Subscribe for unlimited access to DynaMed content, CME/CE & MOC credit, and email alerts on content you follow.

Already subscribed? Sign in now


Allergic Bronchopulmonary Aspergillosis

General Information


  • allergic pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus and rarely other Aspergillus species, characterized by chronic asthma, recurrent pulmonary infiltrates, and bronchiectasis1,2,5
  • occurs almost exclusively in patients with cystic fibrosis (CF) or asthma1,2,5

Also called

  • ABPA


  • Aspergillus-associated respiratory disorders1
    • affecting lower respiratory tract
      • allergic aspergillosis, including
        • allergic bronchopulmonary aspergillosis (ABPA)
        • immunoglobulin E (IgE)-mediated Aspergillosis-induced asthma (AIA)
        • hypersensitivity pneumonitis
      • saprophytic colonization - simple and complex aspergilloma
      • invasive disease - acute and subacute invasive aspergillosis
    • affecting upper respiratory tract
      • allergic aspergillosis (allergic Aspergillosis sinusitis [AAS])
      • saprophytic colonization (sinus fungal balls)
      • invasive disease, including
        • acute fulminant invasive sinusitis
        • chronic invasive sinusitis
        • granulomatous invasive sinusitis


  • stages are classification system and do not reflect sequential disease progression but may help guide treatment1,2,5
  • stages of allergic bronchopulmonary aspergillosis (ABPA)1,2,5
    • stage I (acute) - new, active acute disease
    • stage II (remission) - clinical, radiologic, and serologic remission for ≥ 6 months (asymptomatic)
    • stage III (recurrent exacerbations) - recurrent exacerbation or relapse, defined as
      • development of new infiltrates
      • ≥ 100% increase in total serum immunoglobulin E (IgE) level
    • stage IV (corticosteroid-dependent) - chronic corticosteroid-dependent asthma secondary to ABPA
    • stage V (fibrotic lung disease) - end-stage fibrosis and cavitation secondary to progressive airway inflammation and dilation
  • International Society for Human and Animal Mycology (ISHAM) working group proposed clinical staging1
    • stage 0 - clinically stable and well-controlled asthma without signs/symptoms suggestive of ABPA but with ABPA diagnosis
    • stage 1 (acute) - based on computed tomography and/or bronchoscopic findings
      • 1a - with mucoid impaction
      • 1b - without mucoid impaction
    • stage 2 (response) - clinical and radiological improvement with reduced serum IgE level ≥ 25% after 8 weeks of therapy
    • stage 3 (exacerbation) - any clinical and/or radiological worsening plus increased serum IgE level > 50% of baseline
    • stage 4 (remission) - sustained clinical and radiological improvement plus baseline serum IgE levels (or < 50% increase) for > 6 months without systemic corticosteroids
    • stage 5a (treatment-dependent ABPA)
      • > 2 consecutive relapses within 6 months of stopping treatment
      • worsening of clinical, radiological, or immunological parameters on tapering
    • stage 5b (glucocorticoid-dependent ABPA) - systemic corticosteroids required for asthma control when ABPA is controlled
    • stage 6 (advanced ABPA) - clinical signs of cor pulmonale and type-2 respiratory failure plus radiological evidence of fibrosis
  • further radiologic disease classification1,2
    • ABPA - serologic (ABPA-S, considered precursor to ABPA-CB)
    • ABPA - central bronchiectasis (ABPA-CB)
    • ABPA - high-attenuation mucous (HAM) plugs (ABPA-HAM)
    • ABPA - chronic pleuropulmonary fibrosis (ABPA-CPF)


