Online Health Chat with Daniel Culver, DO, and Leslie Tolle, MD
October 1, 2014
Idiopathic pulmonary fibrosis (IPF) is a progressive disease isolated to the lungs. It is a type of interstitial lung disease, which is a group of 200 diseases with similar symptoms but different causes. In IPF, lung tissue becomes scarred. The scarring typically starts at the edges of the lungs and progresses toward the center of the lungs, making it more difficult for a person to breathe. Unfortunately, IPF is a disabling disease that can be fatal. Close to 130,000 Americans are currently affected by the disease, and more than 50 percent of those affected lose their lives within four years of diagnosis, with almost all cases eventually ending in death.
The cause of IPF is unknown. In some patients, the disease is genetic (you inherited the disease from your parents). Environmental factors (particularly exposure to certain types of dusts) may also play a role. What is known is that IPF changes the lung's ability to function normally. Typically, mild scarring of the lung tissue occurs first, but over months to years, the normal lung tissue is replaced by more heavily scarred lung tissue, which makes it difficult to breathe and deliver needed oxygen to the body.
Interstitial lung disease (ILD) is a group of conditions that cause scarring to the lungs. ILDs include forms of pulmonary fibrosis and interstitial pneumonia, as well as ILDs associated with connective tissue diseases, tobacco use, and exposure to environmental and occupational toxins.
Since ILD is not a single disease but a group of more than 200 different pulmonary disorders, it can be confusing to understand exactly what you are dealing with, how a diagnosis is made and who needs to be involved.
Although scarring is mostly irreversible, medications can help. Relief of symptoms can be achieved through pulmonary treatments and oxygen therapy. In select cases, surgery and lung transplants may be options. The goals of therapy are to preserve current lung function and slow disease progression.
About the Speakers
Daniel Culver, DO, is a Staff Physician in the Department of Pulmonary, Allergy and Critical Care Medicine at Cleveland Clinic's main campus. His clinical interests include sarcoidosis, pulmonary alveolar proteinosis, critical care and interstitial lung diseases. Dr. Culver earned his Doctor of Osteopathic Medicine degree at the Ohio University College of Osteopathic Medicine in Athens, Ohio. After medical school, he did an osteopathic rotating internship at Meridia South Pointe Hospital. He completed his residency in internal medicine and a fellowship in pulmonary and critical care medicine at Cleveland Clinic. Dr. Culver is a fellow of the American College of Chest Physicians and a member of several professional associations, including the American Thoracic Society, the American Osteopathic Association and the World Association of Sarcoidosis.
Leslie Tolle, MD, is a Staff Physician in the Department of Pulmonary and Critical Care Medicine at Cleveland Clinic’s main campus. His clinical interests include critical care, interstitial lung disease and general pulmonary medicine. Dr. Tolle earned his medical degree at Wayne State University School of Medicine in Michigan. He completed his residency in internal medicine and a fellowship in pulmonary and critical care medicine at University of Michigan Medical School in Ann Arbor. Dr. Tolle currently serves as an assistant professor for the Lerner College of Medicine of Case Western Reserve University.
Let’s Chat About Interstitial Lung Disease & Pulmonary Fibrosis
Symptoms and Diagnosis
bkjenks: What are the indications that your condition may be worsening?
Leslie_Tolle,_MD: In general, we use symptom assessment and breathing tests to assess whether or not a patient's disease is progressing. We evaluate symptoms such as worsening shortness of breath, being able to do less activity or increased cough. Periodically, your physician may check breathing tests to see if the values are changing, more specifically, getting worse. Less commonly but on occasion, your doctor may do repeat imaging such as a chest x-ray or CT scan to see if your disease is worsening.
Janred: Do you have any suggestions for a persistent cough associated with my IPF?
Daniel_Culver,_DO: Cough is very common in IPF and can be the most debilitating feature of the disease. It has a major impact on the quality of life, although I am sure you are already well aware of that. Sometimes, it is related to other issues such as silent esophageal reflux or perennial rhinitis. For symptomatic control of the cough, we usually try medications like Tessalon Perles or opiates like hydrocodone. There is one study showing a benefit for thalidomide, but it is not widely used due to cost and tolerability.
MCope: How do you know what stage of IPF you are in when newly diagnosed?
