Genetic Testing Goes Beyond Imaging and Histological Evaluation in Pleuroparenchymal Fibroelastosis

BACKGROUND

Lung biopsy remains the gold standard in the diagnosis of fibrotic interstitial lung disease (F-ILD), but there is a growing appreciation of the role of pathogenic gene variants in telomere and surfactant protein genes, especially in familial pulmonary fibrosis (FPF). Pleuroparenchymal fibroelastosis (PPFE) is a rare disease that can coexist with different patterns of F-ILD, including FPF. It can be progressive and often leads to respiratory failure and death. This study tested the hypothesis that genetic testing goes beyond radiological and histological findings in PPFE and other F-ILD further informing clinical decision-making for patients and affected family members by identifying pathological gene variants in telomere and surfactant protein genes.

METHODS

This is a retrospective review of 70 patients with F-ILD in the setting of FPF or premature lung fibrosis. Six out of 70 patients were diagnosed with PPFE based on radiological or histological characteristics. All patients underwent telomere length evaluation in peripheral blood by Flow-FISH or genetic testing using a customized exome-based panel that included telomere and surfactant protein genes associated with lung fibrosis.

RESULTS

Herein, we identified six individuals where radiographic or histopathological analyses of PPFE were linked with telomere biology disorders (TBD) or variants in surfactant protein genes. Each case involved individuals with either personal early-onset lung fibrosis or a family history of the disease. Assessments of telomere length and genetic testing offered insights beyond traditional radiological and histopathological evaluations.

CONCLUSION

Detecting anomalies in TBD-related or surfactant protein genes can significantly refine the diagnosis and treatment strategies for individuals with PPFE and other F-ILD.

Association of patient-reported outcome measures with lung function and mortality in fibrotic interstitial lung disease: a prospective cohort study

Background

Patient-reported outcome measures (PROMs) may provide clinicians and researchers with direct insights into disease impact and patient well-being. We assessed whether selected PROMs and their domains are associated with baseline and longitudinal changes in lung function and can predict mortality in patients with fibrotic interstitial lung disease (f-ILD).

Methods

A single-centre prospective study of adult patients with f-ILD enrolled over 3 years was conducted assessing baseline and short-term changes in PROMs. Three questionnaires, the modified Medical Research Council dyspnoea scale (mMRC), Chronic Respiratory Questionnaire (CRQ) and Self-Management Ability Scale (SMAS-30) were administered at planned intervals and assessed for their association with baseline clinical findings, change in lung function (% predicted forced vital capacity (FVC%) and diffusion capacity of the lung for carbon monoxide (DLCO%)) and all-cause mortality.

Results

199 patients were enrolled with a mean PROM follow-up of 9.6 months. When stratified by FVC% quartiles at presentation, lower mMRC (less dyspnoea), higher CRQ Physical and Emotional domain (better health-related quality of life) and higher total SMAS-30 scores (better self-management ability) were associated with higher FVC%. Short-term changes in all three PROMs appeared to be associated with changes in FVC% and DLCO%. Adjusted and unadjusted baseline and serial PROM changes were also predictive of mortality.

Conclusions

Baseline and serial assessments of PROMs were associated with changes in lung function and predicted death in patients with f-ILD. PROMs may strengthen comprehensive assessments of disease impact in clinical practice as well as support patient-centred outcomes in research.

Phenotypic subtypes of fibrotic hypersensitivity pneumonitis identified by machine learning consensus clustering analysis

BACKGROUND

Patients with fibrotic hypersensitivity pneumonitis (f-HP) have varied clinical and radiologic presentations whose associated phenotypic outcomes have not been previously described. We conducted a study to evaluate mortality and lung transplant (LT) outcomes among clinical clusters of f-HP as characterized by an unsupervised machine learning approach.

METHODS

Consensus cluster analysis was performed on a retrospective cohort of f-HP patients diagnosed according to recent international guideline. Demographics, antigen exposure, radiologic, histopathologic, and pulmonary function findings along with comorbidities were included in the cluster analysis. Cox proportional-hazards regression was used to assess mortality or LT risk as a combined outcome for each cluster.

RESULTS

Three distinct clusters were identified among 336 f-HP patients. Cluster 1 (n = 158, 47%) was characterized by mild restriction on pulmonary function testing (PFT). Cluster 2 (n = 46, 14%) was characterized by younger age, lower BMI, and a higher proportion of identifiable causative antigens with baseline obstructive physiology. Cluster 3 (n = 132, 39%) was characterized by moderate to severe restriction. When compared to cluster 1, mortality or LT risk was lower in cluster 2 (hazard ratio (HR) of 0.42; 95% CI, 0.21-0.82; P = 0.01) and higher in cluster 3 (HR of 1.76; 95% CI, 1.24-2.48; P = 0.001).

CONCLUSIONS

Three distinct phenotypes of f-HP with unique mortality or transplant outcomes were found using unsupervised cluster analysis, highlighting improved mortality in fibrotic patients with obstructive physiology and identifiable antigens.

Home-Based Pulmonary Rehabilitation and Health Coaching in Fibrotic Interstitial Lung Disease: IMPLEMENTATION AND QUALITATIVE ASSESSMENT OF A PILOT TELEHEALTH PROGRAM

PURPOSE

Pulmonary rehabilitation is a behavioral modification intervention shown to improve exercise tolerance and patient-reported quality of life in patients with fibrotic interstitial lung disease. Home-based rehabilitation may provide easier access for those who struggle to complete center-based rehabilitation programs due to increased symptom burden or frailty.

METHODS

We present the quantitative and qualitative findings of a pilot study of 21 patients with fibrotic interstitial lung disease who participated in a 12-wk home-based pulmonary rehabilitation program with activity monitoring and health coaching.

RESULTS

Pre- and post-intervention patient-reported outcome questionnaires suggested improvements in dyspnea and respiratory-related quality of life but were underpowered to meet statistical significance. Half had increases in mean daily step counts while a quarter declined because of disease progression. Qualitative analysis of semistructured participant interviews suggested a significant baseline disease burden with related secondary impacts, including anxiety regarding disease progression and prognosis. Many who participated had no specific program expectations or self-determined goals but still found the program impactful, particularly on their abilities to adapt and cope with the disease.

CONCLUSION

Our study suggests feasibility in a diverse set of patients with varying severity and diagnostic subtypes. We also provide quantitative and qualitative aspects of program impact on patient well-being and highlight the complex interaction between measured physical and self-reported outcomes and disease experience.

Expert consensus on the management of systemic sclerosis-associated interstitial lung disease

BACKGROUND

Systemic sclerosis (SSc) is a rare, complex, connective tissue disorder. Interstitial lung disease (ILD) is common in SSc, occurring in 35-52% of patients and accounting for 20-40% of mortality. Evolution of therapeutic options has resulted in a lack of consensus on how to manage this condition. This Delphi study was initiated to develop consensus recommendations based on expert physician insights regarding screening, progression, treatment criteria, monitoring of response, and the role of recent therapeutic advances with antifibrotics and immunosuppressants in patients with SSc-ILD.

METHODS

A modified Delphi process was completed by pulmonologists (n = 13) and rheumatologists (n = 12) with expertise in the management of patients with SSc-ILD. Panelists rated their agreement with each statement on a Likert scale from - 5 (complete disagreement) to + 5 (complete agreement). Consensus was predefined as a mean Likert scale score of ≤  - 2.5 or ≥  + 2.5 with a standard deviation not crossing zero.

RESULTS

Panelists recommended that all patients with SSc be screened for ILD by chest auscultation, spirometry with diffusing capacity of the lungs for carbon monoxide, high-resolution computed tomography (HRCT), and/or autoantibody testing. Treatment decisions were influenced by baseline and changes in pulmonary function tests, extent of ILD on HRCT, duration and degree of dyspnea, presence of pulmonary hypertension, and potential contribution of reflux. Treatment success was defined as stabilization or improvement of signs or symptoms of ILD and functional status. Mycophenolate mofetil was identified as the initial treatment of choice. Experts considered nintedanib a therapeutic option in patients with progressive fibrotic ILD despite immunosuppressive therapy or patients contraindicated/unable to tolerate immunotherapy. Concomitant use of nintedanib with MMF/cyclophosphamide can be considered in patients with advanced disease at initial presentation, aggressive ILD, or significant disease progression. Although limited consensus was achieved on the use of tocilizumab, the experts considered it a therapeutic option for patients with early SSc and ILD with elevated acute-phase reactants.

