Inova Lung Services: For Physicians

Inova Lung Services welcomes the opportunity to work with referring physicians to deliver the most appropriate, effective and personalized care for patients dealing with serious lung conditions. Please feel free to contact us with any questions you may have about our program. Referral and Contact Information Referring physicians may speak with members of the transplant and advanced lung disease team 24 hours a day, seven days a week. During business hours, use the following phone numbers to contact our referral coordinators: Pulmonary Hypertension (Pulm HTN) and Chronic Thromboembolic Pulmonary Hypertension (CTEPH): 703-776-6168 Interstitial Lung Disease/Sarcoidosis: 703-776-7939 Cystic Fibrosis and Bronchiectasis: 703-776-7939 Lung Transplant: 703-776-7939 You may also page the lung transplant attending on call with referral information through the operator at 703-596-1832. Recognizing and Diagnosing Interstitial Lung Disease Expand Content Early and accurate diagnosis of all ILDs is essential in formulating and instituting a timely management plan. Inova adopts a multidisciplinary, multiprong approach that includes diagnosis confirmation, consideration of medical therapies, clinical trials, other ancillary interventions, and, when all else fails, the option of lung transplantation. Following are guidelines to help you identify interstitial lung disease in your patients. We also invite you to refer patients to us for diagnosis. STEP 1: RECOGNIZE ILD Typical presentation includes subacute or chronic cough and exertional dyspnea (breathlessness). 1. While performing an H&P Listen carefully for crackles, especially at the lung bases Look for evidence of autoimmune disease based on a comprehensive history and physical exam Walk your patient informally in the hallway to assess for desaturation (>3% drop) 2. Order initial testing based on your H&P and consider the following: Spirometry (normal or low FVC, often with a normal FEV1/FVC ratio in ILD) Lung Volumes (normal or low TLC) DLCO (frequently reduced in ILD) Chest X-ray (CXR) (unexplained, persistent markings) Please note that CXR and lung function tests can often appear normal in the context of mild ILD 3. If you suspect ILD, perform a high-resolution CT chest scan. HRCT should include the following: Inspiratory and expiratory supine imaging High-spatial frequency algorithm reconstruction at 0.625 to 2.5mm thickness No IV contrast required Consider prone imaging when mild dependent ground-glass attenuation is present STEP 2: ATTEMPT TO IDENTIFY THE CAUSE OF ILD Step 2A: Perform a Detailed History and Physical Below is a list of diseases and questions/findings to consider Connective Tissue Joints, skin, Raynaud’s, reflux, dry eyes/mouth, muscle weakness Disease-related ILD or pain Chronic Hypersensitivity Pneumonitis Exposure to mold sources (forced air heating, hot tubs, humidifiers, water damage, or visible mold), Exposure to birds, down bedding, farming, or agriculture Drug/Radiation-induced ILD Chemotherapy, amiodarone, nitrofurantoin, other drugs Check PneumoTox.com. Radiation therapy to the chest Familial ILD Family history of ILD, Sarcoidosis, home oxygen use, autoimmune disease Pneumoconioses Occupational history Vasculitis Sinus disease, hoarseness, hematuria, hemoptysis Step 2B: Order Relevant Blood Tests Eosinophilic pneumonia: CBC with differential • Chronic Hypersensitivity Pneumonitis: HP panel (controversial) CTD-ILD: ESR, CRP Idiopathic inflammatory myositis: ANA, Jo-1, CK, myoglobin, aldolase, consider myositis panel Rheumatoid Arthritis: RF, CCP Sarcoidosis: Serum calcium Scleroderma/MCTD: ANA, Scl70, centromere, U1RNP Sjogren’s: ANA, Ro/SSA, La/SSB Vasculitis: Anti-PR3 and MPO (ANCA), creatinine Step 2C: Consider Surgical Lung Biopsy Contact our multidisciplinary Interstitial Lung Disease team at 703-776-7939 for a consultation, during which a decision will be made regarding the need for a surgical lung biopsy. We will take multiple appropriately sized biopsies from 2–3 lobes (not just the lingula or middle lobe). Our pulmonary pathologist with expertise in ILD will review the biopsy. ILD Management Checklist Recommend smoking cessation Advise patients to purchase a pulse oximeter to monitor oxygen levels immediately after activity: stairs, hills, level ground, exercise, showering Prescribe different oxygen prescriptions at rest, with routine activities, with exercise, and with sleep to maintain oxygen levels over 90% 24 hours per day Consider nocturnal oximetry or polysomnography Prescribe pulmonary rehabilitation Advise patients to achieve a healthy weight Administer influenza, pneumococcal and COVID-19 vaccinations, and COVID-19 boosters Provide information about your local PFF support group Consider lung transplant evaluation Consider clinical trial enrollment Consider pharmacological treatment after a diagnosis is confirmed This content was adapted from the Pulmonary Fibrosis Foundation ILD Pocket Guide. Monthly Disease-Specific Program Meetings Expand Content Our team values the vital relationship with each patient’s primary pulmonologist and other providers. Fostering such relationships through a collaborative approach and close communication enables ongoing comanagement of patients to ensure optimal outcomes. We welcome referring physicians to join our monthly disease-specific program meetings via Zoom, especially physicians with tough cases who could benefit from multispecialty input. CTEPH: 7:00 – 8:00 a.m. Eastern Time on the third Wednesday of the month ILD: 7:30 – 8:30 a.m. Eastern Time on the second Thursday of the month Pulmonary Hypertension: 7:30 – 8:30 a.m. Eastern Time on the seconds Wednesday of the month Sarcoidosis: 7 – 8 a.m. Eastern Time on the fourth Tuesday of the month Email Julieth Munoz at astrid.munoz@inova.org for a Zoom invitation to these meetings. Contact us for meeting invitations by emailing Education and Training Expand Content Inova Lung Services is deeply committed to the medical education and training of physicians who provide care to patients with serious lung conditions, including pre- and post-care for those undergoing a lung transplant. We sponsor two different educational opportunities: a one-year fellowship and a one-month rotation. Inova Lung Services teams and programs are long established and internationally recognized for excellence. In 2018 we received 698 new referrals, evaluated 493 new patients, and cared for 1,526 patients across all of our clinical programs. Advanced Lung Disease and Transplant Fellowship The Advanced Lung Disease and Transplant Fellowship is a one-year, PGY-7 program which offers an opportunity for additional training in the care of patients with the full spectrum of rare and progressive lung diseases. Learn more about the program  One-Month Rotation for Residents and Fellows The team at Inova Lung Services hosts residents for a one-month rotation. Physicians in attendance come from most of the DC metro area's academic institutions, including Howard University, Walter Reed, Georgetown, George Washington, Washington Hospital Center, Eastern Virginia Medical School and Clarilion Health Systems. Residents and fellows routinely rank the rotation among their top programs for unique clinical experience and research opportunities. Download the Fellow and Resident Manual Hear from a Recent Fellow Thank you for a really great rotation. What you guys do for people is very impressive. You are all incredibly good at the type of medicine that you practice and I feel like I learned so much in the short period of time that I was able to work with you. I was also very impressed by how much you all care for the patients and each other. I can understand why so many of our fellows feel like this is the best rotation we have. Looking forward to hopefully coming back next year. Research and Clinical Trials Expand Content Inova participates in numerous clinical trials for a variety of lung diseases including interstitial lung disease, lung transplantation, pulmonary hypertension, chronic obstructive pulmonary disease, and non-CF bronchiectasis. See our active clinical trials