the lung doctor

COPD Chronic Obstructive Pulmonary Disease

2010-11-19T15:23:00.002-06:00

A brief discussion of the diagnosis and management of COPD.

COPD Chronic Obstructive Pulmonary Disease

Allergies Know No Vacations

2010-10-22T11:38:00.005-05:00

Many allergy sufferers are plagued with year-round symptoms. Avoidance of most allergens is nearly impossible. What works?

Topical nasal steroids (like Flonase, Nasacort, Rhinocort, Omnaris) work the best. They are very effective anti-inflammatory agents. However, to achieve the maximal effect they take several days of application. The down side to intranasal steroids is that they can be drying to the nasal mucosa, making nose bleeds more likely. Intranasal steroids also increase susceptibility to viral and bacterial upper respiratory infections, which have the potential to lead to lower respiratory infections.

Topical antihistamines (like Astelin) work within 10-30 minutes of application, and are very effective. They too can be drying, making nose bleeds more likely, and they can also predispose to infections.

Leukotriene inhibitors (another type of anti-inflammatory agent, like Singulair) are tablets that work very effectively. Inflammation is caused by multiple pathways, and leukotriene inhibitors block pathways that are not affected by steroids or antihistamines. They are a great addition to an allergy sufferer's regimen if their allergy symptoms are not under control with other agents. They are not usually used as a first line agent because they are expensive, and because more symptoms can be effectively treated with steroids and antihistamines.

Oral antihistamines work great. They are nearly as effective as topical antihistamines, but take a few hours to feel the effect. The main advantage of oral antihistamines is cost. There is a generic version of loratadine (sold originally as Claritin) available at a cost of only pennies per day, compared to $2-5 per day for intranasal steroids or antihistamines. Easy to take pill form is another advantage.

First line treatment for severe allergy sufferers is intranasal steroids. Topical antihistamines and oral antihistamines can be added as needed.

The most affordable option is generic oral antihistamines followed by the addition of intranasal steroids as needed.

Whatever you and your doctor choose, take the medication as directed. If you are a year-round allergy sufferer, you must take precautions every day of the year.

iRVU Is Here

2010-10-19T15:40:00.004-05:00

e-MedTools, the people who make MedicalTemplates and E/M Code Check, have created a new smartphone app - iRVU.

iRVU tracks the wRVUs a health care provider generates. Not only will iRVU tally the wRVUs, it will also generate a wRVU/Encounter number.

The total number of wRVUs generated and the number of wRVUs/Encounter are benchmarks used to determine individual productivity, estimate revenue generated, and compare one health care provider's productivity with another.

Virtually every medical practice uses these benchmarks to assess physician productivity and relative value to the practice.

e-MedTools have some awesome products.

Allergy Season and Flu Vaccines

2010-10-18T13:40:00.003-05:00

Allergy season is winding down, thank goodness, but flu season is right around the corner!

If you have not already received your influenza vaccine this year, now is a great time to get one. Many drug stores and discount department stores are providing affordable flu vaccines in places where you likely already shop! Convenience, too!

Who can benefit from a flu vaccine? Everyone!

Any person with a chronic medical condition, not just a disease affecting the lungs, needs a flu vaccine. "Comorbid conditions" as it is called, increase a person's susceptibility to worse side effects from an influenza infection.

Others at risk of worse side effects include young children. They have smaller airways and they can succumb very quickly to infections.

Adults caring for children are at higher risk of catching the flu because they are more likely exposed to greater numbers of infected people, AND they can readily spread the flu to other small children.

Residents of a facility that house multiple unrelated people (i.e., nursing homes, apartment buildings, mental health facilities, prisons, etc.) also pose risks due to the increased chance that one or more of the residents will have the flu. In addition, the closer quarters increase the likelihood of being close enough to someone to catch the flu who has already been infected.

Even otherwise healthy people benefit from vaccination. Who does not have family members in school, loved ones with a chronic health condition, or family members in nursing homes? No one wants to be the reason another person gets sick.

Finally, the flu vaccine can not only decrease the likelihood of getting the flu, it can decrease the severity of illness should you get the flu. This can decrease the number of days missed from school or work (or play).

Do yourself and your family and friends a favor. Get the flu vaccine. You'll be glad you did!

Medical Documentation, Billing and Coding

2010-10-15T09:20:00.003-05:00

Medical documentation, billing and coding requires knowledge of complex, changing rules. Thank goodness for medical documentation, billing and coding experts who can be so darn helpful!

Thank goodness, too, for point of care tools that make medical documentation and coding much easier to understand and implement, and save time and money!

A couple of these tools deserve mentioning again.

E/M Code Check is such an exciting smartphone application! It has a concise, easy to follow format. Each page is really information packed, and the buttons to transition to the next page are very easy to use, unlike some other smartphone apps.

E/M Code Check incorporates great graphics, providing a great deal of information (pictures are worth a thousand words!) on personal documentation and coding habits. The feedback this tool provides is terrific, and it will help most anyone to learn where they need to improve.

Like some other companies, E/M Code Check provides a free version, making money by inserting ads, but the $34.99 version is worth every cent!

E/M Code Check provides Medicare reimbursement rates (based on national averages), tallies them based on the encounter types entered, and graphs personal coding distribution levels!

E/M Code Check also reinforces the use of MedicalTemplates for documentation of patient encounters. MedicalTemplates are terrific tools for prompting health care providers to document a complete history and physical exam. Sometimes the situation or conversations in patient encounters can derail a train of thought. Who hasn't had to return to a patient room to ask about some missing piece of the social history? With MedicalTemplates a physician can be confident that they are consistently documenting a thorough patient encounter note. Best of all, thorough documentation using MedicalTemplates saves time. Most aspects of the patient encounter can be documented with a simple check mark, but there is ample space to write personal notes.

If you haven't checked out these products, go to e-MedTools.com

10 Reasons To Own E/M Code Check

2010-10-12T12:12:00.007-05:00

The folks at e-MedTools have created another terrific medical documentation tool!

E/M Code Check is an application for smart phones (iPhone, Android, etc.) that contains important financial data for physicians. This tool not only provides benchmark data from Medicare, such as coding distribution curves and average reimbursement rates, it provides succinct summaries of documentation requirements for coding levels for many types of clinical encounters. E/M Code Check even includes encounter information not found in other medical documentation tools.

The most exciting feature of E/M Code Check is the Personal Productivity Log that tallies all patient encounter codes, then reports the data in a graph format that includes a personalized coding distribution graph, reimbursement, average number work RVUs per encounter, etc.

In today's economy, and with Medicare dropping the reimbursement rates twice in 2010 for sub-specialist physicians, and more cuts to Medicare reimbursement rates planned for December 2010 and January 2011, this tool is indispensable!

10 Reasons to Own EM Code Check

Medical Smartphone App Survey

2010-10-08T19:37:00.001-05:00

Business In Medicine

2010-03-22T08:37:00.001-05:00

The Lung Doctor has published "Business In Medicine" on Scribd. "Business In Medicine" is a brief discussion of the economic impact of the health care industry, health care reform, how physicians are actually paid for health care services provided, physician employment and contract concerns, and medical documentation. The target audience is health care providers, but the information is beneficial to all health care consumers and legislators.

"Business In Medicine" is a great primer for medical students and physicians in training. The health care industry is a complex web of predatory practices involving every component of the health care system: legislation, government run health care insurance, private health care insurance companies, hospitals, and medical professional groups.

The discussion of medical documentation includes the Medicare E&M Service Coding Audit and Worksheet from e-MedTools.

Business in Medicine

Merlin Olsen Has Died of Mesothelioma

2010-03-11T13:14:00.000-06:00

My deepest sympathies to the family of Merlin Olsen, who died as a complication of mesothelioma, a rare but aggressive cancer of the lungs and pleura. It is never easy to lose a loved one. Peace be with you.

Socialism In Medicine

2010-03-02T11:10:00.005-06:00

Medicine is a business! Healthcare providers provide an essential service. Why then are so many people uncomfortable associating healthcare with business and profit-making?

According to Wikipedia, business is defined as follows: "A business . . .is a legally recognized organization designed to provide goods and/or services to consumers.. .The owners and operators of a business have as one of their main objectives the receipt or generation of a financial return in exchange for work and acceptance of risk. Notable exceptions include cooperative enterprises and state-owned enterprises.."

The healthcare system is NOT a free market system. Insurance companies and governmental agencies impose significant restrictions on the healthcare industry. If it were a free market system, healthcare would be forced to focus keenly on the relationship between healthcare consumer and healthcare provider. Satisfaction and competitive, quality service would be critical to financial success and would become standard. Costs are naturally constrained by monetary influences. This is the for many who propose socializing healthcare.

For obvious reasons, there will be a wide range of services that healthcare consumers will be able to afford. A question often used in the context of healthcare is whether individuals have an inherent right to healthcare. A rarely discussed extension of that question then becomes, how much healthcare does an individual have a "right" to access, and who makes that determination?

It is ludicrous to mandate any business to routinely provide services for free, or at unrealistic prices that make their business unsustainable. Yet, the government controls how much physicians and hospitals may charge for their services, then determines a "fair" price, and pays only a percentage of that "fair" price! For example, a healthcare provider may be legally allowed to "charge" no more than $100 for a service, but the government insurer deems that only $60 is a "fair" price, and then proceeds to pay only 80% of $60, or $48! This is why the current healthcare system, based on an artificial government imposed limitations is a financial failure! The current healthcare system has not failed because of healthcare providers. It has failed because of governmental interference.

Ironically, veterinary medicine is a free market business. Perhaps more ironic is the acceptance of a free market system in the production of weapons of mass destruction, ammunition, tanks, planes and military vessels! According to the publication, Government Executive (August 15, 2002), in 2001 more than $92 Billion dollars of taxpayer money were spent on the top 100 government contractors.

Healthcare consumers have been removed from the financial process of healthcare delivery for so long, and have become so reliant on a third party payor system with deep pockets that there has been little accountability for healthcare costs. Government handouts have created a dependent society. Healthcare consumers do not ask, or in many cases care, how much healthcare costs. Advances in healthcare mean that much can be done, but at what cost personally and economically? Because everything can be done, should everything be done?

Congress knows that healthcare is a business, and one that costs a hefty sum in tax revenue. The government is essentially the largest health insurer in the nation. The Centers for Medicare and Medicaid Services provided healthcare insurance to nearly 100 Million U.S. residents (2004,2005) at a cost of $577 Billion, according to the Henry J. Kaiser Family Foundation. The problem, as we all know, is that the number of people utilizing government funded healthcare insurance has increased while the number of people paying taxes has decreased. Medicare/Medicaid is an unsustainable business.

Congress has now mandated reduced payments to healthcare providers in order to offset the national budget. This merely shifts a significant burden of healthcare costs to individual healthcare providers, forcing them into an unsustainable business! On January 1, 2010 Medicare stopped paying for specialist consultations in the clinic or hospital, shifting to a reduced payment similar to what primary care providers receive, resulting in a reduction of approximately 11%. Despite the fact that specialist physicians have more advanced training and treat more complex healthcare problems, Congress has deemed that all physicians be paid the same. On March 1, all healthcare providers received an additional 21% reduction in payment, thus effectively cutting specialist payments by 25%.

Now Congress wants to bundle healthcare payments by paying only hospitals for all healthcare provided. Hospitals would then be in control of determining how much to pay physicians! Where will the accountability be? How will a physician's worth be determined? Physicians will be completely at the mercy of hospitals. Hospitals can effectively force out private practice physicians, and hire cheaper labor. Many hospitals already hire doctors from other countries because they can pay these physicians less money!

What can the motivation be to impose such limitations that effectively force physicians out of business? The socialization of medicine! Creating a socialist society where the government, or the most elite of the wealthy will be in control of healthcare. Are we ready for conglomerate medicine that is insensitive to local or individual needs? Do we want the government knowing in-depth medical information about each of us? There is a frightening conflict of interest here! The government will have the capability of determining who costs "too much". The government could then begin limiting individual benefits based on cost. Sound familiar?

What is next? Eliminating everyone who is not a valuable contribution to society? Imagine the impact of losing geniuses like Stephen Hawking because of healthcare costs! Imagine legislating who has the right to reproduce, or what fetus to carry to term to eliminate disease carrying genes, or to create a more perfect race?

Congress does value profitability in some medical businesses. The pharmaceutical industry has had substantial influence in legislative decisions preventing Americans from purchasing medications outside the U.S. at a cheaper cost. These companies have agreed to provide expensive medications at a cheaper price to some consumers. But, it comes at the cost of Medicare agreeing to not pay for alternative medications that are just as effective, but cost less.

What is the solution? Free market! The government needs to get out of the business of micromanaging our lives, and let the free market system influence the healthcare market.

Stop Congress from crippling healthcare and micromanaging every one of us!

MedicalTemplates' Outpatient Pulmonary Clinic Evaluation

2010-02-08T12:50:00.004-06:00

The folks at e-medtools who create MedicalTemplates have updated their Outpatient Pulmonary Clinic Evaluation for new patient evaluations. This new template looks much better than the previous version! It also appears to have quite a few more convenient features!

The ROS (Review of Systems) has been updated to reflect the ROS on their other templates. Having a ROS with space to document both "yes" and "no" responses makes a great deal of sense medically and legally! The PMH (Past Medical History) is much cleaner, more straightforward, and limited to the most common diagnoses. They have left room, though, for addition of a tailored set of diagnoses, such as specific pulmonary diseases that are not very common. There is also a very nice list of common surgeries that really save on documentation time and effort! Prompters for significant Social History information like ADLs (Activities of Daily Living) and behavioral and occupational risk factors are extraordinarily important to most patients seen by a pulmonologist, but are often excluded from standard medical templates.

The exam is quite extensive with relevant negative and positive findings that, again, stand to save pulmonologists a great deal of time and effort. Time is money, and quality of life is extremely important!

There is significantly more space in the Impression and Plan section, which is a great improvement over the previous version. Space for adequate discussion of the differential diagnoses and treatment options was previously limited.

MedicalTemplates is doing a great job! Documentation of the patient encounter is complex and confusing! There are so many rules that differ with each payor, and often change from year to year, that it makes sense to take a more consistent approach to documenting every patient encounter!

Pulmonary Clinic History and Physical

Trailblazer Medicare Audit Tool

2010-01-03T21:42:00.004-06:00

The folks at e-medtools who create MedicalTemplates, MedSpel and the E and M Audit Tool have created a Trailblazer Medicare Audit Tool. This tool is useful to health care providers in Delaware, Maryland, Virginia and District of Columbia.

Like all their templates, the Trailblazer Medicare Audit Tool is created using a fillable PDF format so that the form can be completed online or printed and completed by hand.

Reimbursement for health care services is complex and confusing. Taking the time to learn and incorporate appropriate medical documentation into every patient encounter note benefits everyone, but is even more critical these days given the severe economic pressures and increased scrutiny by insurance companies.

These Medicare audit tools make great tools for learning the complexities of medical documentation necessary to justify billing levels. When it comes to documentation, if it isn't documented it didn't happen according to medical insurance companies (and lawyers, of course).

Trailblazer Medicare Audit Tool

Lung Cancer

2009-01-16T13:36:00.002-06:00

How do you know if you are at risk of developing lung cancer?
Many things are associated with an increased risk of developing lung cancer.

The National Cancer Institute expected nearly 215,000 people to be diagnosed with lung cancer in 2008, and nearly 162,000 people to die of lung cancer in 2008!

Smoking is the most common cause of lung cancer, and is the best established preventable risk factor for lung cancer (as well as bladder and other cancers). According to the National Cancer Institute, cigarette smoke contains over 4,000 chemical agents and at least 60 known carcinogens (cancer-causing agents)! Few of us would be willing to live or work in an environment that contains that many risky chemicals?!

Other risks include environmental exposures to known carcinogens. A few of them have received significant attention in the media.

Environmental tobacco smoke (aka "second hand smoke") is perhaps the most frequently encountered environmental risk factor known to cause lung cancer. The inhaled smoke is not filtered, and many environments are associated with highly concentrated second hand smoke (i.e., public restaurants, nightclubs, taverns, etc.).

The Environmental Protection Agency estimates that as many as 3,000 people die each year as a result of environmental tobacco smoke exposure. That is 10 times the number of Americans killed in armed conflict in Iraq in 2008, according to globalsecurity.org, and nearly the same number of people who died, directly or indirectly, as a result of the September 11, 2001 attacks on the World Trade Center (according to http://nymag.com/news/articles/wtc/1year/numbers.htm).

While not a common cause of lung cancer, asbestos causes mesothelioma, and has received a great deal of attention from the media, legal system, and Congress. In 1999 nearly 2500 people died in the United States from mesothelioma (Center for Disease Control, National Institute for Occupational Safety and Health). Plumbers, pipefitters and steamfitters are the occupations at greatest risk. For additional occupations associated with exposure to asbestos, please refer to the presentation "Malignant Pleural Mesothelioma". Smoking does not increase the likelihood of developing mesothelioma, however, smoking and exposure to asbestos increases your chance of developing other types of lung cancer by 50 fold!

The second most common cause of lung cancer is radon. According to the National Cancer Institute, it is thought that radon is responsible for as many as 15,000-22,000 deaths from lung cancer each year. Radon is a naturally occurring odorless gas created by the decay of uranium, found in many rocks and soils. Granite counter tops have recently been found to emit radon gas. While in low concentrations outdoors, it can reach concentrated levels indoors in basements and underground mines or shelters. There are radon detectors, like carbon monoxide detectors, that can alert people to dangerous levels of radon gas. Fortunately, the risk of dangerously high radon gas levels can be decreased by improving ventilation systems. For more information about radon gas, visit the Environmental Protection Agency.

