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Berger K, Kaner RJ. Diagnosis and Pharmacologic Management of Fibrotic Interstitial Lung Disease. Life (Basel) 2023; 13:599. [PMID: 36983755 PMCID: PMC10055741 DOI: 10.3390/life13030599] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/23/2023] Open
Abstract
Interstitial lung disease is an umbrella term that encompasses a spectrum of parenchymal lung pathologies affecting the gas exchanging part of the lung. While many of these disease entities are not fibrotic in nature, a number can lead to pulmonary fibrosis which may or may not progress over time. Idiopathic pulmonary fibrosis is the prototypical, progressive fibrotic interstitial lung disease, which can lead to worsening hypoxemic respiratory failure and mortality within a number of years from the time of diagnosis. The importance of an accurate and timely diagnosis of interstitial lung diseases, which is needed to inform prognosis and guide clinical management, cannot be overemphasized. Developing a consensus diagnosis requires the incorporation of a variety of factors by a multidisciplinary team, which then may or may not determine a need for tissue sampling. Clinical management can be challenging given the heterogeneity of disease behavior and the paucity of controlled trials to guide decision making. This review addresses current paradigms and recent updates in the diagnosis and pharmacologic management of these fibrotic interstitial lung diseases.
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Affiliation(s)
- Kristin Berger
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY 10021, USA
| | - Robert J. Kaner
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY 10021, USA
- Department of Genetic Medicine, Weill Cornell Medicine, New York, NY 10021, USA
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Copeland CR, Donnelly EF, Mehrad M, Ding G, Markin CR, Douglas K, Wu P, Cogan JD, Young LR, Bartholmai BJ, Martinez FJ, Flaherty KR, Loyd JE, Lancaster LH, Kropski JA, Blackwell TS, Salisbury ML. The Association between Exposures and Disease Characteristics in Familial Pulmonary Fibrosis. Ann Am Thorac Soc 2022; 19:2003-2012. [PMID: 35877079 PMCID: PMC9743479 DOI: 10.1513/annalsats.202203-267oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/25/2022] [Indexed: 12/15/2022] Open
Abstract
Rationale: Heterogeneous characteristics are observed in familial pulmonary fibrosis (FPF), suggesting that nongenetic factors contribute to disease manifestations. Objectives: To determine the relationship between environmental exposures and disease characteristics of FPF, including the morphological characteristics on chest computed tomography (CT) scan, and timing of FPF symptom onset, lung transplantation, or death. Methods: Subjects with FPF with an exposure questionnaire and chest CT were selected from a prospective cohort at Vanderbilt. Disease characteristics were defined by lung parenchymal findings on chest CT associated with fibrotic hypersensitivity pneumonitis (fHP) or usual interstitial pneumonia (UIP) and by time from birth to symptom onset or a composite of lung transplantation or death. After assessing the potential for confounding by sex or smoking, adjusted logistic or Cox proportional hazards regression models identified exposures associated with fHP or UIP CT findings. Findings were validated in a cohort of patients with sporadic pulmonary fibrosis enrolled in the LTRC (Lung Tissue Research Consortium) study. Results: Among 159 subjects with FPF, 98 (61.6%) were males and 96 (60.4%) were ever-smokers. Males were less likely to have CT features of fHP, including mosaic attenuation (FPF: adjusted [for sex and smoking] odds ratio [aOR], 0.27; 95% confidence interval [CI], 0.09-0.76; P = 0.01; LTRC: aOR, 0.35; 95% CI, 0.21-0.61; P = 0.0002). Organic exposures, however, were not consistently associated with fHP features in either cohort. Smoking was a risk factor for honeycombing in both cohorts (FPF: aOR, 2.19; 95% CI, 1.12-4.28; P = 0.02; LTRC: aOR, 1.69; 95% CI, 1.22-2.33; P = 0.002). Rock dust exposure may also be associated with honeycombing, although the association was not statistically-significant when accounting for sex and smoking (FPF: aOR, 2.27; 95% CI, 0.997-5.15; P = 0.051; LTRC: aOR, 1.51; 95% CI, 0.97-2.33; P = 0.07). In the FPF cohort, ever-smokers experienced a shorter transplant-free survival (adjusted hazard ratio, 1.64; 95% CI, 1.07-2.52; P = 0.02), whereas sex was not associated with differential survival (male adjusted hazard ratio, 0.75; 95% CI, 0.50-1.14; P = 0.18). Conclusions: In FPF, smoking contributes to shortened transplant-free survival and development of honeycombing, a finding that is also likely applicable to sporadic pulmonary fibrosis. Females are more likely to manifest CT features of fHP (mosaic attenuation), a finding that was incompletely explained by sex differences in exposures. These findings may have implications for pulmonary fibrosis classification and management.
