SER-SEPAR recommendations for the management of rheumatoid arthritis-related interstitial lung disease. Part 1: Epidemiology, risk factors and prognosis

OBJECTIVE

To develop multidisciplinary recommendations to improve the management of rheumatoid arthritis-related interstitial lung disease (RA-ILD).

METHODS

Clinical research questions relevant to the objective of the document were identified by a panel of rheumatologists and pneumologists selected based on their experience in the field. Systematic reviews of the available evidence were conducted, and evidence was graded according to the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Specific recommendations were made.

RESULTS

Six PICO questions were selected, three of which analysed the incidence and prevalence of RA-ILD, associated risk factors, and predictors of progression and mortality. A total of 6 specific recommendations on these topics, structured by question, were formulated based on the evidence found and/or expert consensus.

CONCLUSIONS

We present the first official SER-SEPAR document with specific recommendations for RA-ILD management developed to resolve some common clinical questions and facilitate decision-making for patients.

Management of progressive pulmonary fibrosis associated with connective tissue disease

INTRODUCTION

: Fibrotic interstitial lung disease (ILD) is a frequent and severe complication of connective tissue disease (CTD).

AREAS COVERED

: In this narrative review, we update the most relevant differential characteristics of fibrotic ILD associated with CTD (CTD-ILD) and propose a diagnostic and therapeutic approach based on a review of the articles published between 2002 and 2022 through PubMed.

EXPERT OPINION

: The subset of ILD, mainly the radiological/histological pattern and the degree of fibrotic component, usually determines the prognosis and therapeutic strategy for these patients. Some patients with CTD-ILD can develop progressive pulmonary fibrosis (PPF) with severe deterioration of lung function, rapid progression to chronic respiratory failure, and high mortality. PPF has been described in many CTDs, mainly in systemic sclerosis and rheumatoid arthritis, and requires a multidisciplinary diagnostic and therapeutic approach to improve patient outcomes.

Recommendations for the Diagnosis and Management of Asbestos-Related Pleural and Pulmonary Disease

Asbestos is the term used for a set of mineral silicates that tend to break up into fibers. Its use has been associated with numerous diseases affecting the lung and pleura in particular, all of which are characterized by their long period of latency. Asbestos, moreover, has been recognized by the WHO as a Group IA carcinogen since 1987 and its use was banned in Spain in 2002. The publication in 2013 of the 3rd edition of the specific asbestos health monitoring protocol, together with the development of new diagnostic techniques, prompted the SEPAR EROM group to sponsor publication of guidelines, which review the clinical, radiological and functional aspects of the different asbestos-related diseases. Recommendations have also been made for the diagnosis and follow-up of exposed patients. These recommendations were drawn up in accordance with the GRADE classification system.

Treatment of Adult Primary Alveolar Proteinosis

Pulmonary alveolar proteinosis (PAP) is a rare disease characterized by the accumulation of surfactant-like lipoproteinaceous material in the distal air spaces and terminal bronchi, which may lead to impaired gas exchange. This accumulation of surfactant is due to decreased clearance by the alveolar macrophages. Its primary, most common form, is currently considered an autoimmune disease. Better knowledge of the causes of PAP have led to the emergence of alternatives to whole lung lavage, although this is still considered the treatment of choice. Most studies are case series, often with limited patient numbers, so the level of evidence is low. Since the severity of presentation and clinical course are variable, not all patients will require treatment. Due to the low level of evidence, some objective criteria based on expert opinion have been arbitrarily proposed in an attempt to define in which patients it is best to initiate treatment.

[The air belongs to us: the importance of maintaining air quality]

Interest in identifying the long-term harmful effects of atmospheric pollution on respiratory health, and concern about this issue, has prompted several studies, whose results have been published throughout this year. On the occasion of the Spanish Society of Pneumology and Thoracic Surgery's Year of the Environment, from the Section of Occupational and Environmental Respiratory Diseases, we review the advances made in the effects of atmospheric pollution on respiratory health and the actions undertaken by the Society. The main objective of the Society's Year of the Environment is to inform citizens in general and respiratory patients in particular of the benefits of breathing clean air. The first step in achieving this aim is education. The goal is to educate young people in lasting habits that promote a respectful attitude to the environment, inculcating them with the need for sustainable development through responsible energy consumption and reduction of the emission of pollutants. Informed citizens will demand public health policies aimed at maintaining the quality of the air we breathe from politicians. The website www.elaireesnuestro.com provides information and educational material on the subject.

