Understanding and Applying the 2025 “ILAs” (Interstitial lung abnormalities) Guidelines in Clinical Practice

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Alright, I think we'll, 
we'll slowly get underway here. 

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I'm sure more people are going to be 
joining as we go. So, 

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I'll start off just by introducing myself. 
I'm Chris Ryerson. 

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I'm in the Department of Medicine at UBC 
and do a lot of interstitial lung disease 

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work and had the pleasure of being 
involved in the ILA clinical statement or 

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the, the guidelines for this. 
So little bit of insider knowledge into 

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what went into this document and very 
pleased to introduce somebody else who's 

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going to talk to us about this, 
which is great. 

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And pleased to introduce Doctor Amanda 
Grant-Orser. 

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I'll call her Amanda throughout. So, 
Amanda is a clinical assistant professor 

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at the University of Calgary. 
She's a director of the ILD clinic at 

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Foothills Medical Centre and quickly has 
gained a national and even international 

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reputation in the field of ILD. 
She did her fellowship in ILD at the 

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University of Calgary after doing some of 
her training in London, 

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ON as well as in Ireland. 
Her research focuses on ILA 

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as well as familial ILD and prognostic 
biomarkers and she's dedicated her career 

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to improving the outcomes and quality of 
life for patients living with ILD. 

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So very pleased to have Amanda join us to 
speak today. First, 

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a couple of housekeeping things. 
Your cameras are going to be turned off 

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throughout the talk. 
So you won't actually be able to turn 

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your camera on. 
Your microphones are going to be muted 

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throughout the talk, 
but there is going to be an open mic 

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Q&A session at the end of the session. 

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In the meantime, 
you can also put your questions into the 

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chat box and I will be collating those 
and posing some of those towards the end 

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as well, if people don't want to speak up. 
At the end of the session, 

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there will be an evaluation form that's 
shown on the screen and please fill that 

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out if you have a moment to. 
We do have a steering committee that 

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decides what topics to present and what 
speaker to invite and we take feedback 

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from these evaluations quite seriously. 

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Alright, next slide. 
We have received support for this from 

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Boehringer. 
They provide the logistical support, 

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but they didn't provide any input on the 
content that will be discussed today. 

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We've received some speaking honoraria 
well, Amanda has, 

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about this talk from Boehringer as well. 

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Next slide, 

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this is Doctor Grant-Orser's conflicts of 
interest and next slide is is mine. 

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And with that, 
I'll turn the the microphone over to 

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Amanda. 

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Alright, perfect. Thanks, Doctor Ryerson, 
and thanks so much everyone for attending 

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on a Wednesday afternoon evening, 
wherever you are in the country. 

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I'm really excited to talk about these 
2025 ILA guidelines. 

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And over the next about 40 minutes, 
hopefully saving about 15 for questions 

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and answers. 
We'll talk about some key updates of the 

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guidelines and start off with a little 
bit about how we got to the guidelines in 

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the 1st place. 
I'll talk about a few clinical scenarios 

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where I think early recognition of ILAs 
may impact patient outcomes, 

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You know, 
how we can guide timely referral to the 

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right place, right time. 
And then we'll also talk about some case 

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discussions to guide patient management. 

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So to start off with, 
we'll start off with the a polling 

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question. Based on your current knowledge, 
which case represents an ILA? 

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So the first one is a 54-year-old male 
with renal colic presenting to the 

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emergency department, 
has a CT abdo pelvis that gets the lower 

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images of the thorax. 
He does have a family history of 

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interstitial lung disease and might have 
some mild respiratory symptoms. 

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The second case, 
B is an 83-year-old gentleman undergoing 

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nodule follow-up CT scans. 
He does have a bit of dyspnea at baseline, 

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but normal pulmonary function 

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testing and the third - 68 year old 
female with a CT abdomen to investigate a 

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renal mass, same thing. 
There's some lower images of her lungs. 

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She's asymptomatic and has normal 
pulmonary function testing. 

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So one of these, all of the above, 
or none of them. 

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So I'll put up this. There we go. 

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Hopefully people on their phones can 

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click on this. 

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All right, Super. 

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I'll give it another second here. 

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Hopefully everybody can see the end of 
the poll if I do that, share results. 

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OK, 
So hopefully people can see that a little 

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bit of a nice split. 
So 25% thought all of the above, 

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50% thought case C and a few for case B 
and 

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A. 

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All right. 

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So before we really get into the details 
of the, the guidelines, 

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I think it's important to tell a little 
bit of a story about the background of 

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this term, 
interstitial lung abnormalities and, 

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and kind of when it first came on the 
scene and some data behind why these 

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guidelines were felt to be important. 

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So interstitial lung abnormalities was 
first really put forward in 2020 as 

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incidental CT radiologic parenchymal 
abnormalities detected in patients not 

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known to have lung disease. 
And I think the goal of this originally 

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Fleischner paper was to try and somewhat 
harmonize some of the other terms that 

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have been floating around, 
things like incidental ILD, pre-clinical, 

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my favorite, 
geriatric ID to try and harmonize the 

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term in part to guide clinicians, 
also to guide radiologists and 

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researchers. 

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So many of you might be familiar with 
this 2020 Fleischner Society position 

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paper that gave a really nice definition 
of ILA's as being non-dependent 

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abnormalities affecting more than 5% of 
any lung zone. 

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And the abnormalities were ground glass, 
reticulation, lung distortion, traction, 

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bronchiectasis, 
honeycombing and non-emphysematous cysts. 

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And the original ILA recommendations was 
that these are supposed to be in 

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individuals in whom interstitial lung 
disease is not suspected and often 

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incidental finding 

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this position paper went on to define it 
into 3 sub categories. 

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They're pretty self-explanatory. 
Non-subpleural, usually some ground glass, 

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subpleural, 
non-fibrotic and then subpleural, 

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fibrotic. 
And part of this had to do with some 

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prognostic indicators for each of these 
different subcategories. 

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So how does this kind of fit into the 
realm of ILD? 

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I think many of us are familiar with this 
diagram here, you know, 

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the different trajectories that patients 
with pulmonary fibrosis often take. 

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Some patients decline slowly, 
some patients fast, 

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some in a stepwise manner. And so, 
we're often meeting patients, you know, 

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at the time of symptom onset or diagnosis 
after usually a significant amount of 

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fibrosis has already been established. 

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And so the thought is, 
the disease process starts years, 

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months beforehand. And so again, 
just honing in here, 

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this is when we meet patients and it's 
thought that these interstitial lung 

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abnormalities probably start years ahead 
of time and not everybody with ILA is 

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necessarily going to go on to develop 
interstitial lung disease. 

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Some of these ILAs resolve, 
some patients have a mild course, 

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some unfortunately go on to develop the 
disease. 

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We're most familiar with idiopathic 
pulmonary fibrosis, which has 

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quite a bit of mortality and morbidity 
associated with it. 

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And I think really what the goal of this, 
you know, ILA is, 

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is an opportunity for early detection to 
try and risk stratify these patients to 

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determine who will progress and try and 
answer the question, 

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if we intervene early, 
can we prevent irreversible fibrosis? 

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And So what about ILAs just by themselves 
in terms of, you know, 

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do they matter before it's actually 
determined to be a disease? 

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Let's start off with talking about 
prevalence. 

