From the Guidelines
Immune checkpoint inhibitor (ICI) pneumonitis can be managed while the patient remains on high-flow nasal cannula (HFNC) oxygen support, but requires prompt treatment. The management of ICI pneumonitis involves the use of high-dose corticosteroids, typically methylprednisolone 1-2 mg/kg/day IV or equivalent, as soon as ICI pneumonitis is suspected 1. For mild to moderate cases (grade 1-2), continue steroids for 4-6 weeks with a gradual taper. For severe cases (grade 3-4), add immunosuppressive therapy such as infliximab 5 mg/kg IV or mycophenolate mofetil 1-1.5 g twice daily if no improvement occurs within 48-72 hours of steroid initiation 1. Permanently discontinue the causative ICI medication.
Key Considerations
- While on HFNC, maintain oxygen saturation above 92% and closely monitor respiratory status for deterioration that might require escalation to mechanical ventilation 1.
- ICI pneumonitis results from T-cell mediated inflammation in lung tissue triggered by immune checkpoint blockade, leading to diffuse alveolar damage.
- Early intervention with immunosuppression is critical to prevent progression to respiratory failure, with most patients showing improvement within 2-3 weeks of appropriate treatment 1.
Monitoring and Escalation
- Closely monitor the patient's respiratory status, including oxygen saturation and respiratory rate, to assess the need for escalation to invasive mechanical ventilation 1.
- Use a model to predict failure of HFNC therapy based on respiratory rate and oxygenation to guide decision-making regarding the need for mechanical ventilation 1.
From the Research
ICI Pneumonitis on HFNC
- There is limited information available on the use of High Flow Nasal Cannula (HFNC) in the management of Immune Checkpoint Inhibitor (ICI) pneumonitis.
- However, the available evidence suggests that ICI pneumonitis can be a severe and potentially life-threatening condition, with a significant mortality rate, especially in patients who do not respond to corticosteroids 2, 3.
- The use of second-line immunosuppressive therapy, such as infliximab, cyclophosphamide, or intravenous immunoglobulins, may be considered in patients with steroid-refractory ICI pneumonitis 2, 3, 4.
- In some cases, triple combination therapy with high-dose corticosteroids, tacrolimus, and cyclophosphamide may be effective in improving steroid-refractory ICI pneumonitis 5.
- Chronic ICI pneumonitis, which requires ≥12 weeks of immunosuppression, is a distinct entity with specific clinicopathological features, including BALF lymphocytosis and organising pneumonia on lung biopsy 6.
Management of ICI Pneumonitis
- Corticosteroids are the primary treatment for ICI pneumonitis, but some patients may not respond to steroid therapy 2, 3.
- In patients with steroid-refractory ICI pneumonitis, second-line immunosuppressive therapy may be considered, but the optimal treatment approach is not well established 2, 3, 4.
- HFNC may be used as a supportive measure in patients with severe respiratory distress, but its effectiveness in managing ICI pneumonitis is not well studied.
Outcomes of ICI Pneumonitis
- The mortality rate for ICI pneumonitis can be high, especially in patients who do not respond to corticosteroids 2, 3.
- Patients with chronic ICI pneumonitis may require long-term immunosuppression and have a distinct clinical course 6.
- Further research is needed to better understand the management and outcomes of ICI pneumonitis, including the role of HFNC in its treatment.