Surgical Aspects of

Pulmonary Infections
Kibrom Gebreselassie, MD, FCS-ECSA
Cardiovascular and Thoracic Surgeon
Lung Abscess
Background
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.
 Lung abscess was a devastating disease in the
preantibiotic era.
One third of the patients died, one third recovered,
and the remainder developed debilitating illnesses
Recurrent abscesses, chronic empyema, bronchiectasis
 In the early postantibiotic period, sulfonamides did
not improve the outcome of patients with lung
abscess.
After penicillins and tetracyclines became available,
outcomes improved.
Pathophysiology
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.
Microbiology
Anaerobes, aerobes, mixed
The most common anaerobes are
Peptostreptococcus species, Bacteroides species,
Fusobacterium species, and microaerophilic
streptococci.
 Aerobic bacteria that may infrequently cause lung
abscess include
S. aureus, S. pyogenes, K. pneumoniae, H. influenzae
Actinomyces species, Nocardia species, and Gram-
negative bacilli.
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,
HIV, malignancy, and duration of symptoms greater
than 8 weeks.
 The mortality rate for patients with underlying
immunocompromised status or bronchial
obstruction who develop lung abscess may be as
high as 75%.
Clinical manifestations
Anaerobic infection in lung abscess
Patients often present with indolent symptoms that
evolve over a period of weeks to months.
The usual symptoms are fever, cough with sputum
production, night sweats, anorexia, and weight loss.
 The expectorated sputum characteristically is foul
smelling and bad tasting.
Patients may develop hemoptysis or pleurisy
 Other pathogens in lung abscess
These patients generally present with conditions that
are more acute in nature
Cavitation occurs subsequently as parenchymal necrosis
ensues.
Physical Findings
Low-grade fever in anaerobic infections and
temperatures higher than 38.5C in other
infections.
Evidence of gingivitis and/or periodontal disease.
Consolidation may be present
 Evidence of pleural friction rub and signs of
associated pleural effusion, empyema, and
pyopneumothorax may be present.
Digital clubbing may develop rapidly.
Risk Factors
Periodontal disease
Seizure disorder
Alcohol abuse
Dysphagia
 Individuals with an inability to protect their airways
from massive aspiration
Diminished gag or cough reflex, caused by a state of
impaired consciousness (eg, from alcohol or other CNS
depressants, general anesthesia, or encephalopathy).
Investigations
CBC with differential may reveal leukocytosis and a
left shift.
Obtain sputum for Gram stain, culture, and
sensitivity.
Blood culture may be helpful in establishing the
etiology.
 Chest radiography
A typical chest radiographic appearance of a lung
abscess is an irregularly shaped cavity with an air-fluid
level.
 Lung abscesses as a result of aspiration most frequently
occur in the posterior segments of the upper lobes or the
superior segments of the lower lobes.
 The wall thickness of a lung abscess progresses
from thick to thin and from ill-defined to well-
circumscribed as the surrounding lung infection
resolves.
The cavity wall can be smooth or ragged but is less
commonly nodular, which raises the possibility of
cavitating carcinoma.
 The extent of the air-fluid level within a lung
abscess is often the same in posteroanterior or
lateral views.
The abscess may extend to the pleural surface, in
which case it forms acute angles with the pleural
surface.
 Computed tomography
CT scanning is very useful in the identification of
concomitant empyema or lung infarction.
On CT scans, an abscess often is a rounded radiolucent
lesion with a thick wall and ill-defined irregular margins.
 The vessels and bronchi are not displaced by the lesion,
as they are by an empyema.
The lung abscess is located within the parenchyma
compared with loculated empyema, which may be
difficult to distinguish on chest radiographs.
The abscess forms acute angles with the pleural surface
chest wall
Medical treatment
The treatment of lung abscess is guided by the
available microbiology with consideration of the
underlying or associated conditions.
No treatment recommendation has been issued by
major societies specifically for lung abscess.
Surgical treatment
Surgery is very rarely required for patients with
uncomplicated lung abscesses.
The usual indications for surgery are failure to
respond to medical management, suspected
neoplasm, or congenital lung malformation.
The surgical procedure performed is either
lobectomy or pneumonectomy.
Bronchiectasis
Bronchiectasis refers to abnormal dilatation of the
bronchial tree and is seen in a variety of clinical
settings.
CT is the most accurate modality for
diagnosis.
It is largely considered irreversible.
Epidemiology
As there are many causes of bronchiectasis, which
may occur at essentially any age, no single
demographic is particularly involved.
Two groups make up the majority of cases: post-
infectious and cystic fibrosis .
Clinical presentation
Bronchiectasis typically presents with recurrent
chest infections, production of copious amounts
of sputum and haemoptysis.
The later is often the only symptom and is
encountered in up to 50% of cases .
Causes
As is true for most lung pathology, bronchiectasis is
the common response of bronchi to many different
insults.
 Post-infective (most common) necrotizing bacterial
pneumonia, e.g S. aureus, Klebsiella, B. pertussis
Granulomatous disease, e.g tuberculosis, MAIC,
histoplasmosis
Allergic bronchopulmonary aspergillosis (ABPA)
Measles
 Bronchial obstruction malignancy, e.g.
bronchogenic carcinoma
Inhaled foreign bodies
Chronic aspiration lung changes
 Subtypes
According to macroscopic morphology, three types
have been described, which also represent a
spectrum of severity :
 Cylindrical bronchiectasis
bronchi have a uniform calibre, do not taper and have
tram track sign and signet ring
parallel walls (
sign)
commonest form
 Varicose bronchiectasis
relatively uncommon

