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Disclosures of relationships with any entity producing' Pulmonary and Critical Care Medicine marketing. reselling, or distributing health care goods or ACP EditorialStaff services consumed by. or used on, patients. Individuals not Sandy Crump, Medical Editor, Assessment and listed below have nothing to disclose' Education Programs Beclry Krumm, Director, Assessment and Education Neal Chaisson, MD Programs Consultcntship Jackie Twomey, Managing Editor, Assessment and Actelion. Bayer Education Programs Speckers Bureau Gilead. Bayer. United Therapeutics Other ACP PrincipalStaff Putnam Associates, Schlesinger Associates Davoren Chick, MD, FACP Eduardo Mireles-Cabodevila, MD Senior Vice President. Medical Education Patent Holder Tabassum Salam, MD, MBA, FACP Cleveland Clinic Vice President. Medical Education Tabassum Salam, MD, MBA, FACP Margaret Wells, EdM Consultantship V ice President, Learning Assessmen t, Accreditation. Johnson & Johnson and Research Patrick C. Alguire, MD, FACP Acknowledgments MKSAP Senior Deputy Editor The American College of Physicians (ACP) gratefully BeckyKrumm acknowledges the special contributions to the develop- Director, Assessnrent and Education Programs ment and production of the l9th edition of the Medical Jackie Twomey Knowledge Self Assessment Program" (MKSAP' 19) made ManagingEditor by the following people:

Patrick C. Alguire, MD, FACP Acknowledgments MKSAP Senior Deputy Editor The American College of Physicians (ACP) gratefully BeckyKrumm acknowledges the special contributions to the develop- Director, Assessnrent and Education Programs ment and production of the l9th edition of the Medical Jackie Twomey Knowledge Self Assessment Program" (MKSAP' 19) made ManagingEditor by the following people: Julia Nawrocki Graphic Design: Barry Moshinski (Director, Graphic Services), Digital Confen f Asso ciate / Editor Raymond DeJohn (Designer, Graphic Services), Tom Malone (Print/Mail Production Manager, Graphic Services), Mike LinneaDonnarumma Ripca (Technical Administrator, Graphic Services). Senior Medicol Editor Production / Susfems: Dan Hoffmann (Vice President, Amanda Cowley Information Technology). Scott Hurd (Manager, Content Medical Editor Systems), Neil Kohl (Senior Architect), and Chris Sandy Crump Patterson (Senior Architect). Medical Editor MKSAP 19 Digital: Under the leadership of Steven Spadt (Senior Vice President, Information Technology and Chief Georgette Forgione Medical Editor Technology Officer), the development of the digital version of MKSAP 19 was implemented by ACP's Digital Products Beth Goldner and Services Department, directed and led by Brian Medical Editor Sweigard (Vice President, Digital Products and Services). Suzanne Meyers Other members of the team included Dan Barron (Senior Medical Editor Web Application Developer/Architect), Callie Cramer (Data Visualization/Web Developer). Chris Forrest (Senior Elise Paxson Web Application Developer), Kathleen Hoover (Manager, Medical Editor User Interface Design and Development), Kara Regis Chuck Graver (Director, Product Design and Development), Brad Lord (Senior Web Application Developer/Architect), and John Finance and Operations Administrator McKnight (Senior Web Developer). Kimberly Kerns Administ ratiu e Coord inato r

