scarring [9, 23] . Putative initiators of IPF include viruses, cigarette smoke, gastroesophageal refl ux, and occupational exposure to wood and metals [24, 25] . Aging, by reducing effi ciency in repairing damage, represents a cofactor [26] . Th e development of DAD upon UIP may relate to a clinically occult infection [14, 27] , aspiration, or a distinct pathobiological manifestation of IPF [6] . 'Treatment' with high-dose corticosteroids with or without an immunosuppressant proved ineff ective and represents the coup de grace for these patients [8] . IPF exacerbations require rapid decisions about when and whether to initiate mechanical support. However, the con sideration of admission to an intensive care unit (ICU) is a particular clinical and ethical challenge because of poor outcome [28] [29] [30] [31] [32] . Transplantation in this setting presents insurmountable diffi culties.