Fibrosing mediastinitis mimicking sarcoidosis

Fibrosing mediastinitis (FM), also called sclerosing mediastinitis or mediastinal fibrosis, is a rare disease characterized by excessive fibrotic reaction in the mediastinum and may compromise the airway, the great vessels and other mediastinal structures, with a morbidity directly related to the location and extent of fibrosis. The cause is not always known but is often the result of a granulomatous disease, most often the histoplasmosis. We report a 43-year-old woman with a history of tuberculosis infection 23 years ago. She attended the pulmonology clinic for cough and dyspnea. Physical examination revealed jugular venous distention at 90°. In computed tomography scan of the chest with contrast (c/c), we observed a mediastinal nodal cast provoking cava compression and obliteration of main and intermediary right lobar bronchus. The pathological examination was FM.

Recommendations for fitness for work medical evaluations in chronic respiratory patients. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR)

Chronic respiratory diseases often cause impairment in the functions and/or structure of the respiratory system, and impose limitations on different activities in the lives of persons who suffer them. In younger patients with an active working life, these limitations can cause problems in carrying out their normal work. Article 41 of the Spanish Constitution states that «the public authorities shall maintain a public Social Security system for all citizens guaranteeing adequate social assistance and benefits in situations of hardship». Within this framework is the assessment of fitness for work, as a dual-nature process (medico-legal) that aims to determine whether it is appropriate or not to recognise a person's right to receive benefits which replace the income that they no longer receive as they cannot carry out their work, due to loss of health. The role of the pulmonologist is essential in evaluating the diagnosis, treatment, prognosis and functional capacity of respiratory patients. These recommendations seek to bring the complex setting of fitness for work evaluation to pulmonologists and thoracic surgeons, providing action guidelines that allow them to advise their own patients about their incorporation into working life.

Indoor air contaminants and their impact on respiratory pathologies

Humans spend a considerable amount of their time breathing air inside enclosed spaces in which, due to various sources, there may be contaminants that deteriorate the air quality. This is an important risk factor for the health of the general population. This review evaluates the contaminants that are present in the air of indoor air spaces, describing the sources that generate them as well as the physiopathological mechanisms and the diseases that they may cause in the respiratory system.

Asbestos-related disease: screening and diagnosis

Malignant pleural mesothelioma (MPM) is an extremely aggressive tumor which develops in the epithelial lining of the lungs. Exposure to asbestos is the most influential risk factor for developing this disease. Despite recent advances in the treatment of other types of cancer, patients with mesothelioma currently face a poor prognosis. Therefore, it is highly important to develop an early diagnostic method with the greatest challenge on screening techniques to detect the disease at a subclinical stage. Early detection is critical for the development of more effective therapies in these patients. Unfortunately, radiologic studies have not proven effective. Biomarkers might be a useful adjunct tool among populations previously exposed to asbestos. This review will provide an update of recent progress in serum biomarkers (osteopontin (OPN), soluble mesothelin (SM), and megakaryocyte potentiating factor (MPF)) to diagnose, detect, and monitor MPM. Of these, SM has demonstrated the greatest diagnostic potential although MPF may serve as an equal alternative. Despite recent studies, it is apparent that long-term large-cohort research is required to conclusively demonstrate the usefulness of these markers in this disease.

[Exposure to environmental contaminants and respiratory disease. Spotlight on the year 2009]

The continued inhalation of contaminants present in the air that we breathe is a common cause of respiratory disease. Classically, this exposure-disease relationship has been proved in the workplace and as a cause of specific diseases such as pneumoconiosis and occupational asthma. However, there is increasing evidence indicating an association between occupational exposure and other more prevalent respiratory diseases such as Chronic Obstructive Pulmonary Disease and lung cancer. The effect of contamination is also observed outside the workplace. The air in cities can contribute to increasing the morbidity and mortality due to chronic respiratory diseases. Some articles published during the year 2009 that have a bearing on aspects associated with respiratory diseases of occupational or environmental origin are reviewed below.