[German guideline for diagnosis and management of idiopathic pulmonary fibrosis]

Epidemiology, healthcare utilization, and related costs among patients with IPF: results from a German claims database analysis

Background

Idiopathic pulmonary fibrosis (IPF) is a progressive form of fibrosing interstitial pneumonia with poor survival. This study provides insight into the epidemiology, cost, and disease course of IPF in Germany.

Methods

A cohort of incident patients with IPF (n = 1737) was identified from German claims data (2014–2019). Incidence and prevalence rates were calculated and adjusted for age differences compared with the overall German population. All-cause and IPF-related healthcare resource utilization as well as associated costs were evaluated per observed person-year (PY) following the initial IPF diagnosis. Finally, Kaplan–Meier analyses were performed to assess time from initial diagnosis to disease deterioration (using three proxy measures: non-elective hospitalization, IPF-related hospitalization, long-term oxygen therapy [LTOT]); antifibrotic therapy initiation; and all-cause death.

Results

The cumulative incidence of IPF was estimated at 10.7 per 100,000 individuals in 2016, 10.9 in 2017, 10.5 in 2018, and 9.6 in 2019. The point prevalence rates per 100,000 individuals for the respective years were 21.7, 23.5, 24.1, and 24.1. On average, ≥ 14 physician visits and nearly two hospitalizations per PY were observed after the initial IPF diagnosis. Of total all-cause direct costs (€15,721/PY), 55.7% (€8754/PY) were due to hospitalizations and 29.1% (€4572/PY) were due to medication. Medication accounted for 49.4% (€1470/PY) and hospitalizations for 34.8% (€1034/PY) of total IPF-related direct costs (€2973/PY). Within 2 years of the initial IPF diagnosis (23.6 months), 25% of patients died. Within 5 years of diagnosis, 53.1% of patients had initiated LTOT; only 11.6% were treated with antifibrotic agents. The median time from the initial diagnosis to the first non-elective hospitalization was 5.5 months.

Conclusion

The incidence and prevalence of IPF in Germany are at the higher end of the range reported in the literature. The main driver for all-cause cost was hospitalization. IPF-related costs were mainly driven by medication, with antifibrotic agents accounting for around one-third of the total medication costs even if not frequently prescribed. Most patients with IPF do not receive pharmacological treatment, highlighting the existing unmet medical need for effective and well-tolerated therapies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-01976-0.

Value of Cardiopulmonary Exercise Testing in Prognostic Assessment of Patients with Interstitial Lung Diseases

BACKGROUND

Interstitial lung disease (ILD) is associated with high rates of comorbidities and non-infectious lung disease mortality. Against this background, we aimed to evaluate the prognostic capacity of lung function and cardiopulmonary exercise testing (CPET) in patients with ILD.

MATERIALS AND METHODS

A total of 183 patients with diverse ILD entities were included in this monocentric analysis. Prediction models were determined using Cox regression models with age, sex, body mass index (BMI), and all parameters from pulmonary function testing and CPET. Kaplan-Meier curves were plotted for selected variables.

RESULTS

The median follow-up period was 3.0 ± 2.5 years. Arterial hypertension (57%) and pulmonary hypertension (38%) were the leading comorbidities. The Charlson comorbidity index score was 2 ± 2 points. The 3-year and 5-year survival rates were 68% and 50%, respectively. VO₂peak (mL/kg/min or %pred.) was identified as a significant prognostic parameter in patients with ILD. The cut-off value for discriminating mortality was 61%.

CONCLUSION

The present analyses consistently revealed the high prognostic power of VO₂peak %pred. and other parameters evaluating breathing efficacy (VÉ/VCO₂ @AT und VÉ/VCO₂ slope) in ILD patients. VO₂peak %pred., in contrast to the established prognostic values FVC %pred., DLCO/KCO %pred., and GAP, showed an even higher prognostic ability in all statistical models.

An adaptation strategy to urban heat: hospital rooms with radiant cooling accelerate patient recovery

Background

Patients with respiratory diseases are vulnerable to the effects of heat. Therefore, it is important to develop adaptation strategies for heat exposure. One option is to optimise the indoor environment. To this end, we equipped hospital patient rooms with radiant cooling. We performed a prospective randomised clinical trial to investigate potentially beneficial effects of the hospitalisation in rooms with radiant cooling on patients with a respiratory disease exacerbation.

Methods

Recruitment took place in June, July and August 2014 to 2016 in the Charité – Universitätsmedizin Berlin, Germany. We included patients with COPD, asthma, pulmonary hypertension, interstitial lung disease and pneumonia. 62 patients were allocated to either a standard patient room without air conditioning or a room with radiant cooling set to 23°C (73°F). We analysed the patients’ length of stay with a Poisson regression. Physiological parameters, fluid intake and daily step counts were tested with mixed regression models.

