9. Top Consults: Interstitial Lung Disease Diagnosis

This week we are absolutely thrilled to be joined by three Interstitial Lung Disease experts to discuss the workup and differential for a patient with a new presentation of suspected ILD. This is also our first episode in a collaboration between the Pulm PEEPs and the American Thoracic Society Clinical Problems Assembly. In a series of episodes, we will be joined by pulmonary experts from around the country who are leaders in the ATS CP Assembly to provide content on common and cutting-edge topics in PCCM. Meet Our Guests Sonye Danoff is an Associate Professor of Medicine at Johns Hopkins and is Co-Director of the John Hopkins Interstitial Lung Disease and Pulmonary Fibrosis program. She also serves as the Assembly Chair of the Clinical Problems Assembly for the American Thoracic Society. John Kim is an Assistant Professor of Medicine at UVA and has both clinical and research expertise in interstitial lung disease with a focus on pulmonary fibrosis. Shweta Sood is an Assistant Professor of Medicine at Penn Medicine whose expertise is in Interstitial Lung Disease. She is an integral part of fellowship training where she leads the monthly ILD conference for fellows as well as provides didactics for ILD cases. Consult Patient A 66-year-old man who is a never smoker with a past medical history of hypertension and osteoarthritis was admitted to the hospital after presenting with progressive dyspnea on exertion to dyspnea at rest and was found to be hypoxemic. He reports 4 months of progressive dyspnea on exertion but on further questioning, thinks he was last normal about 1.5 years ago when he could walk 2 miles at a time. Currently, he can only walk 0.25 to 0.5 miles before needing to stop. He reports an intermittent, dry cough throughout the day that is not associated with eating, position, or sleeping. A full ROS is negative including for rashes or joint pains. His family history is notable only for hypertension and hyperlipidemia. He is a never smoker, drinks in moderation 1-2 x a week, and lives in the suburbs with his wife. His house has central heating and air conditioning, they have no pets, and they have carpeted floors. He is a retired police detective. His physical exam is notable for fine crackles at the bilateral bases on pulmonary auscultation, and he is breathing comfortably on nasal cannula although mildly tachypneic to 18 breaths per minute. He has no signs of volume overload, no peripheral clubbing, no rashes, and joint exam does not reveal swelling or synovitis. Key Learning Points Take away points from our guests: — ILD is a symptom, not a diagnosis — The first time a patient is evaluated for interstitial lung disease is the best chance for making the diagnosis so take the time to evaluate them thoughtfully — Start the physical exam with the hands first. The hands can reveal a lot about the patient (clubbing, cyanosis, joint, skin, and nailbed findings) and it establishes a personal connection — When doing the pulmonary exam, percuss first from top to bottom to learn the size of the lungs, and then listen from bottom to top — When reading a CT scan the simplest approach is “Is it a UIP pattern or not?”. This can be your first diagnostic divide. UIP is consistent with IPF, and in select circumstances connective tissue disease, occupational lung disease,