GAtherton

COVID-19 Associated Pulmonary Aspergillosis (CAPA) for Expert Patients and non-Specialist Clinicians

Expert Information for Patients, GPs, and Specialist Nurses

🔎 What Is CAPA?

CAPA is a form of invasive pulmonary aspergillosis (IPA) that develops in patients with severe COVID-19, particularly those in intensive care units (ICU) with acute respiratory distress syndrome (ARDS). It is an opportunistic fungal infection caused by Aspergillus fumigatus, occurring without traditional risk factors such as neutropenia.

CAPA is part of the broader group of IAPA (Influenza-Associated Pulmonary Aspergillosis) and VAPA (Viral-Associated Pulmonary Aspergillosis).

🧬 Pathophysiology

  • Severe viral pneumonia (COVID-19) damages the airway epithelium.

  • Inhaled Aspergillus spores invade damaged lung tissue.

  • Corticosteroids (e.g. dexamethasone), immunomodulators (e.g. tocilizumab), and prolonged ventilation increase susceptibility.

👥 Who Is at Risk?

Primarily affects patients with:

  • Severe COVID-19 pneumonia, especially those with:

    • ICU admission

    • Mechanical ventilation

    • ARDS

  • Corticosteroid therapy or IL-6 inhibitors (e.g. tocilizumab)

  • Underlying lung disease (COPD, asthma)

  • Diabetes mellitus

📍 CAPA may occur even in immunocompetent individuals due to local lung immune disruption.

⚠️ Clinical Features

Often non-specific and difficult to distinguish from worsening COVID-19:

  • Persistent or worsening respiratory failure

  • New pulmonary infiltrates on imaging

  • Fever despite antibacterial therapy

  • Haemoptysis or pleuritic chest pain (less common)

  • Increased oxygen or ventilatory support requirement

🧪 Diagnosis

CAPA is challenging to diagnose and relies on clinical suspicion, radiology, and mycological evidence.

Diagnostic Tools:

  • CT Chest:

    • Nodules, cavitations, halo sign (often non-specific in COVID)

  • Bronchoscopy with BAL:

    • Galactomannan (BAL GM ≥1.0 = probable CAPA)

    • Culture and PCR for Aspergillus

  • Serum Galactomannan or β-D-glucan:

    • May be positive but less sensitive than BAL

  • Histopathology (rarely obtained due to ICU setting)

Diagnostic Categories (ECMM/ISHAM 2020):

  • Proven: histology showing fungal invasion

  • Probable: radiology + mycology from BAL

  • Possible: suggestive clinical picture + limited microbiology

💊 Treatment

First-Line:

  • Voriconazole (IV or oral)

  • Isavuconazole (alternative with fewer side effects)

  • Consider liposomal amphotericin B if azole resistance or intolerance

Additional Considerations:

  • Therapeutic drug monitoring (TDM) required for voriconazole

  • Duration: typically 6–12 weeks depending on response and immune status

  • Minimise immunosuppression where possible

Empirical antifungal therapy may be started in ICU when suspicion is high, even before full confirmation.

🧾 Monitoring

  • Respiratory function

  • Repeat imaging to assess progression or resolution

  • Serum galactomannan

  • Liver function, renal function, and drug levels

  • Screen for drug interactions (especially with azoles)

📚 More Information

  • CAPA is a recently recognised entity, requiring close coordination between ICU, respiratory, and infectious disease teams.

  • Early antifungal treatment improves outcomes, but diagnosis is often delayed due to overlapping features with COVID-19 pneumonia.

  • Resources: ECMM/ISHAM CAPA definitions, aspergillosis.org

by GAtherton

Severe Asthma with Fungal Sensitisation (SAFS) for Expert Patients and non-Specialist Clinicians

Expert Information for Patients, GPs, and Specialist Nurses

🔎 What Is SAFS?

