Search

Respiratory failure is a significant concern in neuromuscular diseases (NMDs). This CHEST guideline examines the literature on the respiratory management of patients with NMD to provide evidence-based recommendations. An expert panel conducted a systematic review addressing the respiratory management of NMD and applied the Grading of Recommendations, Assessment, Development, and Evaluations approach for assessing the certainty of the evidence and formulating and grading recommendations. A modified Delphi technique was used to reach a consensus on the recommendations. Based on 128 studies, the panel generated 15 graded recommendations, one good practice statement, and one consensus-based statement. Evidence of best practices for respiratory management in NMD is limited and is based primarily on observational data in amyotrophic lateral sclerosis. The panel found that pulmonary function testing every 6 months may be beneficial and may be used to initiate noninvasive ventilation (NIV) when clinically indicated. An individualized approach to NIV settings may benefit patients with chronic respiratory failure and sleep-disordered breathing related to NMD. When resources allow, polysomnography or overnight oximetry can help to guide the initiation of NIV. The panel provided guidelines for mouthpiece ventilation, transition to home mechanical ventilation, salivary secretion management, and airway clearance therapies. The guideline panel emphasizes that NMD pathologic characteristics represent a diverse group of disorders with differing rates of decline in lung function. The clinician's role is to add evaluation at the bedside to shared decision-making with patients and families, including respect for patient preferences and treatment goals, considerations of quality of life, and appropriate use of available resources in decision-making. [ABSTRACT FROM AUTHOR]

Value-based care aims to improve the health outcomes of patients, eliminate waste and unwarranted clinical variation, and reduce the total cost of care. Professional medical societies have put forward guidelines to raise awareness on unproven practice patterns (Choosing Wisely Campaign), and payers have sought to replace the traditional fee-for-service payment models with value-based contracts that share financial gains or losses based on achieving high-quality outcomes and lowering the cost of care. Regardless of whether their practices are engaged in value-based arrangements, chest physicians should seek understanding of these principles, participate in designing and implementing practical and impactful high-value initiatives in their practices, and have a national voice on the path forward. [ABSTRACT FROM AUTHOR]

Background: Pretreatment invasive nodal staging is paramount for appropriate treatment decisions in non-small cell lung cancer. Despite guidelines recommending when to perform staging, many studies suggest that invasive nodal staging is underused. Attitudes and barriers to guideline-recommended staging are unclear. The National Lung Cancer Roundtable initiated this study to better understand the factors associated with guideline-adherent nodal staging.Research Question: What are the knowledge gaps, attitudes, and beliefs of thoracic surgeons and pulmonologists about invasive nodal staging? What are the barriers to guideline-recommended staging?Study Design and Methods: A web-based survey of a random sample of pulmonologists and thoracic surgeons identified as members of American College of Chest Physicians (CHEST) was conducted in 2019. Survey domains included knowledge of invasive nodal staging guidelines, attitudes and beliefs toward implementation, and perceived barriers to guideline adherence.Results: Among 453 responding physicians, 29% were unaware that invasive nodal staging guidelines exist. Among the 320 physicians who knew guidelines exist, attitudes toward the guidelines were favorable, with 91% agreeing guidelines are generalizable and 90% agreeing that recommendations improved their staging and treatment decisions. Approximately 80% responded that guideline recommendations are based on satisfactory levels of scientific evidence, and 50% stated a lack of evidence linking adherence to guidelines to changes in management or better patient outcomes. Nearly 9 in 10 physicians reported at least one barrier to guideline adherence. The most common barriers included patient anxiety associated with treatment delays (62%), difficulty implementing guidelines into routine practice (52%), and time delays of additional testing (51%).Interpretation: Among physicians who responded to our survey, more than one-quarter were unaware of invasive nodal staging guidelines. Attitudes toward guideline recommendations were positive, although 20% reported insufficient evidence to support staging algorithms. Most physicians reported barriers to implementing guidelines. Multilevel interventions are likely needed to increase rates of guideline-recommended invasive nodal staging. [ABSTRACT FROM AUTHOR]

