History

Fact Explanation
A diagnosed patient with pneumonia Lung abscess is usually suspected when a diagnosed patient with lower respiratory tract infection fails to respond to the conventional and, assumed as adequate antibiotics. [1] The commonest causative organisms for lung abscesses are the anaerobic bacteria (in cases of aspiration pneumonia), aerobic bacteria (rare but in cases of community aqcuired pneumonia), and Mycobacterium. [2] [3] A lung abscess develops when a bacterial infection causes necrosis and produces cavities in the lung parenchyma. [4]
A risk factor for developing pneumonia and lung abscess The commonest risk factors for aspiration pneumonia are are alcoholism related stupor, neurological disability, advanced age and lung malignancies. Once pneumonia is there, the predisposing factors for development of a lung abscess are immunosuppression, steroid therapy, carcinoma at a distant site, alcoholism, and lung cancer. [5] [6] [7] It's more common in males than females. [7]
Fever Some patients present with fever of unknown origin [1] and some patients present with high fever with chills. [4] Fever is one of the commonest symptoms in lung abscess. [8]
Cough with sputum production Productive cough with variable sputum is one of the commonest features in lung abscess. The sputum may be colored, depending on the infected organism, and foul-smelling. [4] [7] [9] There can be tinges of blood also. [10]
Chest pain Chest pain of pleuritic nature is a common feature in lung abscess and pneumonia. [4] [11] But chest pain should be evaluated since it can be a feature of other complications as well. [12]
Non-specific B-symptoms Night sweats, low grade fever and weight loss has also been reported in chronic lung abscesses. [4] [7] [13]
References
  1. CUNHA BURKE A., PHEREZ FRANCISCO M., KATZ DOUGLAS S.. Fever of unknown origin (FUO) due to a solitary cavitary lung lesion: The deadly ferritin-laced doughnut. Heart & Lung: The Journal of Acute and Critical Care [online] 2010 July, 39(4):340-344 [viewed 10 June 2014] Available from: doi:10.1016/j.hrtlng.2009.07.010
  2. HAMMOND JANET M.J.. The Etiology and Antimicrobial Susceptibility Patterns of Microorganisms in Acute Community-Acquired Lung Abscess. CHEST [online] 1995 October [viewed 10 June 2014] Available from: doi:10.1378/chest.108.4.937
  3. BARTLETT J. G.. Anaerobic Bacterial Infections of the Lung and Pleural Space. Clinical Infectious Diseases [online] 1993 June, 16(Supplement 4):S248-S255 [viewed 10 June 2014] Available from: doi:10.1093/clinids/16.Supplement_4.S248
  4. YU HYEON. Management of Pleural Effusion, Empyema, and Lung Abscess. Semin intervent Radiol [online] December, 28(01):075-086 [viewed 10 June 2014] Available from: doi:10.1055/s-0031-1273942
  5. POHLSON EC, MCNAMARA JJ, CHAR C, KURATA L. Lung abscess: a changing pattern of the disease. Am J Surg [online] 1985 Jul, 150(1):97-101 [viewed 10 June 2014] Available from: DOI: 10.1016/0002-9610(85)90016-9
  6. LIGABUE T., VOLTOLINI L., GHIRIBELLI C., LUZZI L., RAPICETTA C., GOTTI G.. Abscess of Residual Lobe after Pulmonary Resection for Lung Cancer. Asian Cardiovascular and Thoracic Annals [online] 2008 April, 16(2):112-114 [viewed 10 June 2014] Available from: doi:10.1177/021849230801600206
  7. MOREIRA JOSé DA SILVA, CAMARGO JOSé DE JESUS PEIXOTO, FELICETTI JOSé CARLOS, GOLDENFUN PAULO ROBERTO, MOREIRA ANA LUIZA SCHNEIDER, PORTO NELSON DA SILVA. Lung abscess: analysis of 252 consecutive cases diagnosed between 1968 and 2004. J. bras. pneumol. [online] 2006 April [viewed 10 June 2014] Available from: doi:10.1590/S1806-37132006000200009
  8. FURMAN AC, JACOBS J, SEPKOWITZ KA. Lung abscess in patients with AIDS. Clin Infect Dis [online] 1996 Jan, 22(1):81-5 [viewed 10 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8824970
  9. FARZAN S. Clinical Methods: The History, Physical, and Laboratory Examinations, 3rd edition: Chapter 38, Cough and Sputum Production. [web] [viewed 11 June 2014] Available from http://www.ncbi.nlm.nih.gov/books/NBK359/
  10. COREY R. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition, Chapter 39; Hemoptysis. [web] [viewed on 11 June 2014] Available from http://www.ncbi.nlm.nih.gov/books/NBK360/
