呼吸内科明智选择：减少CT，降低风险

美国胸科医师协会（ACCP）在2013年会期间发布了呼吸内科领域常用但并非始终必要的检查列表。该列表是AACP和美国胸科学会（ATS）共同努力的结果，是ABIM基金会“明智选择行动”的一部分。该行动旨在就不必要且有潜在危害的检查和治疗对患者和医生进行教育。

ACCP的建议如下：

·切勿为了评估未确定的肺部结节而以超出指南推荐的频率或持续时长进行CT监测。对于无癌症病史的患者而言，2年当中未生长的实性结节发生恶变的风险非常低，另外，尚无研究显示反复进行CT扫描可改善预后，这只会增加患者的辐射暴露时间。

· 切勿对由左侧心脏病或缺氧性肺部疾病导致的肺动脉高压患者常规给予仅获准用于治疗肺动脉高压的高级血管活性药物进行治疗，由左侧心脏病或缺氧性肺部疾病导致的肺动脉高压患者使用血管活性药物无明确益处。

·对于近期出院的出院后要在家中补氧治疗急性病的患者，切勿在未评估患者是否存在低氧血症的情况下更新医嘱处方。低氧血症往往会在急性病康复之后消退，而持续补氧会产生不必要的费用。

· 对于发生肺栓塞的临床概率低且高敏感性D-二聚体水平分析结果呈阴性的患者而言，切勿为评估可能的肺栓塞而进行CT血管造影检查。临床实践指南提示，对肺栓塞验前概率低的患者进行CT血管造影检查的潜在危害超过收益。

·切勿在肺癌低危患者中进行肺癌CT筛查。高危患者进行低剂量的胸部CT筛查有减少肺癌死亡的可能性，但也有可能造成辐射暴露、高假阳性率、与肺部结节下游评估有关的危害以及对惰性肿瘤过度诊断等不良影响。因此，这项检查应该仅用于肺癌高危患者（年龄介于55~74岁、吸烟量≥30包/年的个体以及年龄介于55~74岁、在过去15年内戒烟的既往吸烟者）。

ACCP的建议和针对每条建议的具体解读将于2014年发表在《CHEST》杂志上。如欲获得更多的有关“明智选择行动”的信息，可点击此处。

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By: MADHU RAJARAMAN, Internal Medicine News Digital Network

The American College of Chest Physicians has released its list of common but not always necessary tests in pulmonary medicine.

The list was a result of the collaborative efforts of the AACP and the American Thoracic Society, and is part of the ABIM Foundation’s Choosing Wisely campaign, which aims to educate patients and physicians about unnecessary and potentially harmful testing and treatment. The list was released during CHEST 2013, the annual meeting of the ACCP, which is being held in Chicago.

The ACCP’s recommendations are:

· Do not perform CT surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines. In patients with no cancer history, solid nodules that have not grown over a 2-year period have a very low risk of malignancy. Also, repeating CT scans has not been shown to improve outcomes, and exposes patients to increased radiation over time.

· Do not routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting form left heart disease or hypoxemic lung diseases. There is no established benefit of vasoactive agents for patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung disease.

· For patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, do not renew the prescription without assessing the patient for ongoing hypoxemia. Hypoxemia often resolves after recovery from an acute illness, and continued supplemental oxygen incurs unnecessary costs.

· Do not perform CT angiography to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive d-dimer assay. Clinical practice guidelines indicate that the potential harms of CT angiography outweigh the benefits for patients with a low pretest probability of pulmonary embolism.

· Do not perform CT screening for lung cancer among patients at low risk for lung cancer. Low-dose chest CT screening has the potential to reduce lung cancer death in high-risk patients, but could potentially cause adverse effects such as radiation exposure, high false-positive rates, harms related to downstream evaluation of pulmonary nodules, and overdiagnosis of indolent tumors. Hence, it should be reserved only for patients at high risk of lung cancer (individuals aged 55-74 who smoke at least 30 packs per year and former smokers aged 55-74 who quit within the past 15 years).

The ACCP recommendations and detailed explanations for each will be published in the journal CHEST in 2014. For more information about the Choosing Wisely campaign, click here.