Cough in Ambulatory Immunocompromised Adults: CHEST Expert Panel Report.

BACKGROUND: Cough is a common symptom prompting patients to seek medical care. Like patients in the general population, patients with compromised immune systems also seek care for cough. However, it is unclear whether the causes of cough in immunocompromised patients who are deemed unlikely to have a life-threating condition and a normal or unchanged chest radiograph are similar to those in persons with cough and normal immune systems. METHODS: We conducted a systematic review to answer the question: What are the most common causes of cough in ambulatory immunodeficient adults with normal chest radiographs? Studies of patients ≥ 18 years of age with immune deficiency, cough of any duration, and normal or unchanged chest radiographs were included and assessed for relevance and quality. Based on the systematic review, suggestions were developed and voted on using the American College of Chest Physicians (CHEST) methodology framework. RESULTS: The results of the systematic review revealed no high-quality evidence to guide the clinician in determining the likely causes of cough specifically in immunocompromised ambulatory patients with normal chest radiographs. CONCLUSIONS: Based on a systematic review, we found no evidence to assess whether or not the proper initial evaluation of cough in immunocompromised patients is different from that in immunocompetent persons. A consensus of the panel suggested that the initial diagnostic algorithm should be similar to that for immunocompetent persons but that the context of the type and severity of the immune defect, geographic location, and social determinants be considered. The major modifications to the 2006 CHEST Cough Guidelines are the suggestions that TB should be part of the initial evaluation of patients with cough and HIV infection who reside in regions with a high prevalence of TB, regardless of the radiographic findings, and that specific causes and immune defects be considered in all patients in whom the initial evaluation is unrevealing.

Establishing Pulmonary and Critical Care Medicine in China: 2016 Report on Implementation and Government Recognition: Joint Statement of the Chinese Association of Chest Physicians and the American College of Chest Physicians.

This article provides an update on progress toward establishing pulmonary and critical care medicine (PCCM) fellowship training as one of the first four subspecialties to be recognized and supported by the Chinese government. Designed and implemented throughout 2013 and 2014 by a collaborative effort of the Chinese Thoracic Society (CTS) and the American College of Chest Physicians (CHEST), 12 leading Chinese hospitals enrolled a total of 64 fellows into standardized PCCM training programs with common curricula, educational activities, and assessment measures. Supplemental educational materials, online assessment tools, and institutional site visits designed to evaluate and provide feedback on the programs' progress are being provided by CHEST. As a result of this initial progress, the Chinese government, through the Chinese Medical Doctor's Association, endorsed the concept of subspecialty fellowship training in China, with PCCM as one of the four pilot subspecialties to be operationalized nationwide in 2016, followed by implementation across other subspecialties by 2020. This article also reflects on the achievements of the training sites and the challenges they face and outlines plans to enhance and expand PCCM training and practice in China.

Cystic Lung Diseases: Algorithmic Approach.

Cysts are commonly seen on CT scans of the lungs, and diagnosis can be challenging. Clinical and radiographic features combined with a multidisciplinary approach may help differentiate among various disease entities, allowing correct diagnosis. It is important to distinguish cysts from cavities because they each have distinct etiologies and associated clinical disorders. Conditions such as emphysema, and cystic bronchiectasis may also mimic cystic disease. A simplified classification of cysts is proposed. Cysts can occur in greater profusion in the subpleural areas, when they typically represent paraseptal emphysema, bullae, or honeycombing. Cysts that are present in the lung parenchyma but away from subpleural areas may be present without any other abnormalities on high-resolution CT scans. These are further categorized into solitary or multifocal/diffuse cysts. Solitary cysts may be incidentally discovered and may be an age related phenomenon or may be a remnant of prior trauma or infection. Multifocal/diffuse cysts can occur with lymphoid interstitial pneumonia, Birt-Hogg-Dubé syndrome, tracheobronchial papillomatosis, or primary and metastatic cancers. Multifocal/diffuse cysts may be associated with nodules (lymphoid interstitial pneumonia, light-chain deposition disease, amyloidosis, and Langerhans cell histiocytosis) or with ground-glass opacities (Pneumocystis jirovecii pneumonia and desquamative interstitial pneumonia). Using the results of the high-resolution CT scans as a starting point, and incorporating the patient's clinical history, physical examination, and laboratory findings, is likely to narrow the differential diagnosis of cystic lesions considerably.

Electronic cigarettes. A position statement of the forum of international respiratory societies.