  11. ADEBONOJO SA, OSINOWO O, ADEBO O. Lung Abscess: A Review of Three-Years Experience at the University College Hospital, Ibadan J Natl Med Assoc [online] 1979 Jan, 71(1):39-43 [viewed 11 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2537236
  12. MAGAZINE R, MOHAPATRA AK, MANU MK, SRIVASTAVA RK. Herniation of unruptured tuberculous lung abscess into chest wall without pleural or bronchial spillage Lung India [online] 2011, 28(4):297-299 [viewed 11 June 2014] Available from: doi:10.4103/0970-2113.85695
  13. LION C., LOZNIEWSKI A., ROSNER V., WEBER M.. Lung Abscess Due to -Lactamase-Producing Pasteurella multocida. Clinical Infectious Diseases [online] 1999 November, 29(5):1345-1346 [viewed 11 June 2014] Available from: doi:10.1086/313439

Examination

Fact Explanation
Fever Because of necro-inflammation in the lung parenchyma. IT could be a low grade nocturnal fever in cases of chronic lung abscesses, or high fever with chills in acute lung abscess and bacterial pneumonia. It's one of the commonest presentations. [1] [2] [3]
Digital clubbing Nail clubbing develops sub-acutely in chronic suppurative conditions like lung abscess and empyema. [4] [5] [6] It should be evaluated according to the stage of clubbing. [4]
Cyanosis Since there is an inflammation of the lung tissue which is important in gas exchange, there is going to be an oxygen un-saturation of blood, evident as bluish discolouration of tongue, mucus membranes (central cyanosis) and nail beds (peripheral cyanosis) . [7] [8]
Poor oral hygiene One of the commonest risk factor for lung abscess following aspiration pneumonia. [9]
Tachypnea Due to hypoxia and sympathetic stimulation. Taken alone, it has no diagnostic value in pneumonia. [10]
Features of respiratory distress In severe pneumonia or the infection progressing to acute respiratory distress syndrome. [12] [13] Use of accessory muscles for breathing, tachypnea and tracheal tug are common findings.
Features of lung consolidation The features of lung damage and consolidation might be obvious in respiratory system examination such as reduced lung expansion, reduced air entry, more pronounced vocal resonance and dull note for percussion. [14]
References
  1. CUNHA BURKE A., PHEREZ FRANCISCO M., KATZ DOUGLAS S.. Fever of unknown origin (FUO) due to a solitary cavitary lung lesion: The deadly ferritin-laced doughnut. Heart & Lung: The Journal of Acute and Critical Care [online] 2010 July, 39(4):340-344 [viewed 10 June 2014] Available from: doi:10.1016/j.hrtlng.2009.07.010
  2. YU HYEON. Management of Pleural Effusion, Empyema, and Lung Abscess. Semin intervent Radiol [online] December, 28(01):075-086 [viewed 10 June 2014] Available from: doi:10.1055/s-0031-1273942
  3. FURMAN AC, JACOBS J, SEPKOWITZ KA. Lung abscess in patients with AIDS. Clin Infect Dis [online] 1996 Jan, 22(1):81-5 [viewed 10 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8824970
  4. SARKAR M, MAHESH DM, MADABHAVI I. Digital clubbing Lung India [online] 2012, 29(4):354-362 [viewed 11 June 2014] Available from: doi:10.4103/0970-2113.102824
  5. RWEGERERA GODFREY MUTASHAMBARA, TAOLO ERASMUS KAGO. Chronic multiple lung abscesses presenting as a Left lung apical mass: a ticking bomb?. Pan Afr Med J [online] 2014 December [viewed 13 June 2014] Available from: doi:10.11604/pamj.2014.17.292.3081
  6. D'SOUZA NA, LAKHKAR BB, BHASKARANAND N. Primary lung abscess--a not so rare cause of clubbing. Indian Pediatr [online] 1993 Sep, 30(9):1137 [viewed 13 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8125604
  7. STADIE WC. The Oxygen Of The Arterial And Venous Blood In Pneumonia And It's Relation To Cyanosis. J Exp Med [online] 1919 Sep 1, 30(3):215-40 [viewed 13 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19868355
  8. SNIDER HL. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition; Chapter 45: Cyanosis. [web] [viewed 13 June 2014] Available at http://www.ncbi.nlm.nih.gov/books/NBK367/
