, Volume 74, Issue 4, pp 443–450 | Cite as

Interstitial Lung Disease in Patients with Rheumatoid Arthritis: Spontaneous and Drug Induced

  • Robert W. Hallowell
  • Maureen R. HortonEmail author
Review Article


Rheumatoid arthritis (RA) is an inflammatory autoimmune disease characterized by the destruction of articular joint structures. RA is a systemic condition that often affects multiple organs, including the heart, lungs, and kidneys. Pulmonary complications of RA are relatively common and include pleural effusion, rheumatoid nodules, bronchiectasis, obliterative bronchiolitis, and opportunistic infections. Interstitial lung disease (ILD) is a common occurrence in patients with RA, and can range in severity from an asymptomatic incidental finding to a rapidly progressing life-threatening event. Usual interstitial pneumonia and non-specific interstitial pneumonia are the two most common patterns, though others have been reported. Various disease-modifying anti-rheumatic drugs—in particular, methotrexate and the tumor necrosis factor-alpha inhibitors—have been associated with RA-ILD in numerous case reports and case series, though it is often difficult to distinguish association from causality. Treatment for RA-ILD typically involves the use of high-dose corticosteroids, often in conjunction with alternative immunosuppressant agents such as azathioprine or mycophenolate mofetil, and outcomes vary widely depending on the initial pattern of lung disease. Additional research into the mechanisms driving RA-ILD is needed to guide future therapy.


Rheumatoid Arthritis Rheumatoid Arthritis Patient Idiopathic Pulmonary Fibrosis Interstitial Lung Disease Leflunomide 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Dr Hallowell reports no conflict of interest. Dr Horton reports no conflict of interest. No sources of funding were used to support the writing of this review.


  1. 1.
    Firestein GS. Evolving concepts of rheumatoid arthritis. Nature. 2003;423(6937):356–61.PubMedCrossRefGoogle Scholar
  2. 2.
    Rothschild BM. Rheumatoid arthritis at a time of passage. J Rheumatol. 2001;28(2):245–50.PubMedGoogle Scholar
  3. 3.
    Prete M, Racanelli V, Digiglio L, Vacca A, Dammacco F, Perosa F. Extra-articular manifestations of rheumatoid arthritis: an update. Autoimmun Rev. 2011;11(2):123–31.PubMedCrossRefGoogle Scholar
  4. 4.
    Myasoedova E, Crowson CS, Kremers HM, Therneau TM, Gabriel SE. Is the incidence of rheumatoid arthritis rising? Results from Olmsted County, Minnesota, 1955–2007. Arthritis Rheum. 2010;62(6):1576–82.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Bharadwaj A, Haroon N. Interstitial lung disease and neuropathy as predominant extra-articular manifestations in patients with rheumatoid arthritis: a prospective study. Med Sci Monit. 2005;11(10):CR498–502.Google Scholar
  6. 6.
    Norton S, Koduri G, Nikiphorou E, Dixey J, Williams P, Young A. A study of baseline prevalence and cumulative incidence of comorbidity and extra-articular manifestations in RA and their impact on outcome. Rheumatology (Oxford). 2013;52(1):99–110.CrossRefGoogle Scholar
  7. 7.
    Young A, Koduri G. Extra-articular manifestations and complications of rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2007;21(5):907–27.PubMedCrossRefGoogle Scholar
  8. 8.
    Habib HM, Eisa AA, Arafat WR, Marie MA. Pulmonary involvement in early rheumatoid arthritis patients. Clin Rheumatol. 2011;30(2):217–21.PubMedCrossRefGoogle Scholar
  9. 9.
    Rockall AG, Rickards D, Shaw PJ. Imaging of the pulmonary manifestations of systemic disease. Postgrad Med J. 2001;77(912):621–38.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Sidhu HS, Bhatnagar G, Bhogal P, Riordan R. Imaging features of the pleuropulmonary manifestations of rheumatoid arthritis: pearls and pitfalls. J Clin Imaging Sci. 2011;1:32.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Ishida T, Kotani T, Takeuchi T, Makino S. Pulmonary toxicity after initiation of azathioprine for treatment of interstitial pneumonia in a patient with rheumatoid arthritis. J Rheumatol. 2012;39(5):1104–5.PubMedCrossRefGoogle Scholar
  12. 12.
