses can be further characterized by
the responsible pathogen, such as Staphylococcus lung abscess and anaerobic or Aspergillus lung
abscess.
Most frequently, the lung abscess arises as a complication of aspiration pneumonia caused by mouth
anaerobes. The patients who develop lung abscess are predisposed to aspiration and commonly have
periodontal disease. A bacterial inoculum from the gingival crevice reaches the lower airways, and
infection is initiated because the bacteria are not cleared by the patient's host defense mechanism.
This results in aspiration pneumonitis and progression to tissue necrosis 7-14 days later, resulting in
formation of lung abscess.
Other mechanisms for lung abscess formation include bacteremia or tricuspid valve endocarditis,
causing septic emboli (usually multiple) to the lung. Lemierre syndrome, an acute oropharyngeal
infection followed by septic thrombophlebitis of the internal jugular vein, is a rare cause of lung
abscesses. The oral anaerobe F necrophorum is the most common pathogen.
Microbiology
Because of the difficulty obtaining material uncontaminated by nonpathogenic bacteria colonizing the
upper airway, lung abscesses rarely have a microbiologic diagnosis. The most common anaerobes are
Peptostreptococcus species, Bacteroides species, Fusobacterium species, and microaerophilic
streptococci.

7. Aerobic bacteria that may infrequently cause lung abscess include Staphylococcus aureus,
Streptococcus pyogenes, Streptococcus pneumoniae (rarely), Klebsiella pneumoniae, Haemophilus
influenzae, Actinomyces species, Nocardia species, and gram-negative bacilli.
Nonbacterial and atypical bacterial pathogens may also cause lung abscesses, usually in the
immunocompromised host. These microorganisms include parasites (eg, Paragonimus and
Entamoeba species), fungi (eg, Aspergillus, Cryptococcus, Histoplasma, Blastomyces, and
Coccidioides species), and Mycobacterium species.
Mortality/Morbidity
Most patients with primary lung abscess improve with antibiotics, with cure rates documented at
90-95%.
Host factors associated with a poor prognosis include advanced age, debilitation, malnutrition, human
immunodeficiency virus infection or other forms of immunosuppression, malignancy, and duration of
symptoms greater than 8 weeks.3 The mortality rate for patients with underlying immunocompromised
status or bronchial obstruction who develop lung abscess may be as high as 75%.4
Aerobic organisms, frequently hospital acquired, are associated with poor outcomes
Lung abscesses likely occur more commonly in elderly patients because of the increased incidence of
periodontal disease and the increased prevalence of dysphagia and aspiration
The bacterial infection may reach the lungs in several ways. The most common is aspiration of
oropharyngeal contents.
• Patients at the highest risk for developing lung abscess have the following risk factors:
o Periodontal disease
o Seizure disorder
o Alcohol abuse
o Dysphagia
• Other patients at high risk for developing lung abscess include individuals with an inability to
protect their airways from massive aspiration because of a diminished gag or cough reflex,
caused by a state of impaired consciousness (eg, from alcohol or other CNS depressants,
general anesthesia, or encephalopathy).
• An abscess may develop as an infectious complication of a preexisting bulla or lung cyst.
• An abscess may develop secondary to carcinoma of the bronchus; the bronchial obstruction
causes postobstructive pneumonia, which may lead to abscess formation.
Clinical
History
Symptoms depend on whether the abscess is caused by anaerobic or other bacterial infection.
• Anaerobic infection in lung abscess
o Patients often present with indolent symptoms that evolve over a period of weeks to
months.
o The usual symptoms are fever, cough with sputum production, night sweats,
anorexia, and weight loss.
o The expectorated sputum characteristically is foul smelling and bad tasting.
o Patients may develop hemoptysis or pleurisy
• Other pathogens in lung abscess
o These patients generally present with conditions that are more emergent in nature
and are usually treated while they have bacterial pneumonia.
o Cavitation occurs subsequently as parenchymal necrosis ensues.
o Abscesses from fungi, Nocardia species, and Mycobacteria species tend to have an
indolent course and gradually progressive symptoms.

