appropriately, but this business model increases the potential for intended or unintended overuse of subsequent interventions. We stand by the statement Dr Lamb and colleagues take issue with: “establishing a discounted rate as a strategy to capture patients…creates a structure that can increase harms from excessive investigation of benign nodules.”2 The statement is not cited as evidence; it occurs in the discussion of issues regarding screening. We support making screening accessible to those who need it but stand by the opinion that we need the health-care system to appropriately cover the costs of screening (not just the scan itself) with appropriate quality metrics. It would be a poor health policy decision to provide no other structure for lung cancer screening than an inherently conflicted business model with the assumption that it will always turn out to be managed well. We note that our view is consistent with federal policies enacted as part of the Health Insurance Portability and Accountability Act legislation (§ 1128A(a)(5) of the Social Security Act), which forbids gifting services to patients to garner their business. In the absence of a health-care system structure, we support the efforts of institutions, including the laudable example of the Lahey Clinic, to find a way to appropriately implement screening. We believe that clarity about actual costs and potential conflicts is useful in finding good ways to manage these issues. We have to be careful because it can be difficult to navigate the thin line between superficial statements and attractive sound bites that are motivated primarily by a personal agenda and arguments about how it is best for us to proceed with bringing a potential significant health benefit to those who need it. Frank C. Detterbeck, MD, FCCP New Haven, CT Peter B. Bach, MD, FCCP New York, NY Affiliations: From the Yale University School of Medicine (Dr Detterbeck); and Memorial Sloan-Kettering Cancer Center (Dr Bach). Financial/nonfinancial disclosures: Dr Detterbeck is a member of the International Association for the Study of Lung Cancer International Staging Committee and a speaker in an educational program regarding lung cancer stage classification; both activities are funded by Lilly Oncology (Lilly USA, LLC). He has participated on a scientific advisory panel for Oncimmune (USA) LLC; an external grant administration board for Pfizer, Inc; a multicenter study of a device for Medela; and formerly a multicenter study of a device for Deep Breeze. Compensation for these activities is paid directly to Yale University. Dr Detterbeck also served on the executive committee of the Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-based Clinical Practice Guidelines. Dr Bach has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Frank C. Detterbeck, MD, FCCP, Yale School of Medicine, 330 Cedar St, PO Box 208062, New Haven, CT 06520-8062; e-mail: [email protected] © 2013 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-1736
References 1. Bach PB, Gould MK. When the average applies to no one: personalized decision making about potential benefits of lung cancer screening. Ann Intern Med. 2012;157(8):571-573. 2. Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB. Screening for lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidencebased clinical practice guidelines. Chest. 2013;143(5_suppl): e78S-e92S.
A Multidisciplinary Pulmonary Embolism Response Team To the Editor: In this report, we describe the successful introduction of a novel Pulmonary Embolism Response Team (PERT) to streamline the care of patients with severe pulmonary embolism (PE). The treatment of patients with massive and submassive PE remains controversial.1 Different specialists bring different experience, technical expertise, and therapeutic recommendations.1,2 To provide optimal care for complex patients with PE, a team approach is required. We formed the PERT with an infrastructure that would provide rapid, multidisciplinary consultation; mobilize resources; and facilitate research. The PERT is composed of specialists in cardiology, emergency medicine, vascular medicine, cardiac surgery, and pulmonary/critical care with an interest in PE. We created an activation system consistent with published guidelines for rapid response teams.3,4 An on-call PERT fellow responds to an activation and immediately convenes an online meeting of PERT members using commercially available software. This system enables team members to discuss the case while viewing data and radiologic images from any computer or mobile device via a password-protected login.
Table 1—Characteristics of Enrolled Patients Characteristic
No.