  9. MOREIRA JDA S, CAMARGO JDE J, FELICETTI JC, GOLDENFUN PR, MOREIRA AL, PORTO NDA S. Lung abscess: analysis of 252 consecutive cases diagnosed between 1968 and 2004. J Bras Pneumol [online] 2006 Mar-Apr, 32(2):136-43 [viewed 13 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17273583
  10. PALAFOX M.. Diagnostic value of tachypnoea in pneumonia defined radiologically. [online] 2000 January, 82(1):41-45 [viewed 13 June 2014] Available from: doi:10.1136/adc.82.1.41
  11. SHAH SONAL, BACHUR RICHARD, KIM DANIEL, NEUMAN MARK I.. Lack of Predictive Value of Tachypnea in the Diagnosis of Pneumonia in Children. The Pediatric Infectious Disease Journal [online] 2010 May, 29(5):406-409 [viewed 13 June 2014] Available from: doi:10.1097/INF.0b013e3181cb45a7
  12. BAUER T. T., EWIG S., RODLOFF A. C., MULLER E. E.. Acute Respiratory Distress Syndrome and Pneumonia: A Comprehensive Review of Clinical Data. Clinical Infectious Diseases [online] 2006 September, 43(6):748-756 [viewed 13 June 2014] Available from: doi:10.1086/506430
  13. WINGERTER SARAH L., BACHUR RICHARD G., MONUTEAUX MICHAEL C., NEUMAN MARK I.. Application of the World Health Organization Criteria to Predict Radiographic Pneumonia in a US-based Pediatric Emergency Department. The Pediatric Infectious Disease Journal [online] 2012 June, 31(6):561-564 [viewed 13 June 2014] Available from: doi:10.1097/INF.0b013e31824da716
  14. KUMAR P and CLARK M. Kumar & Clark's Clinical Medicine; 8th edition. Chapter 15: Respiratory disease. p791-839.

Differential Diagnoses

Fact Explanation
Lung carcinoma Lung malignancy is one other important factor in secondary lung abscesses. The obstructing lung neoplasms cause a cavitating abscess distal to it. [1] [2] [3] [4] [5]
Tuberculosis Mycobacterium infection is also a cause of pneumonia and lung abscess. But tuberculous lung cavities with caseation can also mimic a lung abscess. [6] [7] [8] [9] [10]
Hydatid cyst A cavitatory disease caused by the endo-parasite Echinococcus granulosum [11] The pulmonary infection by Echinococcus larval forms can cause hydatid cysts and they can mimic lung abscesses. [11] [12] [13] [14]
Other malignancy with pulmonary metastasis Metastatic deposits with a distant primary malignancy can also mimic lung abscess. [15]
References
  1. YU H. Management of Pleural Effusion, Empyema, and Lung Abscess Semin Intervent Radiol [online] 2011 Mar, 28(1):75-86 [viewed 14 June 2014] Available from: doi:10.1055/s-0031-1273942
  2. KAMIYA K, YOSHIZU A, MISUMI Y, HIDA N, OKAMOTO H, YOSHIDA S. [Lung abscess which needed to be distinguished from lung cancer; report of a case]. Kyobu Geka [online] 2011 Dec, 64(13):1204-7 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22242302
  3. PHERNAMBUCQ ERIK C. J., HARTEMINK KOEN J., SMIT EGBERT F., PAUL MARINUS A., POSTMUS PIETER E., COMANS EMILE F. I., SENAN SURESH. Tumor Cavitation in Patients With Stage III Non–Small-Cell Lung Cancer Undergoing Concurrent Chemoradiotherapy. Journal of Thoracic Oncology [online] 2012 August, 7(8):1271-1275 [viewed 14 June 2014] Available from: doi:10.1097/JTO.0b013e3182582912
  4. LIGABUE T., VOLTOLINI L., GHIRIBELLI C., LUZZI L., RAPICETTA C., GOTTI G.. Abscess of Residual Lobe after Pulmonary Resection for Lung Cancer. Asian Cardiovascular and Thoracic Annals [online] 2008 April, 16(2):112-114 [viewed 14 June 2014] Available from: doi:10.1177/021849230801600206
  5. POHLSON EC, MCNAMARA JJ, CHAR C, KURATA L. Lung abscess: a changing pattern of the disease. Am J Surg [online] 1985 Jul, 150(1):97-101 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/4014575
  6. MAGAZINE R, MOHAPATRA AK, MANU MK, SRIVASTAVA RK. Herniation of unruptured tuberculous lung abscess into chest wall without pleural or bronchial spillage Lung India [online] 2011, 28(4):297-299 [viewed 14 June 2014] Available from: doi:10.4103/0970-2113.85695
  7. HAGAN JL, HARDY JD. Lung abscess revisited. A survey of 184 cases. Ann Surg [online] 1983 Jun, 197(6):755-762 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1352910
  8. PETERS LEROY S.. The Treatment of Cavities in Pulmonary Tuberculosis. Ann Intern Med [online] 1932 December [viewed 14 June 2014] Available from: doi:10.7326/0003-4819-6-6-802