Daniel_Culver,_DO: There is not a widely accepted staging system for IPF. Sometimes, we describe breathing tests using terms like mild or severe, but those are individual tests not meant to define the whole picture for a patient. Some of the aspects that lead us to consider a case to be more severe include: low vital capacity, desaturation during exertion, more severe scarring on chest CT and progressive declines of 5 percent to 10 percent of forced vital capacity or DLCO.
Jsweetie: I was diagnosed with IPF a couple of years ago in 2012. In 2003 my pulmonologist indicated that I could have the start of very early ILD. My FVC is over 100 percent and my DLCO is approx. 56. My doctor says I am not progressing yet. Would pirfenidone be beneficial to someone like me who is not progressing yet? Thank you.
Leslie_Tolle,_MD: First of all, you need to make sure that your diagnosis of IPF is in fact the correct diagnosis. This is often made by lung biopsy, CT scan or through a multidisciplinary team approach based on an overall clinical scenario. Not all ILDs are IPF, and pirfenidone has only been shown to slow progression of IPF. Without knowing all of the values on your breathing tests, it is difficult to say whether or not you would benefit. In general, pirfenidone seemed to work best in patients with mild to moderate disease.
Measuring Lung Function
LAS1930: I have interstitial lung disease from lupus. Pulmonary functions are good except for DLCO. Please expand on this type of issue.
Leslie_Tolle,_MD: DLCO is a measure of how well your lungs transport oxygen from the air into your bloodstream. A low measure means that your lungs have trouble with this process. Occasionally, some patients have normal lung function values except for DLCO. In this scenario, DLCO can be used as a marker of disease severity and progression. If your DLCO drops too much, you may require supplemental oxygen and should be tested with a hall walk test.
Layne3820: I have PF and am not on oxygen. I notice that when flying, my oxygen saturation goes down, especially if I sleep. Is this something I should be concerned about?
Leslie_Tolle,_MD: It is not uncommon for patients with lung disease to drop their oxygen saturations when flying. This is due to the fact that planes are pressurized to approximately 8000 feet, which means there is less atmosphere in the plane compared to ground level. This translates to less oxygen in the air that passengers breathe. Similarly, when sleeping, people tend to slow their breathing rate, which is a natural and normal phenomenon. When your respiratory rate drops and you have abnormal lungs, your oxygen levels may drop as well. You can imagine that this is compounded when you are flying and there is less oxygen to breathe. You can be tested to see if you need supplemental oxygen when you fly as well as when you are sleeping. In general, we recommend that patients use supplemental oxygen if their saturations drop below 88 percent.
Layne3820: I was diagnosed with PF in summer of 2013. My last PFT results show DLCO of 51. I am not on any oxygen and regularly exercise, which I have done most of my adult life. Mostly, I do water aerobics and don't check my oximetry; however, while walking on the treadmill, in the beginning my sats drop to 90 percent or so, but as I continue walking, they improve to the mid-90s. Should I be monitoring my oxygen saturation during water aerobics?
Leslie_Tolle,_MD: It is probably not necessary to monitor your oxygen levels in the pool as long as you feel like you are doing a similar amount of exercise as when you're on the treadmill. I generally tell patients to intermittently check their oxygen (both at rest and with activity) rather than doing so constantly or very frequently. If your oxygen levels are OK, which they are based on the information you provided, I wouldn't focus too much on how they are in the water.
LAS1930: My DLCO is at 52 percent. At what number is oxygen considered? I take prednisone daily to keep lupus in check, and that has been working very well.
Daniel_Culver,_DO: Good question. The DLCO broadly measures how well your lungs transfer oxygen from the air into your bloodstream. We do not use the DLCO to decide on supplemental oxygen, but at 52 percent predicted, you may be getting close to needing it with exertion. Usually, we prescribe oxygen when the saturation falls below 88 percent to 90 percent. However, we really do not understand much about how effective supplemental oxygen is for survival or quality of life. In that regard, I would encourage you and others on this webchat to consider participating in an important study being conducted by Dr. Jeffrey Swigris that is assessing the effects of oxygen therapy on ILD. To participate, you should not be using oxygen right now but have a good chance of needing it in the future. To learn more, go to www.pfresearch.org or call 1.855.609.0010.