    Tsuchiya Y, Takayanagi N, Sugiura H, Miyahara Y, Tokunaga D, Kawabata Y, et al. Lung diseases directly associated with rheumatoid arthritis and their relationship to outcome. Eur Respir J. 2011;37(6):1411–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Balbir-Gurman A, Yigla M, Nahir AM, Braun-Moscovici Y. Rheumatoid pleural effusion. Semin Arthritis Rheum. 2006;35(6):368–78.PubMedCrossRefGoogle Scholar
  14. 14.
    Dascalu C, Mrejen-Shakin K, Bandagi S. Adalimumab-induced acute pneumonitis in a patient with rheumatoid arthritis. J Clin Rheumatol. 2010;16(4):172–4.PubMedCrossRefGoogle Scholar
  15. 15.
    Nannini C, Medina-Velasquez YF, Achenbach SJ, Crowson CS, Ryu JH, Vassallo R, et al. Incidence and mortality of obstructive lung disease in rheumatoid arthritis: a population-based study. Arthritis Care Res (Hoboken). 2013;65(8):1243–50.CrossRefGoogle Scholar
  16. 16.
    Devouassoux G, Cottin V, Liote H, Marchand E, Frachon I, Schuller A, et al. Characterisation of severe obliterative bronchiolitis in rheumatoid arthritis. Eur Respir J. 2009;33(5):1053–61.PubMedCrossRefGoogle Scholar
  17. 17.
    White ES, Tazelaar HD, Lynch JP 3rd. Bronchiolar complications of connective tissue diseases. Semin Respir Crit Care Med. 2003;24(5):543–66.PubMedCrossRefGoogle Scholar
  18. 18.
    Dixon WG, Hyrich KL, Watson KD, Lunt M, Symmons DP. Influence of anti-TNF therapy on mortality in patients with rheumatoid arthritis-associated interstitial lung disease: results from the British Society for Rheumatology Biologics Register. Ann Rheum Dis. 2010;69(6):1086–91.PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Leonel D, Lucia C, A M, Martha-Alicia H, Blanca M. Pulmonary function test: its correlation with pulmonary high-resolution computed tomography in patients with rheumatoid arthritis. Rheumatol Int. 2012;32(7):2111–6.Google Scholar
  20. 20.
    Mohd Noor N, Mohd Shahrir MS, Shahid MS, Abdul Manap R, Shahizon Azura AM, Azhar Shah S. Clinical and high resolution computed tomography characteristics of patients with rheumatoid arthritis lung disease. Int J Rheum Dis. 2009;12(2):136–44.Google Scholar
  21. 21.
    Olson AL, Swigris JJ, Sprunger DB, Fischer A, Fernandez-Perez ER, Solomon J, et al. Rheumatoid arthritis-interstitial lung disease-associated mortality. Am J Respir Crit Care Med. 2011;183(3):372–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Skare TL, Nakano I, Escuissiato DL, Batistetti R, Rodrigues Tde O, Silva MB. Pulmonary changes on high-resolution computed tomography of patients with rheumatoid arthritis and their association with clinical, demographic, serological and therapeutic variables. Rev Bras Reumatol. 2011;51(4):325–30, 36–7.Google Scholar
  23. 23.
    Zou YQ, Li YS, Ding XN, Ying ZH. The clinical significance of HRCT in evaluation of patients with rheumatoid arthritis-associated interstitial lung disease: a report from China. Rheumatol Int. 2012;32(3):669–73.PubMedCrossRefGoogle Scholar
  24. 24.
    Bongartz T, Nannini C, Medina-Velasquez YF, Achenbach SJ, Crowson CS, Ryu JH, et al. Incidence and mortality of interstitial lung disease in rheumatoid arthritis: a population-based study. Arthritis Rheum. 2010;62(6):1583–91.PubMedCrossRefGoogle Scholar
  25. 25.