Results

Patients hospitalised in a room with radiant cooling were discharged earlier than patients in standard rooms (p=0.003). The study participants in chambers with radiant cooling had a lower body temperature (p=0.002), lower daily fluid intake (p<0.001), higher systolic blood pressure (p<0.001) and an increased daily step count (p<0.001).

Conclusion

The results indicate that a radiant cooling system in hospital patient rooms provides clinical benefits for patients with respiratory disease exacerbations during the warm summer months, which may contribute to an earlier mobilisation. Radiant cooling is commended as a suitable adaptation strategy to reduce the clinical impact of climate warming.

A radiant cooling system in hospital patient rooms provides clinical benefits for patients with respiratory disease exacerbations during summertime. Patients hospitalised in rooms with air convection free radiant cooling are discharged earlier.https://bit.ly/3p9Fkqm

S2K Guideline for Diagnosis of Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a severe and often fatal disease. Diagnosis of IPF requires considerable expertise and experience. Since the publication of the international IPF guideline in the year 2011 and the update 2018 several studies and technical advances have occurred, which made a new assessment of the diagnostic process mandatory. The goal of this guideline is to foster early, confident, and effective diagnosis of IPF. The guideline focusses on the typical clinical context of an IPF patient and provides tools to exclude known causes of interstitial lung disease including standardized questionnaires, serologic testing, and cellular analysis of bronchoalveolar lavage. High-resolution computed tomography remains crucial in the diagnostic workup. If it is necessary to obtain specimens for histology, transbronchial lung cryobiopsy is the primary approach, while surgical lung biopsy is reserved for patients who are fit for it and in whom a bronchoscopic diagnosis did not provide the information needed. After all, IPF is a diagnosis of exclusion and multidisciplinary discussion remains the golden standard of diagnosis.

[The updated S2k guideline for the diagnosis of idiopathic pulmonary fibrosis : Essential aspects for pathology]

Idiopathic pulmonary fibrosis (IPF) is a specific form of chronic progressive fibrosing nonreversible interstitial lung disease of largely unknown origin. In high-resolution computer tomography (HRCT) and histopathology it presents with a UIP pattern. To diagnose IPF, (i) an ILD of known origin must be excluded (e.g., hypersensitivity pneumonitis, lung involvement in autoimmune or other systemic disease, and drug-induced ILD) and either (ii) the presence of a UIP pattern in HRCT or (iii) specific combinations of HRCT and histopathology is necessary. The diagnosis of IPF requires interdisciplinary collaboration and a structured procedure. The updated S2k guideline focuses on the IPF diagnostic process and describes the criteria of a UIP pattern in HRCT and histopathology that are differentiated into the categories "UIP pattern," "probable UIP pattern," "indetermined for UIP," and "alternative pattern." Depending on the anamnestic, clinical and serologic findings, HRCT, and - if acquired - histomorphology features, an algorithm to diagnose the IPF is recommended. If a UIP pattern in HRCT is present, IPF can still be diagnosed without further bioptic examination. Additionally, recommendations for the use of surgical lung biopsy (SLB), transbronchial lung biopsy, and the relatively new transbronchial lung cryobiopsy (TBLC) procedure are provided. In contrast to the international guideline, the S2k guideline group evaluated TBLC based on recent studies to be advantageous compared to the SLB, as the diagnostic value and the side-effect rate was assessed to be acceptable and more patients with progressed ILD can be biopsied by TBLC. It is therefore expected that by using TBLC the rate of unclassifiable ILDs can be reduced.

[Day/Night Variability of Coughing Events in Interstitial Lung Disease]

INTRODUCTION

 Besides dyspnea a dry cough is one of the main symptoms in patients with pulmonary fibrosis. Little is known about the 24-hour-variability of this symptom. Moreover, it is unclear if other auscultation phenomena occur.

METHODS

 A long-term auscultation for 24-hours was performed in patients with fibrotic lung diseases (LEOSound, Löwenstein Medical GmbH & Co. KG, Medical-Electronics, Bad Ems, Germany). Coughing and wheezing sounds were recorded. For the following analysis the 24-hour period was divided into two intervals of 12 hours each (daytime and nighttime). Events were registered in epochs (at least one event in 30 seconds).

RESULTS

 20 patients were included (6 with nonspecific interstitial pneumonia and 14 with idiopathic pulmonary fibrosis). On average 166 coughing epochs were recorded in a 24-hour-period (day/night 116/50; P < 0.001). Moreover, 203 wheezing epochs were registered (day/night 84/119; P = 0.273). Auscultation phenomena did not correlate with spirometric and bodyplethymographic data, nor with data of diffusion capacity.