Transplant as Treatment
boyscout2726: I am an IPF sufferer. My FVC is still about 65 percent (I don't need oxygen yet), but it has been dropping at about 10 percent per year. I am 63 years old. It looks like by the time I might be a candidate for a lung transplant, I could be considered too old. Could you describe the process and scoring system for lung transplant priorities? For people in their late sixties, is transplant highly improbable?
Daniel_Culver,_DO: You correctly point out that it is not just the severity but the rate of progression that must be evaluated. A 10 percent deterioration is a bad prognostic sign and increases your chance of death. So, I agree with an earlier evaluation for a lung transplant. If you continue to progress, then perhaps it can be done sooner. It is a misconception that people over 65 years old cannot receive a lung transplant. Some centers use a strict cut-off but other centers, including Cleveland Clinic, look at the sum total of other illnesses and biologic rather than chronologic age. We have transplanted patients over 70 in the past. The scoring system for transplants is designed to prioritize the severity of disease rather than time on the waiting list.
sweet william: I've been recently diagnosed with IPF, which began to show symptoms about four years ago and was diagnosed at that time as COPD in the form of chronic bronchitis. I walk about 1/4 mile in the six-minute walk test. While performing modest work such as mowing the lawn with a self-propelled mower, I last about three to four minutes before serious shortness of breath begins. Infrequently, during modest exertion, I have experienced tingling sensation and collapsed while being totally conscious throughout and able to stand in a few seconds. I have mild hypertension, which is under control with medication. Because IPF is incurable, I am thinking a lung transplant is the best option, especially since I am otherwise very healthy. Does this make sense? What tests are necessary to determine if I am a good candidate for this now rather than later? How available is a suitable lung for someone who has no other unusual conditions?
Daniel_Culver,_DO: The combination of IPF and COPD, known as combined pulmonary fibrosis and emphysema, is particularly deadly. I think that lung transplant could be a reasonable option when the illness starts to cause severe respiratory limitations. If you are not yet using oxygen, you are probably outside of the transplant window right now, but I would suggest an evaluation in a transplant center to discuss the timing and pace of work-up. The passing-out spell might be related to your lungs, but it would be uncommon and I think that you should see your doctor to look for other, more likely causes of passing out.
eileena: What is the connection between pulmonary fibrosis (PF) and connective tissue disease?
Leslie_Tolle,_MD: Many autoimmune conditions and connective tissue disorders are associated with scarring lung conditions such as pulmonary fibrosis. The diagnosis is often quite difficult to make. We believe that the immune system has gone haywire and attacks the lungs, similar to other systems of the body. The symptoms of lung disease can precede the other physical finding of connective tissue disorders, which also complicates the diagnosis. The lung manifestation of these conditions tends to respond somewhat to treatment of the underlying connective tissue disorder, usually with immune suppressing medications. We recommend that patients be evaluated in a center that is comfortable taking care of these highly specialized diseases, preferably centers where the rheumatologists and pulmonologists work closely together.
Francis: I was diagnosed in 2012 with polymyositis/dermatomyositis and ILD. I have improved a lot from 34 percent up now at 78 percent. I am taking 2500 mg of Cellcept® daily. I still feel short of breathe some days. Do you think this is normal or will improve? My overall condition has, but recently I was found to have some heart involvement: mitral valve regurgitation, cardiomyopathy. What are your thoughts or suggestions?
Daniel_Culver,_DO: Polymyositis/dermatomyositis commonly causes ILD, which can be the first manifestation of the inflammatory disease. I am glad to hear that the Cellcept has been so effective for you. I suppose that whether there is more room for improvement would depend on how your CT scan looks, but your dramatic increase in vital capacity is certainly greater than the norm. Heart involvement is also quite common in PM/DM and it is associated with a worse prognosis. I think it is important to consider whether the heart disease is definitely due to PM/DM and if there is still active inflammation there. If there is, there are a variety of other medical approaches that can be used. My bias is to be aggressive in a case like this.
Pat G: I have PAH and lung disease with probable scleroderma spectrum. I am on oxygen 2-4 liters, Cpap, opsumit. I have tried Cellcept with no improvement in ground glass on high resolution CT scan. Do you have any suggestions?
Daniel_Culver,_DO: The first step is to be sure that the ground glass infiltrates are due to active inflammation and not scar or mosaic perfusion from the pulmonary hypertension. If the Cellcept has been ineffective for what is considered to be active inflammation, I think that many physicians would consider using cyclophosphamide or rituximab next. Rituximab is still relatively experimental.