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So these are actually really common. 
So this is some work that our group did, 

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which is a systematic review and meta 
analysis of all of the lung cancer 

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screening programs that have been 
published up until about 2023. 

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And what we found was that ILAs were 
prevalent in about 7% of cases, 

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so quite high 

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In Canada, 
I think this is relevant because there 

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are some provinces that are already doing 
lung cancer screening and more kind of on 

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the way. And so I think, you know, 
even if we're not sure what to do with 

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ILAs and we'll get to that in the 
management side of things, 

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I think these referrals are coming to 
respirologists. 

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And so having some guidance is really, 
really important. 

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What about in general population 
screening? 

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So this is kind of lung health screenings 
that some communities and countries do. 

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Same thing, 
prevalence was quite high at 7%. 

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And then I think maybe unsurprisingly if 
you actually screen really at risk 

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cohorts, 
so this is familial pulmonary fibrosis 

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cohorts where you screen thought to be 
unaffected first-degree family relatives, 

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the prevalence is really high at about 
26%. So, 

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one in four at risk relatives might have 
these radiologic abnormalities. 

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And so I've probably alluded to this, 
you know, 

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the thought is that some of these 
patients like we have early preclinical 

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interstitial lung disease and what we 
know is that many of those with these 

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fibrotic changes will progress over time. 
It really depends on how long you follow 

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them for. So, you know, 
varying follow up time, 

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if you follow them for two years, 
less progressive, 

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if you follow them longer to five years 
more progress. 

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And this is just a nice example here of 
some ILA progression where there's some, 

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you know, 
a little bit of ground glass in the 

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picture. 

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And then on follow up, 
there's been some evolution to some 

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traction bronchiectasis. 

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This is directly from the guidelines as 
supplement. 

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So they looked at all of the studies that 
looked at progression and found similar 

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findings that about 46% of the the data 
that helped inform these guidelines, 

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there's ILA progression over time. 

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The other really striking thing about 
ILA's is that there's an increased risk 

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of all-cause mortality and a pretty, 
you know, 

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significant that we need to pay attention 
to. 

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And this is true across different cohorts, 
lung cancer screening, general population. 

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The other important thing is that this 
can affect treatment for things. So again, 

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coming back to that lung cancer side of 
things, 

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we know that ILAs impact the risk of 
things like radiation pneumonitis, 

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immune checkpoint inhibitor pneumonitis 
and an increased risk of lung cancer 

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mortality overall. So again, 
something to pay attention to. 

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And so, you know, 
the big question is who is going to 

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progress and when? 
And so there's been a quite a bit of work 

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looking at trying to answer this question 
and I'll just highlight a couple of 

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relevant data points. 

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So in terms of clinical predictors of 
progression, 

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so this was a fairly large study that 
looked at the AGES-Reykjavik longitudinal 

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birth cohort. 
So essentially you know normal patients 

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that it gets CT scans vote every five 
years for life and they looked at 

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patients that had violas with progression 
compared to patients who had no Ilas. 

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And so they looked at some kind of 
clinical slash biomarker predictors that 

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were interested in ILD. 

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So I think unsurprisingly, 
patients that have the same risk factors 

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for things like idiopathic pulmonary 
fibrosis, 

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the MUC5B genotype and age had an 
increased risk of both having ILAs, 

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that's on the right. And if you had ILAs, 
there's an increased risk of progression 

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on the left. 
The MUC5B genotype increases your risk of 

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having idiopathic pulmonary fibrosis. 
I think there's a lot of enthusiasm for 

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this, you know, 
let's call it a biomarker for predicting 

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the risk of who's going to get IPF, 
but it's not really clinically 

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used at this point. 
It's still very much a research tool, 

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but age is something, you know, 
as clinicians we could use in our clinic. 

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What else could we use in our clinic? 
What else do we ask patients about? Well, 

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things like sex, body mass index, 
and smoking. 

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While some of these certainly increase 
your risk of having ILA, 

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they weren't very good at predicting who 
was going to progress with ILAs once they 

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were actually established. 

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So [other] things can be used to project 
who's going to progress? 

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What about radiologic predictors of 
progression? 

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So this is kind of collated couple of 
studies that have looked at the 

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radiologic markers and and risk of 
progression. 

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So starting from the bottom up, 
subpleural, 

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nonfibrotic reticulation might increase 
your risk of progression a bit. 

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If you have a definite UIP pattern as per 
the guidelines, definitely increase. 

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And if you have very clear fibrosis, 
traction, bronchiectasis or honeycombing, 

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this is kind of removing some of the 
radiologic distribution definitions, 

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really high risk of progression. 
And so again, 

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this is just trying to highlight that no 
matter how you define fibrosis, 

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it's probably abnormal and it's probably 
going to get worse over time. 

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So just to hone in on those factors a 
little bit, again, 

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this is kind of separating out some of 
those radiologic risks of prediction. 

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We know that if there's a lower lobe 
predominant pattern, 

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there's an increased risk. 

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If there's subpleural reticulation, 
there's an increased risk. 

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If there's traction bronchiectasis, 
definitely an increased risk 

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and if there's honeycombing, 
you likely almost certainly will get 

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worse. Again, 
the question is over how long? 

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So the study that I took this data from 
was over 5 year follow up and everybody 

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who had honeycombing had progression at 
the five year mark. 

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OK. 
So what doesn't increase your risk of 

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progression? 

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So nonemphysematous cysts probably don't 
increase your risk of progression. 

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This is something that was included in 
the previous Fleischner paper and we'll 

00:14:19.297 --> 00:14:22.173 
see that has been taken out of the most 
recent guidelines. 

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Things like centrilobular nodules don't 
increase your risk of progression if 

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you've got an indeterminate pattern for 
UIP and non-subpleural ground glass 

00:14:29.633 --> 00:14:32.071 
opacities, 
those all are pretty good markers that 

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hopefully things won't get worse. 

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OK, so coming back to, you know, 
time to progression. 

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So we know that there's a sanity ILA, 
but I think it would be really helpful to 

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know kind of when that progression is 
going to happen. 

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And so this is a really nice study that 
that tried to answer that question. 

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This looked at about 4700 patients in a 
healthy lung health screening program, 

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and they found that there was about a 7% 
prevalence of ILAs, which is nice, 

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it matched our previous data and looked 
at those who had, you know, 

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true ILAs not indeterminate for ILAs. 
We'll come to this, 

00:15:08.847 --> 00:15:12.645 
but sometimes it's hard based on 
inspiration of the CT scan, 

00:15:12.645 --> 00:15:15.945 
if it's low dose, high resolution, 
things like that, 

00:15:15.945 --> 00:15:20.553 
whether it's a true ILA or not. 
So a lot of these studies sometimes have, 

00:15:20.553 --> 00:15:23.480 
you know, 
hedging your bets and indeterminate, 

00:15:23.560 --> 00:15:25.955 
for ILA. 
This one really tried to include those 

00:15:25.955 --> 00:15:29.000 
that had clear features of an 
interstitial lung abnormality. 

00:15:30.360 --> 00:15:35.140 
They looked at 239 of these patients and 
they removed those patients that had a 

00:15:35.140 --> 00:15:38.068 
suspected undiagnosed interstitial lung 
disease. 

