9/15- Interstitial Lung Disease Flashcards

1
Q

What are the components of the pulmonary interstitium?

A
  • Alveolar epithelium
  • Pulmonary capillary endothelium
  • Basement membrane
  • Perivascular and perilymphatic tissues
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2
Q

What does ILD refer to?

A

Interstitial Lung Diseases

  • Diffuse Parenchymal Lung Disorders
  • Heterogeneous group of disorders grouped together due to similar clinical, physiologic, radiographic, and pathologic features

May be classified by:

  • Known causes or unknown causes
  • Based on histo-pathology: alveolitis/fibrosis or granulomatous or alveolar filling
  • Based on onset: acute or chronic
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3
Q

Flowchart classification of diffuse parenchymal lung disease

A
  • Known cause (drugs, collagen vascular dz…) - Idiopathic interstitial pneumonia
  • Idiopathic pulmonary fibrosis
  • IIP other than idiopathic pulmonary fibrosis (different pneumonias)
  • Granulomatus DPLD (sarcoidosis)
  • Other forms of DPLD
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4
Q

Diagnostic approach to ILD diagnosis?

A

Multidisciplinary Clinical + Radiology + Pathology

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5
Q

Typical presentation of ILD

  • Age
  • Gender
  • Symptoms
A
  • Typ > 50 yo
  • Mostly women > men EXCEPT rheumatoid arthritis and IPF

Symptoms:

  • Progressive dyspnea
  • Dry cough
  • Occ. weight loss
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6
Q

What are some ILDs with acute onset (days-weeks)?

A
  • AIP (Hamman-Rich Syndrome)
  • Acute pneumonitis from collagen vascular disease (especially SLE)
  • Cryptogenic organizing pneumonia
  • Drugs
  • Diffuse alveolar hemorrhage
  • Eosinophilic lung disease
  • Hypersensitivity pneumonitis
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7
Q

What are some ILDs with subacute onset (weeks - months)?

A
  • Collagen vascular disease-associated ILD
  • Cryptogenic organizing pneumonia
  • Drugs
  • Subacute hypersensitivity pneumonitis
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8
Q

What are some ILDs with chronic onset (months - years)?

A
  • IPF, NSIP, and other IIPs
  • Pneumoconioses (lung disorders caused by occpational disorders)
  • Chronic hypersensitivity pneumonitis
  • Collagen vascular disease-associated ILD
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9
Q

What illness are associated with ILDs that you might expect to find in past medical history?

A
  • Collagen vascular disorders
  • Rheumatoid arthritis
  • SLE
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10
Q

What diseases might be expected in family history for someone with ILD?

A
  • Sarcoidosis
  • Interstitial pulmonary fibrosis
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11
Q

What medication history might you find for someone with ILD?

A

MANY

  • Methotrexate
  • Amiodarone
  • Also some illicit drugs
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12
Q

What might you look for in the social history of someone with ILD?

A
  • Occupation: ship-building (demolition– asbestos), insulator, sand-blasting (silica exposure), farming
  • Smoking history: IPF, RB-ILD, DIP

(RB-ILD so associated that it may get better upon smoking cessation)

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13
Q

What might be expected in the physical exam for someone with ILD?

A

Most findings from auscultation

  • Tachypnea
  • Rales (“Velcro” crackles)*
  • Clubbing
  • Exercise desaturation

Late stages:

  • Signs of right heart failure
  • Cyanosis
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14
Q

What labs might you find for someone with ILD?

  • ABG
  • Certain disease disorder labs
  • Others
A

ABG

  • Early stages: no changes
  • Late stages: hypoxemia; elevated A-a gradient

Connective tissue disorder labs:

  • ANA
  • Rheumatoid factor

Others:

  • ACE and Ca elevated in Sarcoidosis
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15
Q

Describe pulmonary function tests for patients with ILD?

