Obstructive sleep apnoea and frequency of occupational injury.

We sought to determine whether patients with obstructive sleep apnoea (OSA) are at increased risk of occupational injury (OI). Patients referred to the University of British Columbia Hospital Sleep Laboratory for suspected OSA (May 2003 to July 2011 were recruited and rates and types of validated OI (that caused at least 1 day of disability) in the 5 years prior to polysomnography were calculated. In a sample of 1236, patients with OSA were twice as likely (OR=1.93, 95% CI 1.06 to 3.50, p=0.03) to suffer at least one OI compared with patients without OSA. This association was attenuated (OR=1.76, CI 0.86 to 3.59, p=0.12) after controlling for confounders. In a secondary analysis, patients with OSA were almost three times more likely (OR=2.88, CI 1.02 to 8.08, p=0.05) to suffer from an injury more likely related to reduced vigilance (eg, a fall or commercial motor vehicle crash) when compared with patients without OSA, and this again was attenuated after controlling for confounders (OR=2.42, CI 0.085 to 6.93, p=0.10).

Endoscopy evaluation to predict oral appliance outcomes in obstructive sleep apnoea.

The objective of this study was to determine the utility of nasoendoscopy of the upper airway as a predictor of the efficacy of oral appliance treatment in obstructive sleep apnoea (OSA).A total of 61 consecutive patients with moderate-to-severe polysomnographically diagnosed OSA were recruited for this study. Using nasoendoscopy, we prospectively assessed the velopharynx and oro/hypopharynx in each patient while awake and in the supine position. We measured cross-sectional area (CSA), and anteroposterior and lateral diameters of the airway before and after mandibular advancement, and expressed the changes in dimensions as expansion ratios (after/before). We then compared the measurements of responders and nonresponders with oral appliance treatment.The expansion ratio (median (interquartile range)) for the CSA was greater in responders compared with nonresponders in the velopharynx (2.9 (2.3-5.0) versus 1.7 (1.5-1.9), p<0.001) and in the oro/hypopharynx (3.4 (2.5-5.6) versus 2.4 (1.8-3.7), p<0.05). Baseline apnoea-hypopnoea index and the CSA expansion ratio of the velopharynx were independent predictors of oral appliance treatment outcome based on a multivariate logistic regression analysis. The estimated area under the receiver operator characteristic curve was 0.87 and the cut-off value of the expansion ratio was 2.00.These results indicate that nasoendoscopy may have significant clinical utility in predicting the success of oral appliance treatment.

Effect of Opioids vs NSAIDs and Larger vs Smaller Chest Tube Size on Pain Control and Pleurodesis Efficacy Among Patients With Malignant Pleural Effusion: The TIME1 Randomized Clinical Trial.

IMPORTANCE: For treatment of malignant pleural effusion, nonsteroidal anti-inflammatory drugs (NSAIDs) are avoided because they may reduce pleurodesis efficacy. Smaller chest tubes may be less painful than larger tubes, but efficacy in pleurodesis has not been proven. OBJECTIVE: To assess the effect of chest tube size and analgesia (NSAIDs vs opiates) on pain and clinical efficacy related to pleurodesis in patients with malignant pleural effusion. DESIGN, SETTING, AND PARTICIPANTS: A 2×2 factorial phase 3 randomized clinical trial among 320 patients requiring pleurodesis in 16 UK hospitals from 2007 to 2013. INTERVENTIONS: Patients undergoing thoracoscopy (n = 206; clinical decision if biopsy was required) received a 24F chest tube and were randomized to receive opiates (n = 103) vs NSAIDs (n = 103), and those not undergoing thoracoscopy (n = 114) were randomized to 1 of 4 groups (24F chest tube and opioids [n = 28]; 24F chest tube and NSAIDs [n = 29]; 12F chest tube and opioids [n = 29]; or 12F chest tube and NSAIDs [n = 28]). MAIN OUTCOMES AND MEASURES: Pain while chest tube was in place (0- to 100-mm visual analog scale [VAS] 4 times/d; superiority comparison) and pleurodesis efficacy at 3 months (failure defined as need for further pleural intervention; noninferiority comparison; margin, 15%). RESULTS: Pain scores in the opiate group (n = 150) vs the NSAID group (n = 144) were not significantly different (mean VAS score, 23.8 mm vs 22.1 mm; adjusted difference, -1.5 mm; 95% CI, -5.0 to 2.0 mm; P = .40), but the NSAID group required more rescue analgesia (26.3% vs 38.1%; rate ratio, 2.1; 95% CI, 1.3-3.4; P = .003). Pleurodesis failure occurred in 30 patients (20%) in the opiate group and 33 (23%) in the NSAID group, meeting criteria for noninferiority (difference, -3%; 1-sided 95% CI, -10% to ∞; P = .004 for noninferiority). Pain scores were lower among patients in the 12F chest tube group (n = 54) vs the 24F group (n = 56) (mean VAS score, 22.0 mm vs 26.8 mm; adjusted difference, -6.0 mm; 95% CI, -11.7 to -0.2 mm; P = .04) and 12F chest tubes vs 24F chest tubes were associated with higher pleurodesis failure (30% vs 24%), failing to meet noninferiority criteria (difference, -6%; 1-sided 95% CI, -20% to ∞; P = .14 for noninferiority). Complications during chest tube insertion occurred more commonly with 12F tubes (14% vs 24%; odds ratio, 1.91; P = .20). CONCLUSIONS AND RELEVANCE: Use of NSAIDs vs opiates resulted in no significant difference in pain scores but was associated with more rescue medication. NSAID use resulted in noninferior rates of pleurodesis efficacy at 3 months. Placement of 12F chest tubes vs 24F chest tubes was associated with a statistically significant but clinically modest reduction in pain but failed to meet noninferiority criteria for pleurodesis efficacy. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN33288337.