What are symptoms concerning for lung cancer?
Symptoms of lung cancer can be nonspecific and can be similar to symptoms of other illnesses, such as congestive heart failure, pneumonia and pulmonary fibrosis. Symptoms of lung cancer can include: chest pain, unexplained weight loss, unexplained fever or chills, new or prolonged cough, bloody cough, new or worsened shortness of breath, decreased appetite. If you have any of these symptoms, you should see your doctor to discuss the possible causes.

What will your doctor do to determine if you have lung cancer?
First, your doctor will ask you questions relating to your past medical health, your family risk factors, and your current symptoms. Your doctor will also perform a thorough physical exam. He or she may also opt to order tests to further evaluate your symptoms, such as blood work, breathing function tests, chest x-rays, CT of the chest, PET scan, etc. Should there be any suspicious looking areas on your chest x-ray, CT of the chest, or PET scan, your doctor may refer you to a pulmonologist (lung doctor) or a cardiothoracic surgeon.

A pulmonologist, a doctor specializing in problems and diseases affecting breathing, will listen to your medical history, perform a physical exam, order tests, and possibly perform a bronchoscopy to obtain tissue samples of your lungs to look for cancer or other causes of apparent lung masses. Bronchoscopy is a means of looking inside the lungs with a tube-shaped camera. Through the camera, the pulmonologist can obtain liquid and tissue samples to be reviewed by a pathologist.

A cardiothoracic surgeon, a surgeon specializing in surgeries involving the heart, lungs, vessels and other organs in the chest cavity, in addition to taking a thorough medical history and performing a medical exam may choose to perform an operative procedure to obtain tissue samples of lungs and lymph nodes in the chest.

What can you expect once you have been diagnosed with lung cancer?
Your doctor will discuss with you
a. the type of cancer you have (based on pathology reports)
b. whether it has spread to other places in your body, like organs or lymph nodes (based on radiologic studies: x-rays, CT scans, PET scans OR based on surgical pathology)
c. what your options are for treatment or palliation (palliation refers to treatment that is NOT designed to cure, but rather to improve the quality of your remaining life)
d. what you would like to do

Your doctor will also likely consult a surgeon, an oncologist or a radiation oncologist to help you understand all of the options available to you. An oncologist is a doctor who specializes in the evaluation and treatment of cancer.

You may want to have a loved one or trusted friend with you when you talk to your doctor about your diagnosis. There will be so much information, and the diagnosis of cancer is very frightening, that you may not be able to remember everything that is said to you. Another person may be able to help you remember information after your appointment, and may also help prompt additional questions for your physician.

While receiving a diagnosis like cancer is stressful, to be forewarned is to be forearmed!

Now is the time to say the things that need to be said, and to do the things that need to be done! Tell your family and friends important things like how much they have meant to you. Say "I love you" to everyone you love. Forgive people, AND TELL THEM THAT YOU FORGIVE THEM! You will feel at peace with yourself, and others will have the joy of knowing how much you care about them! Far too often, family members who have not spoken for years arrive too late, only to find that they missed their last chance to say "I'm sorry" or "I love you". Many people live with the guilt and sadness for the rest of their lives.

Think about what kind of medical treatment you would like to have. Are you someone who wants to fight with all your might, struggling to the bitter end to live every moment, no matter the cost to you? Are you someone who wants to enjoy the last weeks, months or years of your life loving family and friends and taking care of your private affairs? Or, are you somewhere between the two?

Thoughtful, sincere discussions with family members and friends about the kind and extent of medical treatment you would like to receive is very important. From these family and friends you may want to choose a special "spokesperson" to express your desires in the event that you are unable to do so. Just as you will need a Durable Power of Attorney to take care of your private business matters, you will need a Durable Power of Attorney for Health Care to assist with medical decision making when you are unable to do so. You will need someone you can trust to make decisions that you would otherwise make for yourself.

One thing to remember is that YOU are the captain of your ship! Only YOU can make decisions that are best for you!

Cardiogenic Shock

2009-01-14T14:15:00.000-06:00

Cardiogenic Shock

Publish at Scribd or explore others: Health & Medicine Presentations & Slid Medical-Diseases ptca

Controversies in Treating Cardiogenic Shock Martha Burk, MD, MS BAMC/Wilford Hall/UTHSCSA Combined Pulmonary Fellows Conference Cardiogenic Shock  Inadequate perfusion of tissue with relatively decreased cardiac dysfunction is the most common cause of death in patients hospitalized for AMI of AMI complicated by cardiogenic shock remains  It  Treatment Two Minute Assessmen t Evidence of Low Perfusion Narrow pulse pressure Pulsus paradoxus Cool extremities Altered mental status Hyponatremia Worsening renal function Evidence for Congestion Orthopnea Elevated JVP Gallop Edema Ascites Rales Hepatojugular reflux Congestion at rest? No Yes Warm and Wet No Low Perfusion At Rest? Yes Warm and Dry Drug-related hypotension Cold and Dry Cold and Wet Nohria, et al JAMA 2002 Causes of Cardiogenic Shock  Acute MI – Pump failure  Large infarction  Infarct expansion  Reinfarction    Myocarditis Severe septic shock LV outflow obstruction – Aortic stenosis – Hypertrophic LV  Mechanical complications – Acute MR/papillary muscle rupture – Ventricular wall rupture – Ventricular septal defect – Pericardial tamponade  Valvular disease – Mitral stenosis – Left atrial myxoma    Myocardial contusion Hypothyroid state Prolonged CABG  End-stage cardiomyopathy Adapted from UpToDate and Hollenberg, et al Ann Intern Med 1999 Epidemiology    Acute MI is most frequent cause ~10% AMI results in shock SHOCK – (Should we emergently revascularize Occluded Coronaries for shocK) trial registry – 1160 pts with AMI and shock       75% with LV failure 8% had MR 5% had ventricular septal defect 3% had RV failure 2% had tamponade or cardiac rupture 8% had shock for other reasons – Infarctions  55% anterior, 46% inferior  21% posterior, 50% multiple Hollenberg, et al Ann Intern Med 1999 Davies QJ Med 2001 Mortality  TRACE study – – – – Trandolapril Cardiac Evaluation protocol 6676 pts non-invasively managed for AMI 59% pts developed shock within 48 hrs 30 day and 6 year mortality  Without shock 9%/45%  With shock 62%/88%  Euro-Heart-Survey-ACS – – – 10,136 patients presenting with ACS 549 had cardiogenic shock on presentation Mortality of pts presenting with/without shock  50%/3% with STEMI  53%/1% with NSTEMI Lindholm, et al European Heart Journal 2003 Iakobishvili, et al American Heart Journal 200 Mortality In TRACE Lindholm, et al European Heart Journal 2003 Katayama, et al Circ J 2005 Pathophysiolog y       Impaired Thrombolysis Microthrombi develop  Vasoconstrictors released from microthrombi  Vasospasm results in increased flow resistance  No reflow phenomenon  Davies QJ Med 2001 Coronary occlusion Impaired coronary flow Infarct Dysfunction results in hypotension Aortic pressures <85mmHg Extension of infarct/muscle necrosis Neuroendocrine Activation  Neuroendocrine system activated – Increase cardiac output – Include renin, aldosterone, catecholamines, BNP, ANP and adrenomedullin – Adrenomedullin produced unregulated in ischemia, hypotension    Increased demand on myocardium Inadequate coronary flow Increased myonecrosis – Inability to meet increased oxygen demand Davies QJ Med 2001 Katayama, et al Internal Medicine 2004 Regulation of Vascular Smooth Muscle Tone Landry NEJM 2001 Neuroendocrine Markers of Mortality Katayama, et al Internal Medicine 2004 Myocardial Dysfunction Systolic Diastolic ↓ CO ↓ SV ↓Systemic Perfusion Hypotension ↓ Coronary Perfusion Vasoconstriction Pressure Fluid retention Progressive Myocardial Dysfunction Ischemia Death Hollenberg et al, Annals of Internal Medicine 1999 Ischemic myocardium Cell death Reperfusion Significant residual stenosis Segments with Stunning and Hibernation Segments with Hibernating myocardium Segments with Myocardial stunning No return Of function Inotropic Support Relief of Ischemia Return of Myocardial function Hollenberg et al, Annals of Internal Medicine Reperfusion Injury    Free radical production Increased neutrophil adhesion – Complement formation Free fatty acid metabolism restored – Further decreases intracellular pH – Increased calcium influx due to Na-K exchange  Result: further myonecrosis during first 2 hours after reperfusion Davies QJ Med 2001 Diagnosis  Diagnosis requires – Documentation of myocardial dysfunction – Exclusion of alternative causes  Hypovolemia  Sepsis  PE  Tamponade  Aortic dissection  Valvular disease Severity of Heart Failure in AMI Classification Killip – Class I  No clinical heart failure  < 5% mortality – Class IV Cardiogenic shock Stuporous systolic BP < 90 decreased urine output  pulmonary edema and cold clammy skin  mortality near 80%     – Class II  Rales bilaterally in up to 50% of lung fields  isolated S3  good prognosis – Class III  Rales in all lung fields  acute mitral regurgitation  aggressive management required www.ahcpub.com Management Goals  Early recognition  Early reperfusion  Maintenance of adequate preload  Decreased afterload Pfisterer Lancet 2003 Initial Diagnostic and Therapeutic Steps History and Exam Oxygenate/Ventilate ECG ECHO Labs CXR PAC Venous access ECG Pain control Hemodynamic support Tissue perfusion Remains inadequate Inotropes IABP Adequate perfusion Without congestion Adequate perfusion With pulmonary congestion Reperfusion Card cath available Cardiac cath Angioplasty CABG Continued No card cath available Thrombolytics and IABP Clinical management Hollenberg, et al Ann Intern Med 1999 Utility of ECHO  Evaluate – LV function and myocardium at risk – Screen for ventricular septal rupture – Screen for severe mitral regurgitation – Look for tamponade/rupture – Assess right ventricular function – Look for aortic dissection Menon and Hochman Heart 2002 Echo Survival and Response Predictors in Cardiogenic Shock  169 pts with MI randomized w/in 12 hrs of diagnosis of shock to receive – early emergency revascularization  PTCA or CABG was performed w/in 6 hrs  IABP was recommended – initial medical stabilization – Echo performed w/in 24 hrs of randomization, and 7 days later – Study designed and powered to detect 20% difference in overall 30 day mortality  LVEF >/= 28% and Grade 0/1 MR were associated with improved survival – Odds Ratio 4 and 3, respectively Picard, et al Circulation 2003 Pulmonary Artery Catheters UpToDate Importance of Position UpToDate Respiratory Variation With PEEP 0 PEEP 15 PEEP 20 PEEP UpToDate WP is a reliable indicator of LVEDP only when ventricular compliance is stable UpToDate PACs in High Risk Surgical Patients  1994 pts – – – ≥60 years old Deemed ASA class III or IV risk Undergoing elective or urgent major abdominal, thoracic, vascular or hip frax surgery and requiring intensive care – Randomized to receive treatment w/ or w/o PAC guidance  Conclusion Class III = Severe disease, but not incapacitating Class IV = Severe disease that is a constant threat to life – No benefit to therapy directed by PAC versus standard care NEJM 2003 Complications of PAC         Pneumothorax Hemothorax Hematoma Arrhythmias Heart block Arterial laceration Pulmonary artery perforation Valvular damage      Catheter site infection Thrombosis Infarction Endocarditis Thrombocytopenia Layon Chest 1999 Perioperative Use in Cardiac Surgery Conditions in which there is general agreement that RHC is warranted  Differentiation between causes of low CO – Hypovolemia v ventricular dysfunction – Echo is inconclusive – Echo is inconclusive  Differentiation between L v R heart failure and pericardial tamponade Guidance of management of low CO state Diagnosis and management of PAH in patients with systemic hypotension and impaired organ perfusion J American College Cardiology 1998   Conditions In Which Reasonable Differences of Opinion Exist   Guidance of inotropic and/or vasopressor therapy after patients with significant cardiac dysfunction have achieved hemodynamic stability Guidance of management of hypotension and evidence of inadequate organ perfusion when a therapeutic trial of intravascular volume expansion and/or vasoactive agents is associated with moderate risk J American College Cardiology 1998 Intra-Aortic Balloon Pump     Reduces systolic afterload Augments diastolic perfusion pressures Increases cardiac output Improves coronary artery perfusion – Not true for critically stenosed vessels   Decreases reocclusion and cardiac events after emergency angioplasty for AMI No increase in myocardial oxygen demand IABP    Initially improves hemodynamic status – Impact temporary 80% mortality in patients with CS treated with – IABP placement, CCU monitoring and vasopressor Fornaro, et al retrospectively studied 15 patients admitted for AMI with cardiogenic shock – All pts underwent IABP, angiography followed by PTCA, CABG and cardiac surgery or medical treatment – 5 pts (33%) died  Fornaro, al Ital Cardiol ~18% patients in Euro-Heart-SurveyetinGCSHeart J1996 had Iakobishvili, et al Am 2005 Benchmark Counterpulsation Outcomes Registry Prospective registry of all patients who receive IABPs at participating centers 1996-2001  22,663 patients    21% all cause mortality 12% mortality/balloon in place 0.05% IABP-related mortality 1% major limb ischemia 1% severe bleeding 4% balloon failure/leak Cohen, et al European Heart Journal 2003 – 185 US sites, 65 non-US sites – 4314 had cardiogenic shock – Primary endpoints     Major limb ischemia Severe bleeding IABP failure All cause in-hospital mortality     Risks of IABP  Arterial – – – – – Perforation Thrombosis Embolization Limb ischemia Visceral ischemia  Miscellaneous – – – Hemorrhage Infection Entrapment  Balloon – Rupture – Incorrect positioning – Gas embolization Overwalder The Internet Journal of Thoracic and Cardiovascular Surgery 1999 ACC/AHA Guidelines Class I recommendations  STEMI patients with BP <90 – Or 30mm Hg below baseline – No response to other interventions  Level B Evidence STEMI patients with low output states  As a stabilizing measure for angiography and revascularization Class II recommendations Level  STEMI patients with refractory pulmonaryC Evidence congestion Antman, et al JACC 2004 Reestablishing Perfusion NEJM 2002 Benefits of Thrombolysis in AMI Impact of Blood Flow on Survival TIMI 0 absence of any antegrade flow beyond a coronary occlusion. TIMI 1 faint antegrade coronary flow beyond the occlusion although filling of the distal coronary bed is incomplete. TIMI 2 delayed or sluggish antegrade flow with complete filling of the distal territory. TIMI 3 normal flow which fills the distal coronary bed completely. Absolute Reduction in Mortality UpToDate TIMI 0 TIMI 1 Occlusion Penetration 12 10 TIMI 2 Slow Flow P=0.003 vs TIMI 0/1 TIMI 3 Normal Flow 9.3% % Mortality 8 6 4 2 GUSTO 1 6.1% p<0.0001 vs TIMI 0/1 p<0.0001 vs TIMI 2 3.7% GUSTO 1 TAM I 1-7 GUSTO 1 German Team 2 German TAM I 1-7 TAM I 1-7 Team 2 Team 2 German Sample Size of Pooled Analysis: 5,498 Gibson 1998 TIM I 1,4 5,10B TIM I 1,4 5,10B TIM I 1,4 5,10B 0 10 16 33 34 44 4 8 27 13 19 9 15 18 29 34 Both Culprit and Non-Culprit Flow are Abnormal in Acute MI 40 35 30 25 CTFC 20 15 10 5 0 n =1,322 n = 232 n =1,589 n = 78 36.8 + 22.3 6 frames 30.6 + 13.4 30.6 + 14.6 9 frames 21.0 + 3.1 Even PTCA of the culprit artery residual stenosis restores flow only to that observed in the non-culprit (30 frames) and not to normal flow (21 frames) The difference between culprit & non-culprit flow is only 6 frames; the difference between nonculprit and normal flow is 9 frames Culprit Culprit post PTCA Non-Culprit Normal In 25% of cases, flow is slower in the non-culprit than culprit In 33% of cases, flow is abnormal following stent placement Gibson et al, JACC 1999; 34: 974-82 Thrombolytic Therapy in CS  Less benefit once cardiogenic shock occurs  Mortality unaffected by type of thrombolytic – GISSI trial 30 day mortality 70% for each group  Increased risk of significant bleeding with streptokinase versus alteplase – International Study Group  Streptokinase v recombinant Tissue Plasminogen Activator Lancet 1990  Risks of Thrombolysis Bleeding Bleeding Bleeding  Not Thrombolytic Therapy in STEMI – Coronary arteries not usually occluded – IF PTCA not available within 2 hours – Patients w/o contraindications – Present w/in 12 hours of symptom onset – Greatest benefit if given w/in 2 hours of symptoms beneficial in NSTEMI  Useful  ACC/AHA recommends thrombolytics  Approximately 50% will achieve normalized return of blood flow (TIMI grade 3) – 90% of patients undergoing PCI achieve TIMI grade 3 flow UpToDate 30 Day Mortality of Early v Late PTCA GUSTO-1 Trial Berger, et al Circulation 1997 Markers of TIMI 2/3 Flow  Decrease in chest pain – TAMI study  PPV 57% TIMI 3  NPV 86% TIMI 3  <50% decrease in ST – AND absence of arrhythmias at 2 hours after thrombolytics – Predicted LACK of TIMI 3 flow     Sens 81% Spec 88% PPV 87% NPV 83%  ECG changes – >50% decrease in ST elevation  in the lead with the most elevation – PPV 66% – NPV 86%  Mb, CK-Mb, Troponin – Ratio of baseline/60minute myoglobin ≥4 predicts 90% probability of TIMI 3 flow Oldroyd Heart 2000 Is Thrombolysis Obsolete?  Nearly all patients with AMIs are eligible for cardiac catheterization  PCI identifies anatomy involved  Acts as a triage for CT surgery  IABPs can be placed in the cath lab  90% pts achieve TIMI 3 flow with PCI Grines, et al Circulation 2003 Revascularization  SHOCK trial – 302 pts with cardiogenic shock (largely due to LV dysfunction) randomized to early revascularization within 6 hours, or initial medical stabilization – Primary end point was 30 day mortality  No survival difference at 30 days (53% v 44%)  6 month survival 50% v 37% (p = 0.027) – Early revascularization v initial medical stabilization   12 month survival 47% v 34% (p = 0.025) At 1 year, 62% survived if TIMI flow grade 3 was achieved v 19% survival if PTCA was unsuccessful – Conclusion: Rapid revascularization is a survival predictor  American College of Cardiology, American Heart Association guidelines recommend emergency revascularization for pts ≤ 75 years with AMI Menon Congest Heart Fail complicated by cardiogenic shock 2003 Webb, et al J Am Coll Cardiol Menon and Hochman Heart 2002 Barbash et al, Heart 2001  Outcome Predictors After PCI Factor Retrospective review of 113 pts who underwent PCI for AMI complicated by shock – PCI occurred w/in 12 hours of sx onset Prior MI No or Yes Age (years) <70 or ≥70 Failed Reperfusion No or Yes Disease Single/Multivess el In Hospital Mortality 41%77 v 46 v 72 p 5 OR < 0.001 0.02 4 OR 4 OR  Factors w/o impact on survival – – – – Gender Smoking status Diabetes Time to intervention  6, 6-12, or >12 hours 36 v 72 29 v 57 <0.001 0.01 Sutton, et al Heart 2005 Another Look at Outcomes, PCI  Patients with AMI and cardiogenic shock – – – – 152 underwent emergency revascularization 150 underwent medical stabilization Primary endpoint was 30 day mortality Secondary endpoint was 6 month survival  Median time from AMI to shock was 5.6 hours  Mean age of patients was 66 years  32% patients were female  30 day mortality (revascularization v medical treatment) – Not statistically significant (47 v 56%)  6 month mortality – 50 v 63% ( p = 0.027) Hochman, et al NEJM 1999 Predictive Value Troponin T Ohman, et al NEJM 1996 2004 ACC/AHA Guidelines on CABG  Class I Recommendation – STEMI  Pts who fail angioplasty and remain hemodynamically unstable (Level B evidence)  At time of surgical repair of ventricular septal wall rupture or mitral valve insufficiency  CS pts <75 with ST elevation or LBBB (Level B) or posterior MI who develop shock w/in 36 hrs (Level A) – LV dysfunction  Significant left main stenosis (Level B)  Left main equivalent stenosis (Level B)  Proximal LAD with 2 or 3 vessel disease Novel Potential Therapies Nitric Oxide Synthase Inhibition  Nitric oxide is a strong vasodilator  Positive inotropic effect at low levels  Negative inotropic effect at high levels  Large MIs are associated with NO overproduction  Could NO inhibition improve the hemodynamic status of patients with cardiogenic shock? Nitric Oxide Synthase Inhibitor  30 patients with AMI and shock – All received IABP, IVFs, pressors, and were immediately referred for coronary catheterization – Revascularization performed only by PCI – Swan-Ganz catheters used after revascularizaiton    Pts in the treatment arm received L-NAME at 1 mg/kg/h x 5 h Primary end point 1 month Survival 73% v 33% 1 week survival 80% v 40% 4 month survival 73% v 33% Secondary end points – All cause mortality at 1 wk and 4 mos MAP improved by 25mm Hg Urine output 210 v 110cc/h – Time on mechanical ventilation Time on IABP 59h v 103h – Time on IABP Ventilation time 77 v 140h – Urine output at 24 hours – Change in cardiac index – All cause 30 day mortality Cotter, et al European Heart Journal 2003 Other Novel Therapies  Monoclonal antibodies to CD11/CD18 – – – Inhibit neutrophil adhesion HALT-MI AMI pts from ER to cath lab  Randomized by TIMI 0/1 flow to receive drug or placebo  Primary end point: size of infarct by SPECT 5-9 days after MI and angioplasty  No significant difference  Na-H inhibition – -Guardian trial showed no benefit www.acc.org Assess volume status Treat sustained arrhythmias Mechanical ventilation as needed Inotropic/vasopressor support No Acute massive ST elevation Extensive Q waves Or new LBBB Yes No ST elevation Limited ST, Q changes Emergency ECHO with Color flow doppler Cath lab Immediately available Yes No Pump failure RV, LV, both Aortic dissection Tamponade Cath lab ST elevation -> Lysis No ST elevation -> GP IIbIIIa Aspirin, Heparin Acute severe MR VSR Critical AS/MS Rapid IABP Cardiac surgery CABG for severe 3v dz or L main Correct mechanical lesions PTCA for 1, 2, or mod 3 v CAD GP IIb/IIIa antag Coronary stent OR Coronary angio Pulmonary artery cath Menon and Hochman Heart 2002 Treasures of San Antonio

