Obstructive lung abscess. lung abscess

Lung abscess is a limited process, accompanied by the death of lung tissue and the formation of one or more pus-filled cavities in the lung. Abscesses are more often located in the upper lobe of the right lung or the lower lobe of the left lung.

Classification lung abscesses

Along the way:

• hematogenous-embolic;
• aspiration;
• septic;
• traumatic.

With the flow:

• sharp;
• chronic.

By location:

• central;
• peripheral (single or multiple).

According to the presence of complications:

• there are no complications;
• complicated by pleural empyema or bleeding.

The reasons lung abscess

Lung abscess is caused by bacteria: gram-positive cocci - staphylococci and streptococci, gram-negative rods - Pseudomonas aeruginosa. The infection enters the lungs through the bronchi, with blood flow in case of sepsis or pulmonary embolism, with lung injuries.

Predispose to the purulent process weakened immunity, alcoholism, condition after anesthesia.

Clinic

The main symptom of an abscess is coughing. It always appears in the morning, and during the day - as sputum accumulates. The color of sputum is from light, greenish to dirty gray, the smell is sharp, unpleasant, putrid.

Chest pain from the side of the abscess appears with deep breathing or coughing.

An increase in body temperature is accompanied by chills, headache and loss of appetite.

The classical clinical course of an abscess consists of two stages. At the onset of the disease, when an abscess forms, the body temperature rises, a dry cough appears and strong pain in the chest on the affected side.

At the second stage, when an abscess breaks into the bronchus, the body temperature decreases, a cough appears with a large amount of sputum, hemoptysis is possible if the wall of the pulmonary vessel is damaged.

A lung abscess may not open in the bronchus, but exist in the lung for a long time, provoking the development of complications - pleural empyema, the formation of external fistulas (communications between the lung and the chest). Against the background of a decrease in the body's defenses and not timely treatment purulent foci spread to other organs.

Diagnostics lung abscess

Consultation of a therapist or pulmonologist.

General blood analysis.

Radiography chest in two projections.

Sputum examination.

CT scan.

Treatment lung abscess

Lung abscess is treated in a hospital. Administer medication or surgery. Surgical opening of the abscess cavity and washing of its cavity is indicated in several cases:

• the presence of multiple abscesses in the lung,
• abscess located in the lower lobe of the lung
• abscess with a cavity diameter of more than five centimeters,
• danger of suffocation with a large amount of sputum.

Drug treatment of a lung abscess begins with antibiotic therapy. The antibiotic is prescribed immediately upon admission of the patient to the hospital. Upon receipt of the results of the sputum examination, a correction of the treatment regimen is possible. Antibacterial agents are administered intravenously, as well as into the abscess cavity or intrabronchially.

To improve the discharge of purulent sputum from the abscess cavity and promote it through the bronchi, expectorants, proteolytic enzymes, breathing exercises and special physical therapy are prescribed. Treatment measures include puncture (puncture) of the abscess with aspiration of pus from its cavity, external drainage of the abscess cavity with thin drainage, bronchoscopy.

Stimulation of the body's defenses (immunostimulation) is performed with staphylococcal toxoid or antistaphylococcal plasma, or other immunostimulants.

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Lung abscess is a purulent-destructive cavity filled with pus, surrounded by an area of ​​inflammatory perifocal infiltration of the lung tissue.

Lung abscess is a polyetiological disease. Acute pulmonary-pleural suppurations occur as a result of polymicrobial infection by aerobic-anaerobic associations of microorganisms. Among them, pneumococcus, non-spore-forming anaerobic microorganisms (bacteroids, peptococcus, etc.), Staphylococcus aureus, Gram-negative aerobic rod microflora (Proteus, rarely Escherichia coli, etc.).

Staphylococcus, pneumococcus are found in association with Klebsiella, Enterobacter, Serration, Bacteroids. With lung abscesses, a high bacterial contamination is noted (1.0 x 10 4 - 1.0 x 10 6 microbial bodies in 1 ml).

The diseases of the following groups lead to the development of acute abscesses or gangrene of the lung:
. croupous or viral pneumonia. This is the most common, if not the main, cause of lung abscess formation;
. aspiration of foreign bodies, tumors or scars, narrowing the lumen of the bronchus and thereby violating its drainage function with conditions for the development of microflora penetrating from the bronchi;
. septicopyemia, thrombophlebitis, other purulent diseases that can lead to damage to the lungs by the hematogenous or lymphogenous pathway with the development of a pneumonic focus;
. traumatic injuries (open and closed) of lung tissue with primary or secondary infection.

Embolic lung abscesses are more often multiple and localized in the peripheral parts of both lungs. Aseptic pulmonary infarctions rarely abscess.

In acute purulent lesions of the lungs, infection occurs most often by aerogenic means. This is a transbronchial entry of microorganisms with the development of pneumonia, when the infectious agent is mixed in the direction of the respiratory sections with an air stream. The aspiration route of infection is rare, and hematogenous-embolic infection is extremely rare.

The process of abscess formation in the lung can proceed in different ways. I.S. Kolesnikov, M.I. Lytkin (1988) identifies three possible variants (types) of the development of a destructive process in the lung.

Abscess formation of the 1st type develops against the background of the usual favorable dynamics of the inflammatory process in the lung after 1.5-3 weeks from the onset of pneumonia. After the patient's condition improves, the body temperature rises again, chest pains increase, worsening general state with manifestations of increasing intoxication. It all ends with the release of purulent sputum.

Type 2 abscess usually occurs within 3–4 weeks of onset of pneumonia and is clinically manifested as prolonged pneumonia with treatment failure. Saved permanently heat body throughout the entire period of the disease, severe intoxication, then purulent sputum appears, the amount of which increases.

Abscessing of these types leads to postpneumonic abscesses.

Type 3 abscess leads to aspiration abscesses. In these cases, destruction in the lung begins from the first days, and an abscess forms 5-10 days after the onset of the disease.

