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Michael H Baumann
Chest 10/2011; 140(4):837-9. · 5.25 Impact Factor
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ABSTRACT: Pneumothoraces are classified as spontaneous, traumatic and iatrogenic. Spontaneous pneumothoraces that occur without recognized lung disease are termed primary spontaneous pneumothoraces (PSP), whereas those that occur due to an underlying lung disease are termed secondary spontaneous pneumothoraces. The aetiology of secondary, traumatic or iatrogenic pneumothoraces is not usually debated. However, the aetiology of PSP is potentially controversial and often debated. Therefore, PSP is the focus of this article. There are several purported causes, which include blebs, bullae, emphysema-like changes (ELC) and pleural porosity. The controversy is valid because of the importance of recurrence prevention. This article reviews the current available evidence for the causes of PSP. The causes of PSP are likely a combination ELC, pleural porosity and other potential factors.
Respirology 03/2011; 16(4):604-10. · 2.42 Impact Factor
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ABSTRACT: Pneumothoraces are classified as spontaneous, traumatic, and iatrogenic. Spontaneous pneumothoraces (SPs) occur without recognized lung disease [primary spontaneous pneumothoraces (PSPs)] or due to an underlying lung disease [secondary spontaneous pneumothoraces (SSPs)]. Treatment of PSPs and SSPs has been heterogeneous in the United States. This heterogeneity in management is likely due in part to the fact that the American College of Chest Physicians guidelines and the British Thoracic Society guidelines differ on some management recommendations, including recommendations that pertain to simple aspiration. Traumatic pneumothoraces due to penetrating or nonpenetrating (blunt) trauma usually require the placement of a larger-bore chest tube. Iatrogenic pneumothoraces, most commonly due to transthoracic needle aspiration, may be treated in carefully selected patients with observation. The presence of underlying emphysema in the setting of an iatrogenic pneumothorax usually mandates placement of a drainage catheter.
Seminars in Respiratory and Critical Care Medicine 12/2010; 31(6):769-80. · 2.43 Impact Factor
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Michael H Baumann
Chest 03/2010; 137(3):512-4. · 5.25 Impact Factor
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Chest 04/2009; 135(3 Suppl):1S-4S. · 5.25 Impact Factor
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Chest 04/2009; 135(3 Suppl):5S-7S. · 5.25 Impact Factor
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ABSTRACT: A core mission of the American College of Chest Physicians (ACCP) is the education of its members, including continuing medical education (CME). The question of what evidence supports the effectiveness of CME activities became central to the ACCP's Educational Resources Division and its education committee.
An application for consideration as a topic for an evidenced-based guideline was submitted to the ACCP Health and Science Policy Committee in 2004. The application was approved contingent on acceptance by the Agency for Healthcare Research and Quality (AHRQ) as a topic for an evidence-based review to be awarded to an AHRQ evidence-based practice center (EPC). The topic was accepted by AHRQ, with a collaborative revision developed by AHRQ and ACCP of the focused questions submitted in the nomination. The AHRQ awarded the evidence review to The Johns Hopkins University EPC (Baltimore, MD). An expert writing panel was assembled comprising methodologists from the EPC, and recommendations were developed from the EPC evidence review and graded using the ACCP system of categorizing the strength of each recommendation and the quality of evidence.
This section describes the processes used to develop these guidelines, including identifying, evaluating, and synthesizing the evidence; assessing the strength of evidence; and grading each recommendation.
Chest 04/2009; 135(3 Suppl):17S-28S. · 5.25 Impact Factor
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ABSTRACT: Evidence-based clinical practice guidelines (EBGs) can provide an invaluable distillation of knowledge regarding best practices based on the available evidence. EBGs, providing accurate and useful guidance to best clinical practices, require a rigorous development process. The American College of Chest Physicians (ACCP) has developed a process that embodies transparency, thoroughness, and timeliness, and effective conflict-of-interest management, and it continues to evolve. This process employs a quantitative and rigorous grading of the strength of recommendations and of the quality of evidence that incorporates sensitivity to health-care resource utilization and patient values and preferences. A review of this process is provided to inform the ACCP membership and those wishing to embark on EBG development.
Chest 10/2007; 132(3):1015-24. · 5.25 Impact Factor
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ABSTRACT: Pleural tuberculosis (TB) should be considered in any patient with a lymphocytic pleural effusion. The diagnostic approach is under debate. Knowledge of pleural TB epidemiology would be beneficial. To help clarify pleural TB epidemiology, we analyzed US national TB surveillance data for 1993 to 2003.
