Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 18 Fungal Diseases of the Lung Figure 18-1. Fungal...

Copyright © 2006 by Mosby, Inc.Slide 1

Chapter 18Chapter 18 Fungal Diseases of the Lung Fungal Diseases of the Lung

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

consolidation; M, alveolar macrophage.

AC

S

YLS

M


Anatomic Alterations of the LungsAnatomic Alterations of the Lungs

Alveolar consolidationAlveolar consolidation

Alveolar-capillary destructionAlveolar-capillary destruction

Granuloma formationGranuloma formation

Cavity formationCavity formation

Fibrosis of the lung parenchymaFibrosis of the lung parenchyma

Airway secretionsAirway secretions


EtiologyEtiology

Histoplasmosis Histoplasmosis (most common fungal disease(most common fungal diseasein the United States)in the United States)

Screening and diagnosisScreening and diagnosis Fungal cultureFungal culture

Fungal stainFungal stain

SerologySerology


EtiologyEtiology

CoccidioidomycosisCoccidioidomycosis

Screening and diagnosisScreening and diagnosis Direct visualization of distinctive spherulesDirect visualization of distinctive spherules

Blood test that detects antibodies of the fungusBlood test that detects antibodies of the fungus

Culture of the organismCulture of the organism


EtiologyEtiology

BlastomycosisBlastomycosis

Screening and diagnosis and diagnosis Direct visualization of yeast in sputum smearsDirect visualization of yeast in sputum smears

Culture of the fungusCulture of the fungus


EtiologyEtiology

Opportunistic pathogensOpportunistic pathogens

Candida albicansCandida albicans

Cryptococcus neoformansCryptococcus neoformans

AspergillusAspergillus


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

Associated with Associated with FUNGAL DISEASES OF THE LUNGFUNGAL DISEASES OF THE LUNG

The following clinical manifestations result from The following clinical manifestations result from the pathophysiologic mechanisms caused (or the pathophysiologic mechanisms caused (or activated) by activated) by Alveolar ConsolidationAlveolar Consolidation (see (see Figure 9-8)Figure 9-8), , and and Increased Alveolar-Capillary Increased Alveolar-Capillary Membrane ThicknessMembrane Thickness (see Figure 9-9)—the (see Figure 9-9)—the major anatomic alterations of the lungs major anatomic alterations of the lungs associated with fungal diseases of the lung (see associated with fungal diseases of the lung (see Figure 18-1). Figure 18-1).


Figure 9-8. Alveolar consolidation clinical scenario.


Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.


Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside

Vital signsVital signs

Increased respiratory rateIncreased respiratory rate

Increased heart rate, cardiac output, Increased heart rate, cardiac output, blood pressureblood pressure



Chest pain/decreased chest expansionChest pain/decreased chest expansion

CyanosisCyanosis

Digital clubbingDigital clubbing

Peripheral edema and distentionPeripheral edema and distention Distended neck veinsDistended neck veins

Pitting edemaPitting edema

Enlarged and tender liverEnlarged and tender liver


Digital Clubbing

Figure 2-46. Digital clubbing.Figure 2-46. Digital clubbing.


DistendedDistendedNeck VeinsNeck Veins

Figure 2-48. Distended neck veins (Figure 2-48. Distended neck veins (arrowsarrows).).


Figure 2-47. Pitting edema. From Bloom A, Ireland J: Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetesColor atlas of diabetes, ed 2,, ed 2,London, 1992, Mosby-Wolfe.London, 1992, Mosby-Wolfe.



Cough, sputum production, and hemoptysisCough, sputum production, and hemoptysis

Chest assessment findingsChest assessment findings Increased tactile and vocal fremitusIncreased tactile and vocal fremitus

Dull percussion noteDull percussion note

Bronchial breath soundsBronchial breath sounds

Crackles, rhonchi, and wheezingCrackles, rhonchi, and wheezing

Pleural friction rubPleural friction rub

Whispered pectoriloquyWhispered pectoriloquy


Figure 2-11. Figure 2-11. A short, dull, or flat percussion note is typically produced over areas A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.of alveolar consolidation.


Figure 2-16. Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung Auscultation of bronchial breath sounds over a consolidated lung unit.unit.


Figure 2-19. Figure 2-19. Whispered voice sounds auscultated over a normal lungWhispered voice sounds auscultated over a normal lungare usually faint and unintelligible.are usually faint and unintelligible.


