Jessica Glennie, MSN, APRN

Interstitial Lung Abnormalities: Recognition, Risk Stratification, and When to Act

An interstitial lung abnormality (ILA) discovered incidentally on chest CT can be a difficult finding to communicate: the patient feels well, nothing requires immediate treatment, and yet the discovery carries real prognostic weight. Between 20% and 60% of ILAs progress to interstitial lung disease (ILD) over 2 to 5 years — making early recognition and structured follow-up important, and making the absence of a standardized management framework a genuine clinical problem.1 That framework arrived in May 2025, when the American Thoracic Society published its first formal clinical practice guidelines on ILA evaluation and management.2

Jessica Glennie, MSN, APRN, of the Cleveland Clinic ILD Center in Cleveland, Ohio, addressed ILAs in her session at APAP 2026, calling the findings "almost like the origin story of interstitial lung disease."1 She described the new ATS guidelines as a meaningful improvement over prior Fleischner Society guidance — providing more granular direction on monitoring intervals, biomarker testing, and which patient subgroups warrant closer surveillance.

One of the more clinically consequential changes in the 2025 ATS guidelines is the reclassification of high-risk populations, including patients with connective tissue diseases such as rheumatoid arthritis and scleroderma. Previously, these patients were excluded from ILA classification because their findings were considered attributable to known underlying disease. The new guidelines permit an ILA designation in these patients, with the recognition that they carry elevated progression risk and require more intensive monitoring — a change Glennie called important for guiding follow-up in patients she routinely sees in the ILD clinic.2

For APPs encountering an ILA for the first time on a scan, she emphasized risk factor management as a unifying priority regardless of ILA subtype: smoking cessation, vaccination to reduce the risk of pneumonia and respiratory infections that can accelerate progression, and optimization of any underlying rheumatologic disease in coordination with rheumatology. Monitoring frequency — CT scans and pulmonary function testing — should be guided by whether the ILA has fibrotic features and other risk factors for progression per the ATS framework.2

Counseling the patient who feels well and is surprised by the finding requires calibration. Glennie described her approach as honest about the range of outcomes — many ILAs do not progress — while being clear that some do, and that the goal of surveillance is to catch progression early and intervene before function declines. "You sit down with that patient and explain what we find, talk about those percentages of patients that can progress, and then make sure that any risk factors they have are managed," she said. "It's usually a good discussion of preventative medicine."

Integration of the new guidelines into practice is still lagging, she acknowledged — a predictable dynamic for guidance released less than a year ago — but she anticipates their adoption will accelerate as APPs and other clinicians become more familiar with the updated framework.

Glennie J. ILAs. Presented at: APAPP National Conference 2026, June 18-20; Las Vegas, NV.

Raghu G, Remy-Jardin M, Richeldi L, et al. Approach to the evaluation and management of interstitial lung abnormalities: an official ATS clinical practice guideline. 

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Jessica Glennie, MSN, APRN, says the first formal ATS clinical guidelines on interstitial lung abnormalities are filling a real gap — but integration into practice is still catching up.


New Antifibrotics Are Changing the Treatment Calculus in ILD

 (ILD) has been largely static since 2014, when nintedanib and pirfenidone became the first approved agents for idiopathic pulmonary fibrosis (IPF). Effective at slowing fibrosis progression, both drugs carried a tolerability burden that shaped clinical decision-making in a particular way: in patients who were clinically stable or early in their disease course, many providers opted to wait before initiating therapy, weighing the risk of side effects against the uncertain benefit in a patient who felt well. 

That calculus is now shifting, according to Jessica Glennie, MSN, APRN, of the Cleveland Clinic ILD Center in Cleveland, Ohio, who presented as part of the multidisciplinary ILD bootcamp series at the 

Association of Pulmonary Advanced Practice Providers (APAPP) National Conference, held June 28-20 in Colorado Springs

The catalyst is nerandomilast (Jascayd), a first-in-class preferential phosphodiesterase 4B (PDE4B) inhibitor approved by the United States Food and Drug Administration (US FDA) in October 2025 for IPF and subsequently for progressive pulmonary fibrosis (PPF) — the first new antifibrotic mechanism in more than a decade.

 In the FIBRONEER phase 3 trials, nerandomilast significantly reduced the annual rate of forced vital capacity decline versus placebo, with a tolerability profile meaningfully better than existing agents: no requirement for liver function monitoring, no food requirement for administration, and substantially lower rates of gastrointestinal adverse effects.

