Idiopathic pulmonary fibrosis: Difference between revisions
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*Normal lung parenchyma is interspersed with areas of decrease compliance | *Normal lung parenchyma is interspersed with areas of decrease compliance | ||
**Unlike [[ARDS]], in which lung injury more uniform | **Unlike [[ARDS]], in which lung injury more uniform | ||
** | **Mechanical ventilation strategies learned from ARDS not completely transferrable | ||
*Median survival time 3 yrs after diagnosis | *Median survival time 3 yrs after diagnosis | ||
*Prevalence about 10-20 cases per 100,000 people | *Prevalence about 10-20 cases per 100,000 people | ||
| Line 16: | Line 16: | ||
*Presentations with rapid deterioration without obvious cause common | *Presentations with rapid deterioration without obvious cause common | ||
*May co-exist with [[pulmonary hypertension]] and [[heart failure]] | *May co-exist with [[pulmonary hypertension]] and [[heart failure]] | ||
===Acute exacerbation of IPF=== | |||
*Diagnosis of IPF | |||
*Unexplained worsening of [[dyspnea]] within 30 days | |||
*Hypoxemia deviated from baseline ABG | |||
*No evidence of pulmonary infection | |||
*Exclusion of alternative causes (i.e. VTE) | |||
*CT with bilateral ground-glass abnormalities/consolidation on a background reticular/honeycomb pattern consistent with interstitial [[pneumonia]]<ref>Akira M, Kozuka T, Yamamoto S, Sakatani M. Computed tomography findings in acute exacerbation of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 2008;178:372-8.</ref> | |||
**100% have bilateral ground-glass opacities | |||
**~70% have consolidation | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Pulmonary fibrosis differential}} | {{Pulmonary fibrosis differential}} | ||
== | ==Evaluation== | ||
*CBC, leukocytosis | *CBC, leukocytosis | ||
*CRP elevated | *CRP elevated | ||
*LDH elevated | *LDH elevated | ||
*ABG with hypoxemia, hypercapnea | *ABG with hypoxemia, hypercapnea | ||
*ECG | *[[ECG]] | ||
*CXR with likely need for CT | *[[CXR]] with likely need for CT | ||
*Echo to assess for | *Echo to assess for pulmonary hypertension, rule out CHF | ||
*BAL in ICU to | *BAL in ICU to rule out infection | ||
==Management== | ==Management== | ||
*All treatments controversial and of questionable efficacy | *All treatments controversial and of questionable efficacy | ||
* | *[[Methylprednisolone]] 500-1000mg QD for 3 days<ref>Rice AJ, Wells AU, Bouros D, Du Bois RM, Hansell DM, Polychronopoulos V, et al. Terminal diffuse alveolar damage in relation to interstitial pneumonias. An autopsy study. Am J Clin Pathol 2003;119:709-14.</ref><ref>Saydain G, Islam A, Afessa B, Ryu JH, Scott JP, Peters SG. Outcome of patients with idiopathic pulmonary fibrosis admitted to the intensive care unit. Am J Respir Crit Care Med 2002;166:839-42.</ref> | ||
*Heparin drip | *[[Heparin]] drip | ||
**Alveolar injury predisposes to prothrombotic state | **Alveolar injury predisposes to prothrombotic state | ||
**Prevents further vascular injury | **Prevents further vascular injury | ||
*Cyclosporine A 1- | *[[Cyclosporine]] A 1-2mg/kg/day with steroids<ref>Meduri GU, Golden E, Freire AX, Taylor E, Zaman M, Carson SJ, et al. Methylprednisolone infusion in early severe ARDS: Results of a randomized controlled trial. Chest 2007;131:954-63.</ref> | ||
==Mechanical Ventilation Strategies== | |||
*Current strategies controversial, with some contending | ===Mechanical Ventilation Strategies=== | ||
* | *Current strategies controversial, with some contending mechanical ventilation adds insult to AE-IPF | ||
*Non-invasive may be use as a temporizing measure | |||
*Low TVs at 6 cc/kg | *Low TVs at 6 cc/kg | ||
*Permissive hypercapnea may be necessary | *Permissive hypercapnea may be necessary | ||
| Line 54: | Line 56: | ||
**High respiratory rates may be necessary | **High respiratory rates may be necessary | ||
**Heavy sedation with possible paralysis with cisatricurium | **Heavy sedation with possible paralysis with cisatricurium | ||
*Deviations from ARDS | *Deviations from ARDS treatment strategies | ||