Julia Nawrocki Graphic Design: Barry Moshinski (Director, Graphic Services), Digital Confen f Asso ciate / Editor Raymond DeJohn (Designer, Graphic Services), Tom Malone (Print/Mail Production Manager, Graphic Services), Mike LinneaDonnarumma Ripca (Technical Administrator, Graphic Services). Senior Medicol Editor Production / Susfems: Dan Hoffmann (Vice President, Amanda Cowley Information Technology). Scott Hurd (Manager, Content Medical Editor Systems), Neil Kohl (Senior Architect), and Chris Sandy Crump Patterson (Senior Architect). Medical Editor MKSAP 19 Digital: Under the leadership of Steven Spadt (Senior Vice President, Information Technology and Chief Georgette Forgione Medical Editor Technology Officer), the development of the digital version of MKSAP 19 was implemented by ACP's Digital Products Beth Goldner and Services Department, directed and led by Brian Medical Editor Sweigard (Vice President, Digital Products and Services). Suzanne Meyers Other members of the team included Dan Barron (Senior Medical Editor Web Application Developer/Architect), Callie Cramer (Data Visualization/Web Developer). Chris Forrest (Senior Elise Paxson Web Application Developer), Kathleen Hoover (Manager, Medical Editor User Interface Design and Development), Kara Regis Chuck Graver (Director, Product Design and Development), Brad Lord (Senior Web Application Developer/Architect), and John Finance and Operations Administrator McKnight (Senior Web Developer). Kimberly Kerns Administ ratiu e Coord inato r lv

Pulmonary and Critical Care Medicine High Value Care Recommendations The American College of Physicians, in collaboration with doses, longer courses, and intravenous administration multiple other organizations, is engaged in a worldwide (see Item 64).

Pulmonary and Critical Care Medicine High Value Care Recommendations The American College of Physicians, in collaboration with doses, longer courses, and intravenous administration multiple other organizations, is engaged in a worldwide (see Item 64). initiative to promote the practice of High Value Care . A sputum culture is not routinely used to assess COPD (HVC). The goals of the HVC initiative are to improve exacerbations, as it rarely affects management. health care outcomes by providing care olproven benefit o Patients not using baseline oxygen and with a resting and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several oxygen during air travel without additional testing (see programs that integrate the important concept of health Item 82). care value (balancing clinical benefit with costs and . When high-resolution CT findings are classic for usual harms) for a given intervention into a broad range of interstitial pneumonia, lung biopsy is not necessary for educational materials to address the needs of trainees. diagnosis. practicing physicians, and patients. o The diagnosis of cryptogenic organizing pneumonia (COP) may not require lung biopsy if the clinical pre HVC content has been integrated into MKSAP 19 in sev- sentation and high resolution CT findings are consistent eral important ways. MKSAP 19 includes HVC-identified with COP. key points in the text, HVC focused multiple choice ques- . ln patients with radiographic evidence of advanced-stage tions, and, in MKSAP Digital, an HVC custom quiz. From lung cancer, diagnosis and staging are best accomplished the text and questions, we have generated the following with a single invasive test at a location that will establish list of HVC recommendations that meet the definition both the diagnosis and the stage ofdisease. below of high value care and bring us closer to our goal r Benzodiazepines should not be used for treating delirium of improving patient outcomes while conserving finite unless they are needed to treat alcohol withdrawal or resources. seizrrres. High Value Care Recommendation: A recommendation to o In patients receiving enteral feedings, routine measure- choose diagnostic and management strategies for patients ment of gastric residuals is not recommended because it in specific clinical situations that balance clinical benefit delays achievement of feeding goals, increases the risk of with cost and harms with the goal of improving patient clogging the enteral access, and may increase the risk for outcomes. aspiration. o Administration of parenteral nutrition to supplement Below are the High Value Care Recommendations for enteral nutrition may lead to harm and should be the Pulmonary and Critical Care Medicine section of avoided. MKSAP 19. o Bronchoscopy for airway mucous clearance to prevent r A key clinical indicator of occupational asthma is symp- postoperative atelectasis offers no clear benefit compared tom improvement during weekends and time away from with other methods of chest physiotherapy. work; spirometry before and after workplace exposures o Evidence for pulmonary artery catheters demonstrates is a cost-effective way to confirm a suspected diagnosis a lack of benefit and, in some cases, increased risk to of occupational asthma. patients. . Fractional exhaled nitric oxide measurement (FeNO) is o Given the relative expense of colloids, crystalloid adn-rin- not recommended to guide asthma treatment in the istration is generally preferred and recommended by general population (see Item 85). guidelines in the treatment of septic shock. r Administration of a glucocorticoid and a long-acting e There is no role for glucocorticoids in sepsis without Br-agonist in a single inhaler is preferred because it shock. improves adherence and may reduce cost compared with r Clinical presentations of sarcoidosis that do not require a administration of each drug in a separate inhaler (see biopsy include asymptomatic stage I pulmonary sarcoid- Item 13). osis, L0fgren syndrome, and Heerfordt syndrome (see o In patients with COPD exacerbation, short courses of Item 16). Iower-dose oral glucocorticoids (prednisone 40 mg/d r Providing supplemental oxygen in acutely ill medical for 5 days) have been found to be equivalent to higher patients with normal oxygen saturation increases mortality

