1. Management of Idiopathic Pulmonary Fibrosis in the Elderly Patient [ CHEST JULY 2015 ] 호흡기내과 R4. 박세정

3. How Should a Confident Diagnosis Be Made in the Elderly Patient? The American Thoracic Society/European Respiratory Society/Japanese Respiratory Society/Latin American Thoracic Association consensus statement (Am J Respir Crit Care Med, 2011) careful P/Ex (basilar crackles, digital clubbing) PFT (FVC ↓, TLC ↓, D LCO ↓) drug (amiodarone, MTX, nitrofurantoin…) connective tissue disease occupational or environmental exposures

6. What Is the Impact of Disease Complications and Comorbidities? comorbid disorders and complications associated with IPF in elderly patients : intrapulmonary : emphysema, pulmonary HTN, pulmonary embolism, CHF, primary lung cancer, chronic cough, acute exacerbation, pneumonia extrapulmonary : coronary artery disease, GERD, sleep-disordered breathing, anxiety and depression, deconditioning, frailty, osteoporosis, DM coexistent pulmonary fibrosis with emphysema (CPFE) pulmonary hypertension (PH) coronary artery disease (CAD) obstructive sleep apnea (OSA) gastroesophageal reflux disease (GERD)

7. What Are Key Considerations and Challenges for Disease Management in the Elderly Patient? f/u every 3-6 months PFT, 6MWT, oxygen titration walk study supplemental oxygen therapy pulmonary rehabilitation assessment of comorbidities that contribute to shortness of breath (ex. CAD, CHF)

8. What Are Current Treatment Considerations? corticosteroids cytotoxic drug immunosuppressive therapies (x) (cf. PANTHER-IPF) anticoagulation (x) antireflux medications NAC lung transplantation novel antifibrotic agents - ASCEND clinical trial : pirfenidone vs. placebo on FVC and PFS - CAPACITY trials : survival benefit - INPULSIS trials : nitedanib on FVC and risk of acute exaceration

11. What Are Important Prognostic Considerations? degree of fibrotic change on HRCT scan (: survival) changes in FVC, D LCO, and 6MWT distance (: risk of disease progression) need for supplemental oxygen (: risk of disease progression) all-cause and respiratory hospitalizations (: mortality) frailty specific gene polymorphisms statins or proton pump inhibitors biomarkers : matrix metalloproteinase-7, Krebs von den Lungen-6, surfactant proteins GAP (gender, age, lung physiology) index

12. How Can Patient-Centered Care and Personalized Management Be Provided? disease-centered model  patient-centered care model Evaluation for treatable disorders, such as cardiac disease and OSA Deconditioning through pulmonary rehabilitation Oxygen supplementation Emotional burdens

13. When and How Should Disease-Focused Therapies Be Transitioned to Supportive and Palliative Care? Symptom management and palliation Disease-centered approach with antifibrotic therapies and other intervention  palliative care with patient support and symptom control Pulmonary rehabilitation, supplemental oxygen use, cough suppression, counseling, psychosocial support, identification and treatment of comorbidities Respiratory failure : major cause of death (acknowledgement) End-of-life care

14. Summary The prevalence of IPF is highest in the population of affected patientswho are eldery Accurate and timely diagnosis Careful assessment of diease status Provision of disease-specific, supportive, and palliative care High index of suspicion for the presence of common comorbidities