BACKGROUND: Awareness and usage of electronic cigarettes has exponentially increased during the last few years, especially among young people and women in some countries. The rapid acceptance of electronic cigarettes may be attributed in part to the perception created by marketing and the popular press that they are safer than combustible cigarettes. GOALS: To alert and advise policy makers about electronic cigarettes and their potential hazards. METHODS: Using The Union's position paper on electronic cigarettes as the starting template, the document was written using an iterative process. Portions of the manuscript have been taken directly from the position papers of participating societies. RESULTS: Because electronic cigarettes generate less tar and carcinogens than combustible cigarettes, use of electronic cigarettes may reduce disease caused by those components. However, the health risks of electronic cigarettes have not been adequately studied. Studies looking at whether electronic cigarettes can aid smoking cessation have had inconsistent results. Moreover, the availability of electronic cigarettes may have an overall adverse health impact by increasing initiation and reducing cessation of combustible nicotine delivery products. CONCLUSIONS: The health and safety claims regarding electronic nicotine delivery devices should be subject to evidentiary review. The potential benefits of electronic cigarettes to an individual smoker should be weighed against potential harm to the population of increased social acceptability of smoking and use of nicotine, the latter of which has addictive power and untoward effects. As a precaution, electronic nicotine delivery devices should be restricted or banned until more information about their safety is available. If they are allowed, they should be closely regulated as medicines or tobacco products.

Establishing pulmonary and critical care medicine as a subspecialty in China: joint statement of the Chinese thoracic society and the American college of chest physicians.

This commentary heralds the recognition in China of a new subspecialty, Pulmonary and Critical Care Medicine, and the first national fellowship training pathway in any medical specialty. Because of striking environmental health-care similarities that existed in the United States, the Chinese medical community decided to model the specialty after that in the United States. Because of its expertise in educating pulmonary and critical care physicians in the United States, the American College of Chest Physicians was chosen by the Chinese Thoracic Society, with the approval of the Chinese government, to help with the transformation of this new specialty. A work group representing the two societies is collaborating to reorganize ICUs within a select group of large teaching hospitals in China and to introduce standardized and rigorous training in pulmonary and critical care medicine as a national program.

Pulmonary arterial hypertension in human immunodeficiency virus infection.

Because of the improvement in survival rates of human immunodeficiency virus (HIV)-infected patients after the introduction of combined antiretroviral therapy, pulmonary arterial hypertension (PAH) has become an important cause of morbidity. As the awareness of PAH has increased, it is more likely that this condition will be diagnosed more frequently and earlier in the course of the disease and HIV infection. The etiopathogenesis is not clear; no evidence of direct infection of the pulmonary vascular tree has been found and the current evidence seems to favor a role of dysregulated cytokine response to HIV infection. The pathological changes of plexiform arteriopathy are indistinguishable from the pathological changes of idiopathic pulmonary arterial hypertension (IPAH). Dyspnea is the most common presenting symptom. Echocardiography, though always not accurate in diagnosing PAH and estimating its severity, remains the main screening tool. Right heart catheterization is the gold standard investigation for diagnosis. New therapies like prostanoids, endothelin receptor antagonists, and phosphodiesterase inhibitors have improved the outcome of patients with HIV-associated PAH. However, the overall prognosis of HIV-infected patients who develop PAH still remains poor.

Multisociety task force recommendations of competencies in Pulmonary and Critical Care Medicine.

RATIONALE: Numerous accrediting organizations are calling for competency-based medical education that would help define specific specialties and serve as a foundation for ongoing assessment throughout a practitioner's career. Pulmonary Medicine and Critical Care Medicine are two distinct subspecialties, yet many individual physicians have expertise in both because of overlapping content. Establishing specific competencies for these subspecialties identifies educational goals for trainees and guides practitioners through their lifelong learning. OBJECTIVES: To define specific competencies for graduates of fellowships in Pulmonary Medicine and Internal Medicine-based Critical Care. METHODS: A Task Force composed of representatives from key stakeholder societies convened to identify and define specific competencies for both disciplines. Beginning with a detailed list of existing competencies from diverse sources, the Task Force categorized each item into one of six core competency headings. Each individual item was reviewed by committee members individually, in group meetings, and conference calls. Nominal group methods were used for most items to retain the views and opinions of the minority perspective. Controversial items underwent additional whole group discussions with iterative modified-Delphi techniques. Consensus was ultimately determined by a simple majority vote. MEASUREMENTS AND MAIN RESULTS: The Task Force identified and defined 327 specific competencies for Internal Medicine-based Critical Care and 276 for Pulmonary Medicine, each with a designation as either: (1) relevant, but competency is not essential or (2) competency essential to the specialty. CONCLUSIONS: Specific competencies in Pulmonary and Critical Care Medicine can be identified and defined using a multisociety collaborative approach. These recommendations serve as a starting point and set the stage for future modification to facilitate maximum quality of care as the specialties evolve.