Classification of lung abscesses

Clinical picture

The disease occurs predominantly in men (80-85%), most often at the age of 20-50 years (80-90%). The right lung is most commonly affected. The abscess can be localized in different parts of the lungs, but most often occurs in the upper lobe of the right lung. Clinical manifestations of an abscess develop against the background of a previous pathological process in the lung. Most often it is croupous, influenzal pneumonia or atelectasis of the lung tissue. The semiotics of an acute abscess is determined by many factors, but primarily by the phase of development of the process, the general state of the organism, and the virulence of the flora.

The formation of an abscess is accompanied by purulent infiltration and melting of the lung tissue, when there is no communication between the abscess cavity and the bronchial lumen. In this phase, the clinical picture of a lung abscess is very similar to clinical picture severe pneumonia. Lung abscess is accompanied by a general serious condition, pain when breathing on the affected side of the chest, high body temperature, cough, dullness of percussion sound and bronchial, and sometimes weakened breathing over the abscess; leukocytosis increases to 16-30 x 109/l, there is a pronounced shift of the leukocyte formula to the left.

X-ray examination shows a limited shadow different intensity and magnitude.

The described phenomena increase within 4-10 days, then usually the abscess breaks into the bronchus and the second phase of an acute abscess begins with a cough and the release of abundant (up to 200-800 ml / day) fetid purulent sputum containing many leukocytes, erythrocytes, bacteria and elastic fibers and tissue detritus. With the predominance of necrosis in the cavity of the abscess, sputum is especially fetid, often mixed with blood. When settling, sputum is divided into three layers: the lower of pus and decayed tissues, the middle of a yellowish transparent liquid and the upper of a foamy liquid.

The amount of sputum discharge during a lung abscess does not correspond to the size of the abscess cavity. With small abscesses, there can be a lot of sputum, and, conversely, with a large cavity of the abscess, the amount of sputum can be insignificant. The amount of sputum discharge depends on concomitant bronchitis, on the prevalence of pneumonic changes, and on the patency of the draining bronchi.

Diagnosis of a lung abscess presents difficulties in the early phase of development before a breakthrough in the bronchus. Often, an abscess is mixed with focal pneumonia and other diseases. The most persistent symptoms are: cough with phlegm, chest pains that increase as the pleura becomes involved in the inflammatory process, high fever, constant or with large fluctuations and heavy sweats. In the blood, high leukocytosis with neutrophilia, elevated ESR.

The data of percussion, auscultation and X-ray examination, although not pathognomonic for an acute lung abscess, in some cases suggest a diagnosis before opening an abscess in the bronchus or pleural cavity. CG performed in this phase of abscess development often resolves diagnostic doubts, since the revealed heterogeneous structure of the inflammatory infiltrate with areas of different density indicates the beginning process of destruction in the lung.

After opening an abscess in the bronchus, its diagnosis is greatly facilitated: the diagnosis is established on the basis of abundant sputum discharge, which was preceded by a severe inflammatory process in the lung. Physical examination methods usually confirm the diagnosis of a lung abscess. An important role in clarifying the nature and localization of the process is played by X-ray examination, CT, which allow to accurately determine the cavity in the lung with gas and liquid.

The main method for diagnosing purulent lung diseases is radiological, the establishment of a focus of destruction in the lung plays a major, but not exhaustive role. Importance have topical diagnostics - determination of the localization of the pathological process in the lung, the state of the lung tissue.

X-ray changes in lung abscess are different. The most common variant (up to 70% of cases) is a single cavity in the lung with fluid and inflammatory infiltration of the lung tissue around. The cavity is often round in shape with clear contours of the inner walls, but it is also possible irregular shape and uneven wall contours.

In 10-14% of cases of acute abscess, a massive darkening of the lung tissue is determined, caused by an inflammatory process without signs of infiltrate decay. Also, changes occur with prolonged pneumonia with severe purulent pneumonitis, damage to the interstitial tissue and a violation of the drainage function of the bronchi, pronounced regional lymphadenitis in the root of the lung.

In such cases, CT can reveal cavities of lung tissue destruction in the zone inflammatory infiltration. In clinical terms, such changes correspond to a long-term, chronic inflammatory process in the lung. In doubtful cases, CT increases the diagnostic capabilities of X-ray examination.

All these methods do not provide clear information about the condition of the bronchial tree of the examined lung. The absence of any changes in the lung pattern during X-ray examination and CT is the basis for refusing bronchography. With "closed" (not communicating with the bronchus) abscesses, CT helps to resolve doubts about the presence of lung tissue destruction in the area of ​​inflammatory infiltration.

Contrasting of the bronchi (bronchography) allows you to determine the condition of the bronchi, but the method is ineffective for detecting abscesses in the lung, since the abscess cavities are not filled with a contrast agent due to swelling of the mucous membrane of the draining bronchi, and also due to the filling of the abscess with pus, tissue detritus.

The transition of an acute lung abscess to a chronic one is characterized not only by a temporary factor, but also by certain morphological changes in the abscess itself, the surrounding lung tissue and adjacent bronchi, and vessels.

X-ray semiotics of long-term both single and multiple abscesses includes shadows of uneven intensity and varying prevalence. The lung tissue surrounding the abscess cavity has an average compaction with a sharply deformed lung pattern and connective tissue strands.

The state of the lymph nodes in nonspecific lymphadenitis is detected by x-ray examination. The expansion of the shadow of the root of the lung, the blurring of its structure are determined. Tomography, CT allow to differentiate such changes and determine the increase in lymphatic bronchopulmonary nodes. Similar changes in regional lymph nodes are constant sign lung abscess.

This picture does not play a significant diagnostic role, but changes in the nodes during treatment are evaluated as an indicator of the effectiveness of the therapy. Reduction in size, disappearance of nodes is a favorable prognostic criterion. The lymph nodes remain enlarged for another 1-2 months after scarring of the abscess.

Bronchoscopy allows you to assess the condition of the bronchi, determine the draining bronchus, take material for bacteriological examination, sanitize the abscess or catheterize the draining bronchus.

Modern research methods (CT, bronchoscopy) practically eliminate the need for diagnostic puncture, since the risk of complications, in particular, purulent pleurisy, significantly exceeds the diagnostic value of the method.

