1. Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 18 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

2. 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

3. 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

4. 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

5. 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

6. Copyright © 2006 by Mosby, Inc. Slide 6 Etiology Opportunistic pathogens  Candida albicans  Cryptococcus neoformans  Aspergillus

7. 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).

8. Copyright © 2006 by Mosby, Inc. Slide 8 Figure 9-8. Alveolar consolidation clinical scenario.

9. Copyright © 2006 by Mosby, Inc. Slide 9 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.

10. 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

11. 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

12. Copyright © 2006 by Mosby, Inc. Slide 12 Digital Clubbing Figure 2-46. Digital clubbing.

13. Copyright © 2006 by Mosby, Inc. Slide 13 Distended Neck Veins Figure 2-48. Distended neck veins (arrows).

14. Copyright © 2006 by Mosby, Inc. Slide 14 Figure 2-47. Pitting edema. From Bloom A, Ireland J: Color atlas of diabetes, ed 2, London, 1992, Mosby-Wolfe.

15. 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

16. Copyright © 2006 by Mosby, Inc. Slide 16 Figure 2-11. A short, dull, or flat percussion note is typically produced over areas of alveolar consolidation.

17. Copyright © 2006 by Mosby, Inc. Slide 17 Figure 2-16. Auscultation of bronchial breath sounds over a consolidated lung unit.

18. Copyright © 2006 by Mosby, Inc. Slide 18 Figure 2-19. Whispered voice sounds auscultated over a normal lung are usually faint and unintelligible.

19. Copyright © 2006 by Mosby, Inc. Slide 19 Clinical Data Obtained from Laboratory Tests and Special Procedures

20. Copyright © 2006 by Mosby, Inc. Slide 20 Pulmonary Function Study: Expiratory Maneuver Findings FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N PEFR MVV FEF 50% FEV 1% N N or  N N or  FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N PEFR MVV FEF 50% FEV 1% N N or  N N or 

21. 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

22. 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) 

23. Copyright © 2006 by Mosby, Inc. Slide 23 Time and Progression of Disease 100 50 30 80 0 0 Pa CO 2 10 20 40 Alveolar Hyperventilation 60 70 90 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.

24. 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) 

25. Copyright © 2006 by Mosby, Inc. Slide 25 Time and Progression of Disease 100 50 30 80 0 Pa O 2 10 20 40 Alveolar Hyperventilation 60 70 90 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.

26. 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

27. 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  

28. Copyright © 2006 by Mosby, Inc. Slide 28 Hemodynamic Indices (Severe Fungal Disease) CVP RAPPAPCWP  Normal COSVSVICI NormalNormalNormalNormal RVSWILVSWIPVRSVR  Normal  Normal

29. Copyright © 2006 by Mosby, Inc. Slide 29 Abnormal Laboratory Tests and Procedures See Etiology and Primary Pathogen sections in this chapter

30. Copyright © 2006 by Mosby, Inc. Slide 30 Radiologic Findings Chest radiograph  Increased opacity  Cavity formation  Pleural effusion  Calcification and fibrosis  Right ventricular enlargement

31. Copyright © 2006 by Mosby, Inc. Slide 31 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. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)

32. Copyright © 2006 by Mosby, Inc. Slide 32 Figure 18-3. 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.)

33. Copyright © 2006 by Mosby, Inc. Slide 33 General Management of Fungal Disease Pharmacologic agents  Amphotericin B (Fungizone)  Itraconazole (Sporanox)  Fluconazole (Diflucan)

34. 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

35. Copyright © 2006 by Mosby, Inc. Slide 35 Classroom Discussion Case Study: Fungal Diseases of the Lung