We compared pleural TB to pulmonary TB (where each was reported as the major site of TB disease, and no additional sites of disease were reported). Applicable statistical tests were performed; p < 0.05 was considered to be significant.
From 1993 through 2003, 7,549 cases of pleural TB and 156,779 cases of pulmonary TB were reported (in 2003: pleural TB, 536 cases; pulmonary TB, 10,551 cases). The annual proportion of pleural TB was relatively stable (median rate, 3.6%; range, 3.3 to 4.0%) compared to that for pulmonary TB, which steadily decreased (average annual decrease, 0.9%; p < 0.01). Pleural TB occurred significantly more often than pulmonary TB among persons >/= 65 years old (30.4% vs 23.3%, respectively; p < 0.01), and it occurred significantly less often among children < 15 years old (1.8% vs 6.1%, respectively; p < 0.01) and persons 45 to 64 years old (22.9% vs 27.9%, respectively; p < 0.01). Pleural TB patients (63.4%) were born slightly more often in the United States than were pulmonary TB patients (60.9%; p < 0.01). Drug-resistance patterns of pleural TB broadly reflected those of pulmonary TB. However, isolates from pleural TB patients were less often resistant to at least isoniazid (6.0% vs 7.8%, respectively; p < 0.01) and to at least one first-line TB drug (9.9% vs 11.9%, respectively; p < 0.01) compared with pulmonary TB patients.
Knowledge of pleural TB demographic, clinical, and drug-resistance patterns may assist clinicians in making diagnostic and therapeutic decisions.
Chest 04/2007; 131(4):1125-32. · 5.25 Impact Factor
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Michael H Baumann
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ABSTRACT: Management of patients with a spontaneous pneumothorax continues to challenge clinicians. Recent guidelines help provide care pathways for these patients and highlight the many areas in need of additional study. Management options for spontaneous pneumothoraces should be selected based primarily upon a patient's clinical status. Observation or pleural air drainage, in selected patients, plays a significant role in patients with primary spontaneous pneumothorax. By contrast, pleural air drainage plays the central role in patients with a secondary spontaneous pneumothorax. Surgically directed recurrence prevention and air leak management are preferred for both primary and secondary spontaneous pneumothorax patients.
Clinics in Chest Medicine 07/2006; 27(2):369-81. · 3.28 Impact Factor
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Richard S Irwin, Michael H Baumann,
Donald C Bolser,
Louis-Philippe Boulet,
Sidney S Braman,
Christopher E Brightling,
Kevin K Brown,
Brendan J Canning,
Anne B Chang,
Peter V Dicpinigaitis, [......],
Sandra Zelman Lewis,
F Dennis McCool,
Douglas C McCrory,
Udaya B S Prakash,
Melvin R Pratter,
Mark J Rosen,
Edward Schulman,
John Jay Shannon,
Carol Smith Hammond,
Susan M Tarlo
Chest 02/2006; 129(1 Suppl):1S-23S. · 5.25 Impact Factor
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ABSTRACT: Performance measures and pay for performance are terms creating considerable angst among physicians today. Understanding the driving forces behind these concepts will help practitioners to strategically plan for their impact on individual physician practices and on health care in general. Medical societies can play a vital role in assisting physicians in the identification of appropriate performance measures used to gauge physician practices and by supporting efforts to develop equitable principles driving reimbursement based on adherence to those measures. Performance measures and pay for performance are terms evoking considerable angst across all sectors of the health services industry.
Chest 02/2006; 129(1):188-91. · 5.25 Impact Factor
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ABSTRACT: While grading the strength of recommendations and the quality of underlying evidence enhances the usefulness of clinical guidelines, the profusion of guideline grading systems undermines the value of the grading exercise. An American College of Chest Physicians (ACCP) task force formulated the criteria for a grading system to be utilized in all ACCP guidelines that included simplicity and transparency, explicitness of methodology, and consistency with current methodological approaches to the grading process. The working group examined currently available systems, and ultimately modified an approach formulated by the international GRADE group. The grading scheme classifies recommendations as strong (grade 1) or weak (grade 2), according to the balance among benefits, risks, burdens, and possibly cost, and the degree of confidence in estimates of benefits, risks, and burdens. The system classifies quality of evidence as high (grade A), moderate (grade B), or low (grade C) according to factors that include the study design, the consistency of the results, and the directness of the evidence. For all future ACCP guidelines, The College has adopted a simple, transparent approach to grading recommendations that is consistent with current developments in the field. The trend toward uniformity of approaches to grading will enhance the usefulness of practice guidelines for clinicians.
