The new lung cancer stage classification system is the culmination of 10 years of work and an unprecedented analysis and validation process. This article reviews details of the rules governing how to implement the system and discusses areas in which ambiguities and difficulties exist.

Diffuse alveolar hemorrhage (DAH) is often a catastrophic clinical syndrome causing respiratory failure. Recognition of DAH often requires BAL as symptoms are nonspecific, hemoptysis is absent in up to one-third of patients, and radiographic imaging is also nonspecific and similar to other acute alveolar filling processes. Once the diagnosis is established, the underlying cause must be established in order to initiate treatment. This review discusses the diagnosis of the underlying histologies and the clinical entities that are responsible for DAH as well as treatment options.

Patients who are receiving vitamin K antagonist (VKA) therapy pose challenges when they require surgery or invasive procedures because the risk for bleeding during the procedure must be balanced against the risk of an atherothrombotic event if the VKA is interrupted. However, it may be possible to safely perform some procedures, such as coronary angiography with or without percutaneous coronary intervention (PCI), without VKA interruption.

The organizational and staffing structure of an ICU influences the outcome of critically ill and injured patients. A change in the ICU staffing structure frequently occurs at nighttime and on weekends (off-hours). We postulated that patients who are admitted to an ICU during off hours may be at an increased risk of death.

Spontaneous pneumothorax (SPTX) is an uncommon phenomenon in the general population and is most commonly associated with prior bulbous emphysema, cystic parenchymal lung disease, and tuberculous lung disease. A rare cause of SPTX is malignant disease, either in the form of primary lung or pleural cancers, or in metastatic disease to the lungs. The purpose of this investigation was to compile patient characteristics, treatments received, and outcomes of patients with SPTX complicating sarcomatous cancer.

This article provides a brief review of the Système International (SI) and demonstrates how its routine use for measurements in the ICU might improve education and patient safety in the United States. We apply standard information on SI to common ICU situations. We contrast the confusion and waste from obsolete and/or nonstandard systems of measurement still used in the United States to the clarity and consistency that would result from converting to SI. Examples are drawn from basic weights and measures, electrolyte and other chemical solutions, acid-base physiology, blood gas analysis, BPs, vascular resistances, trauma kinematics, indirect calorimetry, cardiac work, and work of breathing. In addition to simplifying physiologic measurements and relationships, SI provides a common language for international collaboration and communication. Because it would thus improve critical care practice, SI should be increasingly accepted in the United States and especially promoted in the ICU.

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

Research into the association between diabetes and pulmonary function has resulted in inconsistent outcomes among studies. We performed a metaanalysis to clarify this association.

Obstructive sleep apnea (OSA) adversely affects multiple organs and systems, with particular relevance to cardiovascular disease. Several conditions associated with OSA, such as high BP, insulin resistance, systemic inflammation, visceral fat deposition, and dyslipidemia, are also present in other conditions closely related to OSA, such as obesity and reduced sleep duration. Weight loss has been accompanied by improvement in characteristics related not only to obesity but to OSA as well, suggesting that weight loss might be a cornerstone of the treatment of both conditions. This review seeks to explore recent developments in understanding the interactions between body weight and OSA. Weight loss helps reduce OSA severity and attenuates the cardiometabolic abnormalities common to both diseases. Nevertheless, weight loss has been hard to achieve and maintain using conservative strategies. Since bariatric surgery has emerged as an alternative treatment of severe or complicated obesity, impressive results have often been seen with respect to sleep apnea severity and cardiometabolic disturbances. However, OSA is a complex condition, and treatment cannot be limited to any single symptom or feature of the disease. Rather, a multidisciplinary and integrated strategy is required to achieve effective and long-lasting therapeutic success.

CMS introduced new pediatric critical care codes and renumbered neonatal and pediatric critical care Current Procedural Terminology (CPT) codes in January 2009. Unlike the time-based critical care codes used for adult care, services for many children use bundled codes for all critical care services by a single physician during a calendar day. New codes have been added for 24- to 60-month old children. CPT codes for critical care of neonates and children 28 days to 24 months were renumbered. This article discusses the changes and the impact on physicians providing critical care services.

The issue of tobacco industry responsibility for population health problems and compensation for their treatment has been growing since the 1960s. In 1999, the state attorneys general collectively launched the largest class action lawsuit in US history and sued the tobacco industry to recover the costs of caring for smokers. In what became known as the Master Settlement Agreement (MSA), states were rewarded billions of dollars and won concessions regarding how cigarettes could be advertised and targeted to minors. Ten years after this settlement, much is known about how MSA monies were distributed and how states have used the money. There is some understanding about how much of the money went toward offsetting the health-care costs attributable to smoking and whether resources were allocated to efforts to reduce smoking in a particular state. However, there are few data on what effect, if any, the MSA had on tobacco control locally and nationally. This commentary explores these issues, as well as how the tobacco industry has evolved to offset the losses incurred by the settlement. Finally, an analysis of the complexities of current tobacco policy making is provided so that physicians and other health-care advocacy groups can more completely understand the present-day political dynamics and be more effective in shaping tobacco control policy in the future.

This consensus statement was developed based on the understanding that patients with advanced lung or heart disease are not being treated consistently and effectively for relief of dyspnea.