  • FEV1/FVC
  • TLC
  • DLCO
A

Restrictive pattern

  • Decreased lung volumes; TLC reduction determines severity of disease
  • Normal FEV1/FVC

Reduced DLCO (diffusion capacity) secondary to physiological alveolar-capillary block

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16
Q

T/F: PFT can help determine specific disease/etiology of ILD?

A

False

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17
Q

What are the radiologic patterns of ILD?

A
  • Reticular: fine lines due to thickening and fibrosis of interstitium
  • Nodular
  • Reticulo-nodular
  • Ground glass: hazy; can see through it, but somewhat obscure (more in acute-onset ILDs)
  • Alveolar
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18
Q

What conditions fall into the following radiologic patterns of ILD:

  • Reticular
  • Nodular
  • Reticulo-nodular
  • Ground glass
  • Alveolar
A

Reticular

  • IPF (idiopathic pulmonary fibrosis)
  • Asbestosis
  • Connective-tissue associated

Nodular

  • Sarcoidosis
  • Silicosis
  • Hypersensitivity
  • Pneumonitis

Reticulo-nodular

Ground glass

  • NSIP (nonspecific interstitial pneumonia)
  • DIP (desquamative interstitial pneumonia)
  • RBILD (respiratory bronchiolitis interstitial lung dz)
  • Pulmonary hemorrhage

Alveolar

  • Cryptogenic organizing pneumonia
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19
Q

Which ILDs are predominantly in the upper lobe? Lower lobe?

A

Upper lobe

  • Sarcoidosis
  • Silicosis
  • Acute
  • Hypersensitivity pneumonitis (HP)
  • Ankylosing spondylosis

Lower lobes:

  • IPF
  • Chronic HP
  • Asbestosis
20
Q

Pneumothorax hints at which ILD?

A

Lymphangioleiomyomatosis (LAM)

21
Q

Pleural plaques hints at which ILD?

A

Asbestosis

  • Asbestos fibers can go down all the way to pleura and cause irritation -> thickening of pleura (doesn’t progress to cancer, but is a marker of exposure)
22
Q

Hilar adenopathy hints at which ILD?

A

Sarcoidosis

23
Q

What is seen here?

A

Reticular pattern, lower lobe predominant

  • Increased “haziness”, esp at base
  • Very fine lines

This could be:

  • IPF
  • CT-disease related
  • Asbestosis
24
Q

What imaging is used to evaluate ILD?

A

High resolution CT; superior to CXR

  • Extent and distribution of disease
  • Patterns
25
Q

What are some pathologic diagnostic tests?

A

Bronchoscopy

  • Bronchoalveolar lavage
  • Transbronchial lung biopsy

Surgical lung biopsy

Other biopsy:

  • Skin: sarcoid
26
Q

What are the pathologic categories and ILDs within them (that we will cover specifically)?

A

Alveolitis/Fibrotic

  • IPF
  • NSIP
  • CT disease related
  • Pneumoconiosis

Granulomatous

  • Sarcoidosis
  • Hypersensitivity pneumonitis

Alveolar filling

  • COP (cryptogenic organizing pneumonia)
27
Q

Characteristics of Idiopathic Pulmonary Fibrosis (IPF)

  • Age of onset
  • Gender bias
  • Onset
  • PE findings
  • Pathology
  • Imaging
A
  • Age of onset 6th-7th decade (rare under 50 yo)
  • Men > women
  • Chronic onset
  • PE: velcro rales and clubbing
  • Pathology: usual interstitial pneumonia

Imaging:

  • Reticular infiltrates
  • Lower lobe predominant
  • Subpleural with honeycombing in late stages (pockets of scared-down lung)
  • Temporal heterogeneity
28
Q

What is seen here?

A

IPF findings/reticular pattern

Arrows point to honeycombing (burnt out lung)

29
Q

Treatment for IPF?