CONCLUSIONS

This modified Delphi study generated consensus recommendations for management of patients with SSc-ILD in a real-world setting. Findings from this study provide a management algorithm that will be helpful for treating patients with SSc-ILD and addresses a significant unmet need.

Dyspnea and cough in a 68-year-old female with light chain deposition disease

Light chain deposition disease (LCDD) is a rare hematologic disorder characterized by non-amyloid monoclonal immunoglobulin light chain deposition in multiple organs. Pulmonary LCDD (PLCDD) is an uncommon manifestation of LCDD usually seen in middle-aged patients presenting with radiologic cystic and nodular findings. We report the case of a 68-year-old female who presented with shortness of breath and atypical chest pain. Chest computerized tomography (CT) scan revealed numerous diffuse but basilar predominant pulmonary cysts and mild bronchiectasis without nodular disease. Given concomitant abnormal renal function and hepatic laboratory indices, she underwent biopsy of both organs confirming the presence of LCDD. Directed chemotherapy was initiated and stabilized renal and hepatic progression, but on follow-up imaging, pulmonary disease appeared worse. While therapeutic options targeting other organ involvement are available, their directed efficacy for progressive lung disease is not well known.

Treatment Outcomes for Rheumatoid Arthritis-Associated Interstitial Lung Disease: A Real-World, Multisite Study of the Impact of Immunosuppression on Pulmonary Function Trajectory

BACKGROUND

Rheumatoid arthritis (RA)-associated interstitial lung disease (ILD) is common in patients with RA and leads to significant morbidity and mortality. No randomized, placebo-controlled data are available that support the role of immunosuppression to treat RA-associated ILD, despite being widely used in clinical practice.

RESEARCH QUESTION

How does immunosuppression impact pulmonary function trajectory in a multisite retrospective cohort of patients with RA-associated ILD?

STUDY DESIGN AND METHODS

Patients with RA who started treatment for ILD with mycophenolate, azathioprine, or rituximab were identified retrospectively from five ILD centers. Change in lung function before and after treatment was analyzed using a linear spline mixed-effect model with random intercept. Prespecified secondary analyses examined the impact of radiologic pattern of ILD (ie, usual interstitial pneumonia [UIP] vs non-UIP) on treatment trajectory.

RESULTS

Two hundred twelve patients were included in the analysis: 92 patients (43.4%) were treated with azathioprine, 77 patients (36.3%) were treated with mycophenolate mofetil, and 43 patients (20.3%) were treated with rituximab. In the combined analysis of all three agents, an improvement in FVC % predicted was found after 12 months of treatment compared with the potential 12-month response without treatment (+3.90%; P ≤ .001; 95% CI, 1.95-5.84). Diffusing capacity of the lungs for carbon monoxide (Dlco) % predicted also improved at 12 months (+4.53%; P ≤ .001; 95% CI, 2.12-6.94). Neither the UIP pattern of ILD nor choice of immunosuppressive agent significantly impacted the pulmonary function trajectory on immunosuppression.

INTERPRETATION

Immunosuppression was associated with an improved trajectory in FVC and Dlco compared with the pretreatment pulmonary function trajectory. Prospective, randomized trials are required to validate these findings.

Effect size of rituximab on pulmonary function in the treatment of connective-tissue disease-related interstitial lung disease: a systematic review and meta-analysis

Background

Rituximab (RTX) has been previously reported as directed treatment in patients with connective-tissue disease-related interstitial lung diseases (CTD-ILD). A systematic assessment of treatment effect size on pulmonary function outcomes and related adverse effects in patients with CTD-ILD has not been previously reported.

Methods

We performed a systematic review and meta-analysis of published reports from PubMed, Embase, and Cochrane Libraries. Randomized and non-randomized controlled trials, case–control, cohort, and case series (with five or more cases) containing individual pulmonary function data and adverse effects were included. Study endpoints were pre- and post-treatment change in percent predicted forced vital capacity (FVC %) and diffusion capacity for carbon monoxide (DLCO%), along with reported drug-related adverse events.

Results

Twenty studies totaling 411 patients were identified with 14 included in the meta-analysis of pulmonary function and six in the descriptive review. Random effects meta-analysis of pre- and post-treatment pulmonary function findings demonstrated increases in FVC% (n = 296) (mean difference (MD) 4.57%, [95% CI 2.63–6.51]) and DLCO% (n = 246) (MD 5.0% [95% CI 2.71–7.29]) after RTX treatment. RTX treatment-related adverse effects were reported in 13.6% of the pooled cohort.

Conclusions

A systematic assessment of post-treatment effect size suggests a potential role for RTX in stabilizing or improving lung function in patients with CTD-ILD, with a modest but not insignificant adverse effect profile.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02082-x.

Quantitative CT and machine learning classification of fibrotic interstitial lung diseases

OBJECTIVES

To evaluate quantitative computed tomography (QCT) features and QCT feature-based machine learning (ML) models in classifying interstitial lung diseases (ILDs). To compare QCT-ML and deep learning (DL) models' performance.

METHODS

We retrospectively identified 1085 patients with pathologically proven usual interstitial pneumonitis (UIP), nonspecific interstitial pneumonitis (NSIP), and chronic hypersensitivity pneumonitis (CHP) who underwent peri-biopsy chest CT. Kruskal-Wallis test evaluated QCT feature associations with each ILD. QCT features, patient demographics, and pulmonary function test (PFT) results trained eXtreme Gradient Boosting (training/validation set n = 911) yielding 3 models: M1 = QCT features only; M2 = M1 plus age and sex; M3 = M2 plus PFT results. A DL model was also developed. ML and DL model areas under the receiver operating characteristic curve (AUC) and 95% confidence intervals (CIs) were compared for multiclass (UIP vs. NSIP vs. CHP) and binary (UIP vs. non-UIP) classification performances.

RESULTS

The majority (69/78 [88%]) of QCT features successfully differentiated the 3 ILDs (adjusted p ≤ 0.05). All QCT-ML models achieved higher AUC than the DL model (multiclass AUC micro-averages 0.910, 0.910, 0.925, and 0.798 and macro-averages 0.895, 0.893, 0.925, and 0.779 for M1, M2, M3, and DL respectively; binary AUC 0.880, 0.899, 0.898, and 0.869 for M1, M2, M3, and DL respectively). M3 demonstrated statistically significant better performance compared to M2 (∆AUC: 0.015, CI: [0.002, 0.029]) for multiclass prediction.

CONCLUSIONS

QCT features successfully differentiated pathologically proven UIP, NSIP, and CHP. While QCT-based ML models outperformed a DL model for classifying ILDs, further investigations are warranted to determine if QCT-ML, DL, or a combination will be superior in ILD classification.

KEY POINTS

• Quantitative CT features successfully differentiated pathologically proven UIP, NSIP, and CHP. • Our quantitative CT-based machine learning models demonstrated high performance in classifying UIP, NSIP, and CHP histopathology, outperforming a deep learning model. • While our quantitative CT-based machine learning models performed better than a DL model, additional investigations are needed to determine whether either or a combination of both approaches delivers superior diagnostic performance.

POS0854 BASELINE CHARACTERISTICS OF PATIENTS WITH IMPROVEMENT OR PROGRESSION OF SYSTEMIC SCLEROSIS-ASSOCIATED INTERSTITIAL LUNG DISEASE (SSc-ILD) DURING THE SENSCIS TRIAL

Background

The course of SSc-ILD is variable, and may include periods of stability or even improvement in forced vital capacity (FVC) as well as periods of decline.

Objectives

To investigate the baseline characteristics of patients with SSc-ILD in the placebo group of the SENSCIS trial whose ILD improved or progressed over 52 weeks.

Methods

The SENSCIS trial enrolled patients with SSc with first non-Raynaud symptom in the prior ≤7 years, extent of fibrotic ILD on high-resolution computed tomography (HRCT) ≥10% and FVC ≥40% predicted. Patients who had been taking a stable dose of mycophenolate for ≥6 months were allowed to participate. We investigated the baseline characteristics of patients in the placebo group whose ILD showed improvement (absolute increase in FVC ≥5% predicted), stability (absolute decline or increase in FVC <5% predicted), progression (absolute decline in FVC ≥5% predicted), or significant progression (absolute decline in FVC ≥10% predicted) over 52 weeks. P-values based on ANOVA or Chi-squared tests were used to compare the baseline characteristics of the patients who showed improvement, stability and progression.

