| 3.1. Pneumonitis |
Work-up and evaluation: - Should include the following: Pulse oximetry and CT chest preferably with contrast if concerned for other etiologies such as pulmonary embolus.
- For G2 or higher, may include the following infectious work-up: nasal swab, sputum culture, and sensitivity, blood culture and sensitivity, urine culture, and sensitivity.
- COVID-19 evaluation – per institutional guidelines where relevant.
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| Grading | Management |
| G1: Asymptomatic; confined to one lobe of the lung or <25% of lung parenchyma; clinical or diagnostic observations only. | - Hold ICPi or proceed with close monitoring.
- Monitor patients weekly with history and physical examination, pulse oximetry; may also offer chest imaging (CXR, CT) if uncertain diagnosis and/or to follow progress.
- Repeat chest imaging in 3 to 4 weeks or sooner if patient becomes symptomatic.
- In patients who have had baseline testing, may offer a repeat spirometry or DLCO in 3 to 4 weeks.
- May resume ICPi with radiographic evidence of improvement or resolution if held. If no improvement, should treat as G2.
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| G2: Symptomatic; involves more than one lobe of the lung or 25 to 50% of lung parenchyma; medical intervention indicated; limiting instrumental ADL. | - Hold ICPi until clinical improvement to ≤G1.
- Prednisone 1 to 2 mg/kg/day and taper over 4 to 6 weeks.
- Consider bronchoscopy with BAL ± transbronchial biopsy.
- Consider empiric antibiotics if infection remains in the differential diagnosis after work-up.
- Monitor at least once per week with history and physical examination, pulse oximetry, consider radiologic imaging; if no clinical improvement after 48 to 72 hours of prednisone, treat as grade 3.
- Pulmonary and infectious disease consults if necessary.
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G3: Severe symptoms; hospitalization required: involves all lung lobes or >50% of lung parenchyma; limiting self-care ADL; oxygen indicated.
G4: Life-threatening respiratory compromise; urgent intervention indicated (intubation). | - Permanently discontinue ICPi.
- Empiric antibiotics may be considered.
- Methylprednisolone IV 1 to 2 mg/kg/day.
- If no improvement after 48 hours, may add immunosuppressive agent. Options include infliximab or mycophenolate mofetil IV or IVIG or cyclophosphamide. Taper corticosteroids over 4 to 6 weeks.*
- Pulmonary and infectious disease consults if necessary.
- May consider bronchoscopy with BAL ± transbronchial biopsy if patient can tolerate.
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