A Day in the Life of a Rheumatology APP: A Focus on Interstitial Lung Disease” (hosted by Amanda Mixon, PA-C) Save

This presentation is made on behalf of Boehringer Ingelheim Pharmaceuticals Inc. The company has provided financial support for this program. Presentation content has been reviewed for consistency with FDA guidelines. The opinions expressed in this program regarding diagnosing disease are those of the speaker and not a replacement for your clinical judgment.

Thank you for joining us for this podcast called A Day in the Life of a Rheumatology APP, a focus on interstitial lung disease. This program will concentrate on recognizing the signs, symptoms, and risk factors of interstitial lung disease or ILD from the perspective of a rheumatology APP. It will also cover strategies for early diagnosis and effective communication techniques to enhance engagement between healthcare providers and patients. I'm Amanda Mixon. I'm a rheumatology PA.

I have been in the field for over seventeen years. I practice in Northern Colorado, and I'm very fortunate because I have had some of the same patients for almost my entire career. And why that is so meaningful is I really get to see people for their entire lifetime. And as part of that, I'm able to really help those patients as we go along in terms of the different potential manifestations that may come across in their disease. Because what they potentially were initially diagnosed with is maybe not the same thing that we discuss ten years later, or they may have a new clinical manifestation.

And I think that that's why this particular podcast will hopefully be relevant to you to remember that, yes, we need to be able to start to see what the symptoms of interstitial lung disease are, but remember, it can come on later. And so that we're always asking the correct questions, listening to patients, listening to their lungs, doing a good physical exam, always throughout their journey because, again, what they initially present with might be entirely different than what you pick up five years later. So let's go ahead and get started in terms of thinking about how an ILD patient could present. Now, for some of our patients, it's a little bit easier in terms of understanding that certain patients are at a higher risk for interstitial lung disease, just based on what diagnosis or disease process they have. So, for example, connective tissue disorders such as scleroderma or Sjogren's syndrome, there's a lot higher of a risk of interstitial lung disease.

And so, I think when we see those patients, it's already on our minds that these patients could potentially start to develop those things, particularly scleroderma patients. And so for me, when I make a diagnosis of scleroderma, one of the very, very first questions I'm asking the patient is, are you experiencing any shortness of breath? Are you tired? Is it challenging when you're going up the stairs just because you get winded? That's a little bit more straightforward because I think we have, you know, really good guidelines that tell us, okay, with a scleroderma patient, I should be doing x, y, and z so that I'm always monitoring for the potential of interstitial lung disease.

I mentioned Sjogren's at the very beginning as well because I think that's less known that our Sjogren's patients also could develop interstitial lung disease. So really, those questions that we're asking our scleroderma patients, that's kind of just in the back of our minds, we really should also be asking our Sjogren's patients as well. Some of the other conditions that I think about in terms of potential disease processes where there's a higher risk for interstitial lung disease are rheumatoid arthritis, as well as myositis. So this can be polymyositis, dermatomyositis, but those are a couple additional, you know, diagnoses where we do know that there's a higher risk for interstitial lung disease. And we should be asking our patients every single time that they come in.

So for me, when I see a new patient that's coming in and it's a new diagnosis of rheumatoid arthritis, for example, right? Like first, I'm asking the patient, of course, about their joints because in rheumatoid arthritis, the number one symptom that someone is gonna have is going to be joint pain, joint swelling. But I've also really made it as part of my practice to ask those patients, are you experiencing any shortness of breath? Are you experiencing fatigue? You know, I tell my patients all the time, the number one thing that people complain of with rheumatoid arthritis is, of course, their joints.

But the number two is going to be fatigue. And so trying to really differentiate that, is this fatigue because of just their disease process of having RA and they're tired because they can't do the things that they wanna do, and it's so much more of an effort? Or are they tired because they're having difficulty breathing? And I think that that's important that we differentiate those things. So when I see a new rheumatoid arthritis patient, I really do a good history, whether it be scleroderma or Sjogren's or dermatomyositis or polymyositis, obviously, all of those patients are going to present a little bit differently and they're going to have different labs that are associated with their diagnosis.

