Other Articles That May Interest You
This is a reading syllabus posted on the American Thoracic Society website. Although this is not
mandatory reading for yourselves (residents rotating through the Pulmonary rotation), you may find
some of the articles of interest to help flesh out certain topics.
ARDS
Ashbaugh DG, Bigelow DB, Petty TL, et al. Acute respiratory distress in adults. Lancet
1967;2:319-323. Original description of ARDS and use of PEEP in treating ARDS.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=4143721
ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes
for ALI and ARDS. NEJM 2000;342:1301-8. Results of ARMA study are basis for low- stretch/low
tidal volume ventilation strategy. http://content.nejm.org/cgi/content/abstract/342/18/1301
Eichacker PQ, Gerstenberger EP, Banks SM, et al. Meta-analysis of ALI and ARDS trials testing
low tidal volumes. AJRCCM 2002;166:1510-14. In this highly controversial analysis, the authors
question the validity of the ARDS network study above, arguing that 1) the mortality benefit
resulted from excess mortality in the traditional arm, 2) the traditional arm did not receive the
standard of care (authors argue the traditional arm received excessively large tidal volumes),
and 3) very low tidal volumes are harmful. See links to commentary for rebuttals to all of these
points. http://ajrccm.atsjournals.org/cgi/content/full/166/11/1510
Weinert CR, Gross CR, Marinelli WA. Impact of randomized trial results on acute lung injury
ventilator therapy in teaching hospitals. AJRCCM 2003;167:1304-9. This study is interesting in
light of the above two studies. It found the average tidal volume used at 2 non-ARDSnet teaching
hospitals in the 5 years leading up to the release of results from ARDSnet was 11.2 ml/kg IBW
(compared to 12 cc/kg IBW used in the ARDSnet traditional arm). Tidal volumes were slowly
declining around the time ARDSnet results were released, but were still 10.1ml/kg of IBW 2
years after their release. Less than 1% of patients were receiving 6 cc/kg IBW or less.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12574072
Amato MBP, Barbas CSV, Medeiros DM, et al. Effect of a protective-ventilation strategy on
mortality in ARDS. NEJM 1998;338:347-54. Small, randomized, study famous for using a
combination of the lower inflection point of the pressure-volume curve to set PEEP, recruitment
maneuvers (CPAP 35-40 cm x 40 sec.), and low-tidal volumes (< 6cc/kg). 28-day mortality was
lower in the intervention group, but the conventional group had an unusually high mortality
(71%). Patients overall received higher PEEP than in the ARMA study.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9449727
Meduri GU, Headley AS, Golden E, et al. Effect of prolonged methyprednisolone therapy in
unresolving ARDS. JAMA 1998;280:159-65. Encouraging results obtained in this small RCT of
steroids vs. placebo in the later, fibrosing stage of ARDS (days 6-12 in this study) including
improved mortality. However, some patients in the placebo group crossed over to the steroid
group.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9669790
Rubenfeld GD, Caldwell E, Granton J, et al. Interobserver variability in applying a radiographic
definition for ARDS. CHEST 1999;116:1347-53. A group of 21 experts in ARDS were asked to
determine whether a series of CXRs met the American-European Consensus Conference
radiographic criterion for ARDS. Interobserver agreement was only moderate.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10559098
Hudson LD, Milberg JA, Anardi D, Maunder RJ. Clinical risks for development of ARDS. AJRCCM
1995;151:293-301. Study describes the incidence of ARDS in patients with various clinical risk
factors. Also found 1) greater mortality in at-risk patients that develop ARDS and 2) ARDS
develops within 48 to 72 hours of the time clinical risk is identified in the vast majority of
patients.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=7842182
Davidson TA, Caldwell ES, Curtis JR, et al. Reduced quality of life in survivors of ARDS compared
with critically ill control patients. JAMA 1999;281:354-60. One of the first studies to look at
quality of life of ARDS survivors. It found decreased quality of life related to severity and
complications of ARDS, rather than duration of mechanical ventilation or hospital stay,
compared to matched, critically-ill control patients.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9929089
**See also Invasive and Non-invasive Mechanical Ventilation
Asthma
Rowe BH, Bota GW, Fabris L, et al. Inhaled budesonide in discharge from the emergency
department: a randomized controlled trial. JAMA 1999;281:2119-26. Study found the addition
of inhaled steroid to oral steroid at the time of discharge from the emergency department
reduced the rate of relapse by about half.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10367823
Haahtala T, Jarvinen M, Kava T, et al. Comparison of a beta-agonist, terbutaline, with an inhaled
corticosteroid, budesonide, in newly detected asthma. NEJM 1991;325:388-92. This
randomized, blinded comparison of the above two drugs was important in establishing inhaled
corticosteroids as the first line treatment for asthma.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=2062329
O'Driscoll BR, Kalra S, Wilson M, et al. Double-blind trial of steroid tapering in acute asthma.
Lancet 1993;341:324-7. Study found tapering steroids after treatment with 10 days of steroids
for an asthma exacerbation was unnecessary as long as patient was on an inhaled
corticosteroid.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=8094111
Laviolette M, Malmstrom K, Lu S, et al. Montelukast added to inhaled beclomethasone in
treatment of asthma. AJRCCM 1999;160:1862-68. This randomized, double-blinded study
supports the addition of a leukotriene inhibitor for asthmatics with inadequate symptom control
with inhaled corticosteroid alone.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10588598
Malmstrom K, Rodriguez-Gomez G, Guerra J, et al. Oral montelukast, inhaled beclomethasone,
and placebo for chronic asthma. A randomized controlled trial. Ann Intern Med 1999;130:48795. Both inhaled steroid and a leukotriene inhibitor were better than placebo. Beclomethasone
was significantly better than montelukast in reducing exacerbations and symptoms.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10075616
Lazarus SC, Boushey HA, Fahy JV et al. Long-acting beta2-agonist monotherapy vs. continued
therapy with inhaled corticosteroids in patients with persistent asthma: a RCT. JAMA
2001;285:2583-93. Switching from low dose ICS to longacting beta2-agonist in patients with
well-controlled, persistent asthma increases the risk of treatment failure and asthma
exacerbations.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11368732
Busse WW. Anti-immunoglobulin E (omalizumab) therapy in allergic asthma. Review
summarizes several large RCT studying the role of anti-IgE antibody in allergic asthma. The use
of anti-IgE is associated with decreased frequency of exacerbations, reductions in corticosteroid
dose, and improved quality of life in symptomatic patients with moderate to severe allergic
asthma.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11704612
Edelman JM, Turpin JA, Bronsky EA, et al. Oral montelukast compared with inhaled salmeterol to
prevent exercise- induced bronchoconstriction. A randomized, double-blind trial. Ann Intern Med
2000;132(2):97-104. Study found leukotriene blockade has equal efficacy to a beta-agonist for
the prevention of EIB and that daily administration is not associated with a reduction in efficacy
that is seen with daily dosing of long-acting beta agonists.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10644288
Suissa S, Blais L, Ernst P. Patterns of increasing beta-agonist use and the risk of fatal or nearfatal asthma. Eur Respir J 1994;7:1602-9. Nested case control study found increased and
escalating use of beta-agonists were associated with an increased risk of death from asthma.
Findings suggest poorly controlled asthma should not be managed with increased dosage of
beta-agonists alone.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=7995388
Lange P, Parner J, Vestbo J, Schnohr P, Jensen G. A 15-year follow-up study of ventilatory
function in adults with asthma. N Engl J Med 1998;339:1194-200. Noteworthy for being one of
the studies showing that a portion of patients with asthma go on to develop fixed airway
obstruction.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9780339
Web site for latest treatment guidelines:
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
**See also Invasive Mechanical Ventilation and Occupational Medicine
Community-acquired Pneumonia
Skerrett SJ. Diagnostic testing for CAP. Clin Chest Med 1999;20:531-48. Covers the techniques
and yield of non-invasive and invasive diagnostic tests as well as the laboratory diagnosis of
specific infections.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10516902
Niederman MS, Mandell LA, Anzueto A, et al. Guidelines for the management of adults with
community-acquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy, and
prevention. AJRCCM 2001;163:1730-54. Latest recommendations from the ATS.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11401897
Bartlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of communityacquired pneumonia in adults. (From the IDSA). Clin Infect Dis 2000;31:347-82. Weighing in at
35 pages, this is more a reference than a read.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10987697
ERS Task Force Report. Guidelines for management of adult community-acquired lower
respiratory tract infections. European Respiratory Society. Eur Respir J 1998;11:986-91. Concise,
sensible, well-referenced guideline that places CAP in the context of other LRTI.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9623709
Ruiz M, Ewig S, Torres A, et al. Severe community-acquired pneumonia. Risk factors and followup epidemiology. AJRCCM 1999;160:923-9. Study out of Barcelona that is the best on this
subject in recent years. Key findings were that the epidemiology of severe CAP evolves over time
and hence, initial empiric treatment needs to as well. Alcohol abuse was the only independent
risk factor for severe CAP, while prior ambulatory antimicrobial therapy was protective,
emphasizing the potential benefit of early empiric treatment.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10471620
Ramirez JA, Vargas S, Ritter GW, et al. Early switch from intravenous to oral antibiotics and early
hospital discharge: a prospective observational study of 200 consecutive patients with
community-acquired pneumonia. Arch Intern Med 1999;159:2449-54. Study found early switch
safe and cost-effective.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10665893
Ruiz-Gonzales AM et al. Is Streptococcus pneumoniae the leading cause of pneumonia of
unknown etiology? A microbiologic study of lung aspirates in consecutive patients with
community-acquired pneumonia. Am J Med 1999;106:385-90. Supports long held belief that
most CAP cases of unknown etiology are probably pneumococcal.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10225239
Fine MJ, Auble TE, Yealy DM et al. A prediction rule to identify low-risk patients with communityacquired pneumonia. NEJM 1997;336:243-50. Oft-cited prediction rule used in above study by
Marrie, et al. incorporates patient demographics, co-morbidities, vitals, labs, and chest film to
identify patients likely to do well with outpatient treatment of CAP. Rule difficult to memorize
and requires an ABG, but otherwise easy to apply.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=8995086
Marrie TJ, Lau CY, Wheeler SL, et al. A controlled trial of a critical pathway for treatment of CAP.