Lung abscess in 30% of cases is complicated by pleural empyema or pyopneumothorax. In these cases, thoracoscopy is performed, which often reveals bronchopleural fistulas and allows you to determine their localization and size, to make a biopsy of the pleura or lung to clarify the etiology of the disease. Pleuroabscessography reflects the state of the empyema cavity.

To verify the pathogen, to establish a bacteriological diagnosis, cultures of bronchial lavages and punctate from the zone of lung destruction are used. Among the isolated flora, pneumococcus, staphylococcus, proteus predominate (1 x 10 4 - 1 x 10 6 microbial bodies in 1 ml) in association with Klebsiella, enterobacter, serration, bacteroids, in some cases coli. The results of microbiological examination of expectorated sputum must be treated critically due to its mixing with the contents of the oral cavity.

Acute lung abscesses must be differentiated from cavernous tuberculosis, actinomycosis, echinococcosis, suppuration of a lung cyst, interlobar encysted pleurisy, focal pneumonia, and secondary abscesses in lung tumors. Cavernous TB is usually ruled out when there is a history of the disease, absence of mycobacterium tuberculosis, and characteristic radiological and CT changes in the lungs outside the fluid-containing cavity.

With actinomycosis, the causative agent of drusen is found in the sputum. However, it is not easy to detect them, and therefore repeated thorough studies are required. With actinomycosis, neighboring organs, the wall of the difficult cell are involved in the process.

Particularly difficult is the differential diagnosis of an abscess with interlobar pleurisy that opened in the bronchus, and with other encysted pleurisy. In such cases, CT is of great benefit, which makes it possible to clarify the true nature of the disease.

It is necessary to differentiate lung abscess with disintegrating peripheral lung cancer. It should be noted that according to the type of decay cavity during X-ray examination, it is possible to differentiate abscess and lung cancer is not always possible. The wall of the cavity with cancer is thicker, there is no purulent sputum, but there is hemoptysis. In the differential diagnosis of decaying peripheral cancer and lung abscess, it is not the type of cavity and the condition of its internal walls that is more important, but the outer outlines of darkening in the lungs and clinical manifestations illness.

The cavity during the decay of the tumor, according to X-ray, CT contains little fluid, but this is taken into account only with the tuberosity of the tissues surrounding the cavity and the thick wall of the decay cavity. The discharge pathways that are detected in cancer, connecting the tumor with the root of the lung, play a role, like a cancerous implantation along the lymphatic outflow path.

In the differential diagnosis of lung abscess and tuberculosis with a cavity, microbiological examination plays a role.

Lung abscess has to be differentiated also with aspergillosis. The disintegration of an aspergiloma leads to the formation of a cavity. The mycelium of the fungus in sputum, bronchoscopy washings, the contents of the decay cavity allows clarifying the diagnosis of pulmonary aspergillosis.

In the differential diagnosis of a lung abscess, data from a comprehensive examination of patients are taken into account: anamnesis, clinical manifestations, course of the disease, instrumental and laboratory research. A certain role is played by the results of bacteriological research. Examine also biopsy specimens obtained during bronchoscopy, thoracoscopy, transparietal puncture. Cytological examination wash water and smears-imprints obtained during bronchoscopy are subjected.

Treatment

Integrated intensive therapy includes:
. optimal drainage and sanitation of the decay cavity in the lung;
. antibacterial therapy, selection of antibiotics taking into account the sensitivity of the isolated microflora to them;
. correction of volemic, electrolyte disturbances, elimination of hypo- and dysproteinemia;
. detoxification therapy: forced diuresis, plasmapheresis, indirect electrochemical;
. blood oxidation with sodium hypochlorite, UVI blood, hemofiltration;
. immunotherapy;
. calorie balanced diet, according to indications - parenteral nutrition and infusion of blood components;
. symptomatic treatment.

Rational antibiotic therapy, along with active local treatment (bronchoscopic aspiration, sanitation, etc.) is the basis for effective conservative therapy and preoperative preparation of patients with purulent lung diseases. The use of proteolytic enzymes with necrolytic and anti-inflammatory properties improved the results of conservative treatment and preoperative preparation of patients with purulent lung diseases. The dissolution of the thick contents of the bronchi and cavities and the anti-edematous effect of enzyme therapy contribute to the restoration of the drainage function of the bronchi, the violation of which plays a leading role in the pathogenesis of pulmonary suppuration.

Thus, the combination of antibiotic and enzyme therapy is a successful combination of etiotropic and pathogenetic treatment.

To restore the patency of the draining bronchial abscess, a complex bronchological sanitation is carried out, in which the leading role belongs to bronchoscopy. Taking into account the data of a preliminary X-ray examination, bronchoscopy makes it possible to catheterize the bronchus draining the purulent focus, rinse it and introduce antiseptics, proteolytic enzymes, and antibiotics.

If necessary, therapeutic bronchoscopy is repeated, which allows in most cases to achieve a positive effect. To improve sputum discharge, proteolytic enzymes, expectorants, and mucolytics are used. Proteinases have a proteolytic effect - they thin the sputum and lyse necrotic tissues. Proteinases have an anti-inflammatory effect and affect the drainage function of the bronchi.

In acute lung abscess, endobronchial application of enzymes and antiseptics (along with general antibiotic therapy) quickly eliminates purulent intoxication. A course of complex bronchological sanitation, as a rule, leads to a complete clinical recovery with scarring of the abscess. Enzyme therapy also gives a pronounced effect with giant lung abscesses, when there is little hope for a cure without surgical intervention.

One of the components of complex bronchological sanitation is inhalation administration medicines. In inhalations, mucolytics, antiseptics, proteolytic enzymes, etc. are administered. Inhalation therapy has a number of valuable properties, but plays only an auxiliary role in the conservative treatment and preparation for surgery of patients with purulent lung diseases.

The main advantages of endotracheal drug infusions are simplicity and the absence of the need for radiological control. For the correct administration of the drug, you need to know exactly the localization of the purulent process and carefully observe the appropriate positions of the chest. With endotracheal administration of drugs, unfortunately, it is not possible to accurately deliver drugs to the draining bronchus, but the drugs are distributed throughout the bronchial mucosa, which is important in diffuse bronchitis.