But asking the same questions, I think is really important. And really, again, trying to differentiate is that fatigue just because of the disease process itself. And, you know, I tell my patients all the time, you know, your body's kind of fighting a war inside, and so that's going to make you tired. And or is it because you actually maybe have the start of an underlying pulmonary disease? And so I would say a history is so, so, so important when you start to talk to all of your patients in any inflammatory condition so that you can help differentiate what is what.

So I would say that's a really good first piece of trying to understand is this patient maybe at higher risk, or is this patient maybe not somebody that I have to worry quite as much about. I think the other thing that can be very helpful to you as you are seeing new patients, whether they are rheumatoid arthritis, again, or scleroderma, is what serologies do they have? Because, for example, in a diffuse scleroderma patient, you know, those patients often will have SCL 70 antibodies as part of the diagnosis that we're making. And we know that people that have SCL 70 antibodies and that are diffuse scleroderma are at a very high risk for interstitial lung disease or developing it. And so, of course, having those serologies in front of you can help guide you in terms of which patients may be higher risk versus, like I said previously, which ones am I not quite as worried about?

Another disease process, the underlying myositis patients, you can run a myositis panel. And based on what antibodies the patient has, can also help clue you in as to whether that patient may be at a little bit higher risk of interstitial lung disease or not. And so I would tell you again, the most important thing initially is to get a really, really good history, but also really looking at those serologies. We know that people with rheumatoid arthritis that are seropositive, I e, rheumatoid factor and CCP, they're gonna be at a higher risk, right, of extra articular manifestations of rheumatoid arthritis versus somebody that is seronegative. And so I would just challenge you to you know, when you're seeing a new patient and you're making a diagnosis, obviously, getting that full history is super important.

But then looking at the labs because the labs will help guide you and really taking another moment, particularly if you are a newer rheumatology APP, to take some time to really understand what those labs mean. I will tell you, even after seventeen years when I get a myositis patient and I order a myositis panel, I often still have to look, okay, that patient is m d a five positive. Well, I know that m d a five positive patients are at a much, much higher risk for progressive interstitial lung disease. So I'm really worried about those patients. But sometimes I'll get an antibody that maybe I haven't seen before or, you know, I'm not as familiar with.

And so I will take the time, after seventeen years, I will take the time to really sit down and look it up and make sure I know what those patients are at a higher risk for. Because again, you know, yes, part of it is going to be underlying lung disease, but it could also be malignancy. It could be the risk of, you know, damage, further damage, or a more progressive disease from rheumatoid arthritis. So, again, a good history will help guide you in terms of, is the patient really having shortness of breath or cough, you know, and trying to differentiate that fatigue. Okay.

So you've done a really good history, and you have helped to differentiate does this patient have shortness of breath? You've asked those questions like, you know, do you have problems going up the stairs? Are you getting more tired when you are walking for extended periods of time? Or sometimes it's even shorter. I think one thing that's important to remember is that people will compensate.

And so they might have had actually symptoms of shortness of breath for many, many years or months, and they don't recognize it because they've just kind of gotten used to it. And so they might there's been times where I've asked a patient, are you short of breath? And they tell me, no, I'm not short of breath. Because they're thinking I'm asking potentially about like, do I think the patient is sick? Do they have a cough or do they have an something acute?

So sometimes I'll frame it a little bit differently and I'll say, well, what about going upstairs? Are you getting more winded? Have you noticed that maybe not just overt shortness of breath where you feel like you might need oxygen, but are you feeling, you know, more tired when you're, you know, going on walks, etcetera? So it can be sometimes hard for patients, and I think it's important for us to recognize that. So I think that rheumatology APPs are really, really good at doing a good physical.

