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Condition · Interstitial lung disease

Interstitial lung disease (ILD): diagnosis and treatment in Bangalore

Interstitial lung disease is not one illness but a family of more than 200. Telling them apart decides everything that follows, because the treatment for an inflammatory ILD and the treatment for a fibrotic one are close to opposites. Dr. Manjunath M Negigoudara runs the advanced lung failure and ILD clinic at KIMS Hospital, Electronic City, Bengaluru.

Medically reviewed Written and reviewed by Dr. Manjunath M Negigoudara, Transplant Pulmonologist, KIMS Hospital, Electronic City, Bengaluru. KMC 116911. Last reviewed · 5 peer-reviewed sources

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What is interstitial lung disease?

Your lungs are not hollow bags. Between the air sacs runs a thin scaffold of tissue called the interstitium, and oxygen has to cross it to reach the blood. Interstitial lung disease is what happens when that scaffold becomes inflamed, thickened or scarred. The crossing gets harder, and the first thing you notice is that you are short of breath doing something you used to do without thinking about it.

More than 200 distinct conditions sit under the ILD label. Some are driven by inflammation and respond well to treatment. Some are driven by scarring and do not reverse. Some begin as one and become the other. The clinical work is to find out which one you have, and the honest answer is that this is often harder than patients are led to expect.

Why the subtype decides everything

An inflammatory ILD is usually treated by suppressing the immune system. A fibrotic ILD is treated with antifibrotic drugs, and immunosuppression can make it worse. Getting the label wrong does not simply delay the right treatment, it can actively cause harm. This is why a careful diagnosis matters more in ILD than in almost any other lung condition.

Dr. Manjunath M Negigoudara

Transplant Pulmonologist, KIMS

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What are the symptoms of interstitial lung disease?

Very few people arrive saying they have interstitial lung disease. They arrive with a story that has usually been going on for a year or more, and often with a diagnosis of something else attached to it.

  • Breathlessness that crept up. First on stairs and slopes, then on the flat, then while dressing. Patients frequently date it to a chest infection that they never fully shook off.
  • A dry cough that will not settle. Usually unproductive, often worse on talking or laughing, and often treated as asthma, acid reflux or post-nasal drip for months first.
  • Crackles at the bases. A fine dry sound on the stethoscope, frequently described as Velcro being pulled apart. It is one of the most useful physical signs in medicine and it is easy to miss if nobody is listening for it.
  • Clubbing of the fingertips. Present in a substantial minority, particularly in fibrotic disease.
  • Oxygen that falls on walking but looks normal at rest. This is the single most commonly missed finding. A resting saturation of 97 percent can sit alongside a drop into the eighties after six minutes of walking.

If breathlessness has been labelled asthma for more than a year and inhalers have not meaningfully helped, that alone justifies an ILD assessment. Asthma that does not respond to asthma treatment is frequently not asthma.

How is interstitial lung disease diagnosed?

Flowchart of the interstitial lung disease diagnostic pathway: symptoms, high-resolution CT to protocol, lung function with DLCO, finding the cause, then either a definite pattern or a multidisciplinary discussion and biopsy
The ILD diagnostic pathway as it runs at KIMS Electronic City. A definite pattern ends the workup; an unclear one goes to multidisciplinary discussion.

The HRCT is the centre of the workup

A high-resolution CT of the chest is the most important single test, and the protocol matters. A true HRCT uses thin slices, and adds images taken lying face down and on breathing out. The prone images separate real early scarring at the back of the lungs from the harmless pooling that gravity causes. The expiratory images reveal air trapping, which points toward hypersensitivity pneumonitis. A routine CT chest ordered without this protocol will miss both. If you already have a CT, bring the images themselves rather than only the report.

Breathing tests, with the diffusion number

Full pulmonary function testing in ILD must include DLCO, the measure of how efficiently gas crosses from air sac to blood. DLCO is usually the first number to fall and the most sensitive marker of progression. Spirometry alone is not enough. A six-minute walk test with continuous oximetry is added, because what happens to your oxygen when you move is far more informative than what it reads while you sit.