Inhalations, endobronchial infusions of proteolytic enzymes, mucolytics, antiseptics are simple sanitation methods, but in terms of their effectiveness and speed of achieving results, they are inferior to therapeutic bronchoscopy. Bronchoscopy is the main method of bronchological sanitation.

Sanitary bronchoscopy is performed under local anesthesia. Therapeutic bronchoscopy with aspiration of the contents of the bronchial tree, its washing and the introduction of medicinal substances is widely used in the surgical clinic and is part of the complex bronchological sanitation.

Modern bronchoscopy allows transnasal insertion of a fiberscope and continuous bronchial lavage with drug instillation through one channel and aspiration through another. Anesthesia is performed with an aerosol preparation of 10% lidocaine.

In patients with purulent sputum, bronchial contents are aspirated already during diagnostic endoscopy to provide conditions for examination. The next stage of rehabilitation is the removal of fibrin deposits and purulent plugs from the mouths of the bronchi.

The next stage of bronchoscopic sanitation is the washing of the bronchi with a solution of enzymes. The position of the table is changed to the opposite drainage. A special tube is inserted into the bronchus draining purulent cavities and 25-30 mg of chymopsin or trypsin, chymotrypsin, ribonuclease or 1 dose of terrilitin per 4-10 ml of sterile isotonic sodium chloride solution are infused.

The number of washings depends on the prevalence of the purulent process and the general condition of the patient. Therapeutic bronchoscopy should be as effective as possible, and the risk associated with hypoxemia and hypercapnia during repeated endobronchial manipulations should be minimal. In seriously ill patients, therapeutic bronchoscopy should be carried out under the control of oxyhemography or oximetry.

Sanitary bronchoscopy with catheterization of an abscess through a segmental bronchus is indicated with the ineffectiveness of conventional sanitation bronchoscopy. They are carried out under x-ray, computed tomography control.

Drainage of an abscess during bronchoscopy to a certain extent replaces conventional bronchoscopic sanitation.

In some cases, it is not possible to perform bronchoscopic sanitation (absence of a bronchoscope, technical difficulties, categorical refusal of the patient). This serves as an indication for the sanitation of the bronchial tree through microtracheostomy.

Special tactics are used in the most seriously ill patients with decompensation of external respiration, severe pulmonary heart failure, when severe dyspnea and hypoxemia at rest are an obstacle to endotracheal administration of drugs. Bronchoscopy is contraindicated in these patients; in some of them, aerosol inhalation alone causes increased dyspnea and cyanosis.

In such a situation, along with parenteral administration of antibiotics, detoxification therapy, etc. local enzyme and antibacterial therapy is carried out by transparietal puncture of the abscess with aspiration of pus, washing the cavity with an antiseptic solution and subsequent administration of proteolytic enzymes. Due to this, purulent intoxication usually decreases, the general condition of the patient improves, partially compensated external respiration and hemodynamic disorders, which allows you to gradually move on to a comprehensive bronchological sanitation.

Punctures of acute abscesses are performed with complete obstruction of the draining bronchus (“blocked abscess”) or insufficient evacuation of pus through it in case of ineffective bronchoscopic sanitation. The point for the puncture is planned under X-ray control or during ultrasound, which visualizes the position of the needle directly during the puncture.

By transparietal puncture, enzyme preparations can be introduced into the cavity of the abscess: chymopsin, trypsin, chymotrypsin, ribonuclease, terrilitin. As antiseptics, solutions of sodium hypochlorite, dioxidine, potassium furagin, chlorhexidine are used.

Transparietal punctures, aspiration of pus and administration of drugs are repeated daily for 3-4 days. If the patient's condition improves, they proceed to bronchological sanitation. The inefficiency of the puncture method with complex treatment serves as an indication for external drainage of an abscess. A contraindication to the introduction of proteolytic enzymes by the puncture method is profuse hemoptysis or pulmonary bleeding.

Transparietal drainage of an abscess or decay cavity in pulmonary gangrene is carried out with insufficient or completely impaired bronchial drainage, when bronchoscopic sanitation does not give the desired effect.

Drainage is performed under local infiltration anesthesia under multiaxial X-ray control. Due to invasiveness, drainage is performed in the X-ray operating room. It is possible for pus or blood (if a pulmonary vessel is damaged) to enter the bronchial tree, so it is necessary to provide equipment for emergency bronchoscopy or tracheal intubation.

Microdrainage is used for lung abscesses up to 5-8 cm in diameter with insufficient or completely impaired bronchial drainage. The drainage is introduced along a fishing line passed through the lumen of the puncture needle and fixed with a suture to the skin. Drainage for lung abscesses with a diameter of more than 8 cm and lung gangrene with a decay cavity is carried out using a trocar or a special needle.

Drainage with a trocar is used for large superficially located intrapulmonary purulent cavities. The drainage tube is passed through the sleeve of the trocar.

Drainage with a long puncture needle with a diameter of 2 mm, on which a drainage tube is put on, is used for deeply located intrapulmonary abscesses.

After drainage of the purulent cavity, its contents are completely evacuated. The cavity is washed with a solution of antiseptic and proteolytic enzymes. The free end of the drainage can be left open under a thick cotton-gauze bandage or connected to a tube pubescent under the aseptic liquid solution according to Bulau-Petrov. The use of continuous vacuum aspiration depends on the size of the purulent cavity. The vacuum during vacuum aspiration should not exceed 50 mm of water. Art., so as not to provoke arrosive bleeding.

The purulent cavity is washed through the drainage 3-4 times a day. The amount of the solution injected through the drainage at one time depends on the size of the cavity, but during the first flushes, no more than 20-30 ml.

Drainage can be removed after normalization of body temperature, cessation of separation of purulent sputum and pus through the drainage. An x-ray examination should make sure that the inflammatory infiltration around the cavity has disappeared, that its size has decreased, and that there is no horizontal fluid level in the cavity.

Complications of puncture and drainage of lung abscesses include hemoptysis, pneumothorax, and chest wall phlegmon, but these are rare.

The combination of therapeutic fibrobronchoscopy with punctures or drainage of a lung abscess creates optimal conditions for removing purulent contents and stopping inflammation, and as a result, for scarring an abscess. The double version of sanitation is effective in case of sequestration in the destruction cavity in the lung: sanitation is performed through drainage tube with transparietal drainage of the abscess cavity and through the draining bronchus.