Hospitalized patients are often at increased risk for oropharyngeal dysphagia following prolonged endotracheal intubation. Although reported incidence can be high, it varies widely. We conducted a systematic review to determine: (1) the incidence of dysphagia following endotracheal intubation, (2) the association between dysphagia and intubation time, and (3) patient characteristics associated with dysphagia. Fourteen electronic databases were searched, using keywords dysphagia, deglutition disorders, and intubation, along with manual searching of journals and grey literature. Two reviewers, blinded to each other, selected and reviewed articles at all stages according to our inclusion criteria: adult participants who underwent intubation and clinical assessment for dysphagia. Exclusion criteria were case series (n < 10), dysphagia determined by patient report, patients with tracheostomies, esophageal dysphagia, and/or diagnoses known to cause dysphagia. Critical appraisal used the Cochrane risk of bias assessment and Grading of Recommendations, Assessment, Development and Evaluation tools. A total of 1,489 citations were identified, of which 288 articles were reviewed and 14 met inclusion criteria. The studies were heterogeneous in design, swallowing assessment, and study outcome; therefore, we present findings descriptively. Dysphagia frequency ranged from 3% to 62% and intubation duration from 124.8 to 346.6 mean hours. The highest dysphagia frequencies (62%, 56%, and 51%) occurred following prolonged intubation and included patients across all diagnostic subtypes. All studies were limited by design and risk of bias. Overall quality of the evidence was very low. This review highlights the poor available evidence for dysphagia following intubation and hence the need for high-quality prospective trials.

Although many studies have suggested that biomass smoke is a risk factor for COPD, the relationship between the two has not been firmly established. In particular, the extent of the association between exposure of biomass smoke and COPD in different populations, as well as the relationship between biomass smoke and cigarette smoke, is not clear. To ascertain the relationship between biomass smoke and COPD, we performed a metaanalysis.

Timely diagnosis of pleural space infections and rapid initiation of effective pleural drainage for those patients with complicated parapneumonic effusions or empyema represent keystone principles for managing patients with pneumonia. Advances in chest imaging provide opportunities to detect parapneumonic effusions with high sensitivity in patients hospitalized for pneumonia and to guide interventional therapy. Standard radiographs retain their primary role for screening patients with pneumonia for the presence of an effusion to determine the need for thoracentesis. Ultrasonography and CT scanning, however, have greater sensitivity for fluid detection and provide additional information for determining the extent and nature of pleural infection. MRI and PET scan can image pleural disease, but their role in managing parapneumonic effusions is not yet clearly defined. Effective application of chest images for patients at risk for pleural infection, however, requires a comprehensive understanding of the unique features of each modality and relative value. This review presents the diagnostic usefulness and clinical application of chest imaging studies for evaluating and managing pleural space infections in patients hospitalized for pneumonia.

There are many complementary techniques for mediastinal staging of lung cancer. It is increasingly apparent that the accuracy of mediastinal staging depends not only on which test is used but also on technical factors of how the procedure is performed. This article reviews data regarding such technical factors and proposes a classification schema of the thoroughness of execution of mediastinal staging tests. Such a schema is needed for a thoughtful discussion of how mediastinal staging tests should be integrated and for the development of standards of good quality care for patients with non-small cell lung cancer.

Cigarette smoking is arguably the major cause of preventable morbidity and mortality in the developed world. The Department of Health and Human Services in the United States classifies cigarette smoking as a chronic, often relapsing disease. Like most complex diseases, genetic and environmental factors play important roles and contribute to both smoking initiation and persistence. This review summarizes pharmacologic and nonpharmacologic interventions for smoking cessation and provides references to evidence-based guidelines and support material. As smoking is an etiologic and exacerbating factor for lung diseases, the pulmonary physician should be particularly expert in smoking cessation interventions.

Massive transfusion (MT) is a lifesaving treatment of hemorrhagic shock, but can be associated with significant complications. The lethal triad of acidosis, hypothermia, and coagulopathy associated with MT is associated with a high mortality rate. Other complications include hypothermia, acid/base derangements, electrolyte abnormalities (hypocalcemia, hypomagnesemia, hypokalemia, hyperkalemia), citrate toxicity, and transfusion-associated acute lung injury. Blood transfusion in trauma, surgery, and critical care has been identified as an independent predictor of multiple organ failure, systemic inflammatory response syndrome, increased infection, and increased mortality in multiple studies. Once definitive control of hemorrhage has been established, a restrictive approach to blood transfusion should be implemented to minimize further complications.

Interventional pulmonology continues to be a specialty that is experiencing an evolution of new technologies, with an emphasis on multidisciplinary care. The diversity and application of these procedures in patients with more complex conditions is leading to the need for more specific recommendations in training within this area. As patient safety and outcomes-based measures of clinical practice and procedures are in the forefront, the need for standardization in procedural training in high-volume centers of excellence beyond pulmonary and critical care fellowships must be considered. Other procedure-based specialties have developed such training programs, with structured curricula to enhance patient safety and outcomes, develop validated metrics for competency assessment of trainees, improve trainee education, and further advance the field by fostering research.

This manuscript provides an overview of how to interpret in vitro clotting studies and how to select studies to evaluate patients with bleeding disorders in the ICU. It provides a practical approach to understanding the complex subject of clotting factor abnormalities, including the most common problems of preanalytical error and anticoagulation therapy. Limitations and pitfalls of diagnostic testing are highlighted.