chapter 18 fungal diseases of the lung

1Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 18Chapter 18

Fungal Diseases of the LungFungal Diseases of the Lung

2Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 18-1. Fungal disease of the lung. Cross-sectional view of alveoli infected with Histoplasma capsulatum. AC, alveolar consolidation; M, alveolar macrophage; S, Fungal spore; YLS, yeastlike substance.

AC

S

YLS

M

3Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Anatomic Alterations of the LungsAnatomic Alterations of the Lungs

Alveolar consolidationAlveolar consolidation Alveolar-capillary destructionAlveolar-capillary destruction Caseous tubercles or granulomasCaseous tubercles or granulomas Cavity formationCavity formation Fibrosis of the lung parenchymaFibrosis of the lung parenchyma Bronchial airway secretionsBronchial airway secretions

4Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Histoplasmosis (Histoplasma capsulatum) Most common fungal disease in the United States Prevalence is especially high alone th major rive

valleys of the Midwest Ohio, Michigan. Illinois, Mississippi, Kentucky, Tennessee,

Georgia, Arkansas Histoplasmosis is also called Ohio Valley Fever

EtiologyEtiology

5Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Screening and Diagnosis—histoplasmosis Fungal culture—considered the gold standard for

detecting histoplasmosis Fungal stain

A positive test result is 100% accurate Serology

A relatively fast and accurate test

Etiology (Cont’d)Etiology (Cont’d)

6Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Coccidioidomycosis (Coccidioides immitis) Endemic in hot, dry regions:

California Arizona Nevada New Mexico Texas Utah

Etiology (Cont’d)Etiology (Cont’d)

7Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Etiology (Cont’d)Etiology (Cont’d)

Coccidioidomycosis is also known as: California Disease Desert Fever San Joaquin Valley Disease Valley Fever

8Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Screening and diagnosis—coccidioidomycosis Direct visualization of distinctive spherules in

patient’s sputum Tissue exudates Biopsies Spinal fluid

Etiology (Cont’d)Etiology (Cont’d)

9Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Blastomycosis (Blastomyces dermatitidis) Also called:

Chicago disease, Gilchrist’s disease, American blastomycosis

Occurs in people living in the south-central and midwestern United States and Canada.

Etiology (Cont’d)Etiology (Cont’d)

10Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Screening and diagnosis−Blastomycosis Direct visualization of yeast in sputum smears Culture of the fungus

Etiology (Cont’d)Etiology (Cont’d)

11Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Opportunistic pathogensOpportunistic pathogens Candida albicansCandida albicans Cryptococcus neoformansCryptococcus neoformans AspergillusAspergillus

Etiology (Cont’d)Etiology (Cont’d)

12Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Overview Overview of the Cardiopulmonary Clinical Manifestations of the Cardiopulmonary Clinical Manifestations

Associated with Associated with Fungal Diseases of the LungsFungal Diseases of the Lungs

The following clinical manifestations result from the The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) pathophysiologic mechanisms caused (or activated) by by

Alveolar Consolidation Increased Alveolar-Capillary Membrane Thickness

13Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

14Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

15Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical Data Obtained at the Patient’s Bedside

16Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

The Physical Examination

Vital Signs Increased

• Respiratory rate (Tachypnea)• Heart rate (pulse)• Blood pressure

17Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

The Physical Examination (Cont’d)

Chest pain/decreased chest expansion Cyanosis Digital clubbing Peripheral edema and venous distention

Distended neck veins Pitting edema Enlarged and tender liver

Cough, sputum production, and hemoptysis

18Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

The Physical Examination (Cont’d)

Chest Assessment Findings Increased tactile and vocal fremitus Dull percussion note Bronchial breath sounds Crackles, rhonchi, and wheezing Pleural friction rub

• if process extends to pleural surface Whispered pectoriloquy

19Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Clinical Data Obtained from Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special

ProceduresProcedures

20Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Pulmonary Function Test FindingsModerate to Severe Cases

(Restrictive Lung Pathophysiology)

Forced Expiratory Flow Rate Findings

FVC FEVT FEV1/FVC ratio FEF25%-75

N or N or N or

FEF50% FEF200-1200 PEFR MVV

N or N or N or N or

21Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Pulmonary Function Test Findings Moderate to Severe Cases

(Restrictive Lung Pathophysiology)

Lung Volume & Capacity Findings

VT IRV ERV RV VC

N or

IC FRC TLC RV/TLC ratio

N

22Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Arterial Blood GasesModerate Fungal Disease

Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis)

pH PaC02 HCO3 Pa02

(slightly)

23Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

PaOPaO22 and PaCO and PaCO22 trends during acute alveolar hyperventilation. trends during acute alveolar hyperventilation.

24Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Arterial Blood GasesSevere Fungal Disease with Pulmonary Fibrosis

Chronic Ventilatory Failure with Hypoxemia (Compensated Respiratory Acidosis)

pH PaC02 HCO3 Pa02

N (Slightly)

25Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

PaOPaO22 and PaCO and PaCO22 trends during acute or chronic ventilatory failure. trends during acute or chronic ventilatory failure.

26Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Arterial Blood Gases

Acute Ventilatory Changes Superimposed On

Chronic Ventilatory Failure Because acute ventilatory changes are frequently seen in

patients with chronic ventilatory failure, the respiratory care practitioner must be familiar with and alert for the following: Acute alveolar hyperventilation superimposed on chronic

ventilatory failure Acute ventilatory failure (acute hypoventilation) superimposed on

chronic ventialtory failure.

27Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Oxygenation IndicesModerate to Severe Stages

QS/QT D02 V02 C(a-v)02 02ER Sv02

N N

28Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Hemodynamic IndicesSevere Stage

CVP RAP PA PCWP CO SV

N N N

SVI CI RVSWI LVSWI PVR SVR

N N N N

29Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Radiologic Findings

Chest Radiograph Increased opacity Cavity formation Pleural effusion Calcification and fibrosis Right ventricular enlargement

30Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 18-2. Acute inhalational histoplasmosis in an otherwise healthy patient. This young man developed Acute inhalational histoplasmosis in an otherwise healthy patient. This young man developed fever and cough after tearing down an old barn. The study shows bilateral hilar adenopathy and diffuse fever and cough after tearing down an old barn. The study shows bilateral hilar adenopathy and diffuse nodular opacities.nodular opacities. (From Hansell DM, Armstrong P, Lynch DA, McAdams HP, eds: Imaging of diseases of the chest, ed 4, Philadelphia, 2005, Elsevier.)

31Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 18-3. Histoplasmoma, showing a well-defined spherical nodule. The central portion of the nodule shows calcification.

32Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Figure 18-4. Chronic cavitary histoplasmosis. Note the striking upper zone predominance of the shadows. Numerous large cavities.

33Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

General Management of General Management of Fungal DiseaseFungal Disease

The antifungal agents are the first line of defense in treating fungal lung infections.

In general, the drug of choice for most fungal infections is the IV administration of the polyene amphotericin B.

34Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Table 18-1 Antifungal Agents

Agents Common Uses (Microorganisms)

Polyenes Amphotericin B (Fungizone) Amphotericin B colloidal dispersion (Amphotec)

Cryptococcus neoformans, Histoplasma capsulatum, Blastomyces dermatitidis, Coccidioides immitisCandida spp., Aspergillus spp.,Candida spp., Aspergillus spp., mucormycosis, C. neoformans

35Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Table 18-1 Antifungal Agents (Cont’d)

Agents Common Uses (Microorganisms)

Azoles Ketoconazole (Nizoral) Fluconazole (Diflucan) Itraconazole (Sporanox)

Candida spp., C. neoformans, H. capsulatum, B. dermatitidis

Candida spp., C. neoformansCandida spp., Aspergillus spp., C. neoformans, H. capsulatum

B. dermatitidis, C. immitis, Sporothrix

schenckii

36Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Table 18-1 Antifungal Agents (Cont’d)

Agents Common Uses (Microorganisms)

Echinocandins Caspofungin (Cancidas) Micafungin (Mycamine) Anidulafungin (ERAXIS)

Aspergillus spp., Candida spp.

37Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Table 18-1 Antifungal Agents (Cont’d)

Agents Common Uses (Microorganisms)

Other Antifungals Flucytosine (Ancobon) Griseofulvin (Fulvicin) Terbinafine (Lamisil)

Aspergillus spp., Candida spp., C. neoformansTinea corporis, tinea cruris, tinea barbaeTinea corporis, tinea pedis, tinea manuum

Modified from Gardenshire DS: Rau’s respiratory care pharmacology, ed 7, St. Louis, 2008, Elsevier.

38Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Respiratory Care Treatment Respiratory Care Treatment ProtocolsProtocols

Oxygen Therapy Protocol Bronchopulmonary Hygiene Therapy Protocol Mechanical Ventilation Protocol