Results

Of 288 patients, 21 (7.3%) showed improvement, 166 (57.6%) stability, and 101 (35.1%) ILD progression, of whom 37 (12.8% of all patients) had significant ILD progression over 52 weeks. Most baseline characteristics were similar across the groups based on progression, but there were differences in DLCO % predicted (p=0.02) and in the proportion of patients taking mycophenolate (p=0.09) among patients who showed improvement, stability and progression (Table 1).

Table 1.

Baseline characteristics of patients in the placebo group of the SENSCIS trial in subgroups based on course of SSc-ILD over 52 weeks.

Improvement (n=21)Stability (n=166)Progression (n=101)Significant progression (n=37) (subset of Progression)P-value for comparison of Improvement, Stability, ProgressionAge, years55.9 ± 12.053.2 ± 12.653.1 ± 12.855.3 ± 11.80.64Female71.475.970.373.00.59Years since first non-Raynaud symptom3.7 ± 1.73.5 ± 1.73.5 ± 1.93.6 ± 1.90.81Diffuse cutaneous SSc47.649.453.556.80.78Anti-topoisomerase I antibody positive61.958.466.356.80.44High sensitivity C-reactive protein, mg/L5.1 ± 8.97.8 ± 23.05.6 ± 9.94.2 ± 4.40.62Modified Rodnan skin score9.3 ± 7.310.5 ± 8.411.9 ± 9.712.7 ± 11.30.29History of gastroesophageal reflux disease (GERD)76.272.978.278.40.62Extent (%) of fibrotic ILD on HRCT*26.4 ± 16.235.5 ± 20.436.6 ± 21.840.8 ± 23.50.12Presence of honeycombing on HRCT14.316.815.526.50.94Presence of ground glass opacities on HRCT81.086.689.784.80.51FVC % predicted77.1 ± 18.071.7 ± 17.273.3 ± 15.274.2 ± 14.80.33DLco % predicted61.5 ± 14.953.4 ± 14.851.1 ± 15.147.3 ± 14.50.02Taking mycophenolate71.448.245.535.10.09

Data are mean ± SD or % at baseline. Missing data were excluded. *Assessed visually in whole lung to nearest 5%. The assessment did not include pure (non-fibrotic) ground glass opacities.

Conclusion

These findings suggest that in the SENSCIS trial, patients who had higher DLCO % predicted or who were taking mycophenolate at baseline were less likely to show progression of SSc-ILD over 52 weeks.

Acknowledgements

The SENSCIS trial was funded by Boehringer Ingelheim. Oliver Distler was a member of the SENSCIS trial Steering Committee.

Disclosure of Interests

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Lilly, Medscape, Merck Sharp & Dohme, Roche, Paid instructor for: Boehringer Ingelheim, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Eric Hachulla Speakers bureau: Johnson & Johnson, GlaxoSmithKline, Roche-Chugai; and research funding from CSL Behring, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Consultant of: Bayer, Boehringer Ingelheim, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, Grant/research support from: GlaxoSmithKline, Roche-Chugai, Sanofi-Genzyme, Ariane Herrick Speakers bureau: Janssen, Consultant of: Arena, Boehringer Ingelheim, Camurus, CSL Behring, Gesynta, Grant/research support from: Gesynta, Teng Moua: None declared, Gabriela Riemekasten Speakers bureau: Boehringer Ingelheim, Janssen, Consultant of: Boehringer Ingelheim, Janssen, Madelon Vonk Speakers bureau: Boehringer Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Janssen, MSD, Novartis, Roche, Consultant of: Boehringer Ingelheim, Corbus, Janssen, Grant/research support from: Boehringer Ingelheim, Ferrer, Galapagos, Janssen, Alexandra James Employee of: Alexandra James is an employee of Elderbrook solutions GmbH that is contracted by Boehringer Ingelheim, Margarida Alves Employee of: Margarida Alves is employee of Boehringer Ingelheim, Oliver Distler Speakers bureau: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Speaker fee: Bayer, Boehringer Ingelheim, Janssen, Medscape

, Consultant of: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Consultancy fee: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur

OD has/had relationships with the following companies in the area of potential treatments for arthritides in the last three calendar years:

Consultancy fee: Abbvie

, Grant/research support from: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Research Grants: Boehringer Ingelheim, Kymera, Mitsubishi Tanabe

0715 Diagnosis of Sleep Disordered Breathing in Patients with Interstitial Lung Disease: A Retrospective Evaluation of Polysomnogram and Home Sleep Apnea Testing Using Peripheral Arterial Tonometry

Introduction

Previous studies have shown that sleep disordered breathing (SDB) is common in patients with Interstitial Lung Disease (ILD), and oximetry is often used for screening prior to further diagnostic testing. Current guidelines recommend polysomnography (PSG) for diagnosis of SDB in patients with significant pulmonary disease, however, home sleep apnea tests (HSAT) are increasingly used in clinical practice for a variety of reasons despite lack of evidence regarding accuracy in this population. In this study, we evaluate the correlation between screening oximetry, a commercial brand HSAT (WatchPAT®) and PSG to examine the diagnostic accuracy of this HSAT technology in patients with ILD.

Methods

The institution electronic medical record was screened for patients with a diagnosis code for ILD who underwent screening oximetry followed by PSG or HSAT using peripheral arterial tonometry from July 1, 2012 to present. Clinical review confirmed presence of ILD according to American Thoracic Society guidelines. Among the respective cohorts, Paired Wilcoxon Test was used to compare the oximetry 4% oxygen desaturation index (ODI) to the HSAT ODI and PSG apnea-hypopnea index (AHI) as well as percent time spent below oxyhemoglobin saturation of 89%. Spearman correlation was used to correlate the oximetry ODI and parameters of SDB on HSAT and PSG.

Results

Data was analyzed for 25 patients who had undergone oximetry/HSAT and for 25 patients who had undergone oximetry/PSG. Oximetry ODI showed no significant difference from PSG AHI (p = 0.2635) or between HSAT ODI (p = 0.0755), and no difference was seen in hypoxic time between oximetry and PSG (p = 0.9789). Hypoxic time on HSAT was significantly longer than that on oximetry (p &lt; 0.001). Using HSAT ODI as the standard, HSAT AHI and respiratory disturbance index (RDI) showed rs of 0.9638 and 0.8913 respectively, while oximetry ODI was 0.3893. Compared to PSG AHI, the PSG RDI and oximetry ODI rs were 0.9759 and 0.7407 respectively.

Conclusion

Among patients with ILD, screening oximetry appears to correlate more strongly with indices of SDB and hypoxic time on PSG rather than HSAT. Further studies are warranted to evaluate efficacy of additional HSAT testing modalities in this patient population.

Support (If Any)

 

Developing a conceptual model of symptoms and impacts in progressive fibrosing interstitial lung disease to evaluate patient-reported outcome measures

Background

An understanding of the experience of patients with progressive fibrosing interstitial lung disease (PF-ILD) is needed to select appropriate patient-reported outcome measures (PROMs) to evaluate treatment effect in clinical trials.

Methods

A systematic literature review was conducted to develop a preliminary conceptual model of the symptoms experienced by patients with PF-ILD and the impacts the disease has on them. An online survey and consensus meetings were then conducted with 12-14 stakeholders (patients, clinicians, regulatory and payer advisors) to refine the conceptual model and critically appraise how key concepts should be measured by PROMs. PROMs assessed included Living with Idiopathic Pulmonary Fibrosis, Living with Pulmonary Fibrosis, the King's Brief Interstitial Lung Disease questionnaire, Cough and Sputum Assessment Questionnaire, Evaluating Respiratory Symptoms, Leicester Cough Questionnaire, Functional Assessment of Chronic Illness Therapy (Dyspnoea/Fatigue) and St George's Respiratory Questionnaire for Idiopathic Pulmonary Fibrosis.

Results

The literature review identified 36 signs/symptoms and 43 impacts directly or indirectly related to pulmonary aspects of PF-ILD. The most relevant symptoms identified by participants included shortness of breath on exertion, fatigue and cough; relevant impacts included effects on physical functioning, activities of daily living and emotional wellbeing. These are presented in a conceptual model. Consensus opinion was that existing PROMs need further modification and validation before use in clinical trials.

Conclusions

The conceptual model improves understanding of the symptoms and impacts that living with PF-ILD has on patients' wellbeing. It can help to inform the choice of PROMs in clinical trials and highlight aspects to assess in the clinical care of patients with PF-ILD.

Late Complications of COVID-19: A Morphologic, Imaging, and Droplet Digital Polymerase Chain Reaction Study of Lung Tissue

CONTEXT

Studies of lungs in patients with COVID-19 have focused on early findings.