DISCUSSION

 The study is showing the clinical potential of long-term auscultation in patients with fibrotic lung diseases. Especially the findings concerning the coughing symptoms were remarkable. It could be shown that there was a decrease of coughing during nighttime in comparison to daytime. In contrast to this, wheezing sounds were increasing at nighttime. The clinical relevance of this finding is yet to be assessed. Finally, there was no correlation between the severity of the disease measured by functional diagnostics and the amount of coughing.

[Treatment of complications and nonpharmacological management of idiopathic pulmonary fibrosis]

Komplikationen der idiopathischen pulmonalen Fibrose (IPF) sind für einen relevanten Mortalitätsanteil verantwortlich. Als wichtigstes Beispiel ist diesbezüglich die akute Exazerbation anzuführen, deren Krankenhausletalität über 50 % beträgt bei einem mittleren Überleben von nur wenigen Monaten. Somit kommt der Betrachtung von Komplikationen eine große Bedeutung für Krankheitsverständnis sowie Therapieplanung zu. Des Weiteren ist in den letzten Jahren die Evidenz für pneumologische Rehabilitation bei IPF deutlich gestiegen und wird von der Amerikanischen und Europäischen Gesellschaft für Pneumologie (American Thoracic Society [ATS]/European Respiratory Society [ERS]) zur Verbesserung der körperlichen Leistungsfähigkeit, Lebensqualität und der Symptome empfohlen.

[What rheumatologists can learn from pneumologists]

BACKGROUND

Pulmonary involvement in patients with underlying autoimmune diseases poses a major diagnostic and therapeutic challenge to the treating physician. Due to the associated increased mortality risk, early diagnosis is crucial.

OBJECTIVE

The incidence and mortality rate of connective tissue disease-related interstitial lung diseases (CTD-ILD) and pulmonary hypertension (PH) were evaluated in patients with rheumatic disease including clinical aspects, diagnostic procedure, prognosis and treatment recommendations.

MATERIAL AND METHODS

An analysis of remarkable publications was carried out and guidelines are presented.

RESULTS

The CTD-ILD and PH are frequent comorbidities with significantly increased mortality risk, especially in patients with systemic sclerosis (SSc). In primary fibrotic and non-inflammatory CTD-ILD, as occurs especially in patients with rheumatoid arthritis, immunosuppressive therapy is only partially effective. Currently, in some eligible patients only lung transplantation remains as a definitive therapy.

CONCLUSION

The diagnostics and treatment of CTD-ILD and PH in patients with an underlying autoimmune disease requires an interdisciplinary approach. The effectiveness of antifibrotic treatment needs to be evaluated in the future.

Clinical characteristics of patients with familial idiopathic pulmonary fibrosis (f-IPF)

Background

The aim of this study was to analyze the relative frequency, clinical characteristics, disease onset and progression in f-IPF vs. sporadic IPF (s-IPF).

Methods

Familial IPF index patients and their family members were recruited into the European IPF registry/biobank (eurIPFreg) at the Universities of Giessen and Marburg (UGMLC). Initially, we employed wide range criteria of f-IPF (e.g. relatives who presumably died of some kind of parenchymal lung disease). After narrowing down the search to occurrence of idiopathic interstitial pneumonia (IIP) in at least one first grade relative, 28 index patients were finally identified, prospectively interviewed and examined. Their family members were phenotyped with establishment of pedigree charts.

Results

Within the 28 IPF families, overall 79 patients with f-IPF were identified. In the same observation period, 286 f-IIP and s-IIP patients were recruited into the eurIPFreg at our UGMLC sites, corresponding to a familial versus s-IPF of 9.8%. The both groups showed no difference in demographics (61 vs. 79% males), smoking history, and exposure to any environmental triggers known to cause lung fibrosis. The f-IPF group differed by an earlier age at the onset of the disease (55.4 vs. 63.2 years; p < 0.001). On average, the f-IPF patients presented a significantly milder extent of functional impairment at the time point of inclusion vs. the s-IPF group (FVC 75% pred. vs. FVC 62% pred., p = 0.011). In contrast, the decline in FVC was found to be faster in the f-IPF vs. the s-IPF group (4.94% decline in 6 months in f-IPF vs. 2.48% in s-IPF, p = 0.12). The average age of death in f-IPF group was 67 years vs. 71.8 years in s-IPF group (p = 0.059). The f-IIP group displayed diverse inheritance patterns, mostly autosomal-dominant with variable penetrance. In the f-IPF, the younger generations showed a tendency for earlier manifestation of IPF vs. the older generation (58 vs. 66 years, p = 0.013).