SAFS describes a clinical subgroup of patients with severe asthma who are sensitised to environmental fungi, particularly Aspergillus fumigatus, but who do not meet criteria for ABPA (i.e. no high total IgE or central bronchiectasis).

Fungal sensitisation may contribute to poor asthma control, airway inflammation, and increased exacerbations.

🧬 Pathophysiology

  • IgE-mediated sensitisation to fungi in the airways

  • Chronic airway inflammation exacerbated by fungal allergens

  • Unlike ABPA, no eosinophilia, mucus plugging, or significant IgE rise

👥 Who Is at Risk?

SAFS affects adults or children with:

  • Severe asthma (high-dose ICS + additional controller medication)

  • Recurrent exacerbations or persistent symptoms

  • Evidence of IgE sensitisation to fungi, especially A. fumigatus, Alternaria, Cladosporium

It may overlap with ABPA, and some patients may transition between the two.

⚠️ Common Symptoms

  • Poor asthma control despite optimal treatment

  • Frequent exacerbations

  • Airflow limitation (FEV1 often <80%)

  • Increased oral corticosteroid use

  • Wheeze, cough, chest tightness

🧪 Diagnosis

SAFS is a diagnosis of exclusion in patients with severe asthma and fungal sensitisation, but without ABPA.

Required Features:

  1. Severe asthma, typically on BTS Step 4–5 therapy

  2. Positive fungal-specific IgE (skin prick or blood) to at least one fungus

    • Aspergillus fumigatus most common

  3. No ABPA: i.e., total IgE <1000 IU/mL, no eosinophilia, no central bronchiectasis

Investigations:

  • Skin prick testing or specific IgE blood test

  • Total IgE to exclude ABPA

  • CT chest to rule out ABPA or CPA

  • Sputum culture for A. fumigatus (not required for diagnosis)

💊 Treatment

Antifungal Therapy:

  • Itraconazole (first-line): 3–6 months may improve asthma control, reduce exacerbations

  • Posaconazole (alternative)

  • Liver function and drug levels must be monitored

The EVITA 3 and Fungal Asthma trials suggest modest benefit with antifungal therapy in SAFS.

Asthma Management:

  • High-dose inhaled corticosteroids + LABA

  • Leukotriene receptor antagonists

  • Macrolides in selected patients (anti-inflammatory benefit)

  • Biologics:

    • Omalizumab (anti-IgE)

    • Mepolizumab, Benralizumab (anti-IL-5)

    • Dupilumab (anti-IL-4/13)

🧾 Monitoring

  • Asthma control questionnaires (ACT, ACQ)

  • Exacerbation frequency

  • Spirometry

  • Fungal IgE titres (do not typically change with treatment)

  • LFTs and drug levels if on antifungals

📚 More Information

  • SAFS patients often benefit from review in a specialist asthma clinic or severe asthma network centre.

  • Overlap with ABPA: patients should be periodically reassessed to detect transition to ABPA.

  • Patient resources: aspergillosis.org, Asthma + Lung UK, BTS asthma guidelines

  • Resource: SAFS

by GAtherton

Allergic Bronchopulmonary Aspergillosis (ABPA) for Expert Patients and non-Specialist Clinicians

Expert Information for Patients, GPs, and Specialist Nurses

🔎 What Is ABPA?

ABPA is a complex hypersensitivity reaction to Aspergillus fumigatus colonising the airways. It is not a fungal infection in the classic sense, but rather an exaggerated immune response — particularly involving IgE and eosinophils — seen in people with asthma or cystic fibrosis (CF).

It leads to recurrent inflammation, mucus plugging, and bronchial damage (including central bronchiectasis) if untreated.

🧬 Disease Mechanism

  • Type I and III hypersensitivity to A. fumigatus

  • Chronic airway inflammation causes mucus impaction and permanent lung damage

  • Associated with elevated total and specific IgE, eosinophilia, and recurrent flares

👥 Who Is at Risk?

