National Association for Medical Direction of Respiratory Care (NAMDRC): Annual Meeting

LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.

The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.

The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.

"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.

Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.

The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.

The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.

With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.

Dr. Kotloff said that he had no disclosures.

LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.

The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.

The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.

"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.

Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.

The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.

The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.

With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.

Dr. Kotloff said that he had no disclosures.

LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.

The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.

The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.

"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.

Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.

The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.

The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.

With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.

Dr. Kotloff said that he had no disclosures.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

LAS VEGAS – The results from the National Lung Screening Trial constitute a "game changer" for lung cancer screening, Dr. James R. Jett said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

The study results, reported in a press release by the National Cancer Institute last November, "changed the landscape" for screening by showing that lung imaging by low-dose helical CT done annually for 3 years in people with a smoking history of least 30 pack-years cut their mortality rate from lung cancer during follow-up by 20%, compared with people who underwent three annual chest x-rays. "This is the biggest advance in lung cancer in my career, an absolutely stunning result," said Dr. Jett, a pulmonologist and lung cancer specialist at National Jewish Health in Denver.

The researchers who ran the National Lung Screening Trial will likely publish their full results this spring, after which annual screening of people who match the profile of those in the study should become the standard of care, Dr. Jett predicted.

The screening trial enrolled 53,454 current or former cigarette smokers aged 55-74 years, who had each accumulated at least 30 pack-years of smoking history but had quit within the previous 15 years. The more than 75,000 total screening events by CT and more than 73,000 total screens by chest x-ray yielded 24% positive CT images and 7% positive x-ray images. During roughly 144,000 person-years of follow-up in each arm, the mortality due to lung cancer reached 246 deaths per 100,000 person-years in the CT group and 308 deaths per 100,000 person-years in the x-ray group, a 20% absolute mortality reduction with CT screening that was statistically significant, and which led the trial’s Data and Safety Monitoring Board to stop the study and release the results.

The people screened by CT also had a 7% reduction in all-cause mortality, compared with those screened by x-ray, also a statistically significant difference.

As about 160,000 Americans die from lung cancer annually, a 20% cut in mortality from low-dose helical CT screening could potentially save about 32,000 lives a year in the United States alone. "That’s almost like eliminating all 40,000 breast cancer deaths each year," Dr. Jett said.

The results did not directly address the question of how long annual screening should continue. In the trial, screening stopped after three annual examinations because of limited financial resources, although despite that the study cost about $200 million, he said. But his review of the results identified no suggestion that in routine practice screening should stop after 3 years. "There was no drop in the number of cancers" during each sequential year of screening. "I don’t see anything that tells me you can stop [screening] after 3 years," he said.

"The biggest question is, can we afford" to do annual CT screening on the scale needed to include all people who fit the profile included in the trial.

A second issue is the safety of annual CT imaging, but Dr. Jett presented a brief analysis suggesting that it is safe. A low-dose CT scan involves a radiation exposure of about 0.65 mSv, less than 10% of the dose of a conventional chest CT, Dr. Jett said. With that level of exposure, annual low-dose CT imaging of currently smoking women aged 50 might cause an excess of 5 cancer deaths for every 10,000 people screened, compared with a background lung cancer mortality of 100 for every 10,000 people with no screening. Because screening could prevent 20% of these 100 deaths, it would avert more deaths that it might cause. For men, the risk: benefit ratio runs even higher because currently smoking men undergoing annual CT screening would have about 2 extra lung cancer deaths per 10,000 people due to the radiation exposure, compared with 110 per 10,000 without screening. Women face a higher risk from the radiation of screening than men because of the impact of chest radiation on breast cancer, Dr. Jett said.

Dr. Jett said that he has been an adviser to Genentech, Pfizer, and Bristol-Myers Squibb, and that he has a research grant pending from Oncimmune.

LAS VEGAS – The results from the National Lung Screening Trial constitute a "game changer" for lung cancer screening, Dr. James R. Jett said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

The study results, reported in a press release by the National Cancer Institute last November, "changed the landscape" for screening by showing that lung imaging by low-dose helical CT done annually for 3 years in people with a smoking history of least 30 pack-years cut their mortality rate from lung cancer during follow-up by 20%, compared with people who underwent three annual chest x-rays. "This is the biggest advance in lung cancer in my career, an absolutely stunning result," said Dr. Jett, a pulmonologist and lung cancer specialist at National Jewish Health in Denver.

The researchers who ran the National Lung Screening Trial will likely publish their full results this spring, after which annual screening of people who match the profile of those in the study should become the standard of care, Dr. Jett predicted.

The screening trial enrolled 53,454 current or former cigarette smokers aged 55-74 years, who had each accumulated at least 30 pack-years of smoking history but had quit within the previous 15 years. The more than 75,000 total screening events by CT and more than 73,000 total screens by chest x-ray yielded 24% positive CT images and 7% positive x-ray images. During roughly 144,000 person-years of follow-up in each arm, the mortality due to lung cancer reached 246 deaths per 100,000 person-years in the CT group and 308 deaths per 100,000 person-years in the x-ray group, a 20% absolute mortality reduction with CT screening that was statistically significant, and which led the trial’s Data and Safety Monitoring Board to stop the study and release the results.

