Five Things Chest Physicians and Respiratory Patients Should Question

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.