CAPITAL Study Investigators. JAMA 2000;283:749-55. Instituting a care pathway for CAP
resulted in decreased rates of admission of low-risk patients and shorter hospital stays among
those admitted without compromising the care of patients.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10683053
Mundy LM, Leet TL, Darst K, et al. Early mobilization of patients hospitalized with communityacquired pneumonia. CHEST 2003;124:883-9. A group randomized trial of 458 patients with
CAP hospitalized on general medical units found patients undergoing early mobilization had
shorter hospital stays without an increase in adverse events compared to usual care.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12970012
Bartlett JG, Gorbach SL. The triple threat of aspiration pneumonia. Chest 1975;68:560-66.
Classic review of the presentation, pathophysiology, and natural history of chemical
pneumonitis, bacterial pneumonia, and airway obstruction resulting from aspiration of toxic
fluids, bacteria, and inert matter respectively.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=1175415
Metlay JP, Kapoor WN, Fine MJ. Does this patient have CAP? Diagnosing pneumonia by history
and physical examination. JAMA 1997;278:1440-5. Systematic review found H & P do not
reliably predict the presence of pneumonia in acutely symptomatic, ambulatory patients.
Physicians' interobserver agreement on exam findings is poor. Article highlights the importance
of chest x-rays in diagnosis of pneumonia but the optimal strategy for their use remains unclear.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9356004
Mittl RL, Schwab RJ, Duchin JS et al. Radiographic resolution of community-acquired
pneumonia. Am J Resp Crit Care 1994;149:630-5. Prospective follow-up of both inpatients and
outpatients with diagnosis of CAP is cited as a guide for when to look for endobronchial lesions
in the setting of slowly clearing pneumonia. The study found age and multilobar disease were
independent predictors of delayed resolution. Radiographic resolution seen in 51% at 2 weeks,
67% at 4 weeks, and 90% at 12 weeks.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=8118630
COPD
Overview
Pauwels RA, Buist AS, Calverley PMA et al. Global strategy for the diagnosis, management, and
prevention of COPD: GOLD workshop summary. AJRCCM 2001;163:1256-76. Supported by the
NHLBI and WHO and endorsed by the ATS, the summary is a bit more flexible than the previous
ATS guidelines, places greater emphasis on the use of NIPPV during exacerbations, and has
revised recommendations for the use of inhaled corticosteroids.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11316667
Supplemental oxygen
Continuous or nocturnal oxygen therapy in hypoxemic COPD. The NOTT group. Ann Intern Med
1980;93(3):391-8. Famous multicenter study showing use of continuous oxygen therapy (>17
hr/d) resulted in lower mortality than use of nocturnal therapy (12 hr/d) in pts. with PaO2 55
mmHg or PaO2 59 mmHg and pulmonary hypertension, right-sided failure, or Hct 55%.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=6776858
Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic
bronchitis and emphysema. MRC Working Party. Lancet 1981;8222:681-5. Another well- known
study showing improved survival with continuous oxygen in hypoxemic COPD patients.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=6110912
Tiep BL. Oxygen conserving devices. Up to Date, 7/30/99. Practical review of different modes of
O2 delivery for LTOT.
O'Donohue W Jr., Tiep BL, Carter R. Long-term supplemental oxygen therapy. Up to Date,
1/16/04. Useful review of the indications and requirements for prescribing long-term oxygen
therapy.
Stoller JK. Oxygen and air travel. Respir Care 2000;45:214-21. Summarizes readily available
means of assessing travelers' in-flight oxygen needs.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10771793
Survival
Traver GA, Cline MG, Burrows B. Predictors of mortality in COPD: A 15-year f/u study. Amer Rev
Res Dis 1979;119:895-902. Ubiquitously-cited study looking at FEV1 and survival. After
controlling for age, the FEV1 after bronchodilator was the best predictor of survival, but was less
predictive in patients over 65. The observed wide variability in survival of individual patients with
similar initial FEV1 values has important implications for patients considering surgical
treatments for their COPD.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=453709
Anthonisen NR. Prognosis in COPD: results from multicenter clinical trials. Am Rev Respir Dis
1989:140:S95-9. This analysis of previous trials found that COPD patients with hypoxemia had
worse survival than non-hypoxemic COPD patients with equivalent FEV1.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=3510578
Inhaled and systemic steroids
Pauwels RA, Lofdahl CG, Laitinen LA, et al. Long-term treatment with inhaled budesonide in
persons with mild COPD who continue smoking. NEJM 1999;340:1948-1953. Study of inhaled
corticosteroid in smokers with mild COPD showed a modest improvement in FEV1 relative to
placebo in the first 6 months, but no benefit during the subsequent 2.5 years.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10379018
Burge PS, Calverley PMA, Jones PW, et al. Randomised, double blind, placebo controlled study of
fluticasone proprionate in patients with moderate to severe COPD: the ISOLIDE trial. BMJ
2000;320:1297-1303. Use of inhaled steroid did not improve the rate of decline in FEV1
compared to placebo. The Flovent group had a median of 0.99 exacerbations/yr vs. 1.32/yr in
the placebo arm. Response to oral steroids given in the run-in phase was not predictive of
subsequent benefit from inhaled steroid.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10807619
The Lung Health Study Research Group. Effect of inhaled triamcinolone on the decline in
pulmonary function in COPD. NEJM 2000;343:1902-09. Randomized, controlled study followed
over 1000 patients for an average of 4.5 yrs and found no difference in rate of decline in FEV1 in
the inhaled steroid group. Patients using triamcinolone had, by some measures, fewer
symptoms, but also had a greater rate of decline in bone density that is of unknown clinical
significance.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11136260
Fan VS, Bryson CL, Curtis JR, et al. Inhaled corticosteroids in COPD and risk of death and
hospitalization. AJRCCM 2003;168;1488-94. Prospective cohort study of over 8,000 patients
from 7 VA medical centers. The authors defined ICS-users as being on medication at least 80%
of the time based on pharmacy records and performed a time-dependent analysis to account for
changing ICS use over time. Unlike a number of recent observational studies, this study found
the use of ICS was not associated with reduced mortality and exacerbations.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=14525798
van der Valk P, Monninkhof E, van der Palen J, et al. Effect of discontinuation of inhaled
corticosteroids in patients with COPD. AJRCCM 2002;166:1358-63. Randomized, blinded,
placebo-controlled, single-center study of 244 patients with a mean FEV1% predicted of 57%
found more patients in the placebo arm experienced an exacerbation over a 6-month follow-up
period (57 vs. 47%; hazard ratio for 1st exacerbation 1.5 [CI] 1.1-2.5). Subgroup analysis found
benefit derived primarily by patients with baseline FEV1 < 50% predicted.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12406823
Calverley P, Pauwels R, Vestbo J, et al. Combined salmeterol and fluticasone in the treatment of
COPD: a RCT. Lancet 2003;361:449-56. Large study found patients receiving combination
therapy had some improvement in symptoms and FEV1 compared to using each component
individually, but there was no difference in frequency of exacerbations.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12583942
Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on
exacerbations of COPD. NEJM 1999;340:1941-7. Multicenter, double-blind, placebo- controlled
study found modest benefit to use of high-dose intravenous steroids. Steroid group had fewer
treatment failures (combined endpoint of death, need for intubation, readmission, or
intensification of pharmacologic therapy), and shorter hospital stays, but the primary benefit was
in decreasing the need to intensify therapy with use of open-label steroids. No benefit from
steroids was present at 6 months of f/u, and 2 week and 8 week courses were equally effective.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10379017
Role of antibiotics
Anthonisen NR, Manfreda J, Warren CPW et al. Antibiotic therapy in exacerbations of COPD. Ann
Intern Med 1987;106:196-204. Famous study often cited by proponents of antibiotic use for
COPD exacerbations. Randomized, blinded, controlled study found use of antibiotics in the
presence of increased dyspnea, increased sputum production, and increased sputum purulence
improved outcomes. The improvement was no longer significant, however, after controlling for
use of oral steroids.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=3492164
Hirschmann JV. Do bacteria cause exacerbations of COPD? vs. Murphy TF, Sethi S, Niederman
MS. The role of bacteria in exacerbations of COPD: A constructive view. Both from CHEST
2000;118:198-209. The articles are presented in a debate format.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10893379
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10893380
Lung volume reduction surgery
Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumonectomy (volume reduction) for
COPD. J Thorac Cardiovasc Surg 1995;109:106-19. This paper revived interest in LVRS for COPD
and has generated lots of controversy.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=7815786
NETT Research Group. Patients at high risk of death after lung-volume-reduction surgery. NEJM
2001;345:1075-83. Early results from NETT found a 16% 30-day mortality following LVRS in the
69 patients with FEV1 < 20% predicted AND homogenous disease per CT OR DLCO < 20%
predicted. This population had higher overall mortality than comparable patients randomized to
medical treatment. Survivors of LVRS had modest improvements in exercise tolerance and FEV1,
but similar measures of quality of life.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11596586
Fishman A, Martinez F, Naunheim K, et al. A randomized trial comparing lung-volume-reduction
surgery with medical therapy for severe emphysema: NETT Research Group. NEJM
2003;348:2059-73. After excluding the 140 pts identified as having high risk of mortality based
on the above interim analysis, a greater proportion of LVRS patients had improved exercise
tolerance compared to the medical therapy arm (16% vs. 3%), but there was no survival
advantage after 24 months. Subgroup analysis found patients with predominantly upper lobe
disease and low exercise capacity had improved mortality, while patients with non-upper lobe
emphysema and high exercise capacity had higher mortality following LVRS compared to
medical therapy.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12759479
**See also Lung Cancer, Lung Transplantation, and Non-invasive Mechanical Ventilation
Cough
Irwin RS, Madison JM. The persistently troublesome cough. AJRCCM 2002;165:1469-74. Good
review covering the evaluation and treatment of acute, subacute, and chronic cough.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12045118
Cystic Fibrosis
Pryor JA. Physiotherapy for airway clearance in adults. Eur Respir J 1999;14:1418-24.