Background: Targeted therapies for advanced non-small cell lung cancer (NSCLC) with oncogenic drivers have caused a paradigm shift in care. Biomarker testing is needed to assess eligibility for these therapies. Pulmonologists often perform bronchoscopy, providing tissue for both pathologic diagnosis and biomarker analysis. We performed this survey to define the existing knowledge and practices regarding the pulmonologists' role in biomarker testing for advanced NSCLC.Research Question: What is the current knowledge and practice of pulmonologists regarding biomarker testing and targeted therapies in advanced NSCLC?Study Design and Methods: This cross-sectional study was performed using an electronic survey of a random sample of 7,238 pulmonologists. Questions focused on diagnostic steps and biomarker analyses for NSCLC.Results: A total of 453 pulmonologists responded. Respondents vary by reported lung cancer patient volume, ranging from 51% evaluating one to four new cases per month to 19% evaluating > 10 cases per month. Interventional training, academic practice setting, and higher volume of endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) were associated with increased knowledge of practice guidelines for the number of recommended passes during EBUS-TBNA (P < .05). Academic pulmonologists more commonly performed or referred for EBUS-TBNA than community pulmonologists (96% and 83%, respectively; P < .0005). Higher testing rates were associated with interventional training, academic setting, and the presence of an institutional policy, whereas lower testing rates were associated with general pulmonologists, practice in community settings, and lack of a guiding institutional policy (P < .05).Interpretation: Substantial differences among pulmonologists' evaluation of advanced NSCLC, variation in knowledge of available biomarkers and the importance of targeted therapies, and differences in institutional coordination likely lead to underutilization of biomarker testing. Interventional training appears to drive improved knowledge and practice for biomarker testing more than practice setting. Improvements are needed in tissue acquisition and interdisciplinary coordination to ensure universal and comprehensive testing for eligible patients. [ABSTRACT FROM AUTHOR]

Organizational Culture Matters: Culture is a key driver of organizational performance and underpins strategy. As previously discussed, if the strategy is the plants and the garden plan for a garden, the culture is the soil. Without a healthy culture, nothing will grow, irrespective of how well planned the garden or how beautiful the individual flowers. Using the case of establishing the culture in an institute at the Cleveland Clinic, the article examines an approach to establishing and maintaining an organizational culture. Anchors for this process are a situational assessment of the current culture as a new leader steps in and mindfulness by the leader of how members of the institute should experience the organization. Critical success factors include open communication and establishing psychological safety as well as modeling integrity. Fundamentally, when cultures are grounded in the seven classical virtues-trust, compassion, courage, justice, wisdom, temperance, and hope-they are best positioned to unleash the discretionary effort of its members. When people expend discretionary effort, they do the right thing when nobody is watching and the performance drivers are internal motivation and alignment with mission rather than external drivers to seek reward (carrots) or to avoid punishment (sticks). [ABSTRACT FROM AUTHOR]

Despite international treaties banning torture, it is still widely practiced by state agents and private citizens alike. Pulmonologists may encounter survivors of torture in routine clinical practice or in the context of a forensic medical evaluation. The Istanbul Protocol delineates the general approach to the effective medical examination, investigation, and reporting of an individual alleging torture, but relatively little text is devoted to the specific pulmonary manifestations of torture. This review intends to address this paucity. [ABSTRACT FROM AUTHOR]

There is an evolution of pleural procedures that involve broadened clinical indication and expanded scope that include advanced diagnostic, therapeutic, and palliative procedures. Finance and clinical professionals have been challenged to understand the indication and coding complexities that accompany these procedures. This article describes the utility of pleural procedures, the appropriate current procedural terminology coding, and necessary modifiers. Coding pearls that help close the knowledge gap between basic and advanced procedures aim to address coding confusion that is prevalent with pleural procedures and the risk of payment denials, potential underpayment, and documentation audits. [ABSTRACT FROM AUTHOR]

