Pulmonary fibrosis

A restrictive lung disease characterised by accumulation of excess fibrous connective tissue in the lung parenchyma, causing reduced lung compliance and oxygen diffusion capacity. This leads to progressive hypoxaemia and shortness of breath.

Causes

Clinical features

Symptoms

• Chronic progressive shortness of breath
• Dry cough

Signs of pulmonary fibrosis

• Tachypnoea
• Reduced expansion
• Fine end-inspiratory crepitations 

Signs of cause

• Clubbing (idiopathic pulmonary fibrosis)
• Hand deformity (RA)
• Telangiectasia, sclerodactyly and microstomia (systemic sclerosis)
• Butterfly rash (SLE)
• Lupus pernio (sarcoidosis)
• Radiation burns
• Kyphosis (ankylosing spondylitis)

Telangiectasia

Rheumatoid arthritis

Clubbing

Investigations

• Chest X-ray: reticulonodular shadowing
• High-resolution CT chest: honeycombing cysts, reticular septal thickening, ground glass changes (indicates inflammatory process which is often steroid responsive)
• Spirometry: restrictive defect with reduced diffusion capacity
• Blood tests: for likely causes, e.g. antinuclear antibody, rheumatoid factor, anti-centromere antibody
• Lung biopsy

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Management

NB: fibrosis is permanent and there is no cure.

• Corticosteroids may help in acute exacerbations 
• Antifibrotics (pirfenidone/nintedanib) may be used in idiopathic pulmonary fibrosis
• Treat/withdraw cause if possible (may include corticosteroids and immunosuppressants)
• Supplementary measures
  • Smoking cessation
  • Pulmonary rehabilitation  
  • Long-term oxygen therapy – indications below
• Lung transplant (option for some patients)

Now time to test yourself

What is the difference between hypoxia and hypoxaemia?

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What is long-term oxygen therapy (LTOT)? What are the indications?

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What is ambulatory oxygen therapy? What are the indications?

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Try some OSCE exam stations!

1. Pulmonary fibrosis exam
2. Interstitial lung disease
3. More here

Picture references

Clubbing: 2009 Desherinka, licensed under the Creative Commons Attribution-Share Alike 4.0 International (https://creativecommons.org/licenses/by-sa/4.0/), 3.0 Unported (https://creativecommons.org/licenses/by-sa/3.0/deed.en), 2.5 Generic (https://creativecommons.org/licenses/by-sa/2.5/deed.en), 2.0 Generic (https://creativecommons.org/licenses/by-sa/2.0/deed.en) and 1.0 Generic license (https://creativecommons.org/licenses/by-sa/1.0/deed.en) and GNU Free Documentation licence 1.2 (https://commons.wikimedia.org/wiki/Commons:GNU_Free_Documentation_License,_version_1.2). Sourced from: https://en.wikipedia.org/wiki/Nail_clubbing#/media/File:Dedos_con_acropaquia.jpg