00:15:38.068 --> 00:15:42.789 
And interstitial lung disease in this 
case was defined as those with extensive 

00:15:42.789 --> 00:15:45.837 
CT abnormalities. 
So basically bilateral fibrosis, 

00:15:45.837 --> 00:15:50.139 
over 5% of three or more lung zones were 
classified as having suspected 

00:15:50.139 --> 00:15:53.784 
interstitial lung disease. 
And basically they followed these 

00:15:53.784 --> 00:15:56.712 
patients. 
Usually they'd have a CT scan at about 

00:15:56.712 --> 00:16:01.493 
every two years and for the purpose of 
this study they wanted to have people to 

00:16:01.493 --> 00:16:02.330 
have a CT scan 

00:16:02.400 --> 00:16:03.850 
and at least the five year follow up. 

00:16:06.620 --> 00:16:11.800 
And what was pretty striking was over the 
course of the the entire study, 

00:16:11.800 --> 00:16:15.300 
81% of patients had some form of ILA 
progression. 

00:16:16.520 --> 00:16:22.410 
ILAs progressed to a clear UIP pattern in 
17% of patients. 

00:16:23.170 --> 00:16:25.746 
And this is I think the really helpful 
data point, 

00:16:25.746 --> 00:16:28.526 
the median time to ILA progression was 3. 
2 years. So, 

00:16:28.526 --> 00:16:31.052 
I think this is the first time we said, 
you know, 

00:16:31.052 --> 00:16:33.680 
this is when we start to see some of 
these changes. 

00:16:34.620 --> 00:16:39.126 
What was helpful from a, you know, 
an a understanding the Natural History of 

00:16:39.126 --> 00:16:42.578 
this process number, 
was that the progression to UIP could 

00:16:42.578 --> 00:16:45.856 
take upwards of close to 12 years. So, 
you know, again, 

00:16:45.856 --> 00:16:48.723 
I think we have all seen patients in our 
clinic. 

00:16:48.723 --> 00:16:53.112 
You look back on a CT 5 plus years ago 
and there's probably something that 

00:16:53.112 --> 00:16:55.746 
started. 
How we translate that into clinical 

00:16:55.746 --> 00:16:59.081 
practice is a little bit harder to 
understand. You know, 

00:16:59.081 --> 00:17:03.705 
following asymptomatic patients for 12 
years might be difficult when we've got 

00:17:03.705 --> 00:17:06.280 
already pretty busy clinical practices, 
but 

00:17:06.350 --> 00:17:10.005 
happy to have that discussion at the 
Q&A section. But really, you know, 

00:17:10.005 --> 00:17:13.708 
I think this is important data showing 
that at least on a median time frame, 

00:17:13.708 --> 00:17:16.210 
it takes three years for these changes to 
progress. 

00:17:19.180 --> 00:17:24.200 
OK, well, you know, we've identified ILAs. 
Let's talk about treatment, with what? 

00:17:24.200 --> 00:17:27.935 
and for who? So right now, 
no studies to date have evaluated 

00:17:27.935 --> 00:17:30.751 
treatment for ILA. I think there's, 
you know, 

00:17:30.751 --> 00:17:35.833 
a lot of enthusiasm and there's a theory 
that earlier treatment of ILD should lead 

00:17:35.833 --> 00:17:39.874 
to better outcomes. So, 
what treatments do we really focus on for 

00:17:39.874 --> 00:17:43.854 
at least ILD right now, 
the established therapies, antifibrotic. 

00:17:43.854 --> 00:17:47.038 
Sorry if this doesn't project very well. 
Of course, 

00:17:47.038 --> 00:17:49.120 
there's nintedanib and pirfenidone 

00:17:49.960 --> 00:17:52.734 
you know, 
we've seen that they reduce FVC decline 

00:17:52.734 --> 00:17:56.063 
over time and you know, 
we think that they have a mortality 

00:17:56.063 --> 00:18:00.557 
benefit of antifibrotic therapy as well. 
There's lots of kind of systematic meta 

00:18:00.557 --> 00:18:04.274 
analyses in real world studies. 
This study in particular was a bit 

00:18:04.274 --> 00:18:08.546 
provocative because it did talk about 
whether or not there was a true signal 

00:18:08.546 --> 00:18:12.874 
for mortality benefit when you took out 
immortal time bias. And so, you know, 

00:18:12.874 --> 00:18:17.201 
we certainly hope that we're doing right 
by our patients and making them live 

00:18:17.201 --> 00:18:17.590 
longer. 

00:18:18.360 --> 00:18:20.840 
Of course, these are wonderful drugs. 
They're what we have. 

00:18:20.840 --> 00:18:24.190 
They also come with some side effects and 
costs that we have to be cognizant of. 

00:18:25.500 --> 00:18:30.073 
OK, what about preventative therapies? 
So this was a nice recent publication 

00:18:30.073 --> 00:18:35.002 
that looked at the impact of vaccination 
in fibrotic interstitial lung disease and 

00:18:35.002 --> 00:18:39.337 
the risk of mortality in COVID. 
And the main take away point was that if 

00:18:39.337 --> 00:18:42.485 
you were vaccinated from COVID and 
contracted COVID, 

00:18:42.485 --> 00:18:46.880 
you had less risk of mortality. 
They also looked at immunosuppression and 

00:18:46.880 --> 00:18:51.513 
there wasn't really a signal of harm or 
benefit if you were immunosuppressed. 

00:18:51.513 --> 00:18:55.789 
But again, this is, you know, 
a really nice paper that shows that there 

00:18:55.789 --> 00:18:56.679 
is some benefit 

00:18:56.750 --> 00:19:00.460 
hopefully in our patients for 
vaccinations and the fibrotic ILD space. 

00:19:02.260 --> 00:19:05.180 
And then of course, 
what about emerging therapies? 

00:19:05.180 --> 00:19:09.075 
What's coming to market soon? 
I think we're all very excited at the 

00:19:09.075 --> 00:19:13.370 
results of the FIBRONEER trials. 
This one data point in particular is from 

00:19:13.370 --> 00:19:14.230 
the PPF cohort. 

00:19:15.090 --> 00:19:17.894 
And you know, 
this is the first trial that's really 

00:19:17.894 --> 00:19:21.455 
shown as a secondary endpoint. 
But in a randomized control trial, 

00:19:21.455 --> 00:19:25.662 
there was a benefit for death in our ILD 
population, which is just, you know, 

00:19:25.662 --> 00:19:28.737 
so exciting. So, 
I think there's some emerging therapies 

00:19:28.737 --> 00:19:32.944 
that are coming to market that, you know, 
hopefully will be beneficial to our 

00:19:32.944 --> 00:19:33.430 
patients. 

00:19:34.920 --> 00:19:38.741 
And I'd like to frame it kind of like 
statin therapy. You know, 

00:19:38.741 --> 00:19:43.399 
I'm hopeful that within my career we get 
a medication that is considered both 

00:19:43.399 --> 00:19:46.982 
primary prevention and secondary 
prevention. And of course, 

00:19:46.982 --> 00:19:49.669 
we have to think about all things like 
cost, 

00:19:49.669 --> 00:19:53.670 
how much is it going to reduce the risk, 
safety, things like that. 

00:19:53.670 --> 00:19:58.268 
But I really hope that we can find 
something like that for interstitial lung 

00:19:58.268 --> 00:20:00.895 
disease. 
And I think focusing on ILAs is an 

00:20:00.895 --> 00:20:02.150 
opportunity for that. 