Somewhat cursory overview of common airway clearance techniques used in the setting of CF,
neuromuscular disease, and other diseases associated with impaired secretion clearance. The
author also touches on the paucity of evidence supporting the superiority of any one approach.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10624775
Fuchs HJ, Borowitz DS, Christiansen DH, et al. Effect of aerosolized recombinant human DNase
on exacerbations of respiratory symptoms and on pulmonary function in patients with cystic
fibrosis: the Pulmozyme Study Group. NEJM 1994;331:637-42. Large RCT found patients
receiving a 24-week course of Pulmozyme had an improvement in FEV1 of 5% compared to
placebo and decreased exacerbation rate (28 vs. 37% in placebo group).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=7503821
Ramsey BW, Pepe MS, Quan JM, et al. Intermittent administration of inhaled tobramycin in
patients with cystic fibrosis. NEJM 1999;340:23-9. Study found use of TOBI on alternating
months improved lung function, decreased bacterial burden, and decreased the relative risk of
hospitalization. The rate of acquired tobramycin resistance was about 7% over 24 weeks.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9878641
Saiman L, Marshall BC, Mayer-Hamblett N, et al. Azithromycin in patients with cystic fibrosis
chronically infected with pseudomonas aeruginosa. JAMA 2003;290:1749-56. Large
multicenter RCT of 6 months duration found chronic azithromycin resulted in a 4.4%
improvement in FEV1% predicted compared to a 1.8% decline in placebo. The azithromycin
group had fewer exacerbations and gained more weight.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=14519709
Kerem E, Reisman J, Corey M, et al. Prediction of mortality in pts with cystic fibrosis. NEJM
1992;326:1187-91. Established FEV1 < 30% predicted as the strongest, albeit suboptimal,
predictor of mortality. A clearly superior means of predicting mortality in order to optimize
timing of lung transplantation remains elusive. See also Lung Transplantation.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=1285737
Drug Toxicities
Rosenow EC, Myers JL, Swensen SJ, et al. Drug-induced pulmonary disease: an update. CHEST
1992;102:239-250. Review covering the more common drug toxicities with some degree of
categorization by clinical presentation. Almost 10 years old. Keep an eye out for something more
recent.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=1623761
Web site: www.pneumotox.com
End of Life Care
Withholding and withdrawing life-sustaining therapy. ATS Statement. Am Rev Respir Dis
1991;144:726-31. Statement covers patient autonomy, surrogate decision-making, and futility.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=1892317
Tonelli MR. Pulling the plug on living wills. CHEST 1996;110:816-22. Discusses the difficulties
and limitations of formulating and applying advanced directives.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=8797430
A controlled trial to improve care for seriously ill hospitalized patients. SUPPORT Investigators.
JAMA 1995;274:1591-8. This landmark study found interventions to increase physician
awareness of prognosis and facilitate communication between physicians and patients or
surrogates made no significant difference compared to controls. Preference for CPR was
discussed with a minority of patients, physicians often were unaware of their patients'
preferences for CPR.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=7474243
Luce JM. Making decisions about the forgoing of life-sustaining therapy. AJRCCM
1997;156:1715-8. Commentary that summarizes much of the recent research in this area.
Emphasizes the need to reaffirm patient autonomy and to be cautious in the use of "futility" as a
reason to withdraw care.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9412545
Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill
patients. AJRCCM 1998;1163-7. Survey of all U.S. training programs with significant critical care
exposure (48% participation) found 38% of dying patients had support withdrawn and only 23%
had full ICU care including CPR. Study noteworthy for marked variation in practice between ICUs.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9769276
Truog RD, Cist AFM, Brackett SE, et al. Recommendations for end-of-life care in the intensive
care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med
2001;29:2332-48. Recommendations for clinical care of dying patients in the ICU derived from
data and expert opinion.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11801837
Hemoptysis
Dweik RA, Stoller JK. Role of bronchoscopy in massive hemoptysis. Clin Chest Med 1999;20:89104. Good resource, but does not incorporate chest CT into the evaluation.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10205720
Hirshberg B, Biran I, Glazer M, et al. Hemoptysis: etiology, evaluation, and outcome in tertiary
referral hospital. Chest 1997;112:440-44. Large case series from Jerusalem included because
few large studies published recently. Study indicates bronchoscopy and chest CT have a
complementary role in evaluation.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9266882
HIV and Pulmonary Disease
Chin DP, Hopewell PC. Mycobacterial complications of HIV infection. Clin Chest Med
1996;17:697-711. Covers the atypical presentation of TB and atypical mycobacterium in this
population.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9016372
Gagnon S, Boota AM, Fischl MA, et al. Corticosteroids as adjunctive therapy for severe PCP in
AIDS. NEJM 1990;323:1444-50. One of three studies published in the same year establishing
the efficacy of steroids in severe PCP in patients with AIDS.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=2233916
Hirschtick RE, Glassroth J, Jordan MC, et al. Bacterial pneumonia in persons infected with the
human immunodeficiency virus. Pulmonary Complications of HIV Infection Study Group. NEJM
1995;333:845-51. Part of the landmark PCHIS study, this is the first and best prospective study
of CAP in HIV-infected patients.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=7651475
Beck JM, Rosen MJ, Peavy HH. Pulmonary complications of HIV infection. Report of the 4 th NHLBI
Workshop. AJRCCM 2001;164:2120-6 Summarizes current knowledge of HIV-associated
pulmonary diseases since the advent of HAART.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11739145
Interstitial Lung Disease
Overviews
American Thoracic Society/European Respiratory Society international multidisciplinary
consensus classification of the idiopathic interstitial pneumonias. AJRCCM 2002;165:277-304.
Written to standardize the diagnostic criteria and terminology for idiopathic interstitial
pneumonias, this article nicely summarizes the clinical, radiologic, and histologic features of the
ILD alphabet soup.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11790668
Mathieson JR, Mayo JR, Staples CA, Muller NL. Chronic diffuse infiltrative lung disease:
comparison of diagnostic accuracy of CT and chest radiography. Radiology 1989;171:111-16.
First study to assess accuracy of CT-based diagnosis for patients with ILD. Correctly diagnosed
UIP in 89% of cases, sarcoid in 77% of cases, and were, for the most part, less accurate in
diagnosing less common diseases. Includes an interesting table of the frequency of selected CT
findings observed among the 5 most common ILDs in the study (e.g. pleural fluid/thickening
seen in only 9% of UIP cases).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=2928513
Organizing Pneumonia
Epler GR, Colby TV, McCloud TC, et al. Bronchiolitis obliterans organizing pneumonia. NEJM
1985;312:152-8. Classic article describing idiopathic BOOP (now known as cryptogenic
organizing pneumonia)
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=3965933
Idiopathic Pulmonary Fibrosis
Douglas WW, Ryu JH, Swensen SJ, et al. Colchicine vs. prednisone in the treatment of IPF: a
randomized prospective study. AJRCCM 1998;158:220-5. Study found colchicine and prednisone
equally ineffective. Colchicine had less toxicity.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9655733
Ziesche R, Hofbauer E, Wittmann K, et al. A preliminary study of long-term treatment with IFN
gamma-1b and low dose prednisolone in patients with IPF. NEJM 1999;341:1264-9. Small study
found use of IFN promising in patients with IPF not responding to initial therapy. Results of a
multicenter study are pending as of 12/03.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10528036
Raghu G, Depaso WJ, Cain K, et al. Azathioprine combined with prednisone in the treatment of IPF. Am Rev
Respir Dis 1991;144:291-6. RCT of prednisone plus imuran vs. prednisone alone found some patients had
greater benefit with the combination of drugs, but overall differences between groups did not reach
statistical significance. Some current trials of new therapies use this combination in the control group.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=185
9050
Hunninghake GW, Zimmerman MB, Schwartz DA, et al. Utility of a lung biopsy for the diagnosis
of idiopathic pulmonary fibrosis. AJRCCM 2001;164:193-6. Study found pulmonologists and
radiologists with expertise in interstitial lung disease reliably made a clinical diagnosis of IPF
when compatible clinical and radiologic data were present (only 50% of all IPF cases).