    Koduri G, Norton S, Young A, Cox N, Davies P, Devlin J, et al. Interstitial lung disease has a poor prognosis in rheumatoid arthritis: results from an inception cohort. Rheumatology (Oxford). 2010;49(8):1483–9.CrossRefGoogle Scholar
  26. 26.
    Gochuico BR, Avila NA, Chow CK, Novero LJ, Wu HP, Ren P, et al. Progressive preclinical interstitial lung disease in rheumatoid arthritis. Arch Intern Med. 2008;168(2):159–66.PubMedCrossRefGoogle Scholar
  27. 27.
    Furukawa H, Oka S, Shimada K, Sugii S, Ohashi J, Matsui T, et al. Association of human leukocyte antigen with interstitial lung disease in rheumatoid arthritis: a protective role for shared epitope. PLoS One. 2012;7(5):e33133.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Giles JT, Danoff SK, Sokolove J, Wagner CA, Winchester R, Pappas DA, et al. Association of fine specificity and repertoire expansion of anticitrullinated peptide antibodies with rheumatoid arthritis associated interstitial lung disease. Ann Rheum Dis. 2013.Google Scholar
  29. 29.
    Saag KG, Kolluri S, Koehnke RK, Georgou TA, Rachow JW, Hunninghake GW, et al. Rheumatoid arthritis lung disease: determinants of radiographic and physiologic abnormalities. Arthritis Rheum. 1996;39(10):1711–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Harlow L, Rosas IO, Gochuico BR, Mikuls TR, Dellaripa PF, Oddis CV, et al. Identification of citrullinated hsp90 isoforms as novel autoantigens in rheumatoid arthritis-associated interstitial lung disease. Arthritis Rheum. 2013;65(4):869–79.PubMedCrossRefGoogle Scholar
  31. 31.
    Inui N, Enomoto N, Suda T, Kageyama Y, Watanabe H, Chida K. Anti-cyclic citrullinated peptide antibodies in lung diseases associated with rheumatoid arthritis. Clin Biochem. 2008;41(13):1074–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Mori S, Koga Y, Sugimoto M. Different risk factors between interstitial lung disease and airway disease in rheumatoid arthritis. Respir Med. 2012;106(11):1591–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Shidara K, Hoshi D, Inoue E, Yamada T, Nakajima A, Taniguchi A, et al. Incidence of and risk factors for interstitial pneumonia in patients with rheumatoid arthritis in a large Japanese observational cohort, IORRA. Mod Rheumatol. 2010;20(3):280–6.PubMedCrossRefGoogle Scholar
  34. 34.
    Ito S, Sumida T. Interstitial lung disease associated with leflunomide. Intern Med. 2004;43(12):1103–4.PubMedCrossRefGoogle Scholar
  35. 35.
    Xiangyang Z, Lutian Y, Lin Z, Liping X, Hui S, Jing L. Increased levels of interleukin-33 associated with bone erosion and interstitial lung diseases in patients with rheumatoid arthritis. Cytokine. 2012;58(1):6–9.PubMedCrossRefGoogle Scholar
  36. 36.
    Schwarz M, King TE, editors. Connective tissue diseases. 5th ed. Shelton: People’s Medical Publishing House; 2011.Google Scholar
  37. 37.
    Park IN, Kim DS, Shim TS, Lim CM, Lee SD, Koh Y, et al. Acute exacerbation of interstitial pneumonia other than idiopathic pulmonary fibrosis. Chest. 2007;132(1):214–20.PubMedCrossRefGoogle Scholar
  38. 38.
    Morrison SC, Mody GM, Benatar SR, Meyers OL. The lungs in rheumatoid arthritis: a clinical, radiographic and pulmonary function study. S Afr Med J. 1996;86(7):829–33.PubMedGoogle Scholar
  39. 39.
    Walker WC, Wright V. Pulmonary lesions and rheumatoid arthritis. Medicine (Baltimore). 1968;47(6):501–20.CrossRefGoogle Scholar
  40. 40.