Finding the cause

A large share of ILD has an identifiable driver, and finding it can change the outlook completely. The workup includes an autoimmune panel, because ILD is sometimes the first sign of rheumatoid arthritis, scleroderma, myositis or Sjogren syndrome. It includes precipitin testing and a forensic exposure history: birds in or near the home, damp and mould, air conditioning and humidifiers, feather bedding, and occupational exposure to stone dust, silica, asbestos, cotton or wood. In and around Bengaluru, stone cutting and construction dust exposure is common enough that it is asked about in every consultation.

The multidisciplinary discussion

Where the pattern is not clear cut, the 2022 ATS/ERS/JRS/ALAT guideline recommends that the case is settled by a pulmonologist, a thoracic radiologist and a pathologist reviewing it together rather than passing reports between them. This changes the working diagnosis often enough that it is now considered the reference standard. At KIMS Electronic City this discussion happens on site, and the transplant team is part of the same department, so a case that turns out to need transplant assessment does not start again somewhere else.

Do I need a lung biopsy for ILD?

Most patients do not need one. When the HRCT shows a definite usual interstitial pneumonia pattern in the right clinical setting, that is sufficient and surgery adds risk without adding information. When the pattern is indeterminate, a bronchoscopy with bronchoalveolar lavage is usually the next step, and transbronchial cryobiopsy can provide tissue with considerably less risk than a surgical lung biopsy. The COLDICE study compared both in the same patients and found cryobiopsy agreed with surgical biopsy in most cases. Dr. Manjunath holds a fellowship in interventional pulmonology, so the diagnostic procedures are performed within the same clinic rather than referred out.

How is interstitial lung disease treated?

Type of ILD Main approach What to expect
Idiopathic pulmonary fibrosis Antifibrotic therapy, transplant assessment early Decline is slowed, not reversed. Referral for transplant at diagnosis if otherwise suitable.
Hypersensitivity pneumonitis Remove the antigen, then immunosuppression if inflammatory Can improve substantially if caught before fibrosis sets in. Identifying the exposure is the treatment.
Connective tissue disease ILD Immunosuppression, jointly with rheumatology Often stabilises. Antifibrotics are added when a progressive fibrotic phenotype emerges.
Sarcoidosis Observation in mild disease, steroids and steroid-sparing agents when organ function is threatened Many cases remit without any treatment at all. Treatment is for the ones that do not.
Progressive fibrosing ILD of any cause Antifibrotic therapy added to whatever treats the underlying disease Recognised as a distinct phenotype that behaves like IPF regardless of the original label, following the INBUILD trial.

Prognosis is staged with the ILD-GAP model, which combines age, sex, lung function and ILD subtype and is worth asking your specialist about, because it frames how closely you should be monitored.

Alongside drug treatment, three things reliably improve how patients actually feel and are too often left out. Pulmonary rehabilitation improves walking distance and breathlessness scores. Supplemental oxygen for those who desaturate on exertion restores activity. And treating the conditions that travel with ILD, particularly reflux, sleep apnoea and pulmonary hypertension, changes symptoms more than patients expect. Where pulmonary hypertension complicates ILD, it is assessed and managed in the same clinic.

When does ILD need a lung transplant?

This is where an ILD clinic run by a transplant pulmonologist differs from one that is not. The honest position is that referral should happen earlier than it usually does. The ISHLT 2021 consensus on candidate selection is to refer at the point of a confirmed fibrotic ILD diagnosis with evidence of progression, rather than waiting until oxygen is needed continuously.

The practical triggers to ask about transplant assessment:

Six triggers for lung transplant referral in fibrotic lung disease: forced vital capacity falling 10 percent over six months, DLCO below 40 percent, any supplemental oxygen, six-minute walk under 250 metres, an admission for a flare, or pulmonary hypertension
Any one of these is a reason to ask about transplant assessment. Referral is an assessment, not a commitment to surgery.
  • Forced vital capacity falling by 10 percent or more over six months
  • DLCO below 40 percent predicted, or falling by 15 percent over six months
  • Any requirement for supplemental oxygen, including only on exertion
  • A six-minute walk distance below 250 metres, or desaturation below 88 percent
  • An admission for an acute exacerbation
  • Development of pulmonary hypertension

Referral is not the same as listing. Most patients referred early are assessed, counselled and then followed, and a good share never need to proceed. The reason to refer early is simply that the assessment takes time, and the patients who do badly are the ones who arrive too unwell to complete it. Read more on lung transplantation at KIMS Electronic City and on who needs a lung transplant.