Malignant Mesothelioma

2009-01-14T13:43:00.000-06:00

Malignant Mesothelioma

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Malignant Pleural Mesothelioma Martha Burk, MD, MS WHMC/BAMC/UTHSCSA Combined Pulmonary Fellows’ Conference February 2005 People We Know Steve McQueen, 1980 Navy Admiral Elmo Zumwalt, 1999 Minnesota Congressman Bruce Vento, 2000 Evolutionary biologist Dr. Stephen Jay Gould, 2001 Epidemiology  80% cases associated with documented asbestos exposure  Highest risk associated with crocidolite, chrysolite and amosite  Other etiologies implicated    Therapeutic radiation Intrapleural thorium dioxide Inhalation of other fibrous silicates  Erionite or zeolite  Latency period 20-40+ years  Peak mortality expected in 2020-2030  Median survival  8-18 months from time of diagnosis  Lifetime risk of MM among asbestos workers is 8-13%  Annual incidence with exposure increases  3.5X for males  1.4X for females Imaging of Diseases of the Chest. Armstrong. Mosby. Toronto 2000 Light, Richard. Textbook of Pleural Disease 2003 Arnold Publishers Asbestos fibers  Serpentine  Curly, pliable  Amphiboles   Crocidolite, amosite, tremolite, anthrophyllite, actinolite Long, needle-like www.som.tulane.edu/.../ AsbestosMinerals.jpg Incidence of MPM Countries UK and Netherlands Western Europe Germany, Spain, Ireland Eastern Europe United States South Africa Western Australia Males (per 100K) 7.4-8.8 2.9-4.2 1-1.9 0.6-1.0 1.5-2.2 >5.4 >4.8 Females (per 100K) 0.8-1.3 0.7-1.3 0.2-0.5 0.3-0.5 0.3-0.4 >2.3 >0.3 Treasure, T and Sedrakyan, A Pleural mesothelioma: little evidence, still time to do trials Lancet 2004 364:1183-1185 U.S. Mortality 1999 Table 7-1. Malignant mesothelioma: Number of deaths by sex, race, and age, and median age at death, U.S. residents age 15 and over, 1999 Site No. of Deaths Underlying Cause (%) Sex Race 15 24 25 34 3544 Age Group (yrs) 45 54 5564 6574 7584 Median Age (yrs) M F W B O 85+ Pleura 252 90.1 219 33 240 10 2 - - 2 12 32 101 86 19 72.0 Peritoneum 92 90.2 62 30 90 2 - - - 2 10 23 31 20 6 69.5 Other Sites 427 90.4 345 82 407 14 6 1 2 3 23 61 134 154 49 74.0 Unspecified 1,773 92.9 1,424 349 1,673 83 17 1 2 26 94 279 572 654 145 73.0 Any Site 2,485 94.3 1,995 490 2,355 105 25 2 4 33 13 8 389 818 888 213 73.0 Center for Disease Control, National Institute for Occupational Safety and Health All Cause Mortality in U.S. in 1999 Compressed Mortality Data for Years: Location: 1999-1999 The United States (FIPS=00) 25-34 years through 85 years and over All Races Age Description 25-34 years 35-44 years 45-54 years Death Count 41,066 89,256 152,974 238,979 452,600 698,590 646,141 Population 40,178,406 45,076,677 36,577,819 23,778,026 18,418,909 12,224,914 4,154,018 Crude Death Rate 102.2 198.0 418.2 1,005.0 2,457.3 5,714.5 15,554.6 Ages: Race: Gender: 55-64 years Both Genders 65-74 years Grouped by: Age 75-84 years 85 years and over Crude Rate Calculated per: 100,000 Total Deaths = 2,319,606 Total Population = 180,408,769 (age > 25) Suggested Citation: United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Office of Analysis, Epidemiology, and Health Promotion (OAEHP), Compressed Mortality File (CMF) compiled from CMF 1968-1988, Series 20, No. 2A 2000, CMF 1989-1998, Series 20, No. 2E 2003 and CMF 1999-2001, Series 20, No. 2G 2004 on CDC WONDER On-line Database. Statistics From 1999 # deaths from mesothelioma = 2,485 = 0.00107 Total # deaths all causes 2,319,606 (0.1%) # deaths from mesothelioma = 2,485 = 0.000014 Total U.S. Population 180,408,769 (0.0014%) United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Office of Analysis, Epidemiology, and Health Promotion (OAEHP), Compressed Mortality File (CMF) compiled from CMF 1968-1988, Series 20, No. 2A 2000, CMF 1989-1998, Series 20, No. 2E 2003 and CMF 1999-2001, Series 20, No. 2G 2004 on CDC WONDER On-line Database. Litigation Crisis Legal Costs/Societal Impact Senate Testimony by Steven Kazan. "Economic Cancer," Lawyer News, September 23, 2002 . . .2001 actuarial study that estimates the cost of asbestos litigation in the United States eventually reaching $200 billion, a legal liability situation that has already bankrupted nine defendants in the past year. It goes on to analyze a new report by the Rand Institute for Civil Justice that claims the asbestos litigation has spread to touch 85% of corporate America. www.kazanlaw.com *200 billion is approximately 2% of the Gross National Product for 2000 Occupations at Risk Mortality by Occupation Table 7-8. Malignant mesothelioma: Proportionate mortality ratio (PMR) adjusted for age, sex, and race by usual occupation, U.S. residents age 15 and over, selected states, 1999 95% Confidence Interval LCL 585 057 575 156 Plumbers, pipefitters, and steamfitters Mechanical engineers Electricians Teachers, elementary school 18 6 12 13 4.76 3.04 2.42 2.13 2.81 1.11 1.25 1.13 UCL 7.51 6.62 4.22 3.64 COC Occupation Number of Deaths PMR COC = Census Occupation Code The PMR is defined as the observed number of deaths with the condition of interest in a specific industry/occupation, divided by the expected number of deaths with that condition. Center for Disease Control, National Institute for Occupational Safety and Health Asbestos Trivia  Low level of asbestos fibers found in general public  Urine, feces, mucus  Found in environment, drinking water, etc.  Rural air typically contains 10 fibers/cubic meter   A typical person breathes about 1 cubic meter air in 1 hour City levels of asbestos fibers are generally 10X higher  Asbestos containing homes typically contain 30-60,000 fibers/cubic meter  EPA proposal limits concentration of asbestos fibers to 7 million fibers (>5 microns in length)/liter drinking water   Most drinking water contains < 1 million fibers/liter Some have as much as 10-300 million fibers/liter  OSHA limits the number of fibers 5 microns or larger to 100,000/cubic meter of workplace air for 8 hour shifts  July 12, 1989 EPA banned new uses of asbestos  Uses established prior to this date are permissible www.atsdr.cdc.gov/toxprofiles Environmental Risks  Rates of MPM development highest in Anatolia region of Turkey 50% of males from one village died of MPM  Six family clusters identified    Possible 6 generation pedigree Autosomal dominant pattern of inheritance with incomplete penetrance  May represent genetic predisposition Volcanic tuffs Pathogenesis  Exact mechanism of carcinogenicity unknown  Carcinogenicity associated with fiber length   >5 microns length <2.5 micron diameter  Inhaled fibers engulfed by macrophage  Long fibers not cleared, and chronic inflammatory process ensues Level and duration of exposure Time since exposure occurred Age at time of exposure Tobacco history Type and length of fibers  Magnitude of risk depends on       Asbestos fibers induce rat protooncogenes  c-fos, c-jun Deletions of 1p, 3p, 9p, and 6q Loss of chromosome 22 Defined and putative tumor suppressing genes SV40 virus  Multiple chromosomal abnormalities associated with MM     Potential Mechanisms for Damage Inhalation of asbestos fibers Chrysotile fibers biodegraded Biopersistence of crocidolite Fibers phagocytosed by macrophages, mesothelial cells and fibroblasts Mesothelial cells release IL-8, Monocyte chemoattractant protein-1, fibronectin Inflammatory cell recruitment, fibroblast and mesothelial cell proliferation Light, Richard. Textbook of Pleural Disease 2003 Arnold Publishers Potential Mechanisms of Carcinogenicity Inhalation of Asbestos Fibers Fibers engulfed by macrophage Inflammatory response Oxygen radicals released Induction of DNA repair enzymes Aneuploidy Chromosomal damage Autophosphorylation Of Epidermal Growth Factor Receptor Increased expression C-fos, C-jun DNA synthesis Light, Richard. Textbook of Pleural Disease 2003 Arnold Publishers Mitotic spindle interference Potential Role of Simian Virus 40  A DNA tumor virus  First suspected in 1991   60% hamsters with SV40 injected into their hearts developed pleural mesothelioma in the absence of asbestos exposure 100% hamsters developed pleural mesothelioma after SV40 injected intrapleurally  In some studies, as many as 50% human mesothelioma tumors coexpress SV40   Not applicable to other countries (Turkey, Finland) May be related to SV40 infected polio vaccines Disrupts genes, including tumor suppressing genes Produces proteins capable of inhibiting tumor suppressor genes, DNA repair Light, Richard. Textbook of Pleural Disease 2003 Arnold Publishers  SV40 DNA inserts itself into host DNA   Clinical Presentation  Mean age approximately 60 years  Early stage  Dyspnea, non-specific pleurisy, moderate effusions Moderate chest tightness Progressive pain, cough, dyspnea Dullness to percussion Palpable chest wall mass Approximately 10% have bilateral involvement at presentation  Later stages      Usually unilateral disease   Death usually is due to progressive dyspnea and respiratory insufficiency  Metastasis seen in approximately 50% at autopsy Presenting Symptoms Retrospective study of 322 Canadian patients with MM: 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% pn ys st De Ch in Pa ea ral eu ions Pl us Eff 90 84 29 3 t i gh We s s Lo <1 ti ma pto c 3 is tys a gh p u Co ver e mo hagi e Fe petit H ysp r’s D rne Ap s Ho lo s ym As Ruffie P et al. Diffuse malignant mesothelioma of the pleura in Ontario and Quebec: a retrospective study of 322 patients Journal of Clinical Oncology 7(8):1157-68, 1989. Traditional Staging Butchart, 1976 LOCALIZED I Disease confined within the capsule of the parietal pleura: ipsilateral pleura, lung, pericardium and diaphragm METASTATIC II III Stage I plus positive intrathoracic LNs Local extension into: chest wall or mediastinum, heart, diaphragm, peritoneum, with/without extrathoracic or contralateral LNs IV Distant metastatic disease Not a valid tool for stratifying for survival outcomes Pistolesi, M and Rusthoven, J Malignant pleural mesothelioma CHEST 2004 126:1308-1329 Malignant mesothelioma. Proposed Tumor Staging 7th World Conference of the International Association for the Study of Lung Cancer T1a T1b T2 Ipsilateral pleura T1a + foci tumor in visceral pleura T1b + diaphragm, confluent visceral tumor or pulmonary parenchyma T3 T1b + endothoracic fascia, mediastinal fat, solitary chest tumor or non-transmural pericardium T4 T1b + diffuse chest wall tumor, transdiaphragmatic peritoneum, contralateral pleura, mediastinal organ, spine or transmural pericardium or myocardium N0 No regional lymph node mets N1 Ipsilateral bronchopulmonary or hilar lymph node N2 Ipsilateral mediastinal lymph node, subcarinal lymph node, internal mammary node N3 Ipsilateral supraclavicular node, contralateral mediastinal node, internal mammary node, supraclavicular node M0 No distant mets M1 Distant mets Ia Ib II III T1a N0 M0 T1b N0 M0 T2 N0 M0 Any T3 M0 Any N1 M0 Any N2 M0 IV Any T4 Any N3 Any M1 Light, Richard. Textbook of Pleural Disease 2003 Arnold Publishers Malignant Mesothelioma www.nci.nih.gov/cancertopics Investigative Options An Open and Closed Case Radiographic Findings  Extensive nodular or lobular thickening of pleura  Pleural effusions  Asbestos related plaques  Chest wall, bone or organ invasion best seen by CT or MRI Imaging of Diseases of the Chest. Armstrong. Mosby. Toronto 2000 Pleural Thickening sprojects.mmi.mcgill.ca/. ../plpsdo_radio.htm Pleural Plaques Emedicine.com Pleural Mass Emedicine.com CT v MRI in Asbestos-related Pleural Disease  21 pts with confirmed long-term asbestos exposure  CT and MRI    4 readers Interobserver agreement for pleural plaque detection was moderate for both  Kappa 0.72 for MRI, and 0.73 for CT  Considered ‘good’ agreement  Sens MRI 88% Pleural thickening, pleural effusion  Interobserver agreement better with MRI Weber, et al. Asbestos-related pleural disease: value of dedicated magnetic resonance imaging techniques Invest Radiol 2004 39:554-564 PET v CT  Retrospective review 18 pts with MPM  Utility of PET in detecting  Mediastinal LNs  Distant metastases CT Sens Spec PPV NPV 43 56 43 56 PET 100 82 71 100 CT True + True False + False Conclusions 3 5 4 4 PET 5 9 2 0 1. MPM metastasizes more commonly than previously thought 2. PET is better than CT for staging 3. May aid in better selection of candidates for aggressive multimodality therapy 4.Benard, et al found Sens 83%, Spec 75% Schneider, et al Positron emission tomography with F18-fluorodeoxyglucose in the staging and preoperative evaluation of malignant pleural mesothelioma Thorac Cardiovasc Surg 2000 120:128-33 Benard, et al Metabolic imaging of malignant pleural mesothelioma with fluorodeoxyglucose positron emission tomography CHEST 1998 114:713-722 MRI and PET Images Benard, et al Metabolic imaging of malignant pleural mesothelioma with fluorodeoxyglucose positron emission tomography CHEST 1998 114:713-722 Value of PET in T Status T Status by PET T0-T3 Surgical/Pathologic T status Total # Patients T0-T3 T4 29 17 46 T4 3 4 7 Total # Patients 32 21 53 Conclusion: PET is relatively poor at defining locoregional disease Flores, et al Positron emission tomography defines metastatic disease but not locoregional disease in patients with malignant pleural mesothelioma J Thorac Cardiovasc Surg 2003 126:11-15 Value of PET in N Status N Status by PET N0 and N1 19 8 27 N2 3 1 4 Total # Patients 22 9 31 Pathologic N Status N0 and N1 N2 Total # Patients Conclusion: PET may be useful in assessing node status Flores, et al Positron emission tomography defines metastatic disease but not locoregional disease in patients with malignant pleural mesothelioma J Thorac Cardiovasc Surg 2003 126:11-15 Thoracentesis        Highly viscous Often bloody Exudative Lymphocyte predominant Protein 4-5 g/dl LDH often >600 IU/l Pleural fluid cytology often inadequate    Mesothelioma Diagnosis achieved in 20-30% cases Epithelioid mesothelioma Adenocarcinoma similar to adenocarcinoma Sarcomatous type similar to fibrosarcoma, hemangiopericytomas Light, Richard. Textbook of Pleural Disease 2003 Arnold Publishers Maskell, et al. Standard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial Lancet 2003 361:1326-31 Imp.ualberta.ca Dpalm.med.uth.tmc.edu Cytology  Criteria for identifying MPM are not highly specific  Abundance of cells with cytoplasmic characteristics of mesothelioma cells       Abundant dense cytoplasm Cell engulfment Intercellular windows Small peripheral vacuoles Presence of collagen and/or basement membrane-like material and hyaluronic acid in background Orangiophilic squamous-like cells Whitaker, D The cytology of malignant mesothelioma Cytopathology 2000 11:139-151 Closed Pleural Biopsy  Often provides inadequate tissue for diagnosis  Diagnosis achieved in approximately 20% cases  Pleural fluid cytology + closed pleural biopsy results in a diagnosis approximately 35-40%  Effectively increases yield by 7-26% UK study of 47 pts with suspected malignant pleural effusions 20 pts had a final diagnosis of MPM Sens Spec NPV PPV Abram’s 55% 100% 72% 100% CT-guided 88% 100% 94% 100% Light, Richard. Textbook of Pleural Disease 2003 Arnold Publishers Maskell, et al. Standard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial Lancet 2003 361:1326-31  Abram’s needle versus CT-guided biopsy   Thoracoscopy  Indications   Mesothelioma suspected Tissue diagnosis not confirmed  95% diagnostic yield in malignancy  Able to visualize tumor   Firm, gray Thick rind Benard, et al Metabolic imaging of malignant pleural mesothelioma with fluorodeoxyglucose positron emission tomography CHEST 1998 114:713-722 Gross Pathologic Appearance Benard, et al Metabolic imaging of malignant pleural mesothelioma