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Course: Medical Surgical Nursing

Topic: Lung Abscess

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Module Goals

Learners will be able to

Describe the clinical manifestation of Lung abscess.
Discuss the assessment and diagnostic findings of lung abscess.
Discuss the complications of lung abscess.
Describe the medical management of lung abscess.
Discuss the nursing management of lung abscess.

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Lung Abscess

Microbial infection of the lung that results in necrosis of the pulmonary parenchyma.
Classification based on:

Duration

Acute (less than four weeks) or
Chronic (more than four weeks) depending on the duration.

Etiology

Primary: Occuring in the absence of underlying pulmonary lesions
Secondary: Occuring in the presence of underlying pulmonary lesions.

Sabbula et. al., 2022

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Classification Based On

The Microorganism Causing The Abscess

Polymicrobial (major) lung abscess: Anaerobic bacteria like Bacteroides, Prevotella, Peptostreptococcus, Fusobacterium, or streptococci.

Monomicrobial lung abscess: Streptococci, Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pyogenes, Burkholderia pseudomallei, Hemophilus influenzae type b, Nocardia, and Actinomyces.

Sabbula et. al., 2022

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Predisposing Factors of Lung Abscess

Immunocompromised hosts (HIV-AIDS).
Post-transplantation.
Receiving prolonged immune suppressive therapy.
Patients with high risk for aspiration: seizures, bulbar dysfunction, alcohol intoxication, and cognitive impairment.
Independent risk factor includes Poor dental hygiene.

Sabbula et. al., 2022

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Pathophysiology of Lung Abscess

Aspiration of oropharyngeal contents with anaerobes.

Bronchogenic causes: Bronchial obstruction by a tumor, foreign body, enlarged lymph nodes, aspiration of oropharyngeal secretions, and congenital malformation.

Hematogenous spread: Abdominal sepsis, infective endocarditis, and septic thromboembolism.

Sabbula et. al., 2022

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Critical Thinking Question

Which of the following clients are more likely to develop lung abscess? (Select all that apply).

A client who is on antiretroviral therapy
A client who is on 10th day of lung transplant
A client who is admitted for tonic-clonic seizure
A client who has dementia from last 2 years
A client who is admitted due to alcohol intoxication

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Assessment and Diagnostic Evaluation

Lung abscess can be indolent or symptomatic
History should focus on finding patients:

Causes of immune incompetence
Oral or rectal instrumentation
Intravenous drug abuse
Recent upper respiratory illness
Risk of aspiration circumstances like:

Impaired cognition
Loss of bulbar motor function
Immobility

Sabbula et. al., 2022

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Laboratory and Diagnostic Evaluation

X-rays and Computed Tomography (CT): Lungs abscess appears as cavitary lesions with infiltrates.
Microbial Analysis of sputum.
Pleural fluid analysis and bronchoscopy with bronchoalveolar lavage (Rare).
Blood cultures & Echocardiography (if hematological spread).

Sabbula et. al., 2022

Contact info: info@nursesinternational.org

X-rays and computerized tomography (CT) of the chest aid in the diagnosis of a lung abscess. On imaging studies, lung abscess appears as cavitary lesions with infiltrates. CT will be able to provide finer details along with anatomic relations of an abscess. Microbiologic analysis of sputum can potentially assist in management. If the patient presents with risk factors for fungi or mycobacteria in their history, particular cultures should be requested. Pleural fluid analysis and bronchoscopy with bronchoalveolar lavage (BAL) also have been utilized in rare cases.
Lung abscesses are more prone to develop over the posterior segment of the right upper lobe and middle lobe, followed by the superior segment of the right lower lobe and sometimes of the left lung in case of aspiration of oropharyngeal contents.
Complicated lung abscess can cause pyopneumothorax or pleural empyema. In such cases, pleural fluid analysis can aid in diagnosis. Lung abscesses can get complicated if the patient is immunocompromised. In immunocompetent patients with adequate treatment, there is less chance of complications, and it usually resolves in three weeks. In cases of lung abscesses secondary to hematologic spread, blood cultures and echocardiography play an essential role in the management of lung abscesses.

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Case Study

A client has developed pleural emphysema due to complicated lung abscess.

Which of the following additional tests might be ordered to confirm the diagnosis and help with the treatment?

CT Scan of the chest
Echocardiography
X-ray
Pleural fluid analysis
Microbial analysis

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General Clinical Manifestations

Fevers
Chills
Weight loss
Fatigue
Loss of appetite
Productive or non-productive cough

Sabbula et. al., 2022

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Complications of Lung Abscess

Complications are secondary to underrecognition, undertreatment, or untreated underlying cause.

They include:

Rupture into pleural space
Pleural fibrosis
Trapped lung
Respiratory failure
Bronchopleural fistula
Pleurocutaneous fistula

Sabbula et. al., 2022

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Case Study

The nurse is conducting the physical assessment of a client who is suspected of having lung abscess. Which of the following clinical manifestations would the nurse expect to find? (Select all that apply).

Cough
Fever and chills
Respiratory failure
Extreme fatigue
No interest on food

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Treatment (Medical Management)

Empirical antibiotic therapy

Beta-lactamase inhibitors

Ticarcillin-clavulanate
Ampicillin-sulbactam
Amoxicillin-clavulanate
Piperacillin-tazobactam

Sabbula et. al., 2022

Contact info: info@nursesinternational.org

Consider empiric antibiotic therapy upon suspicion of a lung abscess. Empiric coverage should target colonized organisms in the upper airway and oropharynx, like gram-positive cocci, respiratory gram-negative cocci, and aerobic and anaerobic gram-negative bacilli. If the patient is exposed to healthcare set three months before the presentation, coverage for MRSA should be considered. Atypical organisms can be found in the setting of an abscess that is not improving with broad-spectrum antibiotic therapy.
Poor prognostic factors are old age, severe comorbidities, immunosuppression, bronchial obstruction, and neoplasms. Beta-lactamase inhibitors (ticarcillin-clavulanate, ampicillin-sulbactam, amoxicillin-clavulanate, and piperacillin-tazobactam) are the preferred initial empiric antibiotic therapy, followed by imipenem or meropenem.