  • Moderate to severe asthma

  • Cystic fibrosis

  • Rarely, patients with bronchiectasis or other chronic airway disease

ABPA is often underdiagnosed, especially in adults with difficult-to-control asthma.

⚠️ Common Symptoms

  • Worsening asthma control

  • Wheeze and chest tightness

  • Cough with thick mucus plugs

  • Shortness of breath

  • Intermittent low-grade fever

  • Haemoptysis (less common, usually mild)

  • Fatigue and poor response to inhaled steroids alone

🧪 Diagnosis

Diagnosis is based on a combination of clinical, radiological, and immunological features.

Core Investigations:

  1. Total IgE ≥1000 IU/mL (or >500 in treated patients)

  2. Aspergillus-specific IgE positive

  3. Aspergillus-specific IgG (or precipitating antibodies)

  4. Blood eosinophilia (>0.5 x10⁹/L typically)

  5. Chest CT: central bronchiectasis, mucus plugging (“finger-in-glove”), fleeting infiltrates

  6. Sputum culture or PCR positive for A. fumigatus

Diagnostic Criteria:

Use updated ISHAM criteria (2024 version preferred) combining major and minor features.

💊 Treatment

First-Line:

  • Oral corticosteroids (e.g. prednisolone) – cornerstone of flare management

    • Typically tapered over 3–6 months

Adjunct:

  • Itraconazole or posaconazole – reduces antigen burden and steroid need

    • 3–6 months or longer; monitor liver function and drug levels

Steroid-Sparing Options:

  • Biologics (increasingly used, especially in steroid-dependent or relapsing patients):

    • Omalizumab (anti-IgE)

    • Mepolizumab, Benralizumab (anti-IL-5)

    • Dupilumab, Tezepelumab (emerging options)

🧾 Monitoring

  • Total IgE every 1–3 months (a 25–50% rise may indicate relapse)

  • Pulmonary function tests (FEV1, peak flow)

  • Repeat CT if clinical deterioration or poor steroid response

  • Sputum cultures in persistent symptoms (to exclude Aspergillus bronchitis)

⚠️ Complications

  • Progression to bronchiectasis

  • CPA (if antifungals are stopped prematurely in chronic cases)

  • Recurrent flares leading to irreversible damage

  • Steroid side effects (weight gain, osteoporosis, adrenal suppression)

📚 More Information

  • Specialist referral: patients should be considered for referral to the National Aspergillosis Centre (NAC) or local respiratory immunology team for persistent/recurrent ABPA.

  • Patient support: aspergillosis.org, CF Trust, Asthma + Lung UK

  • Key guidelines: Guidance

by GAtherton

Aspergillus Tracheobronchitis (ATB) for Expert patients and non-Specialist Clinicians

Expert Information for Patients, GPs, and Specialist Nurses

🔎 What Is Aspergillus Tracheobronchitis?

Aspergillus tracheobronchitis (ATB) is a rare but serious form of airway-invasive aspergillosis that primarily affects the trachea and large bronchi, rather than the lung parenchyma. It occurs predominantly in immunocompromised patients and may present with obstructive airway symptoms or respiratory failure.

ATB can exist on a spectrum from superficial colonisation to ulcerative or pseudomembranous invasion of the bronchial wall.

🧬 Pathophysiology

  • Inhaled Aspergillus spores adhere to and invade damaged airway mucosa.

  • Occurs more commonly when local airway immunity is impaired (e.g. in transplant recipients or critical illness).

  • May co-exist with invasive pulmonary aspergillosis (IPA) or appear in isolation.

👥 Who Is at Risk?

