An Algorithm to Tackle Acute Exacerbations in Idiopathic Pulmonary Fibrosis

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An Algorithm to Tackle Acute Exacerbations in Idiopathic Pulmonary

Fibrosis

Tuesday, 17 June 2008

RedOrbit - Dallas,TX*

By Wuyts, Wim A Thomeer, Michiel; Dupont, Lieven J; Verleden, Geert

M

http://www.redorbit.com/news/health/1436093/an_algorithm_to_tackle_ac

ute_exacerbations_in_idiopathic_pulmonary_fibrosis/

To the Editor : The pulmonary perspective by Dr. Collard and

colleagues (1) provides an overview of the current understanding

about acute exacerbations in idiopathic pulmonary fibrosis (IPF). To

tackle this challenging problem, we developed an algorithm (Figure

1). As a first step, we test for the presence of D-dimer and

clinical probability of pulmonary embolism. If the test is positive,

a specific computed tomography (CT) scan is performed. The CT scan

is an accurate modality (2) with which to detect pulmonary embolism;

moreover, images can be compared with previous CT scans to evaluate

reticular shadowing, honeycombing, and ground-glass appearances.

Echocardiography is performed to rule out left heart failure. At the

same time, (increasing) pulmonary hypertension can be ruled out. If

diffusion capacity is greater than 30%, and if hypoxemia can be

corrected to a PO2 of 75 mm Hg with supplemental oxygen (3), then

bronchoalveolar lavage (BAL) is performed to rule out infection

(bacterial, viral, opportunistic infections, and fungi).

BAL must be performed soon after admission, and broadspectrum

antibiotics are started immediately after bronchoscopy. We usually

start broad-spectrum antibiotics (such as piperacillintazobactam or

third-generation cephalosporins intravenously). However, atypical

bacilli (such as Legionella and Mycoplasma) must be covered by

adding quinolones. As most of these patients with IPF are

immunocompromised, Pneumocystis jiroveci pneumonia needs to be

covered empirically with sulphametoxazole. If infection cannot be

proven, corticosteroids are added to the treatment in a dose of 500-

1,000 mg for 3 consecutive days. Antiviral agents should be

considered when herpesvirus or cytomegalovirus (CMV) is found in

BAL, and antifungal agents should be initiated especially when

Aspergillus is found in an immunocompromised patient or if the

Aspergillus antigen test in BAL is clearly positive (4).

If there is no effect from these therapies, and in the absence of

generalized infection, lung transplantation should be considered as

a treatment for acute exacerbation in IPF. It is the only treatment

that improves survival in patients with interstitial lung disease

(5). The patient can only be put on the high-urgency list when a

transplant workup has been completed before the acute exacerbation.

This is another strong reason to refer patients with IPF in an early

stage to a transplant center for transplant evaluation, as an acute

exacerbation is not related to pulmonary function tests (1).

In conclusion, Collard and coworkers' article gives an excellent

overview of the challenges in acute exacerbations of IPF. We need

carefully chosen protocols to guide us in this challenge. We hope

that the algorithm we propose will help physicians in dealing with

this problem.

Conflict of Interest Statement: W.A.W. has attended an expert

meeting organized by Actelion and received [euro]1,000 as a

consultancy fee. M.T. is a member of Intermune's steering committee

(INSPIRE Study). L.J.D. has no financial relationship with a

commercial entity that has an interest in the subject of this

manuscript. G.M.V. has no financial relationship with a commercial

entity that has an interest in the subject of this manuscript.

References

1. Collard HR, BB, Flaherty KR, Brown KK, Kaner RJ, King TE

Jr, Lasky JA, Loyd JE, Noth I, Olman MA, et al.; Idiopathic

Pulmonary Fibrosis Clinical Research Network Investigators. Acute

exacerbations of idiopathic pulmonary fibrosis. Am J Respir Crit

Care Med 2007;176: 636-643.

2. Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD,

Leeper KV Jr, Popovich J, Quinn DA, Sos TA, et al. Multidetector

computed tomography for acute pulmonary embolism. N Engl J Med

2006;354:2317-2327.

3. American Thoracic Society. Clinical role of bronchoalveolar

lavage in adults with pulmonary disease. Am Rev Respir Dis

1990;142:481-486.

4. Meersseman W, Lagrou K, Maertens J, Wilmer A, Hermans G,

Vanderschueren S, Spriet I, Verbeken E, Van Wijngaerden E.

Galactomannan in bronchoalveolar lavage fluid: a tool for diagnosing

aspergillosis in ICU patients. Am J Respir Crit CareMed 2008;177:27-

34.

5. Thabut G, Mal H, Castier Y, Groussard O, Brugiere O, Marrash-

Chahla R, Leseche G, Fournier M. Survival benefit of lung

transplantation for patients with idiopathic pulmonary fibrosis. J

Thorac Cardiovasc Surg 2003;126:469-475.

WIM A. WUYTS

MICHIEL THOMEER

LIEVEN J. DUPONT

GEERT M. VERLEDEN

University Hospital Gasthuisberg

Leuven, Belgium

Copyright American Thoracic Society Jun 15, 2008

© 2008 American Journal of Respiratory and Critical Care Medicine.

Provided by ProQuest Information and Learning. All rights Reserved.

Source: American Journal of Respiratory and Critical Care Medicine