The one thing worth acting on today

If you have a fibrotic ILD and have never been told whether you are a transplant candidate, ask. Not because you need a transplant now, but because the answer determines how closely you should be monitored and how quickly you should act if things change.

What happens at an ILD consultation in Bangalore?

The first visit is built around your existing imaging. Bring the HRCT on a disc or drive rather than the report alone, along with every previous pulmonary function test, because the trend across time carries more information than any single result. Expect a full history including home, work and hobby exposures, an examination, a walk test, and a clear statement of what is known, what is not yet known, and what the next step is.

Consulting hours are Monday to Saturday, 9 AM to 5 PM, at KIMS Hospital, Survey No. 37 and 38, PES University EC Campus, Hosur Road, Konappana Agrahara, Bengaluru 560100. Evening consultations and video consultations are available by prior appointment. Call or WhatsApp +91 79937 41199.

For patients from Bangalore, across India, and abroad

Bengaluru and Electronic City

KIMS Electronic City sits on Hosur Road opposite the PES University EC Campus, roughly 15 minutes from Silk Board on the Electronic City elevated expressway. Patients travel routinely from HSR Layout, Koramangala, Sarjapur Road, BTM Layout, Jayanagar, JP Nagar, Bannerghatta Road, Whitefield and Marathahalli, and from Bommasandra, Anekal, Chandapura and Attibele on the southern side. See the Electronic City clinic page for directions and parking.

Karnataka and the rest of India

ILD patients come to the clinic from Mysuru, Mangaluru, Hubballi-Dharwad, Belagavi, Kalaburagi, Shivamogga, Tumakuru, Davangere and Ballari within Karnataka, and from Chennai, Coimbatore, Madurai, Salem, Hyderabad, Warangal, Vijayawada, Visakhapatnam, Tirupati, Kochi, Thiruvananthapuram, Kozhikode, Goa, Mumbai, Pune, Nagpur, Ahmedabad, Delhi NCR, Kolkata, Bhubaneswar, Guwahati, Lucknow, Patna, Ranchi and Raipur. For patients travelling a long distance, send the HRCT and pulmonary function reports on WhatsApp first. Most ILD evaluations can be compressed into a single visit or two consecutive days when the imaging has been reviewed in advance. Kempegowda International Airport is about 45 km from the hospital.

International patients

The clinic sees ILD patients from Bangladesh, Nepal, Sri Lanka, the Maldives and Bhutan, from Oman, the UAE, Saudi Arabia, Iraq, Yemen, Kuwait, Bahrain and Qatar, from Kenya, Tanzania, Ethiopia, Uganda, Rwanda, Sudan, Nigeria and Ghana, and from Myanmar, Indonesia and Malaysia. The usual sequence is a remote review of your scans and reports over WhatsApp, a written clinical opinion that can support a medical visa application, a three to four day evaluation visit, and then video follow-up from home. Care in India is delivered at a fraction of Western pricing at centres doing high volumes of this work.

Related reading

References

The clinical statements on this page are drawn from the peer-reviewed literature and international guidelines listed below. Each link opens the source on PubMed.

  1. Idiopathic Pulmonary Fibrosis (an Update) and Progressive Pulmonary Fibrosis in Adults: An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline. American Journal of Respiratory and Critical Care Medicine, 2022. PMID 35486072.
  2. Nintedanib in Progressive Fibrosing Interstitial Lung Diseases. New England Journal of Medicine, 2019. PMID 31566307.
  3. Diagnostic accuracy of transbronchial lung cryobiopsy for interstitial lung disease diagnosis (COLDICE). Lancet Respiratory Medicine, 2020. PMID 31578168.
  4. Predicting survival across chronic interstitial lung disease: the ILD-GAP model. Chest, 2014. PMID 24114524.
  5. Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation. Journal of Heart and Lung Transplantation, 2021. PMID 34419372.

