Huang Yuh Chin, Gu Jessie P
Department of Medicine, Duke University Medical Center, Durham, NC, United States.
Front Med (Lausanne). 2023 Mar 3;10:1109525. doi: 10.3389/fmed.2023.1109525. eCollection 2023.
Hypersensitivity pneumonitis (HP) is an immune-mediated interstitial lung disease from exposure to environmental antigens. Diagnosing HP could be challenging. The American College of Chest Physicians (CHEST) and American Thoracic Society/Japanese Respiratory Society/and Asociación Latinoamericana del Tórax (ATS/JRS/ALAT) have published diagnostic guidelines in 2021 and 2020 respectively. The CHEST guideline uses four grades of confidence: confident (>90%), provisional high (70-89%), provisional low (51-69%), and unlikely (≤50%). The ATS/JRS/ALAT guideline uses five grades of confidence: definite (>90%), high (80-89%), moderate (70-79%), low (51-69%) and not excluded (≤50%). In this study, we determined how these two guidelines could have affected the diagnosis of HP made before the guidelines.
Two hundred and fifty-nine adult patients from a previous cohort with HP (ICD-9:495) made between Jan. 1, 2008, and Dec. 31, 2013, at Duke University Medical Center were included. We simplified the diagnostic confidence into three categories so we could compare the guidelines: high (≥90%), intermediate (51-89%), and low (≤50%).
There were 156 female and 103 male. Mean age was 58 (range: 20-90). 68.8% of the patients had restrictive defects (FVC < 80% pred) and 48.6% had lung biopsy. The CHEST guideline classified 33.6% of the patients into high, 59.5% into intermediate and 6.9% into low confidence categories. The ATS/JRS/ALAT guideline classified 29.7% of the patients into high, 21.2% into intermediate and 49.0% into low confidence categories ( < 0.0001 vs. CHEST). Cohen's kappa was 0.331. In patients with identifiable inciting agents (IAs) ( = 168), the CHEST guideline classified 32.1% of the patients into high, 64.3% into intermediate and 3.6% into low confidence categories. The ATS/JRS/ALAT guideline classified 29.2% of the patients into high, 20.8% into intermediate, and 50.0% into low confidence categories. Cohen's kappa was 0.314.
In our HP cohort with two-thirds of the patients with restrictive defects, we found the two guidelines had fair agreement in diagnosing HP with or without identifiable IAs. They agreed more when the diagnostic confidence was high. When the diagnostic confidence was lower, however, the ATS/JRS/ALAT guideline was more stringent. Clinicians should be aware of the differences between the two guidelines when evaluating patients suspicious of HP.
过敏性肺炎（HP）是一种因接触环境抗原而引发的免疫介导性间质性肺病。诊断HP可能具有挑战性。美国胸科医师学会（CHEST）和美国胸科学会/日本呼吸学会/拉丁美洲胸科学会（ATS/JRS/ALAT）分别于2021年和2020年发布了诊断指南。CHEST指南使用四级置信度：确定（>90%）、高度暂定（70 - 89%）、低度暂定（51 - 69%）和不太可能（≤50%）。ATS/JRS/ALAT指南使用五级置信度：明确（>90%）、高（80 - 89%）、中（70 - 79%）、低（51 - 69%）和未排除（≤50%）。在本研究中，我们确定了这两种指南如何影响在指南发布之前对HP的诊断。
纳入2008年1月1日至2013年12月31日期间在杜克大学医学中心之前队列中诊断为HP（国际疾病分类第九版：495）的259例成年患者。我们将诊断置信度简化为三类以便比较指南：高（≥90%）、中（51 - 89%）和低（≤50%）。
有156名女性和103名男性。平均年龄为58岁（范围：20 - 90岁）。68.8%的患者存在限制性缺陷（用力肺活量<预计值的80%），48.6%的患者进行了肺活检。CHEST指南将33.6%的患者分类为高置信度，59.5%为中置信度，6.9%为低置信度类别。ATS/JRS/ALAT指南将29.7%的患者分类为高置信度，21.2%为中置信度，49.0%为低置信度类别（与CHEST相比，P<0.0001）。科恩kappa系数为0.331。在有可识别激发因素（IA）的患者（n = 168）中，CHEST指南将32.1%的患者分类为高置信度，64.3%为中置信度，3.6%为低置信度类别。ATS/JRS/ALAT指南将29.2%的患者分类为高置信度，20.8%为中置信度，50.0%为低置信度类别。科恩kappa系数为0.314。
在我们三分之二患者有限制性缺陷的HP队列中，我们发现这两种指南在诊断有无可识别IA的HP方面有适度一致性。当诊断置信度高时，它们的一致性更高。然而，当诊断置信度较低时，ATS/JRS/ALAT指南更为严格。临床医生在评估疑似HP的患者时应注意这两种指南之间的差异。
