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Clinical utility of the acute bronchodilator response
Recently, numerous articles evaluating the acute bronchodilator (BD) response in various disease states have appeared in the literature (Chest. 2015;148[6]:1489; J Thorac Dis. 2016;8[1]:14; Int J Chron Obstruct Pulmon Dis. 2016;11:93; Respir Med. 2016;112:45). New algorithms have been proposed to improve quality control in BD (Eur Clin Respir J. 2015;30;2).
In our lab, requests for pre- and post-BD spirometry continue unabated. Undoubtedly, many labs comply with these requests without regard for pre-BD values. The number of these requests far exceeds the number needed to confirm asthma diagnosis, or to assure that post-BD FEV1/FVC ratio remains below 0.7 for COPD diagnosis, which are the only universally accepted indications for BD testing.
Acute BD testing technique, interpretation, and clinical application involve important issues that remain unresolved, even in COPD where this test has been studied more than any other disease state except asthma (Chest. 2011;140[4]:1055; Int J Chron Obstruct Pulmon Dis. 2015;10:407). There remains no clear consensus for a clinically relevant BD response. The ACCP definition proposed in 1974 (FEV1 improvement by greater than 15%) has not been updated, and the widely used ATS/ERS definition (FEV1 and/or FVC improvement by greater than 12% and 200 mL) is felt to be arbitrary and based more on expert opinion than scientific evidence (Respir Care. 2012;57[10]:1564). Literature review (excluding asthma) reveals no well-done, reproducible studies that demonstrate meaningful or widely applicable uses for the acute BD response.
Overcoming the many factors influencing acute bronchodilator testing, developing a unified definition for a positive test, and then showing a predictive significance to the acute-BD response is an extremely difficult task. Until this test is further studied in a rigorous manner, any meaning attached to a positive response outside of asthma is purely arbitrary.
Dr. Oleh Hnatiuk, FCCP
Steering Committee Member
Gun violence in the hospital
Thirty-one thousand fatal gunshot wounds (GSW) occur in the United States each year and are increasing; 55% are self-inflicted, mostly isolated incidents. However, mass shooting events (MSE = more than 3 victims) are rising with 355 events in 2015 (462 deaths and 1,314 injuries). The mortality of GSW has risen due to the use of high caliber automatic handguns. Health-care providers, facilities, and systems need to include preparation for primary prevention and secondary mitigation for violent acts of this nature.
MSE attacker demographics reveal a male predominance (90%) with ethnicity mirroring the US population (65% Caucasian, 16% black, and 9% Asian) and mainly occurring in urban settings. The psychosocial basis of these changes is complex and multifactorial. Two-thirds of mass shooters have a history of mental illness with paranoid schizophrenia predominating. Motives are shifting from self-destruction to grievance-related events. Targets and victims of GSW violence also seem to be changing, and health-care workers are potential targets for GSW violence.
A 12-year review of hospital shooting events (HSE) found 154 events with 235 victims. There is a rise in this type of violent act. Grievance motives are dominant in these events. Most HSE occur in the ED or at the entrance to the hospital or parking lot (77%). The case fatality rate in HSE averages 50%. The perpetrators are injured in 85% of cases. Nurses are the most common victims of HSE.
Prevention strategies such as metal detectors, camera surveillance, strengthened security staff, and emergency protocols are vital. However, in many hospitals, these strategies are inadequate or not considered. Secondary mitigation requires special education and training and some material preparation to be successful. Providers must consider themselves potential gun violence victims. We encourage all medical providers to engage in planning and preparation for HSE, as well as advocate for gun safety laws
Dr. Dennis Amundson, FCCP
NetWork Member
Critical violent injury in the United States: A review and call to action. Crit Care Med. 2015;43(11):2460-2466.
Hospital-based shooting in the United States: 2000-2011. Ann Emerg Med. 2012;60(6):790-798.
The epidemiology of trauma-related mortality in the United States From 2002-2012. J Trauma Acute Care Surg. 2014;76(4):913-920.
Balloon pulmonary angioplasty for CTEPH
The gold-standard treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary thromboendarterectomy (PTE). However, not every patient is a surgical candidate, including those who are deemed technically inoperable (after review by a multidisciplinary, experienced CTEPH team) or those whose goals of care are more palliative.