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Treatment (Medical Management)

Vancomycin and Linezolid: For methicillin-resistant Staphylococcus aureus (MRSA).
Cefazolin: For methicillin-sensitive Staphylococcus aureus (MSSA).
Antibiotic duration is usually around three weeks but varies depending on clinical response.
Amoxicillin-clavulanate: Drug of choice for PO.
Antibiotic installation: Beneficial in chronic lung abscess.

(Sabbula et. al., 2022)

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Clindamycin, as empiric treatment for a lung abscess, is no longer recommended given the risk of Clostridioides difficile infection but remains an alternative for penicillin-allergic patients.
For methicillin-resistant Staphylococcus aureus (MRSA), vancomycin or linezolid are preferred. Daptomycin has no activity against pulmonary infections. For methicillin-sensitive Staphylococcus aureus (MSSA), the choice is cefazolin 2 g IV every 8 hours, nafcillin 2 gm IV every 4 hours or oxacillin 2 gm every 4 hours. Dosing adjustment is considered in patients with compromised renal function.
Antibiotic duration is usually around three weeks but varies depending on clinical response. Consider switching to per oral (PO) antibiotics once patients are afebrile, stable, and able to tolerate an oral diet. Amoxicillin-clavulanate is the drug of choice for PO antibiotics for lung abscesses.
Metronidazole, as a single therapy, does not appear to be particularly useful due to polymicrobial flora.

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Treatment (Surgical Management)

Surgical or percutaneous intervention for abscess larger than 6cm

Lobectomy or pneumonectomy.

Percutaneous and endoscopic drainage: For poor surgical candidates.
For Hematologic causes: Treat underlying conditions.

Sabbula et. al., 2022

Contact info: info@nursesinternational.org

Clindamycin, as empiric treatment for a lung abscess, is no longer recommended given the risk of Clostridioides difficile infection but remains an alternative for penicillin-allergic patients. For methicillin-resistant Staphylococcus aureus (MRSA), vancomycin or linezolid are preferred. Daptomycin has no activity against pulmonary infections. For methicillin-sensitive Staphylococcus aureus (MSSA), the choice is cefazolin 2 g IV every 8 hours, nafcillin 2 gm IV every 4 hours or oxacillin 2 gm every 4 hours. Dosing adjustment is considered in patients with compromised renal function.
Antibiotic duration is usually around three weeks but varies depending on clinical response. Consider switching to per oral (PO) antibiotics once patients are afebrile, stable, and able to tolerate an oral diet. Amoxicillin-clavulanate is the drug of choice for PO antibiotics for lung abscesses.
Metronidazole, as a single therapy, does not appear to be particularly useful due to polymicrobial flora.
Abscesses larger than six centimeters (cm) are unlikely to resolve with antibiotic therapy alone and might require surgical or percutaneous intervention.
In patients who fail to respond to medical therapy, surgical intervention is considered with lobectomy or pneumonectomy.
In patients who are poor surgical candidates, percutaneous and endoscopic drainage is considered.
When the clinical response is inadequate, associated conditions or alternative diagnoses are considered, especially for certain fungi and mycobacteria. Empyema sometimes might be misdiagnosed as a parenchymal abscess.
Antibiotic installation is proven to be beneficial in the case of chronic lung abscesses.
Also, in the case of hematologic causes of lung abscess, underlying conditions such as infective endocarditis, septic thromboembolism, and others should be thoroughly treated.

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Case Study

A client who is diagnosed with lung abscess and is MSSA positive is ordered cefazolin 2g IV every 8 hours. What would the nurse rule out before administering this medication to the client?

(Select all that apply).

Renal disease
Allergy
Liver disease
Cardiac diseases

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Nursing Management

Identify the clients with a high risk of aspiration.
Put them on strict aspiration precautions.
Prompt identification of symptoms and initiate treatment.
Thorough monitor to bed bound clients.
Plan adequate physical therapy for the long hospital clients.
Avoid respiratory muscle fatigue.
Encourage prompt dental care (perform dental care for bedridden clients).

Sabbula et. al., 2022

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Nursing Management (Continued)

Keep the head of the bed in fowler’s (semi or high).
Assess, monitor and report the changes.
Administer antibiotics as per prescription.
Monitor side effects of medications.
Thorough respiratory assessment: Respiratory pattern, rate and spo2 status.
Adhere to infection control practice.
Use standard precautions to the clients who are on contact isolation (MRSA, MSSA).

Sabbula et. al., 2022

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Nurses’ Role: Client Education

On risk factors of developing lung abscess.
Avoiding excessive alcohol intake.
Proper dental care.
Elevation of the head end of the bed to those who are at high risk of aspiration.
Prompt recognition of symptoms.
Importance of compliance with antibiotics.
Monitor for side effects of medications to avoid its complications.

Sabbula et. al., 2022

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Critical Thinking Question

A physician has ordered “Avoid Respiratory Fatigue” to a client who is diagnosed with lung abscess

What would the nurse understand?

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Red Flags

Shortness of breath
Difficulty breathing
Spo2 below 94%
hemoptysis

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References

Agency for Healthcare Research. (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Sabbula BR, Rammohan G, Akella J. Lung Abscess. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555920/

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