Frequently asked questions

Which doctor treats interstitial lung disease in Bangalore?
Interstitial lung disease is managed by a pulmonologist with a specific ILD interest, because the diagnosis depends on reading HRCT patterns alongside serology and occupational history. Dr. Manjunath M Negigoudara runs an advanced lung failure and ILD clinic at KIMS Hospital, Electronic City, Bengaluru. He is a transplant pulmonologist, which matters in ILD because the same clinic that diagnoses you can also tell you honestly whether and when transplant enters the conversation. Call +91 79937 41199, Monday to Saturday, 9 AM to 5 PM.
Is interstitial lung disease the same as pulmonary fibrosis?
Not quite. Interstitial lung disease is the umbrella term for more than 200 conditions that inflame or scar the tissue between the air sacs. Pulmonary fibrosis is what it is called when that process has produced permanent scarring. Some ILDs are inflammatory and can improve substantially with treatment. Others are fibrotic and progressive. Separating the two is the entire point of a proper ILD workup, because the treatments pull in opposite directions. See the pulmonary fibrosis and IPF page for the fibrotic end of the spectrum.
What tests are needed to diagnose ILD?
A high-resolution CT of the chest is the single most important test, and it must be a true HRCT protocol with thin slices and prone and expiratory images, not a routine CT chest. Alongside it: complete pulmonary function testing with DLCO, a six-minute walk test with oximetry, an autoimmune panel, precipitin testing where hypersensitivity pneumonitis is suspected, and a careful occupational and exposure history. A bronchoscopy with lavage, or in selected cases a cryobiopsy, is added when the pattern is not definitive.
Can interstitial lung disease be cured?
Inflammatory ILDs such as hypersensitivity pneumonitis caught early, sarcoidosis, and connective-tissue-disease ILD can improve a great deal and sometimes resolve, particularly once the trigger is removed. Fibrotic ILDs including IPF cannot currently be reversed. For those, the realistic goal is to slow progression with antifibrotic therapy, treat the things that make breathlessness worse, and keep the option of transplant open while the patient is still well enough to take it.
What is a multidisciplinary ILD discussion and why does it matter?
International guidelines recommend that a difficult ILD diagnosis is settled by a pulmonologist, a thoracic radiologist and a pathologist reviewing the case together rather than in sequence. This changes the working diagnosis in a substantial share of cases, which matters because antifibrotics and immunosuppression are close to opposites. At KIMS Electronic City this discussion happens on site, with the transplant team in the same building.
When does interstitial lung disease need a lung transplant?
The referral trigger is earlier than most patients expect. International consensus is to refer at the point of a confirmed fibrotic ILD diagnosis with any evidence of progression, not to wait for oxygen dependence. Practical signals include a forced vital capacity falling by 10 percent or more over six months, a DLCO below 40 percent predicted, any need for supplemental oxygen, or a hospitalisation for a flare. Read who needs a lung transplant for the full criteria.
I have an HRCT report that says UIP pattern. What does that mean?
A usual interstitial pneumonia pattern describes scarring that is worst at the bases and edges of the lungs, with honeycombing and traction bronchiectasis. On its own it does not name a disease. It is seen in idiopathic pulmonary fibrosis, in rheumatoid and other connective tissue disease, in chronic hypersensitivity pneumonitis and in asbestos exposure. What the report tells you is the pattern. What the consultation establishes is the cause, and the cause decides the treatment.
Can I send my scans before travelling to Bangalore?
Yes, and for ILD it is strongly advised. WhatsApp the HRCT images, the pulmonary function report with DLCO, recent blood work and your current medication list to +91 88670 59997 before you travel. Dr. Manjunath reviews them ahead of the visit, which usually avoids repeating tests you have already paid for and means the consultation starts at the decision rather than at the beginning. A formal written second opinion can be issued without an in-person visit.

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