Conclusions

The 28 f-IPF index patients presented an earlier onset and more aggressive natural course of the disease. The disease seems to affect consecutive generations at a younger age.

Trial registration

Nr. NCT02951416http://www.www.clinicaltrials.gov

Psychometric properties and minimal important differences of SF-36 in Idiopathic Pulmonary Fibrosis

Background

Idiopathic pulmonary fibrosis (IPF) is a rare disease with a median survival of 3–5 years after diagnosis with limited treatment options. The aim of this study is to assess the psychometric characteristics of the Short Form 36 Health Status Questionnaire (SF-36) in IPF and to provide disease specific minimally important differences (MID).

Methods

Data source was the European IPF Registry (eurIPFreg). The psychometric properties of the SF-36 version 2 were evaluated based on objective clinical measures as well as subjective perception. We analysed acceptance, feasibility, discrimination ability, construct and criterion validity, responsiveness and test-retest-reliability. MIDs were estimated via distribution and anchor-based approaches.

Results

The study population included 258 individuals (73.3% male; mean age 67.3 years, SD 10.7). Of them 75.2% (194 individuals) had no missing item. The distribution of several items was skewed, although floor effect was acceptable. Physical component score (PCS) correlated significantly and moderately with several anchors, whereas the correlations of mental component score (MCS) and anchors were only small. The tests showed mainly significant lower HRQL in individuals with long-term oxygen therapy. Analyses in stable individuals did not show significant changes of HRQL except for one dimension and anchor. Individuals with relevant changes of the health status based on the anchors had significant changes in all SF-36 dimensions and summary scales except for the dimension PAIN. PCS and MCS had mean MIDs of five and six, respectively. Mean MIDs of the dimensions ranged from seven to 21.

Conclusion

It seems that the SF-36 is a valid instrument to measure HRQL in IPF and so can be used in RCTs or individual monitoring of disease. Nevertheless, the additional evaluation of longitudinal aspects and MIDs can be recommended to further analyse these factors. Our findings have a great potential impact on the evaluation of IPF patients.

Trial registration

The eurIPFreg and eurIPFbank are listed in https://clinicaltrials.gov (NCT02951416).

Electronic supplementary material

The online version of this article (10.1186/s12931-019-1010-5) contains supplementary material, which is available to authorized users.

The European IPF registry (eurIPFreg): baseline characteristics and survival of patients with idiopathic pulmonary fibrosis

BACKGROUND

Since 2009, IPF patients across Europe are recruited into the eurIPFreg, providing epidemiological data and biomaterials for translational research.

METHODS

The registry data are based on patient and physician baseline and follow-up questionnaires, comprising 1700 parameters. The mid- to long-term objectives of the registry are to provide clues for a better understanding of IPF phenotype sub-clusters, triggering factors and aggravating conditions, regional and environmental characteristics, and of disease behavior and management.

RESULTS

This paper describes baseline data of 525 IPF subjects recruited from 11/2009 until 10/2016. IPF patients had a mean age of 68.1 years, and seeked medical advice due to insidious dyspnea (90.1%), fatigue (69.2%), and dry coughing (53.2%). A surgical lung biopsy was performed in 32% in 2009, but in only 8% of the cases in 2016, possibly due to increased numbers of cryobiopsy. At the time of inclusion in the eurIPFreg, FVC was 68.4% ± 22.6% of predicted value, DLco ranged at 42.1% ± 17.8% of predicted value (mean value ± SD). Signs of pulmonary hypertension were found in 16.8%. Steroids, immunosuppressants and N-Acetylcysteine declined since 2009, and were replaced by antifibrotics, under which patients showed improved survival (p = 0.001).

CONCLUSIONS

Our data provide important insights into baseline characteristics, diagnostic and management changes as well as outcome data in European IPF patients over time.

TRIAL REGISTRATION

The eurIPFreg and eurIPFbank are listed in ClinicalTrials.gov( NCT02951416 ).

Idiopathic Pulmonary Fibrosis Among Young Patients: Challenges in Diagnosis and Management

INTRODUCTION

Idiopathic pulmonary fibrosis (IPF) is considered a disease of older patients, being rare in patients ≤ 50 years. Still, IPF can occur in younger patients, but this particular patient group is not well characterised so far. The aim of this study was to compare the diagnostic certainty, clinical features, comorbidities and survival in young versus older IPF patients.

METHODS

We reviewed our medical records from February 2011 until February 2015, to identify IPF patients, who were then classified as young (≤ 50 years) or older IPF (> 50 years). Radiographic and histological findings, lung function parameters, comorbidities, disease progression and survival were analysed and compared between the two groups.