For patients with acute lung destruction admitted to the thoracic surgical department, it is difficult to choose antibiotics, since most of them received massive antibiotic therapy in therapeutic departments or on an outpatient basis. Prior to the isolation of verification and the pathogen, empirical antimicrobial therapy with broad-spectrum drugs is carried out.

In the future, the choice of antibiotics depends on the sensitivity of pathogens. Recommended for severe disease intravenous administration antibiotics, and to create a maximum concentration in the focus of inflammation, catheterization of bronchial arteries is possible, followed by regional antibiotic therapy.

An important place in complex treatment is occupied by detoxification therapy, which is carried out according to general rules for patients with severe purulent diseases. The effectiveness of therapy is much higher if a session of plasmapheresis, hemofiltration, indirect electrochemical blood oxidation is preceded by drainage of a purulent focus, removal of pus, necrectomy. Plasmapheresis has clear advantages over other methods, but its use is not always possible for economic reasons.

Immunotherapy is carried out taking into account the immunocorrective action of drugs - hyperimmune specific plasma, gamma globulins, pentaglobin, gabriglobin.

The option of complex conservative therapy, rehabilitation of an acute lung abscess depends on the drainage function of the bronchi. It is possible to distinguish patients with good, insufficient bronchial drainage and with completely impaired bronchial drainage.

Indications for surgery are the ineffectiveness of conservative therapy and minimally invasive surgical procedures and the development of complications. Complex therapy before and after surgery allows performing both resection operations and the original version of thoracoabscessostomy developed in our clinic, followed by necrosequestrectomy and sanitation of the decay cavity using various methods chemical and physical necrectomy and the use of videoscopic technologies. Thoracoabscessostomy is the main operation for gangrenous abscesses.

With the successful treatment of acute lung abscesses with the use of complex therapy the abscess is replaced by a scar, completely disappear clinical symptoms, and in X-ray examination, fibrous tissues are determined at the site of the abscess cavity. If it was possible to completely eliminate the clinical manifestations, but X-ray examination determines small thin-walled cavities in the lung, the treatment result is considered satisfactory (clinical recovery).

These patients are discharged from the hospital under outpatient observation. The remaining cavities close spontaneously after 1-3 months. We observed good and satisfactory results in 86% of patients, the process turned into a chronic form in 7.8% of cases.

13.3% of patients require surgical treatment.

Indications for surgical treatment acute lung abscesses: the ineffectiveness of a complex of conservative and minimally invasive surgical methods treatment for 6-8 weeks, the development of complications (pulmonary hemorrhage, recurrent hemoptysis, persistent bronchopleural fistulas), transition to a chronic abscess.

The prognosis for acute lung abscesses, if complex conservative treatment is started in a timely manner, is favorable for most patients (up to 90%). In other patients, successful treatment is possible with the use of surgical methods.

Prevention of acute lung abscesses is closely related to the prevention of pneumonia (croupous, influenza), as well as timely and adequate treatment of pneumonia.

Lung abscess is a limited inflammatory process in the lung tissue, which looks like a cavity filled with purulent-necrotic masses. it serious illness, which in some cases even threatens human life - 5-10% of people with such a diagnosis, alas, die.

Mostly men aged 30-35 years are ill - among 7 people with a lung abscess, as a rule, only 1 woman. This is due to the spread among men bad habits(smoking, addiction to alcohol), leading to a violation of the drainage function of the bronchi.

You will learn about why and how a lung abscess occurs, about the symptoms, principles of diagnosis and treatment of this disease from our article.

Causes and mechanism of development

Lung abscess is a disease of an infectious nature. The following infectious agents can become the cause of its formation:

The likelihood of getting a lung abscess is higher in people with severe comorbidities:

• circulatory failure;
• , bronchogenic cancer, and other diseases of the bronchopulmonary system;
• chronic alcoholism, paralysis of the laryngeal nerve and other diseases that contribute to aspiration;
• associated with serious illness or with the use of immunosuppressive drugs.

Ways of infection

Infection in the area of ​​​​the future abscess can get in 4 ways: aspiration, or bronchopulmonary, hematogenous-embolic, lymphogenous, traumatic.

Bronchopulmonary (aspiration) mechanism of infection

It is realized by aspiration (inhalation) by a person of infected particles from the oral cavity or pharynx. Often this happens when the patient is intoxicated or unconscious, as well as at the stage of his recovery from anesthesia. Infected material in such cases is vomit, saliva, food or even tartar. Bacteria (both aerobic and anaerobic), penetrating into the tissue of the lungs, cause inflammation and swelling, resulting in a narrowing or complete blockage of the lumen of the bronchus. Distal (further) to the site of blockage, atelectasis develops, and the lung tissue also becomes inflamed.

Possible obturation of the lumen of the bronchus foreign body, neoplasm or scar tissue. The mechanism of abscess formation is the same. The difference lies in the response to therapy - the restoration of bronchus patency leads to a speedy recovery of the patient.

Such abscesses are found, as a rule, in the posterior segments of the right lung.

Hematogenous-embolic route of infection

In almost 10% of cases, a lung abscess develops as a result of infection entering the tissues of the organ from remotely located foci with blood flow. The primary source in such cases is osteomyelitis, septicopyemia, thrombophlebitis, and so on.

Small blood vessels of the lung are clogged with blood clots, lung infarction develops, tissues in the affected area become necrotic (die off) and undergo purulent fusion.

Such abscesses are usually multiple, located in the lower parts of the lungs.

Lymphatic route of infection

In this case, the infection enters the lung tissue from distant foci with lymph flow. Primary diseases usually become, and others.

Rarely, lymphatic abscesses occur.

Traumatic route of infection

Such abscesses also occur quite rarely. They are caused by open (penetrating wounds) or closed injuries chest.

What happens in the lung with an abscess

An inflammatory process develops in the lung tissue, later areas of necrosis form in the direction from the center to the periphery, in which the infectious agent actively multiplies. Enzymes secreted by bacteria melt the affected tissues that have lost their viability - a cavity is formed, delimited from healthy tissues by a capsule, filled with purulent masses.