%
Age, y, mean (SD) Male Comorbid illness Cardiopulmonary diseasea Prior VTE Cancer Recent surgery or traumab Recent hospitalizationb PE category Suspected Low risk Submassive Massive PE location Saddle Main pulmonary artery Lobar pulmonary artery Segmental pulmonary artery Bilateral PE severity Right-sided heart strainc Troponin ⱖ 0.01 ng/mL NT-proBNP ⱖ 900 pg/mL Residual DVT presentd Clinical severity Endotracheally intubatede Admitted to ICU
57 19
17 63
10 3 8 8 10
33 10 27 27 33
5 5 18 2
17 17 60 7
7 8 9 1 20
28 32 36 4 80
20 16 13 16
80 64 52 64
8 16
27 53
NT-proBNP 5 N-terminal pro-brain natriuretic peptide; PE 5 pulmonary embolism. a Includes any history of coronary artery disease, congestive heart failure, asthma, COPD, or interstitial pulmonary fibrosis. b Within 4 wk of PE. c Based on echocardiogram or CT pulmonary angiogram. d Based on extremity ultrasound or CT venography. e Endotracheally intubated at time of Pulmonary Embolism Response Team activation.
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Correspondence
© 2013 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-1562
References
Figure 1. PE characterization and treatment. *One patient with submassive PE received both CDT and an IVC filter; **One patient with massive PE had an absolute contraindication to anticoagulation. CDT 5 catheter-directed thrombolysis; IVC 5 inferior vena cava; PE 5 pulmonary embolism; PERT 5 Pulmonary Embolism Response Team.
In the first 12 weeks, there were 30 unique PERT activations. Most (17, 57%) originated in the ED, seven (23%) in ICUs, and six (20%) in inpatient hospital units. Twenty-five activations (83%) were for confirmed PE and five (17%) for unstable patients with suspected PE. Median elapsed time from the initial activation to the multidisciplinary online meeting was 54 min (25%-75%: 52-72 min). Data collection was approved by the Human Research Committee of Partners Healthcare (2012P002257). The mean age of patients was 57 ⫾ 17 years, and 19 (63%) were men (Table 1). Seven of 25 confirmed PEs (28%) were saddle and eight (32%) involved a main pulmonary artery. Twenty patients (80%) had right-sided heart strain. After consultation, the PERT considered 18 PEs (72%) submassive and two (8%) massive (Fig 1). Two patients (8%) were treated with thrombolysis (via catheter), 12 (40%) had a contraindication to thrombolysis, and five (20%) had a vena cava filter placed. Three patients (12%) with confirmed PE died. To the authors’ knowledge, the PERT at Massachusetts General Hospital is the first such team in the country. Our initial experience suggests that an innovative, multidisciplinary PERT can streamline the care of patients with severe PE and that there is high demand for this approach. Christopher Kabrhel, MD, MPH Michael R. Jaff, DO Richard N. Channick, MD, FCCP Joshua N. Baker, MD Kenneth Rosenfield, MD Boston, MA Affiliations: From the Department of Emergency Medicine (Dr Kabrhel); the Division of Cardiology and Vascular Medicine (Drs Jaff and Rosenfield); the Division of Pulmonary/Critical Care (Dr Channick), Department of Medicine; and the Division of Cardiac Surgery (Dr Baker), Department of Surgery, Massachusetts General Hospital, Harvard Medical School. Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Christopher Kabrhel, MD, MPH, Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Pl, Ste 3B, Boston, MA 02114; e-mail: ckabrhel@ partners.org
1. Jaff MR, McMurtry MS, Archer SL, et al; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123(16): 1788-1830. 2. Imberti D, Ageno W, Manfredini R, et al. Interventional treatment of venous thromboembolism: a review. Thromb Res. 2012;129(4):418-425. 3. Devita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams [published correction appears in Crit Care Med. 2006;34(12):3070]. Crit Care Med. 2006;34(9):2463-2478. 4. Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med. 2011;365(2):139-146.
