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Choosing Wisely: Five Commonly Performed Tests and Treatments in Pulmonary and Critical Care Medicine That May Not Always Be Necessary

As part of the ABIM Foundation’s Choosing Wisely® campaign, collaborative taskforces assembled by the American Thoracic Society and the American College of Chest Physicians (pulmonary medicine) and  by the Critical Care Societies Collaborative, which includes the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society and the Society of Critical Care Medicine (critical care), have released lists of five commonly performed pulmonary medicine and critical care tests and treatments that may not always be necessary.
These lists are designed to help promote conversations between physicians and patients about which tests and treatments are most appropriate and about avoiding care whose potential harm may outweigh its benefits.

The five recommendations for pulmonary medicine are:

  • Don't perform computed tomography (CT) surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines.
  • Don't routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases (Groups II or III pulmonary hypertension).
  • For patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, don’t renew the prescription without assessing the patient for ongoing hypoxemia.
  • Don't perform chest computed tomography (CT angiography) to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay.
  • Don't perform CT screening for lung cancer among patients at low risk for lung cancer.

The five recommendations for critical care are:

  • Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.
  • Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 g/dL.
  • Don’t use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.
  • Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.
  • Don't continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.

The complete lists with further details on the five recommendations and references are also available on the Choosing Wisely website.