Management of Chronic Pulmonary Aspergillosis

Chronic pulmonary aspergillosis is a progressive and debilitating parenchymal lung disease, with 1-year and 5-year mortality rates of about 5–30% and 40–60%, respectively. Treatment options depend on the radiological phenotypes of the disease. Surgery is a curative option for simple aspergilloma and Aspergillus nodules. Chronic cavitary, chronic fibrosing and chronic necrotising pulmonary aspergillosis forms are managed with long-term or life-long oral antifungal therapy, that is, itraconazole interchangeably with voriconazole as alternative first lines, and posaconazole or isavuconazole as salvage therapy. Intermittent, intravenous antifungals such as intravenous amphotericin B and echinocandins are options for patients who are intolerant to oral triazoles or have pan-azole-resistant isolates of Aspergillus. A treatment duration of 6 months or more is recommended, with duration over 12 months being associated with fewer relapses. Bronchial artery embolization and tranexamic acid are used for the treatment of haemoptysis which is observed in over 50% of patients with chronic pulmonary aspergillosis. Other approaches include bronchoscopic triazole administration, inhaled antifungals, and intracavitary inoculation of antifungals. Adjunctive treatment includes vaccination against common respiratory infections, physiotherapy, and immunotherapy. Novel agents such as olorofim, oteseconazole, opelconazole, ibrexafungarp, fosmanogepix and rezafungin are all potential agents in development for treatment of chronic pulmonary aspergillosis.