• Evans R Fernández Pérez, William D Travis, David A Lynch, Kevin K Brown, Kerri A Johannson, Moisés Selman, Jay H Ryu, Athol U Wells, Tony HuangYuh-ChinYCDepartment of Medicine, Duke University Medical Center, Durham, NC., PereiraCarlos A CCACDepartment of Medicine, Federal University of São Paulo, São Paulo, Brazil., Mary-Beth Scholand, Ana Villar, Naohiko Inase, Richard B Evans, Stephen A Mette, and Lindsy Frazer-Green.
• Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO. Electronic address: Fernandezevans@njhealth.org.
• Chest. 2021 Aug 1; 160 (2): e97-e156.

BackgroundThe purpose of this analysis is to provide evidence-based and consensus-derived guidance for clinicians to improve individual diagnostic decision-making for hypersensitivity pneumonitis (HP) and decrease diagnostic practice variability.Study Design And MethodsApproved panelists developed key questions regarding the diagnosis of HP using the PICO (Population, Intervention, Comparator, Outcome) format. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and vetted evaluation tools were used to assess the quality of included studies, to extract data, and to grade the level of evidence supporting each recommendation or statement. The quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted and voted on using a modified Delphi technique to achieve consensus. A diagnostic algorithm is provided, using supporting data from the recommendations where possible, along with expert consensus to help physicians gauge the probability of HP.ResultsThe systematic review of the literature based on 14 PICO questions resulted in 14 key action statements: 12 evidence-based, graded recommendations and 2 ungraded consensus-based statements. All evidence was of very low quality.InterpretationDiagnosis of HP should employ a patient-centered approach and include a multidisciplinary assessment that incorporates the environmental and occupational exposure history and CT pattern to establish diagnostic confidence prior to considering BAL and/or lung biopsy. Criteria are presented to facilitate diagnosis of HP. Additional research is needed on the performance characteristics and generalizability of exposure assessment tools and traditional and new diagnostic tests in modifying clinical decision-making for HP, particularly among those with a provisional diagnosis.Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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