OSCE — Interstitial Lung Disease

Brief (to candidate)

You will assess a patient with a presentation consistent with Interstitial Lung Disease. You have 8 minutes to take a focused history, outline examination, investigations, and management including red flags.^[6]

Clinical context

Interstitial lung disease (ILD) is a heterogeneous group of disorders sharing inflammation and/or fibrosis of the lung interstitium, producing a restrictive ventilatory defect and a diffuse imaging abnormality. The archetype is idiopathic pulmonary fibrosis (IPF) — about 3 million people worldwide, often elderly men who smoke, with a UIP pattern (bilateral, peripheral, basal reticular changes, traction bronchiectasis, subpleural cystic airspaces). Diagnosis excludes other ILDs and identifies UIP usually on HRCT. Treatment is an antifibrotic (pirfenidone 2403 mg/day or nintedanib 150 mg BID) to slow decline — never combination immunosuppression (PANTHER). ATS 2022 is against antacids and antireflux surgery for treating IPF.^{[6][3][2][7][1]}

Candidate tasks

1. Clarify onset, severity, associated features, and red-flag symptoms.
2. State focused examination priorities.
3. List first-line investigations and any named score/criteria.
4. Give immediate resuscitation steps.
5. Outline definitive management with doses/routes where standard.
6. Name complications and disposition (ward / HDU / theatre / discharge safety-net).
7. Mention one special-population modifier (pregnancy, child, elderly, CKD).^[6]

Examiner checklist

Model outline

Lead with the working diagnosis and life threats. Resuscitate before definitive tests when unstable.^[6]

• History — pace of dyspnoea and dry cough; smoking; occupation/birds/mould; drugs (amiodarone, bleomycin, methotrexate, nitrofurantoin, checkpoint inhibitors, targeted agents, ADCs); CTD symptoms; antigen exposure.^[12][9]
• Examination — basal Velcro crackles, clubbing, signs of CTD, signs of group 3 PH.^[10]
• Investigations — PFTs (restrictive + low DLCO); thin-section HRCT for the Martinez UIP pattern; CTD serology; 6MWT (ASCEND used 6MWD as a secondary end-point). GAP = Gender, Age, FVC, DLCO; stages I–III 1-year mortality 6, 16, 39 percent.^[6][3][14]
• Emergency (AE-IPF) — oxygen for hypoxaemia; IWG 2016 triggered versus idiopathic; exclude heart failure and volume overload; supportive care. Do not quote unsourced 50 percent in-hospital mortality or pulse methylprednisolone as if they were in Kishaba.^[10]
• Definitive (IPF) — MDT; pirfenidone 2403 mg/day or nintedanib 150 mg BID; early transplant referral; not combination immunosuppression; not antacids for treating IPF.^[3][2][7][1]
• SSc-ILD — ILD is a leading cause of SSc-related death; nintedanib slowed FVC decline in SENSCIS (−52.4 vs −93.3 mL/year); SLS II primary endpoint negative — prefer mycophenolate for tolerability.^[5][8]
• PPF (ILD other than IPF) — ATS 2022: ≥2 of 3 (symptoms, radiology, physiology) within the past year; conditional nintedanib. Do not collapse this into INBUILD's 24-month eligibility window.^[1][4]
• Special population — pirfenidone and nintedanib are not recommended in pregnancy (insufficient teratogenicity data).^[1]

References14ShowHide

1. [1]Raghu G, Remy-Jardin M, Richeldi L, et al. Idiopathic Pulmonary Fibrosis (an Update) and Progressive Pulmonary Fibrosis in Adults: An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline Am J Respir Crit Care Med, 2022.PMID 35486072
2. [2]Richeldi L, du Bois RM, Raghu G, et al. Efficacy and safety of nintedanib in idiopathic pulmonary fibrosis N Engl J Med, 2014.PMID 24836310
3. [3]King TE Jr, Bradford WZ, Castro-Bernardini S, et al. A phase 3 trial of pirfenidone in patients with idiopathic pulmonary fibrosis N Engl J Med, 2014.PMID 24836312
4. [4]Flaherty KR, Wells AU, Cottin V, et al. Nintedanib in Progressive Fibrosing Interstitial Lung Diseases N Engl J Med, 2019.PMID 31566307
5. [5]Distler O, Highland KB, Gahlemann M, et al. Nintedanib for Systemic Sclerosis-Associated Interstitial Lung Disease N Engl J Med, 2019.PMID 31112379
6. [6]Martinez FJ, Collard HR, Pardo A, et al. Idiopathic pulmonary fibrosis Nat Rev Dis Primers, 2017.PMID 29052582
7. [7]Raghu G, Anstrom KJ, King TE Jr Prednisone, azathioprine, and N-acetylcysteine for pulmonary fibrosis N Engl J Med, 2012.PMID 22607134
8. [8]Tashkin DP, Roth MD, Clements PJ, et al. Mycophenolate mofetil versus oral cyclophosphamide in scleroderma-related interstitial lung disease (SLS II): a randomised controlled, double-blind, parallel group trial Lancet Respir Med, 2016.PMID 27469583
9. [9]Selman M, Pardo A, King TE Jr Hypersensitivity pneumonitis: insights in diagnosis and pathobiology Am J Respir Crit Care Med, 2012.PMID 22679012
10. [10]Kishaba T Acute Exacerbation of Idiopathic Pulmonary Fibrosis Medicina (Kaunas), 2019.PMID 30884853
11. [11]Sakthivel MK, Hazelton TR, Askin FB, et al. Organizing Pneumonia Phenotype Semin Roentgenol, 2026.PMID 41513514
12. [12]Naraoka T, Sumi T Management of drug-induced interstitial lung disease in the era of evolving lung cancer therapies: A mini-review Respir Investig, 2026.PMID 42520532
13. [13]Hino T, Lee KS, Yoo H, et al. Interstitial lung abnormality (ILA) and nonspecific interstitial pneumonia (NSIP) Eur J Radiol Open, 2021.PMID 33796637
14. [14]Ley B, Ryerson CJ, Vittinghoff E, et al. A multidimensional index and staging system for idiopathic pulmonary fibrosis Ann Intern Med, 2012.PMID 22586007