00:20:04.400 --> 00:20:10.080 
So without further ado, 
I'll get into our guidelines. 

00:20:13.570 --> 00:20:18.007 
So this was the approach to the 
evaluation and management of interstitial 

00:20:18.007 --> 00:20:21.725 
lung abnormalities. 
It was an ATS Society clinical statement. 

00:20:21.725 --> 00:20:25.142 
There was 4 Co-chairs, 
well recognized in the field, Dr. 

00:20:25.142 --> 00:20:30.060 
Podolanczuk, Dr. Hunninghake, our own Dr. 
Chris Ryerson, as well as Dr. Schwartz. 

00:20:32.150 --> 00:20:36.103 
And so this was a committee that was 
combined with both clinical and 

00:20:36.103 --> 00:20:39.712 
methodologic experts. 
There was also two patient partners that 

00:20:39.712 --> 00:20:42.863 
were involved in it. 
The questions were drafted by the 

00:20:42.863 --> 00:20:45.957 
Co-chairs and then put forward to 
committee approval. 

00:20:45.957 --> 00:20:50.540 
There was an evidence synthesis process 
for each of the PICO questions that was 

00:20:50.540 --> 00:20:54.951 
generated and then basically it was kind 
of consensus by discussion with the 

00:20:54.951 --> 00:20:59.248 
voting practice afterwards either to 
accept or not accept a suggestion and 

00:20:59.248 --> 00:21:03.545 
over 70% agreement was required. 
This underwent several peer review cycles 

00:21:03.545 --> 00:21:03.660 
by 

00:21:03.810 --> 00:21:07.124 
experts in the field, 
and there is a planned three-year review 

00:21:07.124 --> 00:21:10.070 
by the ATS to see if there's an update 
that's required. 

00:21:13.840 --> 00:21:18.037 
In terms of core concepts. 
Before we get into some of the details, 

00:21:18.037 --> 00:21:21.921 
the authors, you know, 
off the bat recognize that normal lung 

00:21:21.921 --> 00:21:25.680 
ILA and ILD's are likely a spectrum of 
changes in the lung. 

00:21:27.020 --> 00:21:30.663 
One thing that was important was the 
incidental requirement that was put 

00:21:30.663 --> 00:21:34.157 
forward in the Fleischner Society 
position paper was removed from the 

00:21:34.157 --> 00:21:36.702 
definition. 
I think - #1 radiologists don't always 

00:21:36.702 --> 00:21:40.246 
know why the scan is being done. 
I certainly just sometimes click off, 

00:21:40.246 --> 00:21:44.389 
you know, shortness of breath or you know, 
our colleagues might click off nodule - 

00:21:44.389 --> 00:21:46.984 
follow up, 
but they might have shortness of breath. 

00:21:46.984 --> 00:21:50.627 
So all of that information might not 
actually be there for radiologists. 

00:21:50.627 --> 00:21:53.572 
And it, you know, 
the thought was that it makes a bit more 

00:21:53.572 --> 00:21:55.070 
clinical sense to remove that. 

00:21:56.290 --> 00:22:00.658 
The authors also recognize that some of 
these recommendations are trying to 

00:22:00.658 --> 00:22:04.395 
balance the sensitivity and specificity 
for disease progression. 

00:22:04.395 --> 00:22:09.051 
I think that's what we're all worried 
about is the the progressing type of ILAs. 

00:22:09.051 --> 00:22:13.478 
They also acknowledge that not all 
disease necessarily needs treatment if it 

00:22:13.478 --> 00:22:16.870 
meets that ILD definition that the 
guideline puts forward. 

00:22:18.230 --> 00:22:22.662 
They acknowledge that all imaging is not 
equal and if there's a question if this 

00:22:22.662 --> 00:22:26.712 
is an ILA or indeterminate for ILA, 
probably getting a high resolution CT 

00:22:26.712 --> 00:22:28.190 
with prone images is ideal. 

00:22:28.960 --> 00:22:32.598 
And then they also comment that some of 
the recommendations are there to really 

00:22:32.598 --> 00:22:35.600 
stimulate some evidence generation in a 
field that is pretty new. 

00:22:36.490 --> 00:22:39.253 
Finally, 
and I think really importantly was there 

00:22:39.253 --> 00:22:43.011 
was a patient voice component and the 
patients really thought early 

00:22:43.011 --> 00:22:46.990 
identification was important and so that 
was prioritized in this paper. 

00:22:49.610 --> 00:22:52.730 
OK, so this is the new definition of ILA. 

00:22:54.900 --> 00:23:00.102 
So an ILA is defined as a Chest CT 
showing bilateral and nondependent ground 

00:23:00.102 --> 00:23:04.089 
glass opacities, reticular abnormalities, 
lung distortion, 

00:23:04.089 --> 00:23:08.886 
traction bronchiectasis and or 
honeycombing involving equal to or over 

00:23:08.886 --> 00:23:12.738 
5% of a lung zone. 
And they define upper middle and lung 

00:23:12.738 --> 00:23:16.860 
zones by the inferior arch and right 
inferior pulmonary vein 

00:23:17.600 --> 00:23:21.467 
for a total of 6 lung zones. 
So this is very similar to the Fleischner 

00:23:21.467 --> 00:23:25.390 
Society paper. As mentioned, 
the incidental portion has been taken out. 

00:23:26.840 --> 00:23:30.291 
They also talk about things that are not 
considered ILAs, 

00:23:30.291 --> 00:23:35.052 
so they talk a little bit about extent. 
So #1 if it's a mild focal abnormality, 

00:23:35.052 --> 00:23:38.563 
things like focal paraspinal fibrosis, 
which we see a lot, 

00:23:38.563 --> 00:23:41.718 
you know that that's probably not 
considered an ILA. 

00:23:41.718 --> 00:23:46.122 
They also talk about if something's 
unilateral, it's probably not an ILA. 

00:23:46.122 --> 00:23:50.645 
The one caveat of that is if those 
patients have a strong family history of 

00:23:50.645 --> 00:23:54.870 
familial pulmonary fibrosis, 
there is some data to support that it can 

00:23:54.870 --> 00:23:57.370 
kind of start as a unilateral abnormality. 

00:23:57.900 --> 00:24:00.663 
And then finally, if it's really, 
really extensive disease, 

00:24:00.663 --> 00:24:03.103 
which they go on to define, it's probably, 
you know, 

00:24:03.103 --> 00:24:06.650 
should be considered interstitial lung 
disease as opposed to an abnormality. 

00:24:07.810 --> 00:24:11.358 
The authors also talk about radiologic 
patterns that aren't. 

00:24:11.358 --> 00:24:15.256 
Things like atelectasis, linear scarring, 
non-emphysematous cysts, 

00:24:15.256 --> 00:24:17.815 
centrilobular nodularity. 
PPFE importantly, 

00:24:17.815 --> 00:24:22.294 
is not considered as part of the ILA 
criteria, heart failure and aspiration. 

00:24:22.294 --> 00:24:26.774 
And I think I showed in previous slides 
part of this is because these things 

00:24:26.774 --> 00:24:29.450 
don't really predict the risk of 
progression. 