JoDott: I had a bronchoscopy 1 1/2 years ago. The results were that I had sarcoidosis. I was put on 60 mg prednisone, then shortly after that it was changed to 40 mg. Five months after being diagnosed and not improving with prednisone and having all kinds of side effects from the prednisone, my pulmonologist put me in the hospital and took me off all my drugs and released me five months later. I never took prednisone again but am still very short of breath and tired. With no improvement, I had a VATS biopsy on my right lung. My doctor said it was one of the prettiest lungs he'd ever seen. The results of the biopsy showed a very small amount of emphysema, no sarcoidosis. Why wouldn't any sarcoidosis show up in the lung biopsy? Does it go into remission and shows nothing when in remission?
Daniel_Culver,_DO: Sarcoidosis resolves in approximately 50 percent to 67 percent of cases. I think that if you still have sarcoidosis, it should have been seen on the lung biopsy. So, I think it is very unlikely that any respiratory symptoms that you have are due to persistent sarcoidosis. It is possible that the sarcoidosis could be persisting in your lymph nodes but that almost never causes any clinical problems. So, I do not think it needs to be treated in any event.
boyscout2726: I have IPF diagnosed by open lung biopsy in June 2014. If the two new drugs, pirfenidone and nintedanib, are approved for prescription in the US, which seems possible for 2015, the projected price of more than $60,000 per year for either drug is frightening, especially if the insurance companies balk and say it is still experimental, which also seems possible. It looks like this is the first time there are drugs at hand that are likely to slow the advance of the disease. But could it still be out of reach of most of us because of the enormous price tag? Can you shed any light on what the reality will be? Also, is it still possible to get into trials on these drugs and how? My doctor doesn't seem to know much about it.
Leslie_Tolle,_MD: We expect that both of these medications will be approved by the FDA in the next few months. This is based on published clinical data and studies. If approved by the FDA, they would not be considered experimental medications, and we believe that they would be covered by most insurance companies to some degree. There are likely to be some criteria that need to be met in order for the companies to pay for the medications, such as method of diagnosis and breathing test values. We do not know the exact details of this at this time.
bkjenks: I understand there are a couple of drugs in the pipeline for treatment of ILD. What you tell us about Esbriet® from Intermune pharmaceutical, which has been approved in Canada and Europe, and also nintedanib from Boeringer Ingelheim? Are pirfenidone and Esbriet the same drug? As the ILD worsens, is the coughing more frequent and severe? Thank you.
Leslie_Tolle,_MD: There are a few new therapies that should be approved for IPF in the next few months. These treatments are specific for IPF rather than other types of interstitial lung diseases. Pirfenidone, whose trade name is Esbriet, is already approved in Europe and Canada. It is taken multiple times daily and has been shown to slow the progression of IPF. Likewise, nintedanib has been shown to slow the progression of IPF and should be approved for use in these patients. It is a completely novel medication. These medications have not been compared head-to-head so we do not know which works better, nor do we know if taking these medications together is better than taking either alone.
Belvedere74: Do you believe the drug pirfenidone can help stop the progression of scarring of the lungs? Do you think it will be passed by the FDA soon?
Leslie_Tolle,_MD: As mentioned in earlier questions, we expect pirfenidone to be approved in the next few months. It has been shown to slow progression of IPF in patients with mild to moderate disease.
Bothered by BOOP
Gene1942: I have been diagnosed with BOOP (bronchiolitis obliterans with organizing pneumonia). After a year of corticosteroids at various levels, I still have symptoms: cough, shortness of breath, fatigue, etc. I am scheduled for a CT scan on October 25 and then will meet with my pulmonologist on the 29th. Where should we go from here? My pulmonologist is talking about a light dosage of chemotherapy next (MTX). I am reluctant. What do you think?
Daniel_Culver,_DO: BOOP, which is also called cryptogenic organizing pneumonia, when it is not associated with a particular trigger, usually responds to relatively higher doses of steroids. In a minority of patients, other medications are needed to control it. Azathioprine has the longest track record as a second line agent, but varieties of other options have been reported to be successful. These include methotrexate, cyclophosphamide, mycophenolate and several newer medications. If your CT scan suggests active persistent inflammation and not just scar, then I fully agree with the idea of moving onto a second agent. It is my belief that the risks for steroids are probably much more than the risks of most of the other medications.