Pulmonary complications of HIV infection.

The AIDS epidemic has had a devastating global impact in the last two decades; although prevalence rates are low in Asia and the Pacific, their enormous population is associated with an estimated 1 million people infected with HIV in 2006 alone. Survival from what had been a uniformly fatal illness has improved markedly with combination antiretroviral therapy and restoration of the immune system, but these treatments are expensive and difficult to distribute to the millions who need them around the world. In addition, millions more do not know they are infected with HIV until they develop an opportunistic infection. The lungs are the most frequent sites of these infections, and in different geographic regions, tuberculosis, bacterial pneumonia and Pneumocystis jiroveci are the dominant pathogens. The incidences of lung cancer and HIV-associated pulmonary arterial hypertension are also increasing in patients with HIV infection, and with the use of antiretrovirals, inflammatory disorders associated with immune restoration are being recognized.

Critical care of immunocompromised patients: human immunodeficiency virus.

OBJECTIVE: To describe critical illnesses that occur commonly in patients with human immunodeficiency virus (HIV) infection. METHODS: We reviewed and summarized the literature on critical illness in HIV infection using a computerized MEDLINE search. SUMMARY: In the last 10 yrs, our perception of HIV infection and acquired immune deficiency syndrome (AIDS) has changed from an almost uniformly fatal disease into a manageable chronic illness. Even patients with advanced immunosuppression may have prolonged survival, although usually with exacerbations and remissions, complicated by therapy-related toxicity and medical and psychiatric co-morbidity. The prevalence of opportunistic infections and the mortality have decreased considerably since early in the epidemic. The most common reason for intensive care unit admission in patients with AIDS is respiratory failure, but they are less likely to be admitted for Pneumocystis pneumonia and other HIV-associated opportunistic infections. HIV-infected persons are more likely to receive intensive care unit care for complications of end-stage liver disease and sepsis. Hepatitis C has emerged as a common cause of morbidity and mortality in patients with HIV infection. In addition, some develop life-threatening complications from antiretroviral drug toxicity and the immune reconstitution inflammatory syndrome.

Mechanical complications of central venous catheters.

We analyzed 385 consecutive central venous catheter (CVC) attempts over a 6-month period. All critically ill patients 18 years of age or older requiring a CVC were included. The rate of mechanical complications not including failure to place was 14%. Complications included failure to place the CVC (n = 86), arterial puncture (n = 18), improper position (n = 14), pneumothorax (n = 5 in 258 subclavian and internal jugular attempts), hematoma (n = 3), hemothorax (n = 1), and asystolic cardiac arrest of unknown etiology (n = 1). Male patients had a significantly higher complication rate than female patients (37% vs 27%, P = .04). The subclavian approach had a higher complication rate than the internal jugular or the femoral approach (39% vs 33% vs. 24%, P = .02). The complication rate increased with the number of percutaneous punctures, with a rate of 54% when more than 2 punctures were required.

Improving nurse-physician communication and satisfaction in the intensive care unit with a daily goals worksheet.

OBJECTIVE: To evaluate the effect of a standardized worksheet on physicians' and nurses' perceptions of their understanding of goals of care and on patients' length of stay in an intensive care unit. METHODS: A worksheet was completed daily during multidisciplinary rounds and was posted at each bedside in the medical intensive care unit at Beth Israel Medical Center in New York. Information recorded included tests or procedures, medications, sedation, analgesia, catheters, consultations, nutrition, mobilization, family discussions, consents, and disposition. Attending physicians, residents, and nurses completed a questionnaire before implementation of the worksheet and 3 times afterwards. Responses were scored on a 5-point scale (1 = understand nothing, 5 = completely understand). Continuous variables were analyzed by using a t test; categorical variables, by using a chi(2) test. RESULTS: Before the worksheet was implemented, scores for understanding goals were 3.9 for nurses and 4.6 for physicians. Scores increased to 4.8 for nurses (P = .001) and 4.9 for physicians (P = .03) 6 weeks later, an improvement that remained at 9 months. Both groups showed significant improvement in communication scores that lasted for 9 months. Most responders wanted to continue using the worksheet. During the study, the mean stay in the unit was 4.3 days, down from 6.4 days for the analogous 9-month period in the preceding year (P= .02). CONCLUSION: Nurses' and physicians' perceptions of their understanding of the goals of care and of communication between them were improved and stays in the unit were shortened when the worksheet was used.