Evans R Fernández Pérez1, William D Travis2, David A Lynch3, Kevin K Brown4, Kerri A Johannson5, Moisés Selman6, Jay H Ryu7, Athol U Wells8, Yuh-Chin Tony Huang9, Carlos A C Pereira10, Mary-Beth Scholand11, Ana Villar12, Naohiko Inase13, Richard B Evans14, Stephen A Mette15, Lindsy Frazer-Green16. 1. Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO. Electronic address: Fernandezevans@njhealth.org. 2. Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY. 3. Department of Radiology, National Jewish Health, Denver, CO. 4. Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO. 5. Departments of Medicine and Community Health Science, University of Calgary, Calgary, AB, Canada. 6. Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, México City, México. 7. Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN. 8. Department of Medicine, Royal Brompton Hospital, Imperial College London, London, England. 9. Department of Environmental and Occupational Medicine, Duke University Medical Center, Durham, NC. 10. Department of Medicine, Federal University of São Paulo, São Paulo, Brazil. 11. Department of Medicine, University of Utah, UT. 12. Respiratory Department, Hospital Vall d'Hebron, Barcelona, Spain. 13. Department of Medicine, Tokyo Medical and Dental University, Tokyo, Japan. 14. Department of Medicine, Prairie Lakes Health Care, SD. 15. Department of Medicine, University of Arkansas for Medical Sciences, AR. 16. American College of Chest Physicians, Glenview, IL.
Abstract
BACKGROUND: The purpose of this summary is to provide a synopsis of evidence-based and consensus-derived guidance for clinicians to improve individual diagnostic decision-making for hypersensitivity pneumonitis (HP) and decrease diagnostic practice variability. STUDY DESIGN AND METHODS: Approved panelists developed key questions regarding the diagnosis of HP using the PICO (Population, Intervention, Comparator, and Outcome) format. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion and vetted evaluation tools were used to assess the quality of included studies, to extract data, and to grade the level of evidence supporting each recommendation or statement. The quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted and voted on using a modified Delphi technique to achieve consensus. RESULTS: The systematic review of the literature based on 14 PICO questions resulted in 14 key action statements: 12 evidence-based, graded recommendations, and 2 ungraded consensus-based statements. All evidence was of very low quality. INTERPRETATION: Diagnosis of HP should employ a patient-centered approach and include a multidisciplinary assessment that incorporates the environmental and occupational exposure history and CT pattern to establish diagnostic confidence prior to considering BAL and/or lung biopsy. Additional research is needed on the performance characteristics and generalizability of exposure assessment tools and traditional and new diagnostic tests in modifying clinical decision-making for HP, particularly among those with a provisional diagnosis.
BACKGROUND: The purpose of this summary is to provide a synopsis of evidence-based and consensus-derived guidance for clinicians to improve individual diagnostic decision-making for hypersensitivity pneumonitis (HP) and decrease diagnostic practice variability. STUDY DESIGN AND METHODS: Approved panelists developed key questions regarding the diagnosis of HP using the PICO (Population, Intervention, Comparator, and Outcome) format. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion and vetted evaluation tools were used to assess the quality of included studies, to extract data, and to grade the level of evidence supporting each recommendation or statement. The quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted and voted on using a modified Delphi technique to achieve consensus. RESULTS: The systematic review of the literature based on 14 PICO questions resulted in 14 key action statements: 12 evidence-based, graded recommendations, and 2 ungraded consensus-based statements. All evidence was of very low quality. INTERPRETATION: Diagnosis of HP should employ a patient-centered approach and include a multidisciplinary assessment that incorporates the environmental and occupational exposure history and CT pattern to establish diagnostic confidence prior to considering BAL and/or lung biopsy. Additional research is needed on the performance characteristics and generalizability of exposure assessment tools and traditional and new diagnostic tests in modifying clinical decision-making for HP, particularly among those with a provisional diagnosis.