What is the management of pneumonitis (inflammation of the lungs)?

From the Guidelines

Management of pneumonitis involves identifying and removing the causative agent, providing supportive care, and administering appropriate medications, with corticosteroids being the mainstay of treatment for moderate to severe cases, as recommended by the most recent guidelines 1. The approach to managing pneumonitis should prioritize the patient's clinical response, with a focus on early initiation of empiric antibiotic therapy and subsequent adjustment based on microbiologic cultures and clinical response, as outlined in the guidelines for hospital-acquired pneumonia 1. Key considerations in the management of pneumonitis include:

• Identifying and removing the causative agent
• Providing supportive care, such as supplemental oxygen to maintain oxygen saturation above 92%
• Administering appropriate medications, including corticosteroids for moderate to severe cases, typically starting with prednisone 1-2 mg/kg/day or methylprednisolone 1-2 mg/kg/day
• Considering immunosuppressive agents like mycophenolate mofetil, infliximab, or cyclophosphamide for steroid-refractory cases
• Providing prophylaxis against Pneumocystis jirovecii pneumonia with trimethoprim-sulfamethoxazole for patients on prolonged corticosteroid therapy
• Managing associated bronchospasm with bronchodilators like albuterol The underlying mechanism of pneumonitis involves inflammation of lung tissue, which can be triggered by medications, radiation, infections, or autoimmune processes, leading to impaired gas exchange and respiratory symptoms, as discussed in the guidelines for community-acquired pneumonia 1. It is essential to note that the management of pneumonitis should be tailored to the individual patient's needs, taking into account the severity of the disease, the presence of underlying conditions, and the potential for complications, as highlighted in the guidelines for managing toxicities associated with immune checkpoint inhibitors 1.

From the FDA Drug Label

Pneumonitis, pulmonary fibrosis, pulmonary veno-occlusive disease and other forms of pulmonary toxicity leading to respiratory failure have been reported during and following treatment with cyclophosphamide. Late onset pneumonitis (greater than 6 months after start of cyclophosphamide) appears to be associated with increased mortality Pneumonitis may develop years after treatment with cyclophosphamide. Monitor patients for signs and symptoms of pulmonary toxicity.

Pneumonitis Management:

• Monitor patients for signs and symptoms of pulmonary toxicity.
• Warn patients of the possibility of developing non-infectious pneumonitis.
• Advise patients to report promptly any new or worsening respiratory symptoms 2. No specific management or treatment for pneumonitis is provided in the label.

From the Research

Pneumonitis Management Overview

• Pneumonitis is a common cause of respiratory infection, with symptoms including cough, pleuritic chest pain, fever, fatigue, and loss of appetite 3.
• Severe pneumonia is associated with high mortality and pulmonary and extrapulmonary complications, making appropriate diagnosis and early initiation of adequate antimicrobial treatment crucial 4.

Corticosteroids in Pneumonitis Management

• The benefits of corticosteroids for patients with pneumonia remain unclear, with some studies suggesting they can accelerate the resolution of symptoms and decrease the rate of relapse 5.
• Adjunctive corticosteroids therapy has been shown to be effective and safe for patients with severe community-acquired pneumonia, with a lower rate of all-cause mortality and shorter length of intensive care unit stay 6.
• However, the use of corticosteroids in severe community-acquired pneumonia is not universally recommended, with some studies suggesting no impact on survival and potential harmful effects in certain types of pneumonia 7.

Specific Considerations

• Corticosteroids are recommended in Pneumocystis jiroveci pneumonia in HIV-infected patients, but not in influenza 7.
• The strength of the evidence does not support the safe and widespread use of corticosteroids as adjunctive therapy in all other forms of severe community-acquired pneumonia, except for SARS-CoV-2 pneumonia 7.
• Further studies are needed to identify subgroups of severe community-acquired pneumonia that can benefit or not from corticosteroids 7.