OBJECTIVE

To systematically study histopathologic, imaging features and presence of SARSCoV-2 RNA in lung tissue from patients in later stages of COVID-19.

DESIGN

Autopsies, explants, surgical lung biopsies; and transbronchial, cryo, and needle biopsies were studied from patients with COVID-19, whose onset of symptoms/confirmed diagnosis was more than 28 days before the procedure. Available images were reviewed. Reverse transcription droplet digital polymerase chain reaction (RT-ddPCR) for SARS-CoV-2 RNA was performed on lung tissue.

RESULTS

Forty-four specimens (43 patients, median age 59.3 years, 26 [60.5%] male) showed features of acute lung injury (ALI) in 39 (88.6%), predominantly organizing pneumonia (OP) and diffuse alveolar damage (DAD), up to 298 days after onset of COVID-19. Fibrotic changes were found in 33 specimens (75%), most commonly fibrotic DAD (N=22) and cicatricial OP (N=12). Time between acquiring COVID-19 and specimen was shorter in patients with diffuse ALI (median 61.5 days) compared to patients with focal (140 days) or no ALI (130 days) (P=.009). Sixteen (of 20, 80%) SARS-CoV-2 RT-ddPCR tests were positive, up to 174 days after COVID-19 onset. Time between COVID-19 onset and most recent CT in patients with consolidation on imaging was shorter (median 43.0 days) versus patients without consolidation (87.5 days; P=.02). Reticulations were associated with longer time after COVID-19 onset to CT (median 82 days vs 23.5 days, P=.006).

CONCLUSIONS

ALI and SARS-CoV-2 RNA can be detected in patients with COVID-19 for many months. ALI may evolve into fibrotic interstitial lung disease.

Challenges in the Diagnosis and Management of Fibrotic Hypersensitivity Pneumonitis: A Practical Review of Current Approaches

Recent advances in fibrotic hypersensitivity pneumonitis include improved diagnostic guidance, systematic assessments of immunosuppressive therapy, and the recent availability of antifibrotic therapy (nintedanib) for those with progressive disease. A standardized approach to diagnosis may lead to better inclusion criteria for future therapeutic protocols and delineation of disease or treatment response predictors for real-world management. This review will highlight current diagnostic and treatment challenges and remaining knowledge gaps or areas of uncertainty, with a practical overview of supporting evidence and its clinical implications. Exposure history, serologic testing for antigen sensitivity, bronchoalveolar lavage lymphocytosis, histopathology, and radiologic findings will be covered in the diagnosis section, with immunosuppression, antifibrotic therapy, lung transplantation, and disease prognosis in the treatment and management section.

Antigen Identification and Avoidance on Outcomes in Fibrotic Hypersensitivity Pneumonitis

Suspected causative antigens may be unidentified in 30-50% of patients with fibrotic hypersensitivity pneumonitis (f-HP). It is unclear if antigen identification and avoidance in this setting offer any additional clinical benefit. We hypothesised that antigen identification and avoidance may improve the clinical course of patients with fibrotic disease.Patients meeting recent international practice guidance for f-HP diagnosis evaluated at Mayo Clinic Rochester from January 2005 to December 2018 were included. Causative antigen and antigen avoidance were specifically defined and ascertained through review of the medical records. Cox proportional-hazards regression was performed to assess antigen identification and avoidance as predictors of either all-cause mortality or lung transplantation.A total of 377 patients were included. Of these, suspected causative antigen was identified in 225 (60%). Identification of a suspected antigen (adjusted HR of 0.69 [95% CI, 0.48-0.99]; p=0.04) and subsequent antigen avoidance (adjusted HR of 0.47 [95% CI, 0.31-0.71]; p<0.001) were associated with decreased all-cause mortality and transplantation. Both those with suspected antigen identification but non-avoidance and those with unidentifiable antigen had increased risk of all-cause mortality or transplantation (adjusted HR 2.22 [95% CI, 1.34-3.69]; p=0.002 versus adjusted HR 2.09 [95% CI, 1.34-3.26]; p=0.001, respectively). Exposure to avian antigen was associated with better outcome compared to other antigen subtypes (adjusted HR 0.63 [95% CI 0.43-0.93]; p=0.02).Our findings suggest antigen identification and antigen avoidance remain relevant even in patients with fibrotic disease, where both appear to be associated with improved outcomes.

Bronchoalveolar lavage lymphocytosis in hypersensitivity pneumonitis: a retrospective cohort analysis with elimination of incorporation bias

Background

Recent studies support the diagnostic role of bronchoalveolar lavage lymphocytosis (BALL) in patients with suspected hypersensitivity pneumonitis (HP). Our study aim was to determine the spectrum of BALL findings with elimination of incorporation bias in non-fibrotic and fibrotic patients and assess correlates of positive BALL cut-off and BALL association with long-term outcomes in those with fibrotic disease (f-HP).

Methods

A single-center retrospective cohort study was pursued of patients undergoing diagnostic bronchoscopy for interstitial lung disease. Strict study enrollment was based on recent ATS/JRS/ALAT diagnostic guidance meeting ‘moderate’ or higher diagnostic confidence. BALL findings were assessed in both fibrotic and non-fibrotic HP patients with regression and survival analysis pursued for correlates of positive BALL cut-off and long-term outcome.

Results

A total of 148 patients (88 fibrotic and 60 non-fibrotic) meeting moderate or higher diagnostic confidence were included. Median BALL in f-HP was 15% compared to 19% in non-fibrotic patients, with only 28% of f-HP meeting diagnostic cut-off (≥ 30%) compared to 41% of non-fibrotic. For f-HP, centrilobular nodules on computed tomography was positively correlated with a diagnostic BALL (OR 4.07; p = 0.018) while honeycombing was negatively correlated (OR 6.9 × e⁻⁸; p = 0.001). Higher BALL was also associated with lower all-cause mortality (HR 0.98; p = 0.015).

Conclusion

With elimination of incorporation bias, most patients with well-described HP did not meet diagnostic BALL thresholds. Higher BALL was associated with better long-term survival in those with fibrosis, but its diagnostic role may be more additive than characteristic or distinguishing.

Acute exacerbation of interstitial lung disease in the intensive care unit

Acute exacerbations of interstitial lung disease (AE-ILD) represent an acute, frequent and often highly morbid event in the disease course of ILD patients. Admission in the intensive care unit (ICU) is very common and the need for mechanical ventilation arises early. While non-invasive ventilation has shown promise in staving off intubation in selected patients, it is unclear whether mechanical ventilation can alter the exacerbation course unless it is a bridge to lung transplantation. Risk stratification using clinical and radiographic findings, and early palliative care involvement, are important in ICU care. In this review, we discuss many of the pathophysiological aspects of AE-ILD and raise the hypothesis that ventilation strategies used in acute respiratory distress syndrome might be implemented in AE-ILD. We present possible decision-making and management algorithms that can be used by the intensivist when caring for these patients.

Impact of Antifibrotic Therapy on Mortality and Acute Exacerbation in Idiopathic Pulmonary Fibrosis: A Systematic Review and Meta-Analysis

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a progressive fibrosing interstitial lung disease associated with significant morbidity and mortality. Nintedanib and pirfenidone are two antifibrotic medications currently approved for slowing the rate of lung function decline in IPF, but data on treatment effect on mortality and risk of acute exacerbation (AE) remains limited or unknown.

RESEARCH QUESTION

Does antifibrotic treatment decrease risk of mortality and AE?

STUDY DESIGN AND METHODS

A comprehensive search of several databases, including Ovid MEDLINE(R), Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus, was conducted. Studies were included if they were original articles comparing mortality or AE events in IPF patients with and without antifibrotic treatment. Relative risk (RR) with 95%CI was pooled using random-effects meta-analyses with inverse variance method, assessing two primary outcomes of all-cause mortality and AE risk.

RESULTS

A total of 12,956 patients across 26 studies (eight randomized controlled trials and 18 cohort studies) were included in the meta-analysis. Antifibrotic treatment was associated with decreased risk of all-cause mortality with a pooled RR of 0.55 (95% CI, 0.45-0.66) and I2 of 82%. This effect was consistent across additional subgroup analyses, including stratification by study type, risk of bias, duration of follow-up, and antifibrotic subtype. Antifibrotic treatment also reduced the risk of AE, with a pooled RR of 0.63 (95% CI, 0.53-0.76), and I2 of 0%. Effect on AE risk was consistent across subgroup analyses by study type and for nintedanib but not for pirfenidone.