Background: The role of tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic remains unknown. The goal of this consensus statement is to examine the current evidence for performing tracheostomy in patients with respiratory failure from COVID-19 and offer guidance to physicians on the preparation, timing, and technique while minimizing the risk of infection to health care workers (HCWs).Methods: A panel including intensivists and interventional pulmonologists from three professional societies representing 13 institutions with experience in managing patients with COVID-19 across a spectrum of health-care environments developed key clinical questions addressing specific topics on tracheostomy in COVID-19. A systematic review of the literature and an established modified Delphi consensus methodology were applied to provide a reliable evidence-based consensus statement and expert panel report.Results: Eight key questions, corresponding to 14 decision points, were rated by the panel. The results were aggregated, resulting in eight main recommendations and five additional remarks intended to guide health-care providers in the decision-making process pertinent to tracheostomy in patients with COVID-19-related respiratory failure.Conclusion: This panel suggests performing tracheostomy in patients expected to require prolonged mechanical ventilation. A specific timing of tracheostomy cannot be recommended. There is no evidence for routine repeat reverse transcription polymerase chain reaction testing in patients with confirmed COVID-19 evaluated for tracheostomy. To reduce the risk of infection in HCWs, we recommend performing the procedure using techniques that minimize aerosolization while wearing enhanced personal protective equipment. The recommendations presented in this statement may change as more experience is gained during this pandemic. [ABSTRACT FROM AUTHOR]

Background: In the incidental pulmonary nodule and breast cancer screening settings, high-quality patient-centered communication can improve adherence to evaluation and mitigate patient distress. Although guidelines emphasize shared decision-making before lung cancer screening, little is known about patient-clinician communication after lung cancer screening.Research Question: How do patients and clinicians perceive communication and results notification after lung cancer screening, and are there approaches that may mitigate or exacerbate distress?Study Design and Methods: We conducted interviews and focus groups with 49 patients who underwent lung cancer screening in the prior year and 36 clinicians who communicate screening results (primary care providers, pulmonologists, nurses), recruited from lung cancer screening programs at 4 hospitals. We analyzed transcripts using conventional content analysis.Results: Clinicians and patients diverged in their impressions of the quality of communication after lung cancer screening. Clinicians recognized the potential for patient distress and tailored their approach to disclosure based on how clinically concerning they perceived results to be. Disclosure of normal or low-risk findings usually occurred by letter; clinicians believed this process was efficient and well received by patients. Yet many patients were dissatisfied: several could not recall receiving results at all, and others reported that receiving results by letter left them confused and concerned, with little opportunity to ask questions. By contrast, patients with larger nodules typically received results during an immediate phone call or clinic visit, and both patients and clinicians agreed that these conversations represented high-quality communication that met patient needs. Regardless of their cancer risk, patients who learned their results in a conversation appreciated the opportunity to discuss both the meaning of the nodule and the evaluation plan, and to have their concerns addressed, preempting distress.Interpretation: Tension exists between clinicians' interest in efficiency of results notification by letter in low-risk cases and patients' need to understand and be reassured about screening results, their implications, and the plan for subsequent screening or nodule evaluation-even when clinicians did not perceive results as concerning. Brief conversations to discuss lung cancer screening results may improve patient understanding and satisfaction while reducing distress. [ABSTRACT FROM AUTHOR]