8. Physical
The findings on physical examination of a patient with lung abscess are variable. Physical findings may
be secondary to associated conditions such as underlying pneumonia or pleural effusion. The physical
examination findings may also vary depending on the organisms involved, the severity and extent of
the disease, and the patient's health status and comorbidities.
• Patients with lung abscesses may have low-grade fever in anaerobic infections and
temperatures higher than 38.5°C in other infections.
• Generally, patients with in lung abscess have evidence of gingival disease.
• Clinical findings of concomitant consolidation may be present (eg, decreased breath sounds,
dullness to percussion, bronchial breath sounds, course inspiratory crackles).
• The amphoric or cavernous breath sounds are only rarely elicited in modern practice.
• Evidence of pleural friction rub and signs of associated pleural effusion, empyema, and
pyopneumothorax may be present. Signs include dullness to percussion, contralateral shift of
the mediastinum, and absent breath sounds over the effusion.
• Digital clubbing may develop rapidly.
Abscesses generally develop in the right lung and involve the posterior segment of the right upper
lobe, the superior segment of the lower lobe, or both. This is due to gravitation of the infectious
material from the oropharynx into these dependent areas. Initially, the aspirated material settles in the
distal bronchial system and develops into a localized pneumonitis. Within 24-48 hours, a large area of
inflammation results, consisting of exudate, blood, and necrotic lung tissue. The abscess frequently
connects with a bronchus and partially empties.
After pyogenic pneumonitis develops in response to the aspirated infected material, liquefactive
necrosis can occur secondary to bacterial proliferation and an inflammatory reaction to produce an
acute abscess. As the liquefied necrotic material empties through the draining bronchus, a necrotic
cavity containing an air-fluid level is created. The infection may extend into the pleural space and
produce an empyema without rupture of the abscess cavity. The infectious process can also extend to
the hilar and mediastinal lymph nodes, and these too may become purulent.
Anaerobic necrotizing pneumonia
Usually, anaerobic necrotizing pneumonia is chiefly restricted to one pulmonary segment or lobe,
although it may progress to encompass an entire lung or both lungs. This type of anaerobic lung
infection is the most serious. The inflammatory process often spreads quickly and causes destruction
characterized by greenish staining of the lung and a huge amount of putrid tissue, resulting in
pulmonary gangrene. These patients are gravely ill with a progressive septic course. Leukocytosis is
obvious, and the sputum is putrid.
Secondary lung abscess
In cases of secondary lung abscess, the fundamental process (eg, bacteremia, endocarditis, septic
thrombophlebitis, subphrenic infection) is generally apparent along with the pulmonary pathology.
Infections below the diaphragm may extend to the lung or pleural space by way of the lymphatics,
either directly through the diaphragm or via defects in it.
The most typical hematogenous lung abscesses are observed in persons with staphylococcal
bacteremia, especially in children. These abscesses are multiple and are located in the periphery of
the lung. Infections may arise in or posterior to an obstruction (eg, an enlarged mediastinal lymph
node) and migrate to the lungs. Septic emboli from bacterial endocarditis or emboli from deep pelvic
veins may result in metastatic lung abscess. Septic emboli are suggested when multiple lesions
appear over an extended period.
Fewer than 5% of bland pulmonary infarcts become secondarily infected. Secondary infection of
infarcts is suggested if fever and leukocytosis are present. Abscess formation may also occur within a
necrotic pulmonary tumor.
Amebic lung abscess

9. Patients who develop an amebic lung abscess often have symptoms associated with a liver abscess.
These may include right upper quadrant pain and fever. After perforation of the liver abscess into the
lung, the individual may develop a cough and expectorate a chocolate or anchovy paste–like sputum
that has no odor. The patient may give a history of diarrhea and travel outside the country.
Diagnosis and Workup
Diagnosis
The diagnosis of a typical lung abscess can usually be confirmed based on history and physical
examination findings. Approximately 10-20% of patients with anaerobic lung abscess have no obvious
oral cavity disease or predisposition to aspiration, which are the 2 most important factors in the
development of anaerobic lung infection.
Evaluation of expectorated sputum is the first step in the diagnosis of a patient with a lung abscess.