INTERPRETATION

Antifibrotic treatment appears to reduce the risk of all-cause mortality and AE in IPF. Despite greater heterogeneity with pooled analysis, its effect was robust in subgroup analyses by study type, duration of follow-up, and antifibrotic subtype.

Derivation and validation of a prediction model for histopathologic fibrotic hypersensitivity pneumonitis

BACKGROUND

Clinical differentiation of fibrotic hypersensitivity pneumonitis (f-HP) remains challenging given variable and overlapping presentations with other fibrotic interstitial lung disease (f-ILD).

OBJECTIVE

We derived a multivariable model for predicting histopathologic f-HP to better inform multidisciplinary team discussion (MDD) diagnosis, particularly when biopsy may be unsafe or cannot be achieved.

METHODS

Patients with histopathologically-defined f-HP and other overlapping f-ILD were reviewed for distinguishing clinical and radiological variables. Using elastic net logistic regression, a penalized regression approach to minimize overfitting, a clinical model built on non-invasive assessments was derived for the prediction of histopathologic f-HP. This model was then validated in an independently derived external cohort from three sites.

RESULTS

The derivation and validation cohorts consisted of 248 (84 cHP and 164 other f-ILD) and 157 (82 f-HP and 75 other f-ILD) histopathologically-defined patients, respectively (total study N = 405). Variables retained from the elastic net model included age in years (regression coefficient 0.033), male sex (-1.109), positive exposure history (1.318), percent predicted forced vital capacity (-0.021), radiologic peribronchovascular axial ILD distribution (0.199), mid (-0.22) or lower lobe (-0.839) craniocaudal or patchy (0.287) ILD distribution, upper (1.188) or equivalent upper and lower lobe (0.237) traction bronchiectasis, mosaic attenuation (1.164), and centrilobular nodules (2.045). Bias corrected AUC was 0.84 (standard error = 0.02) for the derivation cohort and 0.80 (CI 0.73-0.87) for the validation cohort.

CONCLUSIONS

This multivariable model demonstrated good predictive performance for delineating histopathologically-defined f-HP from other f-ILD as a means of avoiding or justifying biopsy and supporting MDD diagnostic confidence.

Nintedanib in progressive interstitial lung diseases: data from the whole INBUILD trial

Background

The primary analysis of the INBUILD trial showed that in subjects with progressive fibrosing interstitial lung diseases (ILDs), nintedanib slowed the decline in forced vital capacity (FVC) over 52 weeks. We report the effects of nintedanib on ILD progression over the whole trial.

Methods

Subjects with fibrosing ILDs other than idiopathic pulmonary fibrosis, who had ILD progression within the 24 months before screening despite management deemed appropriate in clinical practice, were randomised to receive nintedanib or placebo. Subjects continued on blinded randomised treatment until all subjects had completed the trial. Over the whole trial, mean±sd exposure to trial medication was 15.6±7.2 and 16.8±5.8 months in the nintedanib and placebo groups, respectively.

Results

In the nintedanib (n=332) and placebo (n=331) groups, respectively, the proportions of subjects who had ILD progression (absolute decline in FVC ≥10% predicted) or died were 40.4% and 54.7% in the overall population (hazard ratio (HR) 0.66, 95% CI 0.53–0.83; p=0.0003) and 43.7% and 55.8% among subjects with a usual interstitial pneumonia (UIP)-like fibrotic pattern on high-resolution computed tomography (HRCT) (HR 0.69, 95% CI 0.53–0.91; p=0.009). In the nintedanib and placebo groups, respectively, the proportions who had an acute exacerbation of ILD or died were 13.9% and 19.6% in the overall population (HR 0.67, 95% CI 0.46–0.98; p=0.04) and 15.0% and 22.8% among subjects with a UIP-like fibrotic pattern on HRCT (HR 0.62, 95% CI 0.39–0.97; p=0.03).

Conclusion

Based on data from the whole INBUILD trial, nintedanib reduced the risk of events indicating ILD progression.

In patients with fibrosing ILDs other than IPF who had shown progression of ILD within the prior 2 years, events indicating further progression occurred frequently. Over a 16-month period, nintedanib reduced the risk of such events versus placebo.https://bit.ly/3yiZXnS

Outcomes for hospitalized patients with idiopathic pulmonary fibrosis treated with antifibrotic medications

Background

Idiopathic Pulmonary Fibrosis is a chronic, progressive interstitial lung disease for which there is no cure. However, lung function decline, hospitalizations, and mortality may be reduced with the use of the antifibrotic medications, nintedanib and pirfenidone. Historical outcomes for hospitalized patients with Idiopathic Pulmonary Fibrosis are grim; however there is a paucity of data since the approval of nintedanib and pirfenidone for treatment. In this study, we aimed to determine the effect of nintedanib and pirfenidone on mortality following respiratory-related hospitalizations, intensive care unit (ICU) admission, and mechanical ventilation.

Methods

Using a large U.S. insurance database, we created a one-to-one propensity score matched cohort of patients with idiopathic pulmonary fibrosis treated and untreated with an antifibrotic who underwent respiratory-related hospitalization between January 1, 2015 and December 31, 2018. Mortality was evaluated at 30 days and end of follow-up (up to 2 years). Subgroup analyses were performed for all patients receiving treatment in an ICU and those receiving invasive and non-invasive mechanical ventilation during the index hospitalization.

Results

Antifibrotics were not observed to effect utilization of mechanical ventilation or ICU treatment during the index admission or effect mortality at 30-days. If patients survived hospitalization, mortality was reduced in the treated cohort compared to the untreated cohort when followed up to two years (20.1% vs 47.8%).

Conclusions

Treatment with antifibrotic medications does not appear to directly improve 30-day mortality during or after respiratory-related hospitalizations. Post-hospital discharge, however, ongoing antifibrotic treatment was associated with improved long-term survival.

Detection and Management of Interstitial Lung Diseases Associated With Connective Tissue Diseases

Interstitial lung disease (ILD) is a common manifestation of connective tissue diseases (CTDs). A proportion of patients with CTD-ILDs develop progressive fibrosing ILD, which is characterized by worsening fibrotic abnormalities on high-resolution computed tomography scan, decline in lung function, worsening symptoms, and early mortality. Here, we review the impact of ILD in patients with CTDs, the importance of prompt diagnosis and close monitoring, and the evidence available to guide the management of CTD-ILDs. Management of patients with CTD-ILDs should be individualized and involve close collaboration between rheumatologists and pulmonologists. Immunosuppression is the mainstay of therapy for CTDs, but evidence for its effectiveness in slowing the progression of ILD is limited. Recently, nintedanib has been approved to slow decline in lung function in patients with systemic sclerosis-associated ILD and chronic fibrosing ILDs with a progressive phenotype. The results of ongoing clinical trials will help clinicians take a more evidence-based approach to the treatment of CTD-ILDs.

Patient-reported quality of life in fibrotic interstitial lung disease: novel assessments of self-management ability and affect

Current medical therapy in the treatment of fibrotic interstitial lung disease (f-ILD) is focused on objective improvement or stabilisation of lung function decline as represented by raw or per cent predicted forced vital capacity (FVC % pred). Patient-reported quality of life (PR-QoL) outcomes, as measured from the viewpoint of how patients assess their own health-related well-being, have not been the primary targets of recent clinical trials. However, it has been reported that lung function (i.e. measured FVC % pred) in f-ILD correlates poorly with patient-reported well-being [1]. This study explored the degree to which two previously unassessed PR-QoL outcomes in f-ILD correlate with clinical and functional parameters, and a respiratory-related QoL instrument applied in a novel manner.

Patient-reported outcomes in fibrotic interstitial lung disease may be additionally predicted by novel assessments of self-management ability and affecthttps://bit.ly/3iwP5M2

Lung cancer in combined pulmonary fibrosis and emphysema: a large retrospective cohort analysis

Background

Combined pulmonary fibrosis and emphysema (CPFE) is characterised by upper lobe emphysema and lower lobe fibrosis. Our study aim was to determine the incident risk, presenting characteristics and outcome of lung cancer diagnoses in a cohort of CPFE patients over time.

Materials and methods

We conducted a retrospective cohort study assessing patients with radiological CPFE followed over a median of 76 months (range 1–237 months). Interval development of lung cancer and clinicopathological characteristics of those with and without lung cancer were compared and survival analysis performed.