with fluorodeoxyglucose positron emission tomography CHEST 1998 114:713-722 Histology Classifications of Malignant Pleural Mesothelioma Epithelial  Comprises ~ 54% of all MPM  Large nuclei with prominent nucleoli Epithelioid Mesothelioma  Eosinophilic cytoplasm  Can mimic other tumors  Example: adenocarcinoma, giant cell, small cell, clear cell, signet cell, glandular, myxoid, microcystic and adenoid cystic carcinomas Adenocarcinoma www.mesothelioma-asbestos-lung-cancer.com/ inf... Imaging of Diseases of the Chest. Armstrong. Mosby. Toronto 2000 Edcenter.med.cornell.edu Sarcomatoid  ~ 21% of MPM  Less common Sarcomatoid Mesothelioma  More aggressive  Spindle-shaped cells resembling fibrosarcomas and leiomyosarcomas Fibrosarcoma www.mesothelioma-asbestos-lung-cancer.com Imaging of Diseases of the Chest. Armstrong. Mosby. Toronto 2000 www.geocities.com Mixed  Approximately 25% of all MPM  Features of epithelioid and sarcomatoid Imaging of Diseases of the Chest. Armstrong. Mosby. Toronto 2000 Diagnostic Aids Technique Histology Periodic Acid Schiff Mucicarmine Immunostaining Carcinoembryonic Assay Leu M-1 Vimentin Cytokeratin Electron microscopy MPM Negative Negative Negative Negative Positive Positive Long microvilli Adeno CA Positive Positive Positive (75%) Positive Negative Negative Short microvilli Whitaker, D The cytology of malignant mesothelioma Cytopathology 2000 11:139-151 Asbestos Fibers www.medicine.creighton.edu Immunostaining Fig. 2A. Malignant mesothelioma, mixed type, stained for calretinin. The epithelial component is strongly stained, while the sarcomatous component is moderately stained. Fig. 2C. Cell block from pleural exudate with adenocarcinoma stained for calretinin. The normal mesothelial cells are stained, while tumour cells are unstained. www.nordiqc.org Treatment Palliation v Aggressive Therapy Pleurodesis  Viallat, et al CHEST 1996 evaluated the efficacy of thoracoscopic talc poudrage in malignant pleural effusions   360 patients 24% had MPM Mesothelioma N=85 Pleural mets N=242 Overall N=327 Complete Response % Partial response % Failure % 78.8 5.9 15.3 88.5 3.7 7.8 85.9 4.3 9.8 Poudrage = thoracoscopic application of sclerosing agent with sprayer Pneumatic pump sprayer used in this study Viallat, et al Thoracoscopic talc poudrage pleurodesis for malignant effusions CHEST 1996 110:1387-93 Definitions  P/D (Pleurectomy/Decortication)  Removal of  Visceral, parietal, pericardial pleura from apex of lung to diaphragm  EPP (Extrapleural pneumonectomy)  En bloc resection of     Visceral and parietal pleura Lung Pericardium Ipsilateral diaphragm Pistolesi, M and Rusthoven, J Malignant pleural mesothelioma: update, current management, and newer therapeutic strategies CHEST 2004 126:1318-1329 Pleurectomy in MPM  Results of pleurectomy trials Author Location Martini et al Memorial Sloan-Kettering Ca Ctr Achatzy et al Germany Brancatisano et al Australia Soysal et al Turkey Year 1975 1989 1991 1997 # Patients 14 118 45 100 % Morbidity 22 6 16 22 % Mortality Median survival 10 8.5 2.2 1 9 months 16 months Roberts, J Surgical treatment of mesothelioma: pleurectomy CHEST 1999 116:446s-449s Pleuropneumonectomy  Aggressive cytoreductive component of multimodality therapy       EPP, chemo, adjuvant radiotherapy Appropriate for only a minority of MPM patients General exclusion criteria include:  FEV1 <1 L/min  EF <45%  Room air PCO2 >45  Room air PO2 <65 Operative mortality rate approximately 4% Overall morbidity is about 24% Survival rates  Overall 36% and 14% (2 and 5 years, respectively)  Epithelial tumors 52% and 21%  Sarcomatous or Mixed tumors 16% and 0% Conclusions  Survival increased for a select few  Morbidity remains high  No reference to quality of life Grondin, S and Sugarbaker, D  Pleuropneumonectomy in the treatment of malignant pleural mesothelioma CHEST 1999 116:450S-454S Survival After Surgery Overall Survival  120 pts  MPM Butchart Stage I  Good performance status Survival Based on Node Status  EPP with adjuvant chemoradiation therapy  Positive nodes indicate worse prognosis Sugarbaker and Garcia Multimodality therapy for malignant pleural mesothelioma CHEST 1997 112:272-275S Chemotherapy  No single therapy has consistently improved survival by >20%  Phase II study of gemcitabine with cisplatin associated with a 48% response rate without improvement in survival  Phase III study of pemetrexed (antifolate agent) and cisplatin versus cisplatin     Survival 12 v. 9 months Time to progression 6 v. 4 months Significant neutropenia and leukocytopenia  Despite B12 and folate supplementation Most common SEs (nausea, vomiting, fatigue) 150 patients with inoperable MPM 15% response rate 69% had stable disease 69% achieved improvement in symptoms     Mitomycin C, Vinblastine and Cisplatin     71% had decreased pain 62% had decreased cough 50% had decreased dyspnea  Median overall survival 7 months Kindler, H Malignant pleural mesothelioma Curr Treat Options Oncol 2000 1:313-326 Vogelzang, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma J Clin Oncology 003 21:2636-2644 Andreopoulou, et al. The palliative benefits of MVP chemotherapy in patients with malignant mesothelioma Ann Oncol 2004 15:1406-12 Survival With Chemotherapy      Histologically confirmed mesothelioma Good functional status Expected to survive > 2 months No prior chemotherapy “Adequate” organ function # Eligible Patients 37 39 41 41 18 20 35 % Response Rate 26 14 7 17 12 25 9 Median Survival (Mos) 8.1 8.8 7.1 6.7 3.9 9.6 5.0 Treatment Regimens Mitomycin & Cisplatin Doxorubicin & Cisplatin Carboplatin DHAC Trimetrexate Edatrexate Paclitaxel Herndon, et al. Factors predictive of survival among 337 patients with mesothelioma treatedbetween 1984 and 1994 by the cancer and leukemia group b CHEST 13:723-31 Survival Predictors N = 337 Excellent Performance Status Age < 49 12.5 mos Age > 49 Hgb > 14.6 14.5 mos Poor Performance Status WBC < 15.6 Chest Pain Weight Loss WBC > 9.8 Hgb > 11.2 9.6 mos Hgb < 11.2 4.9 mos WBC > 15.6 1.4 mos Herndon, et al. Factors predictive of survival among 337 patients with mesothelioma treated between 1984 and 1994 by the cancer and leukemia group b CHEST 13:723-31 Pemetrexed and Cisplatin Survival Disease Progression Vogelzang, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma J Clin Oncology 003 21:2636-2644 Radiation  No survival benefit to radiation therapy alone  Side effects limit dose  Higher doses radiation tolerated after EPP  Small field dosing effective at decreasing biopsy tract seeding  Effective in palliative care Pistolesi, M and Rusthoven, J. Malignant Pleural Mesothelioma: Update, Current Management, and Newer Therapeutic Strategies CHEST 2004: 126:1318-1329 Radiation Therapy Trials Investigators # of Patient s 3 12 6 23 14 9 Dose Outcome (cGy) 20003000 50005500 >4000 >4000 35005000 6000 Symptomatic improvement 1 asymptomatic x 4 yrs, 2 effusion controlled 4 symptomatic relief 1 symptomatic relief 4 alive at 1-41 mos, 10 dead at 1-37 mos. Median survival 15 mos 2 local control of cancer at 20-40 months 66 symptomatic improvement median survival 5 months University of Iowa Brompton/Royal Marsden Joint Center for Radiotherapy Institute GustaveRoussy Thomas Jefferson Medical Center Peter MacCallum Cancer Institute 111 8-60 Chun et al., http://www.vh.org/adult/provider/radiology/LungTumors/Mesothelioma/Text/MesoRadiation.html Mesothelioma Treatment Trials Study # Pts Age Yrs 57 mean 53 median 62 median <60 69 median 59 mean 57 median F (%) Epithelioid (%) 56 100 68 54 73 79 87 Treatment In-Hospital deaths 3.8 6.2 7.9 9.1 6.9 NA 7.5 Median Survival (months) 19 Unclear 17 35 18 24 17 65% 1yr survival EPP v debulking No statistical significance Sugarbaker 4% mortality 1999 50% morbidity 6% mortality 183 32 61 51 26 28 53 73 33 17 19 7 - EPP/C/R EPP/C/R EPP/R EPP/C EPP/C/R EPP/R EPP/R R Not extensive OR 3.0 non epith 1.7 + margin 2.0 EP nodes I (6) II (10) III (16) Survival 33.8 m I-II 10 m III-IV 90/70-T1 85/36-T2 1/3 yr survival Maggi 2001 Rusch 2001 Aziz 2002 Lee 2002 Ahamad 2003 8% mortality 9% mortality 6% mortality 8.5% mortality Stewart 2004 Treasure and Sedrakyan Pleural mesothelioma: little evidence, still time to do trials Lancet 2004 264:1183-85 Treatment Options: Local Disease  Solitary mesotheliomas  Surgical resection en bloc  Intracavitary mesothelioma  Palliative surgery   Pleurectomy and decortication With/without postoperative radiation   Extrapleural pneumonectomy Palliative radiation  Pleural effusions  Pleurodesis Pistolesi, M and Rusthoven, J. Malignant Pleural Mesothelioma: Update, Current Management, and Newer Therapeutic Strategies CHEST 2004: 126:1318-1329 Treatment Options: Advanced Disease  Symptomatic treatment   Drain effusions Pleurodesis  Palliative surgical resection in select patients  Palliative radiation  Chemotherapy  Permetrexed (antifolate) and cisplatin increases survival by approximately 3 months  Multimodality clinical trials  Intracavitary chemotherapy  Better results seen with intraperitoneal mesothelioma Association of Cancer Online Resources Assessing Quality of Life  Chest pain and dyspnea are the most common symptoms at presentation  Questionnaires frequently used to assess QOL  European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30)  Lung Cancer Module (QLQ-LC13)  Nowak, et al., 2004 validated use of above questionnaires  At time of diagnosis, role function and social function more impaired than previously suspected  Worst rated symptoms       Fatigue Dyspnea Pain Insomnia Appetite loss Cough  Dyspnea scores correlated well with FVC Nowak, A, Stockler, M, Byren, M Assessing quality of life during chemotherapy for pleural mesothelioma: feasibility, validity, and results of using the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire and Lung Cancer Module J Clin Oncol 2004 22:3172-3180 Management  Treatment of advanced disease is largely palliative    Chemotherapy Surgery Radiation      Doxorubicin produces partial response in 15-20% No single agent induces > 20% response Operative mortality pleurectomy/decortication < 2% Mortality with extrapleural pneumonectomy 6-30% Radiation useful to alleviate pain  Duration short Talc pleurodesis effective and inexpensive Thoracoscopic pleurodesis more effective than medical pleurodesis  Pleural sclerosis minimizes recurrent pleural effusions   Prognostic Indicators  Poor prognosis      Thrombocytosis Fever of unknown origin Sarcomatous or mixed histology Age > 65 Poor performance status Epithelial histology Stage I disease Good performance status Absence of chest pain Symptomatic < 6 months prior to diagnosis Absence of weight loss Absence of involvement of visceral pleura  Better prognosis        Summary  Smoking NOT associated with increased risk of developing MPM   HOWEVER, smoking increases risk of developing bronchogenic carcinoma when combined with asbestos exposure! Risk approximately 50x greater  Thorough occupational history helpful at determining pts at risk  ~30% of patients have no known exposure to asbestos  CT-guided biopsy may be more cost-effective than thoracentesis  PET useful in early detection of LN involvement and distant mets  MPM metastasizes earlier than once thought  Pts with negative LNs benefit from aggressive multimodality therapy  Pts with advanced disease benefit from palliative therapy www.lung.ca/diseases/cancer References Benard, et al Metabolic imaging of malignant pleural mesothelioma with fluorodeoxyglucose positron emission tomography CHEST 1998 114:713-722 Center for Disease Control, National Institute for Occupational Safety and Health Community Health Sciences Dept., St. George’s Hospital Medical School Dpalm.med.uth.tmc.edu Emedicine.com Grondin, S and Sugarbaker, D Pleuropneumonectomyin the treatment of malignant pleural mesothelioma CHEST 1999 116:450S-454S Flores, et al Positron emission tomography defines metastatic disease but not locoregional disease in patients with malignant pleural mesothelioma J Thorac Cardiovasc Surg 2003 126:11-15 Herndon, et al. Factors predictive of survival among 337 patients with mesothelioma treated between 1984 and 1994 by the cancer and leukemia group b CHEST 13:723-31 Imaging of Diseases of the Chest. Armstrong. Mosby. Toronto 2000 Imp.ualberta.ca Kindler, H Malignant pleural mesothelioma Curr Treat Options Oncol 2000 1:313-326 Light, Richard. Textbook of Pleural Disease 2003 Arnold Publishers Malignant mesothelioma. www.nci.nih.gov Maskell, et al. Standard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial Lancet 2003 361:1326-31 Mesotheliomacenter.org Nowak, A, Stockler, M, Byren, M Assessing quality of life during chemotherapy for pleural mesothelioma: feasibility, validity, and results of using the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire and Lung Cancer Module J Clin Oncol 2004 22:3172-3180 Pistolesi, M and Rusthoven, J. Malignant Pleural Mesothelioma: Update, Current Management, and Newer Therapeutic Strategies CHEST 2004 126:1318-1329 Roberts, J Surgical treatment of mesothelioma: pleurectomy CHEST 1999 116:446s-449s Ruffie P et al. "Diffuse malignant mesothelioma of the pleura in Ontario and Quebec: a retrospective study of 322 patients." Journal of Clinical Oncology 1989 7(8):1157-68 Schneider, et al Positron emission tomography with F18-fluorodeoxyglucose in the staging and preoperative evaluation of malignant pleural mesothelioma Thorac Cardiovasc Surg 2000 120:128-33 Seattlepi.nwsource.com Treasure, T and Sedrakyan, A Pleural mesothelioma: little evidence, still time to do trials Lancet 2004 364:1183-1185 United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Office of Analysis, Epidemiology, and Health Promotion (OAEHP), Compressed Mortality File (CMF) compiled from CMF 1968-1988, Series 20, No. 2A 2000, CMF 1989-1998, Series 20, No. 2E 2003 and CMF 1999-2001, Series 20, No. 2G 2004 on CDC WONDER On-line Database. Viallat, et al Thoracoscopic talc poudrage pleurodesis for malignant effusions CHEST 1996 110:1387-93 Vogelzang, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma Journal of Clinical Oncology 2003 21:2636-2644 Whitaker, D The cytology of malignant mesothelioma Cytopathology 2000 11:139-151 www.atsdr.cdc.gov/toxprofiles www.kazanlaw.com www.lung.ca/diseases/cancer www.som.tulane.edu/.../ AsbestosMinerals.jpg Kappa  Measure of agreement between two observers Interrater reliability  A descriptor rather than an indicator of statistical significance κ = Observed – Expected agreement 1 – Expected agreement  Excellent agreement Very good agreement Fair agreement Poor agreement No agreement 0.93 – 1.0 0.81 – 0.92 0.41 – 0.60 0.01 – 0.20 ≤ 0.00 Basic & Clinical Biostatistics. 3rd ed. Beth Dawson and Robert Trapp. Behavior Modeling . . . Aiding The War Effort . . . Immediate Release January 22, 1943 The men who sail the ships of the American merchant marine will soon be supplied with free cigarettes for use during long voyages with materials for the war effort, the War Shipping Administration announced today. Through an arrangement with a leading cigarette manufacturer, the WSA has established a program whereby the cigarettes will be distributed free of charge to seamen aboard all vessels of the Victory Fleet. The idea was presented to the WSA by the manufacturer as a contribution to the war effort. Cigarettes will be made available to merchant seamen immediately. Shipments are to be made to representatives of the WSA at various ports and will be marked "For distribution to Seamen of the Merchant Marine." WSA officers in the ports will insure distribution in the proper manner. http://www.usmm.net/cigarette.html

