Abscessing pneumonia is a destructive inflammatory process accompanied by the formation of multiple purulent foci in the lung tissue. The symptoms vary depending on the pathogen. Classic manifestations of abscessing pneumonia include febrile fever, chills, severe intoxication, cough with fetid sputum, anorexia, weight loss. Confirming diagnostic methods are radiography and CT of the lungs. In the treatment of abscessing pneumonia, medical methods (antibiotics, infusion therapy, immunotherapy), effects on the focus of infection (sanitization bronchoscopy, thoracocentesis), extracorporeal hemocorrection (blood UV, hemosorption) are combined.
J85.1 Lung abscess with pneumonia
Abscessing pneumonia is a complication of pneumonia of various etiologies, characterized by the formation of intra-pulmonary purulent-necrotic cavities. In pulmonology, the term “abscessing pneumonia” refers to the period during pneumonia, during which, against the background of infiltrative changes, clinical and radiological signs of destruction of the pulmonary parenchyma are determined.
The conditional difference between lung abscess and abscessing pneumonia is considered to be the size of the purulent cavity: in the first case, its diameter exceeds 2 cm. If there are small and multiple foci of destruction in the lung tissue or a solitary cavity with a diameter of less than 2 cm, they talk about abscessing pneumonia. Most often, bacterial and aspiration pneumonia are complicated by suppuration.
Reasons of abscessing pneumonia
In the etiology of abscessing pneumonia, the dominant role belongs to Staphylococcus aureus, Klebsiella pneumonia (Friedlander’s wand) and other enterobacteria; Pneumococcus and hemolytic streptococcus, anaerobic bacteria (fusobacteria, peptostreptococci) become pathogens somewhat less often. These microorganisms are capable of causing destruction and necrosis of lung tissue, followed by the formation of a limited purulent cavity.
The main factors contributing to the entry of pathogens into the lung tissue are aspiration of a significant amount of oropharyngeal secretions and the presence of purulent foci in the body in contact with the blood or lymphatic channel.
- The aspiration mechanism of the occurrence of abscessing pneumonia is most often observed in people suffering from alcoholism and drug addiction, epilepsy, stroke, impaired consciousness, dysphagia, etc.
- Metastatic hematogenous or lymphogenic lung abscess, as a rule, is a consequence of severe furunculosis, endocarditis, osteomyelitis.
- Possible causes of abscess may be foreign bodies of the bronchi, lung tumors.
Patients with abscessing pneumonia often have a history of background pathology (blood diseases, diabetes mellitus, periodontal disease), long-term treatment with glucocorticoids and cytostatics.
In the pathogenesis of abscessing pneumonia, the greatest importance is attached to the species class of the pathogen with its antigenic properties, the sensitivity of the microorganism to antibiotics, concomitant diseases of the respiratory tract and the body as a whole that violate local and general reactivity.
The destruction of lung tissue is due to the fact that pathogens (especially Staphylococcus) produce a large number of enzymes and toxins that have a cytolytic effect and cause necrosis of the alveolar septa. This leads to the formation of multiple cavities filled with air and serous-hemorrhagic exudate, which do not have clear boundaries around the foci of decay. In the future, these cavities can either evolve into a large purulent focus (lung abscess), or merge, giving rise to abscessing pneumonia.
Symptoms of abscessing pneumonia
In most cases, the onset of the disease is not much different from the usual focal pneumonia. The patient is concerned about cough, fever, chest pain with a tendency to increase when breathing; radiologically, focal infiltration in the lungs is determined. Children may have abdominal, neurotoxic or asthmoid syndromes.
Under unfavorable conditions, the condition deteriorates rapidly and at the next stage, abscessing pneumonia itself develops. This stage is accompanied by an increase in signs of intoxication (hyperthermia up to 40 ° C with chills, adynamia, anorexia) and respiratory failure (shortness of breath with the participation of auxiliary muscles in the act of breathing, cyanosis).
