Chronic Pulmonary Infection

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Chronic Pulmonary Infection

• Dr Tom Fardon
• Respiratory SpR

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Diagnosis?

• Shadow on CXR
• Weight loss
• Persistent sputum production
• Chest pain
• Increasing shortness of breath

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Differential Diagnosis

• Lung Cancer
• Not unreasonable
• Intrapulmonary abscess
• Empyema
• Bronchiectasis
• Cystic Fibrosis

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Intrapulmonary Abscess

• Indolent presentation
• Weight loss common
• Lethargy, tiredness, weakness
• Cough sputum
• High mortality if not treated
• Usually a preceding illness of some sort

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Preceding Illnesses

• Pneumonia
• Aspiration pneumonia
• Vomiting
• Lowered conscious level
• Pharyngeal pouch
• Poor host immune response
• Hypogammaglobulinaemia

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Pathogens

• Bacteria
• Streptococcus
• Staphylococcus (Particularly post flu)
• E-Coli
• Gram Negatives
• Fungi
• Aspergillus

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Empyema
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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
• gt 20 of all patients with empyema die

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Progression of Effusion to Empyema

• Simple Parapneumonic Effusion
• Clear fluid
• pH gt 7.2
• LDH lt 1000
• Glucose gt 2.2
• Complicated Parapneumonic Effusion
• pH lt 7.2
• LDH gt 1000
• Glucose lt 2.2
• Requires Chest Tube Drainage
• Emyema
• Frank pus
• No other tests required
• Requires Chest Tube Drainage

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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

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Diagnosis

• Clinical suspicion
• The slow to resolve pneumonia
• Dont 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

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CXR

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

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CXR - D Sign
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Lateral CXR

• Particularly useful in small retro-diaphragmatic
  collections
• Not straightforward in ICU

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USS
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USS in Empyema
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CT Examination of Pleural Space
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Empyema CT
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Use USS or CT to position the drain site
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Insertion of a Surgical Drain
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Trocar Introduction
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Insertion of a Seldinger Drain
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Insertion of a Seldinger Drain
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Other Treatment

• IV antibiotics
• Broad spectrum
• Co-amoxyclav initially
• Oral antibiotics
• Directed towards cultured bacteria
• At least 14 days

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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

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Treatment Options

• Stop smoking
• Flu vaccine
• Pneumococcal vaccine
• Reactive antibiotics
• Send sputum sample
• Give antibiotics appropriate to most recent
  positive culture

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Treatment

• When colonised with persistent bacteria
• Prophylactic antibiotics
• Nebulised colomycin
• Pulsed IV abx
• Alternating oral antibiotics

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Anti-inflammatory Treatment

• Low dose macrolide antibiotics have been shown to
  reduce exacerbation rates in bronchiectasis
• Clarithromycin 250 mg OD

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Prognosis

• Recurrent infection
• Abscesses and empyema
• Colonisation

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Cystic Fibrosis

• Congenital cause of bronchiectasis
• And much more

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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 1990s have a predicted
  survival into the 40s

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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

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Case Study

• Diagnosed at 10 months with steatorrhea and LRTI
• Stable until 13 when she required increasingly
  frequent IVs
• Pregnancy 1996 - TOP _at_ 16 weeks
• Since 1998 she has suffered more frequent
  exacerbations and now requires IVs monthly

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• 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

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

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

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Specialities Involved

• Respiratory
• Gastro-Intestinal
• Obs Gynae
• GP/DN
• Surgery
• Transplant team
• Child Family Psychiatry

• ICU
• Anaesthesia

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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

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