Interstitial Lung Disease for the PCP Jeff Swigris, DO, MS Associate Professor of Medicine Interstitial Lung Disease Program National Jewish Health Denver, Colorado
Objectives Define the interstitium Define ILD Finding the cause Clinical presentation Therapy Define internist’s role
Where is the interstitium?
170, ,000 alveoli in here ~1-1.5cm
Classification based on etiology ILD Exposure-related mold, bacteria, birds medications XRT dusts cigarette smoke Idiopathic Sarcoidosis IIP Genetic FPF CTD-related RA Systemic sclerosis PM/DM Sjögren’s syndrome MCTD UCTD SLE
DAD DIP OP RB-ILD CFA IPF BOOP COP LIP NSIP UIP AIP Hamman-Rich BO HP UIPOB
Idiopathic interstitial pneumonias (IIP) Idiopathic pulmonary fibrosis (IPF) Nonspecific interstitial pneumonia (NSIP) Cryptogenic organizing pneumonia (COP) (Idiopathic BOOP) Acute interstitial pneumonia (AIP) Desquamative interstitial pneumonia (DIP) Respiratory bronchiolitis-ILD (RB-ILD) Lymphoid interstitial pneumonia (LIP)
Classification based on histology
ILD Exposure-related mold, bacteria, birds medications XRT dusts cigarette smoke Idiopathic Sarcoidosis LAM IIP Genetic FPF Autoimmune-related RA Systemic sclerosis PM/DM Sjögren’s syndrome MCTD
Nicholson et al. Am J Respir Crit Care Med 2000;162: Scar = bad prognosis Fibrosis Inflammation
What type of fibrosis is the PCP most likely to see? ++++ Idiopathic pulmonary fibrosis (IPF) Aging population ++++ Connective tissue disease-related RA + Chronic hypersensitivity pneumonitis Organic exposure (M/M/B/B
Making the diagnosis You have to be a detective History Exam Pulmonary physiology Radiography +/- surgical lung biopsy
History: chief complaint Typically, ILD presents with: Dyspnea—subacute, insidious onset “I thought I was just…” Getting older 5# heavier Out of shape +/- dry cough Fatigue No wheeze, no chest pain
History History Be a good detective Symptoms/existence of concurrent disease Patients may… 1. Have known CTD 2. Dyspnea from occult CTD-related ILD Family history Pulmonary fibrosis Rheumatologic illness
History: exposures History: exposures Be a good detective Smoking PEARL IPF DIP, RB-ILD, PLCH Goodpasture’s
History: exposures History: exposures Be a good detective Current or previous medications Chemotherapy Amiodarone Nitrofurantoin External beam radiation Current or previous recreational drug use Occupational, environmental, avocational PEARL
History: exposures History: exposures Be a good detective Microbial agents M/M/B/B Hot tubs (indoor/enclosed) Basement shower Free-standing humidifiers Water damage to home Cooling systems (swamp cooler)
History: exposures History: exposures Be a good detective Birds (proteins) Bloom on feathers Mucin in excrement Feather pillow/down comforter Fumes, dusts, gases Asbestos Beryllium
History: connective tissue diseases RA Symmetric arthritis/small joints Morning stiffness Subcutaneous nodules Smoker PEARL
History: connective tissue diseases SSc Raynauds After 40 y.o. in FEMALE After 30 y.o. in MALE Esophageal dysmotility Skin tightening PEARL
History: connective tissue diseases Sjögren’s Syndrome Dry eyes/mouth Dental caries
History: connective tissue diseases PM/DM Proximal muscle weakness Rashes Rough skin on the hands
Physical Exam
Physical examination Physical examination You’re still a detective Skin Rash Purupura Telangiectasia Nodules Calcinosis
Physical examination Nails Clubbing COPD no clubbing PEARL
Nailfold capillaroscopy Normal Abnormal Fischer et al. Chest. In press
Physical examination Chest Velcro crackles are NEVER normal Must listen here PEARL
Laboratory ANA—the pattern matters Nucleolar ANA any titer – TO RHEUM SSA is a myositis associated ab (ANA -) ACE level non-specific Don’t order it HP panels unhelpful Precipitating IgG to organic antigens Don’t order them PEARLS
Laboratory Isolated high MCV Methotrexate Azathioprine ??? Telomerase abnormality Elevated MCV History of bone marrow irregularities Premature graying Cryptogenic cirrhosis Pulmonary fibrosis PEARLS
Pulmonary physiology Pulmonary function testing Gas exchange
Pulmonary function testing Lung volumes Spirometry DLCO ABG
Patients with ILD have Restrictive Physiology Low static lung volumes Low forced volumes Low FVC Low FEV1 Normal FEV1/FVC
Volumes may be normal if… + …but the DLCO will be very low
Impaired Gas Exchange SpO2 at rest is unhelpful Exercise oximetry Never normal to desaturate 6-minute walk test PEARL
Radiology: diagnosing ILD “ILD protocol” HRCT No IV contrast Supine and prone Inspiratory and expiratory images Reconstruction algorithm — 1-1.5mm thick
HRCT Terminology Opacities Lines (reticular) Dots or Circles (nodules) Patches Attenuation (shade of gray) Consolidation – obscures underlying vessels Ground glass – does not obscure underlying vessels
Lower zone Peripheral/subpleural Reticular opacities Traction bronchiectasis Interlobular septal thickening
Honeycombing
Ground glass opacities
Lung biopsy Transbronchial biopsy Sarcoidosis Lymphangitic carcinomatosis Subacute HP Surgical Thorascopic Usually not if CTD-related
Putting it all Together History Exam Labs ANA, RF, anti-CCP Physiology Full PFTs Gas exchange 6MWT Radiology HRCT Pathology Integrate to get “summary diagnosis”
Therapy for ILD Not all patients require therapy General: treat clinically significant, progressive dz All therapeutic regimens require monitoring Glucocorticoids may be the mainstay Steroid-sparing / immune-suppressing / immunomodulatory / cytotoxic agents Nuance
STABILITY = SUCCESS I don’t want my patients ILD leaving clinic thinking they don’t have a serious condition I don’t want my patients with ILD leaving clinic thinking they should go home, sit on their couch and die
Gauging Response Q 3mos visits to pulm Subjective Symptoms FVC DLCO 6MWT Not HRCT unless scenario mandates
Internist: before ILD dx Thorough history and examination Order HRCT Order serologies ANA with pattern and ENA panel RF/anti-CCP Order PFTs/6MWT/HRCT Refer: ILD on HRCT
Internist: after ILD dx Monitor for side effects of therapy Glucocorticoids Weight Sugar BP Eyes Bones Be on the lookout for infection Monitor need for oxygen Communicate with patient Mood: therapy needed? End-of-life discussions
Internist: after ILD dx Refer to pulmonary rehabilitation Vaccines Sunscreen for all on immunosuppressive Tx Monthly labs for all on immunosuppressive Tx
Five Main Points You will see ILD — be a detective Velcro crackles never normal — get HRCT Surgical lung biopsy often needed to make a confident diagnosis All patients and most therapies require monitoring—the internist is vital here