Transbronchial biopsy was helpful in 2% of cases and pathologists did not agree on the
histologic diagnosis.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11463586
Sarcoidosis
Statement on sarcoidosis. Joint Statement of the American Thoracic Society (ATS), the European
Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous
Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee,
February 1999.. AJRCCM 1999;160:736-55. Comprehensive and relatively readable.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10430755
**See also Pulmonary Hypertension, Lung Transplantation, and Occupational Medicine
Invasive Mechanical Ventilation
Darioli R, Perret C. Mechanical controlled hypoventilation in status asthmaticus. Am Rev Respir
Dis 1984;129:385-7. Noteworthy for being the first description of permissive hypercapnea and
low tidal volumes during mechanical ventilation of asthmatics high airway pressures.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=6703497
Marini JJ, Pierson DJ, and Hudson LD. Acute lobar atelectasis: a prospective comparison of
fiberoptic bronchoscopy and respiratory therapy. Amer Rev Resp Dis 1979;119:971-8. This could
be useful in fending off suck bronchs. Study found FOB followed by RT no better than RT alone at
24-48 hours.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=453712
Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of
identifying patients capable of breathing spontaneously. NEJM 1996;335:1864-9. RCT found
protocol of daily weaning parameters followed by trials of spontaneous breathing in appropriate
patients and subsequent notification of physicians of successful trials reduced the duration of
mechanical ventilation compared to usual care (daily weaning parameters only).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=8948561
Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from
mechanical ventilation. NEJM 1995;332:345-50. Prospective, randomized study found oncedaily or multiple daily trials of spontaneous breathing (T-piece or CPAP <5 cm) resulted in more
rapid successful extubation than gradual weaning of pressure support or IMV.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=7823995
Brochard L, Rauss A, Benito S, et al. Comparison of three methods of gradual withdrawal from
ventilatory support during weaning from mechanical ventilation. AJRCCM 1994;150:896-903.
Prospective, randomized study found weaning with pressure support mode superior to SIMV
mode and T-piece trials.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=7921460
Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning
from mechanical ventilation. NEJM 1991;324:1445-50. Study in a VA population found the rapid
shallow breathing index (RSBI = RR/Vtidal) was the single best predictor of weaning success
(sensitivity 0.97, specificity 0.64).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=2023603
**See also ARDS and Noninvasive Ventilatory Support.
Lung Cancer
Staging
Mountain CF. Revisions in the international system for staging lung cancer. CHEST
1997;111:1710-1717. The staging revisions were made to better group TNM patterns with
similar prognosis and approach to treatment. Includes expected survival for clinically and
surgically staged cancer at 1 through 5 years.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9187198
Van Tinteren H, Hoekstra OS, Smit EF, et al. Effectiveness of PET in the preoperative assessment
of patients with suspected non-small-cell lung cancer: the PLUS multicentre randomised trial.
Lancet 2002;359:1388-93. Efficacy study found addition of PET to conventional work-up
decreased futile thoracotomies and the combination of PET and conventional workup was 79%
sensitive for identifying futile thoracotomies.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11978336
Gould MK, Kuschner WG, Rydzak CE, et al. Test performance of PET and CT for mediastinal
staging in patients with non-small-cell lung cancer. Ann Intern Med 2003;139:879-92. This
meta-analysis found a median sensitivity of 85% and specificity of 90% for PET in determining
the presence of mediastinal disease in known or suspected NSCLC. PET's median sensitivity
improved to 100% and median specificity fell to only 78% in the presence of lymphadenopathy
on CT while PET had a median sensitivity of 82% and median specificity of 93% in the absence
of lymphadenopathy.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=14644890
Fritscher-Ravens A, Davidson BL, Hauber H, et al. Endoscopic ultrasound, PET, and CT for lung
cancer. AJRCCM 2003;168:1293-7. This is the largest study to date comparing PET and
endoscopic ultrasound with fine-needle aspiration for staging potentially operable patients with
known or suspected lung cancer. PET and ultrasound had similar sensitivity and negative
predictive value, but ultrasound had 100% specificity. A cost-analysis favored endoscopic
ultrasound over PET.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12904322
Screening for lung cancer
The following articles are the basis for the belief that screening with CXR and/or sputum
cytology does not work. Many have expressed concern about the quality of these studies.
Fontana RS, Sanderson DR, Taylor WF, et al. Early lung cancer detection: results of the initial
(prevalence) radiologic and cytologic screening in the Mayo Clinic study. Am Rev Respir Dis
1984;130:561-5. Also includes a summary of the combined results of the Mayo, SloanKettering, and Johns Hopkins study sites on pp 565-70.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract
&list_uids=6091507
Melamed MR, Flehinger BJ, Zaman MB, et al. Screening for lung cancer: results of the
Memorial Sloan-Kettering study in New York. CHEST 1984;86:44-53.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract
&list_uids=6734291
Frost JK, Ball WC, Levin ML, et al. Early lung cancer detection: results of the initial
(prevalence) radiologic and cytologic screening in the Johns Hopkins study. Am Rev Respir
Dis 1984;130:549-54
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract
&list_uids=6091505
Kubik A, Parkin DM, Khlat M, et al. Lack of benefit from semi-annual screening for cancer of
the lung: follow-up of a randomized controlled trial on a population of high-risk males in
Czechoslavakia. Int J Cancer 1990;45:26-33.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract
&list_uids=2404878
The following articles address screening with chest CT scans.
Henschke CI, McCauley DI, Yankelevitz DF, et al. Early lung cancer action project: overall
design and findings from baseline screening. Lancet 1999;354:99-105. Study of annual low
dose CT in detecting lung cancer in 1000 heavy smokers identified noncalcified nodules in
23% of patients and 12% of nodules were malignant. The yield was near miraculous as 27
of 28 biopsies were positive for malignancy, and 87% of these were stage I. Large scale
study to confirm findings and assess long-term survival benefit and costs is in progress.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract
&list_uids=10408484
Swenson SJ, Jett JR, Sloan JA, et al. Screening for lung cancer with low-dose spiral computed
tomography. AJRCCM 2002;165:508-13. Unlike the Henschke study above, 66% of 1,520
patients age > 50 and tobacco use > 20 pack-years had one or more non-calcified nodules.
One year after enrollment, 1.7% of enrolled patients were diagnosed with lung cancer (1.1%
of all nodules were malignant) and 0.9% of participants were diagnosed with stage IA
NSCLC. Seven of 29 resected nodules were benign.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract
&list_uids=11850344
Risk factors
Tockman MS, Anthonisen NR, Wright EC, et al. Airways obstruction and the risk for lung cancer.
Annals Intern Med 1987;106:512-18. This study found smokers with COPD had about a 5-fold
risk of developing lung cancer compared to smokers without COPD. The more severe the COPD,
the greater the risk.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=3826952
**See also Solitary Pulmonary Nodule
Lung Transplantation
Overviews
International guidelines for the selection of lung transplant candidates. The American Society for
Transplant Physicians (ASTP)/American Thoracic Society(ATS)/European Respiratory
Society(ERS)/International Society for Heart and Lung Transplantation(ISHLT). AJRCCM
1998;158:335-9. This is an excellent overview of referral criteria for potential lung
transplantation candidates. Oh, by the way, this is also the document used for questions on the
pulmonary boards regarding referral criteria and absolute contraindications to transplant.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9655748
Arcasoy SM, Kotloff RM. Lung transplantation. NEJM 1999;340:1081-91.