beaded appearances where dilated

bronchi have interspersed sites of relative narrowing
 Cystic bronchiectasis
severe form with cyst-like bronchi that extend
to the pleural surface
air-fluid levels are commonly present
Radiographic features

Plain radiograph
Chest x-rays are usually abnormal, but are
inadequate in the diagnosis or quantification of
bronchiectasis.
Tram-track opacities are seen in cylindrical
bronchiectasis, and air-fluid levels may be seen in
cystic bronchiectasis.
 Overall there appears to be an increase in
bronchovascular markings, and bronchi seen end
on may appear as ring shadows .
Pulmonary vasculature appears ill-defined, thought
to represent peribronchovascular fibrosis .
 CT
CT especially excels at demonstrating the airways,
and is able to a greater or lesser degree to
distinguish some of the various underlying causes.
 A number of features are helpful in diagnosing
bronchiectasis :
bronchus visualised within 1cm of pleural surface
especially true of lung adjacent to costal pleura
most helpful sign for early cylindrical change
 lack of tapering
increased bronchoarterial ratio
diameter of a bronchus should measure approximately
0.65-1.0 times that of the adjacent pulmonary artery
branch
between 1 and 1.5 may be seen in normal individuals,
especially those living at high altitude
greater than 1.5 indicates bronchiectasis
Treatment and prognosis

In general treatment of bronchiectasis is medical

and involves promoting sputum clearance, using
positional physiotherapy and early and aggressive
treatment of pulmonary infections.
In some cases chronic prophylactic administration
of antibiotics may be required.
 In cases where bronchiectasis is severe and
significant morbidity is present, surgical resection
of the affected lobe may be of benefit provided
adequate repiratory reserve exists.
In cases where both lungs are extensively involved
(e.g. cystic fibrosis) lung transplantation can be
considered .
Surgical treatment of pulmonary tuberculosis

Pulmonary tuberculosis (TB) is the history of

thoracic surgery.
History tells that the first thoracic surgical
procedure, an open drainage of a TB pleural
empyema was performed by Hippocrates.
 During the first half of last century, the finding that
Mycobacterium tuberculosis was an obligate aerobe
led to rapid growth of thoracic surgical operation:
thoracoplasty, induced pneumothorax, plombage,
and phrenic nerve crushing.
 Remarkably, the thoracoscopy was also first
introduced around first decades of 1900 by
Jacobeus as approach for pleural biopsy and
adhesiolysis in TB patients.
In 1944, the discovery of Streptomycin modified
the therapeutic protocol leaving still a little place
for surgery.
 Developed in the 1960s, Rifampicin and other anti-
TB drugs radically transformed the prognosis of the
disease and undermined the existence of thoracic
surgery as a specialty;
 Multidrug-resistant TB (MDR-TB, resistance to both
Isoniazid and the Rifampicin)
Extensive drug-resistant TB (XDR TB, resistance to
Rifampin and Isoniazid, to fluoroquinolones and at
least one of the following injectable anti-TB drugs:
capreomycin, Kanamycin, or Amikacin)
Surgical indications
TB complications (e.g., haemoptysis, empyema,
cavity formation associated with aspergilloma,
adenopathy with fistula);
Failed medical therapy (cavity, tuberculoma)
Previous relapse(s) in patients with histories of TB
and proper drug regimen.