Lungs abscess and bronchitis

Lungs Abscess And Bronchitis
Chanak Trikhatri

Lungs Abscess
• Introduction and Definition lungs abscess
• Epidemiology
• Etiology and risk factor
• Pathophysiology
• Clinical Feature
• Diagnosis and investigation
• Management
– Medical
– Surgical
– Nursing
• Prognosis
• Complication
• Prevention
• Recent Research

Introduction
• Lungs abscess is a collection of pus within the
lung tissue. In its early stages, the abscess
resembles a localized pneumonia. If a lung
abscess remains unidentified and untreated,
tissue necrosis may occur. Lung abscesses are
become more rare as result of improved
treatment of pneumonia and effective
preventive care clients at high risk for
aspiration.

Introduction contd…..
Single lung abscesses usually occur distal to a
bronchial obstruction. Most of the time they
creates putrid material. The obstruction may
be due to following
• Aspirated foreign material
• Benign and malignant tumors
multiple lungs abscesses can follow
pneumonia caused by necrotizing bacteria

Definition
Lung Abscess is the localized suppurative
necrosis of lung tissue due to infection,
commonly by staphylococci, streptococci,
numerous gram-negative species, and
anaerobes. A lung abscess is a localized
necrotic lesion of the lung parenchyma
containing purulent material that collapses
and forms a cavity.

Definition Contd….
It is generally caused by aspiration of
anaerobic bacteria. By definition, the chest x-
ray will demonstrate a cavity of at least 2 cm.
Lung abscess is considered
• Primary :- when it results from existing lung
parenchymal process.
• Secondary:- when it complicates another
process e.g. vascular emboli or follows rupture
of extra-pulmonary abscess into lung.

Lesions
• Abscesses vary in number (single or multiple) and
size (microscopic to many centimeters in
diameter).
• Single abscess usually occur distal to a bronchial
obstruction, commonly from aspirated foreign
material or tumors.
• Multiple abscesses can follow pneumonia caused
by necrotizing bacteria(s. aureus),which creates
necrotic lung tissue.

Lesions
• Aspiration abscesses are common on the right
due to more vertical right bronchus.
• Contain variable mixtures of pus and air,
depending on available drainage through airways.
• Abscesses due to pneumonia or bronchietasis are
usually, multiple, basal, and diffusely scattered.
• Septic emboli and pyemic abscesses are multiple
and seen in any part of the lungs.
• Chronic abscesses are often surrounded by
reactive fibrous wall.

Cause
• Aspiration of infected material such as:
– In oropharyngial surgery
– Dental sepsis
– Aspiration secondary to diminished consciousness from
coma, drugs, anesthesia and seizures.
• Organisms
– Anaerobic bacteria: Peptostreptococcus, Bacteroides,
species,
– streptococcus: Streptococcus milleri
– Aerobic bacteria: Staphylococcus, Klebsiella,
Haemophilus, Pseudomonas, Escherichia coli,
– Fungi: Candida, Aspergillus

Cause contd…
• Previous primary bacterial infection (Example:
Post-pneumonic abscess).
• Septic embolism from infected emboli, or
vegetations of infective bacterial endocarditis on
the right side of the heart.
• Primary or metastatic tumors may cause
obstruction of the bronchopulmonary segment
leading to infection and abscess formation.
• Direct traumatic puncture of the lungs

Risk Factor
• Person who impaired cough reflexes
• Cannot close the glottis
• Swallowing difficulties
• Central nervous system disorders (seizure,
stroke)
• Drug addiction
• Alcoholism

Risk Factor Contd…
• Esophageal disease
• Bacterial pneumonia
• Compromised immune function
• Those without teeth
• nasogastric tube feedings
• altered state of consciousness from
anesthesia.

Pathophysiology
Alveolar macrophages initiates the inflammatory
response to bolster lower respiratory tract defense
Causative organism and factor invade the pulmonary
tissues
Due to etiology/ risk factor

Pathophysiology contd….
release neutrophils and esionophils
These mediators start to necrotize the tissue
Chemokines (IL-8) and granulocyte colony stimulating factor
(Fever)
Release of inflammatory mediators, such as interleukin(IL-1) and TNF(Tumor
necrosis factor)

Impaired gas exchange and appearance of clinical features
Consolidation in the lung
leukocytosis increase purulent secretion and form lesions
alveolar capillary leak
Pathophysiology contd….

