ESR Essentials: imaging in fibrotic lung diseases—practice recommendations by the European Society of Thoracic Imaging

Category	Detail
Condition	Fibrotic Lung Diseases (FLDs) including Idiopathic Pulmonary Fibrosis (IPF) and Progressive Pulmonary Fibrosis (PPF)
Key Mechanisms	Pulmonary fibrosis characterized by lung parenchyma replacement with fibrotic tissue, progressive behavior, and reduced survival
Target Population	Patients with respiratory symptoms suspicious for ILD, high-risk groups including older males with smoking history for IPF, younger females for CTD-ILD, and first-degree relatives of familial FLD patients
Care Setting	Radiology departments and interdisciplinary clinical settings for diagnosis and management of FLDs

High-resolution chest CT with slice thickness ≤ 1.5 mm and high-resolution reconstruction algorithm is the recommended imaging modality for detecting and classifying pulmonary fibrosis.
Non-invasive diagnosis of FLDs can often be achieved by integrating CT patterns with clinical and laboratory data; biopsy is reserved for indeterminate cases or when it impacts therapy.
Early diagnosis and monitoring of disease progression are critical for timely initiation of antifibrotic therapy in IPF and progressive non-IPF fibrotic lung diseases.

Perform noncontrast volumetric chest CT with high-resolution technique in supine position at deep inspiration with arms above head.
Use CT slice thickness ≤ 1.5 mm and high-resolution reconstruction algorithms for optimal image quality.
Interpret CT patterns in conjunction with clinical and laboratory data to establish diagnosis; reserve biopsy for unclear cases or therapeutic decision-making.
Consider expiratory CT scans selectively to assess small airway involvement, especially at initial assessment.
Chest X-ray is limited but may be used as first-line imaging; findings suggestive of fibrosis should prompt CT.

Identify patients with progressive fibrotic phenotypes early to initiate antifibrotic treatments.
Use interdisciplinary discussion integrating radiological and histological data for diagnosis and management decisions.
Screen first-degree relatives in suspected familial FLD cases with CT.

Compare current CT scans with previous examinations carefully to assess disease progression.
Add expiratory CT scans during follow-up based on symptoms, pulmonary function tests, and inspiratory CT findings.
Quantitative CT methods show promise for monitoring but are not yet routine.

Avoid routine paired inspiratory/expiratory CT scans to limit radiation exposure.
Use dose reduction techniques and keep effective dose below 3 mSv; ultra-low dose protocols are not routinely recommended.
Be aware of radiation risks and optimize CT protocols accordingly.

Patients diagnosed with IPF or non-IPF progressive fibrotic lung diseases

Early identification of progressive fibrotic phenotype is essential to start antifibrotic therapy which may improve prognosis

Use high-resolution CT with appropriate technical parameters for accurate detection and classification of FLDs.
Integrate imaging findings with clinical and laboratory data for non-invasive diagnosis whenever possible.
Engage in interdisciplinary discussions for diagnosis and management decisions.
Screen high-risk populations including familial cases and patients with connective tissue diseases.
Optimize CT protocols to balance image quality and radiation dose.

Clinical Scorecard: Key Insights on Imaging for Fibrotic Lung Disorders: Guidelines from the European Society of Thoracic Imaging