But one thing I will tell you is that sometimes along the way, we can get a little bit complacent in what we're doing. And I have to say, for me personally, I'm guilty of this. Sometimes you kind of just get used to doing things the way that you do them. And I think when we start out, we kind of do a lot of things that maybe as we've been in practice for longer, don't always do those things. But one thing I would tell you is it's so important and crucial that you listen to every person's lungs.

So get out that stethoscope, take it with you into the room, make sure it's around your neck or in the exam room so that you don't forget to listen to every patient's lungs. Now, of course, somebody with a noninflammatory condition like osteoarthritis, you're less concerned, right, about of something like interstitial lung disease. But for your RA patients, don't just examine their joints. You really, really do have to listen because, again, patients compensate. They think, I'm not short of breath.

I'm just tired. But I'm always tired, and so it's not a big deal. And so really listening, I can tell you that I have picked up crackles when the patient told me they weren't having any shortness of breath. And so that's where I have to pause and say, wait a second, there's something else going on here. I can think of a person, you know, just fairly recently that has scleroderma that I asked, you know, are you feeling any shortness of breath?

No. No shortness of breath. And this is a this is a newer diagnosis. And I said, okay. You know, that's great.

I'm glad you're not. You know, obviously, we're worried about patients with scleroderma having, you know, evidence of lung disease. And I listened to this gentleman's lungs and heard classic classic presentation of interstitial lung disease, which would be inspiratory crackles. And then I had to pause for a second. I said, wait a second.

You know, you didn't say you were short of breath breath at all. Are you feeling short of breath? And he said, well, no, but maybe I'm a little bit more tired. And so that's why it's really important because just because a patient tells you they're not feeling it doesn't mean that the disease is not present. And so as you're listening, remember, it is important to listen to, you know, every area of the lung.

We learned that in school. But to remember that you listen to every lobe so that you can hear subtleties in the different lungs. And make sure it's super important to listen at the bases. So what does interstitial lung disease sound like? I've kind of alluded to it, but it really does sound like crackles.

And once you hear it once or twice, it's pretty easy to pick up because it doesn't sound like anything else that I have heard. And so it's going to be an inspiratory crackle that you will hear as the patient is taking a breath in, and that's where you really will hear it. Again, early on, you will hear it at the bases, and then it can kind of move its way up. So that is extremely important. At this time, you will hear what normal lungs sound like.

Now hear what interstitial lung disease sounds like based on those inspiratory crackles. So now you have listened to a patient's lung. Maybe it's a rheumatoid arthritis patient or a scleroderma patient or a myositis patient, and you hear those inspiratory crackles. Now what do you do? Right?

That's always the challenge. And I have to tell you that early on in my career, when I would listen to a patient's lungs and I would hear that, I didn't really know what to do. What does it mean? And it's not really the job of a rheumatology app to diagnose interstitial lung disease or to really be able to give patients all of that information. Right?

Our job truly is to pick it up, pick up some of the signs of it, order the correct tests to determine if that patient potentially does, and then get them into pulmonology. So for my patients, when I hear those inspiratory crackles, the things that I do are, again, I go back to the history and really kind of help differentiate. Did that patient tell me they were experiencing it, or what are they experiencing? You know, just to so just to make sure I have a clear idea in my mind of does this patient potentially have this, or could it be something else? And I'm not in pulmonology, and so I don't try to pretend like I am.

But I also know that a lot of patients with connective tissue diseases develop this, and so that's why it's super important for us to know what to do. So step one is I talk to the patient and say, you know, I'm hearing something that sounds like you could have maybe the start of some inflammation in your lungs. I'm not exactly sure. I don't make the diagnosis of interstitial lung disease. But what I try to do at that point is I say, we need some additional studies to help us differentiate this.

To start, I will do a chest x-ray. And I'm gonna kind of back up here and say, for all of my patients, you know, I'm gonna do usually a chest x-ray for particularly my RA patients, my scleroderma patients. Even if they don't have any inspiratory crackles, I'm going to do that at baseline anyway. That's what I do personally. But certainly, if I hear that, I'm going to order a chest X-ray.