Pathophysiology
Initially, the cavity in the lung may or may not extend
directly into a bronchus. Eventually the abscess
becomes surrounded, or encapsulated, by a wall of
fibrous tissue. The necrotic process may extend until it
reaches the lumen of a bronchus or the pleural space
and establishes communication with the respiratory
tract, the pleural cavity, or both. If the bronchus is
involved, the purulent contents are expectorated
continuously in the form of sputum. If the pleura is
involved, an empyema results. A communication or
connection between the bronchus and pleura is known
as a bronchopleural fistula.

Clinical Feature
• Vary from a mild productive cough to acute
illness
• fever with shivering and night sweating
• Productive cough with moderate to copious
amounts of foul smelling, purulent cough
• Blood in sputum
• Leukocytosis
• Pleurisy

Clinical Feature contd…
• Dull chest pain
• Dyspnea, shortness of breath
• Weakness, lethargy
• Anorexia, and weight loss
• Finger clubbing
• On examination of chest there will be features
of consolidation such as localised dullness on
percussion, bronchial breath sound

Diagnostic Findings
• History taking:
– Dental problem, previous respiratory infection, trauma.
• Physical examination:
– General examination reveals anemia, fever, finger clubbing.
– Dullness on percussion and decreased or absent breath sounds
with an intermittent pleural friction rub (grating or rubbing
sound) on auscultation, crackles may present.
• Chest x-ray:
– To help diagnose and locate lesion ,often shows an opaque area
of consolidation.
• Direct bronchoscopic:
– Visualization to exclude possibility of tumor or foreign body.

• Sputum culture and sensitivity tests:
– To determine causative organisms and antimicrobial
sensitivity and cytological examination for malignant cells.
• CT scan:
– To exclude the malignancies, scan of thorax can detect lung
abscess with certainty.
• CBC:
– anaemia, leucocytosis and raised ESR.
• Immunological test:
– which detects microbial antigens in serum , sputum and
urine.
Diagnostic Findings Cont….

Diagnostic Findings Cont….
• Thoracentesis:
– to obtain a specimen of pleural fluid for
examination
• Ventilation–perfusion scan:
– The test of choice and clinically important in
patients with suspected Pleural Effusion, hence it
is done to exclude the Pleural effusion
• Arterial blood gas analysis:
– May show hypoxemia and hypocapnia (from
tachypnea Peripheral vascular studies

Diagnostic Findings Cont…
• Pulmonary angiogram:
– This test is invasive. A contrast agent is injected into
the pulmonary arterial system, allowing visualization
of obstructions to blood flow and abnormalities.
• Peripheral vascular studies:
– Test results confirm or exclude the diagnosis of PE.
• ECG
• Biopsy
• MRI

Management (Non-Pharmacological)
• According to the findings of the history, physical
examination, chest x-ray, and sputum culture
indicate the type of organism and the treatment
required.
• Pulmonary physiotherapy and postural drainage are
also important.
• Percutaneous chest catheter placed for long-term
drainage of the abscess

• Therapeutic use of bronchoscopy to drain an
abscess
• A diet high in protein and calories is necessary
because chronic infection is associated with a
catabolic state, necessitating increased intake
of calories and protein to facilitate healing
• Fluid and electrolyte management

Management (Pharmacological)
• Most often ampicillin 500mg PO X QIDs or
cotrimoxazole 1g PO X BD or clinadamycin
• On the basis of the result of the sputum
culture and sensitivity IV antimicrobial therapy
is administered Penicillin G or clindamycin
(Cleocin) is the medication of choice with
metronidazole added in serious cases.
Penicillin G benzathine 1 Million U IM single
dose, 400,000-600,000 U PO X q4-q6 h

• Metronidazole 400mg PO X TDS if there is foul
smell of the sputum
• The intravenous dose is continued until there is
evidence of symptom improvement.
• Long-term therapy with oral antibiotics replaces
intravenous therapy after the patient shows signs
of improvement
• Oral administration of antibiotic therapy is
continued for an additional 4 to 8 weeks.
• If treatment stops too soon, a relapse may occur.

Management (Surgical)
• Surgical intervention is rare, but pulmonary
resection (lobectomy) is Performed. And
indication are:-
• Massive hemoptysis
• No response medical management
• Localized malignancy
• Persistent abscess cavity

Nursing Management
• Assessment
– History of food particle aspirations, previous
respiratory problem, trauma
– Examine oral cavity because poor condition of teeth
and gums increases number of anaerobes in oral
cavity
– Perform chest examination, dullness on percussion
and decreased or absent breath sounds with an
intermittent pleural friction rub (grating or rubbing
sound) on auscultation. Crackles may be present.
– Monitor for foul-smelling sputum ,indicate an
anaerobic pulmonary infection.