Medical Documentation: Respiratory Single Organ System Exam

2008-11-02T09:18:00.006-06:00

Documentation of the Respiratory Single Organ System Exam

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Single Organ System Exam Respiratory Created by The Lung Doctor Single Organ System Exam Respiratory Comprehensive Level Perform and document ALL elements in the following organ systems Perform and document at least 1 element in each of the following        Constitutional ENT Inspection Neck Respiratory Cardiovascular Gastrointestinal Lymphatic Musculoskeletal Extremities Skin Neurologic Created by The Lung Doctor Single Organ System Exam Respiratory Constitutional Document at least 3 vital signs as follows  Blood Pressure – Sitting OR Standing  Blood Pressure – Lying  Pulse – Rate AND Regularity  Temperature  Height  Weight Note: May be measured and recorded by ancillary staff Created by The Lung Doctor Single Organ System Exam Respiratory Ears, Nose, Mouth, Throat Inspection of nasal mucosa, septum, turbinates Inspection of teeth and gums Examination of oropharynx  Oral mucosa, hard and soft palates, tongue, tonsils, and posterior pharynx Created by The Lung Doctor Single Organ System Exam Respiratory Neck Examination of neck  Masses, overall appearance, symmetry, tracheal position, crepitus Examination of thyroid  Enlargement, tenderness, mass Examination of jugular veins  Distension, a, v or cannon a waves Created by The Lung Doctor Single Organ System Exam Respiratory Respiratory Inspection of chest with notation of symmetry and expansion Assessment of respiratory effort  Intercostal retractions, accessory muscle use, and diaphragmatic movement Percussion of chest  Dullness, flatness, hyperresonance Palpation of chest  Tactile fremitus Auscultation of lungs  Breath sounds, adventitious sounds, rubs Created by The Lung Doctor Single Organ System Exam Respiratory Cardiovascular Auscultation of heart sounds, abnormal sounds and murmurs Examination of peripheral vascular system by observation and palpation  Swelling and varicosities  Pulses, temperature, edema, tenderness Created by The Lung Doctor Single Organ System Exam Respiratory Gastrointestinal (Abdominal) Examination of abdomen with notation of presence or absence of masses or tenderness Examination of liver and spleen Created by The Lung Doctor Single Organ System Exam Respiratory Lymphatic Palpation of lymph nodes  Neck  Groin  Axilla  Other location Note: Exam of at least 2 locations must be documented Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Musculoskeletal Assessment of muscle strength and tone with notation of any atrophy and abnormal movements  Flaccid, cogwheel, spastic Examination of gait and station Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Extremities Inspection and palpation of digits and nails  Clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Skin Inspection and/or palpation of skin and subcutaneous tissue  Rashes, lesions, ulcers Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Neurological/Psychiatric Brief assessment of mental status  Include orientation to person, time and place  Include mood and affect – Anxiety, depression, agitation Created by The Lung Doctor

A concise summary of the medical documentation requirements for the respiratory single organ system exam. The documentation requirements for the history and medical decision making components are similar in all exam types, and can be reviewed in the Demystifying Medical Documentation presentation.

Medical Documentation: Level of Service Requirements

2008-11-01T11:41:00.004-05:00

Documentation of Level of Service of Medical Encounters

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Documentation of Level of Service of Medical Encounters Created by The Lung Doctor for e-Medtools Inpatient Encounters Initial Hospital Encounter Or Observation Requires 3 components within shaded area Subsequent Inpatient Or Follow up Requires 2 components History Examination Complexity of medical decision LEVEL Init Hosp Care Observation D or C D or C SF/L I 99221 99218 C C M II 99222 99219 C C H III 99223 99220 PF PF SF/L I 99231 99261 EPF EPF M II 99232 99262 D D H III 99233 99263 C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Outpatient, Consults (Outpatient, Inpatient) and ER New Office / Consult / ER Requires 3 components within shaded area Established Office Requires 2 components History PF ER: PF EPF ER: EPF D ER: EPF C ER: D C ER: C Examination Complexity of medical decision LEVEL New Pt Outpt Consult Inpt Consult ER PF ER: PF EPF ER: EPF D ER: EPF C ER: D C ER: C SF ER: SF SF ER: L L ER: M M ER: M H ER: H Minimal problem that may not require presence of physician PF PF SF II -212 EPF EPF L III -213 D D M IV -214 C C H V -215 I 99-201 99-241 99-251 99-281 II -202 -242 -252 --282 III -203 -243 -253 -283 IV -204 -244 -254 -284 V -205 -245 -255 -285 I 99211 Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Documenting Time As a Determinant of Level of Service “If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.” Does documentation reveal total time? Time: Face to face in outpatient setting Unit/floor in inpatient setting □Yes □No □Yes □No □Yes □No Does documentation describe the content of counseling or coordinating care Does documentation reveal that more than half the time was counseling or coordinating care? Documentation of Time requires that ALL of the answers to the above questions are YES Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools

A concise summary of the medical documentation required to determine the overall level of service for medical encounters based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the presentation Demystifying Medical Documentation.

Medical Documentation: Medical Decision Making Requirements

2008-11-01T11:39:00.002-05:00

Documentation of Medical Decision Making

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Documentation of Medical Decision Making Created by The Lung Doctor for e-Medtools Elements of Medical Decision Making • Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality Created by The Lung Doctor for e-Medtools Complexity of Medical Decision Making Number of Diagnoses Or Management Options Minimal Limited Multiple Extensive Amount or Complexity of Data to be Reviewed Minimal or None Limited Moderate Extensive Risk of Complications Morbidity or Mortality Minimal Low Moderate High Complexity of Decision Making Straightforward Low Moderate High out of elements must be met 22out of 33elements must be met 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Created by The Lung Doctor for e-Medtools Worksheets Calculating Documentation Levels HGSAdministrators Documentation Worksheet HGSAdministrators Documentation Worksheet CMS Medicare Part CMS Medicare Part BB Adapted from Adapted from Created by The Lung Doctor for e-Medtools History HPI: Status of chronic conditions □ 1-2 □ 3 □1 condition □2 conditions □3 conditions HPI elements □Location □Severity □Timing □Modifying factors □Quality □Duration □Context □Associated signs & symptoms Review of Systems □Constitutional □ENT □GI □Skin, Breast □Endo/Lymph □Eyes □CV □MS □Neuro □Aller/Immun □Resp □Psych □All others negative PFSH □Past History □Family History □Social History Problem Focused □ Brief 1-3 □ Extended 4 or more □ None □ Pertinent to Problem 1 system □ Extended 2-9 Systems □ Complete 10 or more Systems □ None Expanded Problem Focused □ Pertinent 1 Detailed □ Complete 2 or 3 Comprehensive Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Examination Body Areas □Head, Face □Chest, Breasts, Axilla □Abdomen □Neck □Back, Spine □Genitalia, Groin, Buttocks □Each Extremity Organ Systems □Constitutional □ENT □Resp □MS □GI □Skin □GU □Psych □CV □Eyes □Heme/Lymph □Neuro Problem Focused Expanded Problem Focused □ 1 Body Area or System □ Up to 7 Body Areas or Systems □ Up to 7 Body Areas or Systems □ 8 or more Body Areas or Systems Detailed Comprehensive Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Medical Decision Making Reminder: There are 3 components used to determine the complexity of medical decision making • Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality Created by The Lung Doctor for e-Medtools Number of Diagnoses or Treatment Options Complexity of Medical Decision Making A Problem status Self-limited or minor Established problem (to examiner) Stable or improved B Number Max = 2 x C Points = D Result 1 1 2 Established problem (to examiner) Worsening New problem (to examiner) No additional workup planned Max = 1 3 4 New problem (to examiner) Additional workup planned Total Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Amount and/or Complexity of Data Reviewed Complexity of Medical Decision Making Reviewed Data Clinical lab tests reviewed and/or ordered Review and/or order of tests from radiology section of CPT Review and/or order of tests from medicine section of CPT Discussion of test results with performing physician Decision to obtain history from source other than patient Review and summarization of history obtained from source other than patient Independent visualization of image, tracing or specimen (NOT reviewing report) Points Result 1 1 1 1 1 2 2 TOTAL Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Guide to Determining Risk of Complications Complexity of Medical Decision Making Risk Minimal Presenting Problem -1 self-limited or minor problem Dx Procedure Ordered -Venipuncture -X-rays -EKG -EEG -Urinalysis -ECHO -Physiologic tests NOT under stress i.e., PFTs -Noncardiovascular imaging studies + contrast Barium enema -Superficial needle biopsies -Clinical lab tests requiring arterial puncture -Skin biopsies -Physiologic tests under stress Cardiac stress test Cardiopulmonary exercise test -Diagnostic endoscopies with NO risk factors -Deep needle or incisional biopsy -Cardiovascular imaging studies with contrast NO identifiable risk factors Cardiac catheterization -Obtaining body cavity fluid Thoracentesis -Cardiovascular imaging studies + Risk factors -Cardiac electro-physiologic tests -Diagnostic endoscopies + Risk factors -Discography Management Options Selected -Rest -Gargles -Elastic bandages Low -2 or more self-limited or minor problems -1 stable, well- controlled chronic illness -Acute uncomplicated illness or injury -OTC drugs -Minor surgery without identified risk factors -Physical therapy -Occupational therapy -IV fluids without additives Moderate -Mild exacerbation of 1 or more chronic illnesses -2 or more stable, chronic illnesses -Previously undiagnosed NEW problem with uncertain prognosis (i.e., breast lump) -Acute illness with systemic symptoms -Acute complicated injury -Minor surgery WITH identified risk factors -Elective major surgery with NO identified risk factors -Prescription drug management -Therapeutic nuclear medicine -IV fluids with additives -Closed treatment of fracture High -Severe exacerbation or progression of 1 or more chronic illnesses -Acute or chronic illness or injury that threatens life or limb -Abrupt change in neurologic status -Elective surgery + Risk factors -Emergency Major surgery -Parenteral controlled substances -Drug therapy requiring intensive monitoring -Decision to not resuscitate or to de-escalate care due to poor prognosis The highest level in ANY category determines the overall risk The highest level in ANY category determines the overall risk 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Created by The Lung Doctor for e-Medtools Final Determination Complexity of Medical Decision Making A B C Number of diagnoses or treatment options Highest risk ≤1 Minimal Minimal 2 Limited Low 3 Multiple Moderate ≥4 Extensive High Amount and complexity of data reviewed ≤1 Minimal or Low 2 Limited Low Complexity 3 Multiple Moderate Complexity ≥4 Extensive High Complexity Type of decision making Straightforward Circle the appropriate descriptions for Rows A, B, C Circle the appropriate descriptions for Rows A, B, C The Column with or 3 circles determines the final Complexity of Medical Decision Making The Column with 22 or 3 circles determines the final Complexity of Medical Decision Making Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools

A concise summary of the medical documentation requirements for medical decision making based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the presentation Demystifying Medical Documentation.

Medical Documentation: Medical Exam

2008-11-01T11:37:00.003-05:00

Documentation of the Medical Exam

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Documentation of the Medical Exam Created by The Lung Doctor for e-Medtools Recognized Single Organ Systems Cardiovascular Ears, Nose, Mouth, Throat Detailed Detailed Eyes An extended exam of the affected body area An extended exam of the affected body area or organs/organ system and another Genitourinary (Female) or organs/organ system and another symptomatic or related area symptomatic or related area Genitourinary (Male) Hematologic/Lymphatic/Immunologic Musculoskeletal Comprehensive A general multi-system exam Neurologic A complete exam of an organ system and Psychiatric other related body areas or organ systems Respiratory Skin Most levels require a minimum of a Detailed Exam Most levels require a minimum of a Detailed Exam Created by The Lung Doctor for e-Medtools Multi-organ System Exam Detailed ≥3 vital signs BP, sitting or standing BP, supine Pulse, rate and regularity Respirations Temperature Height Weight ≥2 elements* of at least 6 organ systems or body areas examined OR ≥1 element of at least 12 organ systems Comprehensive ≥2 elements* in at least 9 organ systems or body areas *Refer to 1997 Guidelines for Evaluation & Management Services *Refer to 1997 Guidelines for Evaluation & Management Services Created by The Lung Doctor for e-Medtools Single Organ System Exam Detailed Document ≥12 elements* (NOT Eye and Psychiatric exams) Eye and Psych exams document ≥9 elements Comprehensive Document ALL elements* *Refer to 1997 Guidelines for Evaluation & Management Services *Refer to 1997 Guidelines for Evaluation & Management Services Created by The Lung Doctor for e-Medtools Elements of Individual Organ Systems Constitutional Vital signs General appearance of patient Nutrition, Body habitus, Development, Deformities, Grooming Cardiovascular Palpation of heart Auscultation Carotid artery exam Abdominal aorta exam Femoral arteries exam Pedal pulses exam Extremities for edema or varicosities Eyes Inspection of conjunctivae and lids Exam of pupils and irises Ophthalmoscopic exam of optic discs Ears, Nose, Mouth and Throat External inspection of ears and nose Otoscopic exam Assessment of hearing Inspection of nasal mucosa, septum, and turbinates Inspection of lips, teeth and gums Exam of oropharynx Chest (Breasts) Inspection Palpation Gastrointestinal Abdominal exam Liver and spleen exam Hernia presence or absence Anus, perineum, rectum exam Stool for occult blood 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Neck Exam of neck Thyroid Respiratory Assessment of effort Percussion of chest Auscultation Palpation of chest Created by The Lung Doctor for e-Medtools Exam elements, continued Lymphatic Neck Axilla Groin Other Psychiatric Judgment and insight Orientation to person, time, place Memory, recent and remote Mood and affect Musculoskeletal Gait and station Inspection, palpation digits and nails Exam of bones, joints, muscles AND 1 or more Inspection or palpation Range of motion and presence/absence of pain Stability Muscle strength and tone Genitourinary Male Scrotal contents Penis Digital rectal exam of prostate gland Female External genitalia Urethra Bladder exam Cervix Uterus Adnexa/parametria 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Skin Inspection Palpation Neurologic Cranial nerves Deep tendon reflexes Sensation Created by The Lung Doctor for e-Medtools

A concise summary of the medical documentation requirements for the medical exam based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the presentation Demystifying Medical Documentation.