Karenl213: My husband had a lung biopsy a month ago. They found organizing pneumonia. Before the biopsy they did a bronchoscopy. They had to switch from a flexible to a rigid because they suctioned out a large amount of bronchial casts. The thoracic surgeon said she had never seen anything like it. In your experience, have you seen bronchial casts due to organizing pneumonia or bronchial casts causing organizing pneumonia? What is the best treatment for bronchial casts or organizing pneumonia? Prednisone 40 mgs for two months did not resolve either problem.
Daniel_Culver,_DO: Bronchial casts can be seen in organizing pneumonia, although they can also occur in other syndromes so it is important to review the biopsy slides carefully to make sure the diagnosis is correct. The prednisone dose you mentioned may be too low to get a good handle on the disease. I recognize that taking high doses of steroids for a very long time is really hard to do, so I might ask your physician to try one of the second line agents mentioned in my answer to Gene1942. Bronchopulmonary hygiene to help remove the casts should also be used.
Gene1942: What is the typical prognosis for a patient with BOOP? I was diagnosed about a year ago. High dosages of prednisone worked to alleviate symptoms, but when the dosage was reduced to safer levels, the symptoms returned. At present, I am taking 5 milligrams of prednisone daily (since early June) and I am due for a CT scan and review of my situation at the end of October. My pulmonologist has discussed putting me on MTX depending on the results of the CT scan. Are there other viable options?
Leslie_Tolle,_MD: BOOP, also known as cryptogenic organizing pneumonia (COP) has a variable course. The diagnosis is often delayed as the symptoms, exam and imaging findings are similar to pneumonia. The initial therapy of choice is steroids such as prednisone. The initial course is usually quite long, as long as six months or more. If stopped too quickly, BOOP can recur and require another prolonged course of steroids. There is a subset of patients who develop a more chronic course of BOOP and require long-term immunosuppression. I prefer to use azathioprine or mycophenolate as my therapies of choice for chronic BOOP. There is minimal medical literature about how to treat these patients best, so there is no guidebook of which medication to choose. In general, we try to wean patients off of prednisone, as the long-term side effects can be quite severe. That being said, 5 mg daily is a small dose and may not cause any long-term problems if you can manage your symptoms with that dose.
Perils of Prednisone
LAS1930: What are "the long-term side effects" from prednisoneLeslie_Tolle,_MD: Prednisone has a number of both short- and long-term side effects. Short term it can cause jitteriness, high blood pressure, elevated blood glucose and decreased sleep. Long term it can cause diabetes, worsened high blood pressures, acid reflux, fluid retention, weight gain, osteoporosis, poor wound healing, thinning of the skin and suppression of your adrenal gland.
medlaw: 1. I was just diagnosed last month. What kind of team approach does the Clinic take in caring for those of us with IPF? Is it available only at the downtown campus?
2. I understand the new antibiotic pirfenidone was classified as an orphan drug on Aug. 5th and that trials in Europe were successful in inhibiting progression of IPF. When will it be available to me and others for compassionate use? What kind of side effects has been documented? Thank you!
Daniel_Culver,_DO: At Cleveland Clinic, we have a comprehensive approach that includes expert ILD physicians who will review the diagnosis for accuracy and coordinate with dedicated thoracic radiologists and pathologists. We also work closely with clinical research trials, early access programs for new medications and our large lung transplant program. ILD experts see patients once weekly at several of our satellite facilities including the Avon, Twinsburg, Willoughby and Strongsville facilities in Ohio. Dr. Jose Ramirez in Weston, Florida, also specializes in ILD.
I would not classify the mechanism of action for pirfenidone as an antibiotic, but rather an anti-fibrotic medication. A number of centers, including ours, are participating in the early access program, which would allow you to start pirfenidone immediately. The FDA will make a decision about approval right around Thanksgiving, and I anticipate that it will be available through specialty pharmacies very soon thereafter. The main side effects are GI upset and sensitivity to the sun. Sometimes, liver function tests may become abnormal but this is generally reversible.