Near the cavity are the bronchi. Sooner or later, bacteria destroy the wall of one of them - pus and tissue detritus (destroyed lung tissue) enter the bronchial tree and come out in the form of sputum with the patient's cough.

Single abscesses after a breakthrough in the bronchus are quickly released from purulent-necrotic masses. At the site of the abscess, a scar or a narrow cavity lined with epithelium is formed.

Sometimes abscesses, even after a breakthrough in the bronchus, are released from the contents slowly. At the same time, the capsule of the cavity is replaced by scar tissue, which prevents further healing - this is how a chronic lung abscess is formed.

Classification

Let's start with the fact that, according to the nature of the course, lung abscesses are acute and chronic (more than 6 weeks).

Depending on the number - single (single) and multiple.

Depending on the location - central or peripheral, one- or two-sided.

Depending on the presence of concomitant diseases - primary (developing with healthy bronchi and lungs) and secondary (occurring against the background of bronchial diseases that violate their drainage).

They are also classified according to the route of infection ( possible ways described above) and the type of pathogen (they are also indicated in the previous section).

Symptoms

During a single abscess, as a rule, 3 stages are distinguished:

• maturation, or infiltration;
• breakthrough of an abscess in the bronchus;
• outcome.

The first stage is accompanied acute inflammation area of ​​lung tissue, its purulent fusion. In terms of symptoms, it resembles. The patient complains of general weakness, chills, sweating, fever. All these are symptoms of intoxication of the body with substances that bacteria secrete. Also, a person notes pain in the chest and (it occurs both due to intoxication and due to the fact that part of the lung does not function and respiratory failure develops).

Objectively, the chest on the side of the lesion lags behind the healthy half in the act of breathing. Over the emerging abscess during percussion (tapping), a dullness of sound is detected, on palpation (palpation with fingers) - a weakening of voice trembling, and on auscultation (listening through a phonendoscope) - breathing is rapid, hard, dry or wet, small bubbling rales over the affected area. Tachycardia is recorded (heart rate exceeds the norm). An abscess usually matures within 2-3 weeks.

The beginning of the second stage of the disease can be considered a breakthrough of the abscess into the bronchus cavity. At the same time, the contents leave it, and, in the literal sense, with a full mouth. During the day, the volume of purulent sputum can reach 1.5 liters and this process is accompanied by an unpleasant, and often fetid odor. After the breakthrough of the abscess, the patient's condition improves - the body temperature drops to subfebrile values, chest pain becomes less pronounced, shortness of breath is not so intense. Objectively, as the abscess is freed from pus, an increasingly tympanic percussion sound and auscultatory - amphoric breathing with moist fine, medium and coarse bubbling rales are determined.

At the stage of outcome, the opened abscess is gradually replaced by connective tissue. The patient notes that there is less sputum, less cough, body temperature values ​​have returned to normal.

If sputum drainage is disturbed for any reason (for example, the bronchus into which the abscess has broken through is of small diameter and is located in the upper part of the cavity), purulent inflammation is delayed, chronic purulent bronchitis is formed, and after 60-90 days the abscess is also regarded as chronic .

Multiple lung abscesses: features of the course

They usually run hard. Occur mainly against the background of destructive pneumonia. Inflammatory process affects large areas of the lung. Children and young people get sick more often.

The human condition is deteriorating day by day. Already in the first days, a pronounced intoxication syndrome is detected, after which sepsis often develops.

A breakthrough of one of the purulent foci into the bronchus does not lead to relief of the patient's condition. Foci of necrotic tissue rapidly increase in size. Purulent bronchitis develops with a large amount of fetid sputum. The patient's condition is rapidly deteriorating, soon developing multiple organ failure. Delay in the operation leads to the death of almost all such patients.

Complications

An acute lung abscess can lead to some (often life-threatening) complications. These are:

• transformation of an acute lung abscess into a chronic one;
• abscess breakthrough not into the bronchus, but into the pleural cavity with the formation of purulent or pyopneumothorax (this danger is fraught with peripheral abscesses located at the borders of the lung);
• bleeding into the bronchus cavity (occurs if purulent masses melt the wall of a blood vessel) - in severe cases, when there is a lot of blood, it blocks the lumen respiratory tract and asphyxia sets in - a person suffocates);
• the spread of pus into healthy bronchi with the further formation of abscesses there;
• the entry of a pathogenic microorganism into the bloodstream, followed by the formation of abscesses in remotely located organs, including the brain;
• bronchopulmonary fistulas;
• bacteremic shock, RDS syndrome.

Complications develop mainly in the absence of timely treatment of the abscess or in the case of an immunodeficiency state in the patient.

Diagnostic principles

The diagnosis of "lung abscess" is based on the patient's complaints, anamnesis of his life and current disease (circumstances of occurrence, dynamics of symptoms, and so on), objective examination data (palpation, percussion and auscultation - described above), laboratory and instrumental additional methods research.

The patient will be given:

1. (an increase in the number of leukocytes with a predominance in leukocyte formula immature forms, toxic granularity of neutrophils, high ESR).
2. (the concentration of sialic acids, seromucoid, fibrin, some types of protein is increased).
3. (the amount of cylindrical epithelium is increased, albumin and hematuria take place).
4. Sputum examination. With an abscess, it is characterized by an unpleasant, even fetid odor (this is a sign of an anaerobic infection). When standing in a jar, it is divided into 3 layers: the lower one is pus and necrotic masses, the middle one is a colorless (serous) liquid, the upper one is foamy, mucus. Sometimes traces of blood are found in it. At microscopy - a lot of leukocytes, elastic fibers, several types of bacteria.
5. Examination of pleural effusion (if pleural empyema is suspected).
6. in two - direct and lateral - projections. On the radiograph in the first stage, a uniform darkening is visualized at the site of the forming abscess - an inflammatory infiltrate. After the breakthrough of the abscess into the bronchial tree, an enlightenment is found in the picture (this is the cavity of the abscess) with a horizontal level of fluid; above this level - gas, and sometimes - areas of necrotic tissue. With multiple abscesses at the initial stage, the radiograph will show focal, probably bilateral bronchopneumonia. Further - a large number of cavities with pus, pleural effusion, pyopneumothorax. In children - cavities (bulls, cysts).
7. with aspiration of a small amount of abscess contents for the purpose of its subsequent microscopic examination, bakposev and determination of sensitivity to antibiotics.
8. Computed tomography of the lungs (it is prescribed in complex, doubtful cases in order to clarify the diagnosis).
9. - in case of suspicion of the development of pleurisy.