Such factors created an opportunity for an alternative procedure to manage CTEPH: catheter-based balloon pulmonary angioplasty (BPA). Despite the limited success with early BPA experience, with initial set-backs including high reperfusion edema rates and other procedure complications, BPA has become more refined over time. Initially led by the efforts of several groups based in Japan, modifications included greater precision in “right-sizing” balloons, staging the procedure (average two to five sessions/patient), and better vascular imaging techniques with advancing technical capabilities.
BPA has received attention due to the favorable hemodynamic and functional outcomes reported in select patients. Despite a lack of consensus regarding who might benefit most, these preliminary results have stimulated considerable interest for acquiring this technique worldwide.
Caution should be exercised when BPA is considered for CTEPH treatment. Critical to success is the selection of patients who might benefit, and adequate training and technical expertise is essential for BPA performance. For those with operable CTEPH who are otherwise surgical candidates, data do not yet exist to suggest BPA as a comparable alternative to PTE. Furthermore, the absence of head-to-head comparison between medical therapy and BPA for inoperable CTEPH further blurs the role BPA will have in this unique patient population. But, it holds promise, awaiting further trials data.
Dr. Wassim H. Fares, FCCP, NetWork Member
Dr. William R. Auger, FCCP, Steering Committee Member
Pulmonary nodules: Are you seeing spots?
Pulmonary nodules are increasingly being identified in clinical practice. A recent study estimated that 1.5 million nodules are identified annually in the United States (Gould et al. 2015; Am J Respir Crit Care Med. 192[10], 1208). This 10-fold increase in number over prior estimates reflects the steep escalation in utilization of CT scanning over the past several decades, and is likely to rise further as lung cancer screening is implemented. While the majority of nodules are benign, evaluation necessarily includes an assessment of the probability of malignancy, since this is a major driver of the decision as to whether no further intervention is required, or whether watchful surveillance or further noninvasive or invasive evaluation is appropriate (Gould et al., 2013). It is reassuring that experienced chest physicians perform well in the assessment of the probability of malignancy (Gould et al., 2013; Swensen et al., 1999), but also important to recognize that evidence-based guidelines for nodule evaluation as well as validated tools for assessing the likelihood of malignancy are readily available (Gould, Ananth, Barnett, & Veterans Affairs, 2007; Gould et al., 2013; McWilliams et al., 2013; Swensen, Silverstein, Ilstrup, Schleck, & Edell, 1997). It is important to engage our radiology colleagues in this discussion; guidelines from the Fleischner Society and the American College of Radiology for reporting on incidentally identified small solid nodules, incidentally identified subsolid nodules, and screening-detected nodules are individually distinct in definitions of abnormality as well as recommendations for follow up, and should be applied appropriately in the context of the individual patient as well as the situation for which the CT was performed (“Lung-RADS Version 1.0 Assessment Categories Release date: April 28, 2014,” 2014; MacMahon et al., 2005; Naidich et al., 2013). All of these potential sources of variation highlight the value of standardizing the approach to nodule evaluation, to ensure that appropriate evaluation will be done to maximize the likelihood of identifying nodules that are actually cancer, and minimize harm potentially incurred by unnecessary invasive and noninvasive testing of nodules that are actually benign.
Dr. Lynn Tanoue, FCCP
NetWork Chair
Gould MK, Ananth L, Barnett PG, and Veterans Affairs, S. C. S. G. A clinical model to estimate the pretest probability of lung cancer in patients with solitary pulmonary nodules. Chest. 2007;131(2):383-388.
Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013; 143(5 suppl):e93S.
Gould MK, Tang T, Liu IL, et al. Recent trends in the identification of incidental pulmonary nodules. Am J Respir Crit Care Med. 2015; 192(10):1208-1214.
Lung-RADS Version 1.0 Assessment Categories Release date: April 28,2014. http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/LungRADS/AssessmentCategories.pdf. Accessed Oct 31, 2014.
MacMahon H, Austin JH, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005;237(2):395-400.
McWilliams A, Tammemagi MC, Mayo JR, et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med. 2013;369(10):910-919.
Naidich DP, Bankier AA, MacMahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. Radiology. 2013;266(1):304-317.
Swensen SJ, Silverstein MD, Edell ES, et al. Solitary pulmonary nodules: clinical prediction model versus physicians. Mayo Clin Proc. 1999;74(4):319-329.
Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of malignancy in solitary pulmonary nodules: Application to small radiologically indeterminate nodules. Arch Intern Med. 1997;157(8): 849-855.