  9. SAVE S, DOSHI H, SOMALE A. Lung cavities in an infant: Could it be tuberculosis?. J Postgrad Med [online] 2012 December [viewed 14 June 2014] Available from: doi:10.4103/0022-3859.101408
  10. PALACI M., DIETZE R., HADAD D. J., RIBEIRO F. K. C., PERES R. L., VINHAS S. A., MACIEL E. L. N., DO VALLE DETTONI V., HORTER L., BOOM W. H., JOHNSON J. L., EISENACH K. D.. Cavitary Disease and Quantitative Sputum Bacillary Load in Cases of Pulmonary Tuberculosis. Journal of Clinical Microbiology [online] December, 45(12):4064-4066 [viewed 14 June 2014] Available from: doi:10.1128/JCM.01780-07
  11. PUMP KK. Echinococcosis (Hydatid Disease): Review and Report of a Case of Secondary Echinococcosis Can Med Assoc J [online] 1963 Jul 13, 89(2):73-78 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1921605
  12. TEKINBAS CELAL, GUNDUZ ABDULKADIR, TUREDI SULEYMAN, EROL M. MUHARREM. Hydatid cyst disease of the lung as an unusual cause of massive hemoptysis: a case report. Journal of Medical Case Reports [online] 2009, 3:21 [viewed 14 June 2014] Available from: doi:10.1186/1752-1947-3-21
  13. VON SINNER W.. Pleural complications of hydatid disease (Echinococcus granulosus). Fortschr Röntgenstr [online] December, 152(06):718-722 [viewed 14 June 2014] Available from: doi:10.1055/s-2008-1046955
  14. KUZUCU AKıN, SOYSAL ÖMER, ÖZGEL MEHMET, YOLOGLU SAIM. Complicated hydatid cysts of the lung: clinical and therapeutic issues. The Annals of Thoracic Surgery [online] 2004 April, 77(4):1200-1204 [viewed 14 June 2014] Available from: doi:10.1016/j.athoracsur.2003.09.046
  15. ASANO MICHIKO, FUJIMOTO NOBUKAZU, FUCHIMOTO YASUKO, ONO KATSUICHIRO, OZAKI SHINJI, KIMURA FUMIAKI, KISHIMOTO TAKUMI. Brain abscess mimicking lung cancer metastases; a case report. Clinical Imaging [online] 2013 January, 37(1):147-150 [viewed 14 June 2014] Available from: doi:10.1016/j.clinimag.2012.04.020

Investigations - for Diagnosis

Fact Explanation
Complete blood count To detect leucocytosis or leucopenia together with shifts of differential count. It can direct the diagnosis to the probable causative organism groups. [1] [2] [3]
Sputum for microbiological studies Examination of sputum is important in identifying the causative micro-organism. In the cases where the patient is able to produce sputum, then properly labeled sputum in the specific container should be sent for microscopy. But when the patient is unable to do so, sputum induction should be performed. The required microbiological studies are Gram stain, culuture and antibiotic sensitivity. [4] [5] [6] [7] [8] [9] [10]
Sputum for acid-fast bacilli If tuberculous abscess is suspected. But sputum may not be positive unless the abscess ruptures into an airway. [11]
Chest X-ray The main radiological feature in plain erect chest X-ray is a cavity with an irregular inside layer and air-fluid level. Most of the time the cavities are round in shape, and there is a thick area of consoliation around the cavity. These cavitatory lesions are seen in other conditions as well, i.e. infected bulla, cavitary tumor, mycobacterial infection, pulmonary infarction, pulmonary sequestration, and vasculitis. [12] [13] [14] [15] [16]
Contranst-enhanced computed-tomography of chest More reliable than an X-ray. Vascularity also can be viewed in cases where malignancy is suspected. [12] [16] [17] [18]
References
  1. FURMAN AC, JACOBS J, SEPKOWITZ KA. Lung abscess in patients with AIDS. Clin Infect Dis [online] 1996 Jan, 22(1):81-5 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8824970
  2. HAPIRO MARTIN F.. Diagnostic Decision: The Complete Blood Count and Leukocyte Differential Count: An Approach to Their Rational Application. Ann Intern Med [online] 1987 January [viewed 08 June 2014] Available from: doi:10.7326/0003-4819-106-1-65
  3. BLUMENREICH MS. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition [web]; Chapter 153, The White Blood Cell and Differential Count. [viewed 08 June 2014] Available at http://www.ncbi.nlm.nih.gov/books/NBK261/