Chest 02/2006; 129(1):174-81. · 5.25 Impact Factor
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ABSTRACT: Train-of-four (TOF) monitoring is often recommended during the continuous use of neuromuscular blockade (NMB) [paralysis] in the ICU. Prior study results are conflicting regarding the benefits of TOF monitoring.
Thirty patients in the medical ICU were randomized to TOF monitoring (n = 16) or to clinical assessment (n = 14) during continuous cisatracurium infusion. TOF monitoring was done at least every 4 h, with the goal being maintenance of one to two twitches. Statistical analysis was performed by two-tailed, unpaired t test (with Bonferroni correction for multiple comparisons), chi(2), and Fisher exact test, with p < 0.05 considered significant. Given a power of 80%, and the variance seen in the two groups, we estimate that the sample size used is sufficient to detect a change of > or = 60 min between groups for recovery time.
The mean recovery time after cessation of paralytics was no different between TOF and clinical assessment (45 +/- 7 min vs 38 +/- 10 min, respectively [mean +/- SEM]). No differences were noted for mean APACHE (acute physiology and chronic health evaluation) II entry scores, glomerular filtration rates, or use of corticosteroids. No significant differences were noted between TOF monitoring and clinical assessment in mean total paralysis time (4,118 +/- 1,012 min vs 3,188 +/- 705 min, respectively), mean total cisatracurium dose (920 +/- 325 mg vs 715 +/- 167 mg), or dosage (2.3 +/- 0.2 microg/kg/min vs 2.9 +/- 0.2 microg/kg/min).
TOF monitoring does not lead to improved recovery time or lower cisatracurium dosing compared with monitoring by clinical assessment. We conclude that TOF monitoring is unnecessary, and careful titration of the neuromuscular blocking agent by clinical assessment alone is sufficient in patients undergoing continuous cisatracurium NMB.
Chest 11/2004; 126(4):1267-73. · 5.25 Impact Factor
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ABSTRACT: Spontaneous pneumothoraces can occur without obvious underlying lung disease (primary) or in patients with known underlying lung disease (secondary). Management guidelines for spontaneous pneumothorax have been published by major professional organizations, but awareness and application among clinicians seems poor. First episodes of primary spontaneous pneumothorax can be managed with observation if the pneumothorax is small. If the pneumothorax is large or if the patient is symptomatic, manual aspiration via a small catheter or insertion of a small-bore catheter coupled to a Heimlich valve or water-seal device, should be performed. In general, definitive measures to prevent recurrence are recommended after the first recurrence of the pneumothorax, and can be achieved by medical (e.g. talc) or surgical (video-assisted thoracic surgery) pleurodesis. Secondary pneumothoraces should be treated with chest tube drainage followed by pleurodesis after the first episode to minimize any risk of recurrence. Traumatic pneumothoraces may be occult (not seen on an initial CXR) or non-occult. The majority are treated by placement of a chest tube. Selected patients may be treated conservatively, with approximately 10% of these patients eventually requiring chest tube placement. Iatrogenic pneumothoraces have a myriad of causes with transthoracic lung needle biopsy being most common. Transthoracic needle biopsy-related pneumothoraces have CT findings that can predict their occurrence and the need for chest tube placement. Iatrogenic pneumothoraces, regardless of cause, may be managed by observation or small bore chest tube placement, depending upon patient stability and the size of the pneumothorax.
Respirology 07/2004; 9(2):157-64. · 2.42 Impact Factor
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Michael H Baumann
Chest 01/2004; 124(6):2352-5. · 5.25 Impact Factor
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ABSTRACT: Pleurodesis is important in the management of malignant pleural effusions, but no consensus exists on the optimal agent or methods of pleurodesis. How pleurodesis is practiced worldwide has not been studied.
To identify variations in the clinical practice of pleurodesis in major English-speaking countries, and to quantify the experience of pulmonologists on the effectiveness and adverse effects of different pleurodesis agents worldwide.
