Interstitial lung disease: diagnosis and testing Professor Joanna - - PowerPoint PPT Presentation

This video has been developed and funded by Boehringer Ingelheim This non-promotional material is for medical-to-medical use only Date of preparation: October 2019 | SC-UK-00617

Interstitial lung disease: diagnosis and testing

Professor Joanna Porter, Consultant in Respiratory and General Medicine University College London Hospitals and Senior Lecturer in the Department of Medicine at UCL In conversation with Dr Steve Holmes, GP, Park Medical Partnership, Shepton Mallet and Evercreech Education Lead and Executive, Primary Care Respiratory Society UK

RCGP accredited until 1st April 2020 RCN accredited until 2nd July 2020 Accreditation applies only to the educational content and not to any product RCN cannot confirm competence of any practitioner

By the end of this module you should be able to: ▪ Outline how ILD is reviewed and investigated in secondary care, including:

– Lung function tests – Blood tests for autoimmune disease – Bronchoalveolar lavage – Biopsy

▪ Explain the importance of monitoring disease progression ▪ Explain how ILD is diagnosed in tertiary care and the role of the MDT ▪ Outline the provision of services available in secondary and tertiary ILD care

ILD, interstitial lung disease; MDT, multidisciplinary team

Comprehensive medical history1,2

• Social and family history
• Occupational,

environmental and drug exposures

ILD, interstitial lung disease

• 1. Raghu, G. et al. (2011); 2. NICE clinical guideline 163. June 2013 (last updated May 2017).

ILD diagnostic tools

Comprehensive medical history1,2

• Social and family history
• Occupational,

environmental and drug exposures Pulmonary function tests1,2

• FVC
• DLCO
• 6MWT

Serological tests1,2

ILD diagnostic tools

6MWT, 6-minute walk test; DLCO, diffusing capacity for carbon monoxide; FVC, forced vital capacity; ILD, interstitial lung disease

• 1. Raghu, G. et al. (2011); 2. NICE clinical guideline 163. June 2013 (last updated May 2017).

Comprehensive medical history1,2

• Social and family history
• Occupational,

environmental and drug exposures Pulmonary function tests1,2

• FVC
• DLCO
• 6MWT

Serological tests1,2

ILD diagnostic tools

6MWT, 6-minute walk test; DLCO, diffusing capacity for carbon monoxide; FVC, forced vital capacity; HRCT, high-resolution computed tomography; ILD, interstitial lung disease

• 1. Raghu, G. et al. (2011); 2. NICE clinical guideline 163. June 2013 (last updated May 2017).

Radiological assessment

• Chest x-ray2
• HRCT1,2

Guidelines recommend multidisciplinary diagnosis to improve accuracy

Consultant respiratory physician Consultant radiologist ILD specialist nurse Consultant histopathologist* Thoracic surgeon* MDT coordinator

Please note local practice may differ. NICE recommend at a minimum the MDT is comprised of a consultant respiratory physician, consultant radiologist, interstitial lung disease specialist nurse and a multidisciplinary team coordinator.

*In cases where biopsies or bronchoalveolar lavage are being considered, the MDT should also include a consultant histopathologist and a thoracic surgeon. ILD, interstitial lung disease; MDT, multidisciplinary team.

• 2. NICE clinical guideline 163. June 2013 (last updated May 2017).

ILD diagnostic tools

6MWT, 6-minute walk test; DLCO, diffusing capacity for carbon monoxide; FVC, forced vital capacity; HRCT, high-resolution computed tomography; ILD, interstitial lung disease

• 1. Raghu, G. et al. (2011); 2. NICE clinical guideline 163. June 2013 (last updated May 2017); 4. Mikolasch, T.A. et al. (2017).

Comprehensive medical history1,2

• Social and family history
• Occupational,

environmental and drug exposures Pulmonary function tests1,2

• FVC
• DLCO
• 6MWT

Serological tests1,2 Radiological assessment

• Chest x-ray2
• HRCT1,2

Surgical assessment

• Bronchoalveolar lavage2
• Transbronchial biopsy2
• Surgical lung biopsy1,2
• Cryosurgical assessment4

Newcastle upon Tyne Hospitals NHS Foundation Trust Leeds Teaching Hospitals NHS Trust Sheffield Teaching Hospitals NHS Foundation Trust Hull and East Yorkshire Hospitals NHS Trust Nottingham University Hospitals NHS Trust University Hospitals of Leicester NHS Trust University Hospitals Coventry and Warwickshire NHS Trust Norfolk and Norwich University Hospital NHS Foundation Trust Royal Papworth Hospital NHS Foundation Trust University College London Hospitals NHS Foundation Trust Guy’s and St Thomas' NHS Foundation Trust Imperial College Healthcare NHS Trust Royal Brompton and Harefield NHS Foundation Trust Portsmouth Hospitals NHS Trust Manchester University NHS Foundation Trust Aintree University Hospital NHS Foundation Trust University Hospital of North Midlands NHS Trust University Hospitals Birmingham NHS Foundation Trust North Bristol NHS Foundation Trust Oxford University Hospitals NHS Foundation Trust Royal Devon and Exeter NHS Foundation Trust University Hospital Southampton NHS Foundation Trust

Interstitial lung disease specialist centres in England*

*There are different prescribing rules outside of England.

