AJRCCM: 100-Year Anniversary. Progress in Interstitial Lung Disease

The impact of bronchoalveolar lavage on the diagnosis of undifferentiated interstitial lung disease alongside a multidisciplinary discussion

BACKGROUND AND OBJECTIVE

Cellular analysis of bronchoalveolar lavage (BAL) fluid may aid diagnosis in patients with undifferentiated interstitial lung disease (ILD). The utility of this test in the diagnostic process in conjunction with a multidisciplinary discussion (MDD) is not known. We aim to assess and compare interobserver agreement and diagnostic confidence before and after presenting BAL results in an ILD-MDD.

METHODS

Patients undergoing investigations for ILD at Waikato Hospital were recruited. At the ILD-MDD two respiratory physicians and one respiratory radiologist participated in the discussion, and their diagnosis and diagnostic confidence were assessed at four sequential time points. Assessors were blinded to each others diagnosis and diagnostic confidence scores. The four sequential time points were (1) after clinical and radiology presentation; (2) after subsequent MDD; (3) after reviewing BAL results; (4) after final MDD with all results. Interobserver agreements were calculated using Fleiss κ statistic.

RESULTS

36 patients were recruited, and 77.8% were male. In the first step, the interobserver agreement was substantial κ = 0.622 (95% CI 0.47-0.77), improving in step 2 following MDD to κ = 0.78 (95% CI 0.624-0.935), in step 3 κ = 0.776 (95% CI 0.614-0.937) and step 4 achieved almost perfect agreement of κ = 0.969 (95% CI 0.828-1.11). The diagnostic confidence for individual and group diagnosis increased with the presentation of BAL with and without multidisciplinary MDD.

CONCLUSION

We found that BAL cellular analysis improves interobserver agreement and confidence in diagnosis following MDD, thus aiding decision-making in cases with undifferentiated ILD.

Pain among Individuals with Chronic Respiratory Diseases Attending Pulmonary Rehabilitation

Purpose: This study reports on the prevalence and impact of pain in individuals with different chronic respiratory diseases attending pulmonary rehabilitation (PR). Method: A retrospective review of medical records data was conducted for 488 participants who had attended a PR programme over a 2-year period. Data on pain and medication history taken from multidisciplinary medical records, together with participant demographics and PR outcomes, were extracted. We compared pain among participants with different types of chronic respiratory disease. Results: The overall prevalence of pain was 77%, with a significantly higher prevalence among individuals with obstructive lung diseases (80%) compared with restrictive lung diseases (69%; p = 0.04). Some participants (17%) who took pain medications did not discuss pain with their clinicians. The presence of pain and different reporting of pain did not have a negative impact on the PR programme completion rate (p = 0.74), improvements in exercise capacity (p = 0.51), or health-related quality of life (all four chronic respiratory disease questionnaire domains, p>0.05). Conclusions: The prevalence of pain is high among individuals with chronic respiratory disease attending PR. The presence or absence of pain was not negatively associated with the programme completion rate or PR outcomes; therefore, pain should not deter clinicians from referring patients to PR.

Essential Features of an Interstitial Lung Disease Multidisciplinary Meeting: An International Delphi Survey

RATIONALE

The interstitial lung disease (ILD) multidisciplinary meetings (MDM) composing of pulmonologists, radiologists and pathologists, is integral to the rendering of an accurate ILD diagnosis. However, there is significant heterogeneity in the conduct of ILD MDMs and questions regarding its best practice remain unanswered.

OBJECTIVE

To achieve consensus among ILD experts on essential components of an ILD MDM.

METHODS

Using a Delphi methodology, semi structured interviews with ILD experts were used to identify key themes and features of ILD MDMs. These items informed two subsequent rounds of online questionnaires that were used to achieve consensus among a broader, international panel of ILD experts. Experts were asked to rate their level of agreement on a five-point Likert scale. An a priori threshold for consensus was set at a median score 4 or 5 with an interquartile range of 0.

RESULTS

We interviewed 15 ILD experts and 102 ILD experts participated in the online questionnaires. Five items and two exploratory statements achieved consensus on being essential for an ILD MDM following two questionnaire rounds. There was consensus that the presence of at least one radiologist, a quiet setting with a visual projection system, a high-quality chest high resolution computed tomography and a standardized template summarising collated patient data are essential components of an ILD MDM. Experts also agreed that it would be useful for ILD MDMs to undergo an annual benchmarking process and a validation process by fulfilling a minimum number of cases annually. Twenty-seven additional features were considered to be either highly desirable or desirable features based on the degree of consensus. Although our findings on desirable features are similar to the current literature, several of these remain controversial and warrant further research. The study also showed an agreement among participants on several future concepts to improve the ILD MDM such as performing regular self-assessments and conducting research into shared practices to develop an international expert guideline statement on ILD MDMs.

CONCLUSION

This Delphi study showed consensus among international ILD experts on essential and desirable features of an ILD MDM. Our data represents a first step toward potential collaborative research into future standardisation of ILD MDMs.

The interstitial lung disease multidisciplinary meeting: A position statement from the Thoracic Society of Australia and New Zealand and the Lung Foundation Australia

Interstitial lung diseases (ILD) are a diverse group of pulmonary diseases for which accurate diagnosis is critical for optimal treatment outcomes. Diagnosis of ILD can be challenging and a multidisciplinary approach is recommended in international guidelines. The purpose of this position paper is to review the evidence for the use of the multidisciplinary meeting (MDM) in ILD and suggest an approach to its governance and constitution, in an attempt to provide a standard methodology that could be applied across Australia and New Zealand. This position paper is endorsed by the Thoracic Society of Australia and New Zealand (TSANZ) and the Lung Foundation Australia (LFA).