Screening and Monitoring Chapter 4: Embedding Guidelines Into Practice

Return to the series here.

Hello, and welcome back to the ILD Explainer Video Series. I am Dr Elana Bernstein, an associate professor of medicine at Columbia University Vagelos College of Physicians & Surgeons and an associate attending at New York-Presbyterian Hospital. I am also the founder and director of the Columbia University/New York-Presbyterian Scleroderma Program. 

This series focuses on screening and monitoring ILDs. In this video, we’ll simplify the 2023 American College of Rheumatology—known as ACR—and the American College of Chest Physicians—known as CHEST— recommendations into practical clinic tools, outline disease-specific screening intervals and monitoring thresholds, demonstrate what progression looks like on tests and imaging, and share workflow strategies to embed these guidelines into daily practice. 

Even with clear guidelines, implementation can be challenging. Clinicians may worry about limited time, coordination across specialties, and insurance barriers.  

These challenges can be addressed by integrating screening and monitoring into routine visits, utilizing an electronic medical record, or EMR, to send alerts and save time, and developing simple referral pathways to streamline coordination between specialties.  

To summarize, the guidelines for SARD-ILD are clear, practical, and designed to support clinicians in delivering better care. They remind us to screen early, with baseline PFT and HRCT when indicated for high-risk SARD patients, and to repeat PFTs at least annually, or more often in high-risk diseases such as SSc and IIM. 

Monitoring for progression means not only tracking symptoms, but also following PFT trends, using repeat imaging when needed, and recognizing functional decline.  

The key thresholds to remember are an absolute decline in FVC of 10% or more, a 5% to 9% decline in FVC with symptoms or HRCT changes, and a 10% to 15% decline in DLCO. 

Clinicians should also be alert for worsening symptoms with radiologic progression within 24 months, a decline in 6-minute walk distance of more than 50 meters, increasing dyspnea, and a decline in quality-of-life scores. 

Maria’s case illustrates how structured assessment and regular monitoring can change the disease trajectory, allowing us to intervene earlier and preserve lung function.  

The final step is to embed these recommendations into daily clinical workflow, whether through EMR prompts, standardized order sets, or routine checklists, so that screening, monitoring, and defining progression become second nature in practice. This way, we can translate guidelines into better outcomes for patients. 

For Maria and your patients, these steps can make all the difference. 

Guidelines are not obstacles—they are tools. Use them confidently, and you can change the course of ILD for your patients. 

6MWD – 6-minute walk distance 
ACR – American College of Rheumatology 
Architectural distortion – Irreversible displacement of normal lung structures due to fibrosis 
CHEST – American College of Chest Physicians 
CTD-ILD – Connective tissue disease–associated interstitial lung disease 
DLCO – Diffusing capacity of the lung for carbon monoxide 
EMR – Electronic medical record 
FVC – Forced vital capacity 
GGO – Ground-glass opacity 
HRCT – High-resolution computed tomography 
IIM – Idiopathic inflammatory myopathy 
ILD – Interstitial lung disease 
MCTD – Mixed connective tissue disease 
MDD – Multidisciplinary discussion 
NSIP – Nonspecific interstitial pneumonia 
OP – Organizing pneumonia 
PFT – Pulmonary function testing 
PPF – Progressive pulmonary fibrosis 
Progression (ILD) – Worsening physiologic, radiologic, or symptomatic disease over time 
RA – Rheumatoid arthritis 
Radiologic progression – Worsening fibrotic features on HRCT 
Reticulation – Network of fine linear opacities caused by septal thickening 
SARD – Systemic autoimmune rheumatic disease 
SjD – Sjögren disease 
SSc – Systemic sclerosis 
Traction bronchiectasis – Irreversible airway dilation due to fibrotic pulling 
UIP – Usual interstitial pneumonia 

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