Dear Respiratory friends we are re-posting interesting questions and answers from American College of Chest Physicians and American Thoracic Society!
1
Don’t
perform computed tomography (CT) surveillance for evaluation of
indeterminate pulmonary nodules at more frequent intervals or for a
longer period of time than recommended by established guidelines.
Clinical
practice guidelines for pulmonary nodule evaluation (such as those
issued by the Fleischner Society or the American College of Chest
Physicians) suggest that intensity of surveillance should be guided by
the likelihood of malignancy. In patients with no prior history of
cancer, solid nodules that have not grown over a 2-year period have an
extremely low risk of malignancy (although longer follow-up is suggested
for ground-glass nodules). Similarly, intensive surveillance (e.g.,
repeating CT scans every 3 months for 2 years or more) has not been
shown to improve outcomes such as lung cancer mortality. Meanwhile,
extended or intensive surveillance exposes patients to increased
radiation and prolonged uncertainty.
2
Don’t
routinely offer pharmacologic treatment with advanced vasoactive agents
approved only for the management of pulmonary arterial hypertension to
patients with pulmonary hypertension resulting from left heart disease
or hypoxemic lung diseases (Groups II or III pulmonary hypertension).
Evidence
and clinical practice guidelines have not established benefits of
vasoactive agents (e.g., prostanoids, phosphodiesterase inhibitors,
endothelin antagonists) for patients with pulmonary hypertension
resulting from left heart disease or hypoxemic lung diseases. Moreover,
the use of these agents may cause harm in certain situations and incurs
substantial cost and resource utilization. Patients should be carefully
assessed (including at a minimum right heart catheterization,
echocardiography, chest CT, six minute walk test and pulmonary function
testing) to confirm that they have symptomatic pulmonary arterial
hypertension prior to having approved agents initiated.
3
For
patients recently discharged on supplemental home oxygen following
hospitalization for an acute illness, don’t renew the prescription
without assessing the patient for ongoing hypoxemia.
Hypoxemia
often resolves after recovery from an acute illness, and continued
prescription of supplemental oxygen therapy incurs unnecessary cost and
resource use. At the time that supplemental oxygen is initially
prescribed, a plan should be established to re-assess the patient no
later than 90 days after discharge. Medicare and evidence-based criteria
should be followed to determine whether the patient meets criteria for
supplemental oxygen.
4
Don’t
perform chest computed tomography (CT angiography) to evaluate for
possible pulmonary embolism in patients with a low clinical probability
and negative results of a highly sensitive D-dimer assay.
Clinical
practice guidelines for pulmonary embolism indicate that the cost and
potential harms of CT angiography (including radiation exposure and the
possibility of detecting and treating clinically insignificant pulmonary
emboli with anticoagulation) outweigh the benefits for patients with a
low pre-test probability of pulmonary embolism. In patients with a low
clinical prediction score (e.g., Wells or Geneva score) followed by a
negative D-dimer measured with a high sensitivity test (e.g., ELISA),
pulmonary embolism is effectively excluded and no further imaging is
indicated for pulmonary embolism evaluation.
5
Don’t perform CT screening for lung cancer among patients at low risk for lung cancer.
Low
dose chest CT screening for lung cancer has the potential to reduce
lung cancer death in patients at high risk (i.e., individuals aged 55-74
with at least a 30-pack year history of tobacco use, who are either
still smoking or quit within the past 15 years). However, CT screening
for lung cancer also has the potential to cause a number of adverse
effects (e.g., radiation exposure, high false positive rate, harms
related to downstream evaluation of pulmonary nodules, overdiagnosis of
indolent tumors). Thus, screening should be reserved for patients at
high risk of lung cancer and should not be offered to individuals at low
risk of lung cancer.
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