This is a well written concise introduction to transplant ideal for the fellow. Includes discussions
of listing, surgical technique, and post-transplant outcomes as well as a table summarizing the
side effects and common drug interactions associated with immunosuppressant medications.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10194239
Bronchiolitis obliterans
Estenne M, Hertz MI. Bronchiolitis obliterans after human lung transplantation. AJRCCM
2002;166:440-4. Good review of what is known about bronchiolitis obliterans. Also discusses
the limitations of using the clinical entity “bronchiolitis obliterans syndrome” in the post
transplant recipient.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12186817
Non-pulmonary complications of lung transplantation
Maurer JR, Tewari S. Nonpulmonary medical complications in the intermediate and long-term
survivor. Clin Chest Med 1997;18:367-82.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9187828
Survival
Hosenpud JD, Bennett LE, Keck BM, et al. Effect of diagnosis on survival benefit of lung
transplantation for end-stage lung disease. Lancet 1998;351(9095):24-7. Well-devised analysis
of potential survival benefit for patients afflicted with CF, COPD, and IPF listed for transplant by
UNOS. Major limitations are that the paper evaluates outcomes from more than 10 years ago
and listing practice assumptions from the model may not hold true at this time.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9433425
De Meester J, Smits JM, Persijn GG, et al. Listing for lung transplantation: life expectancy and
transplant effect, stratified by type of end-stage lung disease, the Eurotransplant experience. J
Heart Lung Transplant 2001;20:518-24. Analysis of survival benefit using the Eurotransplant
wait list and post transplant survival.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11343978
Future directions
Gerhardt SG, McDyer JF, Girgis RE, et al. Maintenance azithromycin therapy for bronchiolitis
obliterans syndrome: results of a pilot study. AJRCCM 2003;168:121-5. Interesting pilot study
found chronic macrolide therapy improved the FEV1 in 5 of 6 patients with bronchiolitis
obliterans syndrome.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12672648
Johnson BA, Iacono AT, Zeevi A, et al. Statin use is associated with improved function and
survival of lung allografts. AJRCCM 2003;167(9):1271-1278. Although this is a non-randomized,
retrospective study, the rigorous analysis, improved outcomes, and the postulated mechanism of
benefit for this drug class make the findings provocative.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12615629
Goldfarb NS, Avery RK, Goormastic M, et al. Hypogammaglobulinemia in lung transplant
recipients. Transplantation 2001;71(2):242-246. This retrospective single-institution review of
67 patients found IgG deficiency is common in post-transplant patients and is associated with
increased risk of infection and decreased survival. It remains to be seen if altering treatment to
improve IgG has an effect on subsequent risk for infection.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11213067
**See also Arcasoy et al under Pulmonary Hypertension
Noninvasive Ventilatory Support
In COPD
Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of
COPD. NEJM 1995;333:817-22. Landmark prospective, randomized study found use of NIPPV in
selected patients with COPD exacerbations resulted in fewer intubations, complications, days in
hospital, and lower in-hospital mortality compared to standard treatment.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=7651472
Nava S, Ambrosino N, Clini E, et al. Non-invasive mechanical ventilation in the weaning of
patients with respiratory failure due to chronic obstructive pulmonary disease. Ann Intern Med
1998;128:721-8. Oft-cited RCT included 50 patients intubated for a COPD exacerbation who
failed a T-piece trial. Patients randomized to immediate extubation to NIPPV had decreased
duration of mechanical ventilation and improved survival compared to the control group
undergoing PS wean with twice daily spontaneous breathing trials.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9556465
In hypoxemic respiratory failure (all types):
Declaux C, L'Her E, Alberti C, et al. Treatment of acute hypoxemic nonhypercapnic respiratory
insufficiency with CPAP delivered by face mask. JAMA 2000;284:2352-60. Prospective,
randomized, multicenter study compared oxygen to oxygen plus CPAP in this population (123
patients;17% cardiac etiology, 83% ALI). Study found no difference in the need for intubation,
lenghth of hospital stay, or hospital mortality, and the CPAP group had an increased incidence of
adverse events.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11066186
Antonelli M, Conti G, Rocco M, et al. A comparison on NIPPV and conventional mechanical
ventilation in patients with acute respiratory failure. NEJM 1998;339:429-35. Randomized study
compared NIPPV with immediate intubation and conventional ventilation in 64 patients with
acute, non-hypercapnic, hypoxemic respiratory failure (19% cardiogenic and 25% ARDS). Use of
NIPPV resulted in gas exchange and survival comparable to conventional ventilation but was
associated with fewer serious complications and shorter ICU stays.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9700176
Ferrer M, Esquinas A, Leon M, et al. Non-invasive ventilation in severe hypoxemic respiratory
failure: a randomized clinical trial. AJRCCM 2003;1681140-44. Study of 105 non-hypercapneic
patients found NIPPV decreased need for intubation and improved 90-day survival compared to
oxygen therapy alone. Subgroup analysis found the 34 patients with pneumonia had the
greatest benefit while mask ventilation did not appear to reduce the need for intubation in
patients with ARDS and cardiogenic edema.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=14500259
In cardiogenic hypoxemic respiratory failute:
Bersten AD, Holt AW, Vedig AE, et al. Treatment of severe cardiogenic pulmonary edema with
CPAP delivered by face mask. NEJM 1991;325:1825-30. Randomized study of 39 patients with
hypercapnic cardiogenic respiratory failure found use of CPAP plus oxygen resulted in better gas
exchange in the first 24 hours and less need for intubation than use of oxygen alone.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=1961221
Masip J, Betbese AJ, Paez J, et al. Non-invasive pressure support ventilation versus conventional
oxygen therapy in acute cardiogenic pulmonary oedema: a randomized trial. Lancet
2000;356:2126-32. Study of 37 patients (of whom 43% had hypercapnia) found pressure
support by mask reduced the need for intubation (5% vs. 33%). There was no difference in
duration of hospital admission or mortality.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11191538
Nava S, Carbone G, DiBattista, N, et al. Non-invasive ventilation in cardiogenic pulmonary
edema: a multicenter randomized trial. AJRCCM 2003;168:1432-7. This larger study (130
patients) found non-invasive pressure support did not improve outcomes compared to
conventional therapy. Mask ventilation reduced intubations in the 64 patients with PaCO2 > 45
mmHg (6% vs. 29%), but this difference was not significant after regression analysis.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12958051
In neuromuscular weakness
Benditt JO. Management of pulmonary complications in neuromuscular disease. Phys Med
Rehab Clin 1998;9:167-85. Nice review of negative and positive pressure ventilation, indications,
costs, and benefits of initiating ventilation in this population.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9894139
Occupational Medicine
Asthma/RADS
Blanc PD, Toren K. How much adult asthma can be attributed to occupational factors? Am J Med
1999;107:580-7. Based on a critical review and synthesis of the published literature, the authors
estimate occupational factors are associated with 10% of adult asthma cases.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10625027
Burge PS, O’Brien IM, Harries MG. Peak flow rate records in the diagnosis of occupational
asthma due to isocyanates. Thorax 1979;34:317-24. Landmark study was the first to show
peak flow is a suitable alternative to provocation testing in the diagnosis of OA.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=483205
Charous BL, Blanco C, Tarlo S, et al. Natural rubber latex allergy after 12 years:
recommendations and perspectives. J Allergy Clin Immunol 2002;109:31-4. Reviews the
relationship between exposure to powdered natural rubber latex gloves and asthma and makes
recommendations for non-powdered gloves.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11799362
Brooks SM, Weiss MA, Bernstein IL. Reactive airways dysfunction syndrome (RADS): persistent
asthma syndrome after high level irritant exposures. CHEST 1985;88:376-84. Landmark article
describing 10 patients in which the term “RADS” was coined. In the majority of cases
respiratory symptoms and hyperreactivity persisted for greater than 1 year after a large exposure
to vapor, fumes, or smoke.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=4028848
Zock JP, Jarvis D, Luczynska C, et al. Housing characteristics, reported mold exposure, and
asthma in European Community Respiratory Health Survey. J Allergy Clin Immunol
2002;110:285-92. Multicenter study looked at the association between mold exposure (based
on questionnaire) and asthma (based on symptoms and methacholine challenge) and concluded
that mold growth has an adverse effect on adult asthma.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12170270
Associations with interstitial lung disease and neoplasia
Selikoff IJ, Hammond EC, Churg J. Asbestos exposure, smoking, and neoplasia. JAMA
1968;204:106-12. Landmark study showing the synergistic effect of smoking and asbestos
exposure on developing lung cancer.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=5694532
Wagner JC, Sleggs CA, Marchand P. Diffuse pleural mesothelioma and asbestos exposure in the
NW Cape Province. Br J Ind Med 1960;17:260-71. Landmark study linking mesothelioma to
asbestos exposure.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=13782506
Adverse effects of crystalline silica exposure. American thoracic society committee of the
scientific assembly on environmental occupational health. AJRCCM 1997;155:761-8. Reviews
the epidemiology and prevention of silica-associated lung diseases including silicosis, asthma,
tuberculosis, and extrapulmonary diseases. This document is also available in UpToDate.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9032226
Rossman MD, Kern JA, Elias JA, et al. Proliferative response of bronchoalveolar lymphocytes to
beryllium. A test for chronic beryllium disease. Ann Intern Med 1988;108:687-93. Article
noteworthy for establishing the use of the lymphocyte proliferation test in the diagnosis of
chronic beryllium disease.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=3282464
Infante PF, Newman LS. Beryllium exposure and chronic beryllium disease. Lancet
2004;363:415-6. The authors highlight the lack of adequate protection for workers, the
underdiagnosis of CBD by providers, and the growing number of industries in which exposure
occurs.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=14962519
Parapneumonic Effusion
Light RW, MacGregor MI, Luchsinger PC, et al. Pleural effusions: the diagnostic separation of
transudates and exudates. Ann Intern Med 1972;77:507-13. This paper is the basis for using
pleural fluid LDH and protein to classify effusions as transudative or exudative.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=4642731
Light RW, Girard WM, Jenkinson SG, et al. Parapneumonic effusions. Amer J Med 1980;69:50712. The notion that a parapneumonic effusion with pH less than 7.0 or glucose < 40mg/dl is
"complicated" and requires drainage is derived from this study. Study included a total of 10
patients (7 with + cultures, 3 with pus). 6 of 10 met the pH criteria and 7 of 9 met the glucose
criteria.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=7424940
Berger HA, Morganroth ML. Immediate drainage is not required for all patients with complicated
parapneumonic effusions. CHEST 1990;97:731-5. Oft-cited retrospective study found 13 of 16
patients with complicated effusions (defined as pH < 7.2 or positive GS or positive culture, but
without pus present) had resolution of effusions with antibiotics alone.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=2306975
Bouros D, Schiza S, Siafakas N. Utility of fibrinolytic agents for draining intrapleural infections.