"Now I can put a patient on a medication that they're potentially going to tolerate a lot better, not have these side effects and feel worse — so why not try to get them on something that's potentially going to slow the progression of their disease?" Glennie said. She described offering nerandomilast upfront to antifibrotic-naïve patients, switching patients intolerant of nintedanib, and using it as add-on dual therapy in patients who are tolerating their existing antifibrotic but continuing to show functional decline. Insurance coverage remains an obstacle in some cases, but when it is accessible, patient preference has consistently favored nerandomilast given its tolerability advantages.

The evolution in prescribing approach reflects a broader shift: when side effects were the dominant limiting factor, the rational strategy was to withhold therapy until progression was clear. When a well-tolerated option exists, the equation tips toward earlier intervention — preserving function before irreversible fibrosis accrues, rather than waiting for measurable deterioration to justify treatment.

Glennie J. Bridging specialties in ILD: a multidisciplinary bootcamp series for early recognition and targeted treatment; ILD 102. Presented at: Association of Pulmonary Advanced Practice Providers Annual Meeting (APAP 2026); Las Vegas, NV.

Richeldi L, Azuma A, Cottin V, et al. Nerandomilast in patients with idiopathic pulmonary fibrosis. 

 2025;392:2193–2202. doi:10.1056/NEJMoa2414108

With nerandomilast offering a more tolerable alternative to nintedanib and pirfenidone, Jessica Glennie, MSN, APRN, says the threshold for initiating antifibrotic therapy in early or stable disease is moving up.

APPs Uniquely Positioned in ILD Collaborative Care, With Jessica Glennie, MSN, APRN

 (ILD) presents 1 of pulmonary medicine's most complex management challenges — requiring input from pulmonology, rheumatology, cardiology, and radiology to accurately diagnose and treat, while also demanding sustained, time-intensive patient communication across a continuum that can include antifibrotic therapy, pulmonary hypertension management, transplant evaluation, and palliative care. For advanced practice providers (APPs) working in this space, that complexity is precisely where they add value, according to Jessica Glennie, MSN, APRN, of the Cleveland Clinic ILD Center in Cleveland, Ohio.

, where she presented as part of a multidisciplinary ILD bootcamp that brought together pulmonary, rheumatology, cardiology, and radiology APPs to address the full clinical picture of ILD management. The multidisciplinary team (MDT) approach has become a cornerstone of ILD diagnosis and ongoing management, supported by evidence that integrated collaboration among pulmonologists, radiologists, pathologists, and rheumatologists improves diagnostic confidence and guides treatment decisions.

A recurring theme in the bootcamp was early recognition. ILD often first presents with subtle, nonspecific symptoms — dyspnea, cough — that can easily be attributed to more common conditions such as heart disease or obstructive airways disease. 

"At first we might think of more common things like heart disease or airways-related things like COPD rather than interstitial lung disease," Glennie said. Getting clinicians across specialties to recognize those early presentations and route patients appropriately is a central aim of the multidisciplinary approach.

Beyond diagnosis, Glennie emphasized the sheer scope of what ILD patients need to understand and manage: the disease itself, its prognosis, treatment options and associated toxicities, comorbidities including pulmonary hypertension, and — for some — lung transplant evaluation and end-of-life planning. APPs, she noted, are often better positioned than physicians to provide that sustained engagement. 

"APPs oftentimes have a little bit more time to devote to that patient — available in different ways, via phone or virtual visits — and I'm able to offer a little bit more time in the office," she said. "They can really offer a lot of help along that continuum of care with that patient."

For APPs who don't work in dedicated ILD centers, Glennie offered practical guidance on bridging the gaps that can emerge when complex patients move between specialties: build relationships with radiologists and rheumatologists at your institution, know who in your area has ILD experience, and cultivate the referral networks that can keep patients from being lost between providers. She described APAP's national conference as a key vehicle for that kind of networking — enabling APPs to identify colleagues across subspecialties they can call on when navigating difficult cases.

Glennie has no relevant disclosures to report.

Cottin V, Martinez FJ, Smith V, Walsh SLF. Multidisciplinary teams in the clinical care of fibrotic interstitial lung disease: current perspectives. 

 2022;31(166):220003. doi:10.1183/16000617.0003-2022

Guler SA, et al. Interdisciplinary diagnosis and management of patients with interstitial lung disease and connective tissue disease. 

 2024;166(4). doi:10.1016/j.chest.2024.02.049

The CNP at Cleveland Clinic discusses how early recognition, cross-specialty collaboration, and extended patient engagement make APPs essential in the complex, long-term care of interstitial lung disease.

Jessica Glennie, MSN, APRN

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