    Cervantes-Perez P, Toro-Perez AH, Rodriguez-Jurado P. Pulmonary involvement in rheumatoid arthritis. JAMA. 1980;243(17):1715–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Dawson JK, Fewins HE, Desmond J, Lynch MP, Graham DR. Fibrosing alveolitis in patients with rheumatoid arthritis as assessed by high resolution computed tomography, chest radiography, and pulmonary function tests. Thorax. 2001;56(8):622–7.PubMedCentralPubMedCrossRefGoogle Scholar
  42. 42.
    Gabbay E, Tarala R, Will R, Carroll G, Adler B, Cameron D, et al. Interstitial lung disease in recent onset rheumatoid arthritis. Am J Respir Crit Care Med. 1997;156(2 Pt 1):528–35.PubMedCrossRefGoogle Scholar
  43. 43.
    Rojas-Serrano J, Gonzalez-Velasquez E, Mejia M, Sanchez-Rodriguez A, Carrillo G. Interstitial lung disease related to rheumatoid arthritis: evolution after treatment. Reumatol Clin. 2012;8(2):68–71.Google Scholar
  44. 44.
    Kim EJ, Collard HR, King TE Jr. Rheumatoid arthritis-associated interstitial lung disease: the relevance of histopathologic and radiographic pattern. Chest. 2009;136(5):1397–405.PubMedCentralPubMedCrossRefGoogle Scholar
  45. 45.
    Park JH, Kim DS, Park IN, Jang SJ, Kitaichi M, Nicholson AG, et al. Prognosis of fibrotic interstitial pneumonia: idiopathic versus collagen vascular disease-related subtypes. Am J Respir Crit Care Med. 2007;175(7):705–11.PubMedCrossRefGoogle Scholar
  46. 46.
    Lee HK, Kim DS, Yoo B, Seo JB, Rho JY, Colby TV, et al. Histopathologic pattern and clinical features of rheumatoid arthritis-associated interstitial lung disease. Chest. 2005;127(6):2019–27.PubMedCrossRefGoogle Scholar
  47. 47.
    Kim EJ, Elicker BM, Maldonado F, Webb WR, Ryu JH, Van Uden JH, et al. Usual interstitial pneumonia in rheumatoid arthritis-associated interstitial lung disease. Eur Respir J. 2010;35(6):1322–8.PubMedCrossRefGoogle Scholar
  48. 48.
    Nakamura Y, Suda T, Kaida Y, Kono M, Hozumi H, Hashimoto D, et al. Rheumatoid lung disease: prognostic analysis of 54 biopsy-proven cases. Respir Med. 2012;106(8):1164–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Solomon JJ, Ryu JH, Tazelaar HD, Myers JL, Tuder R, Cool CD, et al. Fibrosing interstitial pneumonia predicts survival in patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD). Respir Med. 2013;107(8):1247–52.PubMedCrossRefGoogle Scholar
  50. 50.
    Flaherty KR, Colby TV, Travis WD, Toews GB, Mumford J, Murray S, et al. Fibroblastic foci in usual interstitial pneumonia: idiopathic versus collagen vascular disease. Am J Respir Crit Care Med. 2003;167(10):1410–5.PubMedCrossRefGoogle Scholar
  51. 51.
    Turesson C, Matteson EL, Colby TV, Vuk-Pavlovic Z, Vassallo R, Weyand CM, et al. Increased CD4+ T cell infiltrates in rheumatoid arthritis-associated interstitial pneumonitis compared with idiopathic interstitial pneumonitis. Arthritis Rheum. 2005;52(1):73–9.PubMedCrossRefGoogle Scholar
  52. 52.
    Choi HK, Hernan MA, Seeger JD, Robins JM, Wolfe F. Methotrexate and mortality in patients with rheumatoid arthritis: a prospective study. Lancet. 2002;359(9313):1173–7.PubMedCrossRefGoogle Scholar
  53. 53.
    Wasko MC, Dasgupta A, Hubert H, Fries JF, Ward MM. Propensity-adjusted association of methotrexate with overall survival in rheumatoid arthritis. Arthritis Rheum. 2013;65(2):334–42.PubMedCentralPubMedCrossRefGoogle Scholar
  54. 54.