Oropharyngeal crowding and obesity as predictors of oral appliance treatment response to moderate obstructive sleep apnea.

BACKGROUND: Oral appliances are increasingly prescribed for patients with moderate obstructive sleep apnea (OSA) instead of nasal CPAP. However, the efficacy of oral appliances varies greatly. We hypothesized that oral appliances were not efficacious in patients with moderate OSA who were obese with oropharyngeal crowding. METHODS: Japanese patients with moderate OSA were prospectively and consecutively recruited. The Mallampati score (MS) was used as an estimate of oropharyngeal crowding. Follow-up polysomnography was performed with the adjusted oral appliance in place. Responders were defined as subjects who showed a follow-up apnea-hypopnea index (AHI) of < 5 with > 50% reduction in baseline AHI. RESULTS: The mean baseline AHI was reduced with an oral appliance from 21 ± 4 to 9.8 ± 8 in 95 subjects. Thirty-five patients were regarded as responders. Logistic regression analyses revealed that both MS and BMI could individually predict the treatment outcome. When the cutoff value of BMI was determined to be 24 kg/m2 based on a receiver operating characteristic curve, 53 obese patients (ie, BMI > 24 kg/m2) with an MS of class 4 were indicative of treatment failure with a high negative predictive value (92) and a low negative likelihood ratio (0.28). CONCLUSIONS: We conclude that patients with moderate OSA who are obese with oropharyngeal crowding are unlikely to respond to oral appliance treatment. This simple prediction can be applied without the need for any cumbersome tools immediately after the diagnosis of OSA.

The impact of a telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial.

STUDY OBJECTIVES: First-line therapy for patients with moderate to severe obstructive sleep apnea (OSA) is positive airway pressure (PAP). Although PAP is a highly efficacious treatment, adherence to PAP is still a substantial clinical problem. The objective of this study was to determine whether PAP adherence can be improved with a telemedicine monitoring system. DESIGN: A nonblinded, single-center, randomized controlled trial that compared standard PAP treatment versus PAP treatment and a telemedicine monitoring system SETTING: University sleep disorders program in British Columbia, Canada PATIENTS: Adult patients (≥ 19 yr of age) with moderate to severe OSA (apnea hypopnea index (AHI) ≥ 15 events/hr determined by polysomnography) prescribed PAP INTERVENTIONS: Patients were randomized to either standard care with an autotitrating PAP machine or an autotitrating PAP machine that transmitted physiologic information (i.e., adherence, air leak, residual AHI) daily to a website that could be reviewed. If problems were identified from information from the website, the patient was contacted by telephone as necessary. MEASUREMENTS: PAP adherence after 3 mo, subjective sleep quality, and side effects RESULTS: Seventy-five patients were enrolled; 39 were randomized to telemedicine and 36 to standard care. The mean age ± standard deviation (SD) was 53.5 ± 11.2 yr, mean AHI was 41.6 ± 22.1 events/hr, and 80% of patients were male. After 3 mo, mean PAP adherence was significantly greater in the telemedicine arm (191 min per day) versus the standard arm (105 min per day; mean difference = 87 min, 95% confidence interval (CI): 25-148 min, P = 0.006, unpaired t test). On days when PAP was used, mean adherence was 321 min in the telemedicine arm and 207 min in the standard arm (difference = 113 min, 95% CI: 62-164 min, P < 0.0001). Significant independent predictors of adherence included age, baseline Epworth Sleepiness Scale score, and use of telemedicine. On average, an additional 67 min of technician time was spent on patients in the telemedicine arm compared with the standard arm (P = 0.0001). CONCLUSIONS: PAP adherence can be improved with the use of a web-based telemedicine system at the initiation of treatment.

