Pediatric Hypersensitivity Pneumonitis Treatment & Management

Updated: May 20, 2016
  • Author: Harold J Farber, MD, MSPH; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
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Treatment

Medical Care

The key to effective treatment of hypersensitivity pneumonitis (HP) is identifying the offending antigen and eliminating further exposure. These goals can be hard to achieve because the offending antigen may not be obvious and may endure long after the antigenic source is removed (ie, avian antigens). [89]

Removal from exposure usually results in complete resolution of symptoms, although substantially more time is required in subacute than in acute disease. In many patients, complete resolution requires weeks to months. Permanent lung damage, continued progression, or both may be seen in advanced cases of chronic hypersensitivity pneumonitis.

Corticosteroids can speed resolution of hypersensitivity pneumonitis; however, corticosteroid therapy does not eliminate or reduce the need to identify the causative antigen and elimination of exposure to it, nor does it change the long-term prognosis. If systemic corticosteroid therapy is used, the same dosage regimen should be continued until clinical improvement of pulmonary function is observed. The dosage should then be gradually tapered downward. In advanced chronic disease, progression of pulmonary fibrosis and death can occur despite aggressive corticosteroid therapy. If the patient has risk factors for tuberculosis, latent tuberculosis infection should be excluded prior to starting corticosteroid therapy.

Antibiotic therapy is not indicated for treatment of hypersensitivity pneumonitis. However, in many cases, antibiotic drugs are administered until a diagnosis of infectious pneumonia is ruled out.

A few case reports have described clinical improvement with rituximab when used as salvage therapy in adults with severe progressive chronic hypersensitivity pneumonitis. [90, 91] Rituximab is an anti-CD20 monoclonal antibody that depletes B cells from the peripheral circulation. One of the reports of clinical experience with rituximab in 6 adults with severe progressive hypersensitivity pneumonitis found that lung function stabilized or improved in 3 and continued to deteriorate in the other 3, all of whom died within 4 months of treatment. [91] There are no reports of pediatric experience with this medication in hypersensitivity pneumonitis.

In this author’s opinion, rituximab should not be considered standard therapy for chronic hypersensitivity pneumonitis. Rituximab may be considered as salvage therapy in a patient with severe, progressive, and life-threatening chronic hypersensitivity pneumonitis in whom standard therapies (including aggressive attempts to identify and eliminate exposure to the offending antigen) have clearly failed. This would be very unusual for a child.

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Consultations

Consulting a pediatric pulmonologist, an allergist, or both who have experience in treating hypersensitivity pneumonitis can be helpful for confirming the diagnosis, assessing complications, educating the patient and family, and providing long-term follow-up care for the patient.

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Diet

No dietary restrictions are needed.

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Activity

If the patient has pulmonary fibrosis, subpleural blebs, or airway obstruction, activities that may increase intrathoracic pressure (eg, scuba diving, playing horn instruments) are contraindicated because of the risk of pneumothorax. Otherwise, activity levels should be adjusted according to the patient's comfort; dyspnea causes most patients to spontaneously reduce their physical activity. If needed, tolerance of physical activity can be objectively assessed with 6-minute walk testing.

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