1 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 18 Fungal Diseases of the Lung

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

3 Mosby 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

4 Mosby 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

5 Mosby 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)

6 Mosby 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)

7 Mosby 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

8 Mosby 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)

9 Mosby 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)

10 Mosby 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)

11 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Opportunistic pathogens  Candida albicans  Cryptococcus neoformans  Aspergillus Etiology (Cont’d)

12 Mosby 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

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

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

15 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Data Obtained at the Patient’s Bedside

16 Mosby 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

17 Mosby 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

18 Mosby 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

19 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Data Obtained from Laboratory Tests and Special Procedures

20 Mosby 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) Forced Expiratory Flow Rate Findings FVC FEV T FEV 1 /FVC ratio FEF 25%-75  N or  N or  N or  FEF 50% FEF PEFR MVV N or  N or 

21 Mosby 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

22 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases Moderate Fungal Disease Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis) pH PaC0 2 HCO 3 Pa0 2    (slightly) 

23 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute alveolar hyperventilation.

24 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases Severe Fungal Disease with Pulmonary Fibrosis Chronic Ventilatory Failure with Hypoxemia (Compensated Respiratory Acidosis) pH PaC0 2 HCO 3 Pa0 2 N   (Slightly) 

25 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute or chronic ventilatory failure.

26 Mosby 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.

27 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Oxygenation Indices Moderate to Severe Stages Q S /Q T D02 V02 C(a-v)02 02ER Sv02   N N  

28 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Hemodynamic Indices Severe Stage CVP RAP PA PCWP CO SV    N N N SVI CI RVSWI LVSWI PVR SVR N N  N  N

29 Mosby 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

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

31 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure Histoplasmoma, showing a well-defined spherical nodule. The central portion of the nodule shows calcification.

32 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure Chronic cavitary histoplasmosis. Note the striking upper zone predominance of the shadows. Numerous large cavities.

33 Mosby 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.

34 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 18-1 Antifungal Agents AgentsCommon 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

35 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 18-1 Antifungal Agents (Cont’d) AgentsCommon 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

36 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 18-1 Antifungal Agents (Cont’d) AgentsCommon Uses (Microorganisms) Echinocandins Caspofungin (Cancidas) Micafungin (Mycamine) Anidulafungin (ERAXIS) Aspergillus spp., Candida spp.

37 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Table 18-1 Antifungal Agents (Cont’d) AgentsCommon 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.

38 Mosby 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