Evaluating for ILD:
A Four Question Model

(4QM-ILD)

The 4 Questions I Seek to Answer When Evaluating for ILD

…so, I know that header is giving Buzzfeed, but nevertheless this conceptual framework will probably still be useful to you! Let’s talk through four questions that I think can help frame evaluating for potential ILD. This approach is genuinely my own, but it is important to share that its first two steps are heavily influenced by the excellent 2025 ERS/ATS Statement for classification of interstitial pneumonia. I recommend you read that document, as well.

These four questions (4QM-ILD, i.e., an acronym that I hope is not the ILD equivalent of trying to make fetch happen) are distinct from the questions I actually ask patients within an encounter, some of which are covered in Overview & Approach to ILD. Instead, these are questions I ask to myself when I need to make my clinical reasoning more explicit, either because I am thinking through a very complex case on my own or because I am trying to teach someone else how to reason in this nuanced, subspecialty context.

Q1. What is the morphologic pattern?

Imaging, histology, relationship between the two

Interstitial v. alveolar filling patterns

Cellular v. fibrotic

Imaging & histologic

UIP, NSIP, BIP, DAD, PPFE, LIP

OP, RB-ILD, AMP, AEP, CEP, PAP

Cyst predominant disease

Combined patterns, uILD

Not ILD

These are explored one by one on this website, under Morphologies.

Q2. When considering the morphologic pattern alongside clinical details, can a multidisciplinary committee assign a diagnosis?

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  • Is all necessary and useful clinical information collected? Is the safety profile for obtaining any desired additional data acceptable or unacc?

  • History/comorbidities, tempo, duration of findings with/without other disease features?

  • Secondary v. idiopathic/primary pattern

Q3.Do any non-diagnostic clinical descriptors apply?

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  • PPF

  • IPAF

  • CPFE

  • Fibrotic v. cellular

Q4. Combining the morphologic features, other clinical descriptors, and the multidisciplinary diagnosis, can a partial, staged, or complete treatment plan be designed?

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Components

  • Treatment

    • Antifibrotics

    • Immunosuppression

    • Combination

      • “staged”

  • Monitoring & surveillance

    • PFT

    • CT Chest

    • TTE

  • Management of co-morbidities & preventative care

    • GERD

    • Chronic hypoxemic respiratory failure

    • Peri-operative considerations

    • Vaccines

  • Symptom management & goals of care