Current Respiratory Medicine Reviews - Volume 8, Issue 5, 2012

Aspergillus is the most common fungal pathogen of the respiratory mycosis. The respiratory diseases caused by Aspergillus are mainly classified into four clinical types, namely allergic bronchopulmonary aspergillosis, invasive aspergillosis, aspergilloma, and chronic pulmonary aspergillosis. Among the four clinical types of pulmonary aspergillosis, invasive aspergillosis is the most dangerous and difficult to treat disease. The diagnosis of invasive aspergillosis is established initially on clinical aspects and confirmed by the finding of pathogen in culture and histopathology. A number of methods can be conducted to obtain tissue samples from patients with invasive aspergillosis, chronic pulmonary aspergillosis or aspergilloma. Besides BAL detection and transbronchial biopsy, a fine-needle biopsy can be performed and guided by CT to diagnose these diseases. Antifungal agents including those with activity against Aspergillus have been developed. Several agents such as voriconazole, amphotericin B lipid complex, caspofungin, micafungin and anidulafungin are promising in the treatment of the pulmonary aspergillosis in the future. Moreover, under certain condition, surgical intervention is needed to combine with antifungal therapy to deal with aspergilloma or chronic pulmonary aspergillosis, and the use of glucocorticoids to control the inflammatory response is also very important in therapy of allergic bronchopulmonary aspergillosis besides antifungal agents.

Penicillium marneffei, an endemic fungus in Southeast Asia and southern China, is the cause of opportunistic infection in HIV-infected patients who may present with respiratory symptoms, and abnormal chest radiographs. In this review, reports of Penicillium marneffei respiratory infections spanning the last 15 years will be summarized. This will include discussions on etiology, pathogenesis, clinical manifestations, diagnoses, treatment and prognosis. Correct diagnosis and timely antifungal treatment should be helpful in reducing the high mortality rate associated with infection.

Cryptococcus is an important opportunistic, pathogenic fungus that can infect both immunocompromised and immunocompetent individuals. The infection always involves the central nervous system (CNS), presenting as meningitis or meningoencephalitis. Cryptococcal infections of the lung also occur; however, these infections have been largely ignored because of the atypical clinical symptoms associated with them. Therefore, it is necessary to study Cryptococcus infections of the lung to gain a better understanding of the epidemiology, treatment and diagnosis of pulmonary cryptococcosis.

Chronic Obstructive Pulmonary Disease (COPD) is a chronic disease and major cause of disability. COPD may be considered a systemic disease, which causes an array of symptoms, one of which is the subjective sensation of fatigue. In recent years, COPD-related fatigue (COPD-RF) has increasingly been recognised as an important area of research. The aim of this paper is to comprehensively review the literature concerning this topic and to summarise existing knowledge on the subjective perception of fatigue in people with COPD. This paper provides a narrative review of literature in this area. The search used the electronic databases of OVID MEDLINE and EMBASE included original studies from 1980 to December 2011. The databases were searched using the key MeSH terms COPD and Fatigue. In total 40 relevant publications were identified. This literature review covers the following areas identified by research studies: fatigue in COPD in comparison with healthy older people, gender differences, patients' experience of fatigue, prevalence of fatigue reporting in COPD, pattern and frequency of fatigue in COPD, the impact of fatigue on an individual's life, predictors of fatigue, coping and treatment strategies for the management of fatigue. Furthermore, this review identifies areas for further research and makes recommendations for clinical practice.

The analysis of pleural fluid (PF) is the most important diagnostic element in identifying the cause of pleural effusions. The measurement of proteins and lactate dehydrogenase in PF and blood establishes the transudative or exudative nature of effusions. Elevated concentrations of natriuretic peptide NT-proBNP (>1500 pg/mL) are virtually pathognomonic of heart failure. In exudates with predominantly polymorphonuclear leukocytes (>50%), a bacterial infection of the pleural space should be considered, particularly if pleural fluid C-reactive protein levels are high. A pleural pH <7.20 in a parapneumonic effusion is an indication for the need of a drainage tube. When lymphocytes predominate in an exudate, cancer and tuberculosis are the two main diagnoses to consider; an adenosine deaminase activity >35 U/L strongly supports the diagnosis of tuberculosis. The cytological study of PF is negative in 40% of malignant effusions. Performing immunocytochemistry on the cell block and measuring tumor markers, such as mesothelin, can increase the diagnostic yield for malignancy.

Asthma in preschool children is common. One in three children has at least one episode of wheezing prior to their third birthday, and the cumulative prevalence of wheeze is almost 50% at the age of 6 years. The management of these patients, especially when symptoms are recurrent and severe, is a challenging task. Clinical benefits of inhaled corticosteroids in preschool asthmatic children are still controversial. Since leukotrienes are potent bronchoconstrictive agents, the leukotriene receptor antagonists (LTRAs) are used in asthmatic patients to inhibit their action in the respiratory tract. Montelukast, the only LTRA approved for young children use in several countries, is also known to have antieosinophilic properties. This review summarizes the most recent evidence on the role of LTRAs, particularly montelukast, in the treatment of preschool asthma. Montelukast seems to be effective in preschool asthma and recurrent wheezing for improving symptoms, lung function, and bronchial inflammation, and for protecting against cold air-induced bronchial hyperreactivity. The scarce data available do not allow to reach definitive conclusions on LTRAs efficacy in acute asthma or in the obese-asthma phenotype. The excellent safety profile of montelukast and the convenience of oral delivery, that entail better compliance from young children, represent the main strengths of its use in preschool children. LTRAs represent a valid alternative to inhaled corticosteroids in young children, and are suggested mainly to reduce virus-induced exacerbations, to overcome the difficulties due to the inhaled therapy, in subjects showing adverse effects related to long-term steroid therapy, or when compliance is poor.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive mediastinal staging tool for lung cancer but also a diagnostic tool for mediastinal lesions near the airway. This review focuses on the technique of linear probe EBUS-TBNA, clinical indications and utility, comparative factors with respect to other mediastinal sampling techniques; and training and financial issues. This review will be relevant to centres considering establishing an EBUS-TBNA service especially in healthcare systems which are resource-limited and rationed. EBUS-TBNA is commonly used for lung cancer staging and diagnosis, specifically non-small cell lung cancer (NSCLC). It is often used for both diagnosis and staging in the setting of bulky mediastinal lymphadenopathy with enlarged N2 or N3 disease on cross-sectional imaging, but is also used for diagnosis of unexplained mediastinal lymphadenopathy and lesions near the airway due to other (often non-malignant) causes. When there is radical treatment intent, many centres still perform cervical mediastinoscopy (CM) first line as the staging procedure and this should certainly be done to corroborate negative EBUS-TBNA results in this scenario or when the clinical probability of lung cancer is high. EBUSTBNA may be increasingly used in the future for staging when the “normal” (according to cross-sectional imaging) mediastinum and also in re-staging. It has a long learning curve requiring appropriate training and mentorship; it offers numerous advantages over CM including being less invasive and reducing operational costs. Long may it continue as one of the interventional pulmonologist's main tools.