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Chapter 7 Body Systems - Lane Community College · Tinea corporis, tinea cruris, tinea barbae Tinea corporis, tinea pedis, tinea manuum Modified from Gardenshire DS: Rau’s respiratory

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Text of Chapter 7 Body Systems - Lane Community College · Tinea corporis, tinea cruris, tinea barbae Tinea...

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    Chapter 18

    Fungal 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 Lungs

    Alveolar consolidation

    Alveolar-capillary destruction

    Caseous tubercles or granulomas

    Cavity formation

    Fibrosis of the lung parenchyma

    Bronchial 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

    Etiology

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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)

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    Coccidioidomycosis (Coccidioides immitis)

    Endemic in hot, dry regions: California

    Arizona

    Nevada

    New Mexico

    Texas

    Utah

    Etiology (Cont’d)

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    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)

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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)

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    Screening and diagnosis−Blastomycosis

    Direct visualization of yeast in sputum smears

    Culture of the fungus

    Etiology (Cont’d)

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    Opportunistic pathogens

    Candida albicans

    Cryptococcus neoformans

    Aspergillus

    Etiology (Cont’d)

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    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

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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

    Laboratory Tests and Special

    Procedures

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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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    PaO2 and PaCO2 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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    PaO2 and PaCO2 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 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.)

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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

    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.

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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 immitis

    Candida 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. neoformans

    Candida 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.

    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.

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    Respiratory Care Treatment

    Protocols

    Oxygen Therapy Protocol

    Bronchopulmonary Hygiene Therapy Protocol

    Mechanical Ventilation Protocol