Residual sleep apnea on polysomnography after 3 months of CPAP therapy: clinical implications, predictors and patterns.

OBJECTIVE: We sought to determine the clinical implications, predictors and patterns of residual sleep apnea on continuous positive airway pressure (CPAP) treatment in patients with moderate-to-severe obstructive sleep apnea (OSA). METHODS: We performed a post hoc secondary analysis of data from a previously reported randomized trial. Sleepy patients with a high risk of moderate-to-severe OSA identified by a diagnostic algorithm were randomly assigned to standard CPAP titration during polysomnography (PSG) or ambulatory titration using auto-CPAP and home sleep testing. We observed them for 3 months and measured apnea-hypopnea index (AHI) on CPAP, Epworth sleepiness scale (ESS), sleep apnea quality of life index (SAQLI), CPAP pressure and objective CPAP compliance. RESULTS: Sixty-one patients were randomized, 30 to the PSG group and 31 to the ambulatory group. Fifteen patients (25%) had residual sleep apnea (AHI > 10/h on CPAP) with similar proportions in the PSG (7/30) and ambulatory (8/31) groups. Baseline variables including age, body mass index (BMI), ESS, SAQLI, respiratory disturbance index (RDI) and CPAP pressure did not differ between the groups. Outcomes including compliance were worse in patients with residual sleep apnea. Periodic breathing was prevalent among patients with residual sleep apnea. CONCLUSIONS: Residual sleep apnea is common in patients with moderate-to-severe OSA, despite careful CPAP titration, and is associated with worse outcomes.

The impact of CPAP on cardiovascular biomarkers in minimally symptomatic patients with obstructive sleep apnea: a pilot feasibility randomized crossover trial.

BACKGROUND: Previous, largely uncontrolled studies demonstrated the substantial effects of continuous positive airway pressure ventilation (CPAP) on a variety of physiologic and biochemical markers known to be risk factors for cardiovascular disease in patients with obstructive sleep apnea (OSA). In this pilot crossover study, we assessed (1) the feasibility of using CPAP in a group of minimally symptomatic patients with OSA, assessed through patient compliance and (2) CPAP therapy's effect on biomarkers in these patients. METHODS: We studied patients with minimal daytime sleepiness who were referred to the University of British Columbia's Hospital Sleep Clinic with suspected OSA and an apnea-hypopnea index (AHI) > 15 events/h. Patients were randomized to either CPAP or no therapy for 4 weeks followed by a washout of 4 weeks, and then a crossover to the other intervention. Fasting morning blood and urine, 24-h blood pressure (BP) measurements, and endothelial function (peak flow-mediated dilation to nitroglycerin-mediated dilation ratio) were assessed before and after each study intervention. RESULTS: Nine adult male and four female patients were studied. Mean (SD) age was 55 (7) years, mean AHI = 27.9/h, mean Epworth Sleepiness Score = 6.8 (11/13 had a score < 10), and mean BMI = 31.1 kg/m(2). Mean compliance with CPAP therapy was 5.53 h/night. Compared to no therapy, potential improvements were observed with CPAP for urinary microalbumin, norepinephrine, and epinephrine to creatinine ratios (decreased by 3.51 mg/mmol, 1.70 nmol/mmol, and 0.95 nmol/mmol, respectively); 24-h BP (systolic decreased by 3.60 mmHg, diastolic by 0.70 mmHg); homeostasis model for insulin resistance score (decreased by 1.11); and endothelial function (increased by 7.4%). However, none of the above differences was significant (p > 0.10). CONCLUSION: In this pilot study there were potential improvements in a variety of cardiovascular biomarkers with CPAP. CPAP compliance was reasonably good even though patients were not particularly sleepy. Accordingly, larger randomized controlled trials in this area appear feasible and warranted.