High-risk groups include:

  • Lung transplant recipients

  • Hematopoietic stem cell transplant patients

  • Severe COPD or structural airway disease

  • Patients with prolonged corticosteroid use

  • Critically ill or mechanically ventilated patients

  • COVID-19 or influenza patients (sometimes overlapping with CAPA/IAPA)

⚠️ Clinical Presentation

Symptoms depend on the degree of airway obstruction and depth of invasion:

  • Cough (dry or productive)

  • Worsening breathlessness

  • Stridor or wheeze

  • Hoarseness or vocal changes

  • Fever unresponsive to antibiotics

  • Haemoptysis (may be life-threatening)

  • Airway obstruction or collapse in advanced cases

ATB may be mistaken for tracheobronchial malignancy, infection, or stenosis.

🧪 Diagnosis

Bronchoscopy is essential for diagnosis:

  • Direct visualisation of:

    • Ulceration

    • Pseudomembranes

    • Plaques

    • Necrotic debris

  • Biopsies may reveal fungal hyphae invading mucosa.

Microbiological Investigations:

  • Culture and PCR for Aspergillus from BAL or brushings

  • BAL galactomannan

  • Serum galactomannan or β-D-glucan may be supportive

  • CT chest may be normal or show airway thickening, bronchial wall invasion, or tree-in-bud opacities

💊 Treatment

Systemic Antifungals:

  • Voriconazole is first-line

  • Isavuconazole or liposomal amphotericin B if azole intolerant or resistant

Airway Management:

  • Debridement or bronchoscopic removal of pseudomembranes in severe obstruction

  • Airway stenting in refractory strictures

  • Nebulised antifungals (e.g. amphotericin B) may be used as adjunct in selected cases

Prompt initiation of antifungal therapy is vital. Delays can lead to respiratory failure or death.

🧾 Monitoring

  • Clinical response: breathlessness, cough, fever

  • Repeat bronchoscopy in some cases

  • CT imaging of airways

  • Antifungal drug levels

  • Liver and renal function

📚 More Information

  • ATB is under-recognised, especially in non-neutropenic or critically ill patients.

  • Should be considered in transplant recipients or ICU patients with persistent respiratory symptoms and negative bacterial cultures.

  • Referral to respiratory, infectious diseases, and ICU teams is essential.

  • Resources: aspergillosis.org ; BTS Statement on  aspergillosis

by GAtherton

Aspergillus Bronchitis for Expert Patients and non-Specialist Clinicians

Expert Information for Patients, GPs, and Specialist Nurses

🔎 What Is Aspergillus Bronchitis?

Aspergillus bronchitis is a chronic fungal infection of the airways by Aspergillus fumigatus (or rarely other Aspergillus species), seen in individuals with structural lung disease or impaired mucociliary clearance. Unlike ABPA, it is not allergic in origin and does not involve systemic invasion, but is characterised by persistent fungal colonisation with active infection.

🧬 Pathophysiology

  • Chronic colonisation of the conducting airways by Aspergillus

  • Local immune dysfunction (but not systemic immunosuppression)

  • Low-grade inflammation and increased mucus production

  • Often coexists with bronchiectasis, COPD, or CF

👥 Who Is at Risk?

Most commonly seen in patients with:

  • Bronchiectasis (non-ABPA)

  • Cystic fibrosis

  • COPD or asthma with sputum production

  • Post-viral or structural airway damage

  • Chronic antibiotic or corticosteroid use

Not typically seen in severely immunocompromised hosts (in whom invasive aspergillosis is more likely).

⚠️ Common Symptoms

  • Persistent productive cough

  • Thick sputum often yellow or green

  • Worsening breathlessness or wheeze

  • Chronic sputum positivity for Aspergillus

  • Mild fever or malaise (but often afebrile)

  • Poor response to antibiotics alone

Symptoms may resemble chronic bacterial bronchitis or overlap with infective exacerbations of bronchiectasis.

🧪 Diagnosis

Diagnosis requires a combination of clinical and microbiological evidence, with exclusion of ABPA and CPA.

