Pneumonitis

Grade 1

• Radiographic changes only
• Ground glass change, non-specific interstitial pneumonia

Grade 2

• Mild/moderate new symptoms
• Dyspnoea, cough, chest pain

Grade 3 or 4

• Severe new symptoms
• New or worsening hypoxia
• Life threatening
• Difficulty in breathing, ARDS

Management escalation pathway

• Consider delay of treatment
• Monitor Symptoms every 2-3 weeks
• When worsening: treat as grade 2 or 3-4

Assessment and Investigations

• Chest X-Ray
• Regular blood analysis including CRP
• Consider sputum sample and screening for viral, opportunistic or specific bacterial infections (mycoplasma, legionella) depending on the clinical contact

Management escalation pathway

• Withhold ICPi

• Monitor symptoms daily: hospitalize patient
• Start antibiotic if suspicion of infection (fever, CRP, neutrophil counts, purulent sputa)
• If no evidence of infection or no improvement with antibiotics after 48h add (methyl)prednisolone 1 mg/kg/day orally
• If no improvement after 48h of oral prednisolone, manage as per Grade 3
• Consider Pneumocystis prophylaxis depending on the clinical context (especially in immunosuppressed patients)

Assessment and Investigations

• High resolution CT
• Regular blood analysis including CRP
• Analyse sputum sample (incl screening for viral, opportunistic or specific bacterial infections (mycoplasma, legionella))
• Discuss bronchoscopy and BAL with pneumologist
• Perform lung function tests, including TCLO

Management escalation pathway

• Discontinue ICPi
• Hospitalize patient, consider ICU care
• Start (methyl)prednisolone i.v. 2 mg/kg/day + cover with empiric antibiotics
• consider treatment with cotrimoxazole for Pneumocystis

Assessment and investigations

• Perform blood test
• Analyze sputum for bacteria, viral and other opportunistic infections
• High resolution CT
• Bronchoscopy and BAL as well as lung function tests to be discussed with pneumologist

If no improvement or worsening after 48h

• Discuss addition of Infliximab 5 mg/kg or other secondary immunosuppressant with pneumologist or in multidisciplinary board
• Continue with i.v. steroids
• Exclude other diagnosis including diaphragm paralysis due to concurrent immune related (cardio)myositis