Idiopathic pulmonary fibrosis (IPF), previously called cryptogenic fibrosing alveolitis, is a rare, progressive illness of the respiratory system. It is characterized by the thickening and stiffening of the lung tissue that surrounds the air sacs, and is associated with the formation of scar tissue. It is a type of chronic pulmonary fibrosis characterized by a progressive and irreversible decline in lung function.
Symptoms typically include gradual onset of shortness of breath and a dry cough. Other symptoms may include feeling tired, and digit clubbing (abnormally enlarged, dome-shaped fingers and toenails). Complications may include pulmonary hypertension, heart failure, pneumonia or pulmonary embolism.
The cause is unknown, hence the term idiopathic. Risk factors include cigarette smoking, gastroesophageal reflux disease, certain viral infections, and a genetic predisposition. The underlying mechanism involves scarring of the lungs. As it is such a severe disease, a full differential diagnosis is necessary, ruling out other potential causes. It may be supported by a high resolution CT scan or lung biopsy which show usual interstitial pneumonia. It is a type of interstitial lung disease.
People often benefit from pulmonary rehabilitation and supplemental oxygen. Anti-fibrotic medications like pirfenidone or nintedanib may slow the progression of the disease. Lung transplantation may also be an option.
About 5 million people are affected globally. The disease newly occurs in about 12 of every 100,000 people per year, with those in their 60s and 70s most commonly affected, and males more commonly affected than females. Average life expectancy following diagnosis is about four years.
Updated international guidelines were published in 2022, which resulted in some simplification in the disease's diagnosis, and the removal of antacids as a possible adjunct therapy.
Signs and symptoms
In many people, symptoms are present for a considerable time before diagnosis. The most common clinical features of IPF include the following: Age over 50 years Dry, non-productive cough on exertion Progressive exertional dyspnea (shortness of breath with exercise) Dry, inspiratory bilateral basal crackles on auscultation (a crackling or popping sound in the lungs during inhalation). Clubbing of the digits, a disfigurement of the finger tips or toes (see image) Abnormal pulmonary function test results, with evidence of restriction and impaired gas exchange.
Some of these features are due to chronic hypoxemia (oxygen deficiency in the blood), and are not specific for IPF, they can occur in other pulmonary disorders. IPF should be considered in all patients with unexplained chronic exertional dyspnea who present with cough, inspiratory bilateral basal crackles, or finger clubbing.
Assessment of crackles on lung auscultation is a practical way to improve the earlier diagnosis of IPF. Fine crackles, also known as "velcro" crackles are easily recognized by clinicians and are characteristic of IPF.
If bilateral fine crackles are present throughout the inspiratory time and are persisting after several deep breaths, and if remaining present on several occasions several weeks apart in a subject aged ≥60 years, this should raise the suspicion of IPF and lead to consideration of an HRCT scan of the chest which is more sensitive than a chest X-ray. As crackles are not specific for IPF, they must prompt a thorough diagnostic process.
Causes Despite extensive investigation, the cause of IPF remains unknown. The fibrosis in IPF has been linked to cigarette smoking, environmental factors (e.g. occupational exposure to gases, smoke, chemicals or dusts), other medical conditions including gastroesophageal reflux disease, or to genetic predisposition (familial IPF).
Certain environmental factors and exposures have been shown to increase the risk of IPF. Cigarette smoking is the best recognized and most accepted risk factor, and increases the risk of IPF by about twofold. Other environmental and occupational exposures such as exposure to metal dust, wood dust, coal dust, silica, stone dust, biologic dusts coming from hay dust or mold spores or other agricultural products, and occupations related to farming/livestock have also been shown to increase the risk for IPF. There is some evidence that viral infections may be associated with idiopathic pulmonary fibrosis and other fibrotic lung diseases.
Pathogenesis
IPF is believed to be the result of an aberrant wound healing process including/involving abnormal and excessive deposition of collagen (fibrosis) in the pulmonary interstitium with minimal associated inflammation. Cellular senescence is suspected to be a central contributing cause, a belief which is supported by benefits seen in patients given senolytic therapy.
It is hypothesized that the initial or repetitive injury in IPF occurs to the lung alveolar epithelial cells (pneumocytes), the type I and type II cells, which line the majority of the alveolar surface. When type I cells are damaged or lost, it is thought that type II cells undergo proliferation to cover the exposed basement membranes. In normal repair, the hyperplastic type II cells die and the remaining cells spread and undergo a differentiation process to become type I cells. Under pathologic conditions and in the presence of transforming growth factor beta (TGF-β), fibroblasts accumulate in these areas of damage and differentiate into myofibroblasts that secrete collagen and other proteins. In the current classification of the pathogenesis of IPF, it is believed that it occurs by way of the formation of a UIP (usual interstitial pneumonia) lesion, which then undergoes the aforementioned pathological condition characteristic of IPF. Other proposed repeated injury mechanisms indicate that IPF may result not just from a UIP lesion, but also from NSIP and DAD (nonspecific interstitial pneumonia and diffuse alveolar damage) lesions, or a combination of several.