  4. ZAR H.J., TANNENBAUM E., HANSLO D., HUSSEY G.. Sputum induction as a diagnostic tool for community-acquired pneumonia in infants and young children from a high HIV prevalence area. Pediatr. Pulmonol. [online] December, 36(1):58-62 [viewed 14 June 2014] Available from: doi:10.1002/ppul.10302
  5. EWIG SANTIAGO. Applying Sputum as a Diagnostic Tool in Pneumonia . Chest [online] 2002 May [viewed 14 June 2014] Available from: doi:10.1378/chest.121.5.1486
  6. REED WW, BYRD GS, GATES RH JR, HOWARD RS, WEAVER MJ. Sputum gram's stain in community-acquired pneumococcal pneumonia. A meta-analysis. West J Med [online] 1996 Oct, 165(4):197-204 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1303744
  7. DREW WL. Value of sputum culture in diagnosis of pneumococcal pneumonia. J Clin Microbiol [online] 1977 Jul, 6(1):62-65 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC274699
  8. GLECKMAN R, DEVITA J, HIBERT D, PELLETIER C, MARTIN R. Sputum gram stain assessment in community-acquired bacteremic pneumonia. J Clin Microbiol [online] 1988 May, 26(5):846-849 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC266472
  9. GARCíA-VáZQUEZ E, MARCOS MA, MENSA J, DE ROUX A, PUIG J, FONT C, FRANCISCO G, TORRES A. Assessment of the usefulness of sputum culture for diagnosis of community-acquired pneumonia using the PORT predictive scoring system. Arch Intern Med [online] 2004 Sep 13, 164(16):1807-11 [viewed 14 June 2014] Available from: doi:10.1001/archinte.164.16.1807
  10. REED WW, BYRD GS, GATES RH JR, HOWARD RS, WEAVER MJ. Sputum gram's stain in community-acquired pneumococcal pneumonia. A meta-analysis. West J Med [online] 1996 Oct, 165(4):197-204 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8987424
  11. MAGAZINE R, MOHAPATRA AK, MANU MK, SRIVASTAVA RK. Herniation of unruptured tuberculous lung abscess into chest wall without pleural or bronchial spillage Lung India [online] 2011, 28(4):297-299 [viewed 14 June 2014] Available from: doi:10.4103/0970-2113.85695
  12. STARK DD, FEDERLE MP, GOODMAN PC, PODRASKY AE, WEBB WR. Differentiating lung abscess and empyema: radiography and computed tomography. AJR Am J Roentgenol [online] 1983 Jul, 141(1):163-7 [viewed 14 June 2014] Available from: doi:10.2214/ajr.141.1.163
  13. WOODRING JH, FRIED AM. Significance of wall thickness in solitary cavities of the lung: a follow-up study. AJR Am J Roentgenol. [online] 1983;140 (3): 473-4. [viewed 14 June 2014] Available from: doi:10.2214/ajr.140.3.473
  14. RYU JH, SWENSEN SJ. Cystic and cavitary lung diseases: focal and diffuse. Mayo Clin. Proc. [web] 2003;78 (6): 744-52. [viewed 14 June 2014] Available from doi:10.4065/78.6.744
  15. GADKOWSKI LB, STOUT JE. Cavitary pulmonary disease. Clin. Microbiol. Rev. [online] 2008;21 (2): 305-33. [viewed 14 June 2014] Available from doi:10.1128/CMR.00060-07
  16. YU H. Management of Pleural Effusion, Empyema, and Lung Abscess Semin Intervent Radiol [online] 2011 Mar, 28(1):75-86 [viewed 14 June 2014] Available from: doi:10.1055/s-0031-1273942
  17. VANSONNENBERG E, D'AGOSTINO HB, CASOLA G, WITTICH GR, VARNEY RR, HARKER C. Lung abscess: CT-guided drainage. Radiology [online] 1991 Feb, 178(2):347-51 [viewed 14 June 2014] Available from: doi:10.1148/radiology.178.2.1987590
  18. RWEGERERA GODFREY MUTASHAMBARA, TAOLO ERASMUS KAGO. Chronic multiple lung abscesses presenting as a Left lung apical mass: a ticking bomb?. Pan Afr Med J [online] 2014 December [viewed 14 June 2014] Available from: doi:10.11604/pamj.2014.17.292.3081

Investigations - Fitness for Management

Fact Explanation
Hemoglobin level The pre-operative hemoglobin count allows the surgeon to correct it with blood before any surgical procedure. Post-operative hemoglobin count is an important predictor in mortality. [1] [2] [3] [4] [5]
Platelet count Both low and high platelet counts are associated with undesirable outcomes following a surgery. [6] [7] [8]
Renal functions Investigations to assess renal functions i.e. urine full report, serum creatine, blood urea, serum electrolytes, should be evaluated before the surgery to prevent acute renal failure happening post-operatively. [9] [10]
Liver functions To assess the fitness of the liver. [11] The required investigations are mainly transaminases.
