Physical examination
The doctor, during an external examination before the breakthrough of the abscess, fixes a slight cyanosis of the face, arms and legs. The affected half of the chest lags behind during breathing if the pleura is involved in the process, and the lesion is extensive. A person often takes a forced position on a sore side. Chronic abscess on examination is characterized by fingers in the form of “drumsticks”, signs of right ventricular failure are also formed.
Typical signs are tachypnea and tachycardia. The first period of the disease lasts from 4 to 12 days. The second period is marked by the beginning of emptying of the destruction cavities. And then in typical cases the patient’s condition becomes better. Palpation reveals pain in the intercostal spaces on the diseased side, which indicates the involvement of the pleura and the intercostal neurovascular bundle in the process. Voice trembling increases with the subpleural location of the abscess. And it weakens – when a massive abscess is emptied.
The percussion method at the beginning of the disease on the affected side detects a shortening of the sound. With a deep location of the abscess, the percussion sound is unchanged. At the second stage, the intensity and area of percussion sound shortening become smaller. Tympanic percussion sound is noted with superficially located large emptied abscesses.
Auscultatory at the beginning of the development of a lung abscess, hard breathing is detected. There may also be bronchial and weakened breathing, against which, in some cases, wet or dry rales are recorded. But the absence of wheezing is not a diagnostic criterion. If the symptoms of pneumonia are “leading”, then crepitus is heard. After opening the abscess, you can hear moist rales of various calibers.
Instrumental diagnostics
X-ray examination of the chest in direct and lateral projections is used in 100% of cases to diagnose a lung abscess. At the beginning of the disease, x-rays can detect intense infiltrative shading of various lengths. In the second phase, against the background of decreasing infiltration, it is possible to determine a round-shaped cavity with a fairly even internal contour and a horizontal liquid level. There may be more than one cavity. Multiple enlightenments of irregular shape with a dark background are detected after a breakthrough of necrotic masses in the bronchus with gangrene of the lung.
With the help of computed tomography, the location of the cavity, the fluid in it (in whatever quantity it may be), sequesters, and also assess the degree of involvement of the pleura are accurately determined.
The study of respiratory function is used in patients with such a symptom as shortness of breath, as well as in preparing the patient for surgery and other invasive interventions. With an abscess, mixed or restrictive ventilation disorders are found. The study of respiratory function is not carried out with hemoptysis in a patient.
Bronchoscopy is a method that is used not only for diagnosis, but also for treatment. Aspiration of pus is carried out in order to alleviate the condition of a person, to obtain material for determining the microflora and its sensitivity to antibiotics.
Laboratory research
A general blood test is mandatory, which detects an increase in the level of ESR and reveals neutrophilic leukocytosis with a shift of the leukocyte formula to the left. Biochemical analysis of blood in severe cases of abscess and gangrene of the lung reveals hypoalbuminemia, iron deficiency anemia, moderate proteinuria. Leukocytes may be found in the urine.
Microscopic analysis of sputum finds neutrophils and bacteria of different types. When standing, sputum stratification occurs. The upper layer is a foamy serous fluid, the middle layer is liquid, contains many leukocytes, erythrocytes, bacteria, and pus is located on the lower layer.
Differential Diagnosis
Differential diagnosis of lung abscess should be carried out with cavity formations of various etiologies, detected on CT and radiographs. These include:
- decaying lung tumors
- tuberculosis
- actinomycosis
- festering cysts
- Wegener’s granulomatosis
- parasitic cysts (rare)
- Sarcoidosis of the lungs (very rare)
Distinguishing in the diagnosis of tuberculous cavities and lung abscess, it is necessary to take into account the contact of the patient (or lack of contact) with bacilli excretors. The appearance of foci-screenings in the lungs is considered characteristic of tuberculosis. In destructive forms of tuberculosis, bacteria are isolated that can be detected by microscopy of a Ziehl-Neelsen-stained smear or bacteriological examination. If there is doubt about the diagnosis, it is best to perform bronchoscopy and bacteriological examination of the contents of the bronchi.
The parietal located abscess in the diagnosis must be distinguished from pleural empyema. The topography of the cavity formation can be determined using computed tomography.
It is important to distinguish an abscess from an cavitary form of peripheral lung cancer. The tumor should be suspected if the patient is over fifty years old, if the sputum is scanty, there is no acute period of the disease. Radiation examination in the presence of a tumor shows a clear outer contour and its bumpy outlines. The internal contour of the cavity with an abscess is clear.
Complications
The most typical complication of abscess and gangrene of the lungs is the spread of a purulent-destructive process into the pleural cavity, and pyopneumothorax or pleural empyema is formed. A complication such as hemoptysis is also common. Pulmonary bleeding is likely, resulting in acute anemia and hypovolemic shock.
Bacteremia often occurs during destructive processes in the lungs of an infectious nature, therefore doctors do not consider it a complication. A massive simultaneous entry of microorganisms and their toxins into the blood can cause bacteremic shock, which, even with timely therapy, often leads to the death of the patient. Severe respiratory distress syndrome in adults is considered a complication of an abscess or gangrene of the lung.
Treatment
With an abscess of the lung, a person must be placed in a hospital. Nutrition should be with a calorie content of up to 3 thousand calories per day, proteins – up to 110-120 g per day. Fat is limited to 80-90 g per day, salt – up to 6-8 grams per day. They also give less liquid than usual.
Medical therapy
Conservative therapy for an abscess implies the appointment of antibacterial drugs until the symptoms and manifestations on the radiograph disappear. Often the course is from 6 to 8 weeks. Preparations are selected based on the results of bacteriological examination of sputum, blood and the determination of the sensitivity of microorganisms to antibiotics.
Antibiotics for lung abscess should be administered intravenously. When the patient’s condition improves, they switch to oral administration. Most often, high doses of penicillin are administered, which gives the desired effect. Apply benzathine benzylpenicillin 1-2 million units intravenously every 4 hours until the person’s condition improves, then phenoxymethylpenicillin 500-750 mg 4 times a day for 3-4 weeks.
Since there are more and more penicillin-resistant strains of pathogens every year, doctors often prescribe clindamycin 600 mg IV every 6 to 8 hours, then 300 mg orally every 6 hours for 4 weeks. With a lung abscess, the following are also used for treatment:
- carbapenems
- respiratory fluoroquinolones
- chloramphenicol
- β-lactam antibiotics with β-lactamase inhibitors
- newer macrolides (azithromycin and clarithromycin)
Drugs of choice:
- ampicillin + sulbactam
- amoxicillin + clavulanic acid
- cefoperazone + sulbactam
- ticarcillin + clavulanic acid
Lincosamides combined with aminoglycosides or cephalosporins of 3-4 generations are considered alternative drugs. Sometimes a combination of fluoroquinolones with metronidazole and monotherapy with carbapenems are prescribed. Symptomatic and detoxification treatment, physical methods of therapy, and surgical operations are also relevant. The latter may mean:
- lobectomy
- lung resection options
- pleuropulmonaryectomy
- pulmonectomy