A

Best supportive care

  • O2 therapy
  • Pulmonary rehab
  • Early recognition of terminal decline and liaison with health care specialists

Lung transplantation only option for some:

  • DLCO under 40% predicted or progressive (>10% decline in FVC)
  • Refer early
  • Single or double

Most pts die on transplant list (typ life expectancy = 5yrs?)

Medications (conditional recommendation):

- Nintedanib (TK inhib with multiple targets, including VEGF, FGF, and PDGF receptors)

- Pirfernidone (oral antifibrotic with pleiotropic effects: regulate important profibrotic/proinflammatory cyotkine cascades while reducing fibroblast proliferation and collagen synthesis)

- Anti-acid therapy (reflux/GERD may contribute to chronic lung inflammation and resultant IPF)

30
Q

What treatments are strongly NOT recommended in IPF?

What about conditionally not recommended?

A
  • Anticoagulation (warfarin)
  • Imatinib (selective TK inhibitor against PDGF)
  • Combo prednisone, azathioprine, and N-acetylcysteine
  • Selective endothelin receptor antagonist (ambrisentan)

(No steroids! Although these are common treatment for some other ILDs)

Conditionally not recommended:

  • PDE5 inhibitor (sildenafil)
  • Dual endothelin receptor antagonists (macitentan, bosentan)
  • N-acetyl monotherapy
31
Q

T/F: Honeycomb lung is specific for IPF?

A

False

  • Sign of “burnt out lung”; any end-stage ILD
  • At this point, lung transplant is really your only hope
32
Q

Characteristics of NSIP?

  • Commonality
  • Age
  • Epidemiology
  • History
  • PE findings
  • Pathology
  • Imaging
  • Diagnosis
A
  • 2nd most common diagnosis
  • Middle aged
  • Majority are smokers
  • Similar hx to IFP
  • Similar PE to IFP, but less clubbing
  • Pathology: homogeneous interstitial thickening
  • Imaging: diffuse ground glass infiltrates
  • Surgical biopsy required to make diagnosis
33
Q

How do connective tissue disease related ILDs differ from IPF?

A
  • Part of multisystem disease, usually apparent prior to pulmonary involvement
  • Pleural involvement common
34
Q

What CT diseases most common involve pulmonary manifestations in CT disease related ILDs?

A
  • SLE
  • Rheumatoid arthritis
35
Q

What does pulmonary involvement in SLE look like?

A
  • Pleuritis/pleural effusion (most common)
  • Alveolar hemorrhage
  • Acute pneumonitis
  • ILD (0-4%)
  • Diaphragmatic weakness
36
Q

What does pulmonary involvement in rheumatoid arthritis?

A

2 unique issues:

1. Joint disease usually precedes pulmonary involvement

2. Males > females

Pulmonary complications are rare

  • Pleural effusion is most common (under 5%)

Also:

  • Fibrosing alveolitis/Fibrosis
  • Necrobiotic nodules
  • Pleural effusion
  • Bronchiolitis obliterans
  • ILD due to drug therapies (e.g. methotrexate)
37
Q

Characteristics of asbestos associated lung disease

  • Exposure
  • Upper or lower lung fields
  • Benign vs. malignant
  • Natural history
  • Symptoms
  • Radiology
  • Complications
A

- Exposure: shipyard workers (WWII), refineries, demolition of old buildings, construction ,insulation, bake repair

- Asbestosis (pulmonary fibrosis)- more in lower lung fields

- Benign asbestosis- related pleural disease (pleural plaques/adhesions)

- Bronchogenic cancer

- Mesothelioma: pleural malignancy (not associated with smoking at all)

- Natural hx: insidious onset; many years after exposure (usually > 20 yrs!)

- Sx: insidious onset of dyspnea and cough

Radiology

  • Irregular opacities primarily in lower lobes
  • May be associated with pleural plaques/thickening

Complications:

  • Acts as co-carcinogen with tobacco smoke
  • Up to 50x increase in lung cancer among asbestos workers who smoke compared to smokers in other trades
38
Q

What is this?