Diagnostic Features:

  1. Chronic productive cough (>4 weeks)

  2. Repeated isolation of Aspergillus from sputum or BAL

  3. Elevated Aspergillus IgG (typically present)

  4. Normal or mildly elevated total IgE (typically <1000 IU/mL)

  5. Absence of cavitary lesions or ABPA features on CT

  6. Response to antifungal treatment supports diagnosis

🛑 Exclude:

  • ABPA (IgE >1000, eosinophilia, central bronchiectasis)

  • CPA (cavities, weight loss, radiological progression)

💊 Treatment

First-Line:

  • Oral antifungals (usually for 3–6 months)

    • Itraconazole (first choice)

    • Voriconazole or posaconazole (if resistant/intolerant)

  • Monitor drug levels and LFTs

Adjuncts:

  • Physiotherapy and airway clearance techniques

  • Nebulised saline or mucolytics

  • Treat co-infections (e.g. Pseudomonas) where relevant

In patients with CF, consider co-management with a specialist CF team.

🧾 Monitoring

  • Sputum cultures to monitor persistence or clearance

  • Aspergillus IgG levels

  • Symptoms (sputum, breathlessness)

  • Liver function and drug monitoring

  • Periodic CT imaging if symptoms worsen or haemoptysis occurs

📚 More Information

by GAtherton

Chronic Pulmonary Aspergillosis (CPA) for Expert Patients and Non-Specialist Clinicians

Expert Information for Patients, GPs, and Specialist Nurses

🔎 What Is CPA?

Chronic Pulmonary Aspergillosis (CPA) is a long-term fungal lung infection caused by Aspergillus, typically A. fumigatus. It occurs in individuals with underlying lung damage and can progress slowly over months to years. It includes several subtypes ranging from cavitary lesions to fibrosing disease and fungal balls (aspergillomas).

🧬 Subtypes of CPA

Subtype Description
Simple aspergilloma Fungal ball within a pre-existing lung cavity
Chronic cavitary pulmonary aspergillosis (CCPA) Multiple cavities ± fungal balls; progressive
Chronic fibrosing pulmonary aspergillosis Advanced form with fibrosis and volume loss
Subacute invasive aspergillosis (SAIA) Intermediate between CPA and invasive disease; more rapid progression over weeks to months
Aspergillus nodules Discrete nodules without cavitation; may mimic malignancy

👥 Who Is at Risk?

CPA typically affects people with pre-existing lung disease or immune dysfunction, including:

  • Tuberculosis (old or active)

  • COPD and emphysema

  • Bronchiectasis

  • Sarcoidosis

  • Prior pneumothorax

  • Lung cancer or surgery

  • Diabetes mellitus

  • Low-dose or chronic steroid use

⚠️ Common Symptoms

CPA symptoms often evolve insidiously over >3 months:

  • Chronic productive cough

  • Haemoptysis (may be mild or massive)

  • Fatigue and weight loss

  • Breathlessness

  • Chest discomfort

  • Fever (occasional)

🧪 Diagnosis

Diagnosis of CPA requires the combination of:

  1. Symptoms ≥3 months

  2. Imaging:

    • CT chest: cavitary lesions, pleural thickening, aspergilloma, fibrotic changes

  3. Microbiology:

    • Positive sputum culture, PCR, or histopathology for A. fumigatus

  4. Serology:

    • Elevated Aspergillus IgG antibodies (essential for diagnosis)

  5. Exclusion of other diseases:

    • Especially active TB, malignancy, and bacterial infections

💊 Treatment

First-Line:

  • Oral triazole antifungals (minimum 6 months, often longer)

    • Itraconazole

    • Voriconazole

    • Posaconazole

  • Therapeutic drug monitoring is crucial

Additional:

  • Inhaled antifungals (e.g. amphotericin B) in selected cases

  • Surgery for localised disease or life-threatening haemoptysis (if fit)

  • Bronchial artery embolisation for bleeding control

  • Physiotherapy and nutritional support

🧾 Monitoring

  • CT scan every 3–6 months during treatment

  • Aspergillus IgG titres to monitor disease activity

  • Liver function and antifungal levels (monthly at minimum)

  • Symptom tracking (cough, energy, weight, breathlessness)

📚 More Information

by GAtherton

Thinking About Supportive (Palliative) Care

Support for living well with chronic aspergillosis

If you’re living with chronic pulmonary aspergillosis (CPA), ABPA, or a long-term lung condition, you may have wondered what help is available when things become harder to manage. You may be feeling more tired, more breathless, or just unsure what the future holds.

