Diagnosis

The usual diagnostic approach for all ILDs is a thorough history and physical examination along with chest radiographic and pulmonary function studies. The chest film typically shows bilateral, often asymmetric reticular opacities in the peripheral and basal lung areas. A normal-appearing radiograph may rarely be encountered but does not exclude microscopic presence of an ILD. Often, x-ray abnormalities can be seen years before the development of symptoms, so past films should be reviewed. HRCT features of idiopathic pulmonary fibrosis may be distinct and include bibasilar subpleural honeycombing, traction bronchiectasis (as illustrated in Fig. 18-11), thick intralobular septa, and minimal ground-glass opacities. If the HRCT pattern shows a predominance of ground-glass opaci-fication, especially located away from the subpleural areas, diagnoses such as nonspecific interstitial pneumonia, bron-chiolitis obliterans organizing pneumonia (BOOP), or hyper-sensitivity pneumonitis should be considered. In some cases, fibrotic scarring and nodules create a mass lesion that must be distinguished from carcinoma or other neoplasm.

The typical PFT pattern is that of a restrictive ventilatory defect with decreased lung flow and volume, increased FEVj/ FVC ratio, and decreased DLco. Biopsy may be necessary to exclude malignancy or to rule in specific conditions such as sarcoidosis. Documenting pulmonary function, exercise capacity (6-minute walk test), and relationship of the ILD to any occupational or environmental exposure are all essential for helping patients receive appropriate worker's compensation or disability support when needed.

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