Lung abscess (Lungenabszess)

General information:

  • Result of a necrotizing pneumonia (e.g. after aspiration of gastric juice, GER).
  • Streptococci, Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginose, or other gram – negative enteric organisms have been found to be responsible.
  • Frequent in children with neurological impairment, seizure disorders and immune suppression.
  • Location: posterior segment of the right upper lobe and the superior segments of the right and left lower lobe.
  • 10% of the affected children have more than one abscess.
  • Notice the probability of an abscess formation in etiological connection with an unknown pre-existing localized pulmonary malformation (CCAM, bronchogenic cyst, lung cyst, infected sequestration).

Symptoms:

  • Cough, fever, tachypnea, decreased (no) breathing sounds and dullness to percussion on the involved side.
  • Respiratory distress.
  • Pulmonary infiltrate, cavity with fluid level.
  • Usually quick development of pleural effusion.
  • Perforation into the pleural cavity leads to empyema usually combined with pneumothorax.

Diagnostic workout:

  • Thoracic X-ray, CT or MRI scan.
  • Bronchial lavage guided by flexible fiberoptic bronchoscopy or thoracocentesis is useful in obtaining culture material used to determine specific antibiotic treatment.

Indication for operation:

  • Bronchopleural fistula.
  • Operation frequently needed in younger and more debilitated children.
  • Large abscesses (approx. more than 5 cm in diameter) with fluid levels, especially located near the lung surface, unresponsive after aggressive conservative treatment.
  • No complete expansion of the lung over a period of about two weeks.
Lung abscess
Right lung abscess

Treatment/Operation:

  • Intravenous antibiotic management continued orally.
  • Closed drainage (multiple chest tubes sometimes necessary).
  • Open drainage (including decortication) of the pleural effusion usually with two large chest tubes.
  • Resection, usually of the complete involved lobe (covering the bronchial closure additionally with a dorsally based intercostal muscle flap). Care must be taken with the induction of anaesthesia or positioning the patient to prevent a spill of the abscess contents into the contralateral lung (bronchoscopically guided suction before!).

Postoperative management:

  • Chest tubes may be removed if the lung is fully expanded and drainage volumes decrease below 20 to 50cc during a 24 hours period.
  • Antibiotic management continued orally after release from the hospital.

Prognosis:

  • Good.
  • Resolution of a sufficiently drained abscess needs several weeks.

Pneumatocele

General information:

  • Thin walled, air filled cyst usually after a necrotizing Staphylococcus aureus pneumonia (other germs involved: Streptococcus, Hemophilus influenzae, Klebsiella, E. coli and Pseudomonas).
  • Endotoxin released from the staphylococcal organisms contributes to the extremely destructive inflammatory process.
  • Mechanically ventilated patients are at increased risk of developing pneumatocele.
  • Adjacent structures may be compressed or a mediastinal shift may occur, when tension pneumatocele develops.
  • 25% of the pneumatoceles rupture, causing a usually insignificant pneumothorax.

Symptoms:

  • Respiratory insufficiency.

Diagnostic workout:

  • Thoracic X-ray or CT scan.
  • Thoracic ultrasound.

Indication for operation:

  • Rapidly enlarging pneumatocele producing mediastinal shift (tension pneumatocele).

Treatment/Operation:

  • Most pneumoatoceles require no treatment, just observation.
  • Percutaneous needle aspiration or chest tube for drainage in large cysts.
  • Thoracotomy, suture or resection is rarely necessary.

Postoperative management:

  • Chest tubes may be removed if the lung is fully expanded and drainage volumes decrease below 20 to 50cc during a 24 hour period.

Prognosis:

  • Good. About 50% resolve within 6 weeks and the remainder within 12 months.
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