00:24:33.740 --> 00:24:38.464 
The guidelines do keep the previous sub 
categorizations of nonsubpleural, 

00:24:38.464 --> 00:24:41.848 
subpleural, 
nonfibrotic and subpleural fibrotic with 

00:24:41.848 --> 00:24:44.658 
examples here on the left-hand side. 
Again, 

00:24:44.658 --> 00:24:49.510 
the thought being that there is some 
prognostic significance. So therefore, 

00:24:49.510 --> 00:24:50.660 
these were kept in 

00:24:55.390 --> 00:25:00.358 
and then interstitial lung abnormalities 
and what's actually a definition of 

00:25:00.358 --> 00:25:04.810 
interstitial lung disease. 
So I think everybody is really excited to 

00:25:04.810 --> 00:25:10.165 
to read this table trying to define kind 
of where that spectrum line is for an ILA 

00:25:10.165 --> 00:25:13.713 
versus an ILD. 
And so the criteria put forth had to do 

00:25:13.713 --> 00:25:16.940 
with symptoms, physiology, 
imaging and pathology. 

00:25:18.250 --> 00:25:21.890 
So if somebody has symptoms, 
the symptoms of interest being dyspnea 

00:25:21.890 --> 00:25:26.173 
and cough that a clinician can attribute 
to interstitial lung disease or the CT 

00:25:26.173 --> 00:25:30.349 
scan, then it's probably a true disease. 
There was comments about things like 

00:25:30.349 --> 00:25:32.972 
fatigue, 
but really it was felt that dyspnea and 

00:25:32.972 --> 00:25:36.559 
cough again probably have the most 
prognostic data behind them for 

00:25:36.559 --> 00:25:40.950 
interstitial lung disease and that's why 
these were included as the main symptoms 

00:25:42.630 --> 00:25:47.710 
Physiology - So any abnormality in the 
pulmonary function testing we're most 

00:25:47.710 --> 00:25:51.867 
interested in for ILD: FVC, 
TLC or DLCO that the clinician can 

00:25:51.867 --> 00:25:56.684 
attribute to essentially the radiologic 
pattern would qualify this as an 

00:25:56.684 --> 00:25:58.400 
interstitial lung disease. 

00:25:59.120 --> 00:26:03.833 
One thing important to note: that they 
did actually make criteria about being 

00:26:03.833 --> 00:26:08.486 
defined as a value or Z-score below the 
lower limit of normal. So, you know, 

00:26:08.486 --> 00:26:12.837 
when I went through training, 
we were still using things like 80%, 75%. 

00:26:12.837 --> 00:26:17.006 
And so this has changed to Z-scores below 
the lower limit of normal. 

00:26:17.006 --> 00:26:21.961 
The other piece that they put in here was 
that if pulmonary function testing over 

00:26:21.961 --> 00:26:26.795 
time satisfies the physiologic criteria 
for progressive pulmonary fibrosis that 

00:26:26.795 --> 00:26:31.629 
the clinician again can attribute to a 
disease process. So many of us have seen 

00:26:31.700 --> 00:26:34.970 
patients that have "normal" pulmonary 
function testing, 

00:26:34.970 --> 00:26:39.116 
but if you look back a year ago, 
all of a sudden they had 200-300 more 

00:26:39.116 --> 00:26:42.445 
milliliters in FVC. 
And so that's not really age-related 

00:26:42.445 --> 00:26:45.424 
changes. 
And so I think that could be considered a 

00:26:45.424 --> 00:26:46.300 
disease process 

00:26:49.110 --> 00:26:50.700 
in terms of imaging. 

00:26:52.180 --> 00:26:57.962 
So the main take away is that if there is 
fibrosis, it's abnormal. And again, 

00:26:57.962 --> 00:27:04.263 
fibrosis being defined by honeycombing or 
reticulation with traction bronchiectasis. 

00:27:04.263 --> 00:27:10.194 
And they do give a cutoff that basically 
is over 5% of the total lung volume by 

00:27:10.194 --> 00:27:14.123 
visual estimation. And so again, 
a reminder for ILA, 

00:27:14.123 --> 00:27:19.090 
it's over 5% of a lung zone. 
This is over 5% of total lung volume. 

00:27:20.240 --> 00:27:22.815 
Importantly, 
if patients have serial CT scans, 

00:27:22.815 --> 00:27:25.719 
for example, 
again like in lung cancer screening and 

00:27:25.719 --> 00:27:29.335 
you've got progressive fibrotic 
abnormalities on serial CT scans, 

00:27:29.335 --> 00:27:32.130 
again that should be considered a disease 
process. 

00:27:32.820 --> 00:27:37.718 
And then finally the presence of one of 
the major fibrotic ILD patterns on chest 

00:27:37.718 --> 00:27:37.900 
CT. 

00:27:38.730 --> 00:27:43.536 
So those being usual interstitial 
pneumonia, UIP, fibrotic HP, 

00:27:43.536 --> 00:27:48.877 
which if some of you have read the new 
guidelines is now slowly being 

00:27:48.877 --> 00:27:54.600 
transitioned to bronchiolocentric 
interstitial pneumonia or fibrotic NSIP. 

00:27:55.310 --> 00:27:59.307 
I think one of the things as radiologists 
and clinicians we struggle with is that 

00:27:59.307 --> 00:28:03.061 
if there isn't that much disease extent, 
it's harder to actually say whether 

00:28:03.061 --> 00:28:07.107 
there's a major fibrotic pattern or not. 
But if there's certain features that kind 

00:28:07.107 --> 00:28:10.130 
of fit that criteria, again, 
it's probably a disease process. 

00:28:11.590 --> 00:28:15.949 
So this again is just an example here 
really highlighting some of the fibrotic 

00:28:15.949 --> 00:28:19.316 
changes that we would consider a disease 
process. And again, 

00:28:19.316 --> 00:28:23.290 
I would quantify that visually, 
there's over 5% of the total lung zone. 

00:28:24.090 --> 00:28:27.577 
Of note, 
they did talk a lot about quantitative CT 

00:28:27.577 --> 00:28:33.183 
scan and I think there's a lot of value 
and hopeful clinical applicability that's 

00:28:33.183 --> 00:28:36.807 
coming down the pipeline. 
But at this point in time, 

00:28:36.807 --> 00:28:42.140 
quantitative CT was not part of the 
definition in terms of visual assessments 

00:28:42.140 --> 00:28:43.850 
and volumes and follow up 

00:28:45.500 --> 00:28:49.606 
and then finally pathology. 
So if there is pathology for whatever 

00:28:49.606 --> 00:28:52.655 
reason. 
So I think realistically the most common 

00:28:52.655 --> 00:28:57.322 
scenario is somebody who's had a lung 
cancer resected and sometimes in the 

00:28:57.322 --> 00:29:02.300 
adjacent parenchyma you see some major 
fibrotic patterns such as UIP that could 

00:29:02.300 --> 00:29:04.790 
be considered a disease process as well. 

00:29:05.570 --> 00:29:09.296 
The guidelines go on to very clearly 
state patients shouldn't have a lung 

00:29:09.296 --> 00:29:12.116 
sample for the sake of getting pathology. 
But you know, 

00:29:12.116 --> 00:29:15.894 
if you have it for for another cause and 
you've got one of these patterns, 

00:29:15.894 --> 00:29:18.110 
that's something that you need to 
consider. 