Interventional pulmonology programs provide clinical benefit to patients and are financially sustainable. To appreciate and illustrate the economic value of interventional pulmonology programs to hospital systems, physicians must have an understanding of basic health-care finance. Total revenue, adjusted gross revenue, contribution margin, variable direct costs, and indirect costs are terms that are essential for understanding the finances of bronchoscopy. Command of such vocabulary and its application is crucial for interventional pulmonologists to successfully establish financially sustainable bronchoscopy programs. Two significant features of an economically sustainable bronchoscopy program are high procedural volume and low direct cost per case. Interventional pulmonology programs are valuable to the patients being served and hospitals as a whole. Consideration of the various factors needed to maintain financial sustainability is essential to improve the quality of care for patients because the cost of care remains a critical driver in defining value. [ABSTRACT FROM AUTHOR]

Several recent cases associating cleaned and high-level disinfected duodenoscopes with outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) and related multidrug-resistant organisms (MDROs) may cause bronchoscopists, pulmonologists, and other stakeholders to inquire about the effectiveness of today's practices for reprocessing flexible bronchoscopes. The primary objectives of this study were to address this question and investigate the risk of bronchoscopes transmitting infections of CRE and related MDROs. The published literature and the US Food and Drug Administration's medical device database of adverse events were searched beginning in 2012, when endoscopy first emerged as a recognized risk factor for transmission of CRE. The Internet was also searched during this same time frame to identify other relevant cases. Several cases associating reprocessed bronchoscopes with infections of CRE or a related MDRO were identified. This study's findings suggest that bronchoscopes may pose an underrecognized potential for transmission of CRE and related MDROs, warranting greater public awareness, enhanced preventive measures, and updated reprocessing guidance. This study's data also suggest that the cleaning and high-level disinfection of bronchoscopes performed in accordance with published guidelines and manufacturer instructions may not always be sufficiently effective to eliminate this risk. Several factors were identified that can adversely affect a bronchoscope's reprocessing and pose a risk of transmission of these multidrug-resistant bacteria, including use of a damaged or inadequately serviced bronchoscope, and formation of an inaccessible biofilm. Recommendations are provided to improve the safety of flexible bronchoscopes, including supplementing their reprocessing with an enhanced measure such as sterilization when warranted, and strict adherence to a periodic servicing and maintenance schedule consistent with the bronchoscope manufacturer's instructions. [ABSTRACT FROM AUTHOR]

Airway stenting has been practiced for several decades. It is one of the most common procedures performed by interventional pulmonologists. Typically, these stents are implanted to maintain the tubular patency of the tracheobronchial tree. They are only considered as a temporizing measure, or when a surgical option cannot be pursued. Through the past few decades, a number of metallic airway stents have been introduced into the market. First generation stents were comparatively simplistic and crafted from stainless steel. The latest generation of metallic airway stents are hybrid in nature and constructed with complex alloys. As airway stenting become more widely practiced, concerns arose regarding their safety. However, with improved understanding of stent-airway interactions, advancements in biomedical engineering, and a larger emphasis on post procedural care, the use of metallic endobronchial stents has been resurrected. We present the history, technological advancement, and contemporary indications of metallic airway stents. [ABSTRACT FROM AUTHOR]

Background: There is limited knowledge on what proportions of patients with COPD receive ambulatory care from primary care physicians, pulmonologists, or other specialists. We evaluated the types and combinations of physicians who provide ambulatory care to patients with COPD.Methods: We conducted a population-based cross-sectional study using health administrative datasets from Ontario, Canada between April 1, 2014 and March 31, 2015. Individuals age 35 years and older with physician-diagnosed COPD were identified, using a previously validated COPD case definition. The primary outcomes were ambulatory visits to primary care physicians, pulmonologists, and all other specialists within a 1-year period.Results: There were 895,155 individuals identified as having physician-diagnosed COPD. Of those, 56,533 individuals (6.3%) had no ambulatory care visits, 802,327 (89.6%) saw primary care physicians, and 95,782 (10.7%) consulted pulmonologists. By comparison, 736,496 (82.3%) saw other specialists, and 218,997 (24.5%) saw cardiologists. There were 32,473 individuals (3.6%) who underwent COPD-related hospitalizations. Of those in the subcohort with one hospitalization, about 30.0% saw pulmonologists; 43.7% of those who underwent two or more hospitalizations saw pulmonologists, and 9.9% with no hospitalization consulted pulmonologists.Conclusions: Primary care physicians play a substantial role in caring for patients with COPD. But only one-half as many patients with COPD saw pulmonologists than cardiologists, suggesting that COPD may receive less specialty care compared with other chronic medical conditions. This information can help inform COPD care strategies to improve COPD care and minimize exacerbations and associated health-care costs. It also suggests a need for more research to provide guidance on when patients with COPD should be referred to pulmonologists. [ABSTRACT FROM AUTHOR]