    Alarcon GS, Kremer JM, Macaluso M, Weinblatt ME, Cannon GW, Palmer WR, et al. Risk factors for methotrexate-induced lung injury in patients with rheumatoid arthritis: a multicenter, case–control study. Methotrexate-Lung Study Group. Ann Intern Med. 1997;127(5):356–64.PubMedCrossRefGoogle Scholar
  55. 55.
    Furukawa H, Oka S, Shimada K, Tsuchiya N, Tohma S. HLA-A*31:01 and methotrexate-induced interstitial lung disease in Japanese rheumatoid arthritis patients: a multidrug hypersensitivity marker? Ann Rheum Dis. 2013;72(1):153–5.PubMedCrossRefGoogle Scholar
  56. 56.
    Saravanan V, Kelly C. Drug-related pulmonary problems in patients with rheumatoid arthritis. Rheumatology (Oxford). 2006;45(7):787–9.CrossRefGoogle Scholar
  57. 57.
    Wolfe F, Caplan L, Michaud K. Rheumatoid arthritis treatment and the risk of severe interstitial lung disease. Scand J Rheumatol. 2007;36(3):172–8.Google Scholar
  58. 58.
    Chikura B, Lane S, Dawson JK. Clinical expression of leflunomide-induced pneumonitis. Rheumatology (Oxford). 2009;48(9):1065–8.CrossRefGoogle Scholar
  59. 59.
    Inokuma S. Leflunomide-induced interstitial pneumonitis might be a representative of disease-modifying antirheumatic drug-induced lung injury. Expert Opin Drug Saf. 2011;10(4):603–11.PubMedCrossRefGoogle Scholar
  60. 60.
    Sawada T, Inokuma S, Sato T, Otsuka T, Saeki Y, Takeuchi T, et al. Leflunomide-induced interstitial lung disease: prevalence and risk factors in Japanese patients with rheumatoid arthritis. Rheumatology (Oxford). 2009;48(9):1069–72.CrossRefGoogle Scholar
  61. 61.
    Suissa S, Hudson M, Ernst P. Leflunomide use and the risk of interstitial lung disease in rheumatoid arthritis. Arthritis Rheum. 2006;54(5):1435–9.PubMedCrossRefGoogle Scholar
  62. 62.
    Horai Y, Miyamura T, Shimada K, Takahama S, Minami R, Yamamoto M, et al. Eternacept for the treatment of patients with rheumatoid arthritis and concurrent interstitial lung disease. J Clin Pharm Ther. 2012;37(1):117–21.PubMedCrossRefGoogle Scholar
  63. 63.
    Perez-Alvarez R, Perez-de-Lis M, Diaz-Lagares C, Pego-Reigosa JM, Retamozo S, Bove A, et al. Interstitial lung disease induced or exacerbated by TNF-targeted therapies: analysis of 122 cases. Semin Arthritis Rheum. 2011;41(2):256–64.PubMedCrossRefGoogle Scholar
  64. 64.
    Pearce F, Johnson SR, Courtney P. Interstitial lung disease following certolizumab pegol. Rheumatology (Oxford). 2012;51(3):578–80.CrossRefGoogle Scholar
  65. 65.
    Daien CI, Monnier A, Claudepierre P, Constantin A, Eschard JP, Houvenagel E, et al. Sarcoid-like granulomatosis in patients treated with tumor necrosis factor blockers: 10 cases. Rheumatology (Oxford). 2009;48(8):883–6.CrossRefGoogle Scholar
  66. 66.
    Cho SK, Oh IH, Park CK, Bae SC, Sung YK. Etanercept induced organizing pneumonia in a patient with rheumatoid arthritis. Rheumatol Int. 2012;32(4):1055–7.PubMedCrossRefGoogle Scholar
  67. 67.
    Taki H, Kawagishi Y, Shinoda K, Hounoki H, Ogawa R, Sugiyama E, et al. Interstitial pneumonitis associated with infliximab therapy without methotrexate treatment. Rheumatol Int. 2009;30(2):275–6.PubMedCrossRefGoogle Scholar
  68. 68.
    Yamazaki H, Isogai S, Sakurai T, Nagasaka K. A case of adalimumab-associated interstitial pneumonia with rheumatoid arthritis. Mod Rheumatol. 2010;20(5):518–21.PubMedCrossRefGoogle Scholar
  69. 69.