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Affiliation(s)
| | - Edwin F. Donnelly
- Department of Radiology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mitra Mehrad
- Department of Pathology, Microbiology, and Immunology
| | | | | | | | - Pingsheng Wu
- Department of Medicine
- Department of Biostatistics, and
| | - Joy D. Cogan
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lisa R. Young
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | | | | | | | - Jonathan A. Kropski
- Department of Medicine
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, Tennessee; and
- Department of Veterans Affairs Medical Center, Nashville, Tennessee
| | - Timothy S. Blackwell
- Department of Medicine
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, Tennessee; and
- Department of Veterans Affairs Medical Center, Nashville, Tennessee
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Cottin V, Martinez FJ, Smith V, Walsh SLF. Multidisciplinary teams in the clinical care of fibrotic interstitial lung disease: current perspectives. Eur Respir Rev 2022; 31:220003. [PMID: 38743511 DOI: 10.1183/16000617.0003-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 07/04/2022] [Indexed: 11/05/2022] Open
Abstract
Multidisciplinary team (MDT) meetings, involving the integrated collaboration of healthcare professionals, are increasingly used in clinical practice to inform the diagnosis and treatment of interstitial lung diseases (ILDs). Over time, the assessment of patients with ILD has transitioned from discussions among clinicians, radiologists and pathologists to the inclusion of a broader range of clinical data and specialist expertise. Studies have shown that a multidisciplinary approach can have many benefits for the clinical care of patients with ILD by improving the diagnostic confidence for different ILDs and guiding treatment decisions. The utility of MDT discussions for diagnosis, monitoring disease progression and management decisions, will need to be considered based on how it is best positioned in the diagnostic and therapeutic process, as well as the practicality and challenges of its use. There are also uncertainties and heterogeneity concerning the optimal practices of MDT meetings in ILD care. In this review, we describe recent developments refining the approach to MDTs in clinical practice, including who should be involved in the MDTs, when it is most needed, their use in patient management, challenges in their implementation, and ongoing controversies in the field that need further research.
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Affiliation(s)
- Vincent Cottin
- Louis Pradel Hospital, Reference Centre for Rare Pulmonary Diseases, Hospices Civils de Lyon, Lyon, France
- Claude Bernard University Lyon 1, UMR754, INRAE, Member of OrphaLung, RespiFil, Radico-ILD and ERN-LUNG, Lyon, France
| | | | - Vanessa Smith
- Dept of Rheumatology, Ghent University Hospital Dept of Internal Medicine, Ghent, Belgium
| | - Simon L F Walsh
- National Heart and Lung Institute, Imperial College London, London, UK
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Kishaba T. Current perspective of progressive-fibrosing interstitial lung disease. Respir Investig 2022; 60:503-509. [PMID: 35431170 DOI: 10.1016/j.resinv.2022.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 06/14/2023]
Abstract
Interstitial lung disease (ILD) is a parenchymal lung disease and restrictive disorder that presents as diffuse infiltrative shadows. The initial diagnosis of ILD is important because management strategies depend on the disease pathogenesis. Connective-tissue disease (CTD)-associated ILD including rheumatoid arthritis (RA), systemic sclerosis (SSc) requires a thorough evaluation of chronic respiratory symptoms such as non-productive cough and exertional dyspnea, as well as physical findings. Moreover, myeloperoxidase-positive anti-neutrophilic cytoplasmic antibody (MPO-ANCA)-associated vasculitis with ILD also shows disease progression. In CTD-associated ILD, the first-line treatment is anti-inflammatory drugs such as prednisolone or immunosuppressants. In hypersensitivity pneumonitis (HP), detailed environmental history-taking is crucial. Therefore, systematic standardized questionnaires are needed. However, the causative