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

ProceduresProcedures


Pulmonary Function Study: Pulmonary Function Study: Expiratory Maneuver FindingsExpiratory Maneuver Findings

FVC FEVT FEF25%-75% FEF200-1200

N or N or N

PEFR MVV FEF50% FEV1%

N N or N N or

FVC FEVT FEF25%-75% FEF200-1200

N or N or N

PEFR MVV FEF50% FEV1%

N N or N N or


Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity Findings Lung Volume and Capacity Findings

VT RV FRC TLC

N or

VC IC ERV RV/TLC%

N

VT RV FRC TLC

N or

VC IC ERV RV/TLC%

N


Arterial Blood GasesArterial Blood Gases

Mild to Moderate Fungal DiseaseMild to Moderate Fungal Disease

Acute alveolar hyperventilation with Acute alveolar hyperventilation with hypoxemiahypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)

pH PaCO2 HCO3- PaO2

(Slightly)


Time and Progression of Disease Time and Progression of Disease

100100

5050

3030

8080

00

PaCO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaO2

Disease OnsetDisease OnsetP

aO2

or

PaC

O2

PaO

2 o

r P

aCO

2

Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.


Arterial Blood GasesArterial Blood Gases

Severe Fungal Disease with PulmonarySevere Fungal Disease with PulmonaryFibrosisFibrosis

Chronic ventilatory failure with hypoxemiaChronic ventilatory failure with hypoxemia

pH PaCO2 HCO3- PaO2

Normal (Significantly)

pH PaCO2 HCO3- PaO2

Normal (Significantly)


Time and Progression of DiseaseTime and Progression of Disease

100100

5050

3030

80

0

PaO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaCO 2

Chronic Ventilatory Failure Chronic Ventilatory FailureDisease OnsetDisease Onset

Point at which disease becomes severe and patient begins to become fatigued

Point at which disease becomes severe and patient begins to become fatigued

Pa0

2 o

r P

aC0 2

Pa0

2 o

r P

aC0 2

Figure 4-7. PaO2 and PaCO2 trends during acute or chronic ventilatory failure.


Acute Ventilatory Changes on Acute Ventilatory Changes on Chronic Ventilatory FailureChronic Ventilatory Failure

Acute alveolar hyperventilation on chronic Acute alveolar hyperventilation on chronic ventilatory failureventilatory failure

Acute ventilatory failure on chronic ventilatory Acute ventilatory failure on chronic ventilatory failurefailure


Oxygenation IndicesOxygenation Indices

QS/QT DO2 VO2 C(a-v)O2

Normal Normal

O2ER SvO2

QS/QT DO2 VO2 C(a-v)O2

Normal Normal

O2ER SvO2


Hemodynamic Indices Hemodynamic Indices (Severe Fungal Disease)(Severe Fungal Disease)

CVP CVP RAPRAP PAPA PCWPPCWP

NormalNormal

COCO SVSV SVISVI CICI

NormalNormal NormalNormal NormalNormal Normal Normal

RVSWIRVSWI LVSWILVSWI PVRPVR SVRSVR

NormalNormal NormalNormal


Abnormal Laboratory Tests Abnormal Laboratory Tests and Proceduresand Procedures

See Etiology and Primary Pathogen See Etiology and Primary Pathogen sections in this chaptersections in this chapter


Radiologic FindingsRadiologic Findings

Chest radiographChest radiograph

Increased opacityIncreased opacity

Cavity formationCavity formation

Pleural effusionPleural effusion

Calcification and fibrosisCalcification and fibrosis

Right ventricular enlargementRight ventricular enlargement


Figure 18-2. Acute inhalational histoplasmosis in an otherwise healthy patient. This young man 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 developed fever and cough after tearing down an old barn. The study shows bilateral hilar

adenopathy. (From Armstrong P et al: adenopathy. (From Armstrong P et al: Imaging of diseases of the chest,Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.) ed 2, St. Louis, 1995, Mosby.)


Figure 18-3. Histoplasmoma, showing a well-defined spherical nodule. The central portion of Figure 18-3. Histoplasmoma, showing a well-defined spherical nodule. The central portion of the nodule shows calcification. (From Armstrong P et al: the nodule shows calcification. (From Armstrong P et al: Imaging of diseases of the chest,Imaging of diseases of the chest,

ed 2, St. Louis, 1995, Mosby.)ed 2, St. Louis, 1995, Mosby.)


General Management of General Management of Fungal DiseaseFungal Disease

Pharmacologic agents Pharmacologic agents

Amphotericin B (Fungizone)Amphotericin B (Fungizone)

Itraconazole (Sporanox)Itraconazole (Sporanox)

Fluconazole (Diflucan)Fluconazole (Diflucan)


General Management of General Management of Fungal DiseaseFungal Disease

Respiratory care treatment protocolsRespiratory care treatment protocols

Oxygen therapy protocolOxygen therapy protocol

Bronchopulmonary hygiene therapy protocolBronchopulmonary hygiene therapy protocol

Hyperinflation therapy protocolHyperinflation therapy protocol

Mechanical ventilation protocolMechanical ventilation protocol


Classroom DiscussionClassroom DiscussionCase Study: Case Study:

Fungal Diseases of the LungFungal Diseases of the Lung

Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 18 Fungal Diseases of the Lung Figure 18-1. Fungal...

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