Lung functions Lung functions are a must in all the patients before any procedure or major surgery since lung functions are already deranged because of the illness. [12] [13]
Electrocardiogram To assess cardiac status and some pulmonary abnormalities, i.e. pulmonary hypertension. [14]
References
  1. CARSON JEFFREY L.. Perioperative Blood Transfusion and Postoperative Mortality. JAMA [online] 1998 January [viewed 14 June 2014] Available from: doi:10.1001/jama.279.3.199
  2. CARSON JEFFREY L., NOVECK HELAINE, BERLIN JESSE A., GOULD STEVEN A.. Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion. Transfusion [online] 2002 July, 42(7):812-818 [viewed 14 June 2014] Available from: doi:10.1046/j.1537-2995.2002.00123.x
  3. CARSON JEFFREY L, DUFF AMY, POSES ROY M, BERLIN JESSE A, SPENCE RICHARD K, TROUT RICHARD, NOVECK HELAINE, STROM BRIAN L. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. The Lancet [online] 1996 October, 348(9034):1055-1060 [viewed 14 June 2014] Available from: doi:10.1016/S0140-6736(96)04330-9
  4. TOMITA M, SHIMIZU T, HARA M, AYABE T, ONITSUKA T. Impact of preoperative hemoglobin level on survival of non-small cell lung cancer patients. Anticancer Res [online] 2008 May-Jun, 28(3B):1947-50 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18630486
  5. YOVINO S, KWOK Y, KRASNA M, BANGALORE M, SUNTHARALINGAM M. An association between preoperative anemia and decreased survival in early-stage non-small-cell lung cancer patients treated with surgery alone. Int J Radiat Oncol Biol Phys [online] 2005 Aug 1, 62(5):1438-43 [viewed 14 June 2014] Available from: doi:10.1016/j.ijrobp.2004.12.038
  6. LIU H. B., GU X. L., MA X. Q., LV T. F., WU Y., XIAO Y. Y., YUAN D. M., LI Y. F., SONG Y.. Preoperative platelet count in predicting lymph node metastasis and prognosis in patients with non-small cell lung cancer. neo [online] 2012 December, 60(02):203-208 [viewed 14 June 2014] Available from: doi:10.4149/neo_2013_027
  7. COX G, WALKER R.A, ANDI A, STEWARD W.P, O'BYRNE K.J. Prognostic significance of platelet and microvessel counts in operable non-small cell lung cancer. Lung Cancer [online] 2000 September, 29(3):169-177 [viewed 14 June 2014] Available from: doi:10.1016/S0169-5002(00)00124-0
  8. LUCKRAZ HEYMAN, ASHOUB AHMED, LAKSHMANAN SURESH. Cardiac surgery in a patient with severe thrombocytopenia: How low is too low?. Ann Card Anaesth [online] 2013 December [viewed 14 June 2014] Available from: doi:10.4103/0971-9784.114258
  9. CHERTOW G. M., LAZARUS J. M., CHRISTIANSEN C. L., COOK E. F., HAMMERMEISTER K. E., GROVER F., DALEY J.. Preoperative Renal Risk Stratification. Circulation [online] 1997 February, 95(4):878-884 [viewed 14 June 2014] Available from: doi:10.1161/​01.CIR.95.4.878
  10. JOEHL RAYMOND J.. Preoperative Evaluation: Pulmonary, Cardiac, Renal Dysfunction and Comorbidities. Surgical Clinics of North America [online] 2005 December, 85(6):1061-1073 [viewed 14 June 2014] Available from: doi:10.1016/j.suc.2005.09.015
  11. IWATA TAKASHI, NISHIYAMA NORITOSHI, NAGANO KOSHI, IZUMI NOBUHIRO, MIZUGUCHI SHINJIRO, MORITA RYUHEI, TSUKIOKA TAKUMA, HANADA SHOJI, INOUE KIYOTOSHI, KUBO SHOJI, TAKEMURA SHIGEKAZU, SUEHIRO SHIGEFUMI. Pulmonary Resection for Non-Small Cell Lung Cancer in Patients with Hepatocellular Carcinoma. World J Surg [online] December, 32(10):2204-2212 [viewed 14 June 2014] Available from: doi:10.1007/s00268-008-9691-9
  12. RANU H, WILDE M, MADDEN B. Pulmonary Function Tests Ulster Med J [online] 2011 May, 80(2):84-90 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3229853