00:29:19.200 --> 00:29:19.900 
OK, 

00:29:21.090 --> 00:29:25.273 
and then we'll go through this. 
So this is the the kind of screening, 

00:29:25.273 --> 00:29:29.157 
detection recommendations, 
the baseline assessment and follow up 

00:29:29.157 --> 00:29:31.009 
assessment that they put forth. 

00:29:32.350 --> 00:29:35.780 
Let's start off with the first box 
talking about screening and detection. 

00:29:36.660 --> 00:29:40.826 
And so I mentioned that, you know, 
this can be found incidentally, 

00:29:40.826 --> 00:29:45.490 
but there's certain populations that A, 
you might go looking for it and B, 

00:29:45.490 --> 00:29:50.092 
might have CT scans for other reasons. 
So the first one being lung cancer 

00:29:50.092 --> 00:29:54.569 
screening eligible populations. 
If a patient is going to have a CT scan 

00:29:54.569 --> 00:29:58.798 
for lung cancer screening, 
it should probably be evaluated for ILAs 

00:29:58.798 --> 00:30:01.658 
as well. 
There's a lot of shared risk factors 

00:30:01.658 --> 00:30:05.700 
between lung cancer and ILD / ILAs, 
things like smoking and age. 

00:30:05.700 --> 00:30:08.809 
And so I think that is slowly being 
incorporated. 

00:30:08.890 --> 00:30:13.231 
A lot of the guidelines about incidental 
findings in lung cancer screening 

00:30:13.231 --> 00:30:15.836 
includes something about pulmonary 
fibrosis, 

00:30:15.836 --> 00:30:18.383 
maybe not specifically the terminology 
ILA, 

00:30:18.383 --> 00:30:22.320 
but I think radiologist recognize they 
might incidentally find that 

00:30:23.810 --> 00:30:29.093 
the next big one for screening was 
patients diagnosed with connective tissue 

00:30:29.093 --> 00:30:32.592 
disease. 
And so I think this is kind of keeping in 

00:30:32.592 --> 00:30:38.288 
line with the 2023 ACR chest guidelines. 
This was a pretty big statement that came 

00:30:38.288 --> 00:30:43.503 
out in 2023-2024 that really made a 
comment that patients with high risk of 

00:30:43.503 --> 00:30:48.306 
having ILD to probably have high 
resolution CT scans as part of their 

00:30:48.306 --> 00:30:51.668 
initial evaluation for their autoimmune 
disease, 

00:30:51.668 --> 00:30:56.060 
pulmonary function testing isn't enough, 
we know that can be an 

00:30:56.260 --> 00:30:59.857 
insensitive marker for ILD. 
And so this is really the first statement 

00:30:59.857 --> 00:31:02.735 
that says people with SARD, 
if you're high risk of ILD, 

00:31:02.735 --> 00:31:05.150 
probably should get a high-resolution CT 
scan. 

00:31:05.150 --> 00:31:09.416 
I think we've had a talk on this already 
and I encourage you to read this document 

00:31:09.416 --> 00:31:12.346 
if you haven't. 
They give a nice table on the right here 

00:31:12.346 --> 00:31:15.943 
about those most at risk for having 
interstitial lung disease with an 

00:31:15.943 --> 00:31:16.920 
autoimmune disease. 

00:31:20.190 --> 00:31:25.442 
And then the next I think pretty bold 
statement that the guidelines came out 

00:31:25.442 --> 00:31:31.036 
with was a screening recommendation for 
first degree relatives over the age of 50 

00:31:31.036 --> 00:31:34.720 
who have a relative with familial 
pulmonary fibrosis. 

00:31:35.770 --> 00:31:40.627 
And so I think this, you know, 
really comes down to some of the data I 

00:31:40.627 --> 00:31:45.622 
presented earlier that having ILA's and 
at risk family members is really 

00:31:45.622 --> 00:31:47.880 
prevalent, you know, one in four. 

00:31:48.840 --> 00:31:52.611 
So again, just to clarify, 
this would be like if my dad has 

00:31:52.611 --> 00:31:57.136 
interstitial lung disease and my brother 
has interstitial lung disease, 

00:31:57.136 --> 00:32:01.598 
I'm a first degree relative, 
I should be screened at the age of 50 for 

00:32:01.598 --> 00:32:02.289 
these ILAs. 

00:32:06.250 --> 00:32:09.820 
they do talk about. 
What about first degree relatives of 

00:32:09.820 --> 00:32:14.580 
those with idiopathic pulmonary fibrosis? 
It sounds like this was a debated 

00:32:16.140 --> 00:32:19.959 
question. There was no consensus. 
If you look at the numbers, 

00:32:19.959 --> 00:32:24.457 
the committee seemed 50/50 split. 
Part of this is because if you look at 

00:32:24.457 --> 00:32:28.461 
the small available screening studies 
that have happened so far, 

00:32:28.461 --> 00:32:33.390 
the numbers are actually pretty close. 
Upwards of about 24% of patients who are 

00:32:33.390 --> 00:32:38.380 
first degree relatives of those with just 
a single sporadic idiopathic pulmonary 

00:32:38.380 --> 00:32:41.954 
fibrosis case can have features of ILAs. 
That being said, 

00:32:41.954 --> 00:32:46.082 
because the data was pretty small 
compared to some of the familial 

00:32:46.082 --> 00:32:48.299 
pulmonary fibrosis screening cohorts 

00:32:48.480 --> 00:32:50.970 
that was not included and there was no 
consensus. 

00:32:52.210 --> 00:32:55.201 
What's not considered familial pulmonary 
fibrosis, 

00:32:55.201 --> 00:32:59.600 
sarcoidosis and PPFE aren't really 
included in that definition of familial 

00:32:59.600 --> 00:33:03.765 
pulmonary fibrosis. In terms of the age, 
I think it's a bit arbitrary, 

00:33:03.765 --> 00:33:06.639 
the 50 cut off of course again showed 
some data. 

00:33:06.639 --> 00:33:10.569 
There's increased prevalence with age. 
We have to start somewhere. 

00:33:10.569 --> 00:33:14.440 
They do comment though in some families 
there might be, you know, 

00:33:14.440 --> 00:33:19.132 
a bit more penetrant gene that causes 
earlier diagnosis and earlier patients to 

00:33:19.132 --> 00:33:24.060 
be affected and it would be reasonable to 
screen five years before the 1st affected 

00:33:24.620 --> 00:33:25.380 
family member. 

00:33:26.950 --> 00:33:31.907 
The guidelines also comment that a lot of 
these familial pulmonary fibrosis cohorts 

00:33:31.907 --> 00:33:36.039 
and genetic studies to date have been 
from European ancestry cohorts. 

00:33:36.039 --> 00:33:39.757 
So I think in our, you know, 
very diverse Canadian population, 

00:33:39.757 --> 00:33:44.183 
we have to take that - number one, 
we need enriched cohorts that are a bit 

00:33:44.183 --> 00:33:44.420 
more 

00:33:46.070 --> 00:33:49.673 
multinational and just kind of make sure 
that we're applying these to the right 

00:33:49.673 --> 00:33:50.710 
patient in front of us. 

00:33:53.760 --> 00:33:56.950 
OK, so you've identified ILAs. 
Now what should we do? 

00:33:58.290 --> 00:34:00.945 
So of course, 
you know it's appropriate to do a 

00:34:00.945 --> 00:34:04.209 
baseline assessment. 
We want to look for those features of 

00:34:04.209 --> 00:34:07.362 
interstitial lung disease by doing a 
symptom assessment, 

00:34:07.362 --> 00:34:10.736 
asking patients about cough, 
exertional shortness of breath. 

