What are the guideline sources, guidelines and references for Hypersensitivity pneumonitis ?
Guideline sources The following summarized guidelines for the evaluation and management of hypersensitivity pneumonitis (HP) are prepared by our editorial team based on guidelines from the American College of Chest Physicians (ACCP 2021), the Latin American Thoracic Association (ALAT/JRS/ATS 2020), the American Thoracic Society (ATS 2011), and the British Thoracic Society (BTS/TSANZ/ITS 2008). 1 2 3 4 Guidelines 1. Screening and diagnosis Diagnosis: As per ACCP 2021 guidelines, consider using clinical improvement with antigen avoidance, if an inciting antigen is identified and then completely avoided, to support the diagnosis in patients with suspected HP. Avoid relying solely on the lack of clinical improvement with antigen avoidance to rule out the diagnosis of HP. C Show 2 more https://web.pathway.md/diseases/recAKcR8Fglc9M2hN 1/4 6/24/23, 12:45 PM Hypersensitivity pneumonitis Pathway As per BTS 2008 guidelines, recognize that the diagnosis of HP requires a high index of suspicion and in difficult cases an integrated multidisciplinary approach is essential. B 2. Classification and risk stratification Classification: Consider classifying patients with suspected HP based on the likelihood of an occupational or environmental inciting antigen exposure. C Consider classifying the disease as fibrotic or non-fibrotic based on the presence or absence of fibrosis on HRCT of the chest in patients with either newly diagnosed or a working diagnosis of HP. C 3. Diagnostic investigations General principles: Consider using a multidisciplinary discussion for diagnostic decision-making in patients with suspected HP. C Consider including an occupational medicine specialist and an environmental hygienist in the multidisciplinary diagnostic workup in patients with suspected HP, if the inciting antigen is thought to be related to an occupational exposure especially if the source of exposure is obscure or unverified. E Exposure history: consider eliciting a thorough clinical history of exposures focused on establishing the type, extent, and temporal relationship of exposures to symptoms in patients with suspected HP. E Antigen-specific antibodies: As per ACCP 2021 guidelines, avoid relying solely on serum antigen-specific IgG or IgA to confirm or rule out the diagnosis in patients with suspected HP. D As per ATS 2020 guidelines, consider obtaining serum IgG targeting potential antigens associated with HP in patients with newly identified ILD if differential diagnosis includes non- fibrotic or fibrotic HP. C Antigen-specific lymphocyte proliferation testing: avoid obtaining antigen-specific lymphocyte proliferation testing to support the diagnosis in patients with suspected pneumonitis. D Computed tomography: consider integrating HRCT findings characteristic of HP with clinical findings to support the diagnosis in patients with suspected HP, but do not use CT findings in isolation to make a definite diagnosis. C 4. Diagnostic procedures Bronchoalveolar lavage: https://web.pathway.md/diseases/recAKcR8Fglc9M2hN 2/4 6/24/23, 12:45 PM Hypersensitivity pneumonitis Pathway As per ACCP 2021 guidelines, do not perform routine BAL fluid analysis to confirm the diagnosis in patients with suspected HP having a compelling exposure history within the appropriate clinical context and a chest HRCT pattern typical for HP. D As per ATS 2020 guidelines: Perform BAL with lymphocyte cellular analysis in patients with newly identified ILD if differential diagnosis includes non-fibrotic HP. B Consider performing BAL with lymphocyte cellular analysis in patients with newly identified ILD if differential diagnosis includes fibrotic HP. C As per BTS 2008 guidelines, recognize that typical BAL cellular profiles may allow a diagnosis of HP with greater confidence, if the diagnosis is uncertain after clinical assessment and HRCT. B Inhalation challenge testing: avoid performing antigen-specific inhalation challenge testing to support the diagnosis in patients with suspected HP. D Lung biopsy: As per ACCP 2021 guidelines: Consider performing histological lung biopsy for additional diagnostic evaluation in patients with suspected HP if all available data such as clinical, laboratory and radiologic findings along with bronchoscopic results do not yield a confident diagnosis and results may help guide management. C Consider integrating biopsy findings with clinical and radiological findings to support the diagnosis in patients with suspected HP in the context of multidisciplinary discussion. C As per ATS 2020 guidelines, consider performing transbronchial forceps lung biopsy in patients with newly identified ILD if differential diagnosis includes non-fibrotic HP. C Show 4 more 5. Medical management Corticosteroids: consider offering corticosteroids for the management of patients with severe or progressive HP. C 6. Nonpharmacologic interventions Avoidance of causative antigens: offer avoiding of the causative antigens, when identified, as the most important and effective aspect of management. B 7. Specific circumstances Patients with hypersensitivity pneumonitis related to Aspergillus: Advise avoidance of Aspergillus exposure in patients with HP related to Aspergillus and, when necessary, initiate corticosteroid therapy up to 60 mg/day, tapering over 1 month. B https://web.pathway.md/diseases/recAKcR8Fglc9M2hN 3/4 6/24/23, 12:45 PM Hypersensitivity pneumonitis Pathway Do not use antifungal therapy in patients with HP related to Aspergillus. D References 1. Ganesh Raghu, Martine Remy-Jardin, Christopher J Ryerson et al. Diagnosis of Hypersensitivity Pneumonitis in Adults. An Official ATS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med. 2020 Aug 1;202 3):e36-e69. Open 2. Evans R Fern ndez P rez, William D Travis, David A Lynch et al. Diagnosis and Evaluation of Hypersensitivity Pneumonitis: CHEST Guideline and Expert Panel Report. Chest. 2021 Aug;160 2):e97- e156. Open 3. B Bradley, H M Branley, J J Egan Irish Thoracic Society) et al. Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society. Thorax. 2008 Sep;63 Suppl 5:v1 58. Open 4. Andrew H Limper, Kenneth S Knox, George A Sarosi et al. An official American Thoracic Society statement: Treatment of fungal infections in adult pulmonary and critical care patients. Am J Respir Crit Care Med. 2011 Jan 1;183 1 96 128. Open 5. Jonathan P Parsons, Teal S Hallstrand, John G Mastronarde et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med. 2013 May 1;187 9 1016 27. Open https://web.pathway.md/diseases/recAKcR8Fglc9M2hN 4/4