I'm also going to order pulmonary function test. It's important to do that with DLCO so that you can get a full picture of what's going on. And do they have any restriction that might make us more suspicious of ILD? And then the other thing, and this is really kind of, you know, the gold standard is I'm going to order a high resolution CT scan of that patient's lungs. I start the process of all of those things.

I order all of those things because I know that patient needs to get in with pulmonology, and I want that patient to be as ready as possible so that the first time that that patient gets in with pulmonology, they have everything that they need, at least on the upfront, to help them make an official diagnosis. And so those are the things that I do in every patient that I am suspicious may have interstitial lung disease. And then from there, I am going to try and do a fast referral to pulmonology. I'll explain what that means, but I think it's super important that you remember time is tissue. And the longer that that patient goes without a diagnosis, you're talking about lung.

And once fibrosis or scarring happens, unfortunately, it's just like with rheumatoid arthritis, right? Like we tell patients all the time. Once damage happens, there's not a whole lot we can do about it. Right? And so I would say it's the exact same thing with the lungs.

Time is of the essence. We want those patients to be seen by pulmonology as fast as possible. Okay. So you've done a really good physical exam. You've done a great history.

You've looked at those labs. You hear those inspiratory crackles, and you've ordered the appropriate testing. Now what? It's really, really important that you refer to pulmonology as soon as possible so that that diagnosis of interstitial lung disease can be confirmed. I understand that this is not as easy as just refer to pulmonology and they can get them in in a week because we also struggle with that in rheumatology.

There has been times where I will see a patient and they have waited months to see me. And, again, going back to that whole time is tissue, time is lung. I think it's important that you try to look in your area to see if there is an ILD center close to you. I am really fortunate in Colorado because we have a couple, and that can be really helpful for me to know. So really look within your system, look within your state to see, is there a place where people specialize in interstitial lung disease?

The second thing that I would do is I would try to connect with one of those people. You know, I think sometimes APPs can feel a little bit scared to talk to other specialties. I have to say for many years early in my career, I was really scared to talk to people. You wouldn't know that now for as much as I talk and all the people that I know, But there was a long time where I was afraid to pick up the phone because I didn't want to sound stupid. I didn't want to sound like I didn't know what was going on.

And I want you to remember a couple of things. Number one, you are fully capable. You absolutely can change patients' lives. You absolutely can make these diagnoses. Please remember that.

And hopefully that will help with your confidence because it is so important for the patient that they get in with a specialist as soon as possible, just like it was so important for them to get in with you. So look around. See who your local pulmonologists are. See who your local pulmonary APPs are. I mean, I think that's what's so beautiful is with rheumatology, you know, kinda knowing other rheumatology APPs around the country can be super helpful and also in your area so that you can connect.

But also knowing other specialties, I think, is so, so important. So So if you're scared or you don't wanna reach out to the pulmonologist that does all the ILD at the institution, look and see if they have an APP and see if you can talk to them. That might be a little bit easier of a way for you to just kinda start to know who these people are. And you've done the work. You've ordered the appropriate studies.

You've listened to the patient. You've ordered the serologies. And so it's so important to get those patients seen soon. Often, I will do personally is if I am suspicious that this patient has interstitial lung disease, I will immediately do a referral, but I will also pick up the phone, or I'm fortunate in my system, I'm able to send a message, but I will send a message to the pulmonologist that I know that does interstitial lung disease. And I will say, hey, I have this patient.

I've started the workup. This is what I've done. Can you please take a look and get this patient in? And I have found that to be very, very effective. Again, you might be in a place where maybe there is not an interstitial lung disease center, and that's okay.

That's okay. Find your local pulmonology team and make a connection with that person. Really talk to them. Call them up. Hi, I have this patient.

They have scleroderma. I'm hearing inspiratory crackles. You know, I did a high resolution CT, and I'm noting there's some honeycombing on the CT scan, which can be a sign of of interstitial lung disease. You know, is it possible that you can get this patient in sooner rather than later because they're not doing well, or I'm I'm just nervous about that patient? People probably do that with you.

And so just think about how nice it is when a person calls you and says, hey, I have this patient, and I really think they need to be seen. And then ultimately, when you see that patient, how amazing it is for the patient. Because at the end of the day, that's why we're all doing this. This is why rheumatology does this. This is why pulmonology does this.

And I feel like that's what you have to remember. So if you get nervous and you don't necessarily wanna pick up the phone, just remember, you have to get beyond that because it's not about you, it's about the patient. And I I try to remember and I treat every single patient like they are a member of my own family. And I think about what would I want for my sister or for my parent if they were experiencing this. And I try to remember that before I go into every exam room when I'm about to see a patient, even if I'm tired, even if it's the twenty second patient that I have that day.

I try to remember and reset myself before I walk into that room. And making those connections can be absolutely key. I've got a few people on my speed dial that I can call if I'm really, really nervous about a patient. And so it just takes the time to just pick up the phone, and I think it will be truly helpful for you. And again, kind of creating this referral network.

I would say just remember, it's going to go both ways though. What ends up happening that I have found is that I have made these connections with other subspecialties like pulmonology. And then when they need to get a patient in, they're gonna call me. And I am totally good with that because I feel like we all help each other so that we can give the best possible care for the patient. I'm gonna try to summarize everything that I have said for you in just a couple of minutes so that you can really take these things home with you.

Number one, do a good history. Number two, look at those serologies. Order the appropriate serologies, and then look at them. Try your hardest to interpret those things so that you know which patients are at a higher risk versus which patients may be at a lower risk. Number three, do a good physical exam.

Listen to every patient's lungs. What might be helpful for you is just not even to differentiate it, but just listen to everybody's lungs. Then I think it's really important to understand and know what tests to order. So we went over that pulmonary function test, a chest x-ray, a high resolution CT scan, and then finally getting that patient seen by pulmonology in a timely manner, which again is much much easier said than done. But making those connections with your local pulmonologist, pulmonology APP, or finding that interstitial lung disease center.

That way you can get that patient seen as soon as possible. Because again, time is tissue. So now you might be wondering, okay. I got it. I I I understand how what I'm supposed to be doing.

And also, I know I've said I've done this for seventeen years. I have to remind myself of these things. So you are not alone if you feel like, oh my gosh, I haven't always been doing this, or maybe I need to get that stethoscope out from the desk or below all the books. That's okay. We all do those things.

It's just an important reminder. But now what? Right? Like, you might want some additional resources, and BI actually has some really good ones that you should check out. One of them is the Insights in ILD website, which is really a comprehensive look at interstitial lung disease.

We don't usually make a diagnosis of ILD. I'm sure there are some rheumatologists out there that do, but I don't feel comfortable, and I've not met many rheumatology APPs that just solely do this. It's really important to work with a good pulmonology team. But understanding what interstitial lung disease is, and also more importantly, what it's not, this can help you differentiate that. There are also pocket guides, and that has been awesome.

I have mine in my exam room so that I can kinda pick it up and look at it. But that's just a quick resource that you can use that can help you along the way if you kind of are forgetting what to do, what it looks like, what it sounds like, etcetera. And then the one thing that I think that I can be a little bit weak in is radiology. And what I'm kind of told all over the country when I, you know, speak to various people is that radiology can be a weaker area of APPs just because, you know, when we're in school, it's like rapid fire trying to learn all of these things. So there is a radiology app also that can really help you differentiate and familiarize yourself with what a high resolution CT looks like, as well as what interstitial lung disease looks like.

Don't forget that this is just one of a series of podcasts. And so please check out the other ones, and I really appreciate you listening today. I hope it was helpful.