Differential Diagnosis

Some lung diseases present with symptoms similar to those of an abscess. The correct diagnosis is very important, since it practically guarantees adequate treatment, and therefore improves the prognosis. If a lung abscess is suspected, differential diagnosis should be carried out with the following diseases:

• benign neoplasms (cysts) of the lung;
• cavernous tuberculosis;
• bronchiectasis;
• destructive pneumonia;
• thromboembolism pulmonary artery complicated by pulmonary infarction;
• septic embolism.

Principles of treatment

The tactics of treating a lung abscess directly depends on the severity of its course. Depending on the clinical situation, the doctor may offer the patient conservative or surgical treatment, but in any case it is carried out in a hospital setting.

Conservative treatment includes:

• bed rest with a draining position for 15-30 minutes several times a day (with a raised foot and lowered head end, so that sputum can be more easily discharged);
• high-calorie, fortified, protein-enriched food;
• antibiotics (first - a wide spectrum of action (semi-synthetic aminopenicillins, aminoglycosides, fluoroquinolones), after determining the sensitivity of the pathogen microbe to antibiotics - changing the drug to a more suitable one);
• drugs that thin sputum (acetylcysteine, ambroxol and others);
• expectorant drugs (based on extracts of plantain, ivy);
• inhalation of sodium bicarbonate solution 2%;
• immunomodulators (in order to normalize the functioning of the immune system);
• infusion of solutions (in order to reduce intoxication and normalize the water-salt balance);
• autohemotransfusion;
• according to indications - gamma and antistaphylococcal globulin;
• vibration chest massage;
• oxygen therapy;
• in severe cases - hemosorption, plasmapheresis.

If necessary, if the sputum does not come out in sufficient volume, bronchoscopy is performed with active suction of the contents of the cavity and the subsequent introduction of antibiotic solutions into it.

If the abscess is not localized in the center, but at the borders of the lung, next to the chest wall, a transthoracic puncture is performed - the chest wall is pierced above the cavity, the contents are aspirated and the cavity is washed with an antiseptic solution.

In cases where the patient's condition is initially severe, or conservative therapy has been ineffective, or there are any complications, surgery is performed to remove the affected part of the lung.

Forecast and prevention

With a favorable course of the disease, recovery occurs in 1.5-2 months from the moment it began.

In every 5th patient, an acute abscess transforms into a chronic one.

5-10% of lung abscesses end, alas, with a fatal outcome.

Specific preventive actions missing. To prevent the development of this disease, you should:

• treat in a timely manner acute bronchitis, pneumonia, severe somatic diseases depressing immunity;
• monitor the state of the foci chronic infection, in the event of an exacerbation - do not ignore, but eliminate them;
• do not allow aspiration of the respiratory tract with anything;
• treat alcoholism, if any;
• stop smoking;
• avoid hypothermia.

Which doctor to contact

If you suspect infection lungs, including an abscess, you need to contact a pulmonologist. Additionally, a consultation with a thoracic surgeon will be scheduled. In chronic abscesses, an examination by an infectious disease specialist, an immunologist is necessary. Also, an endoscopist, a physiotherapist, a specialist in physiotherapy exercises take part in the treatment.

Conclusion

Lung abscess is an acute or chronic infectious disease characterized by the formation of one or more pus-filled cavities in the lung tissue. Accompanied by symptoms of general intoxication of the body, chest pain, shortness of breath and cough. After the breakthrough of the abscess into the bronchus cavity, the patient notes a significant improvement in the condition, but at the same time - the discharge of a large amount of fetid sputum.

An important role in the diagnosis is played by sputum analysis, radiography, and in severe cases - CT scan chest organs. Treatment depends on the clinical situation - someone is quite conservative, and some patients cannot avoid the intervention of surgeons.

The prognosis also varies depending on the severity of the disease - some patients recover completely, in others the process becomes chronic, and 5-10% of people with such a diagnosis die.

In order to prevent the development of a lung abscess, one should be attentive to health: give up bad habits, do not overcool, treat acute and sanitize chronic foci of infection in a timely manner, maintain somatic diseases in a state of compensation, and if symptoms similar to manifestations of a lung abscess occur, contact immediately for help to the doctor.

Lung abscess is a necrotic focus in the lung tissue with purulent contents, delimited from the healthy part of the organ by a pyogenic membrane. Currently, in developed countries, this pathology is quite rare. In most cases, it occurs in immunocompromised individuals, alcoholics, or heavy smokers.

Causes of the disease

The changes that occur in the lung tissue during an abscess are in many ways similar to those in pneumonia. The formation of a cavity with purulent contents instead of a focus of inflammation depends on the ability of the pathogen to cause necrosis and on the general reactivity of the organism itself. A certain role in this is played by smoking, which contributes to the development and reduction of local immunity.

Often, suppuration in the lungs develops against the background of:

• diabetes;
• long-term use of corticosteroids;
• leukemia;
• radiation sickness;
• other heavy pathological conditions that reduce the protective function of the body.

They also weaken the immune system (flu, parainfluenza), which contribute to the development of bacterial inflammation in the lungs.

The most common causative agents of pulmonary suppuration are the following microorganisms:

• golden staphylococcus aureus;
• klebsiella;
• Pseudomonas aeruginosa;
• fusobacteria;
• group A streptococci;
• anaerobic cocci;
• bacteroids, etc.

A prerequisite for the formation of a focus of destruction is the penetration of pyogenic microflora into the lung tissue. This is done in 4 main ways:

• bronchogenic (aspiration of the contents of the oropharynx, nasopharynx or stomach, as well as inhalation of pathogenic bacteria);
• hematogenous (infection with blood flow from the focus of inflammation in osteomyelitis, thrombophlebitis, bacterial endocarditis);
• traumatic (for example, with gunshot wounds of the chest);
• lymphatic (spread of pathogens with lymph flow).