In the past, it was thought that inflammation was the first event in initiating lung tissue scarring. Later findings showed that the development of fibroblastic foci precedes the accumulation of inflammatory cells and the consequent deposition of collagen. This pathogenetic model is indirectly supported by the clinical features of IPF, including an insidious onset over several years, relatively infrequent acute exacerbations, and failure to respond to immunosuppressive therapy. However, it is the belief of some researchers that the disease is a multi-mechanistic one, wherein the trigger for the disease may stem from abnormalities in any number of wound healing pathways, including the inflammatory response. Such abnormalities could occur in any number of the nine implicated pathways (clotting cascade, antioxidant pathways, apoptosis, inflammatory cytokines, angiogenesis and vascular remodelling, growth factors, surfactant and matrix regulatory factors), and that through further investigation into all nine, novel therapies and approaches could be proposed on a unique or case-by-case basis should attempts at treating or circumventing complications in any one pathway prove unsuccessful. A number of therapies that target fibroblast activation or the synthesis of extracellular matrix are currently in early testing or are being considered for development.
Familial IPF accounts for less than 5% of the total of patients with IPF and is clinically and histologically indistinguishable from sporadic IPF. Genetic associations include mutations in pulmonary surfactant proteins A1, A2, C (SFTPA1, SFTPA2B) and mucin (MUC5B). A remarkable aspect of the MUC5B variant is its high frequency of detection, as it is found in approximately 20% of individuals with Northern and Western European ancestry and in 19% of the Framingham Heart Study population. Mutations in human telomerase genes are also associated with familial pulmonary fibrosis and in some patients with sporadic IPF (e.g. the TERT, TERC genes). Recently an X-linked mutation in a third telomerase-associated gene, dyskerin (DKC1), has been described in a family with IPF.
Diagnosis An earlier diagnosis of IPF is a prerequisite for earlier treatment and, potentially, improvement of the long-term clinical outcome of this progressive and ultimately fatal disease. If IPF is suspected, diagnosis can be challenging but a multidisciplinary approach involving a pulmonologist, radiologist and pathologist expert in interstitial lung disease has been shown to improve the accuracy of IPF diagnosis.
A Multidisciplinary Consensus Statement on the Idiopathic Interstitial Pneumonias published by the American Thoracic Society (ATS) and the European Respiratory Society (ERS) in 2000 proposed specific major and minor criteria for establishing the diagnosis of IPF. However, in 2011, new simplified and updated criteria for the diagnosis and management of IPF were published by the ATS, ERS, together with the Japanese Respiratory Society (JRS) and Latin American Thoracic Association (ALAT). Currently, a diagnosis of IPF requires: Exclusion of known causes of interstitial lung disease (ILD), e.g., domestic and occupational environmental exposures, connective tissue disorders, or drug exposure/toxicity The presence of a typical radiological pattern of usual interstitial pneumonia (UIP) on high-resolution computed tomography (HRCT).
In the right clinical setting, it is possible to make the diagnosis of IPF by HRCT alone, obviating the need for surgical lung biopsy.
Various technologies using artificial intelligence have been developed to help with diagnosis. A deep learning algorithm for categorizing high-resolution CT images reported high accuracy Lynch DA, Sverzellati N, Travis WD, Brown KK, Colby TV, Galvin JR, et al. Diagnostic criteria for idiopathic pulmonary fibrosis: a Fleischner Society White Paper. Lancet Respir Med. 2018;6:138–53 and a research project led by Nagoya University Graduate School of Medicine and Riken used a combination of deep learning and machine learning algorithm to accurately diagnose the disease.Taiki Furukawa et al. A comprehensible machine learning tool to differentially diagnose idiopathic pulmonary fibrosis from other chronic interstitial lung diseases. Respirology, 27(9) pp.739-746. First published: 13 June 2022 https://doi.org/10.1111/resp.14310
Recent developments indicate a potential benefit of positron emission tomography (PET) for diagnosis of IPF if suitable radiotracers are applied. Since IPF is driven by transforming growth factor beta (TGF-β), cellular mechanisms that enhance the interstitial TGF-β concentration are also a key factor for IPF development. The likely most important activator of TGF-β is αvβ6-integrin, which releases TGF-β from its latent form. Hence, αvβ6-integrin has been recognized earlier as a potential prognostic biomarker for IPF. Radiopharmaceuticals targeting αvβ6-integrin have thus been proposed for diagnosis of IPF by means of PET/CT imaging. The tracer 68Ga-Trivehexin showed an uptake of SUVmax = 5.53 in fibrotic lung tissue and enabled a differentiation between fibrotic and non-fibrotic lung areas in PET/CT images. 68Ga-Trivehexin yielded clear PET signals in IPF lesions which were PET-negative using the standard metabolic PET tracer 18F-FDG.
Differential diagnosis