Lung Abscess

LUNG ABSCESS
BY PRAJWAL RAO. K, 8TH TERM

CONTENTS
 Definition
 Common organisms
 Predisposing factors
 Pathophysiology
 Pathology
 Clinical presentation
 Investigations
 Management
 Complications
 Differential diagnosis
 Prognosis
INTRODUCTION
 DEFINITION:
It is a localised infectious suppurative necrosis of lung tissue of
> 2 cm in diameter.
 COMMON ORGANISMS:
Anaerobes, staphylococci, Pseudomonas, Legionella sp,
Streptococcus pneumoniae, M. tuberculosis, Nocardia sp.

P R E D I S P O S I N G FA C T O R S
1. Aspiration of infected material (oropharyngeal surgical procedures,
dental sepsis, coma, drugs, alcohol, anaesthesia, bulbar palsy, seizures,
achalasia cardia).
2. Inadequately treated pneumonia.
3. Bronchial obstruction (tumour, foreign body).
4. Pulmonary infarction.
5. Septic emboli.
6. Spread of infection from adjacent organs, e.g. liver.
7. Infection of congenital or acquired cysts.

Abscesses vary in size and number.
Aspiration abscesses are more common on right, reflecting
the more vertical right bronchus.
Posterior segment of right upper lobe or apical segment of
either lower lobe are commonly involved.
Chronic abscesses are often surrounded by a reactive fibrous
wall.
PAT H O L O G Y
SYMPTOMS
1. Mild general toxaemia – with slight fever. No symptoms
referable to respiratory tract.
2. Sudden onset – with high fever, pleuritic chest pain, cough
and later copious expectoration.
3. Symptoms of subacute or chronic respiratory disease –
cough, foetid breath, expectoration and general toxaemia.
Haemoptysis may occur, or pain due to associated pleurisy.

SIGNS
 Depend on situation and size of abscess and surrounding
infiltration.
1. In early stages – Pleural rub, local area of dullness and weak
breath sounds or signs of consolidation.
2. After evacuation of pus – Signs of cavitation or signs of localized
consolidation with amphoric or cavernous breath sounds and
crackles of the resonating variety.
3. Signs of effusion – may overshadow those of the lung lesion.
4. Clubbing of fingers.
I N V E S T I G AT I O N S
1. Leucocyte count – 20,000 to 30,000 cells per c.mm.

2. Sputum – Pus cells, organisms and necrotic lung
tissue.
3. Chest radiograph – In acute phase dark shadow,
later cavity with fluid level.
4. Bronchoscopy – to exclude foreign body or
carcinoma.
5. CT scan.
IMAGING
Radiological images
reveal diagnostic
appearance of lung
abscess with air–fluid
level.
Chest x-ray film: PA

view (A), lateral
view (B), and CT (C).
C O M P L I C AT I O N S
1. Haemoptysis.
2. Extension of inflammation to other parts of lung.
3. Cerebral abscess.
4. Rupture into pleural cavity.

DIFFERENTIAL DIAGNOSIS
1. Bronchiectasis
2. Cavitated bronchial carcinoma (elderly patient)
3. Purulent bronchitis (long history)
4. Caseating tuberculosis
5. Interlobar empyema
6. Infected lung cyst (particularly bronchogenic and hydatid)
7. Pulmonary infarction…
D/D – cont’d
1. Empyema with bronchopleural fistula
2. Pulmonary haematoma
3. Pulmonary mycoses
4. Infected pulmonary bulla with fluid level
5. Cavitated pneumoconiosis (Caplan’s nodules)
6. Cystic fibrosis (mucoviscidosis)
7. Wegener’s granulomatosis.
MANAGEMENT
G E N E R A L :
a) Rest in bed. Ambulation as soon as signs of toxicity
disappear.
b) High caloric, high protein diet with additional
vitamins.
c) Transfusions as indicated.
d) Deep breathing exercises to encourage drainage.

MECHANICAL PROCEDURES:
a) Postural drainage – Percussion therapy or “clapping” over the site of
the abscess with the patient in the postural drainage position.
b) Bronchoscopy – Suction is applied to the orifices of the bronchi.
c) Oxygen inhalations – when sputum is foul because it checks the
anaerobic organisms.
d) Head elevation – patient bed should be inclined to 45º.
e) Minimal sedation used to avoid aspiration.

