John E. Heffner

An Official American Thoracic Society Clinical Policy Statement: Palliative Care for Patients with Respiratory Diseases and Critical Illnesses

Executive Summary Introduction Methods Goals, Timing, and Settings for Palliative Care Decision-making Process Advance Directives Care Planning and Delivery Hospice Care Alternative End-of-Life Decisions Symptom Management Dyspnea Management Pain Management Management of Psychological and Spiritual Distress and Suffering Withdrawal of Mechanical Ventilation Process of Decision Making Process of Withdrawing Mechanical Ventilation Bereavement Care Barriers to Palliative Care Program Development, Education, Training, and Research in Palliative Care

Recent Advances in the Diagnosis and Management of Malignant Pleural Effusions

Malignant pleural effusions (MPEs) are an important complication for patients with intrathoracic and extrathoracic malignancies. Median survival after diagnosis of an MPE is 4 months. Patients can present with an MPE as a complication of far-advanced cancer or as the initial manifestation of an underlying malignancy. Common cancer types causing MPEs include lymphomas, mesotheliomas, and carcinomas of the breast, lung, gastrointestinal tract, and ovaries. However, almost all tumor types have been reported to cause MPEs. New imaging modalities assist the evaluation of patients with a suspected MPE; however, positive cytologic or tissue confirmation of malignant cells is necessary to establish a diagnosis. Even in the presence of known malignancy, up to 50% of pleural effusions are benign, underscoring the importance of a firm diagnosis to guide therapy. Rapidly evolving interventional and histopathologic techniques have improved the diagnostic yield of standard cytology and biopsy. Management of an MPE remains palliative; it is critical that the appropriate management approach is chosen on the basis of available expertise and the patients clinical status. This review summarizes the pathogenesis, diagnosis, and management of MPE. Studies in the English language were identified by searching the MEDLINE database (1980-2007) using the search terms pleura, pleural, malignant, pleurodesis, and thoracoscopy.

Diagnosis and management of malignant pleural effusions.

Abstract:u2003 Malignant pleural effusions (MPEs) complicate the clinical course of patients with a broad array of malignancies, which are most often due to lymphomas or carcinomas of the breast, lung, gastrointestinal tract or ovaries. Patients may present with a MPE as the initial manifestation of a cancer or develop an effusion during the advanced phases of a known malignancy. In either circumstance, the median survival after presentation with a MPE is 4 months. Effusions may result from direct pleural invasion (MPE) or indirect effects (paraneoplastic effusions), such as impairment of fluid efflux from the pleural space by lymphatic obstruction or pleural effects of cancer radiation or drug therapy. Because only 50% of patients with cancer who develop a pleural effusion during their clinical course have a MPE, careful evaluation of the effusion to establish its aetiology is required to direct therapy. Management is palliative with interventions directed towards decreasing the volume of intrapleural fluid and the severity of associated symptoms.

A vision statement on guideline development for respiratory disease : the example of COPD

Introduction Professional societies, like many other organisations worldwide, have recognised the need to use rigorous processes to ensure that health-care recommendations are informed by evidence from the best available research. This vision statement summarises the main results and conclusions of the workshop Integrating and Coordinating Eff orts in Guideline Development: COPD as a Case in Point, which was organised by the American Thoracic Society (ATS) and the European Respiratory Society (ERS) with participation of experts from more than 40 international organisations (listed in the webappendix). The workshop content followed the recent review of WHO’s methods for guideline development. Although this vision statement represents the views of the programme development committee that planned and organised this workshop, it does not necessarily refl ect the offi cial opinions of the sponsoring or participating organisations. We intend this statement to stimulate discussions between relevant organisations that can identify collaborative strategies for further developing and realising the visions that we express in this Viewpoint. Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death worldwide, with a prevalence that is projected to increase over the next 20 years. COPD served as an example for this workshop because of the dilemma of multiple existing, overlapping, and sometimes confl icting COPD guidelines. Therefore, best possible clinical practice guidelines and implementation of guideline recommendations at the point of care represent crucial strategies for addressing the COPD epidemic. The committee drew an overall conclusion from the conference: an international collaboration with common aims and free of proprietary infl uences seems to be an achievable goal and the most eff ective strategy for development of comprehensive evidence-based guidelines to advance the care of patients with respiratory disease and related comorbid disorders. Achieving this goal, however, will require a new structural approach and multidisciplinary collaborative framework for guideline development in respiratory disease, building on the unique strength of all contributors. This framework could include a central coordination unit and an innovative but secure approach to funding, updating, and implementing these guidelines. We will describe the call for proposals and ideas for such an approach in more detail below. We will proceed by listing ten key visions that emerged from the conference and the rationales and necessary steps that a collaborative guideline eff ort should take to advance every vision. Implicit throughout this article is the principle that designing a new model for COPD guidelines can serve as a template to assist the eff orts of guideline developers for other respiratory and nonrespiratory diseases.