Clinical utility of the acute bronchodilator response
Recently, numerous articles evaluating the acute bronchodilator (BD) response in various disease states have appeared in the literature (Chest. 2015;148[6]:1489; J Thorac Dis. 2016;8[1]:14; Int J Chron Obstruct Pulmon Dis. 2016;11:93; Respir Med. 2016;112:45). New algorithms have been proposed to improve quality control in BD (Eur Clin Respir J. 2015;30;2).
In our lab, requests for pre- and post-BD spirometry continue unabated. Undoubtedly, many labs comply with these requests without regard for pre-BD values. The number of these requests far exceeds the number needed to confirm asthma diagnosis, or to assure that post-BD FEV1/FVC ratio remains below 0.7 for COPD diagnosis, which are the only universally accepted indications for BD testing.
Acute BD testing technique, interpretation, and clinical application involve important issues that remain unresolved, even in COPD where this test has been studied more than any other disease state except asthma (Chest. 2011;140[4]:1055; Int J Chron Obstruct Pulmon Dis. 2015;10:407). There remains no clear consensus for a clinically relevant BD response. The ACCP definition proposed in 1974 (FEV1 improvement by greater than 15%) has not been updated, and the widely used ATS/ERS definition (FEV1 and/or FVC improvement by greater than 12% and 200 mL) is felt to be arbitrary and based more on expert opinion than scientific evidence (Respir Care. 2012;57[10]:1564). Literature review (excluding asthma) reveals no well-done, reproducible studies that demonstrate meaningful or widely applicable uses for the acute BD response.
Overcoming the many factors influencing acute bronchodilator testing, developing a unified definition for a positive test, and then showing a predictive significance to the acute-BD response is an extremely difficult task. Until this test is further studied in a rigorous manner, any meaning attached to a positive response outside of asthma is purely arbitrary.
Dr. Oleh Hnatiuk, FCCP
Steering Committee Member
Gun violence in the hospital
Thirty-one thousand fatal gunshot wounds (GSW) occur in the United States each year and are increasing; 55% are self-inflicted, mostly isolated incidents. However, mass shooting events (MSE = more than 3 victims) are rising with 355 events in 2015 (462 deaths and 1,314 injuries). The mortality of GSW has risen due to the use of high caliber automatic handguns. Health-care providers, facilities, and systems need to include preparation for primary prevention and secondary mitigation for violent acts of this nature.
MSE attacker demographics reveal a male predominance (90%) with ethnicity mirroring the US population (65% Caucasian, 16% black, and 9% Asian) and mainly occurring in urban settings. The psychosocial basis of these changes is complex and multifactorial. Two-thirds of mass shooters have a history of mental illness with paranoid schizophrenia predominating. Motives are shifting from self-destruction to grievance-related events. Targets and victims of GSW violence also seem to be changing, and health-care workers are potential targets for GSW violence.
A 12-year review of hospital shooting events (HSE) found 154 events with 235 victims. There is a rise in this type of violent act. Grievance motives are dominant in these events. Most HSE occur in the ED or at the entrance to the hospital or parking lot (77%). The case fatality rate in HSE averages 50%. The perpetrators are injured in 85% of cases. Nurses are the most common victims of HSE.
Prevention strategies such as metal detectors, camera surveillance, strengthened security staff, and emergency protocols are vital. However, in many hospitals, these strategies are inadequate or not considered. Secondary mitigation requires special education and training and some material preparation to be successful. Providers must consider themselves potential gun violence victims. We encourage all medical providers to engage in planning and preparation for HSE, as well as advocate for gun safety laws
Dr. Dennis Amundson, FCCP
NetWork Member
Critical violent injury in the United States: A review and call to action. Crit Care Med. 2015;43(11):2460-2466.
Hospital-based shooting in the United States: 2000-2011. Ann Emerg Med. 2012;60(6):790-798.
The epidemiology of trauma-related mortality in the United States From 2002-2012. J Trauma Acute Care Surg. 2014;76(4):913-920.
Balloon pulmonary angioplasty for CTEPH
The gold-standard treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary thromboendarterectomy (PTE). However, not every patient is a surgical candidate, including those who are deemed technically inoperable (after review by a multidisciplinary, experienced CTEPH team) or those whose goals of care are more palliative.