I & D OF
ABSCESS
This lung abscess is a build-up of
fluid near the lung (A). To drain
it, the patient is placed on his or
her side, and an incision is made
(B). A rib is exposed (C) and cut
(D). The fluid in the abscess is
suctioned (E), and the incision is
closed around a temporary
drainage tube (F). (Illustration by
GGS Inc.)
Read more:
https://www.surgeryencyclopedia.com
/A-Ce/Abscess-Incision-and-Drainage.
html#ixzz61UN8dXm7
C H E M O T H E R A P Y :
 Amoxicillin 1 g. t.d.s. p.o. + Metronidazole 400 mg t.d.s. p.o. or
Co-amoxiclav 500 mg t.d.s. or Clarithromycin 250–500 mg t.d.s.
 Inj. Clindamycin 600 mg three times a day till fever disappears
then switched to 300 mg four times a day orally or Inj. Β
lactam/β lactamase inhibitor combination is used.
 Oral therapy as fever subsides.

 B R O N C H O S C O P Y – may be needed to
remove particulate matter or to exclude bronchial

obstruction.
S U R G I C A L R E S E C T I O N – If at end
of 3 weeks, there is no clinical and radiological
improvement, segmental resection of lung,
lobectomy or pneumonectomy. Also if localized
malignancy or massive haemoptysis.
PROGNOSIS
Following factors indicate poor prognosis:
1. Age > 60 years;
2. Sepsis at presentation;
3. Abscess size > 6 cm;
4. Aerobic growth on culture;
5. Symptoms longer than 8 weeks.

REFERENCES
1. Golwalla’s MEDICINE for students – 25th edition.

2. R. Alagappan manual of practical medicine – 4th
edition.
3. Images from google.
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LUNG ABSCESS

BY PRAJWAL RAO. K, 8TH TERM

It is a localised infectious suppurative necrosis of lung tissue of

Anaerobes, staphylococci, Pseudomonas, Legionella sp,

Streptococcus pneumoniae, M. tuberculosis, Nocardia sp.

1. Aspiration of infected material (oropharyngeal surgical procedures,

dental sepsis, coma, drugs, alcohol, anaesthesia, bulbar palsy, seizures,

2. Inadequately treated pneumonia.

3. Bronchial obstruction (tumour, foreign body).

6. Spread of infection from adjacent organs, e.g. liver.

7. Infection of congenital or acquired cysts.

Aspiration abscesses are more common on right, reflecting

the more vertical right bronchus.

Posterior segment of right upper lobe or apical segment of

either lower lobe are commonly involved.

Chronic abscesses are often surrounded by a reactive fibrous

1. Mild general toxaemia – with slight fever. No symptoms

referable to respiratory tract.

2. Sudden onset – with high fever, pleuritic chest pain, cough

and later copious expectoration.

3. Symptoms of subacute or chronic respiratory disease –

cough, foetid breath, expectoration and general toxaemia.

Haemoptysis may occur, or pain due to associated pleurisy.

 Depend on situation and size of abscess and surrounding

1. In early stages – Pleural rub, local area of dullness and weak

breath sounds or signs of consolidation.

2. After evacuation of pus – Signs of cavitation or signs of localized

consolidation with amphoric or cavernous breath sounds and

crackles of the resonating variety.

3. Signs of effusion – may overshadow those of the lung lesion.

1. Leucocyte count – 20,000 to 30,000 cells per c.mm.

Chest x-ray film: PA

2. Extension of inflammation to other parts of lung.

4. Rupture into pleural cavity.

2. Cavitated bronchial carcinoma (elderly patient)

3. Purulent bronchitis (long history)

6. Infected lung cyst (particularly bronchogenic and hydatid)

1. Empyema with bronchopleural fistula

4. Infected pulmonary bulla with fluid level

5. Cavitated pneumoconiosis (Caplan’s nodules)

6. Cystic fibrosis (mucoviscidosis)

a) Rest in bed. Ambulation as soon as signs of toxicity

b) High caloric, high protein diet with additional

d) Deep breathing exercises to encourage drainage.

a) Postural drainage – Percussion therapy or “clapping” over the site of

the abscess with the patient in the postural drainage position.

b) Bronchoscopy – Suction is applied to the orifices of the bronchi.

c) Oxygen inhalations – when sputum is foul because it checks the

d) Head elevation – patient bed should be inclined to 45º.

e) Minimal sedation used to avoid aspiration.

fluid near the lung (A). To drain

it, the patient is placed on his or

her side, and an incision is made

(B). A rib is exposed (C) and cut

(D). The fluid in the abscess is

suctioned (E), and the incision is

closed around a temporary

drainage tube (F). (Illustration by

 Amoxicillin 1 g. t.d.s. p.o. + Metronidazole 400 mg t.d.s. p.o. or