initiative to promote the practice of High Value Care . A sputum culture is not routinely used to assess COPD (HVC). The goals of the HVC initiative are to improve exacerbations, as it rarely affects management. health care outcomes by providing care olproven benefit o Patients not using baseline oxygen and with a resting and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several oxygen during air travel without additional testing (see programs that integrate the important concept of health Item 82). care value (balancing clinical benefit with costs and . When high-resolution CT findings are classic for usual harms) for a given intervention into a broad range of interstitial pneumonia, lung biopsy is not necessary for educational materials to address the needs of trainees. diagnosis. practicing physicians, and patients. o The diagnosis of cryptogenic organizing pneumonia (COP) may not require lung biopsy if the clinical pre HVC content has been integrated into MKSAP 19 in sev- sentation and high resolution CT findings are consistent eral important ways. MKSAP 19 includes HVC-identified with COP. key points in the text, HVC focused multiple choice ques- . ln patients with radiographic evidence of advanced-stage tions, and, in MKSAP Digital, an HVC custom quiz. From lung cancer, diagnosis and staging are best accomplished the text and questions, we have generated the following with a single invasive test at a location that will establish list of HVC recommendations that meet the definition both the diagnosis and the stage ofdisease. below of high value care and bring us closer to our goal r Benzodiazepines should not be used for treating delirium of improving patient outcomes while conserving finite unless they are needed to treat alcohol withdrawal or resources. seizrrres. High Value Care Recommendation: A recommendation to o In patients receiving enteral feedings, routine measure- choose diagnostic and management strategies for patients ment of gastric residuals is not recommended because it in specific clinical situations that balance clinical benefit delays achievement of feeding goals, increases the risk of with cost and harms with the goal of improving patient clogging the enteral access, and may increase the risk for outcomes. aspiration. o Administration of parenteral nutrition to supplement Below are the High Value Care Recommendations for enteral nutrition may lead to harm and should be the Pulmonary and Critical Care Medicine section of avoided. MKSAP 19. o Bronchoscopy for airway mucous clearance to prevent r A key clinical indicator of occupational asthma is symp- postoperative atelectasis offers no clear benefit compared tom improvement during weekends and time away from with other methods of chest physiotherapy. work; spirometry before and after workplace exposures o Evidence for pulmonary artery catheters demonstrates is a cost-effective way to confirm a suspected diagnosis a lack of benefit and, in some cases, increased risk to of occupational asthma. patients. . Fractional exhaled nitric oxide measurement (FeNO) is o Given the relative expense of colloids, crystalloid adn-rin- not recommended to guide asthma treatment in the istration is generally preferred and recommended by general population (see Item 85). guidelines in the treatment of septic shock. r Administration of a glucocorticoid and a long-acting e There is no role for glucocorticoids in sepsis without Br-agonist in a single inhaler is preferred because it shock. improves adherence and may reduce cost compared with r Clinical presentations of sarcoidosis that do not require a administration of each drug in a separate inhaler (see biopsy include asymptomatic stage I pulmonary sarcoid- Item 13). osis, L0fgren syndrome, and Heerfordt syndrome (see o In patients with COPD exacerbation, short courses of Item 16). Iower-dose oral glucocorticoids (prednisone 40 mg/d r Providing supplemental oxygen in acutely ill medical for 5 days) have been found to be equivalent to higher patients with normal oxygen saturation increases mortality xill