Such factors created an opportunity for an alternative procedure to manage CTEPH: catheter-based balloon pulmonary angioplasty (BPA). Despite the limited success with early BPA experience, with initial set-backs including high reperfusion edema rates and other procedure complications, BPA has become more refined over time. Initially led by the efforts of several groups based in Japan, modifications included greater precision in “right-sizing” balloons, staging the procedure (average two to five sessions/patient), and better vascular imaging techniques with advancing technical capabilities.
BPA has received attention due to the favorable hemodynamic and functional outcomes reported in select patients. Despite a lack of consensus regarding who might benefit most, these preliminary results have stimulated considerable interest for acquiring this technique worldwide.
Caution should be exercised when BPA is considered for CTEPH treatment. Critical to success is the selection of patients who might benefit, and adequate training and technical expertise is essential for BPA performance. For those with operable CTEPH who are otherwise surgical candidates, data do not yet exist to suggest BPA as a comparable alternative to PTE. Furthermore, the absence of head-to-head comparison between medical therapy and BPA for inoperable CTEPH further blurs the role BPA will have in this unique patient population. But, it holds promise, awaiting further trials data.
Dr. Wassim H. Fares, FCCP, NetWork Member
Dr. William R. Auger, FCCP, Steering Committee Member
Pulmonary nodules: Are you seeing spots?
Pulmonary nodules are increasingly being identified in clinical practice. A recent study estimated that 1.5 million nodules are identified annually in the United States (Gould et al. 2015; Am J Respir Crit Care Med. 192[10], 1208). This 10-fold increase in number over prior estimates reflects the steep escalation in utilization of CT scanning over the past several decades, and is likely to rise further as lung cancer screening is implemented. While the majority of nodules are benign, evaluation necessarily includes an assessment of the probability of malignancy, since this is a major driver of the decision as to whether no further intervention is required, or whether watchful surveillance or further noninvasive or invasive evaluation is appropriate (Gould et al., 2013). It is reassuring that experienced chest physicians perform well in the assessment of the probability of malignancy (Gould et al., 2013; Swensen et al., 1999), but also important to recognize that evidence-based guidelines for nodule evaluation as well as validated tools for assessing the likelihood of malignancy are readily available (Gould, Ananth, Barnett, & Veterans Affairs, 2007; Gould et al., 2013; McWilliams et al., 2013; Swensen, Silverstein, Ilstrup, Schleck, & Edell, 1997). It is important to engage our radiology colleagues in this discussion; guidelines from the Fleischner Society and the American College of Radiology for reporting on incidentally identified small solid nodules, incidentally identified subsolid nodules, and screening-detected nodules are individually distinct in definitions of abnormality as well as recommendations for follow up, and should be applied appropriately in the context of the individual patient as well as the situation for which the CT was performed (“Lung-RADS Version 1.0 Assessment Categories Release date: April 28, 2014,” 2014; MacMahon et al., 2005; Naidich et al., 2013). All of these potential sources of variation highlight the value of standardizing the approach to nodule evaluation, to ensure that appropriate evaluation will be done to maximize the likelihood of identifying nodules that are actually cancer, and minimize harm potentially incurred by unnecessary invasive and noninvasive testing of nodules that are actually benign.
Dr. Lynn Tanoue, FCCP
NetWork Chair
Gould MK, Ananth L, Barnett PG, and Veterans Affairs, S. C. S. G. A clinical model to estimate the pretest probability of lung cancer in patients with solitary pulmonary nodules. Chest. 2007;131(2):383-388.
Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013; 143(5 suppl):e93S.
Gould MK, Tang T, Liu IL, et al. Recent trends in the identification of incidental pulmonary nodules. Am J Respir Crit Care Med. 2015; 192(10):1208-1214.
Lung-RADS Version 1.0 Assessment Categories Release date: April 28,2014. http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/LungRADS/AssessmentCategories.pdf. Accessed Oct 31, 2014.
MacMahon H, Austin JH, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005;237(2):395-400.
McWilliams A, Tammemagi MC, Mayo JR, et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med. 2013;369(10):910-919.
Naidich DP, Bankier AA, MacMahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. Radiology. 2013;266(1):304-317.
Swensen SJ, Silverstein MD, Edell ES, et al. Solitary pulmonary nodules: clinical prediction model versus physicians. Mayo Clin Proc. 1999;74(4):319-329.
Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of malignancy in solitary pulmonary nodules: Application to small radiologically indeterminate nodules. Arch Intern Med. 1997;157(8): 849-855.
