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Interstitial Lung Disease

 

Thank you for asking me to examine Harry who presented with SOB. I would have like to have completed my examination by taking pulse oximetry and peak flow measurements.

 

My salient findings were basal / apical predominant fine inspiratory crepitations, which are consistent with interstitial lung disease.

 

I will now present my findings in full before commenting on potential aetiology, severity and complications.

 

The patient was comfortable at rest with normal/increased WOB with/without evidence of accessory muscle use. There was no evidence of CO2 narcosis with no asterixis. There was / was not supplemental oxygen. The patient had a dry/loose/productive cough on prompting. There was / was no sputum cup at the bedside.

 

The respiratory rate was ___, and the pulse was ___ and regular/irregular.

 

On examination of the hands, there was / was not clubbing, nicotine staining, or peripheral cyanosis.

 

On examination of the face, there was / was not conjunctive pallor, ptosis, or central cyanosis.

 

The trachea was midline / displaced with/without tracheal tug. There was / was not cervical, supraclavicular or axillary lymphadenopathy.

 

On inspection of the chest, there was / was no obvious deformity with / without kyphoscoliosis, pectus carinatum, pectus excavatum. There were / were not previous surgical scars. There were / were not radiotherapy skin changes.

 

Chest expansion was reduced / normal and symmetrical / asymmetrical.

 

Percussion showed normal / reduced resonance.

 

On auscultation, there was fine inspiratory crepitations throughout the lower / middle / upper lobes bilaterally with/with no added wheeze. Vocal resonance was / was not normal.

 

In regard to cardiovascular complications, there was / was not evidence of pulmonary hypertension and right heart dysfunction. More specifically, there was / was not a left parasternal heave, a palpable P2, an elevated JVP with prominent A-waves, or peripheral oedema.

 

In regard to potential aetiology of this lower/upper zone fibrosis, there were/were not:

  • Upper: features of sarcoidosis, cystic fibrosis, ankylosing spondylitis, or radiation

  • Lower: features of rheumatoid arthritis or scleroderma

  • The presence of clubbing suggests idiopathic pulmonary fibrosis

 

In terms of findings suggestive of a particular treatment:

  • There was / was not signs of steroid complications, such as a Cushingoid appearance, bruising, skin atrophy, cataracts, or proximal myopathy. 

 

In summary, Harry is a patient who presented with SOB. My findings are suggestive of basal/apical predominant interstitial lung disease with/without evidence of pulmonary hypertension or cor pulmonale, and no evidence of complications of long-term steroid use. I could no elicit a specific aetiology.

 

My differentials are:

  • HF

  • Bronchiectasis - coarse

  • Atelectasis

  • COPD - early, coarse

 

Assuming this is ILD, my differentials for the ILD are....

 

I would proceed from here by:

  • Confirming the diagnosis and assessing severity with a CXR, HRCT, ABG and RFTs. I would also like to complete a 6-minute walk test.

  • Assessing for aetiology by taking a history, including exposure history and drug history.

  • Completing an assessment of complications with a TTE to assess for pulmonary hypertension and right ventricular function, and if on steroids, a HbA1c, osteoporosis screen, and CV risk profile.

 

What are the causes of upper and lower lobe ILD?

  • Upper:

    • Coal workers pneumoconiosis

    • Histiocytosis

    • Allergic bronchopulmonary aspergillosis, and hypersensitivity pneumonitis

    • Ankylosing spondylitis

    • Radiation

    • Tuberculosis

    • Sarcoidosis

    • Silicosis

 

  • Lower:

    • Idiopathic interstitial pneumonias includes:

      • IPF

      • Non-specific interstitial pneumonia

      • Cryptogenic organising pneumonia

      • Desquamative interstitial pneumonia

    • CTD/Rheumatological

      • RA, Scleroderma, dermatomyositis

    • Other - drugs (MTX, bleomycin, nitrofurantoin)

    • Asbestosis

    • Aspiration

    • AAT deficiency

​

 

How would you interpret these RFTs?

  • KCO is corrected for volume (in simple terms for exam)

  • Learn how to interpret RFTs. 

    • FER < 0.7

    • FVC < 70% restrictive

    • TLC < 80% is restrictive

    • DLCO 76% to 140% normal (< 40% is severe)

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