Nursing Management
• Nursing diagnosis
– Ineffective breathing pattern related to presence
of supportive lung diseases.
– Imbalance nutrition less than body requirement
related to catabolic state from chronic infection.
– Acute pain related to congestion, possible lung
infraction.
– Anxiety related to dyspnea ,pain and seriousness
of condition.
– Knowledge deficit regarding home management
of diseases

Nursing Management
• Nursing Intervention
– Improving respiratory status
• Observe patient’s breathing pattern, and other vital
signs, for evidence of improvement or deterioration.
• Monitor patient’s response to antimicrobial therapy:
take temperature at prescribed intervals.
• administers antibiotics and intravenous therapies as
prescribed and monitors for adverse effects.
• Chest physiotherapy is initiated as prescribed to
facilitate drainage of the abscess.

Nursing Management
• Implement additional interventions as indicated:
– Postural drainage may be recommended.
– position to be assumed depend on location of abscess
– improve the patient’s respiratory and vascular status.
– Oxygen therapy is administered to correct the
hypoxemia, relieve the pulmonary vascular
vasoconstriction, and reduce the pulmonary
hypertension.
– Carry out coughing and breathing exercises
– Measure and record the volume of sputum to follow
patients clinical course
– Give adequate fluids to enhance liquefying of
secretions

Nursing Management
– Control of pain
• Assess degree and characteristics of discomfort/pain.
• Monitor vital signs, noting elevated temperature.
• Position semi-Fowler’s position
• Turning and reposition frequently
• Administers opioid analgesics as prescribed for severe
pain.

Nursing Management
• Nursing intervention
– Attaining comfort
• Use nursing measure to generalized discomfort; oral
hygiene ,position of comfort .
• monitor vital signs to determine the severity of
infectious process.
• Encourage rest and limitation of physical activity.
• Monitor chest tube functioning.
• Evaluate signs of hypoxia, monitor pulse oximeter to
know oxygen level. ,
• Administer analgesics as directed.

Nursing Management
– Improved nutritional status
• Provide a high protein ,calorie diet.
• Offer liquid supplement for additional nutritional
support when anorexia limits patients intake.

Nursing Management
• Promoting Home and Community – Based
Care
– Teaching Patients Self-Care.
• How to monitor for signs and symptoms of infection
• How to care for and maintain the drain or tube
• Instructs the patient to perform deep-breathing and
coughing exercises every 2 hours during the day
• Perform chest percussion and postural drainage to
facilitate expectoration of lung secretions
• Importance of completing the antibiotic regimen
• Suggestions for rest and appropriate activity

Nursing Management
• Teach the patient how to contain airborne droplets and
secretions to reduce the risk of spreading the infection
• Practice good hand hygiene techniques to reduce the
risk of spreading the infection
• Explain disease transmission to the patient and the
need for prolonged therapy to help increase his
compliance with the treatment plan
• Encourage the patient to maintain adequate dietary
intake to maintain nutritional status, build strength, and
improve the body’s defense mechanisms
• Weigh the patient daily to assess nutritional status
• Teach patient for the follow up visit

Nursing Management
• Evaluations/expected outcomes:
– Cyanosis and dyspnea reduced; Sao2 improved.
– Coughs effectively, and dullnesss absence of
crackles.
– Appears more comfortable, free from pain.
– Fever controlled, no signs of infection.
– Understood the drug regime, self care activities
and nutritional support

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

Complication
• Bronchiectasis
• Empyema
• bacteraemia with metastatic infection such as
brain abscess
• bronchopleural fistula
• Pleuritis
• Progressive damage of lungs tissues

Prevention
• Appropriate antibiotic therapy before any
dental procedures in patients who must have
teeth extracted while their gums and teeth are
infected
• Adequate dental and oral hygiene, because
anaerobic bacteria play a role in the
pathogenesis of lung abscess
• Appropriate antimicrobial therapy for patients
with pneumonia

Bronchitis
• Introduction and Definition Bronchitis
• Epidemiology
• Etiology and risk factor
• Pathophysiology
• Clinical Feature
• Diagnosis and investigation
• Management
– Medical
– Surgical
– Nursing
• Prognosis
• Complication
• Prevention
• Recent Research

Introduction
A bronchitis, is an inflammation of the
mucous membranes of the the bronchial tree,
often follows infection of the upper
respiratory tract. A patient with a viral
infection has decreased resistance and can
readily develop a secondary bacterial
infection. Thus, adequate treatment of upper
respiratory tract infection is one of the major
factors in the prevention of bronchitis.

