What is the best management approach for a 93-year-old patient with a history (Hx) of pulmonary fibrosis and a cough that is unresponsive to prednisone?

Management of Pulmonary Fibrosis with Persistent Cough in a 93-Year-Old Patient

For a 93-year-old patient with pulmonary fibrosis and cough unresponsive to prednisone, antifibrotic therapy with nintedanib is recommended as the most appropriate next step in management, along with targeted symptom management for the cough. 1

Assessment of Cough in Pulmonary Fibrosis

When evaluating persistent cough in pulmonary fibrosis that hasn't responded to prednisone:

1. Rule out common causes of cough:

   • Assess for acid reflux (even without typical symptoms)
   • Evaluate for upper airway cough syndrome
   • Consider post-infectious causes if recent respiratory infection 2

2. Determine cough characteristics:

   • Duration (acute, subacute, or chronic)
   • Pattern (paroxysmal, nocturnal, productive)
   • Aggravating and alleviating factors

Treatment Approach

First-Line Management

1. Discontinue corticosteroids:

   • Corticosteroid therapy (with or without immunomodulators) is not recommended for pulmonary fibrosis as no survival benefit has been demonstrated 2
   • Long-term corticosteroid use carries substantial morbidity, particularly concerning in elderly patients 2

2. Consider antifibrotic therapy:

   • Nintedanib (150mg twice daily) is recommended for progressive pulmonary fibrosis 1
   • Reduces annual FVC decline by approximately 107 ml compared to placebo 1
   • More effective in patients with UIP pattern (128 ml/yr vs 75.3 ml/yr in non-UIP) 1

3. Targeted cough management:

   • Trial of inhaled ipratropium as it may attenuate post-infectious cough 2
   • Consider gabapentin for refractory chronic cough 2
   • Speech pathology therapy for persistent cough 2

Advanced Symptom Management

For persistent, troublesome cough that significantly impacts quality of life:

1. Opiates for symptom control:

   • Recommended when alternative treatments have failed 2
   • Use in palliative care setting with reassessment at 1 week and monthly thereafter 2
   • Central-acting antitussives (codeine, dextromethorphan) when other measures fail 2

2. Avoid ineffective treatments:

   • Do not use proton pump inhibitors unless acid reflux is confirmed 2
   • Avoid colchicine, cyclosporine A, interferon-γ-1b, or etanercept 2
   • Oral anti-vitamin K anticoagulants are not recommended 2

Supportive Care

1. Oxygen therapy:

   • Long-term oxygen therapy for severe hypoxemia at rest 2
   • Ambulatory oxygen for exercise desaturation

2. Pulmonary rehabilitation:

   • Exercise training program to improve exercise capacity 2
   • May not be feasible in patients with advanced disease 2

3. Preventive measures:

   • Annual influenza vaccination
   • Pneumococcal vaccination 1

Monitoring and Follow-up

• Regular assessment of symptoms and oxygen saturation
• Pulmonary function tests every 3-6 months
• HRCT if unexplained clinical changes or suspected acute exacerbation

Special Considerations for Elderly Patients

• Balance standard-of-care measures with overall health status (robustness vs frailty) 3
• Consider patient's wishes, desires, and expectations 3
• Monitor for drug-drug interactions with other medications
• Address comorbidities common in elderly patients with pulmonary fibrosis 3

Prognosis and Palliative Care

• Early integration of palliative care for symptom management 1
• Focus on reducing symptoms and providing comfort
• Consider advance care planning discussions

Caution

The evidence for treating pulmonary fibrosis in very elderly patients is limited. Treatment decisions should carefully weigh potential benefits against risks, particularly given the patient's advanced age and potential for medication side effects. Nintedanib commonly causes gastrointestinal side effects (diarrhea, nausea, vomiting) and requires liver function monitoring, which may be challenging in frail elderly patients 1.