RESULTS

Of 440 patients with interstitial lung disease, 129 patients with IPF were identified, including 30 (23.3%) ≤50 years and 99 (76.7%) > 50 years. There were no differences between age groups in baseline demographics; younger patients were less likely to have a confirmed diagnosis by high-resolution computed tomography (p = 0.014), more likely to require a biopsy (p = 0.08) and less likely to have received antifibrotic therapy (p = 0.006). Despite an overall limited prognosis, younger patients had a significantly better median survival after diagnosis (p = 0.0375), with a significantly higher proportion of older patients dying due to respiratory failure (p = 0.0383).

CONCLUSION

IPF patients under the age of 50 years have similar features and clinical course compared to older IPF patients. These patients should be diagnosed by adopting a multidisciplinary team approach, potentially benefitting from earlier intervention with effective antifibrotic therapy.

Real-World Experience with Nintedanib in Patients with Idiopathic Pulmonary Fibrosis

BACKGROUND

Nintedanib, an oral tyrosine kinase inhibitor, has been shown to slow down the progression of idiopathic pulmonary fibrosis (IPF) in two randomised placebo-controlled trials by reducing the annual decline in forced vital capacity (FVC). However, real-world experience is limited.

OBJECTIVE

To assess the efficacy and safety of nintedanib in a large cohort of patients treated at a tertiary referral site for interstitial lung diseases.

METHODS

The records of patients with a confirmed diagnosis of IPF were reviewed. Full medical history, pulmonary function, and adverse events (AEs) were recorded from each clinic visit. Disease progression was defined as a reduction in FVC ≥5% and/or in diffusing capacity of the lung for carbon monoxide ≥15% according to recent publications. Only patients with a treatment duration ≥3 months were included in the efficacy evaluation.

RESULTS

A total of 64 patients were treated. Mean ± standard deviation (SD) FVC was 71 ± 21% predicted, and the mean time from diagnosis to initiation of nintedanib treatment was 23.8 months. Nearly half of patients (n = 30, 47%) had received prior pirfenidone treatment. The mean duration of follow-up was 11 months. At 6 months following initiation of nintedanib, 67% of the patients were stable. The mean ± SD change in percent predicted FVC from baseline was 0.2 ± 7.8% at 3 months, -1.3 ± 7.9% at 6 months, and -2.1 ± 9% at 9 months. Diarrhoea was the most common AE experienced by 33% of patients and was generally manageable.

CONCLUSION

The results from this real-world clinical setting support findings from previously conducted clinical trials and show that nintedanib is effective for the management of IPF and is associated with disease stabilisation. Nintedanib is generally well tolerated.

[Interstitial lung disease - what the gereneral practitioner should know]

Kurzatmigkeit, Atemnot, trockener Husten — bei diesen Symptomen sollten Sie auch eine interstitielle Lungenerkrankung in Betracht ziehen und abklären. Dies gilt insbesondere, wenn bei der Auskultation beidseitig basal Knisterrasseln zu hören ist.

The Differential Diagnosis of Dyspnea

BACKGROUND

Dyspnea is a common symptom affecting as many as 25% of patients seen in the ambulatory setting. It can arise from many different underlying conditions and is sometimes a manifestation of a life-threatening disease.

METHODS

This review is based on pertinent articles retrieved by a selective search in PubMed, and on pertinent guidelines.

RESULTS

The term dyspnea refers to a wide variety of subjective perceptions, some of which can be influenced by the patient's emotional state. A distinction is drawn between dyspnea of acute onset and chronic dyspnea: the latter, by definition, has been present for more than four weeks. The history, physical examination, and observation of the patient's breathing pattern often lead to the correct diagnosis, yet, in 30-50% of cases, more diagnostic studies are needed, including biomarker measurements and other ancillary tests. The diagnosis can be more difficult to establish when more than one underlying disease is present simultaneously. The causes of dyspnea include cardiac and pulmonary disease (congestive heart failure, acute coronary syndrome; pneumonia, chronic obstructive pulmonary disease) and many other conditions (anemia, mental disorders).

CONCLUSION

The many causes of dyspnea make it a diagnostic challenge. Its rapid evaluation and diagnosis are crucial for reducing mortality and the burden of disease.

