An IPF patient is referred to the ICU for severe acute respiratory failure as a consequence of the clinical scenarios (mentioned above) that may lead to ventilatory support (Figure 1 ). Progression to the fi nal end reaches a point at which spontaneous ventilation in no longer possible (Figure 1a ). ICU admission of these patients, because of the poor outcome, should be avoided [2] ( Figure 2 ). In 'true' IPF exacerbations (Figure 1b) , ventilatory support and ICU transfer buy time and could have some infl uence on fi nal outcome in specifi c patients. Unfortunately, in the vast majority, this does not happen, and the mortality of this patient population is high, higher even than that predicted by the usual clinical score HRCT shows, at the lung bases, ground-glass opacities upon extensive peripheral thickening of intralobular septa. The patient was a 65-year-old male with IPF and initiated treatment with high doses of corticosteroids. (c) Four months later, HRCT denotes diff use ground-glass with irregular reticulation. Note the extensive lipomatosis of the mediastinum due to chronic steroid use. Owing to deterioration of dyspnea, he was admitted to another hospital, where bronchoalveolar lavage (BAL) was performed and the immunosuppressive treatment was intensifi ed. A few weeks later, he was admitted to our department with respiratory failure, severe corticosteroid-related myopathy, diabetes mellitus, severe dyspnea, and purulent sputum. Clinical examination disclosed herpes simplex virus keratitis in the left eye, and BAL cultures grew positive for Pseudomonas aeruginosa. Corticosteroids were tapered, and antimicrobial and antiviral treatment was initiated. Both eye and lower respiratory tract infections subsided, and the patient was discharged home a few weeks later. (d) Eighteen months after the exacerbation, the groundglass opacities completely resolved as did the lipomatosis of the mediastinum. The patient is still alive and at home. [2, 31] (Figure 3 ). Admission of an IPF patient to the ICU because of reversible causes either aff ecting the lung or not (Figures 1c and 4 ) bears better prognosis, but special attention should be paid to avoid further complications. Th e complexity of the above scenarios underscores the importance of good communication between referring and ICU physicians.