Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO.
Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY.
Chest. 2021 Aug;160(2):e97-e156. doi: 10.1016/j.chest.2021.03.066. Epub 2021 Apr 20.
The purpose of this analysis is to provide evidence-based and consensus-derived guidance for clinicians to improve individual diagnostic decision-making for hypersensitivity pneumonitis (HP) and decrease diagnostic practice variability.
Approved panelists developed key questions regarding the diagnosis of HP using the PICO (Population, Intervention, Comparator, Outcome) format. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and vetted evaluation tools were used to assess the quality of included studies, to extract data, and to grade the level of evidence supporting each recommendation or statement. The quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted and voted on using a modified Delphi technique to achieve consensus. A diagnostic algorithm is provided, using supporting data from the recommendations where possible, along with expert consensus to help physicians gauge the probability of HP.
The systematic review of the literature based on 14 PICO questions resulted in 14 key action statements: 12 evidence-based, graded recommendations and 2 ungraded consensus-based statements. All evidence was of very low quality.
Diagnosis of HP should employ a patient-centered approach and include a multidisciplinary assessment that incorporates the environmental and occupational exposure history and CT pattern to establish diagnostic confidence prior to considering BAL and/or lung biopsy. Criteria are presented to facilitate diagnosis of HP. Additional research is needed on the performance characteristics and generalizability of exposure assessment tools and traditional and new diagnostic tests in modifying clinical decision-making for HP, particularly among those with a provisional diagnosis.
本分析旨在为临床医生提供循证和共识指导，以改善对过敏性肺炎 (HP) 的个体诊断决策，并减少诊断实践的变异性。
经批准的专家小组成员使用 PICO（人群、干预、对照、结局）格式制定了有关 HP 诊断的关键问题。系统地检索了 MEDLINE（通过 PubMed）和 Cochrane 图书馆中的相关文献，并进行了手动检索。筛选参考文献以纳入，并使用经过验证的评估工具评估纳入研究的质量，提取数据，并对支持每项建议或陈述的证据水平进行分级。使用 GRADE（推荐分级、评估、制定和评价）方法评估证据质量。使用改良 Delphi 技术起草并投票分级推荐和基于共识的非分级陈述，以达成共识。提供了一个诊断算法，尽可能使用建议中的支持数据以及专家共识来帮助医生评估 HP 的可能性。
基于 14 个 PICO 问题的文献系统评价得出 14 个关键行动陈述：12 个基于证据的分级推荐和 2 个基于共识的非分级陈述。所有证据的质量均非常低。
HP 的诊断应采用以患者为中心的方法，并包括多学科评估，该评估应结合环境和职业暴露史以及 CT 模式，在考虑 BAL 和/或肺活检之前建立诊断信心。提出了标准以促进 HP 的诊断。需要进一步研究暴露评估工具以及传统和新的诊断测试在改变 HP 临床决策方面的性能特征和通用性，特别是在那些具有暂定诊断的人群中。
