Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 18 Fungal Diseases of the Lung Figure 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
Copyright © 2006 by Mosby, Inc. Slide 2 Anatomic Alterations of the Lungs Alveolar consolidation Alveolar-capillary destruction Granuloma formation Cavity formation Fibrosis of the lung parenchyma Airway secretions
Copyright © 2006 by Mosby, Inc. Slide 3 Etiology Histoplasmosis (most common fungal disease in the United States) Screening and diagnosis Fungal culture Fungal stain Serology
Copyright © 2006 by Mosby, Inc. Slide 4 Etiology Coccidioidomycosis Screening and diagnosis Direct visualization of distinctive spherules Blood test that detects antibodies of the fungus Culture of the organism
Copyright © 2006 by Mosby, Inc. Slide 5 Etiology Blastomycosis and diagnosis Screening and diagnosis Direct visualization of yeast in sputum smears Culture of the fungus
Copyright © 2006 by Mosby, Inc. Slide 6 Etiology Opportunistic pathogens Candida albicans Cryptococcus neoformans Aspergillus
Copyright © 2006 by Mosby, Inc. Slide 7 Overview of the Cardiopulmonary Clinical Manifestations Associated with FUNGAL DISEASES OF THE LUNG The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Alveolar Consolidation (see Figure 9-8), and Increased Alveolar-Capillary Membrane Thickness (see Figure 9-9)—the major anatomic alterations of the lungs associated with fungal diseases of the lung (see Figure 18-1).
Copyright © 2006 by Mosby, Inc. Slide 8 Figure 9-8. Alveolar consolidation clinical scenario.
Copyright © 2006 by Mosby, Inc. Slide 9 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.
Copyright © 2006 by Mosby, Inc. Slide 10 Clinical Data Obtained at the Patient’s Bedside Clinical Data Obtained at the Patient’s Bedside Vital signs Increased respiratory rate Increased heart rate, cardiac output, blood pressure
Copyright © 2006 by Mosby, Inc. Slide 11 Clinical Data Obtained at the Patient’s Bedside Chest pain/decreased chest expansion Cyanosis Digital clubbing Peripheral edema and distention Distended neck veins Pitting edema Enlarged and tender liver
Copyright © 2006 by Mosby, Inc. Slide 12 Digital Clubbing Figure Digital clubbing.
Copyright © 2006 by Mosby, Inc. Slide 13 Distended Neck Veins Figure Distended neck veins (arrows).
Copyright © 2006 by Mosby, Inc. Slide 14 Figure Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2, London, 1992, Mosby-Wolfe.
Copyright © 2006 by Mosby, Inc. Slide 15 Clinical Data Obtained at the Patient’s Bedside Cough, sputum production, and hemoptysis Chest assessment findings Increased tactile and vocal fremitus Dull percussion note Bronchial breath sounds Crackles, rhonchi, and wheezing Pleural friction rub Whispered pectoriloquy
Copyright © 2006 by Mosby, Inc. Slide 16 Figure A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.
Copyright © 2006 by Mosby, Inc. Slide 17 Figure Auscultation of bronchial breath sounds over a consolidated lung unit.
Copyright © 2006 by Mosby, Inc. Slide 18 Figure Whispered voice sounds auscultated over a normal lung are usually faint and unintelligible.
Copyright © 2006 by Mosby, Inc. Slide 19 Clinical Data Obtained from Laboratory Tests and Special Procedures
Copyright © 2006 by Mosby, Inc. Slide 20 Pulmonary Function Study: Expiratory Maneuver Findings FVC FEV T FEF 25%-75% FEF N or N or N PEFR MVV FEF 50% FEV 1% N N or N N or FVC FEV T FEF 25%-75% FEF N or N or N PEFR MVV FEF 50% FEV 1% N N or N N or
Copyright © 2006 by Mosby, Inc. Slide 21 Pulmonary Function Study: Lung Volume and Capacity Findings V T RV FRC TLC N or VC IC ERV RV/TLC% N V T RV FRC TLC N or VC IC ERV RV/TLC% N
Copyright © 2006 by Mosby, Inc. Slide 22 Arterial Blood Gases Mild to Moderate Fungal Disease Acute alveolar hyperventilation with hypoxemia pH PaCO 2 HCO 3 - PaO 2 (Slightly) pH PaCO 2 HCO 3 - PaO 2 (Slightly)
Copyright © 2006 by Mosby, Inc. Slide 23 Time and Progression of Disease Pa CO Alveolar Hyperventilation Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa O 2 Disease Onset Pa O 2 or Pa CO 2 Figure 4-2. Pa O 2 and Pa CO 2 trends during acute alveolar hyperventilation.
Copyright © 2006 by Mosby, Inc. Slide 24 Arterial Blood Gases Severe Fungal Disease with Pulmonary Fibrosis Chronic ventilatory failure with hypoxemia pH PaCO 2 HCO 3 - PaO 2 Normal (Significantly) pH PaCO 2 HCO 3 - PaO 2 Normal (Significantly)
Copyright © 2006 by Mosby, Inc. Slide 25 Time and Progression of Disease Pa O Alveolar Hyperventilation Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa CO 2 Chronic Ventilatory Failure Disease Onset Point at which disease becomes severe and patient begins to become fatigued Pa 0 2 or Pa C0 2 Figure 4-7. PaO 2 and PaCO 2 trends during acute or chronic ventilatory failure.
Copyright © 2006 by Mosby, Inc. Slide 26 Acute Ventilatory Changes on Chronic Ventilatory Failure Acute alveolar hyperventilation on chronic ventilatory failure Acute ventilatory failure on chronic ventilatory failure
Copyright © 2006 by Mosby, Inc. Slide 27 Oxygenation Indices Q S /Q T D O 2 V O 2 C(a-v) O 2 Normal Normal O 2 ER Sv O 2 Q S /Q T D O 2 V O 2 C(a-v) O 2 Normal Normal O 2 ER Sv O 2
Copyright © 2006 by Mosby, Inc. Slide 28 Hemodynamic Indices (Severe Fungal Disease) CVP RAPPAPCWP Normal COSVSVICI NormalNormalNormalNormal RVSWILVSWIPVRSVR Normal Normal
Copyright © 2006 by Mosby, Inc. Slide 29 Abnormal Laboratory Tests and Procedures See Etiology and Primary Pathogen sections in this chapter
Copyright © 2006 by Mosby, Inc. Slide 30 Radiologic Findings Chest radiograph Increased opacity Cavity formation Pleural effusion Calcification and fibrosis Right ventricular enlargement
Copyright © 2006 by Mosby, Inc. Slide 31 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. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
Copyright © 2006 by Mosby, Inc. Slide 32 Figure Histoplasmoma, showing a well-defined spherical nodule. The central portion of the nodule shows calcification. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
Copyright © 2006 by Mosby, Inc. Slide 33 General Management of Fungal Disease Pharmacologic agents Amphotericin B (Fungizone) Itraconazole (Sporanox) Fluconazole (Diflucan)
Copyright © 2006 by Mosby, Inc. Slide 34 General Management of Fungal Disease Respiratory care treatment protocols Oxygen therapy protocol Bronchopulmonary hygiene therapy protocol Hyperinflation therapy protocol Mechanical ventilation protocol
Copyright © 2006 by Mosby, Inc. Slide 35 Classroom Discussion Case Study: Fungal Diseases of the Lung