Speech and Mechanical Ventilation To the Editor: We read with interest the recent CHEST article by Garguilo et al1 (May 2013) about speech in patients with tracheostomy and mechanical ventilation (TMV) support being facilitated by simultaneously using two devices to permit essentially continuous speech. In 1990, we reported on 104 users with TMV (82 of whom had neuromuscular diseases [NMDs] and were continuously TMV dependent) who spoke by using cuffless tubes or tubes with deflated cuffs.2 Nineteen had Duchenne muscular dystrophy. Most of them had the exhalation valves of their active ventilator circuits capped for continuous speech; this is a simpler and less expensive method for continuous speech during TMV, without requiring additional devices or causing dyspnea or hypercapnia from slight rebreathing. Indeed, most of the patients were chronically hypocapnic from long-term TMV. Passy-Muir valves also accomplish the same thing and are simpler and cheaper than the proposed positive end expiratory pressure (PEEP),1 but neither these valves nor capping were discussed by Garguilo et al.1 Thirty-four of the 104 users with TMV from our study were among the 69 decannulated to continuous noninvasive ventilatory support (CNVS) who preferred it to TMV for convenience, speech, swallowing, appearance, comfort, and safety unanimously overall; none underwent tracheotomy a second time.3 After successfully extubating all “unweanable” patients with NMD other than those with amyotrophic lateral sclerosis,4 we no longer consider tracheotomy for any NMDs other than amyotrophic lateral sclerosis. Over 760 further users on CNVS have been reported from 18 centers.5 Thus, none of the 12 patients reported by Garguilo et al1 would have undergone tracheotomy by our center, and all would have been able to speak well without PEEP. Indeed, only one-half of their 12 patients were continuously TMV dependent, despite having had tracheostomies for an average of . 13 years. Because long-term survival is possible by both TMV and CNVS (albeit at a mean 10 years longer for Duchenne muscular dystrophy with fewer hospitalizations and pneumonias by CNVS), TMV should
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References 1. Bach PB, Gould MK. When the average applies to no one: personalized decision making about potential benefits of lung cancer screening. Ann Intern Med. 2012;157(8):571-573. 2. Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB. Screening for lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidencebased clinical practice guidelines. Chest. 2013;143(5_suppl): e78S-e92S.
A Multidisciplinary Pulmonary Embolism Response Team To the Editor: In this report, we describe the successful introduction of a novel Pulmonary Embolism Response Team (PERT) to streamline the care of patients with severe pulmonary embolism (PE). The treatment of patients with massive and submassive PE remains controversial.1 Different specialists bring different experience, technical expertise, and therapeutic recommendations.1,2 To provide optimal care for complex patients with PE, a team approach is required. We formed the PERT with an infrastructure that would provide rapid, multidisciplinary consultation; mobilize resources; and facilitate research. The PERT is composed of specialists in cardiology, emergency medicine, vascular medicine, cardiac surgery, and pulmonary/critical care with an interest in PE. We created an activation system consistent with published guidelines for rapid response teams.3,4 An on-call PERT fellow responds to an activation and immediately convenes an online meeting of PERT members using commercially available software. This system enables team members to discuss the case while viewing data and radiologic images from any computer or mobile device via a password-protected login.
Table 1—Characteristics of Enrolled Patients Characteristic
No.
%
Age, y, mean (SD) Male Comorbid illness Cardiopulmonary diseasea Prior VTE Cancer Recent surgery or traumab Recent hospitalizationb PE category Suspected Low risk Submassive Massive PE location Saddle Main pulmonary artery Lobar pulmonary artery Segmental pulmonary artery Bilateral PE severity Right-sided heart strainc Troponin ⱖ 0.01 ng/mL NT-proBNP ⱖ 900 pg/mL Residual DVT presentd Clinical severity Endotracheally intubatede Admitted to ICU
57 19
17 63
10 3 8 8 10
33 10 27 27 33
5 5 18 2
17 17 60 7
7 8 9 1 20
28 32 36 4 80
20 16 13 16
80 64 52 64
8 16
27 53
NT-proBNP 5 N-terminal pro-brain natriuretic peptide; PE 5 pulmonary embolism. a Includes any history of coronary artery disease, congestive heart failure, asthma, COPD, or interstitial pulmonary fibrosis. b Within 4 wk of PE. c Based on echocardiogram or CT pulmonary angiogram. d Based on extremity ultrasound or CT venography. e Endotracheally intubated at time of Pulmonary Embolism Response Team activation.
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Correspondence
© 2013 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-1562
References
Figure 1. PE characterization and treatment. *One patient with submassive PE received both CDT and an IVC filter; **One patient with massive PE had an absolute contraindication to anticoagulation. CDT 5 catheter-directed thrombolysis; IVC 5 inferior vena cava; PE 5 pulmonary embolism; PERT 5 Pulmonary Embolism Response Team.