One type of support that many people find helpful is palliative care – though a better word might be supportive care. This isn’t just about end of life. It’s about making sure you have the right support to feel as well as you can, for as long as you can. Try to seek it out earlier rather than leaving it to late. Many patient find that they get a big improvement in their quality of life, and that is important for the carer as well as the patient.

💬 What Is Supportive (Palliative) Care?
Supportive care means looking after all parts of your wellbeing — not just the illness.
It helps with:

  • Controlling symptoms like breathlessness, pain, cough, or fatigue
  • Improving your daily quality of life
  • Support for anxiety, low mood, or fear
  • Making plans for your future care and treatment
  • Supporting your family or carers

You don’t need to stop treatment (like antifungal medicines or inhalers). In fact, many people receive supportive care alongside ongoing treatment.

✅ When Might It Help?
You might want to ask about this type of care if:

  • You’re having more flare-ups or hospital stays
  • Your energy or breathing is getting worse
  • You’re finding treatment difficult to manage
  • You want to talk about the future, or make plans
  • You’re feeling overwhelmed, low, or unsure what to expect

It’s about being proactive, not giving up.

📄 Planning Ahead: Being in Control of Your Care
Planning ahead helps you stay in control and gives peace of mind to you and your family.

This might include:

  • Saying where you would like to be cared for (home, hospital, hospice)
  • Writing down what matters most to you
  • Choosing someone to speak for you if you can't (Lasting Power of Attorney)
  • Deciding whether you want to be resuscitated if your heart stops (DNACPR form)

You don’t have to decide everything at once — and your choices can change over time.

🏡 Where Can Supportive Care Be Provided?
You don’t have to go to a hospice to get help. Supportive care can be arranged:

  • At home – with help from nurses or a palliative care team
  • In hospital, especially if symptoms become hard to manage
  • In a hospice, which can also offer outpatient care or short stays
  • Through phone or video calls with nurses or support services

Ask your GP, hospital team, or nurse about what’s available in your area.

💛 Why Talking Now Can Help

  • Many people delay talking about supportive care — but starting the conversation early can help you feel more secure and more in control.
  • You’re not giving up. You’re choosing the kind of care that respects your values and helps you live well.

“I wish I’d asked sooner. It wasn’t about dying — it was about living better.”

📞 What You Can Do Next
Talk to your GP, consultant, or nurse and ask:

  • “Can I speak to someone about supportive care and planning ahead?”
  • Ask about local palliative care services or advance care planning
  • Let your family or carers know your thoughts and wishes
  • Supportive online resources

by GAtherton

Why the Microbiome Matters for Aspergillosis Patients

Looking after the microbiome is increasingly recognised as important for people with aspergillosis, especially those with chronic pulmonary aspergillosis (CPA), ABPA, or recurrent infections. Many of these patients are on long-term antifungals, corticosteroids, or antibiotics — all of which can disrupt the body’s natural microbial balance.

Here’s a patient-focused guide with practical advice:

🦠 Why the Microbiome Matters for Aspergillosis Patients
Your microbiome (especially in the gut, lungs, and skin) plays a vital role in:

  • Regulating the immune system
  • Protecting against harmful microbes
  • Supporting digestion and nutrient absorption
  • Possibly influencing lung inflammation and fungal balance

✅ Practical Steps to Support Your Microbiome
1. Be Aware of Medications That Disrupt the Microbiome

  • Antifungal medications (e.g. itraconazole, voriconazole) can affect fungal balance beyond the lungs.
  • Broad-spectrum antibiotics kill good gut bacteria as well as infections.
  • Steroids (oral or inhaled) may also affect gut and respiratory flora.