antigens are often not identified in daily clinical practice. When an antigen is identified or suspected, the first action is avoidance. If antigen avoidance does not contribute to clinical improvement, anti-inflammatory drugs such as prednisolone might be introduced. Regarding sarcoidosis, while most patients do not require treatment for lung involvement, some need anti-inflammatory drugs or immunosuppressants. Additionally, steroid treatment should be considered for the critical status of extrapulmonary sarcoidosis including cardiac, neurogenic and ocular sarcoidosis. Once starting treatment for ILD, multi-dimensional approaches are applied, including symptom tracking, chest imaging, pulmonary function test (PFT), and 6-min walking test. Recently, the concept of progressive-fibrosing interstitial lung disease (PF-ILD) has been proposed as a new disease entity. The definition of PF-ILD includes symptom progression, PFT decline, and extension of chest high-resolution computed tomography (HRCT) findings. This mini-review describes the background, definition, clinical characteristics, management, and challenges of PF-ILD.
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Affiliation(s)
- Tomoo Kishaba
- Department of Respiratory Medicine, Okinawa Chubu Hospital, Miyazato 281, Uruma City, Okinawa 〒904-2293, Japan.
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Todd NW, Atamas SP, Hines SE, Luzina IG, Shah NG, Britt EJ, Ghio AJ, Galvin JR. Demystifying idiopathic interstitial pneumonia: time for more etiology-focused nomenclature in interstitial lung disease. Expert Rev Respir Med 2022; 16:235-245. [PMID: 35034567 PMCID: PMC8983480 DOI: 10.1080/17476348.2022.2030710] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION A major focus of interstitial lung disease (ILD) has centered on disorders termed idiopathic interstitial pneumonias (IIPs) which include, among others, idiopathic pulmonary fibrosis, idiopathic nonspecific interstitial pneumonia, cryptogenic organizing pneumonia, and respiratory bronchiolitis-interstitial lung disease. AREAS COVERED We review the radiologic and histologic patterns for the nine disorders classified by multidisciplinary approach as IIP, and describe the remarkable amount of published epidemiologic, translational, and molecular studies demonstrating their associations with numerous yet definitive environmental exposures, occupational exposures, pulmonary diseases, systemic diseases, medication toxicities, and genetic variants. EXPERT OPINION In the 21st century, these disorders termed IIPs are rarely idiopathic, but rather are well-described radiologic and histologic patterns of lung injury that are associated with a wide array of diverse etiologies. Accordingly, the idiopathic nomenclature is misleading and confusing, and may also promote a lack of inquisitiveness, suggesting the end rather than the beginning of a thorough diagnostic process to identify ILD etiology and initiate patient-centered management. A shift toward more etiology-focused nomenclature will be beneficial to all, including patients hoping for better life quality and disease outcome, general medicine and pulmonary physicians furthering their ILD knowledge, and expert ILD clinicians and researchers who are advancing the ILD field.
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Affiliation(s)
- Nevins W. Todd
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA,,Baltimore Veterans Affairs Medical Center, Baltimore, Maryland, USA
| | - Sergei P. Atamas
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA,,Baltimore Veterans Affairs Medical Center, Baltimore, Maryland, USA
| | - Stella E. Hines
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Irina G. Luzina
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA,,Baltimore Veterans Affairs Medical Center, Baltimore, Maryland, USA
| | - Nirav G. Shah
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Edward J. Britt
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Andrew J. Ghio
- Environmental Protection Agency, Research Triangle Park, North Carolina, USA
| | - Jeffrey R. Galvin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA,,Department of Diagnostic Radiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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