Clinical utility of the acute bronchodilator response
Recently, numerous articles evaluating the acute bronchodilator (BD) response in various disease states have appeared in the literature (Chest. 2015;148[6]:1489; J Thorac Dis. 2016;8[1]:14; Int J Chron Obstruct Pulmon Dis. 2016;11:93; Respir Med. 2016;112:45). New algorithms have been proposed to improve quality control in BD (Eur Clin Respir J. 2015;30;2).
In our lab, requests for pre- and post-BD spirometry continue unabated. Undoubtedly, many labs comply with these requests without regard for pre-BD values. The number of these requests far exceeds the number needed to confirm asthma diagnosis, or to assure that post-BD FEV1/FVC ratio remains below 0.7 for COPD diagnosis, which are the only universally accepted indications for BD testing.
Acute BD testing technique, interpretation, and clinical application involve important issues that remain unresolved, even in COPD where this test has been studied more than any other disease state except asthma (Chest. 2011;140[4]:1055; Int J Chron Obstruct Pulmon Dis. 2015;10:407). There remains no clear consensus for a clinically relevant BD response. The ACCP definition proposed in 1974 (FEV1 improvement by greater than 15%) has not been updated, and the widely used ATS/ERS definition (FEV1 and/or FVC improvement by greater than 12% and 200 mL) is felt to be arbitrary and based more on expert opinion than scientific evidence (Respir Care. 2012;57[10]:1564). Literature review (excluding asthma) reveals no well-done, reproducible studies that demonstrate meaningful or widely applicable uses for the acute BD response.
Overcoming the many factors influencing acute bronchodilator testing, developing a unified definition for a positive test, and then showing a predictive significance to the acute-BD response is an extremely difficult task. Until this test is further studied in a rigorous manner, any meaning attached to a positive response outside of asthma is purely arbitrary.
Dr. Oleh Hnatiuk, FCCP
Steering Committee Member
Gun violence in the hospital
Thirty-one thousand fatal gunshot wounds (GSW) occur in the United States each year and are increasing; 55% are self-inflicted, mostly isolated incidents. However, mass shooting events (MSE = more than 3 victims) are rising with 355 events in 2015 (462 deaths and 1,314 injuries). The mortality of GSW has risen due to the use of high caliber automatic handguns. Health-care providers, facilities, and systems need to include preparation for primary prevention and secondary mitigation for violent acts of this nature.
MSE attacker demographics reveal a male predominance (90%) with ethnicity mirroring the US population (65% Caucasian, 16% black, and 9% Asian) and mainly occurring in urban settings. The psychosocial basis of these changes is complex and multifactorial. Two-thirds of mass shooters have a history of mental illness with paranoid schizophrenia predominating. Motives are shifting from self-destruction to grievance-related events. Targets and victims of GSW violence also seem to be changing, and health-care workers are potential targets for GSW violence.
A 12-year review of hospital shooting events (HSE) found 154 events with 235 victims. There is a rise in this type of violent act. Grievance motives are dominant in these events. Most HSE occur in the ED or at the entrance to the hospital or parking lot (77%). The case fatality rate in HSE averages 50%. The perpetrators are injured in 85% of cases. Nurses are the most common victims of HSE.
Prevention strategies such as metal detectors, camera surveillance, strengthened security staff, and emergency protocols are vital. However, in many hospitals, these strategies are inadequate or not considered. Secondary mitigation requires special education and training and some material preparation to be successful. Providers must consider themselves potential gun violence victims. We encourage all medical providers to engage in planning and preparation for HSE, as well as advocate for gun safety laws
Dr. Dennis Amundson, FCCP
NetWork Member
Critical violent injury in the United States: A review and call to action. Crit Care Med. 2015;43(11):2460-2466.
Hospital-based shooting in the United States: 2000-2011. Ann Emerg Med. 2012;60(6):790-798.
The epidemiology of trauma-related mortality in the United States From 2002-2012. J Trauma Acute Care Surg. 2014;76(4):913-920.
Balloon pulmonary angioplasty for CTEPH
The gold-standard treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary thromboendarterectomy (PTE). However, not every patient is a surgical candidate, including those who are deemed technically inoperable (after review by a multidisciplinary, experienced CTEPH team) or those whose goals of care are more palliative.