Sem Resp Infect 1999;14:39-47. Reviews the somewhat limited data indicating use of lytics
decreases the need for surgery compared to chest tube drainage alone in patients with
empyema and complicated effusions. Patients successfully managed without surgery about 85%
of time. Chest tube patency maintained with qid NS flushes in successful trials.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10197396
Wait MA, Sharma S, Hohn J, Dal Nogare A. A randomized trial of empyema therapy. CHEST
1997;111:1548-51. Only randomized trial comparing immediate VATS to tube thoracostomy
plus 3 days of daily SK (only 20 patients total). The surgical group had better primary treatment
success and earlier hospital discharge, but outcomes of patients randomized to chest tube/lytics
was much worse than other reported series, suggesting suboptimal management of those
patients. All medical failures were salvageable with VATS.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9187172
Davies CWH, Kearney SE, Gleeson FV, Davies RJO. Predictors of outcome and long-term survival
in patients with pleural infection. AJRCCM 1999;160:1682-87. In the absence of frank
empyema, tube thoracostomy plus lytics had a PPV of 93% for successful treatment (i.e. no
need for surgery). The presence of pus had a PPV for failure of medical management of 26%.
Fluid characteristics, effusion size, and degree of pleural thickening were not predictive of
medical failure. Study didn't consider presence of loculations or assess long-term outcomes. In
part included because it is a good model of how to optimally manage patients when electing to
use chest tube drainage rather than VATS.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10556140
Ashbaugh DG. Empyema thoracis. Factors influencing morbidity and mortality. Chest
1991;99:1162-5. Study of 122 consecutive patients looked at the morbidity and mortality of
delaying treatment of empyema. Waiting more than 3 days to place a chest tube, and more than
14 days to proceed to surgical drainage when chest tubes fail, was associated with increased
morbidity and mortality.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=2019172
Colice GL, Curtis A, Deslauriers J, et al. Medical and surgical treatment of parapneumonic
effusions. CHEST 2000;188:1158-71. "Evidence-based" guideline derived from relatively low
quality evidence reflective of above references. Tables summarize study designs, patient
populations, and outcomes of the better studies.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11035692
Pre-op Pulmonary Assessment
Bolliger CT, Perruchoud AP. Functional evaluation of the lung resection candidate. Eur Respir J
1998;11:198-212. Good summary of use of PFTs, split function tests, and exercise tests to
assess operative risk of lung resection.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9543294
Pollock M, Roa J, Benditt JO, et al. Estimation of ventilatory reserve by stair climbing: a study in
patients with chronic airflow obstruction. Chest 1993;104:1378-83. Study found linear increases
in VO2 and Ve with stair climbing. In order to reach a VO2 of 20ml/kg/min, subjects had to walk
4.6 flights of stairs, suggesting the tradition of walking patients up one or two flights is an
inadequate stress to predict tolerance of surgery.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=8222791
Thoren L. Post-operative pulmonary complication: observations on their prevention by means of
physiotherapy. Acta Chir Scand 1954;193-205. Pioneering study on the prevention of post-op
pulmonary complications found initiation of chest PT prior to surgery was superior to exclusively
post-operative therapy, which in turn was better than no therapy.
Procedures
Bronchoscopy
Cowl CT, Prakash UBS, Kruger BR. The role of anticholinergics in bronchoscopy. CHEST
2000;118:188-92. RCT found anticholinergics did not improve secretions, reduce the need for
topical anesthetic, or improve patient comfort.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10893378
Wang KP. Transbronchial needle apiration and percutaneous needle aspiration for staging and
diagnosis of lung cancer. Clin Chest Med 1995;16:535-52. Focuses on the nuts and bolts of the
technique rather than indications, yield, and risks. Diagrams of endobronchial landmarks for
different nodes may be of practical use just prior to procedure.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=8521707
Weiss SM, Hert RC, Gianola FJ et al. Complications of fiberoptic bronchoscopy in
thrombocytopenic patients. Chest 1993;104:1025-8. Established safety of transnasal bronchs in
thrombocytopenic patients.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=8404159
Herth FJF, Becker HD, Ernst A. Aspirin does not increase bleeding complications after
transbronchial biopsy. CHEST 2002;122;1461-4 Prospective study compared 285 patients
taking ASA within 24 hrs of TBB to 932 non-ASA users and found no difference in the risk of
minor, moderate, or major bleeding.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12377879
Chest Tubes
Gilbert TB, McGrath BJ, Soberman M. Chest tubes: indications, placement, management, and
complications. J Intensive Care Med 1993;8:73-86.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&lis
t_uids=10148363
Pleural Biopsy, Percutaneous
Schwartz ML, Sessler CN. When-and how- to perform percutaneous pleural biopsy. J Respir Dis
1991;12:1155-69. Offers a nice summary of the role of biopsy in the diagnosis of tuberculous
and malignant effusions and reviews biopsy technique with Abrams and Cope needles. See also
Light’s textbook “Pleural Diseases” if you do not have access to this journal. **See also
Tuberculosis
Thoracentesis
Jones PW, Moyers JP, Rogers JT et al. Ultrasound-guided thoracentesis: is it a safer method?
CHEST 2003;123:418-423. Prospective descriptive study of 605 patients referred for a total of
941 ultrasound-guided thoracenteses. 2.5% sustained a pneumothorax of whom a third
received a chest tube; this is a lower incidence than most reported studies without ultrasound
guidance, but all procedures were performed by 7 experienced interventional radiologists. As
with previous studies, the yield of routine post-procedure films was low in asymptomatic
patients; 3 of 907 had a pneumothorax managed with a chest tube. Of note, 2 of 373 patients
(0.5%) developed re-expansion pulmonary edema following removal of > 1 liter of fluid.
Investigators terminated fluid removal if the patient developed dyspnea or excessive cough.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12576360
Sallach SM, Sallach JA, Vasquez E, et al. Volume of pleural fluid required for diagnosis of pleural
malignancy. CHEST 2002;122:1913-17 In this retrospective case series, the yield of
thoracentesis for the diagnosis of malignancy was independent of the volume of fluid collected.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12475826
Pulmonary Embolism
Diagnosis:
PIOPED Investigators. Value of the ventilation/perfusion scan in pulmonary embolism: results of
the PIOPED. JAMA 1990;263:2753-2759. This ubiquitously-cited study found that VQ scans are
useful when they are high probability and normal, but that most of the time PE can't be ruled in
or out by VQ scan. Includes a useful table comparing clinical suspicion and VQ scan result
relative to PA gram result.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=2332918
Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of
patients with suspected pulmonary embolism. Ann Intern Med 1998;129:997-1005. Study used
a "minimally invasive" approach to managing patients with suspected PE, emphasizing use of
serial dopplers rather than PA grams in patients with a non-diagnostic initial work-up. Approach
is comparable to the 1999 ATS guidelines; it does not include CT angiography. A particular
strength of the study was the use of set criteria to establish clinical suspicion.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9867786
Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without
diagnostic imaging: management of patients with suspected pulmonary embolism presenting to
the emergency department by using a simple clinical model and d-dimer. Ann Intern Med
2001;135:98-107. Large prospective cohort study using the SimpliRED d-dimer assay (which
has sensitivity lower than, and specificity higher than, most other d-dimer tests) found the
combination of a low clinical suspicion for PE and a negative d-dimer safely ruled out pulmonary
embolism without additional testing.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11453709
Rathbun SW, Raskob GE, Whitsett TL. Sensitivity and specificity of helical CT in the diagnosis of
pulmonary embolism: a systematic review. Ann Intern Med 2000;132:227-32. This systematic
review concluded 1) the methodology of published studies is poor. 2) compared to pulmonary
angiography, sensitivity of helical CT ranged between 53 and 100% and specificity 81 to 100%.
3) studies had limited follow-up of patients with a negative CT. 4) CT can provide alternative
diagnosis in up to 33% of cases. 5) abnormal scans effectively rule in P.E.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10651604
Musset D, Parent F, Meyer G, et al. Diagnostic strategy for patients with suspected pulmonary
embolism: a prospective multicentre outcome study. Lancet 2002;360:1914-20 This prospective
cohort study found the combination of a good quality negative CT and negative lower extremity
ultrasound safely excluded PE in outpatients with low or moderate clinical probability (0.8%
diagnosed with PE during follow-up). Among inpatients, 4.8% with negative CT and ultrasound
were diagnosed with PE, or possibly had a PE, during follow-up. Of note, 15% of patients
diagnosed with PE had a negative CT but positive ultrasound.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12493257
Oudkerk M, van Beek EJ, Wielopolski P, et al. Comparison of contrast-enhanced magnetic
resonance angiography and conventional pulmonary angiography for the diagnosis of pulmonary
embolism: a prospective study. Lancet 2002;359:1643-7. MRA is a potentially attractive
alternative in the substantial number of patients with a non-diagnostic work-up and a
contraindication to CT angiogram. This study included 118 unselected patients with nondiagnostic perfusion scans who all underwent MRA and PA-grams. MRA had a sensitivity of 77%
and specificity 98% with higher sensitivity for central clot.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12020524
Dalen JE, Banas JS, Brooks HL, et al. Resolution rate of acute pulmonary embolism in man.
