Lines and crackles. Making sense of ILD

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2 Lines and crackles Making sense of ILD

3 Case JM 65 year old male Gradual shortness of breath, going on over a year Some dry cough Ex-smoker, quit 10 years ago Crackles in the bases CXR presented Sent to Cardiology, they felt not heart, must be lungs

4 Intro to ILD Over 200 causes/diseases Distribution worldwide Prevalence increasing Median survival of IPF 3-5 years History is crucial Most present with progressive dyspnea and dry cough and abnormal CXR/CT New meds available for IPF/UIP

5 General causes of ILD Infection: viral, bacterial, fungal, PCP Dusts Drugs Radiation CTD Sarcoid CHF Lymphangitic spread of cancer COP HP

6 ILD cause in the US 20% IPF 20% CTD-ILD 20% Chronic HP 20% Sarcoidosis 10% Pneumoconioses 10% Other ILD Lederer, NEJM 2018

7 ILD history taking Occupational hx Connective tissue disease symptoms Drugs Family history Environmental exposures: hypersensitivity pneumonitis Radiation

8 Occupational lung disease HISTORY! Silicosis Asbestosis Talcosis Berylliosis Coal worker s pneumoconiosis Hard metal disease

9 Connective tissue diseases SLE RA PSS DM/PM AS MCTD Vasculitides

10 Drugs causes of ILD Nitrofurantoin Cyclophosphamide Methotrexate Rituximab (Rituxan) Bleomycin Amiodarone

11 Hypersensitivity pneumonitis Extrinsic allergic alveolitis Farmer s lung Bird fancier s lung Hot tub lung (MAC) Bagassosis Paprika slicer s lung Mummy handler s lung

12 Case JM No clear occupational risks No radiation or drugs that would suggest cause Possible family history: uncle that died of some lung problem No history that would suggest a HP Exam: mild clubbing suggested Exam: fine crackles in the bases Remainder of exam normal

13 Examination in ILD Skin: signs of CTD CV: cor pulmonale Lungs: fine crackles MS: signs of CTD

14 CTD causes of ILD

15 Clubbing

16 Finger clubbing

17 Diffenterial diagnosis of clubbing Lung cancer ILD Asbestosis TB Cyanotic heart disease IBD Cystic fibrosis Bronchiectasis

18 Fine crackles

19 Fine crackles ILD CHF Pneumonia Bronchiectasis Atelectasis

20 Radiology in ILD Get the old CXRs! Reticular Nodular Mixed Most will need High Resolution CT

21 Case JM After exam and CXR now suspect some type of ILD CT chest: high resolution/thin section Pulmonary function studies: spirometry/static lung volumes/dlco Laboratory: ANA, RA

22 Radiology

23 Honeycomb lung

24 Differential diagnosis for honeycomb lung IPF/UIP NSIP Hypersensitivity pneumonitis Sarcoidosis Bleomycin/methotrexate Langerhans cell histiocytosis Asbestosis

25 UIP CT scan definitions HRCT must be done according to criteria Definite: Subpleural basal predominance Reticular abnormality Honeycomb +/- traction bronchiectasis Absent of features inconsistent with UIP

26 Pulmonary function tests Flow volume loop: restrictive/no bronchodilator response Total lung capacity: low Diffusion capacity: low

27 Laboratory CBC UA Liver enzymes, BUN, Creatinine CPK ANA RA titer HP testing ACE level?

28 Biomarkers Matrix metalloproteinase 1 & 7 YKL-40 Osteopontin S100A9 in BAL fluid Kerbs von Lungren (KL)-6

29 Cardiac evaluation EKG BNP Echo

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31 Case JM PFT s show restrictive mechanics and low DLCO Now have CT evidence of pulmonary fibrosis Lab: RA negative ANA 1:40 No clear reason for these findings Now suspect Idiopathic Pulmonary Fibrosis-IPF Next step: tissue or not?

32 Bronchoscopy in workup of ILD BAL: mainly to rule out infection Cell types not often done in US TBB: sarcoid, cancer, COP Problems are crush artifact and small specimens Transbronchial cryo lung biopsy

33 TBCLB Transbronchial cryo lung biopsy Yield 74-80% Bigger pieces Less crush artifact?safety: pneumo/bleeding Same day Less anesthesia

34 Surgical lung biopsy Gold standard 2-4 days in the hospital 3-4% mortality Complications 16% Air leak, ex ILD, bleeding, delayed wound healing 57% of patients still have pain at incision site 6-12 months post op

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36 Pathogenesis Repetitive alveolar injury Aberrant wound healing Fibroblast proliferation Expansion of extracellular matrix Loss of normal lung architecture Environmental exposure to genetically susceptible individuals

37 Usual interstitial pneumonia Classic IPF or Pulmonary Fibrosis Pathology in asbestosis Also advanced HP, RA, drugs, PSS

38 Non-specific interstitial pneumonia Most common pathology in CTD Subacute setting, fever More treatable than UIP

39 Desquamative interstitial pneumonia Smokers Less than 10% of all idiopathic ILD pts Ground glass in CT scan Occasional seen in CTD Lots of macrophages Steroid responsive 80% live 10 years or more

40 Respiratory bronchiolitis-ild Smokers 2% of idiopathic ILD patients years old Mild symptoms More common in males Smoking cessation

41 Acute interstitial pneumonia ARDS without a cause Acute, rapidly progressive On pathology Diffuse Alveolar Damage No treatment High mortality

42 Pathology

43 IPF Progressive Rate of progression variable 50% five year survival years old on presentation More common in males UIP cell type Now two medications for this disease

44 Co-morbidities in IPF Pulmonary hypertension: 30-50% poorer prognosis Lung cancer: 7 times general population COPD/emphysema: normal flow rates, low DLCO GERD: cause and exacerbations VTE CAD: second leading cause of death King, Lancet Respir 2017

45 Case JM Decided did not need biopsy Diagnosis: IPF/UIP Now discussion on therapy Medications over $100K per year!

46 Pirfenidone (Esbriet) Inhibits transforming growth factor beta Slowed the reduction in the FVC GI issues, liver enzymes, rash Titration difficult: lots of pills 267 mg dose caps/tabs 1 three times a day, then 2 three times a day, then 3 three times a day 801 mg tablet available

47 Nintedanib (Ofev) Tyrosine kinase blocker Slowed the reduction in the FVC Liver, GI issues Dosing easier 150 mg BID 100 mg pill available

48 Adjunct therapies Pulmonary Rehabilitation: improved symptoms, if transplant candidate will likely be required Smoking cessation Education Treat GERD: 90% have it? Vaccines Oxygen: treat if hypoxemia, not good data Palliative care

49 Lung transplantation Consider referral early 1,000 per year in US for ILD Fibrosis does not recur in the transplanted lung One year survival 74-84% Five year survival 40-50%

50 Multidisciplinary team Pulmonary Radiology Pathology Rheumatology GI? Cardiology?

51 Summary Think of it! Dyspnea, crackles, dry cough, abnormal CXR Extensive history for CTD, occupations, medications Ok to get the HRCT if suspected Likely will refer for confirmation and treatment

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53 References Martinez, Lancet Respir 2017 King, Lancet Respir 2017e Mikolasch et al, Clin Med 2016 Adegunsoye, Chest 2016 Raghu et al, AJRCCM 2015 Lederer and Martinez, NEJM 2018

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