Depression and sleep-related symptoms in an adult, indigenous, North American population.

STUDY OBJECTIVES: Symptoms related to sleep disorders are common and may have substantial adverse impacts on mental health. Indigenous North Americans (American Indian) are a medically vulnerable population with reduced access to healthcare services. The purposes of this study were to assess (1) the prevalence of sleep symptoms and (2) the relationships between symptoms and depression in this population. METHODS: We performed a community-based, door-to-door, cross-sectional survey of 3 indigenous North American groups (Gitxsan, Nisga'a and Tsimshian) living in the northwestern part of British Columbia. Between May and September of 2006, subjects completed a comprehensive questionnaire that included questions about sleep habits, medical history, subjective sleepiness (Epworth Sleepiness Scale), and depression (Personal Health Questionnaire [PHQ-9]). Weights and heights were also measured. RESULTS: Four hundred thirty adults participated in the study (response rate = 42%). Their mean age was 43.2 years. Three hundred ninety-three agreed to have heights and weights measured. Their mean body mass index (BMI) was 31.0 +/- 9.2 kg/m2; 45% of them (177/393) were obese (BMI > 30 kg/m2), and 11% (43/393) were morbidly obese (BMI > 40 kg/m2). The prevalence of sleep complaints was high; insomnia symptoms was reported by 17.2%, symptoms of restless legs syndrome (RLS) by 17.7%, and frequent witnessed apneas reported (i.e., being told they stopped breathing at least 3 nights per week) by 7.6%. Of the 76 patients who had RLS symptoms, only 3 (3.9%) reported having received a diagnosis of RLS from a physician. Thirty-three subjects reported having frequent witnessed apneas, but only 5 of them (15.1%) reported having received a diagnosis of OSA from a physician. The mean PHQ9 score was 4.86 +/- 5.13 (reported by 389 subjects). Twenty-eight subjects (7.20%) had moderate to severe depression, with a PHQ-9 score of 15 or greater. In multivariable linear regression analysis, insomnia symptoms, witnessed apneas, and RLS symptoms were independently associated with an increase in PHQ9 score; frequent witnessed apneas were associated with an increase in PHQ9 by 2.46 (95% confidence interval: 0.47-4.46), insomnia symptoms by 4.49 (95% confidence interval: 3.14-5.83), and RLS symptoms by 1.82, (95% confidence interval: 0.53-3.12). CONCLUSIONS: Sleep symptoms and depression are common in the indigenous North American population of northern British Columbia. Sleep-related symptoms (insomnia symptoms, witnessed nocturnal apneas, and RLS symptoms) are independently associated with depression scores. Improving access to sleep-related diagnostic and therapeutic services may substantially improve mental health in this vulnerable patient population.

Knowledge-based data analysis: first step toward the creation of clinical prediction rules using a new typicality measure.

Clinical prediction rules play an important role in medical practice. They expedite diagnosis and limit unnecessary tests. However, the rule creation process is time consuming and expensive. With the current developments of efficient data mining algorithms and growing accessibility to medical data, the creation of clinical rules can be supported by automated rule induction from data. A data-driven method based on the reuse of previously collected medical records and clinical trial statistics is cost-effective; however, it requires well defined and intelligent methods for data analysis. This paper presents a new framework for knowledge representation for secondary data analysis and for generation of a new typicality measure, which integrates medical knowledge into statistical analysis. The framework is based on a semiotic approach for contextual knowledge and fuzzy logic for approximate knowledge. This semio-fuzzy framework has been applied to the analysis of predictors for the diagnosis of obstructive sleep apnea. This approach was tested on two clinical data sets. Medical knowledge was represented by a set of facts and fuzzy rules, and used to perform statistical analysis. Statistical methods provided several candidate outliers. Our new typicality measure identified those, which were medically significant, in the sense that the removal of those important outliers improved the descriptive model. This is a critical preprocessing step towards automated induction of predictive rules from data. These experimental results demonstrate that knowledge-based methods integrated with statistical approaches provide a practical framework to support the generation of clinical prediction rules.

