We analyzed clinical features of chronic necrotizing pulmonary aspergillosis (CNPA) in patients with underlying chronic respiratory disease, and evaluated the efficacy and tolerability of voriconazole against CNPA in those patients. Voriconazole therapy was indicated in 45 CNPA patients between October 2005 and September 2007, in 23 patients as first-line treatment and in 22 after lack of response to or intolerance of prior antifungal agent. The most common underlying respiratory disease was sequelae of tuberculosis (n = 23) followed by COPD (n = 13). Cavitary lesions were found in 32 patients. Galactomannan antigen test was positive in 29 patients while 28 patients out of 36 were positive for anti-Aspergillus serum antibody. The antibody-negative group had significantly higher levels of galactomannan antigen than the antibody-positive group. Mycological culture or hyphae were positive in 15 patients. Beta-D glucan level was within the normal limit in 27 patients. Clinical, radiological improvement, or both was obtained in 30 patients after an average voriconazole treatment of 4.8 months, with the main adverse effects being visual disturbance and hepatotoxicity. During the observation period 14 patients died due to CNPA or other causes. Although voriconazole demonstrated good efficacy against CNPA, the outcome is still unsatisfactory.