NEJM 1969;280:1194-99. This retrospective case series of non-consecutive patients is the basis
for the belief that use of pulmonary angiogram for the diagnosis of PE is not compromised if
performed within 7 days of presentation. Most patients had a large PE and use of
anticoagulation was sporadic.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=5767460
Nicod P, Peterson K, Levine M, et al. Pulmonary angiography in severe chronic pulmonary
hypertension. Ann Intern Med 1987;107:565-568. This study established the safety of
angiography in patients with chronic, severe pulmonary hypertension.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=3631791
Treatment
Hermann RE, Davis JH, Holden WD. Pulmonary embolism: a clinical and pathologic study with
emphasis on the effect of prophylactic therapy with anticoagulants. Amer J Surg 1961;102:1928. Study helped establish anticoagulation as the standard of care for the treatment of PE. The
40% mortality from embolism in this series likely reflects the ability to detect only larger emboli
at that time. Regardless, this high mortality has been cited as the rationale for anticoagulation.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=13713631
Schulman S, Granqvist S, Holmstrom M, et al. The duration of oral anticoagulation after a second
episode of venous thromboembolism. NEJM 1997;336:393-98. Randomized trial comparing
anticoagulation for 6 months compared to indefinitely in patients with a history of recurrent
embolism (including idiopathic and with risk factors). Recurrent thromboembolism occurred in
21% of patients in the 6 month group and in 2.7% of the indefinite group after 4 yrs of f/u. Major
bleeding occurred in 5% of patients of whom 18% died.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9010144
Agnelli G, Prandoni P, Becattini C, et al. Extended oral anticoagulant therapy after a first episode
of pulmonary embolism. Ann Intern Med. 2003;139:19-25. Randomized, non-blinded study of
extending anticoagulation beyond 3 months in patients with first episode of idiopathic PE and PE
associated with temporary risk factors. Extending anticoagulation in patients with idiopathic PE
from 3 to 12 months only delayed onset of what proved to be a high recurrence rate (4-5% per
patient-year once off anticoagulation). Findings highlight the need for new ways of identifying
patients at high risk of recurrence so that they can receive indefinite anti-coagulation.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12834314
Konstantinides S, Geibel A, Heusel G, et al. Heparin plus altepase compared with heparin alone
in patients with submassive pulmonary embolism. NEJM 2002;347:1143-50. Randomized,
double-blind study found lytic therapy in submassive PE did not improve mortality. Patients
randomized to lytics were significantly less likely than the placebo group to require escalation of
therapy, which primarily entailed administration of lytics. The indication for rescue therapy was
worsening respiratory symptoms, short of intubation, two-thirds of the time.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12374874
Prevention with vena caval filters.
Streiff MB. Vena caval filters: a comprehensive review. Blood 2000;95:3669-77. Excellent review
of the data available on each of the commonly placed filters, including efficacy and rate of
complications. A more recent update on the use of retrievable filters is needed. The author notes
the paucity of randomized trials and lack of long-term follow-up in existing studies, addresses
the controversies surrounding caval filters, and offers recommendations.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10845895
Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of
pulmonary embolism in patients with proximal DVT. NEJM 1998;338:409-15. This is the only
randomized trial involving filters. All patients were aniticoagulated and LMW and unfractionated
heparin were equally effective. 4.8% of patients receiving anticoagulation alone had PE vs. 1.1%
in filter + anticoagulation group at study day 12. There was no difference in rate of PE after
anticoagulation was discontinued, but the filter group had significantly more recurrent DVT.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9459643
Thromboendarterectomy for chronic thromboembolic disease
Snyder WA, Kent DC, Baisch BF. Successful endarterectomy of chronically occluded pulmonary
artery: clinical report and physiologic studies. J Thorac Cardiovasc Surg 1963;45:482-9. This, and
the Moser article below, are the first reports of the procedure.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=13993170
Moser KM, Rhodes G, Hufnagel CC. Chronic unilateral pulmonary artery thrombosis: successful
thromboendarterectomy with 30 month follow-up. NEJM 1965;272:1195-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=14284991
Jamieson SW, Kapelanski DP, Sakakibara N, et al. Pulmonary endarterectomy: experience and
lessons learned in 1,500 cases. Ann Thorac Surg 2003;76:1457-64. Summarizes entire UCSD
experience with thromboendarterectomy. The most recent 500 cases (through 12/02) are
discussed in greater detail. 30-day mortality in this group was 4.4%, which varied according to
type of thrombotic lesion and preoperative hemodynamics.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=14602267
Pulmonary Function Testing
General reviews
Clinics in Chest Medicine, volume 22, number 4, December 2001 contains reviews on the
measurement and interpretation of the entire spectrum of pulmonary function testing. A
particular strength is the discussion of how the pathophysiologic changes associated with
various disease states are reflected in studies of pulmonary function.
Exercise Testing
Weisman IM, Zeballos RJ. Clinical exercise testing. Clin Chest Med 2001;22:679-701. The focus
is on cardiopulmonary exercise testing, but this review also briefly summarizes the 6-minute
walk, testing for exercise-induced bronchoconstriction, and cardiac stress testing. An excellent
starting point for the novice.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11787659
ATS/ACCP Statement on cardiopulmonary exercise testing. AJRCCM 2003;167:211-77.
Somewhere between a textbook and a clinical review, this article provides more details on CPET
than the above Weisman
article.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstr
act&list_uids=12524257
Pulmonary Hypertension
Barst RJ, Rubin LJ, Long WA, et al. A comparison of continuous intravenous epoprostenol
(prostacyclin) and conventional therapy for primary pulmonary hypertension. NEJM
1996;334:296-301. RCT found the epoprostenol group had improved hemodynamics, quality of
life, and survival.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=8532025
Rich S, Kaufman E, Levy PS. The effect of high doses of calcium-channel blockers on survival in
primary pulmonary hypertension. NEJM 1992;327:76-81. Study with suboptimal design but
convincing hemodynamic data found improved survival and is the basis for use of CCBs in
patients with a good response to vasodilators.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=1603139
Badesch DB, Tapson VF, McGoon MD, et al. Continuous intravenous epoprostenol for pulmonary
hypertension due to scleroderma spectrum of disease. Ann Intern Med 2000;132:425- 34.
Noteworthy for showing benefit from prostacyclin in patients with a secondary cause of
pulmonary hypertension. RCT found prostacyclin improved exercise tolerance, modestly reduced
PA pressures, and improved dyspnea scores in some patients, but was associated with frequent
side effects and more adverse events. No difference in survival but trial was only of 12 weeks
duration.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10733441
Channick RN, Simonneau G, Sitbon O, et al. Effects of the dual endothelin-receptor antagonist
bosentan in patients with pulmonary hypertension: a randomized placebo-controlled study.
Lancet 2001;358:1119-23 First study of chronic bosentan in 32 patients with primary or
scleroderma-related pulmonary hypertension. Over the 12 weeks of the study, bosentan was
well-tolerated and improved cardiac index and exercise capacity (70 meter gain in 6-minute
walk). Similar results were obtained in a subsequent larger study of 213 patients (Rubin LJ et al.
NEJM 2002;346:896-903).
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=11597664
Arcasoy SM, Christie JD, Ferrari VA, et al. Echocardiographic assessment of pulmonary
hypertension in patients with advanced lung disease. AJRCCM 2003;167:735-40. The cardiology
literature indicates echocardiography-derived estimates of pulmonary artery pressures are
accurate. This study found 52% of echo estimates were inaccurate (off by > 10 mmHg) in 166
lung transplant candidates and the difference was > 20 mmHg in 28%. In patients without
hypertension, echo was more likely to overestimate pressures while in patients with pulmonary
hypertension, it was as likely to over as underestimate. Accuracy and ability to obtain an
estimate varied with the underlying disease.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12480614
Sleep Medicine
Sleep Disordered Breathing
Sullivan CE, Berthon-Jones M, Issa FQ et al. Reversal of obstructive sleep apnoea by continuous
positive airway pressure applied through the nares. Lancet 1981 April 18;1(8225):862-5. First
description of CPAP in the treatment of OSA.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=6112294
Iber C, O'Brien C, Schluter J, et al. Single night studies in obstructive sleep apnea. Sleep
1991;14:383-385. Contrary to the accompanying editorial, this study first documented the
effectiveness of split-night studies for the evaluation of OSA and helped establish split-night
studies as the standard of
care.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract
&list_uids=1759089.
Flemons WW, Littner MR, Rowley JA, et al. Home diagnosis of sleep apnea: A systematic review
of the literature. CHEST 2003;124:1543-79. A summary of where we are with out-of-lab
diagnosis of sleep disordered breathing. Although the effectiveness of these methods may be
improving, the appropriate usefulness is a moving target as technology advances faster than the
publications that
follow. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Search&DB=PubMed
Schwab RJ, Pasirstein M, Pierson R, et al. Identification of upper airway anatomic risk factors for
obstructive sleep apnea with volumetric magnetic resonance imaging. AJRCCM 2003;168:52230. Elegant publication demonstrating the anatomy behind sleep disordered breathing – how
can a patient with a normal BMI have OSA? How can an overweight patient not have OSA?
Don’t miss the online
supplement.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=
Abstract&list_uids=12746251
Shahar E, Whitney C, Redline S, et al. Sleep-disordered breathing and cardiovascular disease.
