Lung Abscess

Definition

Lung abscess is an acute or chronic infection of the lung, marked by a localized collection of pus, inflammation, and destruction of tissue.

Description

Lung abscess is the end result of a number of different disease processes ranging from fungal and bacterial infections to cancer. It can affect anyone at any age. Patients who are most vulnerable include those weakened by cancer and other chronic diseases; patients with a history of substance abuse, diabetes, epilepsy, or poor dental hygiene; patients who have recently had operations under anesthesia; and stroke patients. In children, the most vulnerable patients are those with weakened immune systems, malnutrition, or blunt injuries to the chest.

Causes and symptoms

The immediate cause of most lung abscesses is infection caused by bacteria. About 65% of these infections are produced by anaerobes, which are bacteria that do not need air or oxygen to live. The remaining cases are caused by a mixture of anaerobic and aerobic (airbreathing ) bacteria. When the bacteria arrive in the lung, they are engulfed or eaten by special cells called phagocytes. The phagocytes release chemicals that contribute to inflammation and eventual necrosis, or death, of a part of the lung tissue. There are several different ways that bacteria can get into the lung.

Aspiration

Aspiration refers to the accidental inhalation of material from the mouth or throat into the airway and lungs. It is responsible for about 50% of cases of lung abscess. The human mouth and gums contain large numbers of anaerobic bacteria; patients with periodontal disease or poor oral hygiene have higher concentrations of these organisms. Aspiration is most likely to occur in patients who are unconscious or semi-conscious due to anesthesia, seizures, alcohol and drug abuse, or stroke. Patients who have problems swallowing or coughing, or who have nasogastric tubes in place are also at risk of aspiration.

Bronchial obstruction

The bronchi are the two branches of the windpipe that lead into the lungs. If they are blocked by tissue swelling, cancerous tumors, or foreign objects, a lung abscess may form from infection trapped behind the blockage.

 

Spread of infection

About 20% of cases of pneumonia that cause the death of lung tissue (necrotizing pneumonia) will develop into lung abscess. Lung abscess can also be caused by the spread of other infections from the liver, abdominal cavity, or open chest wounds. Rarely, AIDS patients can develop lung abscess from Pneumocystis carinii and other organisms that take advantage of a weakened immune system.

Lung abscess is usually slow to develop. It may take about two weeks after aspiration or bronchial obstruction for an abscess to produce noticeable symptoms. The patient may be acutely ill for two weeks to three months. In the beginning, the symptoms of lung abscess are difficult to distinguish from those of severe pneumonia. Adults will usually have moderate fever (101-102°F/38-39°C), chills, chest pain, and general weakness. Children may or may not have chest pain, but usually suffer weight loss and high fevers. As the illness progresses, about 75% of patients will cough up foul or musty-smelling sputum; some also cough up blood.

Lung abscess can lead to serious complications, including emphysema, spread of the abscess to other parts of the lung, hemorrhage, adult respiratory distress syndrome, rupture of the abscess, inflammation of the membrane surrounding the heart, or chronic inflammation of the lung.

Diagnosis

The diagnosis is made on the basis of the patient's medical history (especially recent operations under general anesthesia) and general health as well as imaging studies. Smears and cultures taken from the patient's sputum are not usually very helpful because they will be contaminated with bacteria from the mouth. The doctor will first use a bronchoscope (lighted tube inserted into the wind-pipe) to rule out the possibility of lung cancer. In some cases of serious infection, the doctor can use a fiberoptic bronchoscope with a protected specimen brush to take material directly from the patient's lungs, for identification of the organism. This technique is time-consuming and expensive, and requires the patient to be taken off antibiotics for 48 hours. It is usually used only to evaluate severely ill patients with weakened immune systems.

In most cases, the doctor will use the results of a chest x ray to help distinguish lung abscess from empyema, cancer, tuberculosis, or cysts. In patients with lung abscess, the x ray will show a thick-walled unified clear space or cavity surrounded by solid tissue. There is often a visible air-fluid level. The doctor may also order a CT scan of the chest, in order to have a clearer picture of the exact location of the abscess.

Blood tests cannot be used to make a diagnosis of lung abscess, but they can be useful in ruling out other conditions. Patients with lung abscess usually have abnormally high white blood cell counts (leukocytosis) when their blood is tested, but this condition is not unique to lung abscess.

Treatment

Lung abscess is treated with a combination of antibiotic drugs, oxygen therapy, and surgery. The antibiotics that are usually given for lung abscess are penicillin G, penicillin V, and clindamycin. They are given intravenously until the patient shows signs of improvement, and then continued in oral form. The patient may need to take antibiotics for a month or longer, until the chest x ray indicates that the abscess is healing. Oxygen may be given to patients who are having trouble breathing.

Surgical treatment

Most patients with lung abscess will not need surgery. About 5% of patients—usually those who do not respond to antibiotics or are coughing up large amounts of blood (500 mL or more)—may have emergency surgery for removal of the diseased part of the lung or for insertion of a tube to drain the abscess. Antibiotic treatment is considered to have failed if fever and other symptoms continue after 10-14 days of treatment; if chest x rays indicate that the abscess is not shrinking; or if the patient has pneumonia that is spreading to other parts of the lung.

Supportive care

Because lung abscess is a serious condition, patients need quiet and bed rest. Hospital care usually includes increasing the patient's fluid intake to loosen up the secretions in the lungs, and physical therapy to strengthen the patient's breathing muscles.

Follow-up

Patients with lung abscess need careful follow-up care after the acute infection subsides. Follow-up usually includes a series of chest x rays to make sure that the infection has cleared up. Treatment with antibiotics may continue for as long as four months, to prevent recurrence.

Prognosis

About 95% of lung abscess patients can be treated successfully with antibiotics alone. Patients who need surgical treatment have a mortality rate of 10-15%.

Prevention

Some of the conditions that make people more vulnerable to lung abscess concern long-term lifestyle behaviors, such as substance abuse and lack of dental care. Others, however, are connected with chronic illness and hospitalization. Aspiration can be prevented with proper care of unconscious patients, which includes suctioning of throat secretions and positioning patients to promote drainage. Patients who are conscious can be given physical therapy to help them cough up material in their lungs and airways. Patients with weakened immune systems can be isolated from patients with pneumonia or fungal infections.