Prevalence of Diagnosed Sleep Apnea Among Patients With Type 2 Diabetes in Primary Care

BACKGROUNDnAlthough up to 90% of patients with type 2 diabetes mellitus (T2DM) have obstructive sleep apnea (OSA), the rate at which primary care providers diagnose OSA in patients with diabetes has not been assessed.nnnMETHODSnA retrospective, population-based, multiclinic study was performed to determine the proportion of patients with T2DM managed in primary care clinics who were given a diagnosis of OSA and to identify factors associated with an OSA diagnosis. Electronic health records of adult patients with a diagnosis of T2DM were reviewed for a coexisting diagnosis of OSA, and the diagnostic prevalence of OSA was compared with the expected prevalence.nnnRESULTSnA total of 16,066 patients with diabetes with one or more primary care office visits in 27 primary care ambulatory practices during an 18-month period from 2009 to 2010 were identified. Analysis revealed that 18% of the study population received an OSA diagnosis, which is less than the 54% to 94% prevalence reported previously. The 23% prevalence of OSA among obese study patients was lower than the expected 87% prevalence. In a logistic model, male sex, BMI, several chronic conditions, and lower low-density lipoprotein levels and hemoglobin A1c identified patients more likely to carry an OSA diagnosis (likelihood ratio, χ(2) = 1,713; P < .0001).nnnCONCLUSIONSnPrimary care providers underdiagnose OSA in patients with T2DM. Obese men with comorbid chronic health conditions are more likely to receive a diagnosis of OSA. Efforts to improve awareness of the association of OSA with T2DM and to implement OSA screening tools should target primary care physicians.

Tracheostomy decannulation: marathons and finish lines

Critically ill patients with a tracheostomy who are recovering from respiratory failure eventually require evaluation for airway decannulation. Although expert recommendations guide decisions for managing decannulation, few if any investigative data exist to inform evidence-based care. Consequently, practice variation limits the effectiveness of weaning from tracheostomy. In an investigation reported in this issue of Critical Care, the authors surveyed experienced physicians and respiratory therapists to assess their opinions on managing airway decannulation and identified several clinical factors that they recommend for selecting patients for tracheostomy tube removal. The authors propose that these factors can assist with designing clinical trials of tracheostomy decannulation. Pending completion of such studies, this report underscores the problem of practice variation in managing tracheotomized patients after critical illness. An important implication of the study is that care providers should recognize our knowledge deficit and develop systematic protocols for improving patient care using quality improvement techniques. Such models exist in the literature for adult patients and for children with tracheostomies who are managed by expert teams with requisite knowledge and skills.

COPD Performance Measures: Missing Opportunities for Improving Care

During the last decade, mounting evidence worldwide has heightened awareness that patients with diverse health conditions commonly do not receive recommended care despite the proliferation of clinical practice guidelines. This is a particular problem for patients with COPD, who only receive recommended care during 30% to 55% of encounters with providers. Considering that COPD is the fourth leading cause of death worldwide, failure to implement guideline-directed care represents a major concern for respiratory professional societies. For other health conditions, inadequacies of care have stimulated public and private agencies to increase provider accountability by linking the results of performance measures to various quality-improvement interventions. Despite limited evidence that these interventions improve care, widespread adoption of value-based reimbursement has occurred in the United States and United Kingdom, and the prominence of these strategies in health-care reform suggest future growth and the likely proliferation of the performance measures upon which they are based. Of note, relatively few performance measures exist for COPD as compared with other conditions that have less impact on global health. The lack of COPD measures diminishes public awareness of COPD, allows diversion of quality improvement resources toward other conditions with existing measures, and negatively impacts COPD care. Respiratory professional societies can play an important role in stimulating the development of valid COPD measures derived from COPD practice guidelines and coordinate future measures to avoid burdensome reporting requirements for physicians if COPD measures are developed by competing payers and agencies in a fragmented or non-patient-centered manner.

The Story of Oxygen

The history of oxygen from discovery to clinical application for patients with chronic lung disease represents a long and storied journey. Within a relatively short period, early investigators not only discovered oxygen but also recognized its importance to life and its role in respiration. The application of oxygen to chronic lung disease, however, took several centuries. In the modern era, physiologists pursued the chemical nature of oxygen and its physiologic interaction with cellular metabolism and gas transport. It took brazen clinicians, however, to pursue oxygen as a therapeutic resource for patients with chronic lung disease because of the concern in the 20th century of the risks of oxygen toxicity. Application of ambulatory oxygen devices allowed landmark investigations of the long-term effects of continuous oxygen that established its safety and efficacy. Although now well established for hypoxic patients, many questions remain regarding the benefits of oxygen for varying severity and types of chronic lung disease.

Road ahead to respiratory health: experts chart future research directions.

Respiratory illnesses are a huge and rising burden to health‐care systems and societies worldwide. Research is crucial to tackle the enormous problem of chest diseases. However the vast number of research questions and available research approaches often creates confusion and risks dilution of resources by spreading them too diffusely. Clear research directions will help to use research funds efficiently to provide treatment advances that benefit patient care. This paper presents the visions of leading experts on future research directions, focusing on what should rather than what is going to be done. These opinions provide a guide for new investigators and a platform for intellectual debates through which coordinated research efforts can help progress towards respiratory health.

Reply to the letter: Delayed radiotherapy related effusions: Malignant or not malignant, that is the question?

I thank Dr Chotirmall and colleagues for so clearly emphasizing the importance of considering prior radiotherapy as a potential cause of new onset pleural effusions in patients with previously treated malignancies. I had mentioned in the opening paragraph of my review that radiotherapy and chemotherapy can cause pleural effusions in patients with pre-existing malignancies. But I did not have sufficient space to elaborate further. The case and comments presented by Dr Chotirmall and colleagues highlight the variable nature of these effusions, their delayed onset, and the attendant challenges for considering radiotherapy as a potential aetiology. I would only add that these effusions may be recurrent and refractory, bilateral, massive in size and characterized by chylous pleural fluid. In evaluating patients with a history of cancer for the aetiology of an obscure exudative or transudative pleural effusion, clinicians should always consider prior radiotherapy as a cause even when patients received that therapy many years earlier. One should also consider radiation-induced constrictive pericarditis when faced with a recalcitrant transudative effusion in this setting. REFERENCES