Patients with advanced respiratory illness are often hospitalized, requiring close follow-up after discharge and also requiring care coordination outside of traditional face-to-face outpatient visits. Primary care providers and specialists often provide services outside of outpatient visits that have not been captured and reimbursed with traditional billing evaluation and management codes. Within the last 5 years, the Centers for Medicare & Medicaid added new codes to the Medicare Physician Fee Schedule that reimburse for care coordination services not paid for by traditional evaluation and management codes. Transitional care management includes the 30-day period following hospitalization in which a clinician is responsible for care of the patient postdischarge from the hospital. Chronic care management provides reimbursement for coordination of care for chronic conditions that is performed by any clinician and his or her staff on a monthly basis that is > 20 min in duration. [ABSTRACT FROM AUTHOR]

CT scanning of the chest is one of the most important imaging modalities available to a pulmonologist. The advent of high-resolution CT scanning of the chest has led to its increasing use. Although chest radiographs are still useful as an initial test, their utility is limited in the diagnosis of lung diseases that depend on higher resolution images such as interstitial lung diseases and pulmonary vascular diseases. Several metaphoric chest CT scan signs have been described linking abnormal imaging patterns to lung diseases. Some of these are specific to a disease, whereas others help narrow the differential diagnosis. Recognizing these imaging patterns and CT scan signs are thus vitally important. In the present article, we describe a comprehensive list of the commonly encountered metaphoric chest CT scan signs and their clinical relevance. [ABSTRACT FROM AUTHOR]

Background: American College of Chest Physicians (CHEST) clinical practice guidelines on the evaluation of pulmonary nodules may have low adoption among clinicians in Asian countries. Unique patient characteristics of Asian patients affect the diagnostic evaluation of pulmonary nodules. The objective of these clinical practice guidelines was to adapt those of CHEST to provide consensus-based recommendations relevant to practitioners in Asia.Methods: A modified ADAPTE process was used by a multidisciplinary group of pulmonologists and thoracic surgeons in Asia. An initial panel meeting analyzed all CHEST recommendations to achieve consensus on recommendations and identify areas that required further investigation before consensus could be achieved. Revised recommendations were circulated to panel members for iterative review and redrafting to develop the final guidelines.Results: Evaluation of pulmonary nodules in Asia broadly follows those of the CHEST guidelines with important caveats. Practitioners should be aware of the risk of lung cancer caused by high levels of indoor and outdoor air pollution, as well as the high incidence of adenocarcinoma in female nonsmokers. Furthermore, the high prevalence of granulomatous disease and other infectious causes of pulmonary nodules need to be considered. Therefore, diagnostic risk calculators developed in non-Asian patients may not be applicable. Overall, longer surveillance of nodules than those recommended by CHEST should be considered.Conclusions: TB in Asia favors lesser reliance on PET scanning and greater use of nonsurgical biopsy over surgical diagnosis or surveillance. Practitioners in Asia are encouraged to use these adapted consensus guidelines to facilitate consistent evaluation of pulmonary nodules. [ABSTRACT FROM AUTHOR]