In the first 12 weeks, there were 30 unique PERT activations. Most (17, 57%) originated in the ED, seven (23%) in ICUs, and six (20%) in inpatient hospital units. Twenty-five activations (83%) were for confirmed PE and five (17%) for unstable patients with suspected PE. Median elapsed time from the initial activation to the multidisciplinary online meeting was 54 min (25%-75%: 52-72 min). Data collection was approved by the Human Research Committee of Partners Healthcare (2012P002257). The mean age of patients was 57 ⫾ 17 years, and 19 (63%) were men (Table 1). Seven of 25 confirmed PEs (28%) were saddle and eight (32%) involved a main pulmonary artery. Twenty patients (80%) had right-sided heart strain. After consultation, the PERT considered 18 PEs (72%) submassive and two (8%) massive (Fig 1). Two patients (8%) were treated with thrombolysis (via catheter), 12 (40%) had a contraindication to thrombolysis, and five (20%) had a vena cava filter placed. Three patients (12%) with confirmed PE died. To the authors’ knowledge, the PERT at Massachusetts General Hospital is the first such team in the country. Our initial experience suggests that an innovative, multidisciplinary PERT can streamline the care of patients with severe PE and that there is high demand for this approach. Christopher Kabrhel, MD, MPH Michael R. Jaff, DO Richard N. Channick, MD, FCCP Joshua N. Baker, MD Kenneth Rosenfield, MD Boston, MA Affiliations: From the Department of Emergency Medicine (Dr Kabrhel); the Division of Cardiology and Vascular Medicine (Drs Jaff and Rosenfield); the Division of Pulmonary/Critical Care (Dr Channick), Department of Medicine; and the Division of Cardiac Surgery (Dr Baker), Department of Surgery, Massachusetts General Hospital, Harvard Medical School. Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Christopher Kabrhel, MD, MPH, Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Pl, Ste 3B, Boston, MA 02114; e-mail: ckabrhel@ partners.org
1. Jaff MR, McMurtry MS, Archer SL, et al; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123(16): 1788-1830. 2. Imberti D, Ageno W, Manfredini R, et al. Interventional treatment of venous thromboembolism: a review. Thromb Res. 2012;129(4):418-425. 3. Devita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams [published correction appears in Crit Care Med. 2006;34(12):3070]. Crit Care Med. 2006;34(9):2463-2478. 4. Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med. 2011;365(2):139-146.
Speech and Mechanical Ventilation To the Editor: We read with interest the recent CHEST article by Garguilo et al1 (May 2013) about speech in patients with tracheostomy and mechanical ventilation (TMV) support being facilitated by simultaneously using two devices to permit essentially continuous speech. In 1990, we reported on 104 users with TMV (82 of whom had neuromuscular diseases [NMDs] and were continuously TMV dependent) who spoke by using cuffless tubes or tubes with deflated cuffs.2 Nineteen had Duchenne muscular dystrophy. Most of them had the exhalation valves of their active ventilator circuits capped for continuous speech; this is a simpler and less expensive method for continuous speech during TMV, without requiring additional devices or causing dyspnea or hypercapnia from slight rebreathing. Indeed, most of the patients were chronically hypocapnic from long-term TMV. Passy-Muir valves also accomplish the same thing and are simpler and cheaper than the proposed positive end expiratory pressure (PEEP),1 but neither these valves nor capping were discussed by Garguilo et al.1 Thirty-four of the 104 users with TMV from our study were among the 69 decannulated to continuous noninvasive ventilatory support (CNVS) who preferred it to TMV for convenience, speech, swallowing, appearance, comfort, and safety unanimously overall; none underwent tracheotomy a second time.3 After successfully extubating all “unweanable” patients with NMD other than those with amyotrophic lateral sclerosis,4 we no longer consider tracheotomy for any NMDs other than amyotrophic lateral sclerosis. Over 760 further users on CNVS have been reported from 18 centers.5 Thus, none of the 12 patients reported by Garguilo et al1 would have undergone tracheotomy by our center, and all would have been able to speak well without PEEP. Indeed, only one-half of their 12 patients were continuously TMV dependent, despite having had tracheostomies for an average of . 13 years. Because long-term survival is possible by both TMV and CNVS (albeit at a mean 10 years longer for Duchenne muscular dystrophy with fewer hospitalizations and pneumonias by CNVS), TMV should
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