Results

Lung cancer occurred in 26 (11.6%) out of 230 CPFE patients, dominated by nonsmall cell lung cancer (88%, n=23) with squamous cell carcinoma comprising the majority (57%, n=13). There was a predominance of lower lobe (62%) and subpleural (64%) radiological presentation. Survival was reduced for the whole cohort by lung cancer even after adjusting for a priori covariables of age, sex, smoking pack-years, presenting forced vital capacity and radiological honeycombing. Univariable predictors of increased mortality after lung cancer diagnosis included honeycombing (hazard ratio (HR) 3.03, 95% CI 1.16–7.91; p=0.02) and later stage presentation (HR 4.77, 95% CI 1.8–14.94; p=0.001), with those able to undergo surgical resection having better survival (HR 0.29, 95% CI 0.09–0.87; p=0.02).

Conclusion

Lung cancer occurred in 26 (11.6%) out of 230 CPFE patients and was dominated by squamous cell carcinoma presenting in a lower lobe peripheral distribution. Surgical resection appeared to improve survival in selected patients with earlier stage disease. Further studies are needed to develop a relevant screening programme for CPFE patients.

Lung cancer is common in CPFE patients followed over time, with possibly better survival in those diagnosed at earlier stages and successfully resected. Further studies to formulate disease-specific cancer screening protocols are needed.https://bit.ly/3445Bxr

Consensus Guidelines for Evaluation and Management of Pulmonary Disease in Sjögren's

Background

Pulmonary disease is a potentially serious yet underdiagnosed complication of Sjögren’s syndrome, the second most common autoimmune rheumatic disease. Approximately 16% of patients with Sjögren’s demonstrate pulmonary involvement with higher mortality and lower quality of life.

Research Question

Clinical practice guidelines for pulmonary manifestations of Sjögren’s were developed by the Sjögren’s Foundation after identifying a critical need for early diagnosis and improved quality and consistency of care.

Study Design and Methods

A rigorous and transparent methodology was followed according to American College of Rheumatology guidelines. The Pulmonary Topic Review Group (TRG) developed clinical questions in the PICO (Patient, Intervention, Comparison, Outcome) format and selected literature search parameters. Each article was reviewed by a minimum of two TRG members for eligibility and assessment of quality of evidence and strength of recommendation. Guidelines were then drafted based on available evidence, expert opinion, and clinical importance. Draft recommendations with a clinical rationale and data extraction tables were submitted to a Consensus Expert Panel for consideration and approval, with at least 75% agreement required for individual recommendations to be included in the final version.

Results

The literature search revealed 1,192 articles, of which 150 qualified for consideration in guideline development. Of the original 85 PICO questions posed by the TRG, 52 recommendations were generated. These were then reviewed by the Consensus Expert Panel and 52 recommendations were finalized, with a mean agreement of 97.71% (range, 79%-100%). The recommendations span topics of evaluating Sjögren’s patients for pulmonary manifestations and assessing, managing, and treating upper and lower airway disease, interstitial lung disease, and lymphoproliferative disease.

Interpretation

Clinical practice guidelines for pulmonary manifestations in Sjögren’s will improve early identification, evaluation, and uniformity of care by primary care physicians, rheumatologists, and pulmonologists. Additionally, opportunities for future research are identified.

Bronchoscopic Cryobiopsy and Forceps Biopsy for the Diagnostic Evaluation of Diffuse Parenchymal Lung Disease in Clinical Practice

Objective

To assess the contribution and safety of bronchoscopic cryobiopsy vs traditional forceps biopsy used in clinical practice for diagnosing diffuse parenchymal lung disease (DPLD).

Patients and Methods

We identified 271 patients who underwent bronchoscopic biopsy for DPLD at Mayo Clinic, MN (June 1, 2013, through September 30, 2017). Medical records were reviewed including prebiopsy clinical and radiographic impressions. Diagnostic yield was assessed in terms of a specific histologic pattern resulting in a diagnosis when combined with the clinical-radiologic context. Clinical utility was defined as a biopsy result deemed useful in patient management.

Results

The cohort included 120 cryobiopsy and 151 forceps biopsy cases with mean age 61±14 years and 143 (53%) men. Diagnostic yield (55% vs 41%; odds ratio [OR], 1.73; 95% CI, 1.07 to 2.83; P=.026) and clinical utility (60% vs 40%; OR, 2.21; 95% CI, 1.36 to 3.63; P=.001) were higher for the cryobiopsy group, and the association remained after control for prebiopsy clinical impressions (OR, 2.21; 95% CI, 1.22 to 4.08; P=.010 and OR, 3.23; 95% CI, 1.76 to 6.10; P<.001, respectively). However, pneumothorax (5.4% vs 0.7%; P=.022) and serious bleeding (7.1% vs 0%; P=.001) rates were higher for the cryobiopsy group. Thirty-day mortality was 1.6% in the cryobiopsy group vs 0% for the forceps biopsy group (P=.20).

Conclusion

Bronchoscopic cryobiopsy revealed higher diagnostic yield and clinical utility than did forceps biopsy. However, procedure-related complications were higher in the cryobiopsy group. The choice of bronchoscopic biopsy procedure for patients with DPLD depends on the clinicalradiologic context.

Exposure assessment in hypersensitivity pneumonitis: a comprehensive review and proposed screening questionnaire

Hypersensitivity pneumonitis is an immune-mediated inflammatory lung disease characterised by the inhalation of environmental antigens leading to acute and chronic lung injury. Along with suggestive clinical and radiological findings, history and timing of suspected antigen exposure are important elements for diagnostic confidence. Unfortunately, many diagnoses remain tentative and based on vague and imprecise environmental or material exposure histories. To date, there has not been a comprehensive report highlighting the frequency and type of environmental exposure that might lead to or support a more systematic approach to antigen identification. We performed a comprehensive literature review to identify and classify causative antigens and their associated environmental contexts or source materials, with emphasis on the extent of the supportive literature for each exposure type. Eligible publications were those that reported unique inciting antigens and their respective environments or contexts. A clinical questionnaire was then proposed based on this review to better support diagnosis of hypersensitivity pneumonitis when antigen testing or other clinical and radiological variables are inconclusive or incomplete.

Mechanical Ventilation and Predictors of In-Hospital Mortality in Fibrotic Interstitial Lung Disease With Acute Respiratory Failure: A Cohort Analysis Through the Paradigm of Acute Respiratory Distress Syndrome

OBJECTIVES

Prior studies report significant mortality in fibrotic interstitial lung disease patients undergoing mechanical ventilation. Little is known about baseline characteristics or ventilator strategies that might improve outcomes. We analyzed the ventilator characteristics of a large cohort of fibrotic interstitial lung disease patients from the perspective of an acute respiratory distress syndrome paradigm to see if any specific mechanical ventilation strategies might improve in-hospital mortality.

DESIGN

Retrospective cohort study.

SETTING

Single-center, multihospital medical ICUs.

PATIENTS

Consecutive fibrotic interstitial lung disease patients who experienced mechanical ventilation for acute respiratory failure.

INTERVENTIONS

Interstitial lung disease characteristics, demographics, and ventilator variables were analyzed for univariable and multivariable predictors of in-hospital mortality, adjusted for confounding with an a priori causation model.

MEASUREMENTS AND MAIN RESULTS

A total of 111 patients accounted for 114 admissions. Idiopathic pulmonary fibrosis comprised 34% with idiopathic acute exacerbation (65%) being the most common admission type. Ninety-five percent were initiated on mandatory volume-control ventilation with only 50% achieving a low tidal volume strategy (plateau pressure ≤ 30 cm H2O) within 3 hours of intubation. Unadjusted clinical predictors of in-hospital mortality included age (unit odds ratio, 1.05; 1.01-1.10; p = 0.015), time from admission to intubation (hr) (unit odds ratio, 1.01; 1.01-1.03; p = 0.017), and use of paralytics (relative risk, 1.54; 1.26-1.90, p < 0.001). Adjusted mechanical ventilation-related predictors of in-hospital mortality included achieving early targeted plateau pressures (odds ratio, 0.23; 0.07-0.76; p = 0.016), PaO2/FIO2 ratio at 3 (unit odds ratio, 0.98; 0.96-0.99, p = 0.002) and 48 hours (unit odds ratio, 0.98; 0.97-0.99, p = 0.018), initial mean airway pressure (unit odds ratio, 1.13; 1.02-1.28, p = 0.019), and total net fluid status (mL) (unit odds ratio, 1.01; 1.001-1.02, p = 0.0001).

CONCLUSIONS

Several factors predict in-hospital mortality in fibrotic interstitial lung disease-associated mechanical ventilation when viewed through an acute respiratory distress syndrome model. Further research is needed to refine strategies that may perhaps improve survival if mechanical ventilation is pursued in this set of patients.

