Table of contents
Hypersensitivity pneumonitis
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of hypersensitivity pneumonitis 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).
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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
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Classification and risk stratification
Classification
As per ACCP 2021 guidelines:
Consider classifying patients with suspected HP based on the likelihood of an occupational or environmental inciting antigen exposure.
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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.
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Diagnostic investigations
General principles
As per ACCP 2021 guidelines:
Consider using a multidisciplinary discussion for diagnostic decision-making in patients with suspected HP.
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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.
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Exposure history
Antigen-specific antibodies
Antigen-specific lymphocyte proliferation testing
CT
Diagnostic procedures
Bronchoalveolar lavage: as per ACCP 2021 guidelines, do not perform routine bronchoalveolar lavage 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.
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Inhalation challenge testing
Lung biopsy
Medical management
Nonpharmacologic interventions
Specific circumstances
Patients with HP related to Aspergillus
As per ATS 2011 guidelines:
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.
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Do not use antifungal therapy in patients with HP related to Aspergillus.
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