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ILD
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British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society (2008) [85] |
Minimum MDT participants: expert clinicians, pathologists, and radiologists Patients with ILD should have access to an MDT based in a regional centre with expertise in ILD
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IPF
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French practical guidelines (2022) [86] |
Minimum MDT participants: pulmonologists, radiologists and pathologists with experience in the field of interstitial pneumonia MDT discussion should take place in an expert or specialised centre
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The decision to perform a biopsy is taken during an MDT discussion after a risk assessment based on age, the functional impact of the disease, the existence of comorbidities and the ILD evolution MDT is used for diagnostic decision-making, and therapeutic management is also discussed
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Haute Autorité de Santé guidelines (2021) [87] |
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ATS/ERS/JRS/ALAT (2018) [8] |
Minimum MDT participants: pulmonologist, radiologist and pathologist (and rheumatologist on a case-by-case basis) The method of interaction is decided by the involved clinicians and could be face to face, or using telephone, email, text or fax
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MDD can be used to reach a confident diagnosis of IPF when HRCT and histopathological patterns are discordant MDD can be used to reclassify to a more specific diagnosis when HRCT and histopathological patterns are both indeterminate for IPF The decision to perform SLB should be made by experienced clinicians in an MDT
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Fleischner Society (2018) [23] |
Key features of MDT process:
Not all patients with IPF require MDD and should be used when patients are not adequately categorised based on evidence base. MDT may be useful to:
• decide whether to perform a biopsy if imaging and clinical features do not provide enough diagnostic confidence • review the clinical, imaging and pathological features after a biopsy • review cases where the longitudinal course is discordant with diagnosis
Minimum MDT participants: clinician, radiologist and pathologist; rheumatologists, occupational physicians and geneticists may be important in specific cases Diagnosis should be clearly communicated on whether formal IPF diagnostic criteria were reached or if clinical reasoning was used to obtain a working diagnosis
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When is MDD necessary in the context of suspected IPF?
Where the clinical context and/or the CT pattern are indeterminate outcome of MDD will be a decision whether to perform additional clinical evaluation and/or BAL and/or diagnostic biopsy After biopsy is performed, to integrate the clinical, imaging and histological features When diagnostic tissue is not available, to consider a working diagnosis of IPF Goals of multidisciplinary conference include: diagnosis, management plan, review of disease progression
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Desirable features of multidisciplinary conference:
Frequency of meeting: weekly/monthly Nature of meeting: direct contact/telemedicine Participants: clinician, radiologist, pathologist. If not experienced in ILD, linkage to an experienced group is needed Documentation: first-choice diagnosis, realistic differential diagnoses. Recommendation for additional diagnostic test Communication: final multidisciplinary diagnosis recorded in case notes and communicated in discharge statement
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NICE guidelines (2017) [24] |
Minimum MDT participants:
After clinical evaluation, PFTs and CT: physician, radiologist, specialist nurse, MDT coordinator When considering BAL, TBB, SLB: include thoracic surgeon and histopathologist When considering results of BAL, TBB, SLB: include histopathologist
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If the MDT cannot make a confident diagnosis from clinical features, lung function and radiological findings, consider: BAL, TBB and/or SLB, with the agreement of the thoracic surgeon
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HP
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ATS/ERS/JRS/ALAT practice guideline (2020) [29] |
If patients cannot be diagnosed with HP with high confidence (based on identified exposure, typical HP pattern on HRCT, and BAL lymphocytosis) they should undergo an MDT discussion that includes a pulmonologist, chest radiologist and pathologist (if transbronchial lung biopsies were performed at time of BAL) If the patient has a culprit exposure, initial assessments include HRCT and BAL followed by MDD If the patient has no culprit exposures, and is a male former smoker and >60 years old, then the 2018 ATS/ERS/JRS/ALAT guidelines for IPF diagnosis should be applied (HRCT scan followed by an MDD)
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CHEST guideline and expert panel report (2021) [88] |
If the inciting antigen is suspected to be related to an occupational exposure, an occupational medicine specialist and an environmental hygienist should be included in the multidisciplinary diagnostic workup If the biopsy is indeterminate for HP or compatible with HP, a provisional diagnosis can be made after careful consensus MDD
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CTD-ILD
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Thoracic Society of Australia and New Zealand (2021) [89] |
Face-to-face discussion by treating clinician with respiratory physicians, a radiologist and, if relevant, a histopathologist
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Fibrotic ILDs
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Canadian Thoracic Society (2017) [90] |
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MDT discussions are an iterative process, and patients should be re-reviewed if new information becomes available MDTs should review patients before use of disease-specific treatments
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PPF
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Erice ILD working group (2020) [53] |
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Patients should be reassessed by MDTs at regular intervals to ensure the early identification of patients meeting the definition of PPF For patients with PPF, treatment with antifibrotic therapy and immunosuppression should involve a case-by-case assessment by an MDT
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