Relationship between functional endoscopy and impedance-pH measurement

Classic gastroenterological diagnostic tools have proven to be insufficient in identifying the causal relationship between extra-esophageal symptoms and presumed pathological reflux activity. Some new methodological approaches, such as functional endoscopy (video panendoscopy, VPE), are considered to be helpful. However, there are currently no data objectively verifying the success of this method. In a previous study, we found a good correlation between the reflux symptom index (RSI) according to Belafsky and endoscopic findings. Impedance-pH measurement is considered to be the gold standard in esophageal reflux disease diagnostics. Therefore, the relationship between endoscopic findings and the results of impedance-pH monitoring is now studied in patients with extra-esophageal reflux symptoms. The pathological findings of the VPE correlate with impedance-pH measurements regarding the parameters "number of reflux episodes," "fraction time," and "DeMeester score."

[Relationship between functional endoscopy and impedance-pH measurement. German version]

Classic gastroenterological diagnostic tools are proving increasingly insufficient for analyzing the complex causal relationship between extra-esophageal symptoms and presumed pathological reflux activity. Some new methodological approaches, such as functional endoscopy (videopanendoscopy, VPE), are considered to be helpful. However, there are currently no data objectively verifying the usefulness of this method. In a pilot study, a good correlation between the reflux symptom index (RSI) and endoscopic findings was shown. Impedance-pH measurement is considered to be the "gold standard" in esophageal reflux disease diagnostics. Therefore, the relationship between endoscopic findings and the results of impedance-pH monitoring are now studied in patients with extra-esophageal reflux symptoms. The investigation demonstrates that the pathological findings of VPE correlate well with impedance-pH measurements in terms of the parameters "number of reflux episodes", "fraction time", and "DeMeester score".

Krankheitsbilder

Das Spektrum der pneumologischen Krankheitsbilder ist groß und oft fächerübergreifend. Neben den häufigsten Erkrankungen wie COPD, Asthma bronchiale oder Tumoren des Thorax werden hier weitere häufige und seltene Erkrankungen dargestellt, die im Alltag das Bild einer pneumologischen Station prägen. Die führende Symptomatik, der diagnostische Weg und auch therapeutische Vorgehensweisen werden verständlich erörtert, um so den Umgang mit pneumologischen Erkrankungsbildern zu erleichtern.

[Dyspnea in airway and pulmonary diseases]

The subjective perception of pulmonary dyspnea varies based on behavioral and physiological responses. Acute pulmonary dyspnea is the most common symptom of diseases of the airways and the lungs and the differential diagnosis includes harmless causes, such as lack of training as well as acute life-threatening diseases, such as thromboembolism, obstruction of the upper or lower airway, pneumonia, pulmonary hemorrhage and pneumothorax. Most cases of chronic pulmonary dyspnea result from asthma, chronic obstructive pulmonary disease (COPD), pulmonary arterial hypertension, pulmonary fibrosis and pleural disorders. Listening to the patient's "language of dyspnea" may already provide indications for the diagnosis. Initial testing includes chest radiography, spirometry, complete blood count and the basic metabolic panel. Measurement of brain natriuretic peptide levels may help to exclude heart failure in COPD and D-dimer testing may help rule out pulmonary embolisms. Computed tomography of the chest is the most appropriate imaging procedure for diagnosing pulmonary embolism and interstitial lung disease. To diagnose pulmonary arterial hypertension echocardiography and right heart catheterization may be necessary.

Smoking-related interstitial lung disease

BACKGROUND

Smoking-related interstitial lung diseases (SR-ILDs) are a heterogeneous group of diseases with major clinical significance. Reliable epidemiological data are not yet available.

METHOD

Review of pertinent literature retrieved by a selective search in PubMed.

RESULTS

The available data on many aspects of SR-ILDs are sparse, but recent studies on the pathophysiology and targeted treatment of these conditions have revealed ways in which clinical outcomes can be improved. Highresolution computerized tomography should be used for differential diagnosis; lung biopsy is often unnecessary. Oncogenic mutations play a role in the pathogenesis of pulmonary Langerhans-cell histiocytosis (PLCH). In the future, cladribine and vemurafenib may be treatment options for PLCH. Desquamative interstitial pneumonia (DIP) may be difficult to distinguish from respiratorybronchiolitis-associated interstitial lung disease (RB-ILD); DIP is treated with steroids and sometimes with immune suppressants. In idiopathic pulmonary fibrosis (IPF), the antifibrotic drugs pirfenidone and nintedanib can delay disease progression. Smoking is also a risk factor for combined pulmonary fibrosis and emphysema (CPFE), rheumatoid-arthritis-associated interstitial lung disease (RA-ILD), pulmonary alveolar proteinosis (PAP), acute eosinophilic pneumonia (AEP), and diffuse alveolar hemorrhage (DAH) in Goodpasture syndrome.