Perform a Gram stain and culture for both gram-positive and gram-negative organisms and special
staining for acid-fast bacteria and fungi. Generally, in patients with a typical anaerobic lung abscess,
sputum analysis is not useful, but the analysis is helpful to exclude other causes of lung abscess (eg,
tuberculosis, aerobic bacteria). The sputum Gram stain in patients with anaerobic lung abscesses
often shows numerous polymorphonuclear leukocytes along with a mixture of bacteria, some of which
are contaminants of oral flora.
Because of the presence of anaerobes in the oral cavity, cultures of these microorganisms are not
worthwhile. Regular aerobic culture of expectorated sputum should always be performed. When a
single predominant organism is cultured, it is accepted to be the pathogen.
Empyema fluid, if accessible, provides an excellent medium. Occasionally, particularly with metastatic
lung abscesses, blood culture findings may be positive. Most patients never have appropriate
specimens obtained for culture; most are treated empirically and do well despite the lack of exact
microbiologic culture results.
Chest radiographs
The chest radiograph of a lung abscess is not pathognomic in the early stages, ie, before
communication is achieved between the abscess cavity and draining bronchus. An area of thick
pneumonic consolidation precedes the emergence of the typical cavitary air-fluid form. The distinctive
characteristic of lung abscess, the air-fluid level, can only be observed on a chest x-ray film taken with
the patient upright or in the lateral decubitus position. In the presence of associated pleural thickening,
atelectasis, or pneumothorax, the air-fluid level may be obscured. When better anatomic interpretation
is required, CT scans have proven very useful.
Opportunistic lung abscesses are more difficult to diagnose. They occur in patients at the extremes of
age and in patients with multiple medical problems. Under these conditions, multiple abscesses often
evolve, and most of these are nosocomial. Typically, the microbial flora in these patients is gram-
negative. Similar to aspiration-induced lung abscess, cavitation is generally apparent on chest
radiographs 2 weeks after the onset of cough, fever, and pleuritic chest pain.
Chest CT scan images are valuable for demonstrating cavitation within an area of consolidation, for
evaluating the thickness and regularity of the abscess wall, and for determining the exact position of
the abscess with regard to the chest wall and bronchus. CT scan images can also aid in evaluating the
extent of bronchial involvement proximal or distal to the abscess.
Invasive diagnostic procedures
Invasive diagnostic techniques occasionally recommended to diagnose lung abscesses include
transtracheal aspirates, transthoracic aspirates, and fiberoptic bronchoscopy. These procedures must
be performed prior to the institution of antibiotic therapy in order to acquire dependable microbiological
data. The indications and comparative benefits of such procedures are controversial and depend to a
great extent on operator ability. Most pulmonologists believe that these diagnostic procedures should
not be performed routinely in patients with possible anaerobic lung abscesses; they should be
reserved for patients with atypical presentations.

10. Fiberoptic bronchoscopy is a useful adjunct in the diagnostic evaluation of patients with lung abscess.
Secretions obtained from the lower respiratory tract via either lavage or brush can be submitted for
culture and sensitivity. Rigid, sterile, and aseptic technique is crucial (eg, use of lidocaine without
preservatives, minimal use of topical anesthetic, specimen transport under anaerobic conditions,
avoidance of delays in processing), although prior or concurrent antibiotic therapy can cause confusing
results.
Thus, in patients who have a classic history and radiological presentation of anaerobic lung abscess,
the medically sound decision may be to start with empirical antibiotic therapy without prior
bronchoscopy. However, for patients with atypical presentations or unclear diagnoses, bronchoscopy
should be considered. Bronchoscopy may also be used to exclude the presence of a foreign body or
neoplasm.
If no specimens are available for analysis and diagnosis, percutaneous transtracheal aspiration is an
easy, safe, and dependable way of establishing the specific cause of a lung abscess. This procedure
should be avoided in patients with coagulation disorders or bleeding tendencies and in those for whom
it is difficult to provide adequate oxygenation.
