Approach to the adult with interstitial lung disease: Clinical evaluation
- Talmadge E King, Jr, MD
Talmadge E King, Jr, MD
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Interstitial Lung Disease
- Dean, School of Medicine
- Vice Chancellor, Medical Affairs
- University of California San Francisco
The diffuse parenchymal lung diseases, often collectively referred to as the interstitial lung diseases (ILDs), are a heterogeneous group of disorders that are classified together because of similar clinical, radiographic, physiologic, or pathologic manifestations (algorithm 1) [1-6]. The descriptive term "interstitial" reflects the pathologic appearance that the abnormality begins in the interstitium, but the term is somewhat misleading, as most of these disorders are also associated with extensive alteration of alveolar and airway architecture.
An overview of the clinical findings that can aid in the diagnosis of ILD will be presented here (algorithm 2). The individual causes of ILD and the diagnostic testing that is helpful in evaluating patients with ILD are discussed separately. (See "Idiopathic interstitial pneumonias: Clinical manifestations and pathology" and "Clinical manifestations and diagnosis of pulmonary sarcoidosis" and "Pulmonary toxicity associated with systemic antineoplastic therapy: Clinical presentation, diagnosis, and treatment" and "Approach to the adult with interstitial lung disease: Diagnostic testing" and "Role of bronchoalveolar lavage in diagnosis of interstitial lung disease" and "Role of lung biopsy in the diagnosis of interstitial lung disease".)
The diffuse parenchymal lung diseases are divided into those that are associated with known causes and those that are idiopathic. The treatment choices and prognosis vary among the different causes and types of ILD, so ascertaining the correct diagnosis is important.
A variety of infections can cause interstitial opacities on chest radiograph, including fungal pneumonias (eg, coccidioidomycosis, cryptococcosis, Pneumocystis jirovecii), atypical bacterial pneumonias, and viral pneumonias. These infections often occur in immunocompromised hosts and are discussed separately. (See "Approach to the immunocompromised patient with fever and pulmonary infiltrates".)
The most common identifiable causes of ILD are exposure to occupational and environmental agents, especially to inorganic or organic dusts (table 1A-B), drug-induced pulmonary toxicity, and radiation-induced lung injury. (See "Asbestos-related pleuropulmonary disease" and "Chronic beryllium disease (berylliosis)" and "Silicosis" and "Classification and clinical manifestations of hypersensitivity pneumonitis (extrinsic allergic alveolitis)" and "Diagnosis of hypersensitivity pneumonitis (extrinsic allergic alveolitis)" and "Pulmonary toxicity associated with systemic antineoplastic therapy: Clinical presentation, diagnosis, and treatment" and "Radiation-induced lung injury".)
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- CLINICAL PRESENTATION
- Age and gender
- Onset of symptoms
- Past medical history
- Smoking history
- Family history
- Prior medication use and irradiation
- Occupational and environmental exposures
- PHYSICAL EXAMINATION
- Lung examination
- Cardiac examination
- Extrapulmonary findings of systemic disease
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS