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Table 3. Lung Toxicities
3.1 Pneumonitis
Workup/Evaluation:
• Should include the following : Pulse oximetry, CT chest preferably with contrast if
concerned for other etiologies such as pulmonary embolus.
• For G2 or higher, may include the following infectious workup: nasal swab, sputum
culture and sensitivity, blood culture and sensitivity, urine culture and sensitivity.
• COVID-19 evaluation — per institutional guidelines where relevant.
Grading Management
G1: Asymptomatic; confined
to one lobe of the lung or less
than 25% of lung parenchyma;
clinical or diagnostic
observations only
• Hold ICPi or proceed with close monitoring.
• Monitor patients weekly with history and physical
examination, pulse oximetry; may also offer chest
imaging (CXR, CT) if uncertain diagnosis and/or
to follow progress.
• Repeat chest imaging in 3–4 weeks or sooner if
patient becomes symptomatic.
• In patients who have had baseline testing, may offer
a repeat spirometry/diffusing capacity of lung for
carbon monoxide (DLCO) in 3–4 weeks.
• May resume ICPi with radiographic evidence
of improvement or resolution if held. If no
improvement, should treat as G2.
G2: Symptomatic; Involves
more than one lobe of the
lung or 25–50% of lung
parenchyma; medical
intervention indicated;
limiting instrumental ADL
• Hold ICPi until clinical improvement to ≤G1.
• Prednisone 1–2 mg/kg/day and taper over 4–6
weeks.
• Consider bronchoscopy with bronchoalveolar
lavage (BAL) +/- transbronchial biopsy.
• Consider empiric antibiotics if infection remains in
the differential diagnosis after workup.
• Monitor at least once per week with history and
physical examination, pulse oximetry, consider
radiological imaging ; if no clinical improvement
after 48–72 hours of prednisone, treat as Grade 3.
• Pulmonary and infectious disease consults if
necessary.
