Pneumonitis (inflammation of lung alveoli)

Grading Toxicity


Definition:  A disorder characterized by inflammation focally or diffusely affecting the lung parenchyma

  • Asymptomatic; clinical or diagnostic observations only; intervention not indicated
  • Symptomatic; medical intervention indicated; limiting instrumental ADLs
  • Severe symptoms; limiting self-care ADLs; oxygen indicated
  • Life-threatening respiratory compromise; urgent intervention indicated (tracheostomy, intubation)


Definition: A disorder characterized by decrease in the level of oxygen to the body

  • N/A
  • Decreased oxygen saturation with exercise (e.g., pulse ox < 88%); intermittent supplemental oxygen
  • Decreased oxygen saturation at rest (e.g., pulse ox < 88%)
  • Life-threatening airway compromise; urgent intervention indicated (tracheostomy, intubation)


Overall Strategy:

  • Assess for other etiologies such as infection, pulmonary embolism, progressive lung metastases, or lung disease
  • Early intervention to maintain or improve physical function and impact on QOL
  • Assess pulse oximetry (resting & on exertion) at baseline and at each visit to assist in identifying a decrease at early onset.
  • No known interventions
  • Anticipate immunotherapy to continue
  • Continue to monitor via radiology testing (q 2-4 weeks, as needed)
  • Review symptoms to watch for with patient and family, and remember to assess at every subsequent visit
  • Immunotherapy to be withheld for Grade 2 events (resume when Grade 0/1)
  • Immunotherapy to be discontinued for recurrent (pembrolizumab, nivolumab) or persistent Grade 2 events (ipilimumab, pembrolizumab, nivolumab)
  • Anticipate treatment with:
    • Corticosteroids (e.g., prednisone 1-2 mg/kg/day or equivalent) until symptoms improve to baseline, and then slow taper over at least 1 month
    • If symptoms do not improve within 48-72 hours, corticosteroid dose will be escalated. IV corticosteroids may be considered
    • Additional supportive care medications may also be initiated
  • Anticipatory guidance on proper administration
  • Anticipate the use of empiric antibiotics until infection is excluded
  • Anticipate that bronchoscopy may be ordered by provider
  • Assess patient & family understanding of recommendations and rationale
  • Identify barriers to adherence
  • Discontinue immunotherapy for Grade 3/4 events
  • Patient will likely need to be admitted to the hospital for further management and supportive care
  • Anticipate the use of high-dose IV corticosteroids (e.g., methylprednisolone 2-4 mg/kg/day or equivalent)
  • Once symptoms have resolved to baseline or Grade 1, convert to equivalent oral corticosteroid dose and then taper slowly over at least 1 month
  • Anticipate the use of empiric antibiotics until infection is excluded
  • Anticipate the use of additional immunosuppressive agents if symptoms do not improve in 48-72 hours (e.g., infliximab, mycophenolate, cyclophosphamide)
  • Assess patient & family understanding of toxicity and rationale for treatment discontinuation
  • Identify barriers to adherence, specifically compliance with medication, physical activity.

Nursing Implementation:

  • Identify high-risk individuals (e.g., asthma, COPD) and those with cardiopulmonary symptoms prior to initiating immunotherapy. Establish a thorough baseline
  • Educate patients that new pulmonary symptoms should be reported immediately
  • Anticipate that the steroid requirements to manage pneumonitis are high (1-4 mg/kg/day) and patient will be on corticosteroid therapy for at least 1 month
  • Educate patients and family about the rationale for discontinuation of immunotherapy in patients who do develop moderate or severe pneumonitis


  • Risk of acute onset
  • Risk of mortality if pneumonitis treatment is delayed
  • Risk of pneumonitis is greater in patients receiving combination immunotherapy regimens