Introduction contd…..
Aside from infection, inhalation of physical
and chemical irritants, gases, and other air
contaminants can also cause acute bronchial
irritation. According to the length and severity
there are two types of bronchitis
• Acute bronchitis
• Chronic bronchitis

Acute Bronchitis
Bronchitis having short clinical course with
cough, expectoration and fever often caused
by the upper respiratory viral infection to the
bronchi

Chronic Bronchitis
Chronic or recurrent excess mucus secreation
in to the bronchial tree without a
demonstrable cause either local or general
occurring on most of the days at least three
months of the year at least two successive
year.

Cause
• Prolong exposure to the environmental pollution
• Prolong use of cigarette
• Occupation related to pollutant, allergens and fume
• Prolong use of fire wood
• Upper respiratory infection viral and bacterial
• Ascending infection from the adjacent anatomy

Risk Factor Contd…
• Fire wood kitchen
• Irritant gaseous pollutent

Pathophysiology
Inflammation features infiltration by neutrophils with fibrino-purulent exudation
Spread to the whole bronchus
The quantity of accumulated exudate from the inflammatory mediators
Inflammatory mediator release
Inflammatory response started accumulatoin of macrophage to phagocyte
Mircoorganism and polluent travel through the lungs tissue
Due to etiology and risk factor

Clinical Feature
• Initially, the patient has a dry, irritating cough and
expectorates scanty amount of mucoid sputum.
• Raw burning pain over the upper anterior chest wall
over the medisternm
• Pain increase with exposure of cold environments,
ciggrette smoking, cough
• Complains of sternal soreness from coughing
• Cough related syncope
• Fever or chills and night
• Sweats, headache, and general malaise.

Clinical Feature contd…
• As the infection progresses, the patient may
be short of breath
• Noisy inspiration and expiration (inspiratory
stridor and expiratory wheeze),
• Produce purulent (pus-filled) sputum.
• With severe bronchitis
• blood-streaked secretions may be
expectorated as a result of the irritation of the
mucosa of the airways.

Diagnostic Findings
• History taking:
– Personal habits smoking, prolong use of fire wood, previous
respiratory infection, trauma.
• Physical examination:
– General examination reveals fever, pallor, weakness.
– Dullness on percussion and decreased or absent breath sounds
with an intermittent pleural friction rub (grating or rubbing
sound) on auscultation, crackles may present.
• Chest x-ray:
– To help diagnose and locate lesion ,often shows an opaque area
of consolidation.
• Direct bronchoscopic:
– Visualization to exclude possibility of tumor or foreign body.

• Therapeutic use of bronchoscopy to drain an secretion
• The patient is advised to rest.
• Avoid irritant, cold, and pollutant, stop smoking
• Nutritional support
• Promote airway clearance by encouraging coughing
• Fluid and electrolyte management
• Fluid intake is increased to thin the viscous and
tenacious secretions.
• Changing position

• Treatment focus on cause of cough
• Symptomatic treatment elimination of irritant
and pain relief analgesic and antipyretic
• Antibiotic treatment may be indicated depending
on the symptoms, sputum purulence, and results
of the sputum culture.
• Antihistamines are usually not prescribed
because they may cause excessive drying and
make secretions more difficult to expectorate.
• Expectorants may be prescribed, although their
efficacy is questionable.

• Rarely, endotracheal intubation may be required
in cases of bronchitis leading to acute respiratory
failure.
• This may be necessary for patients who are
severely debilitated or who have coexisting
diseases that also impair the respiratory system.
• Humidified air increased through, aerosols
• Cool vapor therapy or steam inhalations may help
relieve laryngeal and tracheal irritation. Moist
heat to the chest may relieve the soreness and
pain.

Reference
Lippincott W. and Wilkins, Mannual of Nursing
Practice, (2006), 8th edition. J.P., Brothers,
India.
Black, JM, Hawks and Jane Hokanson, (2009). 8th
Ed. Medical-Surgical Nursing. Published by
Elsevier, India.
Smeltzer, SC et al., (2008). 11th Ed. Brunner &
Suddarth's Textbook of Medical-Surgical
Nursing. Published by Wolters Kluer, India.

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Lungs abscess and bronchitis

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