A

Asbsestosis

39
Q

Characteristics of Silicosis?

  • Overall
  • Work environment
  • Natural history
  • Radiographic features
  • Diagnosis
  • Complications
A

Chronic, fibronodular lung disease caused by long term exposure to crystalline silica

- Work environment: stone cutting/polishing, mining, foundry work, sandblastin

  • Usually requires exposure of > 5 yrs

- Natural hx: variable; most commonly slowly progressive dyspnea, cough, sputum

Radiographically:

  • Upper lobe (apex)
  • Hilar adenopathy (egshell calcifications)

Diagnosis:

  • CXR and history
  • Occasionally need lung biopsy
  • High resolution CT may be helpful

Complications:

  • Increased risk for TB (5-43%)
  • No increased risk for lung cancer (?)
40
Q

Characteristics of Sarcoidosis:

  • Gender
  • Epidemiology
  • Clinical presentation
  • Symptoms
  • Radiologic changes
A
  • Multisystem disease of unknown etiology
  • Females > males
  • Black > white
  • Usually under 40

Clinical presentation: multi-system disease which may present acutely, subacutely, or chronically

  • CNS, eye, skin, bone, cardiac, endocrine
  • Most commonly pts are asymptomatic with an abnormal CXR

Radiologic stages

0: no CXR anbormality (5-10%, ie sarcoid diagnosed in another organ system)

I: LN enlargement without parenchymal change, most common*

II: nodes +, diffuse parenchymal changes

III: nodes -, diffuse chagnes IV: evidence of fibrosis

41
Q

Diagnosis of sarcoidosis?

A
  • Rests on clinical assessment and compatible tissue biopsy
  • Hallmark pathology is non-caseating granuloma
  • Rule out other disorders, esp TB
  • Tissue diagnosis: transbronchial biopsy + ve in 50-60% with normal CXR; 85-90% with abnormal CXR
42
Q

Treatment of Sarcoidosis?

  • Natural history
  • When to treat
  • Treat with what
A

Course:

  • 30-50% spontaneously remit in 3 yr period
  • 20-30% remain stable
  • 30% progressive

Treat if symptomatic or vital organ involvement

Treat with immunosuppression

43
Q

Characteristics of Hypersensitivity Pneumonitis

  • Exposure
  • Radiology
  • Diagnosis
  • Pathology
A

Exposure

  • From inhalation of and sensitivity to organic dusts
  • Antigens are quite varied but clinical response to all is similar
  • Most common is after exposure to thermophilic actinomyces in moldy hay, silos etc. (Farmer’s lung)

Radiology

  • Diffuse, small nodules that appears as ground glass infiltrates
  • Acute upper lobe and chronic lower lobe

Diagnosis: requires a high index of suspicion

Pathology: Peribronchial lymphocytic infiltrates with poorly formed granulomas

44
Q

Treatment for Hypersensitivity Pneumonitis?

A
  • Avoidance of causative antigenic agent
  • Corticosteroids may have role in treating severe or progressive disease
45
Q

Characteristics of COP (Cryptogenic Organizing Pneumonia)

  • Epidemiology
  • Symptoms
  • CXR features
  • HRCT
  • Pathology
  • Prognosis
  • Treatment
A

Idiopathic “BOOP”: bronchiolitis obliterans organizing pneumonia

  • Unknown etiology

Epidemiology: 5th-6th decades (equal genders)

Symptoms:

  • Malaise
  • Weight loss
  • Mylagias
  • Cough
  • SOB
  • Typically following respiratory infection

CXR: patchy or diffuse infiltrates

  • Often recurrent or migratory

HRCT: airspace around ground glass opacities and bronchial wall thickening/dilation

Pathology: patchy cellular airspace fibrosis in alveoli and alveolar ducts

Prognosis: good; spontaneous remission in 50%

Treatment: steroids; very sensitive

46
Q

Summary

A