• 8. British Lung Foundation. Pulmonary fibrosis services in the UK.

Summary: diagnosis and testing ▪ A good medical history is key to diagnosis1,2,4 ▪ As well as lung function testing, blood tests will be used to investigate any possible autoimmune

disease1,2,4

▪ A CT scan will also be carried out; if the diagnosis is unclear or more information is needed

bronchoalveolar lavage may be performed and, if necessary, a lung biopsy1,2,4

▪ The differentiation between fibrotic and inflammatory ILD, and identifying a cause where

possible, is important because of the complexity of the condition and the treatment options available1,4

COPD, chronic obstructive pulmonary disease; CT, computed tomography; ILD, interstitial lung disease

• 1. Raghu, G. et al. (2011); 2. NICE clinical guideline 163. June 2013 (last updated May 2017); 4. Mikolasch, T.A. et al. (2017).

Summary: diagnosis and testing ▪ Many people with ILD are managed in secondary care, while complex cases may be referred to

a specialist tertiary centre; these centres are the only ones able to prescribe some treatments

▪ Patients may be concerned about travelling to a specialist centre and shared care arrangements

between secondary and tertiary care are sometimes made, although contact with the tertiary centre needs to be maintained

ILD, interstitial lung disease

References

1.

Raghu, G., Collard, H.R., Egan, J.J., Martinez, F.J., Behr, J., Brown, K.K., Colby, T.V., Cordier, J.F., Flaherty, K.R., Lasky, J.A., Lynch, D.A., Ryu, J.H., Swigris, J.J., Wells, A.U., Ancochea, J., Bouros, D., Carvalho, C., Costabel, U., Ebina, M., Hansell, D.M., Johkoh, T., Kim, D.S., King, T.E. Jr, Kondoh, Y., Myers, J., Müller, N.L., Nicholson, A.G., Richeldi, L., Selman, M., Dudden, R.F., Griss, BS., Protzko, S.L. and Schünemann, H.J.; ATS/ERS/JRS/ALAT Committee on Idiopathic Pulmonary Fibrosis. (2011). An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med, 183(6), pp. 788–824.

2.

National Institute for Health and Care Excellence. Clinical guideline 163. June 2013 (last updated May 2017). Idiopathic pulmonary fibrosis in adults: diagnosis and management. Available at: www.nice.org.uk/guidance/cg163 (accessed October 2019).

3.

British Lung Foundation. January 2017. Tests to measure your breathing. Available at: cdn.shopify.com/s/files/1/0221/4446/files/1._Tests_to_measure_your_breathing.pdf?6157169238646367902&_ga=2.145315060.197531 3960.1568016302-1905844842.1559040729 (accessed October 2019).

4.

Mikolasch, T.A., Garthwaite, H.S. and Porter, J.C. (2017). Update in diagnosis and management of interstitial lung disease. Clin Med, 17(2), pp. 146–153.

5.

Cottin, V., Hirani, N.A., Hotchkin, D.L., Nambiar, A.M., Ogura, T., Otaola, M., Skowasch, D., Park, J.S., Poonyagariyagorn, H.K., Wuyts, W. and Wells, A.U. (2018). Presentation, diagnosis and clinical course of the spectrum of progressive-fibrosing interstitial lung

• diseases. Eur Respir Rev, 27(150), pii: 180076.

6.

Hutchinson, J.P., Fogarty, A.W., McKeever, T.M. and Hubbard, R.B. (2016). In-hospital mortality after surgical lung biopsy for interstitial lung disease in the United States 2000 to 2011. Am J Respir Crit Care Med, 193(10), pp. 1161–1167.

References

7.

Meyer, K.C. and Raghu, G. (2011). Bronchoalveolar lavage for the evaluation of interstitial lung disease: is it clinically useful? Eur Respir J, 38(4), pp. 761–769.

8.

British Lung Foundation. Pulmonary fibrosis services in the UK. September 2016. Available at: www.blf.org.uk/sites/default/files/Table%20of%20UK%20PF%20services%20in%20the%20UK%20v2.1.pdf (accessed October 2019).