Justine46: I was recently diagnosed with PF, by CXR. The cause is unknown at this time, but I do have sleep apnea (I am on bipap) and GERD. My recent PFT's showed 70 percent lung functions and DLCO of 20.45 percent, no oxygen needed. I am on the treadmill three times per week up to 1.1 miles. A recent echo showed my PAP at 26 (previously in 2010, was 24), normal atrium, new: mild TR, mild MVR, slight thickening of my LV wall. My pulmonary doctor says I don't need an HRCT or bloodwork at this time and was hinting that I will eventually be “too old” for a lung transplant. I feel I need to see a specialist down in Los Angeles (out of my pocket). I'm 62. How to proceed?
Leslie_Tolle,_MD: My general recommendation is that anyone diagnosed with pulmonary fibrosis should be seen at least once in a center that specializes in interstitial lung diseases (ILD). This helps to ensure that the diagnosis is made correctly and that patients are offered the correct therapies that are available. These centers are experienced with how to manage patients such as yourself and are also are more comfortable with determining when to refer someone to lung transplantation. Oftentimes, the ILD centers are the same as the transplant centers.
Whether or not to order a CT or bloodwork is individualized based on the patient’s history and patient/physician preferences. It is difficult to say whether or not another scan is necessary at this time.
jackpat2: What is the significance of Vitamin K1 in the arrest of pulmonary fibrosis?
It seems to be used in Europe.
Leslie_Tolle,_MD: I am unaware of any trials involving Vitamin K and pulmonary fibrosis. There is some data with vitamin K and cystic fibrosis, which is an entirely different disease process. An anti-vitamin K medication, warfarin, was tried in IPF patients and was found to lead to worse outcomes compared to patients who received placebo.
Moderator: I’m afraid that’s all the time we have today for questions. Thank you everyone for participating today; and thank you, Daniel Culver, DO and Leslie Tolle, MD, for your insightful answers to our questions about ILD and Pulmonary Fibrosis.
Daniel_Culver,_DO: Thank you all for attending today. I apologize that we could not get to all of the questions but I hope this gave you some useful information. This is an extremely exciting time for IPF with two new drugs likely to be approved in November and several other promising medications well into the pipeline.
Leslie_Tolle,_MD: Thank you everyone for attending this session. We try to answer as many questions as possible but are unable to get to them all. We are planning on having another session in the near future and, hopefully, we can answer more of your questions at that time. I echo Dr. Culver's sentiment about the exciting time in IPF with the new therapies that should be available. Hopefully, we can positively impact this disease.
To make an appointment with Dr. Culver, Dr. Tolle or any of the other specialists in Cleveland Clinic’s Respiratory Institute, please call 216.444.8994, toll-free at 800.223.2273 (extension 8994) or visit us at clevelandclinic.org/interstitiallungdisease for more information.
For More Information
On Cleveland Clinic
At Cleveland Clinic, our Sarcoidosis and Interstitial Lung Disease Program is experienced in providing the most advanced diagnostic testing and treatment options for patients with all types of ILD, including rare disorders. We have designed our services so that all of the specialists you need—including pulmonologists, rheumatologists, thoracic radiologists, thoracic surgeons, pulmonary pathologists, and genetics and transplant experts—work together to provide the most accurate diagnosis and appropriate treatment plan. Whenever possible, our multidisciplinary team utilizes the least invasive procedures and steroid-minimizing or steroid-free treatments.
On Interstitial Lung Disease
Interstitial Lung Disease Treatment Guide
Please use this guide as a resource to learn about ILD and Pulmonary Fibrosis and your treatment options. As a patient, you have the right to ask questions and seek a second opinion.
For additional information about clinical trials: ClinicalTrials.gov.
STX-100 in Patients with Idiopathic Pulmonary Fibrosis
A study of a humanized monoclonal antibody targeting integrin αvβ6 in IPF patients. For more information, please contact Tani Martin, RN, at 216.444.9975
Letrozole in Pulmonary Lymphangioleiomyomatosis with or Without Measurable Tumors in Lymph Nodes (TRAIL).
In postmenopausal women, estrogens are mainly derived from the action of the aromatase enzyme. Therefore, estrogen suppression might be expected to prevent or delay progression of LAM in this population. Letrozole is an aromatase inhibitor that competitively binds to a subunit of the enzyme, thereby reducing estrogen biosynthesis. For more information, please contact Tani Martin, RN, at 216.444.9975.
For more information or to make an appointment, please contact our ILD Clinic Coordinator Howard Christie at 216.444.8994.
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