Cross-sectional results of the Sleep Heart Health Study. AJRCCM 2001;163:19-25. One of a
number of important articles derived from the landmark Sleep Heart Health Study, this study
found even mild OSA (apnea-hypopnea index of ≥ 11) confers a 2.38 relative risk of self-reported
CHF independent of other known risk
factors.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstr
act&list_uids=11208620
Nieto FJ, Young TB, Lind BK, et al. Association of sleep-disordered breathing, sleep apnea, and
hypertension in a large community-based study: Sleep Heart Health Study. JAMA
2000;283:1829–1836. This landmark study demonstrated that sleep disordered breathing
confers a higher risk of hypertension, independent of age, sex, race, weight, BMI, neck
circumference, waist-to-hip ratio, alcohol, smoking, favorite NFL
team….http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstr
act&list_uids=10770144
Peppard PE, Young T, Palta M, et al. Prospective study of the association between sleepdisordered breathing and hypertension. NEJM 2000;342:1378–84. Even more convincing is the
Wisconsin Sleep Cohort Study that demonstrated an independent dose-response relation
between sleep-disordered breathing at baseline and the development of new hypertension 4
years
later.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstrac
t&list_uids=10805822
Peker Y, Hedner J, Kraiczi H, et al. Respiratory disturbance index: an independent predictor of
mortality in coronary artery disease. AJRCCM 2000;162:81-6. Small (59 patients) prospective
study with 5 years of follow-up found patients with untreated OSA and coronary artery disease
were at increased on cardiovascular
death.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstra
ct&list_uids=10903224
Parasomnias
Schenck CH, Bundlie SR, Ettinger MG, et al. Chronic behavioral disorders of human REM sleep: a
new category of parasomnia. Sleep 2002;9:293-308. The first description of REM Behavior
Disorder.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abs
tract&list_uids=11902435
Circadian Rhythm Disorders
Ancoli-Israel S, Cole R, Alessi C, et al. The role of actigraphy in the study of sleep and circadian
rhythms. Sleep 2003;26:342-92. This review summarizes the role of actigraphy in the
evaluation of patients with insomnia and circadian rhythm
disorders.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Ab
stract&list_uids=12749557
Restless Legs Syndrome
Earley, CJ. Restless legs syndrome. NEJM 2003;348:2103-9. RLS – easy to diagnose, easy to
treat, and your patients will think you are a genius and be forever grateful. This review covers
the topic well.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12761367
Solitary Pulmonary Nodule
Ost D, Fein AM, Feinsilver SH. The solitary pulmonary nodule. NEJM 2003;348:2535-42. Concise
review of risks and yield of the currently used diagnostic modalities, including PET scans. Unlike
some recently published guidelines, the authors consider both clinical suspicion for malignancy
and operative risk in making management recommendations. The authors advocate the use of
serial CT scans in patients with low probability of cancer as well as patients with intermediate
probability with negative additional workup.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&li
st_uids=12815140
Swenson SJ, Silverstein MD, Ilstrup DM et al. The probability of malignancy in solitary
pulmonanary nodules. Arch Int. Med 1997;157:849-855. Authors developed a prediction model
for likelihood of malignancy in indeterminant 4-30mm SPNs. Age, cigarette use, hx of any
cancer more than 5 years previously, diameter of SPN, spiculation, and upper lobe location were
independent predictors of malignancy. Article includes a table with the odds a SPN is malignant
based on the above factors.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9129544
Torrington KG, Kern JD. The utility of fiberoptic bronchoscopy in the evaluation of the solitary
pulmonary nodule. CHEST 1993;104;1021-1024. Study found low yield for use of FOB in the
work-up of radiographic Stage I lung cancer. FOB confirmed the diagnosis of cancer in 30% of
cases (no higher yield with use of fluoroscopic guidance), but this did not affect surgical
management. Unsuspected synchronous tumor found in only 1% of cases. Study population
skewed in that a high proportion (87%) of SPNs were malignant.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=8404158
**See also screening screening under Lung Cancer
Tuberculosis
ATS Statement: Targeted tuberculin testing and treatment of latent tuberculosis infection.
AJRCCM 2000;161:S221-S247. Emphasizes restricting testing to patients you intend to treat if
positive and defines positive for patients with different risk factors. Recommended duration of
INH increased to 9 months. Significant risk of hepatotoxicity with combination INH and rifampin
reported since this statement published.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10764341
International Union Against Tuberculosis Committee on Prophylaxis. Efficacy of various durations
of isoniazid preventive therapy for tuberculosis: five years of follow-up in the IUAT trial. Bull WHO
1982;60:555-64. Noteworthy for being the only study of the efficacy and safety of different
durations of INH prophylaxis.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=6754120
Stead WW. Management of health care workers after inadvertent exposure to TB: a guide for the
use of preventive therapy. Ann Intern Med 1995;122:906-12. Based on early TB outbreaks and
more recent studies of health care and nursing home exposures, the author makes
recommendations for the management of health care workers with heavy exposure to active
disease. Specifically, workers with prior positive PPD do not need treatment unless they become
symptomatic per the author. Skin test negative workers should receive INH prophylaxis until they
are tested for conversion 8 weeks after exposure.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=7755225
Blumberg HM, Burman WJ, Chaisson RE, et al. ATS/CDC/IDSA: Treatment of tuberculosis.
AJRCCM 2003;167:603-662. Comprehensive consensus guide to treatment.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12588714
Bock NN, McGowan JE, Ahn J, et al. Clinical predictors of tuberculosis as a guide for respiratory
isolation policy. AJRCCM 1996;154:1468-72. Study found upper lobe infiltrate, presence of
cavity, self- report of prior positive PPD, and history of TB exposure were predictive of active
disease while history of INH prophylaxis was negatively predictive. Basing isolation solely on
these criteria, however, would have resulted in 19% of active cases not being isolated.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=8912766
ATS Workshop: Rapid diagnostic tests for tuberculosis: what is the appropriate test? AJRCCM
1997;155:1804-14. The article focuses on the indications and limitations to use of direct
amplification tests (DAT) for rapid diagnosis of TB in smear-positive and smear-negative cases.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9154896
Roth BJ. Searching for tuberculosis in the pleural space. CHEST 1999;116:3-4. Reviews use of
ADA in work-up of pleural TB.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10424494 http://www.chestjournal.org/cgi/content/full/116/1/3
Kirsch CM, Kroe DM, Azzi RL, et al. The optimal number of pleural biopsy specimens for a
diagnosis of tuberculous pleurisy. CHEST 1997;112:702-6. Single institution, mostly
retrospective study of 30 patients with proven pleural TB found sensitivity of 87% when a single
specimen was sent for culture and the remaining 3 to 9 were sent for histology. Only 40% of
submitted samples actually contained pleura, and the diagnostic yield was 100% in the 18/30
patients with more than 6 specimens submitted.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9315802
Conde MB, Loivos AC, Rezende VM, et al. Yield of sputum induction in the diagnosis of pleural
tuberculosis. AJRCCM 2003;167:723-5 Prospective study of 84 patients with pleural
tuberculosis found induced sputum culture was helpful in patients with no infiltrate on CXR; 55%
of patients with effusion and clear CXR were culture positive, although only 12% had a rapid
diagnosis via positive smears.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=12598215
**See also section for mycobacterial disease in HIV infection.
Ventilator-associated Pneumonia
Fagon J, Chastre J, Wolff M, et al. Invasive and noninvasive strategies for management of
suspected ventilator-associated pneumonia. Ann Intern Med 2000;132:621-30. Randomized
study found use of BAL or PSB to dictate antibiotic treatment in suspected VAP resulted in lower
mortality at 14 days and less antibiotic use compared to standard approach of clinical
impression coupled with endotracheal aspirates. Initiation of antibiotic treatment for VAP was
withheld until after obtaining specimens and antibiotics were stopped if cultures were negative.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10766680
Chastre J, Fagon J, Bornet-Lesco M, et al. Evaluation of bronchoscopic techniques for the
diagnosis of nosocomial pneumonia. AJRCCM 1995;152:231-240. Study compared immediate
post-mortem BAL and PSB to lung biopsy histology and culture and found bronchoscopic
specimens had a sensitivity of 82-91% and specificity of 78-89% compared to the gold standard
of lung biopsy cultures, provided patients had no recent antibiotic changes prior to death and
had not developed pneumonia prior to the terminal phase of their disease. Pertinent in that the
above study by Fagon et al is predicated on the belief that BAL and PSB accurately diagnose
VAP.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=7599829
Kirtland SH, Corley DE, Winterbauer RH, et al. The diagnosis of VAP: a comparison of histologic,
microbiologic, and clinical criteria. CHEST 1997;112:445-57. Study with a similar design to the
Chastre study but without restrictions on use of antibiotics or recent pneumonia. Authors found
poor correlation between histologic findings and quantitative cultures from bronch specimens.
Tracheal aspirates were 87% sensitive but 31% specific compared to biopsy culture. A sterile
BAL had a PPV of 91% for sterile lung parenchyma.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9266883
Kollef MH. The prevention of ventilator-associated pneumonia. NEJM 1999;340:627-634. Makes
recommendations for or against known preventive strategies and grades the quality of data
supporting each intervention.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10029648
Drakulovic MB, Torres A, Bauer TT, et al. Semirecumbancy to prevent VAP. Lancet
1999;354:1851-8. Study found supine position is an independent risk factor for VAP and
positioning at 45 reduces the risk, especially if patient receiving tube feeds.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=10584721
Cook DJ, Walter SD, Cook RJ, et al. Incidence of and risk factors for VAP in critically-ill patients.
Ann Intern Med 1998;129:433-40. This is a well-done, large, multicenter study. Witnessed
aspiration, use of paralytics, and underlying medical conditions were among the risk factors
identified.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list
_uids=9735080