Medical Documentation: Medical History

2008-11-01T10:51:00.003-05:00

Documentation of the Medical History

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A concise summary of the medical documentation requirements for the medical history based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the presentation Demystifying Medical Documentation.

E and M Documentation and Coding Tool: Aqua

2008-10-29T10:27:00.007-05:00

This version uses a different color theme, making it easier to view and use the worksheet in a printed format.
This form is also available as a fillable PDF.

E and M Documentation and Coding Worksheet in Aqua and Gray - Upload a Document to Scribd

Patient Facility DOB Encounter Date Chief Complaint is required in ALL documentation Criteria Status of 1-2 Chronic Conditions OR Status of 1-2 Chronic Conditions OR MRN History Components HPI (History of Present Illness) Status of 3 chronic problems 1 2 3 Status of 3 Chronic Conditions OR Status of 3 Chronic Conditions OR Choose Elements Quality Location Duration Severity Timing Context Modifying factors Associated Signs/Symptoms ROS (Review of Systems) Constitutional ENT Eyes CV Skin/Breasts Resp Endo GI GU Heme/Lymph MS Neuro Psych Allergy/Immunology PFSH (Past Medical, Family Social History) Past History (Illnesses, Surgeries, Injuries) Past Family (Diseases, Hereditary illnesses) Social (Review of current, past activities) *Complete PFSH 3 history areas for ALL NEW Patients 2 history areas for ALL Follow Up/Established Visits OR Patients seen in Emergency Department OR Brief 1-3 Elements Brief 1-3 Elements Pertinent to Problem Extended ≥4 Elements Extended (Pertinent to problem and other related systems) 2-9 Total Extended ≥4 Elements Complete (Pertinent and all related systems) NA 1 NA NA 10 Total Pertinent *Complete 1 Area PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED DETAILED 2-3 Areas COMPREHENSIVE ALL Criteria for selected level MUST be MET or EXCEEDED Examination Exam description Limited to affected body area or organ system Affected body area/organ system and other symptomatic or related organ systems Extended exam of affected body areas/organ systems and other symptomatic or related organ systems General Multi-System Complete Single Organ System 1995 Guideline 1997 Guideline Type of Exam 1 Body Area or Organ System 1-5 Bulleted Items PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED 6-11 or more 2-7 12-17 or more for 2 or more systems 18 or more for 9 or more systems Refer to Guideline 2-7 ≥8 Not Defined DETAILED COMPREHENSIVE See 1995 or 1997 Guidelines for Evaluation & Management Services for specific requirements 1 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates Patient Facility DOB Encounter Date MRN A. Complexity of Medical Decision Making Number of Diagnoses or Treatment Options Problem (Status) Self-limited or minor (stable, improved or worsening) Est. problem (to examiner) stable, improved Est. problem (to examiner) worsening New problem (to examiner) no additional workup planned New problem (to examiner) additional workup planned MDM = Medical Decision Making (Number x Number Max = 2 Max = 1 Check corresponding box below on Line A Final Result for Complexity of MDM Points Points 1 1 2 3 4 Total = Result) Result B. Amount and/or Complexity of Data Reviewed Reviewed Data Review and/or Order of lab tests Review and/or Order of tests in the radiology section of CPT Review and/or Order of tests in the medicine section of CPT Discussion of test results with performing physician Decision to obtain old records and/or obtain history from someone other than the patient Review and summarization of old records and/or obtaining history from someone other than the patient and/or discussion of case with another health care provider Independent visualization of image, specimen or tracing (NOT simply review of report) Points 1 1 1 1 1 2 2 Check corresponding box below on Line B of Final Result for Complexity of MDM MDM = Medical Decision Making TOTAL C. Risk of Complications, Morbidity and/or Mortality Risk Min Choose highest risk level and select corresponding risk level on line B in Final Result for Complexity Presenting problems Dx procedures ordered Management options 1 minor or self-limited Venipuncture, CXR, EKG, EEG Rest, elastic bandages 2 or more minor 1 stable chronic problem Acute uncomp illness/injury Mild exac  1 chron prob Physiol tests NOT under stress Non CV imaging with contrast Superficial needle biopsies Physiologic tests under stress Dx endoscopies NO risk factors Deep needle or incisional bx CV imaging + contrast Obtain fluid from body cavity CV imaging + contrast, risk factors Card electrophysiologic studies Dx endoscopies + risk factors Discography OTC drugs, PT, OT IV fluids without additives Minor surgery NO risk factors Minor surgery + risk factors Mod Elective major surgery 2 stable chron prob Prescription drug therapy Acute illness + systemic Sx Therapeutic nuclear medicine Acute complicated injury IV fluids + additives Elective maj surg + risk factors High Sev exac, 1 chron prob Emergency major surgery Acute or chronic illness Parenteral controlled sub posing threat to life/limb Rx requiring intense monitoring Abrupt change neuro status DNR or de-escalation of care Check corresponding box below on Line C of Final Result for Complexity of MDM Low Final Result for Complexity of Medical Decision Making The column with 2 or 3 circles determines overall complexity of Medical Decision Making A B C Number Tx Options See TOTAL above in Box A Amount of Data See TOTAL above in Box B Highest Risk See Box C Above 1 or less Minimal 1 or less Minimal Minimal 2 Limited 2 Limited Low 3 Multiple 3 Multiple Moderate 4 Extensive 4 Extensive High Decision Making Level SF Low Moderate High 2 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates Patient Facility DOB Encounter Date MRN OVERALL OUTPATIENT ENCOUNTER LEVEL New Office / Consult / ER History Exam Complexity Medical Decision LEVEL Requires 3 components within shaded area PF EPF D C ER: PF ER: EPF ER: EPF ER: D PF EPF D C ER: P ER: EPF ER: EPF ER: D SF SF L M ER: SF ER: L ER: M ER: M C ER: C C ER: C H ER: H Established Office Requires 2 components within shaded area Minimal PF EPF D problem that may PF EPF D not require SF L M presence of physician C C H I II III IV V I II III IV V PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity OVERALL INPATIENT ENCOUNTER LEVEL History Exam Complexity Medical Decision LEVEL Initial Hosp Encounter or Observation D or C C C D or C C C SF / L M H I II III Subsequent Inpatient or Follow Up PF EPF D PF EPF D SF / L M H I II III PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity Time If ALL responses regarding time are “Yes”, billing may be based on Time “If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.” Does documentation reveal total time? Must be face-to-face (Outpatient or Inpatient) Does documentation discuss the content of counseling or coordination of care? Does documentation reveal that more than half the time was spent on counseling or coordination of care? □Yes □No □Yes □No □Yes □No References 1997 Guidelines for Evaluation and Management Services http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf HGSAdministrators Documentation Worksheet www.aace.com/advocacy/pdf/AUDITTOOLMEDICARE.pdf Evaluation and Management Coding and Documentation Reference Guide Trailblazer Health Enterprises, LLC 3 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates

E and M Documentation Tool

2008-10-27T20:22:00.006-05:00

E and M Documentation Tool

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Patient Facility DOB Encounter Date Chief Complaint is required in ALL documentation Criteria Status of 1-2 Chronic Conditions OR Brief 1-3 Elements Status of 1-2 Chronic Conditions OR Brief 1-3 Elements Pertinent to Problem MRN History Components HPI (History of Present Illness) Status of 3 chronic problems 1 2 3 Status of 3 Chronic Conditions Status of 3 Chronic Conditions OR Choose Elements Quality Location Duration Severity Timing Context Modifying factors Associated Signs/Symptoms ROS (Review of Systems) Constitutional ENT Eyes CV Skin/Breasts Resp Endo GI GU Heme/Lymph MS Neuro Psych Allergy/Immunology PFSH (Past Medical, Family Social History) Past History (Illnesses, Surgeries, Injuries) Past Family (Diseases, Hereditary illnesses) Social (Review of current, past activities) *Complete PFSH 3 history areas for ALL NEW Patients 2 history areas for ALL Follow Up/Established Visits OR Patients seen in Emergency Department OR Extended ≥4 Elements Extended (Pertinent to problem and other related systems) 2-9 Total OR Extended ≥4 Elements Complete (Pertinent and all related systems) NA 1 NA NA 10 Total Pertinent *Complete 1 Area PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED DETAILED 2-3 Areas COMPREHENSIVE ALL Criteria for selected level MUST be MET or EXCEEDED Examination Exam description Limited to affected body area or organ system Affected body area/organ system and other symptomatic or related organ systems Extended exam of affected body areas/organ systems and other symptomatic or related organ systems General Multi-System Complete Single Organ System 1995 Guideline 1997 Guideline Type of Exam 1 Body Area or Organ System 1-5 Bulleted Items PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED 6-11 or more 2-7 12-17 or more for 2 or more systems 18 or more for 9 or more systems Refer to Guideline 2-7 ≥8 Not Defined DETAILED COMPREHENSIVE See 1995 or 1997 Guidelines for Evaluation & Management Services for specific requirements 1 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates Patient Facility DOB Encounter Date MRN A. Complexity of Medical Decision Making Number of Diagnoses or Treatment Options Problem (Status) Self-limited or minor (stable, improved or worsening) Est. problem (to examiner) stable, improved Est. problem (to examiner) worsening New problem (to examiner) no additional workup planned New problem (to examiner) additional workup planned Number Number Max = 2 x Max = 1 Circle corresponding answer on Line A of Final Result for Complexity Points = Points 1 1 2 3 4 Total Result Result B. Amount and/or Complexity of Data Reviewed Reviewed Data Review and/or Order of lab tests Review and/or Order of tests in the radiology section of CPT Review and/or Order of tests in the medicine section of CPT Discussion of test results with performing physician Decision to obtain old records and/or obtain history from someone other than the patient Review and summarization of old records and/or obtaining history from someone other than the patient and/or discussion of case with another health care provider Independent visualization of image, specimen or tracing (NOT simply review of report) Points 1 1 1 1 1 2 2 Circle corresponding answer Line B of Final Result for Complexity TOTAL C. Risk of Complications, Morbidity and/or Mortality Choose highest risk level and select corresponding risk level on line C in Final Result for Complexity Risk Min Low Mod Presenting problems 1 minor or self-limited 2 or more minor 1 stable chronic problem Acute uncomp illness/injury Mild exac  1 chron prob Dx procedures ordered Venipuncture, CXR, EKG, EEG Physiol tests NOT under stress Non CV imaging with contrast Superficial needle biopsies Physiologic tests under stress Dx endoscopies NO risk factors Deep needle or incisional bx CV imaging + contrast Obtain fluid from body cavity CV imaging + contrast, risk factors Card electrophysiologic studies Dx endoscopies + risk factors Discography Management options Rest, elastic bandages OTC drugs, PT, OT IV fluids without additives Minor surgery NO risk factors Minor surgery + risk factors Elective major surgery Prescription drug therapy Therapeutic nuclear medicine IV fluids + additives Elective maj surg + risk factors Emergency major surgery Parenteral controlled sub Rx requiring intense monitoring DNR or de-escalation of care 2 stable chron prob Acute illness + systemic Sx Acute complicated injury High Sev exac, 1 chron prob Acute or chronic illness posing threat to life/limb Abrupt change neuro status Final Result for Complexity of Medical Decision Making The column with 2 or 3 circles determines overall complexity of Medical Decision Making A B C Number Tx Options Amount of Data Highest Risk Decision Making Level 1 or less Minimal 1 or less Minimal Minimal 2 Limited 2 Limited Low 3 Multiple 3 Multiple Moderate 4 Extensive 4 Extensive High SF 2 Low Moderate High FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates Patient Facility DOB Encounter Date MRN OVERALL OUTPATIENT ENCOUNTER LEVEL New Office / Consult / ER History Exam Complexity Medical Decision LEVEL Requires 3 components within shaded area PF EPF D C ER: PF ER: EPF ER: EPF ER: D PF EPF D C ER: P ER: EPF ER: EPF ER: D SF SF L M ER: SF ER: L ER: M ER: M C ER: C C ER: C H ER: H Established Office Requires 2 components within shaded area Minimal PF EPF D problem that may PF EPF D not require SF L M presence of physician C C H I II III IV V I II III IV V PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity OVERALL INPATIENT ENCOUNTER LEVEL History Exam Complexity Medical Decision LEVEL Initial Hosp Encounter or Observation D or C C C D or C C C SF / L M H I II III Subsequent Inpatient or Follow Up PF EPF D PF EPF D SF / L M H I II III PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity Time If ALL responses regarding time are “Yes”, billing may be based on Time “If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.” Does documentation reveal total time? Must be face-to-face (Outpatient or Inpatient) Does documentation discuss the content of counseling or coordination of care? Does documentation reveal that more than half the time was spent on counseling or coordination of care? Yes Yes Yes No No No References 1997 Guidelines for Evaluation and Management Services http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf HGSAdministrators Documentation Worksheet www.aace.com/advocacy/pdf/AUDITTOOLMEDICARE.pdf Evaluation and Management Coding and Documentation Reference Guide Trailblazer Health Enterprises, LLC 3 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates

Demystifying Medical Documentation

2008-10-26T12:48:00.002-05:00

Demystifying Medical Documentation - Upload a Document to Scribd

Medical Templates Demystifying Medical Documentation Created by The Lung Doctor for e-Medtools A Quick Review of Medical Documentation Requirements Created by The Lung Doctor for e-Medtools Patient Encounters The Centers for Medicare and Medicaid Services (CMS) has published definitions and documentation guidelines for the key components of a medical encounter note, using CPT codes. Created by The Lung Doctor for e-Medtools Key Components of Documentation History Exam Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time Created by The Lung Doctor for e-Medtools Key components in selecting the level of E/M services 1997 Guidelines for Evaluation & Management Services 1997 Guidelines for Evaluation & Management Services http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf The History Created by The Lung Doctor for e-Medtools History Components and Levels HPI Brief Brief Extended Extended ROS N/A Problem pertinent Extended Complete PFSH N/A N/A Pertinent Complete Type of History Problem Focused Expanded Problem Focused Detailed Comprehensive New patient evaluations MUST have at least a Detailed History Created by The Lung Doctor for e-Medtools History of Present Illness EVERY encounter MUST contain a Chief Complaint! Preferentially stated in patients’ words Elements of HPI Location Brief Brief Quality Contains 1-3 elements listed Contains 1-3 elements listed Severity Extended Duration Extended Contains ≥ 4 elements Timing Contains ≥ 4 elements OR discusses 3 chronic or inactive conditions OR discusses 3 chronic or inactive conditions Context Modifying factors Associated Signs and Symptoms Created by The Lung Doctor for e-Medtools Review of Systems Constitutional Symptoms Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Musculoskeletal Integumentary (Skin, Breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergy/Immunologic Problem Pertinent Problem Pertinent Documents responses to the system Documents responses to the system directly related to the presenting directly related to the presenting problem problem Extended Extended Documents positive and negative Documents positive and negative responses to 2-9 systems related to responses to 2-9 systems related to the problem the problem Complete Complete Documents all positive and negative Documents all positive and negative responses to systems related to the responses to systems related to the presenting problem AND all other presenting problem AND all other systems (10 or more total) systems (10 or more total) Created by The Lung Doctor for e-Medtools Past, Family and Social History Past Medical History Illnesses, Operations, Injuries and Treatments Family Medical History Include heritable diseases and those that place the patient at increased risk Social History An age appropriate review of past and current activities Pertinent Pertinent Document at least item from ANY of the areas Document at least 11item from ANY of the 33areas must be directly related to the problems identified in the HPI ItItmust be directly related to the problems identified in the HPI Complete All initial inpatient services require a Complete PFSH Document at least 1 item from EACH of the 3 areas Created by The Lung Doctor for e-Medtools The Exam Created by The Lung Doctor for e-Medtools Recognized Single Organ Systems Cardiovascular Ears, Nose, Mouth, Throat Detailed Detailed Eyes An extended exam of the affected body area An extended exam of the affected body area or organs/organ system and another Genitourinary (Female) or organs/organ system and another symptomatic or related area symptomatic or related area Genitourinary (Male) Hematologic/Lymphatic/Immunologic Musculoskeletal Comprehensive A general multi-system exam Neurologic A complete exam of an organ system and Psychiatric other related body areas or organ systems Respiratory Skin Most levels require a minimum of a Detailed Exam Most levels require a minimum of a Detailed Exam Created by The Lung Doctor for e-Medtools Multi-organ System Exam Detailed ≥3 vital signs BP, sitting or standing BP, supine Pulse, rate and regularity Respirations Temperature Height Weight ≥2 elements* of at least 6 organ systems or body areas examined OR ≥1 element of at least 12 organ systems Comprehensive ≥2 elements* in at least 9 organ systems or body areas *Refer to 1997 Guidelines for Evaluation & Management Services *Refer to 1997 Guidelines for Evaluation & Management Services Created by The Lung Doctor for e-Medtools Single Organ System Exam Detailed Document ≥12 elements* (NOT Eye and Psychiatric exams) Eye and Psych exams document ≥9 elements Comprehensive Document ALL elements* *Refer to 1997 Guidelines for Evaluation & Management Services *Refer to 1997 Guidelines for Evaluation & Management Services Created by The Lung Doctor for e-Medtools Elements of Individual Organ Systems Constitutional Vital signs General appearance of patient Nutrition, Body habitus, Development, Deformities, Grooming Cardiovascular Palpation of heart Auscultation Carotid artery exam Abdominal aorta exam Femoral arteries exam Pedal pulses exam Extremities for edema or varicosities Eyes Inspection of conjunctivae and lids Exam of pupils and irises Ophthalmoscopic exam of optic discs Ears, Nose, Mouth and Throat External inspection of ears and nose Otoscopic exam Assessment of hearing Inspection of nasal mucosa, septum, and turbinates Inspection of lips, teeth and gums Exam of oropharynx Chest (Breasts) Inspection Palpation Gastrointestinal Abdominal exam Liver and spleen exam Hernia presence or absence Anus, perineum, rectum exam Stool for occult blood 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Neck Exam of neck Thyroid Respiratory Assessment of effort Percussion of chest Auscultation Palpation of chest Created by The Lung Doctor for e-Medtools Exam elements, continued Lymphatic Neck Axilla Groin Other Psychiatric Judgment and insight Orientation to person, time, place Memory, recent and remote Mood and affect Musculoskeletal Gait and station Inspection, palpation digits and nails Exam of bones, joints, muscles AND 1 or more Inspection or palpation Range of motion and presence/absence of pain Stability Muscle strength and tone Genitourinary Male Scrotal contents Penis Digital rectal exam of prostate gland Female External genitalia Urethra Bladder exam Cervix Uterus Adnexa/parametria 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Skin Inspection Palpation Neurologic Cranial nerves Deep tendon reflexes Sensation Created by The Lung Doctor for e-Medtools Medical Decision Making Created by The Lung Doctor for e-Medtools Elements of Medical Decision Making • Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality Created by The Lung Doctor for e-Medtools Complexity of Medical Decision Making Number of Diagnoses Or Management Options Minimal Limited Multiple Extensive Amount or Complexity of Data to be Reviewed Minimal or None Limited Moderate Extensive Risk of Complications Morbidity or Mortality Minimal Low Moderate High Complexity of Decision Making Straightforward Low Moderate High out of elements must be met 22out of 33elements must be met 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Created by The Lung Doctor for e-Medtools Worksheets Calculating Documentation Levels HGSAdministrators Documentation Worksheet HGSAdministrators Documentation Worksheet CMS Medicare Part CMS Medicare Part BB Adapted from Adapted from Created by The Lung Doctor for e-Medtools History HPI: Status of chronic conditions □ 1-2 □ 3 □1 condition □2 conditions □3 conditions HPI elements □Location □Severity □Timing □Modifying factors □Quality □Duration □Context □Associated signs & symptoms Review of Systems □Constitutional □ENT □GI □Skin, Breast □Endo/Lymph □Eyes □CV □MS □Neuro □Aller/Immun □Resp □Psych □All others negative PFSH □Past History □Family History □Social History Problem Focused □ Brief 1-3 □ Extended 4 or more □ None □ Pertinent to Problem 1 system □ Extended 2-9 Systems □ Complete 10 or more Systems □ None Expanded Problem Focused □ Pertinent 1 Detailed □ Complete 2 or 3 Comprehensive Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Examination Body Areas □Head, Face □Chest, Breasts, Axilla □Abdomen □Neck □Back, Spine □Genitalia, Groin, Buttocks □Each Extremity Organ Systems □Constitutional □ENT □Resp □MS □GI □Skin □GU □Psych □CV □Eyes □Heme/Lymph □Neuro Problem Focused Expanded Problem Focused □ 1 Body Area or System □ Up to 7 Body Areas or Systems □ Up to 7 Body Areas or Systems □ 8 or more Body Areas or Systems Detailed Comprehensive Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Medical Decision Making Reminder: There are 3 components used to determine the complexity of medical decision making • Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality Created by The Lung Doctor for e-Medtools Number of Diagnoses or Treatment Options Complexity of Medical Decision Making A Problem status Self-limited or minor Established problem (to examiner) Stable or improved B Number Max = 2 x C Points = D Result 1 1 2 Established problem (to examiner) Worsening New problem (to examiner) No additional workup planned Max = 1 3 4 New problem (to examiner) Additional workup planned Total Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Amount and/or Complexity of Data Reviewed Complexity of Medical Decision Making Reviewed Data Clinical lab tests reviewed and/or ordered Review and/or order of tests from radiology section of CPT Review and/or order of tests from medicine section of CPT Discussion of test results with performing physician Decision to obtain history from source other than patient Review and summarization of history obtained from source other than patient Independent visualization of image, tracing or specimen (NOT reviewing report) Points Result 1 1 1 1 1 2 2 TOTAL Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Guide to Determining Risk of Complications Complexity of Medical Decision Making Risk Minimal Presenting Problem -1 self-limited or minor problem Dx Procedure Ordered -Venipuncture -X-rays -EKG -EEG -Urinalysis -ECHO -Physiologic tests NOT under stress i.e., PFTs -Noncardiovascular imaging studies + contrast Barium enema -Superficial needle biopsies -Clinical lab tests requiring arterial puncture -Skin biopsies -Physiologic tests under stress Cardiac stress test Cardiopulmonary exercise test -Diagnostic endoscopies with NO risk factors -Deep needle or incisional biopsy -Cardiovascular imaging studies with contrast NO identifiable risk factors Cardiac catheterization -Obtaining body cavity fluid Thoracentesis -Cardiovascular imaging studies + Risk factors -Cardiac electro-physiologic tests -Diagnostic endoscopies + Risk factors -Discography Management Options Selected -Rest -Gargles -Elastic bandages Low -2 or more self-limited or minor problems -1 stable, well- controlled chronic illness -Acute uncomplicated illness or injury -OTC drugs -Minor surgery without identified risk factors -Physical therapy -Occupational therapy -IV fluids without additives Moderate -Mild exacerbation of 1 or more chronic illnesses -2 or more stable, chronic illnesses -Previously undiagnosed NEW problem with uncertain prognosis (i.e., breast lump) -Acute illness with systemic symptoms -Acute complicated injury -Minor surgery WITH identified risk factors -Elective major surgery with NO identified risk factors -Prescription drug management -Therapeutic nuclear medicine -IV fluids with additives -Closed treatment of fracture High -Severe exacerbation or progression of 1 or more chronic illnesses -Acute or chronic illness or injury that threatens life or limb -Abrupt change in neurologic status -Elective surgery + Risk factors -Emergency Major surgery -Parenteral controlled substances -Drug therapy requiring intensive monitoring -Decision to not resuscitate or to de-escalate care due to poor prognosis The highest level in ANY category determines the overall risk The highest level in ANY category determines the overall risk 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Created by The Lung Doctor for e-Medtools Final Determination Complexity of Medical Decision Making A B C Number of diagnoses or treatment options Highest risk ≤1 Minimal Minimal 2 Limited Low 3 Multiple Moderate ≥4 Extensive High Amount and complexity of data reviewed ≤1 Minimal or Low 2 Limited Low Complexity 3 Multiple Moderate Complexity ≥4 Extensive High Complexity Type of decision making Straightforward Circle the appropriate descriptions for Rows A, B, C Circle the appropriate descriptions for Rows A, B, C The Column with or 3 circles determines the final Complexity of Medical Decision Making The Column with 22 or 3 circles determines the final Complexity of Medical Decision Making Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Determining Overall Service Levels Created by The Lung Doctor for e-Medtools Inpatient Encounters Initial Hospital Encounter Or Observation Requires 3 components within shaded area Subsequent Inpatient Or Follow up Requires 2 components History Examination Complexity of medical decision LEVEL Init Hosp Care Observation D or C D or C SF/L I 99221 99218 C C M II 99222 99219 C C H III 99223 99220 PF PF SF/L I 99231 99261 EPF EPF M II 99232 99262 D D H III 99233 99263 C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Outpatient, Consults (Outpatient, Inpatient) and ER New Office / Consult / ER Requires 3 components within shaded area Established Office Requires 2 components History PF ER: PF EPF ER: EPF D ER: EPF C ER: D C ER: C Examination Complexity of medical decision LEVEL New Pt Outpt Consult Inpt Consult ER PF ER: PF EPF ER: EPF D ER: EPF C ER: D C ER: C SF ER: SF SF ER: L L ER: M M ER: M H ER: H Minimal problem that may not require presence of physician PF PF SF II -212 EPF EPF L III -213 D D M IV -214 C C H V -215 I 99-201 99-241 99-251 99-281 II -202 -242 -252 --282 III -203 -243 -253 -283 IV -204 -244 -254 -284 V -205 -245 -255 -285 I 99211 Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Documenting Time As a Determinant of Level of Service “If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.” Does documentation reveal total time? Time: Face to face in outpatient setting Unit/floor in inpatient setting □Yes □No □Yes □No □Yes □No Does documentation describe the content of counseling or coordinating care Does documentation reveal that more than half the time was counseling or coordinating care? Documentation of Time requires that ALL of the answers to the above questions are YES Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Summary Examples Documentation Requirements Created by The Lung Doctor for e-Medtools Initial Hospital Care Must meet ALL criteria 99223 Comprehensive History and Exam High complexity Medical decision making 99222 Comprehensive History and Exam Moderate complexity Medical decision making 99221 Detailed OR Comprehensive History and Exam Straightforward or Low Complexity Medical decision making Created by The Lung Doctor for e-Medtools Initial Inpatient Consultation Must meet ALL criteria 99255 Comprehensive History AND Exam High complexity medical decision making 99254 Comprehensive History AND Exam Moderate complexity medical decision making 99253 Detailed History AND Exam Low complexity medical decision making Created by The Lung Doctor for e-Medtools New Outpatient Encounter Not a Consult Must meet ALL criteria 99205 Comprehensive History and Exam High complexity medical decision making 99204 Comprehensive History and Exam Moderate complexity medical decision making 99203 Detailed History and Exam Low complexity medical decision making Created by The Lung Doctor for e-Medtools New Outpatient Consult Must meet all criteria 99245 Comprehensive History Comprehensive Exam High complexity medical decision making 99244 Comprehensive History Comprehensive Exam Moderate complexity medical decision making 99243 Detailed History Detailed Exam Low complexity medical decision making Created by The Lung Doctor for e-Medtools Established Outpatient Encounter Must meet 2 out of 3 criteria 99215 Comprehensive History Comprehensive Exam High complexity medical decision making 99214 Detailed History Detailed Exam Moderate complexity medical decision making 99213 Expanded Problem Focused History Expanded Problem Focused Exam Low complexity medical decision making Created by The Lung Doctor for e-Medtools We hope you found this presentation helpful! Remember to thank all the patient and knowledgeable billing and coding specialists who make themselves available to answer your questions in more detail! Created by The Lung Doctor for e-Medtools