**Must restrict PEEP given to AE-IPF | **Must restrict PEEP given to AE-IPF | ||
**No place for [[recruitment maneuver]] or prone postioning | **No place for [[recruitment maneuver]] or prone postioning | ||
Latest revision as of 08:13, 7 July 2017
Background
- Normal lung parenchyma is interspersed with areas of decrease compliance
- Unlike ARDS, in which lung injury more uniform
- Mechanical ventilation strategies learned from ARDS not completely transferrable
- Median survival time 3 yrs after diagnosis
- Prevalence about 10-20 cases per 100,000 people
- AE-IPF = Acute Exacerbation of IPF
- Acute exacerbations carry mortality up to 80%
- 60% die from idiopathic pulmonary fibrosis, others die from:
Clinical Features
- Diagnosis of exclusion
- Presentations with rapid deterioration without obvious cause common
- May co-exist with pulmonary hypertension and heart failure
Acute exacerbation of IPF
- Diagnosis of IPF
- Unexplained worsening of dyspnea within 30 days
- Hypoxemia deviated from baseline ABG
- No evidence of pulmonary infection
- Exclusion of alternative causes (i.e. VTE)
- CT with bilateral ground-glass abnormalities/consolidation on a background reticular/honeycomb pattern consistent with interstitial pneumonia[1]
- 100% have bilateral ground-glass opacities
- ~70% have consolidation
Differential Diagnosis
Pulmonary Fibrosis
- Interstitial pneumonias (acute, lymphocytic)
- Lung malignancy
- Aspiration pneumonia or pneumonitis
- Bacterial, viral, or fungal pneumonia
- Cryptogenic organizing pneumonia
- Interstitial lung disease associated with collagen vascular disease
- Drug-induced pulmonary toxicity (amiodarone, bleomycin, amphotericin B, carbamazepine, etc.)
- Eosinophilic granuloma (Histiocytosis X)
- Radiation pneumonitis
- Sarcoidosis
- Pneumoconiosis (Workplace exposure)
- Asbestosis
- Berylliosis
- Chemical worker's lung
- Coal worker's pneumoconiosis
- Silicosis
Evaluation
- CBC, leukocytosis
- CRP elevated
- LDH elevated
- ABG with hypoxemia, hypercapnea
- ECG
- CXR with likely need for CT
- Echo to assess for pulmonary hypertension, rule out CHF
- BAL in ICU to rule out infection
Management
- All treatments controversial and of questionable efficacy
- Methylprednisolone 500-1000mg QD for 3 days[2][3]
- Heparin drip
- Alveolar injury predisposes to prothrombotic state
- Prevents further vascular injury
- Cyclosporine A 1-2mg/kg/day with steroids[4]
Mechanical Ventilation Strategies
- Current strategies controversial, with some contending mechanical ventilation adds insult to AE-IPF
- Non-invasive may be use as a temporizing measure
- Low TVs at 6 cc/kg
- Permissive hypercapnea may be necessary
- Maintaining minute ventilations
- High respiratory rates may be necessary
- Heavy sedation with possible paralysis with cisatricurium
- Deviations from ARDS treatment strategies
- Must restrict PEEP given to AE-IPF
- No place for recruitment maneuver or prone postioning
- Questionable benefit of APRV (BiVent) and high-frequency oscillation ventilation
Disposition
- ICU
- ECMO has been used as a bridge to lung transplant
- Transfer to transplant center if candidate
- Lung transplant is the only proven therapy to increase long term survival
See Also
References
- ↑ Akira M, Kozuka T, Yamamoto S, Sakatani M. Computed tomography findings in acute exacerbation of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 2008;178:372-8.
- ↑ Rice AJ, Wells AU, Bouros D, Du Bois RM, Hansell DM, Polychronopoulos V, et al. Terminal diffuse alveolar damage in relation to interstitial pneumonias. An autopsy study. Am J Clin Pathol 2003;119:709-14.
- ↑ Saydain G, Islam A, Afessa B, Ryu JH, Scott JP, Peters SG. Outcome of patients with idiopathic pulmonary fibrosis admitted to the intensive care unit. Am J Respir Crit Care Med 2002;166:839-42.
- ↑ Meduri GU, Golden E, Freire AX, Taylor E, Zaman M, Carson SJ, et al. Methylprednisolone infusion in early severe ARDS: Results of a randomized controlled trial. Chest 2007;131:954-63.