Chapter 18 Fungal Diseases of the Lung
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Transcript of 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
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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 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
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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
EtiologyEtiology
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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)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)Etiology (Cont’d)
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Etiology (Cont’d)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)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)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)Etiology (Cont’d)
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Opportunistic pathogensOpportunistic pathogens Candida albicansCandida albicans Cryptococcus neoformansCryptococcus neoformans AspergillusAspergillus
Etiology (Cont’d)Etiology (Cont’d)
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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
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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 Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special
ProceduresProcedures
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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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PaOPaO22 and PaCO and PaCO22 trends during acute alveolar hyperventilation. 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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PaOPaO22 and PaCO and PaCO22 trends during acute or chronic ventilatory failure. 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 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.)
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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 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.
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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 immitisCandida 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. neoformansCandida 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. 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.
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Respiratory Care Treatment Respiratory Care Treatment ProtocolsProtocols
Oxygen Therapy Protocol Bronchopulmonary Hygiene Therapy Protocol Mechanical Ventilation Protocol