The people screened by CT also had a 7% reduction in all-cause mortality, compared with those screened by x-ray, also a statistically significant difference.

As about 160,000 Americans die from lung cancer annually, a 20% cut in mortality from low-dose helical CT screening could potentially save about 32,000 lives a year in the United States alone. "That’s almost like eliminating all 40,000 breast cancer deaths each year," Dr. Jett said.

The results did not directly address the question of how long annual screening should continue. In the trial, screening stopped after three annual examinations because of limited financial resources, although despite that the study cost about $200 million, he said. But his review of the results identified no suggestion that in routine practice screening should stop after 3 years. "There was no drop in the number of cancers" during each sequential year of screening. "I don’t see anything that tells me you can stop [screening] after 3 years," he said.

"The biggest question is, can we afford" to do annual CT screening on the scale needed to include all people who fit the profile included in the trial.

A second issue is the safety of annual CT imaging, but Dr. Jett presented a brief analysis suggesting that it is safe. A low-dose CT scan involves a radiation exposure of about 0.65 mSv, less than 10% of the dose of a conventional chest CT, Dr. Jett said. With that level of exposure, annual low-dose CT imaging of currently smoking women aged 50 might cause an excess of 5 cancer deaths for every 10,000 people screened, compared with a background lung cancer mortality of 100 for every 10,000 people with no screening. Because screening could prevent 20% of these 100 deaths, it would avert more deaths that it might cause. For men, the risk: benefit ratio runs even higher because currently smoking men undergoing annual CT screening would have about 2 extra lung cancer deaths per 10,000 people due to the radiation exposure, compared with 110 per 10,000 without screening. Women face a higher risk from the radiation of screening than men because of the impact of chest radiation on breast cancer, Dr. Jett said.

Dr. Jett said that he has been an adviser to Genentech, Pfizer, and Bristol-Myers Squibb, and that he has a research grant pending from Oncimmune.

LAS VEGAS – The results from the National Lung Screening Trial constitute a "game changer" for lung cancer screening, Dr. James R. Jett said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

The study results, reported in a press release by the National Cancer Institute last November, "changed the landscape" for screening by showing that lung imaging by low-dose helical CT done annually for 3 years in people with a smoking history of least 30 pack-years cut their mortality rate from lung cancer during follow-up by 20%, compared with people who underwent three annual chest x-rays. "This is the biggest advance in lung cancer in my career, an absolutely stunning result," said Dr. Jett, a pulmonologist and lung cancer specialist at National Jewish Health in Denver.

The researchers who ran the National Lung Screening Trial will likely publish their full results this spring, after which annual screening of people who match the profile of those in the study should become the standard of care, Dr. Jett predicted.

The screening trial enrolled 53,454 current or former cigarette smokers aged 55-74 years, who had each accumulated at least 30 pack-years of smoking history but had quit within the previous 15 years. The more than 75,000 total screening events by CT and more than 73,000 total screens by chest x-ray yielded 24% positive CT images and 7% positive x-ray images. During roughly 144,000 person-years of follow-up in each arm, the mortality due to lung cancer reached 246 deaths per 100,000 person-years in the CT group and 308 deaths per 100,000 person-years in the x-ray group, a 20% absolute mortality reduction with CT screening that was statistically significant, and which led the trial’s Data and Safety Monitoring Board to stop the study and release the results.

The people screened by CT also had a 7% reduction in all-cause mortality, compared with those screened by x-ray, also a statistically significant difference.

As about 160,000 Americans die from lung cancer annually, a 20% cut in mortality from low-dose helical CT screening could potentially save about 32,000 lives a year in the United States alone. "That’s almost like eliminating all 40,000 breast cancer deaths each year," Dr. Jett said.

The results did not directly address the question of how long annual screening should continue. In the trial, screening stopped after three annual examinations because of limited financial resources, although despite that the study cost about $200 million, he said. But his review of the results identified no suggestion that in routine practice screening should stop after 3 years. "There was no drop in the number of cancers" during each sequential year of screening. "I don’t see anything that tells me you can stop [screening] after 3 years," he said.

"The biggest question is, can we afford" to do annual CT screening on the scale needed to include all people who fit the profile included in the trial.

A second issue is the safety of annual CT imaging, but Dr. Jett presented a brief analysis suggesting that it is safe. A low-dose CT scan involves a radiation exposure of about 0.65 mSv, less than 10% of the dose of a conventional chest CT, Dr. Jett said. With that level of exposure, annual low-dose CT imaging of currently smoking women aged 50 might cause an excess of 5 cancer deaths for every 10,000 people screened, compared with a background lung cancer mortality of 100 for every 10,000 people with no screening. Because screening could prevent 20% of these 100 deaths, it would avert more deaths that it might cause. For men, the risk: benefit ratio runs even higher because currently smoking men undergoing annual CT screening would have about 2 extra lung cancer deaths per 10,000 people due to the radiation exposure, compared with 110 per 10,000 without screening. Women face a higher risk from the radiation of screening than men because of the impact of chest radiation on breast cancer, Dr. Jett said.

Dr. Jett said that he has been an adviser to Genentech, Pfizer, and Bristol-Myers Squibb, and that he has a research grant pending from Oncimmune.