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The American College of Chest Physicians recently published a statement summarizing the results of the Consensus Conference on Mechanical Ventilation (Chest 1993; 104:1833-1859). In this statement, the physiology of mechanical ventilation was extensively reviewed, and 5 principles and 38 guidelines or recommendations on which consensus was reached were presented. The following critique (1) summarizes the findings of the conference; (2) comments on selected principles, recommendations, and physiological concepts presented in the statement; and (3) discusses the strengths and the limitations of the consensus conference format, as well as the errors and biases inherent in the policy-making process. The Consensus Conference statement is one of the clearest, most complete reviews of physiology and techniques of mechanical ventilation I have yet encountered. The suggested guidelines and recommendations clearly follow from the physiological principles discussed. Unfortunately, numerous problems with the consensus conference format and the almost total lack of controlled randomized studies limit the confidence with which these suggestions can be accepted. Our experts in respiratory care are remiss for not providing outcome-based or preference-based data, and the pulmonary and critical care community is remiss for not demanding that they do so before changing our approaches on the basis of their suggestions.
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Tobacco use, particularly cigarette smoking, is widely recognized by the medical community and the general public as a major public health problem. Physicians and medical organizations share a public health duty to address this problem. Physicians and their professional organizations must contribute effectively to measures undertaken to deal with cigarette smoking. The issues involved are complex and affect medical practice in a number of ways. The following statement developed by six international organizations--the American College of Chest Physicians, the American Thoracic Society, the European Respiratory Society, the Asian Pacific Society of Respirology, the Canadian Thoracic Society, and the International Union Against Tuberculosis and Lung Disease--is intended to state the physician's responsibilities both to patients and to the community with regard to these general issues.
INTRODUCTION: The available clinical guidelines have been successful in improving awareness of the inflammatory nature of asthma and have promoted the use of inhaled corticosteroids (ICSs) to achieve long-term control of symptoms. Because of lingering concerns over the possible adverse consequences of ICS use, an expert panel was convened with a mandate to identify the critical questions that impact decisions regarding the use of ICSs and to evaluate the available evidence with respect to risk. METHODS: A university librarian retrieved citations and abstracts from the MEDLINE and EMBASE databases using a list of National Library of Medicine search terms and key words. Reviewers were asked to systematically abstract relevant information from each of their assigned articles and to list their own clinical or scientific conclusions based on the study results. A predefined grading algorithm was used to calculate a summary quality rating score for the relevant evidence. RESULTS: The results are presented as a series of key questions followed by a summary of the relevant evidence. An evidence grade is assigned, followed by a summary statement reflecting the panel's consensus opinion following review. CONCLUSIONS: The preponderance of evidence supports a conclusion that the proven clinical effectiveness of ICS treatment decidedly outweighs the proven risks.
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Tobacco use, particularly cigarette smoking, is a major cause of preventable disease and premature death worldwide. Both smokers and nonsmokers exposed to environmental tobacco smoke are at risk. Cessation of smoking reduces risks. Although the addicting properties of nicotine can make cessation difficult, both medical interventions aimed at helping smokers quit and social policies aimed at control of cigarette smoking can have significant benefits. Physicians should play an active role in control of smoking by ensuring that counselling and pharmacological therapy must be available for the individual smoker. Physicians should also participate in the public debate regarding smoking both individually and through medical organizations. As smoking represents a threat to the public health, physicians must take a strong and active role seeking its control.
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BACKGROUND: The American College of Chest Physicians addressed the dilemma of identifying optimal therapy for venous thromboembolism (VTE) prophylaxis and published their Fourth Consensus Conference on Antithrombotic Therapy in 1995, with recommendations for prophylactic therapy. Despite these recommendations, appropriate VTE prophylactic therapy is underused. OBJECTIVES: To examine routine practices in the prevention of VTE in high-risk surgical patients and to determine the extent of adoption of grade A prophylactic therapies as recommended by the American College of Chest Physicians. METHODS: Retrospective medical record review in 10 teaching or community-based hospitals located in the United States. Medical charts of 1907 patients were randomly selected for review from the population of patients who underwent high-risk major abdominal surgery, total hip replacement, hip fracture repair, or total knee replacement between January 1, 1996, and February 28, 1997. RESULTS: Of 1907 patients, VTE prophylaxis was used in 89.3%; use was 93.7% in each of the 3 orthopedic surgery groups and 75.2% in the high-risk major abdominal surgery group. The percentage of patients receiving grade A therapy was highest in the hip replacement group (84.3%) vs. the other groups (knee replacement, 75.9%; hip fracture repair, 45.2%; abdominal surgery, 50.3%). CONCLUSIONS: The use of grade A prophylaxis was related to the type of surgery, with the highest use seen in total hip replacement and the lowest in hip fracture repair. One in 4 patients who underwent high-risk major abdominal surgeries failed to receive any form of VTE prophylaxis. Publication of consensus statements alone may be insufficient to ensure the incorporation of important new clinical information into routine practice.
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