Functional contribution of mandibular advancement to awake upper airway patency in obstructive sleep apnea.

In the narrowed upper airway of patients with obstructive sleep apnea (OSA), a neuromuscular compensatory mechanism augments the activity of the upper airway dilator muscles in defense of upper airway patency, particularly during inspiration. We hypothesized that mechanical enlargement of the upper airway by a mandibular advancement oral appliance would permit a reduction in this neuromuscular compensation during wakefulness. To test this hypothesis, we focused on changes in the cross-sectional (CS) area of the upper airway before and after emplacement of a ventrally titrated oral appliance in 12 awake OSA patients. The CS areas at the end of tidal expiration (CS area-EET) and at the nadir of intraluminal pressure during inspiration (CS area-IN) were obtained using videoendoscopy. The median apnea-hypopnea index decreased with mandibular advancement. Before mandibular advancement, there was no difference between CS area-EET and CS area-IN in the velopharynx, oropharynx, and hypopharynx. This indicates that upper airway dilator muscle activity increased during inspiration to counteract the intraluminal negative pressure of the upper airway. After mandibular advancement, CS area-EET increased in the velopharynx, oropharynx, and hypopharynx, but CS area-IN was unchanged at any level and was less than CS area-EET in the velopharynx and oropharynx. These findings suggest that mandibular advancement enlarges the upper airway and may reduce upper airway dilator muscle activity during inspiration. We conclude that oral appliances act to return the upper airway towards a normal configuration and pattern of muscle function in OSA patients.

Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study.

BACKGROUND: Polysomnography (PSG), despite limited availability and high cost, is currently recommended for diagnosis of obstructive sleep apnea and titration of effective continuous positive airway pressure (CPAP). OBJECTIVE: To test the utility of a diagnostic algorithm in conjunction with ambulatory CPAP titration in initial management of obstructive sleep apnea. DESIGN: A randomized, controlled, open-label trial that compared standard PSG with ambulatory CPAP titration in high-risk patients identified by a diagnostic algorithm. SETTING: A tertiary referral sleep disorders program in Vancouver, British Columbia, Canada. PATIENTS: 68 patients with a high pretest probability of moderate to severe obstructive sleep apnea (apnea-hypopnea index [AHI] >15 episodes/h) identified by sequential application of the Epworth Sleepiness Scale (ESS) score, Sleep Apnea Clinical Score, and overnight oximetry. INTERVENTION: Patients were randomly assigned to PSG or ambulatory titration by using a combination of auto-CPAP and overnight oximetry. They were observed for 3 months. MEASUREMENTS: Apnea-hypopnea index on CPAP, ESS score, quality of life, and CPAP adherence. RESULTS: The PSG and ambulatory groups had similar median BMI (38 kg/m2), age (55 years), ESS score (14 points), and respiratory disturbance index (31 episodes of respiratory disturbance/h). Each episode is determined by a computer algorithm based on analysis of oxygen saturation measured by pulse oximetry. After 3 months, there were no differences in the primary outcome, AHI on CPAP (median, 3.2 vs. 2.5; difference, 0.8/h [95% CI, -0.9 to 2.3]) (P = 0.31), between the PSG and ambulatory groups, or in the secondary outcomes, ESS score, Sleep Apnea Quality of Life Index, and CPAP. Adherence to CPAP therapy was better in the ambulatory group than in the PSG group (median, 5.4 vs. 6.0; difference, -1.12 h/night [CI, -2.0 to 0.2]) (P = 0.021). CONCLUSIONS: In the initial management of patients with a high probability of obstructive sleep apnea, PSG confers no advantage over the ambulatory approach in terms of diagnosis and CPAP titration. The ambulatory approach may improve adherence to treatment. When access to PSG is inadequate, the ambulatory approach can be used to expedite management of patients most in need of treatment.

Cost-effectiveness of continuous positive airway pressure therapy for moderate to severe obstructive sleep apnea/hypopnea.