    Herrinton LJ, Harrold LR, Liu L, Raebel MA, Taharka A, Winthrop KL, et al. Association between anti-TNF-alpha therapy and interstitial lung disease. Pharmacoepidemiol Drug Saf. 2013;22(4):394–402.PubMedCrossRefGoogle Scholar
  70. 70.
    Ogiwara Y, Mochizuki H, Morioka T, Sugihara T, Makino F, Takahashi H. A case with life-threatening interstitial pneumonia associated with bucillamine treatment. Mod Rheumatol. 2008;18(5):522–5.PubMedCrossRefGoogle Scholar
  71. 71.
    Koike R, Tanaka M, Komano Y, Sakai F, Sugiyama H, Nanki T, et al. Tacrolimus-induced pulmonary injury in rheumatoid arthritis patients. Pulm Pharmacol Ther. 2011;24(4):401–6.PubMedCrossRefGoogle Scholar
  72. 72.
    Vassallo R, Thomas CF. Advances in the treatment of rheumatic interstitial lung disease. Curr Opin Rheumatol. 2004;16(3):186–91.PubMedCrossRefGoogle Scholar
  73. 73.
    Antoniou KM, Mamoulaki M, Malagari K, Kritikos HD, Bouros D, Siafakas NM, et al. Infliximab therapy in pulmonary fibrosis associated with collagen vascular disease. Clin Exp Rheumatol. 2007;25(1):23–8.Google Scholar
  74. 74.
    Furst DE, Keystone EC, So AK, Braun J, Breedveld FC, Burmester GR, et al. Updated consensus statement on biological agents for the treatment of rheumatic diseases, 2012. Ann Rheum Dis. 2013;72 Suppl 2:ii2–34.Google Scholar
  75. 75.
    Genovese MC, Breedveld FC, Emery P, Cohen S, Keystone E, Matteson EL, et al. Safety of biological therapies following rituximab treatment in rheumatoid arthritis patients. Ann Rheum Dis. 2009;68(12):1894–7.PubMedCrossRefGoogle Scholar
  76. 76.
    Kekow J, Moots RJ, Emery P, Durez P, Koenig A, Singh A, et al. Patient-reported outcomes improve with etanercept plus methotrexate in active early rheumatoid arthritis and the improvement is strongly associated with remission: the COMET trial. Ann Rheum Dis. 2010;69(1):222–5.PubMedCrossRefGoogle Scholar
  77. 77.
    Kelly C, Saravanan V. Treatment strategies for a rheumatoid arthritis patient with interstitial lung disease. Expert Opin Pharmacother. 2008;9(18):3221–30.PubMedCrossRefGoogle Scholar
  78. 78.
    Fischer A, Brown KK, Du Bois RM, Frankel SK, Cosgrove GP, Fernandez-Perez ER, et al. Mycophenolate mofetil improves lung function in connective tissue disease-associated interstitial lung disease. J Rheumatol. 2013;40(5):640–6.PubMedCentralPubMedCrossRefGoogle Scholar
  79. 79.
    Matteson EL, Choi HK, Poe DS, Wise C, Lowe VJ, McDonald TJ, et al. Etanercept therapy for immune-mediated cochleovestibular disorders: a multi-center, open-label, pilot study. Arthritis Rheum. 2005;53(3):337–42.PubMedCrossRefGoogle Scholar
  80. 80.
    Gallelli L, Falcone D, Pelaia G, Renda T, Terracciano R, Malara N, et al. Interleukin-6 receptor superantagonist Sant7 inhibits TGF-beta-induced proliferation of human lung fibroblasts. Cell Prolif. 2008;41(3):393–407.PubMedCrossRefGoogle Scholar
  81. 81.
    Mohr M, Jacobi AM. Interstitial lung disease in rheumatoid arthritis: response to IL-6R blockade. Scand J Rheumatol. 2011;40(5):400–1.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2014

Authors and Affiliations

  1. 1.Division of Pulmonary and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreUSA

Personalised recommendations