Amyloid in the Lung

Amyloidosis is the term given to abnormal deposition of misfolded precursor proteins at single or multiple sites, leading to organ dysfunction or clinical signs and symptoms. Pulmonary manifestations are nonspecific and may be associated with several amyloid protein subtypes, commonly AL (light chain) and AA (autoimmune) amyloids. Signs or symptoms of amyloid disease may often involve more of the clinical abnormalities of other affected organs than the lungs themselves. Radiologic pulmonary findings include septal and parenchymal ground glass or nodular infiltrates, multiple nodules, cysts, and focal tracheobronchial abnormalities. Lymphadenopathy with or without calcification and pleural effusions has also been reported. Directed therapy is initiated in response to clinical signs or symptoms often as a result of systemic or secondary diseases or conditions. Long-term prognosis is more dependent on the extent of organ involvement where morbidity is often the highest in those with multisystemic disease.

Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

Treatment of the Connective Tissue Disease-Related Interstitial Lung Diseases: A Narrative Review

Interstitial lung disease (ILD) is a frequent complication of patients with connective tissue disease (CTD) and significantly affects morbidity and mortality. Disease course may vary from stable or mildly progressive to more severe, with rapid loss of lung function. We conducted a search of PubMed (National Library of Medicine) and the Web of Science Core Collection using the key words lung, pulmonary, pneumonia, pneumonitis, and alveolar and subtypes of CTD. All clinical studies from January 1, 1980, through September 1, 2018, were reviewed for descriptions of specific therapies and their efficacy or safety and were categorized as controlled interventional trials, observational prospective or retrospective cohort studies, case series (>5 patients), and case reports (<5 patients). Low-quality reports (<5 patients) before 2000, reviews, editorials, popular science papers, and letters to the editor without complete descriptions of the therapies used or their outcomes were excluded. Directed therapy for CTD-ILD is dominated by empirical use of immunosuppressive agents, with the decision to treat, treatment choice, and treatment duration limited to cases and cohort observations. Only a few higher-level controlled studies were available specifically in scleroderma-related ILD. We summarize herein for the clinician the published treatment scope and experience, highlighted clinical response, and common adverse reactions for the management of CTD-ILD.

Differences in Clinical Characteristics and Outcomes Between Men and Women With Idiopathic Pulmonary Fibrosis: A Multicenter Retrospective Cohort Study

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a disease with a male predominance. Prior data suggest that male sex is associated with disease progression and survival. The basis for this sex difference is unknown.

RESEARCH QUESTION

Are there differences in clinical disease characteristics and outcomes between men and women with IPF?

STUDY DESIGN AND METHODS

Two tertiary care center IPF cohorts were pooled to analyze sex differences in outcomes of time to lung transplantation or death. Predictors of outcome that were analyzed included age, FVC % predicted, diffusion capacity for carbon monoxide (Dlco) % predicted, BMI, smoking history, and respiratory variables of cough, phlegm, and need for supplemental oxygen. The associations of these factors with mortality were estimated by sex and then compared using tests for interaction.

RESULTS

There were a total of 1,263 patients in the pooled cohort with follow-up data; approximately 71% of the patients were men. Male sex was independently associated with higher risk for death or lung transplantation after adjusting for age, FVC % predicted, and Dlco % predicted (hazard ratio for men, 1.4; 95% CI, 1.2-1.7; P < .001). Older age, lower Dlco % predicted, and presence of cough or phlegm were negatively associated with transplant-free survival in men but not in women, but only the association for cough differed statistically by sex (interaction P = .007).

INTERPRETATION

Male sex is associated with worse transplant-free survival in IPF. Cough may be a sex-specific predictor of survival in this population.

Pulmonary nodular and cystic light chain deposition disease: A retrospective review of 10 cases

INTRODUCTION

Light chain deposition disease (LCDD) rarely involves the lungs. We report clinical and radiologic findings of pulmonary LCDD.

METHODS

We retrospectively identified patients with biopsy-proven pulmonary LCDD seen at Mayo Clinic (Rochester, Minnesota) from January 1997 through December 2018. Demographic, clinical, and imaging features were analyzed.

RESULTS

We identified 10 patients with pulmonary LCDD (median age at diagnosis, 55 years; range, 39-77 years). Eight patients were women and 7 were never-smokers. Dyspnea (n = 3) and chest pain (n = 3) were the most common respiratory symptoms. Associated conditions included Sjögren syndrome (n = 6), sarcoidosis (n = 1), and limited scleroderma (n = 1). Eight patients had mucosa-associated lymphoid tissue (MALT) lymphoma. Among the 9 patients with chest computed tomography (CT) images, 8 (89%) had cysts. Cysts were predominantly distributed in the lower lung and were round or oval. All patients had multiple cysts (5 patients had 1-5 cysts, 3 had >20 cysts). The median diameter of the largest cyst was 18 mm (range, 5-68 mm). All 9 patients had solid nodules (3 had >10 nodules). Five patients had subsolid nodules. The median diameter of the largest solid nodules was 13 mm (range, 6-26 mm). Positron emission tomography-CT images were available for 8 patients. The median maximum standardized uptake value of the most avid pulmonary nodule was 2.2 (range, 1.9-6.0). Two patients died during a median follow-up of 2.3 years (range, 0.5-9.9 years).

CONCLUSIONS

Pulmonary LCDD is characterized by cysts and nodules. The disease is associated with MALT lymphoma, especially in the setting of Sjögren syndrome.

Longitudinal prediction of outcome in idiopathic pulmonary fibrosis using automated CT analysis

The advent of antifibrotic agents [1, 2] as standard of care in idiopathic pulmonary fibrosis (IPF) requires that new non-inferiority IPF drug trials will need to identify smaller declines of forced vital capacity (FVC). Marginal annualised FVC declines (between 5.00 and 9.99%) are particularly challenging to interpret as they might reflect measurement variation or genuine clinical deterioration [3]. Following on from previous baseline-only computed tomography (CT) analyses [4], the current study examined whether changes in computer features (CALIPER) across serial CT examinations could be considered as a trial co-endpoint, particularly with regard to adjudicating marginal FVC declines, and therefore improve the sensitivity of IPF drug trials.

Change in the vessel-related structures, a computer-derived CT variable, is a strong predictor of outcome in idiopathic pulmonary fibrosis and can increase power in future drug trials when used as a co-endpoint alongside forced vital capacity changehttp://bit.ly/2M7DfKS

Comparing effectiveness of prognostic tests in idiopathic pulmonary fibrosis

Introduction: Idiopathic pulmonary fibrosis (IPF) is a debilitating and progressive fibrotic interstitial lung disease often resulting in death over several years. Prediction of disease course or survival remains of keen interest for clinicians and patients though a commonly used test or tool remain elusive. Areas covered: We undertook a comprehensive review of the published literature highlighting prognostic indicators and predictors of survival in IPF. Baseline and longitudinal clinical, functional, histopathologic, and radiologic findings have been extensively studied as prognostic predictors, both individually and in composite models. Recent approaches include automated quantifiable radiologic scoring, circulating biomarkers, and genetic polymorphisms or abnormalities. This review highlights individual and composite predictors and their relative utility in clinical practice and research studies. Expert opinion: There is a growing body of knowledge highlighting readily available individual and composite predictors of outcome, though none have come to the forefront for common clinical use. Recent advances include quantitative imaging analysis, circulating serologic markers, and genetic testing, which may be more standardized and less prone to lead-time bias or related complications and comorbidities.

Obstacles to early treatment of idiopathic pulmonary fibrosis: current perspectives

Idiopathic pulmonary fibrosis is a progressive and fatal fibrotic lung disease which has seen new opportunity for drug treatment in the last several years with the approval of nintedanib and pirfenidone, two antifibrotic agents aimed at slowing decline in lung function as defined by FVC on pulmonary function testing. Despite these promising effects, delays in drug initiation have been reported undermining the premise that earlier drug initiation may sustain lung function and prolong survival. This review explores obstacles to earlier treatment, inclusive of defining so-called early idiopathic pulmonary fibrosis, difficulties in achieving a confident diagnosis in that setting, and uncertainties regarding drug-related benefits among specific patient subgroups such as those with no symptoms or advanced disease at presentation. Goals of therapy balanced with the burdens associated with antifibrotic drug therapy are negotiated on an individual basis. We review the evidence for and against earlier initiation of antifibrotic drug therapy along with its role in patient-centered outcomes.