For patients with amebic liver abscess, Entamoeba histolytica may be recovered from the sputum. The
vast majority of patients with extraintestinal amebiasis have high titers of hemoagglutinin in the serum.
Differential diagnosis
Cavitary lesions in the lung parenchyma have several causes, but a patient with an acute presentation
of an illness with air-fluid levels should elicit consideration of a lung abscess. Lung parenchymal cystic
lesions and secondarily infected bullae can occasionally confuse the picture. The prior existence of
these lesions, as documented by old radiographs and the segmental location, are not typical of lung
abscess.
Patients with squamous cell bronchial carcinomas can also present with cavitary lesions that are
sometimes difficult to differentiate from lung abscesses. Realizing that the wall of the carcinomatous
abscess is usually thicker and more irregular than that of the primary abscess is helpful. Further, foul
sputum, no response to antibiotics, and the absence of fever may help distinguish the 2 entities.
Because an abscess distal to bronchial obstruction usually occurs in an area of lobar pneumonitis and
atelectasis—but otherwise appears as a primary abscess—early bronchoscopy is recommended in all
cases.
Antibiotics in lung abscess
• Anaerobic organisms1
o First choice - Clindamycin (Cleocin 3)
o Alternative - Penicillin
o Oral therapy - Clindamycin, metronidazole (Flagyl), amoxicillin (Amoxil)
• Gram-negative organisms
o First choices - Cephalosporins, aminoglycosides, quinolones
o Alternatives - Penicillins and cephalexin (Biocef)
o Oral therapy - Trimethoprim/sulfamethoxazole (Septra)
• Pseudomonal organisms: First choices include aminoglycosides, quinolones, and
cephalosporin.
• Gram-positive organisms
o First choices - Oxacillin (Bactocill), clindamycin, cephalexin, nafcillin (Nafcil), and
amoxicillin
o Alternatives - Cefuroxime (Ceftin) and clindamycin
o Oral therapy - Vancomycin (Lyphocin)
• Nocardial organisms: First choices include trimethoprim/sulfamethoxazole and tetracycline
(Sumycin).
Drainage

11. Most lung abscesses communicate with the tracheobronchial tree early in the course of the infection
and drain spontaneously during the course of therapy. Dependent drainage (with appropriate positions
based on the pulmonary segment) is commonly advocated using chest physical therapy and
sometimes bronchoscopy. Bronchoscopy can also facilitate abscess drainage by aspiration of the
appropriate bronchus through the bronchoscope. Transbronchial drainage by catheterization of the
appropriate bronchus under fluoroscopy has been successful.
Generally, augmenting this passive drainage with invasive procedures is unnecessary. In fact,
attempts at therapeutic bronchoscopy may sometimes produce adverse consequences. Reports have
been received of bronchoscopy-induced release of large amounts of purulent material from the
involved lung segment into other parts of the lung, occasionally inducing acute respiratory failure,
acute respiratory distress syndrome (ARDS), or both.
Course of treatment
If treatment is started in the acute stage of the disease and is continued for 4-6 weeks, approximately
85-95% of patients with anaerobic lung abscesses respond to medical management alone. Successful
medical therapy resolves symptoms with no radiographic evidence or only a residual thin-walled cystic
cavity (<2 cm after 4-6 wk of antibiotic therapy).
The success of medical therapy is dependent on the duration of symptoms and the size of the cavity
before the initiation of therapy. Antibiotic therapy is rarely successful if symptoms are present for
longer than 12 weeks before the initiation of antibiotic therapy or if the original diameter of the cavity is
more than 4 cm. When patients with lung abscesses do not respond to proper medical therapy,
consider the probability of an underlying malignancy.
Surgical Treatment
Contraindications to surgery
Several important factors must be considered prior to undertaking surgery. Because of the high risk of
spillage of the abscess into the contralateral lung, it is almost essential that a double-lumen tube be
used to protect the airway. If this is not available, surgery poses a very high risk of abscess in the
other lung and a risk of ARDS. In such cases, postponing the surgery is a wise decision. Another, less-
satisfactory method to deal with this problem includes positioning the patient in the prone position. The
surgeon must be skilled in resecting the abscess and in rapid clamping of the bronchus to prevent
spillage into the trachea. These factors are extremely important when dealing with the surgical aspects
of treating a lung abscess. If doubt persists, postponing the surgery is best.