00:34:10.736 --> 00:34:15.328 
We should probably ask them about things 
like connective tissue disease and family 

00:34:15.328 --> 00:34:18.149 
history. 
And then it's probably a good idea to get 

00:34:18.149 --> 00:34:21.690 
some pulmonary function testing again, 
spirometry, TLC and DLCo 

00:34:22.790 --> 00:34:27.485 
it's worthwhile talking to patients about 
risk reduction, recognizing that, 

00:34:27.485 --> 00:34:30.451 
you know, 
the data supporting that this makes a 

00:34:30.451 --> 00:34:33.788 
really meaningful clinical outcome is is 
forthcoming. 

00:34:33.788 --> 00:34:38.607 
But it's probably good to talk about 
smoking cessation, exposure remediation, 

00:34:38.607 --> 00:34:41.635 
environmental, 
occupation and medication and age 

00:34:41.635 --> 00:34:43.180 
appropriate vaccinations. 

00:34:45.270 --> 00:34:48.338 
Importantly, 
recommendations against in terms of both 

00:34:48.338 --> 00:34:52.828 
for a screening purpose to decide who 
should get a CT scan as well as once you 

00:34:52.828 --> 00:34:56.749 
have an ILA and determining, you know, 
who's at risk of progression, 

00:34:56.749 --> 00:35:01.465 
the guideline recommends against testing 
for the MUC5B as well as telomere length. 

00:35:01.465 --> 00:35:05.671 
I think both of these are really, 
really exciting biomarkers in the field 

00:35:05.671 --> 00:35:09.194 
of interstitial lung disease. 
They at some point they will be 

00:35:09.194 --> 00:35:13.740 
incorporated into baseline assessments, 
but there's still a bit at the research 

00:35:13.740 --> 00:35:14.650 
phase right now. 

00:35:15.910 --> 00:35:20.074 
They also talk about lung sampling, 
including bronchoalveolar lavage and 

00:35:20.074 --> 00:35:23.782 
transbronchial biopsies, 
as well as cryo biopsies that's felt to 

00:35:23.782 --> 00:35:28.290 
be not necessary as a baseline assessment 
for interstitial lung abnormalities. 

00:35:31.570 --> 00:35:35.409 
And then what about follow up assessment? 
And so this is nice to see kind of a, 

00:35:35.409 --> 00:35:37.665 
you know, 
a bit of numbers about how often you 

00:35:37.665 --> 00:35:40.497 
should be following these patients. 
So of course, if they, 

00:35:40.497 --> 00:35:43.904 
you know on your first assessment you 
determined that they've got ILD, 

00:35:43.904 --> 00:35:46.688 
they should go to the right, 
they should be referred to a 

00:35:46.688 --> 00:35:49.424 
pulmonologist for evaluation, 
management and monitoring. 

00:35:49.424 --> 00:35:50.480 
As for ILD guidelines, 

00:35:51.310 --> 00:35:54.168 
what about if you're really convinced 
this is really just an ILA? 

00:35:54.168 --> 00:35:56.420 
How how long should be follow them, 
How frequently? 

00:35:57.210 --> 00:35:59.935 
So of course, you know, 
I like to tell my patients, 

00:35:59.935 --> 00:36:03.813 
monitor for signs of, you know, 
progressive cough and shortness of breath 

00:36:03.813 --> 00:36:05.910 
and then repeat some PFT's and CT chest, 

00:36:07.470 --> 00:36:10.895 
they qualify ILAs as being either high 
risk or low risk, 

00:36:10.895 --> 00:36:15.823 
with high risk suggesting PFTs every six 
months to a year and imaging at the year 

00:36:15.823 --> 00:36:20.450 
mark and low risk being every two to 
three years for both pulmonary function 

00:36:20.450 --> 00:36:24.657 
testing and imaging. And so, 
what's considered high risk or low risk? 

00:36:24.657 --> 00:36:27.241 
Again, 
it comes back to many of those data 

00:36:27.241 --> 00:36:31.808 
points I've already presented things like 
demographic and clinical factors. 

00:36:31.808 --> 00:36:35.594 
If you do have a family history, 
older age, genetic, you know, 

00:36:35.594 --> 00:36:39.260 
if for whatever reason you do have MUC5B 
promoter variant or 

00:36:39.340 --> 00:36:42.430 
got telomere length testing on a patient. 
And of course, 

00:36:42.430 --> 00:36:46.931 
the imaging characteristics are probably 
I think kind of one of the biggest things 

00:36:46.931 --> 00:36:51.378 
if you do have signs of that fibrosis as 
well as physiologic borderline pulmonary 

00:36:51.378 --> 00:36:52.300 
function testing. 

00:36:55.030 --> 00:36:58.037 
So you know, 
there's no comments about you how long 

00:36:58.037 --> 00:37:02.492 
[forever] to follow them. Like I said, 
the I think it really is by a case by 

00:37:02.492 --> 00:37:05.326 
case basis, but the guidelines do say, 
you know, 

00:37:05.326 --> 00:37:09.549 
I think it's reasonable to at least do a 
minimum of three to four years. 

00:37:09.549 --> 00:37:14.234 
Again reflecting on that Park et al data, 
that if progression is going to happen 

00:37:14.234 --> 00:37:15.970 
the median time was 3.2 years. 

00:37:20.050 --> 00:37:24.601 
the guidelines go on to to give a lot of 
work to to the community about unsolved 

00:37:24.601 --> 00:37:27.243 
questions and future research needs. 
You know, 

00:37:27.243 --> 00:37:31.570 
I think that all of these are really, 
really exciting lines of inquiry and I 

00:37:31.570 --> 00:37:35.560 
suspect we'll get some of these answers 
over the next couple of years. 

00:37:38.070 --> 00:37:40.380 
So, 
so that's the guidelines in a nutshell. 

00:37:40.380 --> 00:37:44.530 
Really looking forward to comments and 
discussion. Just before I turn to that, 

00:37:44.530 --> 00:37:48.626 
I do want to take a minute just to talk 
about maybe some of the challenges of 

00:37:48.626 --> 00:37:50.990 
implementing this in our Canadian 
landscape. 

00:37:51.710 --> 00:37:54.744 
And I think everybody's busy to start off 
with. 

00:37:54.744 --> 00:37:59.170 
We have a bit of a different family 
practice setup of both, you know, 

00:37:59.170 --> 00:38:02.711 
locally here in Alberta as well as across 
the province, 

00:38:02.711 --> 00:38:05.683 
many patients don't even have a family 
doctor. 

00:38:05.683 --> 00:38:08.654 
And so who's going to be ordering these 
tests? 

00:38:08.654 --> 00:38:12.954 
Who's going to be following up on these 
tests and things like that? 

00:38:12.954 --> 00:38:17.380 
I think access to imaging here on the 
left hand side is a huge issue. 

00:38:18.680 --> 00:38:22.922 
There are certainly ways that we could 
expand access to imaging. Uh, you know, 

00:38:22.922 --> 00:38:25.285 
tele-radiology, mobile units, 
purchase CTs. 