BACKGROUND: Obstructive sleep apnea/hypopnea (OSAH) is a common disorder characterized by recurrent collapse of the upper airway during sleep, and is associated with an increased risk of motor vehicle crashes (MVCs). Common first-line therapy for OSAH is continuous positive airway pressure (CPAP). We assessed the cost-effectiveness of CPAP therapy vs none for the treatment of OSAH. METHODS: We used a 5-year Markov model that considers the costs and quality-of-life improvements of CPAP therapy, accounting for the gains from reduced MVC rates. Utility values were obtained from published studies. The MVC rates under the CPAP and no-CPAP scenarios were calculated from National Highway Traffic Safety Administration data and a systematic review of published studies. Costs of MVCs, equipment, and physicians were obtained from US Medicare and the National Highway Traffic Safety Administration. The target population included male and female patients aged 25 to 54 years and newly diagnosed as having moderate to severe OSAH. We examined the findings from the perspectives of a third-party payer and society. RESULTS: From a third-party payer or a societal perspective, CPAP therapy was more effective but more costly than no CPAP, with incremental cost-effectiveness ratios of $3354 or $314 per quality-adjusted life-year gained, respectively. The incremental cost-effectiveness ratio estimate was most dependent on viewpoint (varying more than 10-fold between societal and third-party payer perspectives) and choice of utility measurement method (varying more than 5-fold between the use of standard gamble and EuroQol 5D utility assessment values). CONCLUSION: When quality of life, costs of therapy, and MVC outcomes are considered, CPAP therapy for patients with OSAH is economically attractive.

Prevalence, risk factors and impact on daytime sleepiness and hypertension of periodic leg movements with arousals in patients with obstructive sleep apnea.

STUDY OBJECTIVE: To determine the prevalence, risk factors, and impact on daytime sleepiness and hypertension of periodic leg movements of sleep (PLMS) with associated arousals in patients with obstructive sleep apnea (OSA). METHODS: A single-center retrospective case series of 798 consecutive patients who underwent diagnostic overnight polysomnography for suspected OSA. We performed discriminant function analysis using clinical and polysomnographic variables to examine the relationship between PLMS (periodic leg movement arousal index > or =5 per hour) and potential risk factors, including OSA. RESULTS: Mean +/- SD age was 50 +/- 12 years, body mass index 32 +/- 8 kg/m2, Epworth Sleepiness Scale (ESS) score 11 +/- 5, and apnea-hypopnea index 31 +/- 26 per hour. Sixty-eight percent were men, 30% had systemic hypertension, and 19% were smokers. Ninety-two percent had OSA (apnea-hypopnea index +/- 5); 47% had PLMS; 44% had both OSA and PLMS; and among patients with OSA, 48% had PLMS. Significant predictors of PLMS, in order of importance, were number of predisposing medical conditions, age, number of predisposing medications, obesity, and OSA. Medical conditions that significantly predicted PLMS were depression, fibromyalgia, and diabetes mellitus. The ESS score and hypertension status were no different between those with both OSA and PLMS and those with OSA alone. CONCLUSIONS: One in 2 patients investigated for OSA has PLMS. Risk factors for PLMS include preexisting medical conditions-particularly depression, fibromyalgia, and diabetes mellitus-increasing age, predisposing medications, obesity, and OSA. The combination of OSA and PLMS results in no greater subjective daytime sleepiness or prevalence of hypertension than OSA alone.

Aspergillus-related lung disease.

Aspergillus is a ubiquitous dimorphic fungus that causes a variety of human diseases ranging in severity from trivial to life-threatening, depending on the host response. An intact host defence is important to prevent disease, but individuals with pre-existing structural lung disease, atopy, occupational exposure or impaired immunity are susceptible. Three distinctive patterns of aspergillus-related lung disease are recognized: saprophytic infestation of airways, cavities and necrotic tissue; allergic disease including extrinsic allergic alveolitis, asthma, allergic bronchopulmonary aspergillosis, bronchocentric granulomatosis and chronic eosinophilic pneumonia; and airway and tissue invasive disease -- pseudomembranous tracheobronchitis, acute bronchopneumonia, angioinvasive aspergillosis, chronic necrotizing aspergillosis and invasive pleural disease. A broad knowledge of these clinical presentations and a high index of suspicion are required to ensure timely diagnosis and treatment of the potentially lethal manifestations of aspergillus-related pulmonary disease. In the present report, the clinical, radiographic and pathological aspects of the various aspergillus-related lung diseases are briefly reviewed.