CONCLUSION

In smokers with exertional dyspnea and/or a nonproductive cough, SR-ILDs must be considered in the differential diagnosis. If an SR-ILD is suspected, the patient should be referred to a pulmonary specialist. Early treatment and smoking cessation can improve clinical outcomes, particularly in the acute and chronically progressive types of SR-ILD.

Qualitative European survey of patients with idiopathic pulmonary fibrosis: patients' perspectives of the disease and treatment

Background

‘Living with IPF and an exploration of Esbriet® – a new treatment’ was an exploratory, qualitative, real-world survey of European patients with idiopathic pulmonary fibrosis (IPF) who were receiving treatment with pirfenidone prior to its commercial availability. The aim of the survey was to probe the impact of IPF on patients’ quality of life; the role of healthcare professionals and caregivers; the information needs of both patients and their caregivers; and patients’ perceptions of pirfenidone as a new treatment option for IPF.

Methods

Patients from the UK, Germany and Italy, with a diagnosis of IPF (duration >3 months), who were being treated with pirfenidone, were recruited from patient support groups, specialist centres and advocacy groups. Semi-structured, qualitative, in-depth patient interviews of 1-h duration were conducted by an independent researcher. Patients were initially asked about their experiences of living with IPF and then prompted to describe their experiences of taking pirfenidone. Techniques utilised included: the bubble-speech technique; the icon cards projective exercise; and the free association exercise. All interviews were transcribed and analysed by an independent researcher.

Results

Forty-five patients (71 % male) were interviewed (mean age 68.5 years; mean time since diagnosis 3.5 years); 87 % of patients reported that diagnosis took >1 year. Patients reported that IPF had a significant physical and emotional impact on their quality of life. The beneficial role played by caregivers and interstitial lung disease specialist nurses (where available) was specifically highlighted. Although most patients were keen for information on IPF, this was often of poor quality, out of date, or in English only. Patients’ perceptions of pirfenidone were largely positive and associated with ‘hope’ but were also influenced by the level of side effects experienced.

Conclusions

This survey highlights the impact of IPF on patients’ lives, and the need to adequately support both patients and their caregivers. These findings demonstrate the value of seeking patients’ perspectives of a chronic disease such as IPF and how this information can be used to guide improvements in care, to best support the needs of patients with this devastating condition.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0171-y) contains supplementary material, which is available to authorized users.

Management of patients with idiopathic pulmonary fibrosis in clinical practice: the INSIGHTS-IPF registry

After introduction of the new international guidelines on idiopathic pulmonary fibrosis (IPF) in 2011, we investigated clinical management practices for patients with IPF according to physicians' diagnoses. A prospective, multicenter, noninterventional study with comprehensive quality measures including on-site source data verification was performed in Germany. 502 consecutive patients (171 newly diagnosed, 331 prevalent; mean±SD age 68.7±9.4 years, 77.9% males) with a mean disease duration of 2.3±3.5 years were enrolled. IPF diagnosis was based on clinical assessments and high-resolution computed tomography (HRCT) in 90.2%, and on surgical lung biopsy combined with histology in 34.1% (lavage in 61.8%). The median 6-min walk distance was 320 m (mean 268±200 m). The mean forced vital capacity was 72±20% pred and diffusing capacity of the lung for carbon monoxide was 35±15% pred. No drugs were administered in 17.9%, oral steroids in 23.7%, N-acetylcysteine in 33.7%, pirfenidone in 44.2% and other drugs in 4.6% of patients. Only 2.8% of the cohort was listed for lung transplantation. IPF patients were diagnosed in line with the new guidelines. They had more severe disease than those enrolled in recent randomised controlled trials. In addition to HRCT, the frequency of lung biopsies was surprisingly high. Treatment patterns varied substantially.

The diagnosis and treatment of idiopathic pulmonary fibrosis

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is the most common idiopathic interstitial disease of the lung and has the worst prognosis of all such diseases, with a median survival time of three to four years. Its prevalence is 2-29 per 100,000 persons and its incidence approximately 10 per 100,000 persons per year, with an upward trend.

METHOD

Selective literature search in the EMBASE and PubMed databases for pertinent publications from 1996 to 2012, with special attention to randomized controlled trials.

RESULTS

IPF manifests itself clinically with exertional dyspnea, dry cough, and inspiratory crepitations (sclerosiphonia). The diagnosis is confirmed by the demonstration of a usual interstitial pneumonia (UIP) pattern in a high-resolution thin-slice CT (HRCT) of the lungs, or else histologically by lung biopsy, along with the exclusion of other causes such as asbestosis or connective tissue disease. In 15 randomized controlled therapeutic trials carried out since 2004, most of the drugs that were tested, including immune suppressants, were found to be ineffective against IPF or even harmful. Only pirfenidone lessens the annual reduction of pulmonary volume (FVC, forced expiratory vital capacity) and of the distance walked in 6 minutes by about 30%, with corresponding improvement of progression-free survival, but without any significant lessening of overall mortality (placebo, 10%; pirfenidone, 8%). Pirfenidone also commonly causes gastrointestinal and cutaneous side effects. The efficacy of N-acetyldysteine and nintedanib has not yet been definitively demonstrated. Lung transplantation is the only current treatment that enables long-term survival.

