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

Chapter 18

Fungal 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 Lungs

Alveolar consolidation

Alveolar-capillary destruction

Caseous tubercles or granulomas

Cavity formation

Fibrosis of the lung parenchyma

Bronchial 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

Etiology

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)

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)

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

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)

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)

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)

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

Opportunistic pathogens

Candida albicans

Cryptococcus neoformans

Aspergillus

Etiology (Cont’d)

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

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

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

Laboratory Tests and Special

Procedures

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.

PaO2 and PaCO2 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.

PaO2 and PaCO2 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 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.)

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

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.

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 immitis

Candida 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. neoformans

Candida 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.

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.

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

Respiratory Care Treatment

Protocols

Oxygen Therapy Protocol

Bronchopulmonary Hygiene Therapy Protocol

Mechanical Ventilation Protocol