Surgical treatment is now rarely necessary and is almost never the initial choice in the treatment of
lung abscesses. In current practice, fewer than 15% of patients need surgical intervention for the
unchecked disease and for complications that occur in both the acute and chronic stages of the
disease.
Surgical management is reserved for specific indications such as little or no response to medical
treatment, inability to eliminate a carcinoma as a cause, critical hemoptysis, and complications of lung
abscess (eg, empyema, bronchopleural fistula). In addition, if after 4-6 weeks of medical treatment a
notable residual cavity remains and the patient is symptomatic, surgical resection is advocated.
The results of surgery are difficult to assess because of the varying patient population and the
tremendous increase in illicit drug abuse, alcoholism, AIDS, and infections by gram-negative and
opportunistic organisms. These factors have increased the incidence of lung abscess and the
associated morbidity.
A great deal of caution is needed during anesthesia when patients with lung abscess undergo surgery
because spillage of the abscess material into the uninvolved lung can occur. Therefore, a double-
lumen endotracheal tube is used in all cases.
Indications for surgery
• Probable carcinoma
• Significant hemoptysis

12. Percutaneous drainage
Percutaneous drainage of a complicated abscess (ie, one associated with fever and signs of sepsis) is
beneficial in selected patients who do not respond to adequate medical therapy.2 These are ventilator-
dependent patients who are not candidates for extensive thoracic procedures.
Other indications for drainage include ongoing sepsis despite adequate antimicrobial therapy,
progressively enlarging lung abscess in imminent danger of rupture, failure to wean from mechanical
ventilation, and contamination of the opposite lung. In current practice, most of these lung abscesses
are drained under CT guidance.2
Results achieved with percutaneous drainage show it to be safe and effective compared to surgery.
Percutaneous drainage is rarely complicated by empyema, hemorrhage, or bronchopleural fistula.
Although a few patients who undergo percutaneous drainage develop bronchopleural fistulas, most of
these fistulas close spontaneously with resolution of the abscess cavity. Percutaneous drainage may
be used to stabilize and prepare critically ill patients for surgery.
Hospital-acquired gram-negative infections are usually due to nosocomial organisms (eg,
Pseudomonas, Enterobacter, Proteus). Patients with these infections are often elderly, debilitated with
numerous major medical disorders, or have sustained multiple trauma. These patients are typically
treated in a critical care unit.
The infection is usually with a resistant organism originating from a single source. The lung abscess
appears rapidly as an area of pneumonitis with associated pleural involvement. These patients often
require percutaneous drainage as an emergency procedure. Unfortunately, the infection is systemic
and often out of control, and the pulmonary pathology represents only one aspect of a multiorgan
involvement with a rapidly deteriorating course.
Among fungal infections, Candida albicans has become a major organism in lung abscesses. Fungal
infections are difficult to treat, and amphotericin/fluconazole and surgical drainage remain the only
modalities of treatment; however, at best, they have had only limited success.
Complications and Prognosis
Complications
Approximately one third of lung abscesses are complicated by empyema. This may be observed with
or without bronchopleural fistulas. Hemoptysis is a common complication of a lung abscess and can be
treated with bronchial artery embolization. Occasionally, the hemoptysis can be massive, thus
requiring urgent surgery. Brain abscess may also be a complication in patients who receive inadequate
treatment.
Prognosis
The prognosis of patients with lung abscesses depends on the underlying or predisposing pathologic
event and the speed with which appropriate therapy is established. Negative prognostic factors include
a large cavity (>6 cm), necrotizing pneumonia, multiple abscesses, immunocompromise, age
extremes, associated bronchial obstruction, and aerobic bacterial pneumonia. The mortality rate
associated with an anaerobic lung abscess is less than 15%, although it is slightly higher in patients
with necrotizing anaerobic pneumonia and pneumonia caused by gram-negative bacteria. The
prognosis associated with amebic lung abscess is good when treatment is prompt.