CONCLUSION

IPF has a worse prognosis than many types of cancer. Drugs can delay the progression of the disease but probably cannot bring it to a permanent standstill.

[Update: standardized CT/HRCT classification of occupational and environmental thoracic diseases in Germany]

The high-resolution computed tomography (HRCT) coding scheme of the international classification of occupational and environmental respiratory diseases (ICOERD) presented here is an instrument for a standardized semiquantitative description of occupation and environment-linked as well as other pulmonary and pleural diseases. Analogous to the International Labour Organization (ILO) classification, the ICOERD coding scheme should always be used when the CT/HRCT examination is employed for occupational medical investigations or expert opinions. After publication of the guidelines and recommendations on diagnostics and expert assessment of asbestos-linked diseases and silicosis, the application of a standardized investigation program and assessment with the ICOERD classification form are obligatory, at least for the initial assessment. Furthermore, its use in the field of follow-up assessments of occupational diseases should be encouraged in order to guarantee comparability between individual reports (interreader variability) and at least a semiquantitative assessment of disease progression in isolated cases. Because the anatomical structures in projection radiography and CT are not presented identically, a 1:1 transfer of the results of the ILO classification to the CT/HRCT coding scheme is not possible. An overview image of the thorax does not allow overlap-free reproduction of structures, in contrast to CT. These methodological differences can in cases of isolated assessment result in different opinions of projection and CT images mostly by different investigators. In cases of discrepant opinions an integrated report of findings by combination of all information from both procedures is necessary.

[Update pulmonary pathology : Report of the Pulmonary Pathology Working Group of the German Society of Pathology]

The Pulmonary Pathology Working Group of the German Society of Pathology (Deutsche Gesellschaft für Pathologie DGP) can look back on an eventful year. Apart from the autumn meeting in Bremen in November 2012 and the sessions at the annual DGP congress in Heidelberg in May 2013, several articles dealing with the classification of pulmonary carcinoids as well as predictive analyses of cytological specimens and small biopsies of non-small cell lung cancer (NSCLC) could be published with support and co-authorship of a large number of members of the working group. In this report, the key aspects of the last year's activities of the working group are summarized, including molecular diagnosis of lung tumors, NSCLC classification, neuroendocrine tumors, TNM and R classification, interstitial lung diseases, pneumoconioses, and pleural mesothelioma.

Radiological diagnosis in lung disease: factoring treatment options into the choice of diagnostic modality

BACKGROUND

Chest X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) each have characteristic advantages and disadvantages that need to be considered in clinical decision-making. This point is discussed in reference to the main types of lung disease that are encountered in practice.

METHOD

A selective literature search was performed in the PubMed and Google Scholar databases. Existing clinical guidelines on the main types of lung disease and studies concerning radiological diagnosis were also con - sidered in this review.

RESULTS

There have been no more than a few large-scale, controlled comparative trials of different radiological techniques. Chest X-ray provides general orientation as an initial diagnostic study and is especially useful in the diagnosis of pneumonia, cancer, and chronic obstructive pulmonary disease (COPD). Multi-detector CT affords nearly isotropic spatial resolution at a radiation dose of only 0.2-5 mSv, much lower than before. Its main indications, according to current guidelines, are tumors, acute pulmonary embolism, pulmonary hypertension, pulmonary fibrosis, advanced COPD, and pneumonia in a high-risk patient. MRI is used in the diagnosis of cystic fibrosis, pulmonary embolism, pulmonary hypertension, and bronchial carcinoma. The positive predictive value (PPV) of a chest X-ray in outpatients with pneumonia is only 27% (gold standard, CT); in contrast, an initial, non-randomized trial of MRI in nosocomial pneumonia revealed a PPV of 95%. For the staging of mediastinal lymph nodes in bronchial carcinoma, MRI has a PPV of 88% and positron emission tomography with CT (PET/CT) has a PPV of 79%, while CT alone has a PPV of 41% (gold standard, histology).

CONCLUSION

The choice of radiologicalal technique for the detection, staging, follow-up, and quantification of lung disease should be based on the individual clinical options, so that appropriate treatment can be provided without excessive use of diagnostic testing.