Eight hundred fifty-nine pulmonologists practicing in the United States, United Kingdom, Canada, Australia, and New Zealand participated in a Web-based survey.
The respondents collectively perform > 8,300 pleurodesis annually. Talc was the preferred agent by most respondents (slurry, 56%; poudrage, 12%), followed by tetracycline derivatives (26%), and bleomycin (7%). Differences were seen in pleurodesis practice patterns among practitioners among and within the surveyed countries. Physicians' overall satisfaction with the available pleurodesis agents was modest (5.0 out of 8), and the reported success rate averaged only 66%. Talc (both poudrage and slurry) was perceived as significantly more effective, but was associated with significantly more pain, nausea, and fever (p < 0.05). Respiratory failure occurred more commonly with talc poudrage than with other agents (p < 0.05), and had been observed by 70% and 54% of physicians who used talc poudrage and slurry, respectively.
Significant variations exist in how pleurodesis is performed worldwide. Pleurodesis agents currently available are perceived as suboptimal. Talc poudrage and slurry were perceived to be more effective, but were associated with more complications, including respiratory failure.
Chest 01/2004; 124(6):2229-38. · 5.25 Impact Factor
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Michael H Baumann
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ABSTRACT: Chest tubes and their accompanying pleural drainage units continue to present challenging questions regarding their optimal use. Appropriate chest tube size selection to accommodate the clinical situation is key, especially in the setting of large pleural air leaks lest a tension pneumothorax ensue. Connection of an appropriate pleural drainage unit to the chest tube is equally important to obviate impeding airflow after successful evacuation by the chest tube. Large-bore chest tubes are generally required for patients with pneumothoraces, regardless of etiology, if the patient is mechanically ventilated, or for patients requiring drainage of viscous pleural liquids such as blood. Smaller bore tubes may be adequate in patients with limited production of pleural air or of free-flowing pleural liquid. Chest tubes may be removed successfully at either end expiration or end inspiration, and potentially as soon as </=200 mL/fluid output per day is achieved. Additional prospective studies are needed to provide evidence-based answers to the many questions remaining regarding chest tube placement, ongoing management, and removal.
Current opinion in pulmonary medicine 07/2003; 9(4):276-81. · 3.08 Impact Factor
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ABSTRACT: Flow rates and pressures generated by commercially available pleural drainage units (PDUs) and flow rates through available pleural drainage catheters (PDCs) are not known. This information may be important clinically depending on the volume of air leak associated with a bronchopleural fistula.
Eight PDUs were assessed for flow rates at various suction levels and for the percent accuracy of suction pressures generated at various settings. Eleven commonly used PDCs were assessed for flow rates at various suction control levels. All devices were donated by their manufacturer. Flow rates and pressures were measured by a RT 200 Calibration Analyzer (Timeter Instrument Corporation; St. Louis, MO) at body temperature, ambient pressure, saturated with water vapor. Five devices of each type were tested. Analysis of variance was performed with p < 0.05 being significant.
Multiple significant differences between PDUs were noted at a pressure of - 20 cm H(2)O. The Argyle Sentinel Seal (Sherwood Medical; Tillamore, Ireland) had significantly lower flow rates (mean +/- SD, 10.8 +/- 0.6 L/min) compared with all other models. The Argyle Aqua-Seal (Sherwood Medical) had the highest PDU flow rate of devices tested (42.1 +/- 1.0 L/min). The accuracy of PDUs at manufacturer-suggested settings varied from a mean percentage error of 0.0 to 15.5% from expected pressures; significant differences were noted in accuracy among multiple interdevice pressure comparisons. Similarly, multiple significant flow rate differences between PDCs were noted at - 20 cm H(2)O. Lowest flow rates were noted with thoracentesis catheters (used as PDCs) containing side ports. Arrow drainage catheters (14F, pigtail and straight) [Arrow International; Reading, PA] both had significantly greater flow rates (both, 16.8 +/- 0.1 L/min), compared with the 14F (12.8 +/- 0.3) and 16F (14.8 +/- 0.6) Cook devices (Cook; Bloomington, IN).
These differences in flow rates for PDUs and PDCs may be clinically important, particularly in patients with large pneumothorax-related air leaks. Observed differences in PDU-generated pressures are likely not clinically important.
Chest 06/2003; 123(6):1878-86. · 5.25 Impact Factor
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Journal of the Mississippi State Medical Association 05/2002; 43(4):113.