  13. WIN T.. Relationship between pulmonary function and lung cancer surgical outcome. European Respiratory Journal [online] 2005 April, 25(4):594-599 [viewed 14 June 2014] Available from: doi:10.1183/09031936.05.00077504
  14. BECKLES MA, SPIRO SG, COLICE GL, RUDD RM, AMERICAN COLLEGE OF CHEST PHYSICIANS. The physiologic evaluation of patients with lung cancer being considered for resectional surgery. Chest [online] 2003 Jan, 123(1 Suppl):105S-114S [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12527570

Management - General Measures

Fact Explanation
Optimize co-morbid conditions Presence of co-morbid conditions increases the morbidity and mortality in any medical condition. [1] In emergency setting, of-course there isn't much valuable time left for dwelling on prolonged history taking. [2] In cases where the elderly or immobilized patients aspirating frequently, and also in cases where lung abscess is secondary to another lung disease such as lung carcinoma, ensuring that the patient's quality of life is improved is important. [3] Medical and surgical palliative care should be discussed with different specialists, so sometimes a multi-disciplinary team is needed. Most important are chest physiotherapy, stenting the airways, analgesics and antipyretics. All these include de-briefing the patient and the family previous to them. [3] [4] [5] [6] [7] [8]
References
  1. CLOUGH ROBERT A.. The Effect of Comorbid Illness on Mortality Outcomes in Cardiac Surgery. Arch Surg [online] 2002 April [viewed 15 June 2014] Available from: doi:10.1001/archsurg.137.4.428
  2. LIMMER S., UNGER L., CZYMEK R., KUJATH P., HOFFMANN M.. Emergency thoracic surgery in elderly patients. JRSM Short Reports [online] December, 2(2):13-13 [viewed 15 June 2014] Available from: doi:10.1258/shorts.2011.010108
  3. MEYER KEITH C. Diagnosis and management of interstitial lung disease. Translational Respiratory Medicine [online] December 2014, 2:4 [viewed 15 June 2014] Available from: doi:10.1186/2213-0802-2-4
  4. FERRELL B, KOCZYWAS M, GRANNIS F, HARRINGTON A. Palliative Care in Lung Cancer Surg Clin North Am [online] 2011 Apr, 91(2):403-ix [viewed 15 June 2014] Available from: doi:10.1016/j.suc.2010.12.003
  5. GOMPELMANN D., EBERHARDT R., HERTH F.J.F.. Advanced Malignant Lung Disease: What the Specialist Can Offer. Respiration [online] 2011 December, 82(2):111-123 [viewed 15 June 2014] Available from: doi:10.1159/000329703
  6. LIM KH, TAN YM, CHOW PK. Liver abscess metastasizing to prostate and lung J R Soc Med [online] 2002 Nov, 95(11):554-555 [viewed 15 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1279255
  7. RäSäNEN J, BOOLS JC, DOWNS JB. Endobronchial drainage of undiagnosed lung abscess during chest physical therapy. A case report. Phys Ther [online] 1988 Mar, 68(3):371-3 [viewed 15 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3347655
  8. WALI SIRAJO. An update on the drainage of pyogenic lung abscesses. Ann Thorac Med [online] 2012 December [viewed 15 June 2014] Available from: doi:10.4103/1817-1737.91552

Management - Specific Treatments

Fact Explanation
Prolonged course of antibiotics Prolonged (1-3 months) oral antibiotics are the commonest mode of management. [1] Oral clindamicin is the drug of choice. Metronidazole, moxifloxacin are also valuable. [1] [2] [3] [4] [5] [6] [7] [8] Even though it is so, medical treatment can be failed if the patient has poor prognostic factors, such as a large abscess cavity (> 6 cm), compromised immunity, neoplasm, advanced age, reduced level of consciousness, or infection with certain aerobic pathogens (Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus). [1]
