chapter 7 body systems - lane community college · tinea corporis, tinea cruris, tinea barbae tinea...
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Chapter 18
Fungal Diseases of the Lung
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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
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Anatomic Alterations of the Lungs
Alveolar consolidation
Alveolar-capillary destruction
Caseous tubercles or granulomas
Cavity formation
Fibrosis of the lung parenchyma
Bronchial airway secretions
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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
Etiology
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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)
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Coccidioidomycosis (Coccidioides immitis)
Endemic in hot, dry regions: California
Arizona
Nevada
New Mexico
Texas
Utah
Etiology (Cont’d)
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Etiology (Cont’d)
Coccidioidomycosis is also known as: California Disease
Desert Fever
San Joaquin Valley Disease
Valley Fever
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Screening and diagnosis—
coccidioidomycosis Direct visualization of distinctive spherules in
patient’s sputum
Tissue exudates
Biopsies
Spinal fluid
Etiology (Cont’d)
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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)
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Screening and diagnosis−Blastomycosis
Direct visualization of yeast in sputum smears
Culture of the fungus
Etiology (Cont’d)
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Opportunistic pathogens
Candida albicans
Cryptococcus neoformans
Aspergillus
Etiology (Cont’d)
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Overview
of the Cardiopulmonary Clinical Manifestations
Associated with
Fungal Diseases of the Lungs
The following clinical manifestations result from the
pathophysiologic mechanisms caused (or activated)
by Alveolar Consolidation
Increased Alveolar-Capillary Membrane Thickness
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Clinical Data Obtained at the
Patient’s Bedside
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The Physical Examination
Vital Signs Increased
• Respiratory rate (Tachypnea)
• Heart rate (pulse)
• Blood pressure
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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
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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
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Clinical Data Obtained from
Laboratory Tests and Special
Procedures
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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
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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
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Arterial Blood GasesModerate Fungal Disease
Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis)
pH PaC02 HCO3 Pa02
(slightly)
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PaO2 and PaCO2 trends during acute alveolar hyperventilation.
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Arterial Blood GasesSevere Fungal Disease with Pulmonary Fibrosis
Chronic Ventilatory Failure with Hypoxemia (Compensated Respiratory Acidosis)
pH PaC02 HCO3 Pa02
N (Slightly)
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PaO2 and PaCO2 trends during acute or chronic ventilatory failure.
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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.
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Oxygenation IndicesModerate to Severe Stages
QS/QT D02 V02 C(a-v)02 02ER Sv02
N N
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Hemodynamic IndicesSevere Stage
CVP RAP PA PCWP CO SV
N N N
SVI CI RVSWI LVSWI PVR SVR
N N N N
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Radiologic Findings
Chest Radiograph Increased opacity
Cavity formation
Pleural effusion
Calcification and fibrosis
Right ventricular enlargement
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Figure 18-2. 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 nodular opacities. (From Hansell DM, Armstrong P, Lynch DA, McAdams HP, eds: Imaging of diseases of the chest, ed 4, Philadelphia, 2005, Elsevier.)
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Figure 18-3. Histoplasmoma, showing a well-defined spherical nodule. The central portion of the nodule shows calcification.
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Figure 18-4. Chronic cavitary histoplasmosis. Note the striking upper zone predominance of the shadows. Numerous large cavities.
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General Management of
Fungal 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.
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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 immitis
Candida spp., Aspergillus spp.,
Candida spp., Aspergillus spp.,
mucormycosis, C. neoformans
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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. neoformans
Candida spp., Aspergillus spp., C.
neoformans, H. capsulatum
B. dermatitidis, C. immitis, Sporothrix
schenckii
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Table 18-1
Antifungal Agents (Cont’d)
Agents Common Uses
(Microorganisms)
Echinocandins
Caspofungin (Cancidas)
Micafungin (Mycamine)
Anidulafungin (ERAXIS)
Aspergillus spp., Candida spp.
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Table 18-1
Antifungal Agents (Cont’d)
Agents Common Uses
(Microorganisms)
Other Antifungals
Flucytosine (Ancobon)
Griseofulvin (Fulvicin)
Terbinafine (Lamisil)
Aspergillus spp., Candida spp., C.
neoformans
Tinea corporis, tinea cruris, tinea barbae
Tinea corporis, tinea pedis, tinea manuum
Modified from Gardenshire DS: Rau’s respiratory care pharmacology, ed 7, St. Louis, 2008, Elsevier.
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Respiratory Care Treatment
Protocols
Oxygen Therapy Protocol
Bronchopulmonary Hygiene Therapy Protocol
Mechanical Ventilation Protocol