00:38:25.285 --> 00:38:27.702 
I know a lot here are a little bit 
outdated, 

00:38:27.702 --> 00:38:31.461 
but of course that takes government input 
and government funding and, 

00:38:31.461 --> 00:38:34.200 
and that's something that we need to 
advocate for. 

00:38:35.510 --> 00:38:39.566 
I've mentioned workforce limitations, 
both from a primary care perspective as 

00:38:39.566 --> 00:38:43.831 
well as from a respirology perspective. 
And finally, as ILD physicians, you know, 

00:38:43.831 --> 00:38:48.252 
I think every province is struggling with 
primary care recruitment. We've certainly, 

00:38:48.252 --> 00:38:52.049 
I'm sure been following some of the news 
in certain provinces right now. 

00:38:52.049 --> 00:38:56.313 
So how do we make sure that to start off 
with, family doctors actually, you know, 

00:38:56.313 --> 00:39:00.318 
are present to care for these patients 
and refer them for simple things like 

00:39:00.318 --> 00:39:04.739 
lung cancer screening. And then of course, 
we'd love to see some more ILD fellows go 

00:39:04.739 --> 00:39:06.820 
through to increase our, our practice of 

00:39:06.900 --> 00:39:10.910 
interstitial lung disease who many go on 
to practice community general respirology 

00:39:11.900 --> 00:39:15.694 
in terms of socioeconomics, 
I think that's important to address in 

00:39:15.694 --> 00:39:18.979 
Canada, you know, 
it's a big country and a lot of care is 

00:39:18.979 --> 00:39:22.547 
often urban centric. 
We know that in the world of interstitial 

00:39:22.547 --> 00:39:25.662 
lung disease, 
patients often have to travel really far 

00:39:25.662 --> 00:39:29.910 
distances to get to subspecialty clinics. 
And I know in Alberta, you know, 

00:39:29.910 --> 00:39:33.818 
the access to respirology really, 
really varies where you are in the 

00:39:33.818 --> 00:39:36.650 
province. 
And so how can we address this - things 

00:39:36.650 --> 00:39:41.124 
like providing travel subsidies as well 
as, you know, public health campaigns, 

00:39:41.124 --> 00:39:43.390 
trying to recruit more respirologists to 

00:39:43.650 --> 00:39:47.140 
in need areas. And then finally, 
of course, system level barriers. 

00:39:48.580 --> 00:39:53.063 
There are many different, you know, 
networks across the the provinces as well 

00:39:53.063 --> 00:39:56.800 
as across the country. 
Provinces don't really talk to each other 

00:39:56.800 --> 00:40:01.111 
when it comes to things like EMRs. 
And so how do we make sure that there's 

00:40:01.111 --> 00:40:04.675 
an integrated care both locally, 
provincially and nationally? 

00:40:04.675 --> 00:40:08.067 
Things like can we do care pathways and 
referral networks? 

00:40:08.067 --> 00:40:12.436 
How do we incorporate some of these 
recommendations into EMRs and of course 

00:40:12.436 --> 00:40:15.195 
promote CME both at the family physician 
level, 

00:40:15.195 --> 00:40:17.839 
respirology level as well as radiology 
level? 

00:40:20.940 --> 00:40:26.051 
So we'll come back to this poll question 
and and this was developed a little bit 

00:40:26.051 --> 00:40:30.343 
before the guidelines came out. 
And so based on the new guidelines, 

00:40:30.343 --> 00:40:35.454 
I would actually probably agree with 50% 
of you that kind of C is the answer for 

00:40:35.454 --> 00:40:40.440 
who would actually qualify as kind of an 
ILA based on these newest guidelines. 

00:40:40.440 --> 00:40:44.290 
And so these are all three patients of 
mine that I care for. 

00:40:45.230 --> 00:40:49.191 
The first patient actually presented many, 
many times for renal colic, 

00:40:49.191 --> 00:40:52.260 
always got a CT scan, 
always had a little bit of these 

00:40:52.260 --> 00:40:55.441 
radiologic changes in the abdomen. 
It was in the report, 

00:40:55.441 --> 00:40:58.175 
but wasn't really highlighted in the 
impression. 

00:40:58.175 --> 00:41:02.304 
And you can see on each following CT scan 
it was getting worse and worse. 

00:41:02.304 --> 00:41:05.820 
So this is just an example. 
After two years of this happening, 

00:41:05.820 --> 00:41:10.060 
you can see clearly see some progression 
with some traction bronchiectasis, 

00:41:10.060 --> 00:41:13.408 
ground glass changes. 
Taking into account the difference in 

00:41:13.408 --> 00:41:16.812 
imaging techniques, 
he had a really strong family history of 

00:41:16.812 --> 00:41:16.980 
ILD 

00:41:17.150 --> 00:41:20.831 
And when he met me, you know, 
he was diagnosed with idiopathic 

00:41:20.831 --> 00:41:24.454 
pulmonary fibrosis. 
Idiopathic pulmonary fibrosis is a really 

00:41:24.454 --> 00:41:28.018 
aggressive phenotype. 
He was started on antifibrotics and is 

00:41:28.018 --> 00:41:30.940 
currently going undergoing transplant 
evaluation. 

00:41:32.940 --> 00:41:37.712 
The second patient had a CT for nodule 
follow up and then on a subsequent CT a 

00:41:37.712 --> 00:41:41.276 
few years later. 
There was progression documented and they 

00:41:41.276 --> 00:41:46.229 
were referred even though they had normal 
FVC and DLCo at the initial time of the 

00:41:46.229 --> 00:41:49.794 
nodule follow up. 
By the time I met them they were already 

00:41:49.794 --> 00:41:54.083 
desaturating on their six-minute walk 
test and required oxygen. Again, 

00:41:54.083 --> 00:41:58.070 
this patient was diagnosed with IPF and 
started on antifibrotics. 

00:41:58.990 --> 00:42:01.928 
and then finally this female has been 
asymptomatic, 

00:42:01.928 --> 00:42:06.730 
has had normal pulmonary function testing. 
She's had a CT scan on follow up that you 

00:42:06.730 --> 00:42:09.442 
can see here. 
A little bit of reticular change. 

00:42:09.442 --> 00:42:13.285 
It might not project well. 
I'm planning on repeating CT scan in two 

00:42:13.285 --> 00:42:17.579 
years and if it's still stable I may 
discharge her from my clinic with some 

00:42:17.579 --> 00:42:20.800 
recommendations about signs and symptoms 
to monitor for. 

00:42:23.570 --> 00:42:25.859 
So in summary, 
you know ILAs are prevalent. 

00:42:25.859 --> 00:42:29.761 
These referrals if you're already not 
getting them are going to be coming. 

00:42:29.761 --> 00:42:34.132 
And so I think having some guidance about 
what to do with them is really important. 

00:42:34.132 --> 00:42:38.086 
I think we are getting to the point that 
an evidence based approach to risk 

00:42:38.086 --> 00:42:39.960 
stratify these patients is possible. 

00:42:40.680 --> 00:42:44.864 
Of course there's a huge healthcare 
resource required to manage some of the 

00:42:44.864 --> 00:42:49.435 
expected volumes as CT scans become a bit 
more ubiquitous. But I'm really excited. 

00:42:49.435 --> 00:42:53.785 
I think there's some really exciting 
future biomarker and clinical trials that 

00:42:53.785 --> 00:42:58.080 
will give us even more tools to help 
manage them, and it is a space to watch.