Hypersensitivity pneumonitis

2008-10-09T16:24:00.000-05:00

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Hypersensitivity Pneumonitis Extrinsic Allergic Alveolitis Martha Burk MD, MS Definition “…a group of immunologically mediated lung diseases in which the repeated inhalation of certain finely dispersed antigens of a wide variety, mainly including organic particles or low molecular weight chemicals, provokes a hypersensitivity reaction with granulomatous inflammation in the distal bronchioles and alveoli of susceptible subjects” Bourke et al Eur Respir J 2001 Epidemiology  First recognized in grain workers in 1713  Prevalence difficult to assess  Not  caused by a single etiologic agent  A complex syndrome varying in Intensity  Clinical presentation  Lack of agreement on diagnostic criteria Causative Antigens The Simple List  Bacteria  Fungi  Animal proteins  Insect proteins  Amoebae  Chemicals  Medications  Soybean hulls Causative Agent Source Thermophilic actinomycetes Aspergillus Aureobasidium sp Alternaria sp Candida albicans Mixed ameba, fungi, bacteria Moldy hay, plant materials, compost Animal bedding Ubiquitous Contaminated water Wood, wood pulp Saxophone mouthpiece Cold mist and other humidifiers, air conditioners Metal working fluids Paints, plastics Plastics Disease Farmer’s Lung Dog house disease Sauna-taker’s disease Wood worker’s lung Sax lung Nylon plant Office worker’s Air conditioner’s lung Ventilation pneumonitis Machine operator’s lung Paint refinisher’s lung Chemical worker’s lung Plastic worker’s lung Epoxy worker’s lung Hard metal lung disease Berylliosis Patel et al J Allergy Clin Immunol 2001 Bacteria, fungi Isocyanates Anhydrides Cobalt Berylliosis Worksite-related Agents Organic Antigens Farmer’s lung Antigen Micropolyspora faeni Aspergillus species Streptomyces albus Sacharopolyspora rectivirgula Malt worker’s lung Wood worker’s lung Aspergillus species Penicillium chrysogenum Alternaria species Merulius lacrymans Saccharomonospora viridis Cryptostroma corticale Aureobasidium pullulans Wood dust Cheese worker’s lung Sugar cane worker’s lung (Bagassosis) Detergent worker’s lung Cork worker’s lung Coffee worker’s lung Cotton worker’s lung (Bysinnosis) Wheat worker’s lung Metal worker’s lung Penicillium casei Thermoactinomyces vulgaris Bacillus subtilis Penicillium frequentens Coffee bean dust Bract of cotton flower Wheat weevil Rapid growing mycobacteria www.lungcancerfrontiers.com Inorganic Antigens Associated with HP Paints, resins, plastics Insulation, polyurethane Vineyard sprayer’s lung (fungicide) Pesticide/insecticide Non-microbial Diisocyanates Trimellitic anhydride Copper sulfate Pyrethrum Home or Work-related Agents Humidifier lung Organic Antigens Microbial Acanthamoebae castellani Acanthamoebae polyphaga Naegleria gruberi Thermoactinomyces candidus Bird breeder’s lung (budgies, pigeons) Rodent handler’s lung Hot tub/spa lung Bird droppings Urinary antigens, serum, pelts Mycobacterium avium complex Inorganic Antigens Associated with HP Polyurethane foam insulation Non-microbial Diisocyanates How much antigen are we talking about? Airborne Fungi In Industrial Environments  Study of six industrial facilities  Poultry house  Swinery  Feed preparing and storing house at swinery  Grain Mill  Wooden panel factory  Organic waste recycling facility  Samples collected by multiple methods Lugauskas et al Ann Agric Environ Med 2004  Grain Mill  49 species of 20 fungal genera isolated  Penicillium, Aspergillus, Mucor, Alternaria, Cladosporium, Rhizopus and others  Poultry House  31 species of 13 fungal genera  Aspergillus, Penicillium, Rhizopus, Trichophyton  Swinery  33 species from 15 fungal genera  Aspergillus, Penicillium, Cladosporium, Zygomycetes  Food processing and storing house  35 fungal species from 18 genera  Aspergillus, Zygomycetes, Staphylotrichum  Wood panel factory  21 fungal species from 10 genera  Paecilomyces, Rhizopus*  Organic waste recycling facility  40 fungal species from 21 genera  Penicillium, Aspergillus, Cladosporium, Geotrichum Rhizopus cause of ODTS among wood trimmers Inciting antigens are ubiquitous! So why doesn’t everyone exposed to these environments develop hypersensitivity pneumonitis? Antigen Qualities  Size  1-5 microns, usually <3 microns  Inhaled into distal bronchial tree and alveoli  Induce an IgG response  IgE sometimes formed as well  Many are capable of stimulating the complementary cascade  Delayed cellular response Environmental Factors  Antigen concentration  Duration of exposure  Frequency/intermittency of exposure  Particle size  Antigen solubility  Use of airway protection  Variability in work practice Hypersensitivity pneumonitis: current concepts Eur Respir J 2001 18:81s-92s Genetic Susceptibility  Approximately 5-15% of exposed individuals develop disease  ~4% budgerigar’s fanciers  ~8% pigeon breeders  ~4% farmers  Males affected > females  Familial forms of HP documented No confirmed genetic factors  May represent undetected common exposures   Ethnicity may matter  Pigeon fancier’s disease worse in Mexican Americans compared with Caucasian Americans  Higher prevalence of HLA-DR7 in Mexican Americans  HLA-DPB1 associated with more severe disease in beryllium exposure Hypersensitivity pneumonitis: current concepts Eur Respir J 2001 18:81s-92s Additional Factors  Occurs more frequently in nonsmokers  Onset may be triggered by  Non-specific  Infections  lung inflammation Mycoplasma – Case studies of HP development after Mycoplasma infection  Influenza A common in lower airways of patients presenting with acute HP Inhibitory Effect of Nicotine  Fewer inflammatory diseases in smokers  Sarcoidosis  Ulcerative colitis  Radiation pneumonitis  In vivo and in vitro experimental HP in rats  Nicotine associated with dose-dependent decreases in   Macrophage, lymphocytes and neutrophils IFN gamma, TNF  Smokers develop fewer antibodies when exposed to antigens     Yet, if they do develop HP More insidious More chronic Worse prognosis Blanchet et al Am J Resp Crit Care Med 2004 Occupational Respiratory Disease Surveillance Sex Yr No. of Deaths Under-lying Cause (%) M 31 28 14 31 28 24 35 25 31 36 283 F 10 8 4 15 8 13 16 13 7 21 115 W 38 34 17 44 36 32 49 38 37 56 381 Race B 1 1 1 5 2 1 1 12 O 2 2 1 5 1524 2 2 2534 1 1 1 1 3 3 10 3544 1 1 2 1 3 1 2 11 Age Group (yrs) 4554 3 2 2 4 2 6 5 2 2 9 37 5564 8 4 2 7 5 4 7 6 3 5 51 6574 11 11 3 14 8 7 11 8 10 11 94 7584 15 11 7 14 12 14 16 14 17 19 139 85 + 2 5 1 5 9 5 6 7 6 8 54 Median Age (yrs) 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 TOTAL 41 36 18 46 36 37 51 38 38 57 398 63.4 72.2 77.8 52.2 75.0 62.2 76.5 71.1 63.2 64.9 67.1 73.0 73.5 72.5 71.5 76.5 75.0 73.0 76.0 78.5 74.0 74.0 Table 8-1. Hypersensitivity pneumonitis: Number of deaths by sex, race, and age, and median age at death, U.S. residents age 15 and over, 1990-1999 CDC National Instititute for Occupational Safety and Health Hypersensitivity pneumonitis: Number of deaths, crude and age-adjusted mortality rates, U.S. residents age 15 and over, 1979-1999 CDC National Instititute for Occupational Safety and Health Immunopathogenesis  Acute phase  Inhaled Ag binds IgG Ab  Macrophage activated and release IL-8, IL-6     Chemotactic for monocytes/macrophage Differentiation of CD4+ TH0 cells to TH1 cells Differentiation of B cells to plasma cells (IL-6) Maturation of CD8+ cells into cytotoxic cells  TH1 cells secrete TNF alpha -> fever  Subacute phase  Macrophage develop into epithelioid cells and multinucleated giant cells  Lymphoid follicles with plasma cells develop in lesions  Chronic phase  Macrophage express TGF beta   Fibrosis Angiogenesis Patel et al J Allergy Clin Immunol 2001 Ag Memory cells Stimulates T cell Activates Cytotoxic cells Lymphocyte Stimulates Helper cells Chemokines Lymphokines Ab formation Over-expressed In rat models of HP IFN gamma key to granuloma formation in mouse models Opal and DePalo Chest 2000 Gudmundsson et al J Immunology 1998 Patel et J Allergy Clin Immunol 2001 Key Players In Fibrosis Angiotensin II TGF-β Macrophage TNF-α IL-1 Neutrophils TGF-β TNF−α Alveolar Epithelial Cell Fibroblast IFN-γ Angiotensin II TGF-β Lymphocyte Fibroblast Proliferation Extracellular Matrix Formation Clinical Features Classification Systems Classical Acute Boyd Acute progressive Cormier Active Selman Active Nonprogressive and intermittent Subacute Acute intermittent nonprogressive Nonacute Residual Active Progressive and intermittent Chronic Chronic Progressive Nonprogressive J Allergy Clin Immunol 1989;89:839 Clin Allergy 1982;12(suppl):53 Clin Pulm Med 1996;3:72 Interstitial Lung Disease Schwarz, MI, King, TE Jr, (Eds) 4th Ed, Hamilton, BC Decker 2003 UpToDate Acute  Abrupt onset           Clinical Diffuse rales  Tachypnea  Central cyanosis  Cough Dyspnea Chest tightness Fevers Chills Malaise Myalgias Anorexia Nausea/vomiting  Labs Leukocytosis  Restrictive pattern on PFTs  Positive serum precipitins   Sx 4-8 hrs after high level  Radiographs exposure  Sx subside over hours -days   Prognosis good complete recovery in 7-10 days Kupeli, et al Postgrad Med 2003 1-5mm bilateral pulmonary nodules  Bilateral consolidation  Ground glass infiltrates  Non-neoplastic Disorders of the Lower Respiratory Tract 2002 American Registry of Pathology and the Armed Forces Institute of Pathology Acute HP London Southbank University@myweb.lsbu.ac.uk www.emedicine.com Differential Diagnosis Acute stage          Acute tracheobronchitis, bronchiolitis, pneumonia Acute endotoxin exposure Organic dust toxic syndrome Allergic bronchopulmonary aspergillosis Reactive airways dysfunction syndrome Acute Respiratory Distress Syndrome Aspiration pneumonitis Bronchiolitis obliterans organizing pneumonia Diffuse alveolar damage Patel et al J Allergy Clin Immunol 2001 Subacute  More insidious onset  Dyspnea  Cough  Occurs after weeks to  Exam  Diffuse rales  Hypoxia  Labs Restrictive defect  Hypoxemia  months of exposure  Prognosis good  Radiographs  Air trapping  Micronodules Kupeli, et al Postgrad Med 2003 Non-neoplastic Disorders of the Lower Respiratory Tract 2002 American Registry of Pathology and the Armed Forces Institute of Differential Diagnosis  Subacute stage          Recurrent pneumonia ABPA Granulomatous lung diseases Infection – mycobacteria, fungi Pneumoconiosis Langerhans’ cell histiocytosis Churg-Strauss syndrome Wegener’s granulomatosis Sarcoidosis Patel et al J Allergy Clin Immunol Chronic  Sx occur over 4-12  Labs  months Dyspnea  Fatigue  Cough  Same as for prior stages  Pathology Fibrosis  Patchy alveolar infiltrate     Prognosis is poor  Inciting antigen Mononuclear cells Bronchocentric pattern unlikely to be isolated Non-necrotizing granulomas  Bronchiolitis obliterans  Organizing pneumonia   Radiographs  Honeycombing Kupeli, et al Postgrad Med 2003 Non-neoplastic Disorders of the Lower Respiratory Tract 2002 American Registry of Pathology and the Armed Forces Institute of Pathology Chronic HP www.emedicine.com Hayakawa et al Respirology 2002 Differential Diagnosis Chronic stage     Idiopathic pulmonary fibrosis Chronic obstructive pulmonary disease with pulmonary fibrosis Bronchiectasis/bronchiolectasis Mycobacterium avium complex Patel et al J Allergy Clin Immunol 2001 Clinical Course  Acute illness resolves in weeks if recognized early and patient exposure to antigen is eliminated  Subacute or chronic illness  More insidious symptoms  Increased risk of emphysema, fibrosis, asthma  Avian sensitivity associated with poor prognosis similar to interstitial lung disease 5 year mortality 50%  Clubbing on exam portends a worse prognosis  Diagnostic Criteria Major      History of symptoms compatible with HP  Appear or worsen within hours after antigen exposure History, Environmental investigation, Serum Ab or BAL Ab Evidence of exposure to antigen  BAL lymphocytosis Histologic findings compatible with HP Compatible radiographic findings Basilar crackles Decreased diffusion capacity Decreased O2 saturation with rest or activity Synopsis of Diseases of the Chest 3rd ed Minor    1. Known exposure to offending antigen A.History of appropriate exposure B. Environmental tests confirm Ag presence C. Positive serum IgG to Ag 2. Compatible clinical, radiologic, physiologic findings Definite A. Respiratory (+/- constitutional) Si/Sx B. Compatible CXR/CT findings C. Altered PFTs, gas exchange 3. BAL with lymphocytosis A.Low CD4/CD8 B. Positive specific imm response to Ag A. Reexposure to environment B. Lab exposure to suspected Ag Probable Subclinical Sensitization 1,2,3 1,2,4A 1,2A,3,5 1,2A,3 1,3A 1 4. Positive inhalation challenge test 5. Compatible histopathology A. Poorly formed, noncaseating granulomas B. Mononuclear infiltrate Atlas of Nontumor Pathology Travis, et al 2002 American Registry of Pathology and the Armed Forces Institute of Pathology Diagnostic Value to History/Exam  Multicenter trial studying consecutive patients presenting with a pulmonary syndrome for which HP was considered in the differential diagnosis  Objective: Identify diagnostic criteria and develop clinical prediction rule       History of exposure to Ag Presence of precipitating Ab Recurrent episodes of Sx Inspiratory crackles on exam Sx occurring 4-8 hrs after exposure Weight loss  400 patients in derivation cohort  261 patients in validation cohort  HRCT and BAL defined presence or absence of HP Lacasse et al Am J Respir Crit Care Med 2003 Significant Predictors of HP Variables Exposure Precipitating Abs present Recurrent episodes Inspiratory rales Sx 4-8 hrs after exposure Weight loss Sensitivity 86% OR 38.8 5.3 3.3 4.5 7.2 2.0 Specificity 86% CI 11.6-129.6 2.7-10.4 1.5-7.5 1.8-11.7 1.8-28.6 1.0-3.9 Rules do not apply to subacute or chronic forms HP Lacasse et al Am J Respir Crit Care Med 2003 Pulmonary Function  Classically, a restrictive pattern  Decreased FEV1 and FVC  Decreased total lung capacity  Decreased diffusion capacity  Concomitant bronchiolitis may result in obstructive defect  Hypoxemia  Bronchial hyperreactivity Chest Radiography CXR  Acute Fine micronodular pattern  Diffuse ground-glass opacity  Normal  CT  Acute Profuse centrilobular micronodules  Ground-glass opacities  Evidence of air trapping   Chronic   Chronic Honeycombing  Poorly defined nodules  Fibrosis  Lobar volume loss  Interstitial fibrosis Imaging of Diseases of the Chest 3rd ed Armstrong et al Mosby London 2000 Ground Glass Opacities www.emedicine.com Bronchoalveolar Lavage  Immediate (within 48 hours)  Neutrophils  Days later  T lymphocyte predominant alveolitis   CD8+ predominant CD4/CD8 usually < 1.0 Few disease processes > 50%   20-70% lymphocytes  Increased mast cells, usually > 1%  Problem  Lymphocytic response seen in asymptomatic patients with antigen exposure, and patients with organic dust toxic syndrome Atlas of Nontumor Pathology Non-Neoplastic Disorders of the Lower Respiratory Tract Hypersensitivity pneumonitis: current concepts Eur Respir J 2001 18:81s-92s Histopathology  Cellular bronchiolitis  Interstitial lymphocytic infiltrate  Usually bronchocentric  Scattered, small, poorly formed non-necrotizing granulomas  Large histiocytes with foamy cytoplasm  Fibrosis  Indistinguishable from other causes in advanced disease Approximately 80% of subacute and chronic cases have this triad Differential Diagnosis Table Modified from Atlas of Nontumor Pathology Histologic Hypersensitivity Sarcoidosis feature Pneumonitis Granulomas Frequency Morphology Distribution Intraluminal fibrosis Lymphocyte infiltrates Dense fibrosis BAL lymphocytosis 2/3 open biopsies 100% of cases LIP 5-10% cases; Well formed or poorly formed Random Poorly formed Mostly random, some peribronchiolar 2/3 open biopsies Mild-moderate Peribronchiolar Advanced cases CD8>CD4 (CD4/CD8 < 1.0) Well formed Lymphangitic, peribronchiolar, perivascular Very rare Absent or minimal Advanced cases CD4>CD8 (> 3.5 has a PPV 75%) Unusual Extensive, diffuse Unusual Usually B cells Non-neoplastic Disorders of the Lower Respiratory Tract Predictive Value of BAL Cell Differentials in the Diagnosis of Interstitial Lung Disease (ILD)  Retrospective evaluation  3,975 BALF samples from 3,118 pts  Collected January 1997 – November 2003  Determine pre-test and post-test probabilities  Relative frequencies of diagnoses based on available information (prior to BAL) were used as pre-test probabilities  Post-test probabilities determined using Bayes’ rule based on cell differentials and the CD4/CD8 ratio Eur Respir J 2004; 24: 1000-1006 Probability of ILD as a function of CD4/CD8 in suspected ILD n CD4/CD8 Sarcoidosis UIP EAA 239 112 66 33.7 15.8 9.3 Pre-test 9.1 * 13.6 27.3 * Post-test <0.5 0.5-3.5 40.3 12.2 17.2 * >3.5 69.1 *** 5.2 * 12.5 p<0.05; *** p<0.001 Versus the respective a priori value Likelihood of EAA rose 3x with a CD4/CD8 <0.5 Eur Respir J 2004; 24: 1000-1006 Probability of ILD as a function of lymphocytes and CD4/CD8 in suspected ILD when the percentage of granulocytes was low (eosinophils <2% and neutrophils <4%) Post-test Lymph % and CD4/CD8 Sarcoidosis UIP EAA n 182 25 35 Pretest 45.2 6.2 8.7 <30 Low High 30-50 Low High Low >50 High 28.6 86.1 56.1 *** *** 9.4 1.4 *** 5.6 0.0 3.5 17.5 * 86.5 *** 0.0 2.7 33.3 3.0 39.4 *** 55.6 0.0 29.6 *** Likelihood of EAA rose nearly 4x independently of CD4/CD8 when lymphocytes were very high and granulocytes were low •p<0.05; *** p<0.001 •Low CD4/CD8 <3.5 Eur Respir J 2004; 24: 1000-1006 Probability of ILD as a function of lymphocytes and CD4/CD8 in suspected ILD when the percentage of granulocytes was high (eosinophils >1% and neutrophils >3%) Lymph % and CD4/CD8 Sarcoidosis UIP Pretest 18.6 28.3 Post-test <30 Low High 30-50 Low High >50 Low High n 57 87 13.9 44.4 23.1 * 34.2 22.2 11.5 50.0 * 6.3 21.4 0.0* 0.0 0.0 EAA 31 10.1 3.0* 5.6 34.6 *** 37.5 *** 50.0 *** 50.0 Likelihood of EAA rose nearly 5x independently of CD4/CD8 when lymphocytes were very high and granulocytes were high p<0.05; *** p<0.001 Low CD4/CD8 <3.5 Eur Respir J 2004; 24: 1000-1006 Who Gets HP? Farmers Farmers moving hay into a barn, [between 1895 and 1910] Bartle Brothers Glass plate negative Reference Code: C 2-10232-1729  Thermophilic actinomycetes  Hay, grain, compost, manure Pigeon, duck, turkey, quail Contaminated air conditioning systems Contaminated air conditioning systems  Avian proteins   Amoebae (Naegleria, Acanthamoeba)   Thermophilic actinomycetes  Bird Fanciers www.ryancordell.com Bird Fanciers  Avian proteins  Case study  67 yo 150+ pack-yr smoker www.ladygouldianfinch.com  Raised budgerigars 1980-88  Diagnosed as IPF 1988  1994 diagnosed with Bird Fancier’s Lung   Lymphocytic alveolitis and organizing pneumonia by TBBx Serum precipitins positive for bird antigens Developed low grade fever and increased dyspnea Bronchocentric alveolitis on CT/chest Patient acquired feather duvet Inase et al Internal Medicine 2004  Disease stable until 2000    Nursing Home Aviary Factory Workers  Metalworking fluid aerosols  Pseudomonas fluorescans  Mycobacterium avium complex  Cheese mold  www.groupnch.com www.defra.gov.uk Penicillium  Plastics and resins  Anhydrides  Paint catalysts, adhesives, and foam  Diisocyanates  Contaminated ventilation systems  Naegleria, Acanthamoebae Patients With H/O Medication Use  Amiodarone  Gold  Procarbazine  Minocycline  Chlorambucil  Sulfasalazine  Beta blockers  HMG co-A Reductase inhibitors Others  Wood workers  Alternaria species  Malt workers  Aspergillus  Bathtub refinishers   Domestic engineers  Ventilation systems, compost, chemicals, greenhouses  Office employees  and Paint refinishers Diisocyanates Ventilation systems  Lab workers  Rat urinary proteins  Anybody!  Household mold  Air conditioning  Saunas, Hot tubs  Birds  Goose down Diagnostic Approach  Detailed history and physical exam Patient may not associate symptoms with antigen exposure  Symptoms may be delayed for hours  Temporal relationship weaker with chronic forms   Positive precipitating antibodies        Once thought to be hallmark Demonstrates immune response Lack sensitivity and specificity for HP Serve as markers for antigen exposure Poorly standardized antigens Improper quality controls More sensitive, but less specific  Enzyme-linked immunosorbent assay  Bronchoscopy  Lung biopsy  No single clinical or laboratory feature is diagnostic Occupational History  Current and previous occupations  Description of job processes  Chemical exposure  Symptom improvement away from work?  Similar symptoms in coworkers?  Use of respiratory protection at work Environmental History  Pets (especially birds)  Hobbies and recreational activities  Presence of humidifiers, swamp coolers, indoor        vented dryers Use of hot tubs, saunas Visible fungal growth in household/workplace History of flooding or water damage to walls and carpets History of recent renovation/remodeling Similar symptoms in home occupants Feather pillows, comforters, bedding, jackets Use of air fresheners, spray cleaners www.brickleyenv.com www.indoorairpro.com Treatment  Antigen avoidance  Responsible antigen may be difficult to isolate  Multiple antigens may be involved  Half-lives of animal dander, proteins measured in years  Exposure may be unavoidable  Disease may progress in spite of antigen avoidance  Corticosteroids      0.5 mg/kg/d for severe, acute episodes Subacute episodes may benefit from 1 mg/kg/day 2-4 weeks Improved short term effect No difference in long term effects (5 years)  Role of inhaled steroids and beta agonists unclear  May provide symptomatic relief UpToDate Monkare Eur J Respir Dis 1983 Kokkarinen et al Am Rev Respir Dis 1992 Patel et al J Allergy Clin Immunol 2001 Value of steroids Monkare Eur J Respir Dis 1983  93 pts with Farmer’s lung studied prospectively   No impact on lung function or work capacity Minor improvements in radiographic changes Kokkarinen et al Am Rev Respir Dis 1992  36 pts in double blind, placebo control  20 received prednisolone x 8 wks  16 received placebo  1 month follow up  Steroids improved DLCO No statistical significance between groups Symptoms recurred – 6 pts receiving steroids – 1 pt in placebo group  5 year follow up   Summary of HP  Antigen exposure is necessary but insufficient  Important exposures occur at home  Pet birds, feathers, humidifiers, indoor molds and bacteria  Challenging to diagnose Nonspecific symptoms  Variable clinical presentation  Variable radiographic findings  Lack of a “gold standard” diagnostic test   Immunopathogenesis remains unclear  Can be improved with antigen avoidance, and steroids in severe, acute cases  Unrecognized/untreated it may lead to development of asthma, emphysema or interstitial fibrosis