Background: Geographic clusters in prevalence and hospitalizations for COPD have been identified at national, state, and county levels. The study objective is to identify county-level geographic accessibility to pulmonologists for adults with COPD.Methods: Service locations of 12,392 practicing pulmonologists and 248,160 primary care physicians were identified from the 2013 National Provider Identifier Registry and weighted by census block-level populations within a series of circular distance buffer zones. Model-based county-level population counts of US adults ≥ 18 years of age with COPD were estimated from the 2013 Behavioral Risk Factor Surveillance System. The percentages of all estimated adults with potential access to at least one provider type and the county-level ratio of adults with COPD per pulmonologist were estimated for selected distances.Results: Most US adults (100% in urbanized areas, 99.5% in urban clusters, and 91.7% in rural areas) had geographic access to a primary care physician within a 10-mile buffer distance; almost all (≥ 99.9%) had access to a primary care physician within 50 miles. At least one pulmonologist within 10 miles was available for 97.5% of US adults living in urbanized areas, but only for 38.3% in urban clusters and 34.5% in rural areas. When distance increased to 50 miles, at least one pulmonologist was available for 100% in urbanized areas, 93.2% in urban clusters, and 95.2% in rural areas. County-level ratios of adults with COPD per pulmonologist varied greatly across the United States, with residents in many counties in the Midwest having no pulmonologist within 50 miles.Conclusions: County-level geographic variations in pulmonologist access for adults with COPD suggest that those adults with limited access will have to depend on care from primary care physicians. [ABSTRACT FROM AUTHOR]

Lung transplantation is now an established treatment for a broad spectrum of end-stage pulmonary diseases. According to the International Society for Heart and Lung Transplantation Registry, more than 50,000 lung transplants have been performed worldwide, with nearly 11,000 lung transplant recipients alive in the United States. With the increasing application of lung transplantation, pulmonologists must be cognizant of common complications unique to the postlung transplant period and the associated radiologic findings. The aim of this review is to describe clinical manifestations and prototypical radiographic features of both common and rare complications encountered in lung transplant recipients. [ABSTRACT FROM AUTHOR]

Background: As lung cancer screening with low-dose CT scanning is implemented, an increasing number of people will be diagnosed with pulmonary nodules. Primary care clinicians care for the vast majority of these patients, but their experiences with communication and managing distress in this population are not well understood.Methods: We conducted qualitative interviews of 15 primary care providers (PCPs) at two academic medical centers who care for patients with pulmonary nodules. We used qualitative description analysis, focusing on clinicians' information exchange and other communication behaviors.Results: Most PCPs believed they had inadequate information to counsel patients regarding lung nodules, although this information is desired. PCPs were concerned patients could "fall through the cracks" but did not have access to a reliable system to ensure follow-up adherence. They were limited by time, knowledge, and resources in providing the preferred level of care. Most PCPs did not discuss the specific risk a nodule was lung cancer, in part because they did not have ready access to this information. PCPs believed most patients did not have substantial distress as a result of nodule detection. Most PCPs did not include patients when making decisions about the follow-up plan.Conclusions: PCPs often lack systemic resources to optimize patient-centered approaches when discussing incidental pulmonary nodules with patients. With the advent of lung cancer screening, pulmonologists can assist primary care colleagues by providing accurate information to counsel patients and assisting in managing conversations about the risk of cancer. Pulmonologists should support efforts to implement reliable systems to ensure adherence to follow-up. [ABSTRACT FROM AUTHOR]