👉 Ask your team whether regular use is necessary or whether treatment can be pulsed or minimised during stable phases.

2. Eat to Support Gut Health

  • Include prebiotic fibres: oats, onions, leeks, bananas, chicory, garlic, asparagus
  • Add fermented foods (if tolerated): yoghurt (live cultures), kefir, sauerkraut, kimchi, miso
  • Include polyphenol-rich foods: berries, green tea, olive oil, nuts
  • ❗ Avoid unpasteurised or homemade ferments if immunocompromised — check with your specialist first.

3. Consider Probiotics — with Caution

  • Some evidence suggests benefit after antibiotics, especially in reducing gut side effects.
  • Not all probiotics are equal; discuss with your clinical team if you:
    • Are on long-term antifungals
    • Are immunosuppressed
    • Have had recent hospitalisation or central lines

👉 Probiotics may be risky in certain patients (e.g. severe immunosuppression or gut damage).

4. Stay Active and Manage Stress

  • Moderate physical activity supports a healthier microbiome.
  • Chronic stress and poor sleep can negatively affect gut flora.

5. Avoid Overuse of Antimicrobials

  • Don’t use antiseptic mouthwashes, medicated shampoos, or antibacterial soaps routinely.
  • Only use topical antifungals or antibiotics where medically advised.

6. Lung Microbiome: Avoid Over-sanitising

  • Inhaled antifungals (e.g. amphotericin B) may affect lung flora but are sometimes essential.
  • Good airway clearance, physiotherapy, and hydration help maintain a stable lung environment.

💬 What to Ask Your Doctor

  • Could gut support (prebiotics or probiotics) help during or after treatment?
  • Are any medications I’m on harming my microbiome unnecessarily?
  • Could faecal microbiota transplant (FMT) ever be an option in my case?
  • What dietary changes would benefit me, given my medications?

by GAtherton

Patient referrals in the NHS - how it works

Here’s why GPs in the NHS usually refer patients first to a local specialist (e.g. a local respiratory team) rather than directly to a national centre like the National Aspergillosis Centre (NAC):

🏥 1. The NHS Referral Pathway Is Tiered (Local → Regional → National)

  • The NHS is designed to escalate care through “levels”:

    • GP → Local Consultant → Tertiary/National Centre

  • This structure ensures efficient use of resources and prioritises local care where appropriate.

  • National centres are not intended to be the first point of contact, except in emergencies or highly specialised pre-agreed pathways.

🧠 Analogy: You don’t go straight to a brain surgeon for a headache — you start with your GP.

📝 2. Referral Criteria for NAC Require Specialist Input

  • The NAC (based in Manchester) is a nationally commissioned tertiary centre, which means:

    • It only accepts referrals from consultants (not GPs directly)

    • It expects that basic tests (CT scan, IgE, Aspergillus-specific IgE/IgG, eosinophils, spirometry) have been done

    • Local teams should attempt initial diagnosis and management, and refer on if the case is complex, resistant, or unusual

📄 The NAC’s referral form specifically asks for consultant details and supporting investigations.

⚖️ 3. Clinical Governance and Local Responsibility

  • Local respiratory consultants are responsible for:

    • Ruling out common conditions first

    • Starting standard ABPA or CPA treatment (e.g. steroids, itraconazole)

    • Monitoring early response

  • This ensures that patients who are referred to the NAC are those who really need advanced care, e.g.:

    • Antifungal resistance

    • Multiple relapses

    • Atypical radiology

    • Drug intolerance or failure

    • Need for biologics, surgery, or MDT input

🧭 4. NHS Resource Planning and Fairness

  • National centres are funded to manage only the most complex or rare cases across the UK.