Since microabcesses are already forming in the lung tissue at this time, the appearance of sputum with a putrid odor, sometimes with an admixture of blood, is noted. The patient is adynamic, inhibited; the skin is pale gray in color; confusion may be noted. With the further development of the disease, a lung abscess occurs, during which the stages of formation and drainage of the abscess are distinguished.
Local purulent complications that aggravate the outcome of abscessing pneumonia include pleural empyema, pyopneumothorax, mediastinitis. Metastasis and generalization of infection lead to the development of bacterial pericarditis, purulent arthritis, sepsis, etc. The consequence of partial or complete obturation of the bronchus may be atelectasis of the lung. With vascular erosion, there is a risk of pulmonary bleeding. With an extremely rapid and severe course of septic pneumonia, it is possible to develop multiple organ failure requiring intensive therapy.
The examination is carried out by a pulmonologist, includes the following diagnostic measures:
- Objective examination. Physical data are characterized by a weakening of breathing, shortening of percussion sound, the presence of wet wheezing, tachypnea, tachycardia.
- Radiography of the lungs. The results of the X-ray examination play a fundamental role in establishing the diagnosis. At the same time, standard lung radiography does not always allow visualizing small cavities against the background of pneumonic infiltration.
- Chest CT scan. Therefore, if abscessing pneumonia is suspected, it is advisable to resort to CT. In the case of the formation of a lung abscess, a thick-walled cavity formation with the presence of a characteristic level of liquid and gas is determined on the images.
- Laboratory tests. Blood tests show signs of severe systemic inflammation (significant leukocytosis, increased ESR).
As part of the differential diagnosis, exclusion of tuberculosis and lung cancer, a three-time sputum examination of tuberculosis pathogens and atypical cells is carried out. To isolate the pathogenic flora, sputum or bronchial flushing waters are seeded with the determination of antibiotic sensitivity. In some cases, diagnostic bronchoscopy is indicated to clarify the causes of abscessing pneumonia.
Treatment of of abscessing pneumonia
Abscessing pneumonia is difficult to treat and requires a combination of therapeutic and surgical methods. Patients require careful care, high-calorie nutrition with replenishment of protein loss.
- Antibiotic therapy. Etiotropic therapy is based on the sensitivity of isolated pathogens to antibacterial agents. Its duration can range from 4 weeks to several months; the question of changing and combining drugs is decided by a pulmonologist individually, taking into account clinical and radiological dynamics. Benzylpenicillin + metronidazole, lincosamides (clindamycin, lincomycin), aminopenicillins (amoxicillin / clavulanic acid, ampicillin / sulbactam), etc. are usually used as the starting therapy for abscessing pneumonia.
- Additional therapy. In order to improve the drainage of the purulent focus, expectorant, mucolytic, broncholytic drugs, and medicinal inhalations are prescribed. With confirmed staphylococcal etiology of abscessing pneumonia, the administration of hyperimmune antistaphylococcal plasma is effective.
- Infusion therapy. With severe hypoproteinemia, parenteral administration of albumin, plasma is carried out. At the same time, correction of respiratory insufficiency, hypovolemia, violations of the water-mineral balance is carried out.
- Extracorporeal hemocorrection. In order to detoxify, gravitational blood surgery is used (plasmapheresis, UV blood, hemosorption).
In order to sanitize purulent foci, therapeutic bronchoscopy is used, according to indications, puncture or drainage of the abscess is performed with active aspiration of pus, rinsing of the cavity with antiseptic solutions, the introduction of proteolytic enzymes and antibiotics. If conservative treatment of the abscess is impossible, resection of the affected parts of the lung is indicated.
The prognosis of abscessing pneumonia is serious; the mortality rate is high 15-25%. In the event of complications, the presence of concomitant diseases and foci of purulent infection, the percentage of adverse outcomes is significantly higher. The course of abscessing pneumonia can end in recovery, the formation of pulmonary fibrosis, chronic lung abscess.