General guidelines for monitoring and management of new airflow obstruction
| Guidelines . |
|---|
| A. Significant new airflow obstruction with a % predicted FEV1 ≥70% |
| 1. Initiate inhaled corticosteroid therapy |
| • Fluticasone (Flovent) 440 mcg BID, or |
| • Advair 500/50 mcg BID (if symptoms of airway obstruction are present) |
| • Treatment should continue until either % FEV1 becomes <70% (see below), or until GVHD resolves (ie, resolution of all reversible manifestations of GVHD without exacerbation after at least 6 mo after discontinuation of all systemic immunosuppressive treatment) |
| 2. Other immunosuppressive treatment as indicated to control GVHD in other organs |
| • Treatment should continue until either % FEV1 becomes <70% (see below), or until GVHD resolves (ie, resolution of all reversible manifestation of GVHD without exacerbation after at least 12 mo after discontinuation of all systemic treatments) |
| 3. Monitor PFTs or spirometry monthly for at least 3 mo |
| • If % FEV1 stabilizes, PFTs or spirometry every 3 mo for 1 y, then if stable continue at 6-mo intervals for 1 y and at 6-12 mo intervals thereafter |
| • If % FEV1 continues to decrease, go to B below |
| B. Significant airflow obstruction with a % FEV1 <70% with/without significant air-trapping by high resolution chest CT |
| 1. Consider bronchoscopy to rule out an undetected infectious etiology for airflow obstruction, even if no infiltrate is apparent |
| 2. After infection has been ruled out, evaluate the patient eligibility for clinical trial for treatment of BOS and initiate (or increase) prednisone dose to 1 mg/kg/d |
| • Start standard chronic GVHD taper at 2 wk (Table 5) |
| • Consider continuing inhaled corticosteroids throughout prednisone therapy |
| 3. If % FEV1 decreases further to <70% during treatment, discuss changes of immunosuppressive treatment with transplant physician |
| 4. CMV monitoring in blood per standard practice |
| 5. Monitor PFTs or spirometry monthly for at least 3 mo |
| • If % FEV1 stabilizes, continue PFTs or spirometry every 3 mo for 1 y |
| • If % FEV1 continues to decrease, go to C below |
| C. Corticosteroid-resistant airflow obstruction defined as progressive decline of FEV1 by ≥10% despite treatment with 1 mg/kg/d of prednisone (or similar corticosteroids) |
| 1. May consider increasing the dose of prednisone to 2 mg/kg/d for a maximum of 2 wk, followed by a taper to reach a dose of 1 mg/kg/d by 2-4 wk |
| 2. Another treatment must be considered and discussed with the transplant team |
| 3. Monitor CMV in blood per standard practice |
| 4. Monitor PFTs monthly for at least 3 mo |
| • If % FEV1 stabilizes, monitor PFTs every 3 mo for 1 y |
| D. Additional considerations |
| 1. Consider changing prophylaxis for encapsulated bacterial infection to azithromycin 250 mg on Mondays-Wednesdays-Fridays |
| • Assure patient is receiving adequate prophylaxis for Pneumocystis, varicella virus, and herpes simplex virus infections |
| • Fungal prophylaxis per standard practice |
| 2. Monitor CMV in blood per standard practice |
| 3. May continue inhaled corticosteroids throughout prednisone therapy |
| 4. Discontinuation of inhaled corticosteroid treatment can be considered 12 mo after treatment with prednisone has been discontinued |
| Guidelines . |
|---|
| A. Significant new airflow obstruction with a % predicted FEV1 ≥70% |
| 1. Initiate inhaled corticosteroid therapy |
| • Fluticasone (Flovent) 440 mcg BID, or |
| • Advair 500/50 mcg BID (if symptoms of airway obstruction are present) |
| • Treatment should continue until either % FEV1 becomes <70% (see below), or until GVHD resolves (ie, resolution of all reversible manifestations of GVHD without exacerbation after at least 6 mo after discontinuation of all systemic immunosuppressive treatment) |
| 2. Other immunosuppressive treatment as indicated to control GVHD in other organs |
| • Treatment should continue until either % FEV1 becomes <70% (see below), or until GVHD resolves (ie, resolution of all reversible manifestation of GVHD without exacerbation after at least 12 mo after discontinuation of all systemic treatments) |
| 3. Monitor PFTs or spirometry monthly for at least 3 mo |
| • If % FEV1 stabilizes, PFTs or spirometry every 3 mo for 1 y, then if stable continue at 6-mo intervals for 1 y and at 6-12 mo intervals thereafter |
| • If % FEV1 continues to decrease, go to B below |
| B. Significant airflow obstruction with a % FEV1 <70% with/without significant air-trapping by high resolution chest CT |
| 1. Consider bronchoscopy to rule out an undetected infectious etiology for airflow obstruction, even if no infiltrate is apparent |
| 2. After infection has been ruled out, evaluate the patient eligibility for clinical trial for treatment of BOS and initiate (or increase) prednisone dose to 1 mg/kg/d |
| • Start standard chronic GVHD taper at 2 wk (Table 5) |
| • Consider continuing inhaled corticosteroids throughout prednisone therapy |
| 3. If % FEV1 decreases further to <70% during treatment, discuss changes of immunosuppressive treatment with transplant physician |
| 4. CMV monitoring in blood per standard practice |
| 5. Monitor PFTs or spirometry monthly for at least 3 mo |
| • If % FEV1 stabilizes, continue PFTs or spirometry every 3 mo for 1 y |
| • If % FEV1 continues to decrease, go to C below |
| C. Corticosteroid-resistant airflow obstruction defined as progressive decline of FEV1 by ≥10% despite treatment with 1 mg/kg/d of prednisone (or similar corticosteroids) |
| 1. May consider increasing the dose of prednisone to 2 mg/kg/d for a maximum of 2 wk, followed by a taper to reach a dose of 1 mg/kg/d by 2-4 wk |
| 2. Another treatment must be considered and discussed with the transplant team |
| 3. Monitor CMV in blood per standard practice |
| 4. Monitor PFTs monthly for at least 3 mo |
| • If % FEV1 stabilizes, monitor PFTs every 3 mo for 1 y |
| D. Additional considerations |
| 1. Consider changing prophylaxis for encapsulated bacterial infection to azithromycin 250 mg on Mondays-Wednesdays-Fridays |
| • Assure patient is receiving adequate prophylaxis for Pneumocystis, varicella virus, and herpes simplex virus infections |
| • Fungal prophylaxis per standard practice |
| 2. Monitor CMV in blood per standard practice |
| 3. May continue inhaled corticosteroids throughout prednisone therapy |
| 4. Discontinuation of inhaled corticosteroid treatment can be considered 12 mo after treatment with prednisone has been discontinued |
Before considering treatment, all potential infectious etiologies of airflow obstruction must be investigated and treated if present. Investigations that should be considered (directed by clinical symptoms), include sinus CT scan, nasal washes, sinus aspiration, high-resolution chest CT scan, sputum culture, bronchoalveolar lavage, and lung biopsy.
BID, twice daily; CT, computed tomography scan.