General references used

  1. Shah A, Panjabi C. Allergic Bronchopulmonary Aspergillosis: A Perplexing Clinical Entity. Allergy Asthma Immunol Res. 2016 Jul;8(4):282-97full-text
  2. Greenberger PA, Bush RK, Demain JG, Luong A, Slavin RG, Knutsen AP. Allergic bronchopulmonary aspergillosis. J Allergy Clin Immunol Pract. 2014 Nov-Dec;2(6):703-8full-text
  3. Stevens DA, Moss RB, Kurup VP, et al. Allergic bronchopulmonary aspergillosis in cystic fibrosis-state of the art: Cystic Fibrosis Foundation Consensus Conference. Clin Infect Dis. 2003 Oct 1;37 Suppl 3:S225-64full-text, correction can be found in Clin Infect Dis. 2004 Jan 1;38(1):158
  4. Limper AH, Knox KS, Sarosi GA, et al; American Thoracic Society Fungal Working Group. An official American Thoracic Society statement: Treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med. 2011 Jan 1;183(1):96-128
  5. Bains SN, Judson MA. Allergic bronchopulmonary aspergillosis. Clin Chest Med. 2012 Jun;33(2):265-81

Recommendation grading systems used

  • Cystic Fibrosis Foundation (CFF) grading system
    • grade of evidence
      • Grade I - evidence obtained from ≥ 1 properly randomized controlled trial (RCT)
      • Grade II-1 - evidence obtained from well-designed controlled trials without randomization
      • Grade II-2 - evidence obtained from well-designed cohort or case-control analytic studies, preferably from > 1 center or research group
      • Grade II-3 - evidence obtained from multiple time series with or without intervention; dramatic results in uncontrolled experiments
      • Grade III - opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committee
    • Reference - CFF guideline on allergic bronchopulmonary aspergillosis in cystic fibrosis (Clin Infect Dis 2003 Oct 1;37 Suppl 3:S225full-text), correction can be found in Clin Infect Dis. 2004 Jan 1;38(1):158
  • European Respiratory Society/American Thoracic Society (ERS/ATS) grading system
    • strength of recommendation
      • Strong - most individuals should receive intervention; adherence to recommendation according to guideline could be used as quality criterion or performance indicator
      • Conditional - different choices will be appropriate for individual patients; help each patient arrive at management decision consistent with his or her values and preferences
    • levels of evidence
      • High - further research is very unlikely to change our confidence in the estimate of effect
      • Moderate - further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
      • Low - further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
      • Very low - any estimate of effect is very uncertain
    • Reference - ERS/ATS guideline on definition, evaluation, and treatment of severe asthma (24337046Eur Respir J 2014 Feb;43(2):343full-text)
  • American Thoracic Society (ATS) grading system for recommendations
    • strength of recommendations
      • Category A - good evidence to support a recommendation for use
      • Category B - moderate evidence to support a recommendation for use
      • Category C - poor evidence to support a recommendation for or against use
      • Category D - moderate evidence to support a recommendation against use
      • Category E - good evidence to support a recommendation against use
    • grades of evidence
      • Grade I - evidence from at least 1 properly randomized controlled trial
      • Grade II - evidence from at least 1 well-designed clinical trial without randomization, from cohort and case-controlled analytical studies (preferably from > 1 center), from multiple patient series studies, or from dramatic results of uncontrolled experiments
      • Grade III - evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
    • Reference - ATS guideline on treatment of fungal infections in adult pulmonary and critical care patients (21193785Am J Respir Crit Care Med 2011 Jan 1;183(1):96)

Synthesized Recommendation Grading System for DynaMed Content

  • The DynaMed Team systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based Methodology).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed content, we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed Team-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

  • DynaMed topics are created and maintained by the DynaMed Editorial Team and Process.
  • All editorial team members and reviewers have declared that they have no financial or other competing interests related to this topic, unless otherwise indicated.
  • DynaMed content includes Practice-Changing Updates, with support from our partners, McMaster University and F1000.

Special acknowledgements

  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T115466, Allergic Bronchopulmonary Aspergillosis; [updated 2018 Nov 30, cited place cited date here]. Available from Registration and login required.

Published by EBSCO Information Services. Copyright © 2020, EBSCO Information Services. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission.

EBSCO Information Services accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional.


Subscribe for unlimited access to DynaMed content.
Already subscribed? Sign in