In rare cases, a lung abscess is formed as a result of direct contact with a purulent focus during a breakthrough of subdiaphragmatic abscesses or abscesses of the liver.

It should be noted that more often than others, suppuration is caused by the aspiration of infected lumps of mucus or food masses. Contributes to this:

• state of deep intoxication;
• epileptic seizures;
• traumatic brain injury;
• acute disorders of cerebral circulation.

Main symptoms

In the clinic of an acute destructive process in the lungs, two periods are distinguished:

• the formation of a focus of purulent fusion of tissues until the breakthrough of its contents into the bronchial tree;
• after the breakthrough.

The first period has an acute onset:

• The patient's body temperature rises sharply to febrile numbers, chills appear.
• Acute pain in the chest on the side of the lesion, aggravated by deep inspiration, tilt or palpation of the intercostal spaces in the area of ​​the abscess.
• From the very beginning of the disease, there is a dry paroxysmal and (as a result of limited chest excursion and development).
• At the same time, signs of intoxication appear with severe weakness, sweating, and headache.

The condition of such patients approaches severe. Skin become pale with cyanosis of the lips. The affected side of the chest lags behind in the act of breathing. At the site of the lesion, dullness of percussion sound and weakened vesicular breathing are determined.

As the pathological process progresses, purulent fusion of the bronchus wall begins, which passes through the abscess cavity or close to the pyogenic membrane. Thus begins the second period of the disease.

• The patient begins to secrete purulent sputum with an unpleasant odor. Moreover, after the start of emptying the cavity of the abscess, sputum is separated by a “full mouth”. Its quantity can reach 1000 ml.
• In this case, the body temperature decreases, and the general condition begins to improve.
• Objectively, bronchial breathing with moist rales is heard over the cavity of the draining abscess. In the case of its complete emptying, breathing over the hearth can become amphoric.

With adequate treatment, the abscess cavity is cleared of pus, deformed and gradually reduced. It may take several weeks or months for it to disappear completely.

In the case of insufficient drainage of the cavity, a decrease in general reactivity, or improper treatment, the pathological process can continue and become chronic.

• Such patients lose their appetite, lose weight.
• Their body temperature rises daily with chills and profuse sweats.
• A large amount of sputum with a putrid odor is separated.

Complications

The unfavorable course of suppuration of the lungs contributes to the development of complications, often requiring surgical intervention. These include:

1. Pyopneumothorax.
2. Pleural empyema.
3. Subcutaneous.
4. Pulmonary bleeding.
5. Sepsis.
6. Metastatic brain abscesses.
7. Respiratory distress syndrome.

Diagnostic principles

The diagnosis of "lung abscess" the doctor may suspect in the aggregate clinical signs taking into account the patient's complaints, the history of his disease and an objective examination. Additional laboratory and instrumental studies help him confirm the diagnosis.

1. A clinical blood test (confirms the presence of bacterial inflammation by the presence of leukocytosis, a shift in the white blood formula to the left, an increase in ESR).
2. Sputum analysis (when settling, sputum is divided into three layers: the upper one is foamy, consists of mucus mixed with pus, the middle one is a mixture of saliva with a serous component, and the lower one has a heterogeneous structure, it includes pus, fragments of lung tissue, etc. microscopic examination reveals a variety of microorganisms and a large number of neutrophils).
3. (at the beginning of the disease, it reveals an area of ​​blackout with fuzzy contours, after opening the abscess - a cavity with thick walls and a horizontal level of fluid).
4. Computed tomography (is a more accurate method and is used when conventional radiography data is not enough to make a diagnosis).
5. (appointed in doubtful cases in order to clarify the localization of the abscess and the patency of the draining bronchus).

The key to success in making an accurate diagnosis is to differential diagnosis With:

• tuberculous cavity;
• festering cyst;

Treatment

Due to the severity of the course and the high risk of complications, the treatment of infectious destructions of the lungs is carried out in a hospital.

Conservative treatment is aimed at suppressing the infectious process, adequate drainage of purulent cavities and their sanitation.

1. All patients with lung abscess are treated with antibiotics. At the first stage, drugs from the group of aminoglycosides, cephalosporins, macrolides, carbapenems in high doses are used. After bacteriological examination of sputum and determination of the sensitivity of pathogenic microorganisms to antibiotics, therapy can be adjusted. In this case, the course of treatment averages 6 weeks.
2. In order to improve bronchial patency and drainage, bronchodilators, expectorants and mucolytic drugs are prescribed. If these measures are not effective, such patients are shown repeated endoscopic sanitation with intrabronchial administration of antiseptics, antibiotics and proteolytic enzymes.
3. In parallel with this, detoxification therapy is carried out with intravenous infusion of plasma-substituting solutions, hemosorption. If indicated, oxygen therapy is used.
4. To improve the impaired immunological reactivity, various immunocorrectors are used (thymus preparations, etc.).

With the ineffectiveness of conservative therapy or the development of complications, surgical treatment is indicated for such patients.

Conclusion

The prognosis for a lung abscess is determined by the severity of its course, the presence of complications, the general reactivity of the body and the adequacy of the therapeutic tactics for managing the patient. Mortality among patients with suppuration of the lungs reaches 10-15%.

It should be noted that in most cases, with timely and proper treatment in patients with an acute destructive process in the lung tissue, clinical recovery occurs. Some of them with complete obliteration of the pathological focus, and some with preservation of the cavity and pneumofibrosis around it. At the same time, good drainage and epithelialization of the inner surface of the abscess cavity contribute to the cessation of the purulent process. This condition can last for many years, but under adverse conditions that weaken the immune system, a repeated outbreak of infection with the development of the disease is possible. In 15-20% of these patients, a chronic lung abscess develops.

A specialist at the Moscow Doctor clinic talks about a lung abscess:

Are you an active person who cares and thinks about his respiratory system and overall health, keep exercising, healthy lifestyle life, and your body will delight you throughout your life, and no bronchitis will bother you. But do not forget to undergo examinations on time, maintain your immunity, this is very important, do not overcool, avoid severe physical and severe emotional overload.