Surgical drainage Some almost 20% of the patients with lung abscesses require surgical or percutaneous drainage due to medical treatment failure at some point. [1] CT-guided drainage offers best option and highest success rate. Endoscopy, ultrasound also can be used. [1] [8] [9] [10] [11]
Open surgery Indicated in cases where there is a malignancy predisposing the lung cavitation (or suspected of a malignancy) or there are multiple cavities. [12] [13]
References
  1. YU H. Management of Pleural Effusion, Empyema, and Lung Abscess Semin Intervent Radiol [online] 2011 Mar, 28(1):75-86 [viewed 14 June 2014] Available from: doi:10.1055/s-0031-1273942
  2. SMIEJA M. Current indications for the use of clindamycin: A critical review Can J Infect Dis [online] 1998, 9(1):22-28 [viewed 14 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3250868
  3. KAPILA R., SEN P., SALAKI J., LOURIA D. B.. Evaluation of Clindamycin and Other Antibiotics in the Treatment of Anaerobic Bacterial Infections of the Lung. Journal of Infectious Diseases [online] 1977 March, 135(Supplement):S58-S64 [viewed 14 June 2014] Available from: doi:10.1093/infdis/135.Supplement.S58
  4. GUDIOL FRANCESC. Clindamycin vs Penicillin for Anaerobic Lung Infections. Arch Intern Med [online] 1990 December [viewed 14 June 2014] Available from: doi:10.1001/archinte.1990.00390230077010
  5. BARTLETT J. G.. Anaerobic Bacterial Infections of the Lung and Pleural Space. Clinical Infectious Diseases [online] 1993 June, 16(Supplement 4):S248-S255 [viewed 14 June 2014] Available from: doi:10.1093/clinids/16.Supplement_4.S248
  6. KUMAR KJAGADISH, MAMATHA S, KUDAKASSERIL ANUSHS, MANJUNATH VG. Lung abscess in a child. Ann Trop Med Public Health [online] 2012 December [viewed 14 June 2014] Available from: doi:10.4103/1755-6783.92884
  7. POLENAKOVIK H., BURDETTE S. D., POLENAKOVIK S.. Moxifloxacin Is Efficacious for Treatment of Community-Acquired Lung Abscesses in Adults. Clinical Infectious Diseases [online] 2005 September, 41(5):764-765 [viewed 14 June 2014] Available from: doi:10.1086/432626
  8. BARTLETT JOHN G.. Editorial Commentary: The Role of Anaerobic Bacteria in Lung Abscess. CLIN INFECT DIS [online] 2005 April, 40(7):923-925 [viewed 14 June 2014] Available from: doi:10.1086/428586
  9. WALI SIRAJO. An update on the drainage of pyogenic lung abscesses. Ann Thorac Med [online] 2012 December [viewed 14 June 2014] Available from: doi:10.4103/1817-1737.91552
  10. YELLIN ALON, YELLIN EDWIN O., LIEBERMAN YAIR. Percutaneous Tube Drainage: The Treatment of Choice for Refractory Lung Abscess. The Annals of Thoracic Surgery [online] 1985 March, 39(3):266-270 [viewed 14 June 2014] Available from: doi:10.1016/S0003-4975(10)62593-3
  11. HERTH FELIX. Endoscopic Drainage of Lung Abscesses . Chest [online] 2005 April [viewed 14 June 2014] Available from: doi:10.1378/chest.127.4.1378
  12. PFITZNER J.. Lobectomy for cavitating lung abscess with haemoptysis: strategy for protecting the contralateral lung and also the non-involved lobe of the ipsilateral lung. [online] 2000 November, 85(5):791-794 [viewed 14 June 2014] Available from: doi:10.1093/bja/85.5.791
  13. SCHWEIGERT MICHAEL, DUBECZ ATTILA, STADLHUBER RUDOLF J., STEIN HUBERT J.. Modern History of Surgical Management of Lung Abscess: From Harold Neuhof to Current Concepts. The Annals of Thoracic Surgery [online] 2011 December, 92(6):2293-2297 [viewed 14 June 2014] Available from: doi:10.1016/j.athoracsur.2011.09.035