Healthcare utilisation and costs in the diagnosis and treatment of progressive-fibrosing interstitial lung diseases

There are over 200 interstitial lung diseases (ILDs). In addition to patients with idiopathic pulmonary fibrosis (IPF), a percentage of patients with other ILDs also develop progressive fibrosis of the lung during their disease course. Patients with progressive-fibrosing ILDs may show limited response to immunomodulatory therapy, worsening symptoms and lung function and, ultimately, early mortality. There are few data for ILDs that may present a progressive fibrosing phenotype specifically, but we believe the burden and healthcare costs associated with these conditions may be comparable to those reported in IPF. This review discusses the burden of ILDs that may present a progressive fibrosing phenotype and the factors impacting healthcare utilisation.

Combined pulmonary fibrosis and emphysema as a clinicoradiologic entity: Characterization of presenting lung fibrosis and implications for survival

BACKGROUND

The prevalence of classifiable and unclassifiable causes of lung fibrosis and its implications for survival are mostly unknown in combined pulmonary fibrosis and emphysema (CPFE).

MATERIALS AND METHODS

Patients with >10% involvement of both emphysema and lung fibrosis seen over 11 years at our institution were reviewed independently by expert radiologists for fibrotic and emphysematous findings and overall fibrotic CT pattern. Underlying interstitial lung disease (ILD) diagnoses and baseline demographic and clinical characteristics were collated and assessed for predictors of comparative survival.

RESULTS

In this retrospective cohort, 179 CPFE patients were identified and categorized as 58 usual interstitial pneumonia/idiopathic pulmonary fibrosis (UIP/IPF) (32%), 42 secondary ILD (23%), and 79 unclassifiable ILD (44%). The most prevalent (47%) radiologic pattern was 'unclassifiable', followed by 'consistent' and 'possible' UIP pattern in 38%. Adjusted predictors of mortality for the cohort as a whole included age (HR 1.03[1.01-1.06], P = 0.002), percent predicted diffusing capacity for carbon monoxide (unit HR 0.97 [0.96-0.99], P = 0.001), honeycombing (HR 1.58 [1.02-2.43], P = 0.04), and right ventricular dysfunction (HR 2.28 [1.39-3.97], P = 0.002). Survival was similar between CPFE with secondary ILD and CPFE with UIP/IPF, while CPFE with unclassifiable ILD had better comparative survival (Log rank = 0.026).

CONCLUSIONS

Our findings suggest only about a third of CPFE patients represent suspected UIP/IPF; the majority were clinically and radiologically unclassifiable ILD whose survival was comparatively better. Identifiable or secondary causes of lung fibrosis in CPFE occurred in about a fifth of presenting patients.

Evolution of diagnostic UIP computed tomography patterns in idiopathic pulmonary fibrosis: Disease spectrum and implications for survival

BACKGROUND

Whether current diagnostic computed tomography (CT) patterns in idiopathic pulmonary fibrosis (IPF) represent distinct clinical phenotypes or simply temporal evolution of the same underlying radiologic process is unknown. We studied IPF patients presenting with 'possible' or 'inconsistent' usual interstitial pneumonia (UIP) CT patterns and characterized the frequency and timing of evolution to 'consistent' UIP and its effect on survival.

MATERIAL AND METHODS

Consecutive IPF patients seen at our institution from 1/1/2005 through 12/31/2013 were assessed for study inclusion. Presenting and serial CT scans were reviewed by two expert radiologists. Baseline and interval clinical data were collated.

RESULTS

Ninety one patients (mean age 67.4 years, 59% male) met study criteria with 'possible' and 'inconsistent' UIP CT patterns present in 58 (64%) and 33 (36%) cases, respectively. Twenty nine (32%) transitioned to a 'consistent' UIP pattern over a median of 57 months (interquartile range 33-78 months). Decline in pulmonary function was statistically significant on interval follow-up for those with or without pattern evolution, but no different between them in terms of degree. Evolution to 'consistent' UIP did not confer worse survival from the date of disease diagnosis or date of first CT with 'consistent' UIP pattern.

CONCLUSIONS

A portion of IPF patients with initial 'possible' or 'inconsistent' UIP CT pattern will go on to develop 'consistent' UIP CT pattern over months to years. Despite this, there appeared to be similar risk and cause of death in those with or without pattern evolution, suggesting similar morbidity across the radiologic spectrum in IPF.

Obliterative bronchiolitis associated with rheumatoid arthritis: analysis of a single-center case series

BACKGROUND

Rheumatoid arthritis (RA) is a systemic autoimmune condition characterized by erosive inflammation of the joints. One rare pulmonary manifestation is obliterative bronchiolitis (OB), a small airways disease characterized by the destruction of bronchiolar epithelium and airflow obstruction.

METHODS

We retrospectively reviewed the clinical data of patients with rheumatoid arthritis-associated obliterative bronchiolitis (RA-OB) from 01/01/2000 to 12/31/2015. Presenting clinical features, longitudinal pulmonary function testing, radiologic findings, and independent predictors of all-cause mortality were assessed.

RESULTS

Forty one patients fulfilled criteria for diagnosis of RA-OB. There was notable female predominance (92.7%) with a mean age of 57 ± 15 years. Dyspnea was the most common presenting clinical symptom. Median FEV1 was 40% (IQR 31-52.5) at presentation, with a mean decline of - 1.5% over a follow-up period of thirty-three months. Associated radiologic findings included mosaic attenuation and pulmonary nodules. A majority of patients (78%) received directed therapy including long-acting inhalers, systemic corticosteroids or other immunosuppressive agents, and macrolide antibiotics. All-cause mortality was 27% over a median follow-up of sixty-two months (IQR 32-113). No distinguishable predictors of survival at presentation were found.

CONCLUSIONS

RA-OB appears to have a stable clinical course in the majority of patients despite persistent symptoms and severe obstruction based on presenting FEV1.

Treatment of acute exacerbations of interstitial lung disease

INTRODUCTION

Interstitial lung diseases (ILD) include a broad range of diffuse parenchymal lung disorders of known and unknown etiologies. Patients with ILD can experience acute exacerbations (AE) which are associated with extremely high morbidity and mortality. Little is known about the etiology of AEs, and whether inciting triggers (such as infection) result in an aberrant inflammatory response in a predisposed host. Areas covered: The majority of data regarding AE-ILD comes from the idiopathic pulmonary fibrosis (IPF) population and is extrapolated to other forms of ILD. For the purposes of this review we have summarized the current literature regarding AE of IPF, and when available have included data from AE of other ILDs. Expert commentary: Therapeutic options for AE are limited without definitive treatments available, and the prognosis is often poor. Treatment is mainly based on correcting hypoxemia, looking for reversible etiologies of respiratory decline, and palliation of symptoms. Overall little is known about the pathogenesis of ILDs and AE-ILD, more research is needed in hopes of identifying better treatment options.

Overlap of interstitial pneumonia with autoimmune features with undifferentiated connective tissue disease and contribution of UIP to mortality

BACKGROUND AND OBJECTIVE

Criteria for interstitial pneumonia with autoimmune features (IPAF) were recently established for research purposes in a joint statement from the European Respiratory Society (ERS) and American Thoracic Society (ATS). We reviewed the utility of these criteria in patients previously diagnosed as broadly defined undifferentiated connective tissue disease (UCTD) and noted overlapping IPAF findings. Additional review was given to IPAF patients with usual interstitial pneumonia (UIP) on histopathology or radiology in terms of survival and outcome.

METHODS

Patients with prior UCTD-interstitial lung disease (ILD) were screened by ERS/ATS criteria for IPAF. Clinical data along with all-cause mortality were collated and compared with selected idiopathic pulmonary fibrosis (IPF) patients from the same study period. Survival was compared between IPAF subgroups with and without UIP features.

RESULTS

One hundred and one UCTD-ILD subjects (91%) evaluated from 2005 to 2012 also met strict criteria for IPAF. Frequent clinical findings included Raynaud's phenomenon, positive anti-nuclear antibody (ANA) and non-specific interstitial pneumonia (NSIP) pattern on chest computed tomography (CT). Nineteen had features of UIP either on histopathology or CT imaging. As compared with IPF, IPAF patients had overall better survival except in those with UIP features.

CONCLUSION

Current IPAF criteria encompassed the majority of broadly defined UCTD-ILD and included those with UIP findings. Survival compared with IPF in those with UIP was similar. Further studies are necessary to refine IPAF definitions for clinical use and guide directed management strategies.