Background: Selecting a strategy (surveillance, biopsy, resection) for pulmonary nodule evaluation can be complex given the absence of high-quality data comparing strategies and the important tradeoffs among strategies. Guidelines recommend a three-step approach: (1) assess the likelihood of malignancy, (2) evaluate whether the patient is a candidate for invasive intervention, and (3) elicit the patient's preferences and engage in shared decision-making. We sought to characterize how pulmonologists select a pulmonary nodule evaluation strategy and the extent to which they report following the guideline-recommended approach.Methods: We conducted semistructured qualitative interviews with 14 pulmonologists who manage patients with pulmonary nodules at four clinical sites. Transcripts of audiorecorded interviews were analyzed using the principles of grounded theory.Results: Pulmonologists reported consistently performing steps 1 and 2 but described diverse approaches to step 3 that ranged from always engaging the patient in decision-making to never doing so. Many described incorporating patients' preferences only in particular circumstances, such as when the patient appeared particularly anxious or was aggressive in questioning management options. Indeed, other factors, including convenience, physician preferences, physician anxiety, malpractice concerns, and physician experience, appeared to drive decision-making as much as, if not more than, patient preferences.Conclusions: Although pulmonologists appear to routinely personalize pulmonary nodule evaluation strategies based on the individual patient's risk-benefit tradeoffs, they may not consistently take patient preferences into account during the decision-making process. In the absence of high-quality evidence regarding the optimal methods of pulmonary nodule evaluation, physicians should strive to ensure that management decisions are consistent with patients' values. [ABSTRACT FROM AUTHOR]

The article discusses various topics published within the issue including the management of pulmonary nodules by physicians, the use of guidelines by pulmonologists and the information exchange and communication behaviors of physicians.

The article discusses a study which examined the link between hospital readmission and pulmonologist follow-up visits in patients with chronic obstructive pulmonary disease (COPD). Topics discussed include factors that were independently associated with not attending the follow-up visit, and a comparison of demographic and clinical characteristics of patients who did and did not attend follow-up visits.

The article offers information on doctor Steven E. Weinberger, a pulmonologist, and his achievements. Topics discussed include the influence that he has had on medical profession and on medical education, his work with several leaders in the field of pulmonary medicine, and his work at the National Institutes of Health of the U.S.

The article presents a profile of respiratory physiologist, pulmonologist, researcher and professor John B. West. Topics discussed include West's participation in an expedition to the Himalayas in 1960 to study high-altitude physiology, his research about ventilation-perfusion ratio and regional differences in perfusion, ventilation and gas exchange, and his creation of the Department of Medicine's Division of Physiology in the School of Medicine at the University of California in San Diego.

The article focuses on the official policy statement of the American Thoracic Society/American College of Chest Physicians (ATS/ACCP) and their selection of the Top Five adult pulmonary medicine in the Choosing Wisely campaign. Methodology include setting ground rules and goals for an eight-member task force of pulmonologists and criteria on issue prevalence and strength of evidence. Conclusions listed five policy statements that includes not performing computed tomography (CT) scan frequently.

Background: Patients with refractory asthma frequently have elements of laryngopharyngeal reflux (LPR) with potential aspiration contributing to their poor control. We previously reported on a supraglottic index (SGI) scoring system that helps in the evaluation of LPR with potential aspiration. However, to further the usefulness of this SGI scoring system for bronchoscopists, a teaching system was developed that included both interobserver and intraobserver reproducibility.Methods: Five pulmonologists with expertise in fiber-optic bronchoscopy but novice to the SGI participated. A training system was developed that could be used via Internet interaction to make this learning technique widely available.Results: By the final testing, there was excellent interreader agreement (κ of at least 0.81), thus documenting reproducibility in scoring the SGI. For the measure of intrareader consistency, one reader was arbitrarily selected to rescore the final test 4 weeks later and had a κ value of 0.93, with a 95% CI of 0.79 to 1.00.Conclusions: In this study, we demonstrate that with an organized educational approach, bronchoscopists can develop skills to have highly reproducible assessment and scoring of supraglottic abnormalities. The SGI can be used to determine which patients need additional intervention to determine causes of LPR and gastroesophageal reflux. Identification of this problem in patients with refractory asthma allows for personal, individual directed therapy to improve asthma control. [ABSTRACT FROM AUTHOR]

An abstract of the article "The Role of the Pulmonologist in Rapid On-site Cytologic Evaluation of Transbronchial Needle Aspiration: A Prospective Study" by Martina Bonifazi and colleagues is presented.