in a dose-dependent manner and is not recommended . In older persons with nonexertional hyperthermia, ice (see Item 45). water immersion is associated with increased mortality . Approximately 2oY" of laboratory tests obtained in hospi- and should not be used (see Item 4). talized patients are not needed (see Item 76). . In patients with portal hypertension and acute gastro- . Excessive laboratory testing in hospitalized patients can intestinal bleeding, transfusion to t0 gldl (100 glL) or result in iatrogenic anemia (see Item 76). higher can rapidly increase portal pressure, putting the o Discontinuing antibiotic therapy is appropriate in patients patient at significant risk for rebleeding and is not rec- who initially were thought to have sepsis but do not (see ommended (see Item 53). Item 96). : xtv

Pulmonary and Critical Care Medicine and patient factors, including poor effort. coughing. and fail Pu I mona ry Diag nostic Tests ure to exhale for a minimum of 6 seconds, may result in suboptimal test performance and misinterpretation lf spirom- Pulmonary Function Testing etry is unable to be performed. lractional exhaled nitric Pulmonary function testing can include spirometry response oxide measurement may help in the diagnosis of asthma (see to bronchodilators, bronchial challenge testing, lung volume following section). testing, and measurement of Drco. These findings are com pared with age. sex, height. and race adjusted population Bronchial Challenge Testing norms and are expressed as a percentage ofthe predicted value (Table f). The 2005 American Thoracic Society guidelines Bronchial challenge testing is used to identifl' bronchial hyper responsiveness. This is particularly helpful in patients whose define the lower limit of normal as below the fifth percentile symptoms suggest asthma but fbr n'hom other pulmonary of the predicted value; some laboratories use this as their cut function test results are normal. Patients inhale increasing ofl and typically this coincides with 807, of the predicted doses of a substance known to induce bronchospasm, such as value. methacholine or histamine, in a stepwise fashion. This is fol- rEY POI lII lowed by repeated measurement olFEV'; the test is considered . In general, pulmonary function test results below 807, positive if FEV, falls by 20"/,' or more from the baseline value. of predicted indicate pulmonary impairment. Bronchial challenge testing has a high negative predictive value for ruling out asthma. However, a positive test can be caused by other conditions, including COPD. smoking. upper Spirometry respiratory infections, allergic rhinitis, bronchiectasis, and Spirometry measures the maximal volume and flow of air dur cystic fibrosis. ing a best elfort forced exhalation; repofted values include I(EY POIl{I FEVr, FVC, and the FEVr /FVC ratio. Spirometry correlates with home peak expiratory flow meter measurements but is more . Bronchial challenge testing is a helpful diagnostic tool HVC

and patient factors, including poor effort. coughing. and fail Pu I mona ry Diag nostic Tests ure to exhale for a minimum of 6 seconds, may result in suboptimal test performance and misinterpretation lf spirom- Pulmonary Function Testing etry is unable to be performed. lractional exhaled nitric Pulmonary function testing can include spirometry response oxide measurement may help in the diagnosis of asthma (see to bronchodilators, bronchial challenge testing, lung volume following section). testing, and measurement of Drco. These findings are com pared with age. sex, height. and race adjusted population Bronchial Challenge Testing norms and are expressed as a percentage ofthe predicted value (Table f). The 2005 American Thoracic Society guidelines Bronchial challenge testing is used to identifl' bronchial hyper responsiveness. This is particularly helpful in patients whose define the lower limit of normal as below the fifth percentile symptoms suggest asthma but fbr n'hom other pulmonary of the predicted value; some laboratories use this as their cut function test results are normal. Patients inhale increasing ofl and typically this coincides with 807, of the predicted doses of a substance known to induce bronchospasm, such as value. methacholine or histamine, in a stepwise fashion. This is fol- rEY POI lII lowed by repeated measurement olFEV'; the test is considered . In general, pulmonary function test results below 807, positive if FEV, falls by 20"/,' or more from the baseline value. of predicted indicate pulmonary impairment. Bronchial challenge testing has a high negative predictive value for ruling out asthma. However, a positive test can be caused by other conditions, including COPD. smoking. upper Spirometry respiratory infections, allergic rhinitis, bronchiectasis, and Spirometry measures the maximal volume and flow of air dur cystic fibrosis. ing a best elfort forced exhalation; repofted values include I(EY POIl{I FEVr, FVC, and the FEVr /FVC ratio. Spirometry correlates with home peak expiratory flow meter measurements but is more . Bronchial challenge testing is a helpful diagnostic tool HVC reliable, provides more data, and is used in diagnosis and to use for patients whose symptoms suggest asthma but management of airways disease. Although spirometry is easily for whom other pulmonary function test results are perfbrmed in the outpatient setting, technical test validation normal.

