Table 1.

Pneumonitis diagnostic evaluation and management considerations in setting of COVID-19

Pneumonitis grading*	Diagnostic evaluation, safety procedures and management	Treatment
		COVID-19 negative	COVID-19 positive
G1†: clinically asymptomatic with radiographic changes ONLY	Assess oxygenation at baseline and with ambulation Testing for respiratory pathogens including COVID-19 should be made on case-by-case basis	Hold immunotherapy Follow-up with treating oncologist in 3–7 days‡ If develops symptoms in follow-up, treat as G2
G2: clinically symptomatic, restricting instrumental activities of daily living	Screening at COVID-19 testing facility (if possible)§ If screen positive in clinic, provide patient mask and place in private room with negative pressure (if available) COVID-19 testing±RVP as appropriate Pulmonary medicine/infectious disease consultation, as appropriate Hold immunotherapy	Hospitalization not required Commence oral prednisone 1 mg/kg/day (or equivalent) Consider empiric antimicrobials (as appropriate) Follow-up with treating oncologist in 48–72 hours‡: If clinical improvement, follow-up in 1–2 weeks with clinic visit±chest imaging If no improvement, treat according to G3	Consult relevant institutional infection control representative Hospitalization unlikely required Counsel on infection prevention measures Counsel on concerning signs/symptoms that warrant presentation to hospital or emergency room COVID-19 directed therapy per individualized institutional management guidelines in consultation with infectious disease and infection control specialists Consider discontinuing corticosteroids (where appropriate)
G3: severe symptoms limiting activities of daily living, oxygen indicated G4: life-threatening respiratory compromise	As above for G2 Prioritize expedited hospitalization Commence empiric pneumonitis treatment with intravenous methylprednisolone 1–2 mg/kg/day (or equivalent) Consider empiric antimicrobials	Permanently discontinue immunotherapy Continue intravenous corticosteroids If no improvement after 48–72 hours consider: Repeat COVID-19 testing±RVP Additional immunosuppressive therapy such as infliximab 5 mg/kg x1 (can repeat after 14 days if needed), mycophenolate mofetil 1–1.5 g two times per day, IVIG 2 g/kg in divided doses If clinical suspicion for COVID-19 remains, consult infectious disease specialists and consider COVID-19 directed therapy where appropriate (eg, anti-IL-6)	Discontinue corticosteroids Consult infectious disease specialists Implement COVID19-directed therapy per individualized institutional management guidelines in consultation with infectious disease and infection control specialists (eg, anti-IL-6)

*Grade by Common Terminology Criteria for Adverse Events (CTCAE) criteria version 4.03.

†For G1 pneumonitis, a chest CT with contrast should be obtained if not already performed. Guidelines also suggest obtaining pulmonary function testing (PFTs) but in the setting of COVID-19 and risk of virus transmission with PFTs, we do not recommend obtaining routine PFTs if there is any suspicion for COVID-19.

‡Follow-up preferable by virtual telemedicine visit or telephone.

§Practitioner should wear contact personal protective equipment with eye protection (PAPR or N95 with face shield/goggles), gown, and gloves.

G, grade; IVIG, intravenous immunoglobulin; PAPR, powered air purifying respirator; RVP, respiratory viral panel.