  • If GPs referred patients directly, national centres would become overwhelmed — and many patients would bypass the local care they actually need.

💡 It's not about gatekeeping — it's about managing capacity and focusing expertise where it’s most needed.

🛠️ What Can Patients Do?

If you suspect ABPA or CPA and your GP doesn’t know about NAC:

  1. Ask to be referred to a local respiratory team — ideally one with fungal disease knowledge.

  2. Share NAC information NAC referral criteria & guidance, Support for professionals

  3. If already under a consultant and you're not improving, ask:

    “Would you consider referring me to the National Aspergillosis Centre for specialist input?”

  4. If you're already diagnosed with ABPA or CPA and not improving, you can request your consultant refer you to NAC, citing lack of progress or drug intolerance.

by GAtherton

⚠️ Warning Signs for Possible Aspergillosis in Primary Care

We often state that a GP does not need to know all the details of what aspergillosis is, they just need to know what the warning signs might be so that they know when they should refer the patient to their local hospital specialist. What are those warning signs?

🟠 1. Asthma Not Responding to Guidelines-Based Treatment

  • Poor control despite high-dose inhaled steroids or long-acting bronchodilators

  • Frequent oral steroid bursts (>2 in a year)

  • Persistent cough or breathlessness between attacks

  • Thick or brown mucus plugs coughed up

🟢 Ask: “Are you still having symptoms even though you’re taking all your preventers?”

🟠 2. Recurrent Chest Infections

  • Multiple antibiotic courses (especially in bronchiectasis or COPD patients)

  • Sputum samples that repeatedly show Aspergillus or colonising fungi

  • Chest x-rays showing cavities, nodules, or persistent infiltrates

🟢 Ask: “Have you had several chest infections this year that needed antibiotics or steroids?”

🟠 3. Unexplained Fatigue, Weight Loss, or Night Sweats

  • Especially if imaging shows lung abnormalities or patient is immunocompromised

  • May indicate CPA, not just asthma

🟢 Ask: “Have you lost weight without trying, or felt unusually tired for weeks?”

🟠 4. Pre-existing Lung Conditions with New or Worsening Symptoms

  • Especially in patients with:

    • Bronchiectasis

    • COPD/emphysema

    • Old TB

    • Sarcoidosis

  • These conditions increase risk of CPA or colonisation becoming invasive

🟠 5. High Total IgE or Eosinophils

  • Total IgE > 1000 IU/mL with asthma + mucus plugs = strong ABPA clue

  • Blood eosinophils persistently >0.5 (especially off steroids)

  • Aspergillus-specific IgE or IgG positive

🟢 Flag: “Could this patient have allergic fungal disease or ABPA?”

🟠 6. Radiology That Doesn’t Match the Diagnosis

  • If the patient is being treated as asthma or pneumonia but:

    • HRCT shows bronchiectasis with mucus plugging

    • X-rays don’t improve despite treatment

    • Old TB scar now shows a cavity

🟢 Flag: “Does this imaging suggest something more than asthma or infection?”

🧭 What Should GPs and Nurses Do Next?

✅ Request:

  • Blood tests: Total IgE, eosinophils, Aspergillus-specific IgE/IgG

  • Sputum for fungal culture if available

  • CXR or HRCT if not done recently

✅ Refer:

  • Respiratory specialist or Advice & Guidance

  • National Aspergillosis Centre (NAC) in Manchester is a national specialist (tertiary) NHS centre, so does not accept referrals directly from GP's, instead GP's should refer to their local respiratory specialist team at a hospital nearby. NHS referral structure

📋 Clinical Triggers for Flagging Aspergillosis

Trigger Possible Condition
Uncontrolled asthma + high IgE + mucus ABPA
Chronic cough + weight loss + cavity on CT CPA
Asthma + sensitisation to fungi + frequent steroids SAFS

by GAtherton