Management of Bleomycin-Induced Lung Fibrosis
The management of bleomycin-induced lung fibrosis requires immediate cessation of bleomycin therapy, administration of oral corticosteroids (prednisolone 0.5 mg/kg for 7 days with subsequent tapering), and referral to a respiratory physician with expertise in interstitial lung disease. 1
Diagnosis and Assessment
- Diagnosis is made by combining systemic symptoms (particularly dry cough and shortness of breath) with typical radiological changes on high-resolution computed tomography (HRCT) 1
- Cough is the most sensitive symptom for predicting bleomycin-induced pulmonary toxicity and should trigger immediate investigation 1
- HRCT is the investigation of choice for suspected bleomycin-induced lung toxicity, as chest X-ray has extremely low sensitivity 1
- Pulmonary function tests (PFTs) provide supportive evidence but are not diagnostic on their own; diffusion capacity for carbon monoxide (DLCO) is the most significant parameter 1, 2
Acute Management
- Immediate discontinuation of bleomycin therapy when pulmonary toxicity is suspected or confirmed 1, 2
- Oral prednisolone at 0.5 mg/kg for 7 days with subsequent tapering is recommended for all CT-confirmed diagnoses of bleomycin lung toxicity 1
- Low threshold for antimicrobial therapy as infection can mimic, coexist with, and drive the development of fibrosis 1
- Referral to or discussion with a respiratory physician with expertise in interstitial lung disease is strongly recommended in cases of confirmed toxicity 1
Monitoring and Follow-up
- All patients receiving more than 300 units of bleomycin should receive a post-treatment CT scan 1
- Further investigations should be symptom-led, with particular attention to new or worsening cough or dyspnea 1
- Monthly monitoring of DLCO is recommended if it is employed to detect subclinical pulmonary toxicity; discontinue bleomycin when DLCO falls below 30-35% of the pretreatment value 2
- Long-term follow-up is essential as lung fibrosis may develop or progress years after cessation of bleomycin therapy 3
Special Considerations
- Avoid high oxygen concentrations in patients with a history of bleomycin treatment, as this can trigger or exacerbate pulmonary fibrosis 2, 4
- For patients requiring surgery after bleomycin therapy, maintain FIO₂ at concentrations approximating room air (25%) during surgery and the postoperative period 2
- Monitor fluid replacement carefully, focusing more on colloid administration rather than crystalloid 2
- Patients over 40 years of age, those with renal dysfunction, significant smoking history, and pre-existing lung disease are at higher risk for developing bleomycin-induced pulmonary fibrosis 1, 5
Experimental Approaches
- MRTF/SRF pathway inhibitors have shown promise in preventing bleomycin-induced lung fibrosis in preclinical studies 6
- Adenovirus-mediated gene transfer of bleomycin resistance genes has demonstrated potential in preventing bleomycin-induced pulmonary fibrosis in animal models 7
Patient Education
- Every patient receiving bleomycin should receive a post-treatment advice sheet regarding potential pulmonary complications 1
- Patients should be instructed to report new respiratory symptoms promptly, particularly cough and dyspnea 1
- Patients should inform all healthcare providers about their history of bleomycin treatment, especially before procedures requiring oxygen administration 2, 4