reliable, provides more data, and is used in diagnosis and to use for patients whose symptoms suggest asthma but management of airways disease. Although spirometry is easily for whom other pulmonary function test results are perfbrmed in the outpatient setting, technical test validation normal. Lung Volumes and Drco TABLE 1, Characterization of lmpairment Severity in Pulmonary Function Tests Lung volumes can be measured by body plethysmography of nitrogen diffusion. Measures include total tung capacity (TI-C). Severity of lmpairment % of Prediaed vital capacity, functional residual capaciry expiratory resenre FEVl volume. and residual volume. Dr.co measurement estimates MiId 70-79 the amount of gas transf'er through the alveolar capillarl' unit Moderate 60-69 and is proportional to the surface area of functional lung. Dr.co Moderately severe 50-59 is measured by inhalation of a gas mixture containing carbon

Lung Volumes and Drco TABLE 1, Characterization of lmpairment Severity in Pulmonary Function Tests Lung volumes can be measured by body plethysmography of nitrogen diffusion. Measures include total tung capacity (TI-C). Severity of lmpairment % of Prediaed vital capacity, functional residual capaciry expiratory resenre FEVl volume. and residual volume. Dr.co measurement estimates MiId 70-79 the amount of gas transf'er through the alveolar capillarl' unit Moderate 60-69 and is proportional to the surface area of functional lung. Dr.co Moderately severe 50-59 is measured by inhalation of a gas mixture containing carbon Severe 35-49 monoxide and helium; the resulting value is corrected lor hemoglobin level. Very severe <35 DLCo Pulmonary Funstion Testing I nterpretation Mild <LLN but >60 The purpose of pulmonary function testing interpretation is to Moderate 40-60 classify abnormal results as obstructive, restrictive, or mixed Severe <40 obstructiverrestrictive and to assess the sereritl, olimpairment LLN = lower limit of normal; below the fifth percentile of healthy never smokers. (Figure l). A reduced FEVII'FVC ratio is consistent with Reproduced w th permission of the @ ERS 202 1, from Pelleqrino R, Vieqi G, Brusasco V obstruction, and the severity of obstruction is determined i et al. nterpretative strategies for lung function tests. Eur Respir J. 2005;26:957. according to the nleasured FEV, as a percentage of the pre IPMID: 162640581. dicted value (see Table 1). The American Thoracic Society and

Severe 35-49 monoxide and helium; the resulting value is corrected lor hemoglobin level. Very severe <35 DLCo Pulmonary Funstion Testing I nterpretation Mild <LLN but >60 The purpose of pulmonary function testing interpretation is to Moderate 40-60 classify abnormal results as obstructive, restrictive, or mixed Severe <40 obstructiverrestrictive and to assess the sereritl, olimpairment LLN = lower limit of normal; below the fifth percentile of healthy never smokers. (Figure l). A reduced FEVII'FVC ratio is consistent with Reproduced w th permission of the @ ERS 202 1, from Pelleqrino R, Vieqi G, Brusasco V obstruction, and the severity of obstruction is determined i et al. nterpretative strategies for lung function tests. Eur Respir J. 2005;26:957. according to the nleasured FEV, as a percentage of the pre IPMID: 162640581. dicted value (see Table 1). The American Thoracic Society and 1