Such factors created an opportunity for an alternative procedure to manage CTEPH: catheter-based balloon pulmonary angioplasty (BPA). Despite the limited success with early BPA experience, with initial set-backs including high reperfusion edema rates and other procedure complications, BPA has become more refined over time. Initially led by the efforts of several groups based in Japan, modifications included greater precision in “right-sizing” balloons, staging the procedure (average two to five sessions/patient), and better vascular imaging techniques with advancing technical capabilities.
BPA has received attention due to the favorable hemodynamic and functional outcomes reported in select patients. Despite a lack of consensus regarding who might benefit most, these preliminary results have stimulated considerable interest for acquiring this technique worldwide.
Caution should be exercised when BPA is considered for CTEPH treatment. Critical to success is the selection of patients who might benefit, and adequate training and technical expertise is essential for BPA performance. For those with operable CTEPH who are otherwise surgical candidates, data do not yet exist to suggest BPA as a comparable alternative to PTE. Furthermore, the absence of head-to-head comparison between medical therapy and BPA for inoperable CTEPH further blurs the role BPA will have in this unique patient population. But, it holds promise, awaiting further trials data.
Dr. Wassim H. Fares, FCCP, NetWork Member
Dr. William R. Auger, FCCP, Steering Committee Member
Pulmonary nodules: Are you seeing spots?
Pulmonary nodules are increasingly being identified in clinical practice. A recent study estimated that 1.5 million nodules are identified annually in the United States (Gould et al. 2015; Am J Respir Crit Care Med. 192[10], 1208). This 10-fold increase in number over prior estimates reflects the steep escalation in utilization of CT scanning over the past several decades, and is likely to rise further as lung cancer screening is implemented. While the majority of nodules are benign, evaluation necessarily includes an assessment of the probability of malignancy, since this is a major driver of the decision as to whether no further intervention is required, or whether watchful surveillance or further noninvasive or invasive evaluation is appropriate (Gould et al., 2013). It is reassuring that experienced chest physicians perform well in the assessment of the probability of malignancy (Gould et al., 2013; Swensen et al., 1999), but also important to recognize that evidence-based guidelines for nodule evaluation as well as validated tools for assessing the likelihood of malignancy are readily available (Gould, Ananth, Barnett, & Veterans Affairs, 2007; Gould et al., 2013; McWilliams et al., 2013; Swensen, Silverstein, Ilstrup, Schleck, & Edell, 1997). It is important to engage our radiology colleagues in this discussion; guidelines from the Fleischner Society and the American College of Radiology for reporting on incidentally identified small solid nodules, incidentally identified subsolid nodules, and screening-detected nodules are individually distinct in definitions of abnormality as well as recommendations for follow up, and should be applied appropriately in the context of the individual patient as well as the situation for which the CT was performed (“Lung-RADS Version 1.0 Assessment Categories Release date: April 28, 2014,” 2014; MacMahon et al., 2005; Naidich et al., 2013). All of these potential sources of variation highlight the value of standardizing the approach to nodule evaluation, to ensure that appropriate evaluation will be done to maximize the likelihood of identifying nodules that are actually cancer, and minimize harm potentially incurred by unnecessary invasive and noninvasive testing of nodules that are actually benign.
Dr. Lynn Tanoue, FCCP
NetWork Chair
Gould MK, Ananth L, Barnett PG, and Veterans Affairs, S. C. S. G. A clinical model to estimate the pretest probability of lung cancer in patients with solitary pulmonary nodules. Chest. 2007;131(2):383-388.
Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013; 143(5 suppl):e93S.
Gould MK, Tang T, Liu IL, et al. Recent trends in the identification of incidental pulmonary nodules. Am J Respir Crit Care Med. 2015; 192(10):1208-1214.
Lung-RADS Version 1.0 Assessment Categories Release date: April 28,2014. http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/LungRADS/AssessmentCategories.pdf. Accessed Oct 31, 2014.
MacMahon H, Austin JH, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005;237(2):395-400.
McWilliams A, Tammemagi MC, Mayo JR, et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med. 2013;369(10):910-919.
Naidich DP, Bankier AA, MacMahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. Radiology. 2013;266(1):304-317.
Swensen SJ, Silverstein MD, Edell ES, et al. Solitary pulmonary nodules: clinical prediction model versus physicians. Mayo Clin Proc. 1999;74(4):319-329.
Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of malignancy in solitary pulmonary nodules: Application to small radiologically indeterminate nodules. Arch Intern Med. 1997;157(8): 849-855.
