The sequence for diagnostic testing in patients with suspected pulmonary embolism (PE) depends on the clinical circumstances. The certainty of a negative diagnosis for PE via an algorithm including a negative D-dimer result is enhanced when the algorithm follows a multibranch diagnostic pathway. While combining a negative D-dimer result with a low or moderate clinical probability for PE rules out these diagnoses, the use of D-dimer is not helpful in patients with a high probability clinical assessment since a negative D-dimer does not exclude PE in more than 15 percent of such patients.

According to Wells’ criteria for deep vein thrombosis, a score of less than two indicates low risk, and above two indicates intermediate/high risk. The high score is ≥4.5 in the two-tier model and >6 in the three-tier model (2-6 indicates moderate risk in this model).

An evaluation of D-dimer in the diagnosis of pulmonary embolism: a randomized trial. Kearon C, Ginsberg JS, Douketis J, Turpie AG, Bates SM, Lee AY, Crowther MA, Weitz JI, Brill-Edwards P, Wells P, Anderson DR, Kovacs MJ, Linkins LA, Julian JA, Bonilla LR, Gent M, Canadian

D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, Biel RK, Bharadia V, Kalra NK, Ann Intern Med. 2004;140(8):589

D-dimer test for excluding the diagnosis of pulmonary embolism. Crawford F, Andras A, Welch K, Sheares K, Keeling D, Chappell FM. Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD010864

Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Righini M, Le Gal G, Aujesky D, Roy PM, Sanchez O, Verschuren F, Rutschmann O, Nonent M, Cornuz J, Thys F, Le Manach CP, Revel MP, Poletti PA, Meyer G, Mottier D, Perneger T, Bounameaux H, Perrier A, Lancet. 2008 Apr;371(9621):1343-52

Pulmonary Embolism Diagnosis Study (CANPEDS) Group Ann Intern Med. 2006;144(11):812

Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV Jr, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD, PIOPED II investigators, Am J Med. 2006;119(12):1048

Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, Kovacs G, Mitchell M,

Lewandowski B, Kovacs MJ. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003 Sep 25;349(13):1227-35. doi: 10.1056/NEJMoa023153. PMID: 14507948.

Despite their ongoing and frequent use, there is insufficient evidence regarding efficacy of systemic corticosteroids in the treatment of COPD without exacerbations. Well- known side-effects of this drug group are obesity, respiratory and peripheral muscle weakness, hypertension, psychiatric disorders, diabetes mellitus, osteoporosis, skin thinning and bruising. The burden of cardiovascular disease has a significant impact on all-cause mortality in COPD patients. The combination of limited efficacy and potential toxicity of the drugs, especially in the at-risk patients who tend to be older, less active and have histories of smoking, means that long term use of systemic corticosteroids in COPD is not recommended. 

In the cases of the exacerbations of COPD, a 2018 systematic review from Cochrane suggests that a five-day course of oral corticosteroids is likely to be sufficient and that the likelihood that shorter courses of systemic corticosteroids (of around five days) lead           to worse outcomes compared with longer courses (10 to 14 days) is low.

Corticosteroids contribute to muscle weakness in chronic airflow obstruction. M Decramer, L M Lacquet, R Fagard, and P Rogiers American Journal of Respiratory and Critical Care Medicine Volume 150, Issue 1

Falk JA, Minai OA, Mosenifar Z. Inhaled and systemic corticosteroids in chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2008;5(4):506-512. doi:10.1513/pats.200707-096ET
Adverse effects of corticosteroid therapy for COPD. A critical review. McEvoy CE1, Niewoehner DE. Chest. 1997 Mar;111(3):732-43

McGarvey LP, John M, Anderson JA, et al Ascertainment of cause-specific mortality in COPD: operations of the TORCH Clinical Endpoint CommitteeThorax 2007;62:411-415.
Adverse effects of corticosteroid therapy for COPD. A critical review. McEvoy CE1, Niewoehner DE. Chest. 1997 Mar;111(3):732-43

Olof Selroos (2004) The place of inhaled corticosteroids in chronic obstructive pulmonary disease, Current Medical Research and Opinion, 20:10, 1579-1593, DOI: 10.1185/030079904X3708

Optimal assessment and management of chronic obstructive pulmonary disease (COPD) N.M. Siafakas, P. Vermeire, N.B. Pride, P. Paoletti, J. Gibson, P. Howard, J.C. Yernault, M. Decramer, T. Higenbottam, D.S. Postma, J. Rees, on behalf of the Task Force Eur Respir J, 1995, 8, 1398–1420

The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2019
 
Walters JAE, Tan DJ, White CJ, Wood‐Baker R. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD006897. DOI: 10.1002/14651858.CD006897.pub4.

 

Most patients with COPD present with mild disease and few complaints but tend to live a very sedentary lifestyle. The cornerstone of management of mild COPD is smoking cessation, the only proven intervention to relieve symptoms, modify the natural history of disease and lower mortality rates. For asymptomatic or minimally symptomatic patients, quitting smoking is often the only required therapy. Other effective behavioural interventions include maintaining or increasing physical activity, ensuring adequate sleep and a healthy diet and the use of effective stress management strategies.

Inhalers have evidence for only reducing exacerbations and do not modify disease. The use of short- or long-acting bronchodilators on a regular basis is not generally recommended for minimally symptomatic COPD patients with a low risk of exacerbation.

Diagnosis and Management of Stable COPD. Achilleos KM, Powrie JD. BJMP 2011;4(3): a427

Global Initiative for Chronic Obstructive Lung Disease (GOLD). GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD

Treatment of mild chronic obstructive pulmonary disease. Chee A & Sin DD. Int J Chron Obstruct Pulmon Dis. 2008 Dec; 3(4): 563–573
  

There is a lack of direct evidence related to cancer probability in small nodules in low-risk patients. The National Lung Screening Trial, the largest randomised study of lung cancer screening in a high-risk population to date, showed that that CT lung screening reduces lung cancer mortality in high-risk patients when the minimum size of a positive pulmonary nodule is set at 4 mm. As more than half of baseline examinations in the study were positive for nodules 4 to 6 mm in size, raising the threshold for a positive result to 6 mm would decrease the baseline positive rate from 27.3% to around 13.4%.

Since the positive predictive value (PPV) of an examination deemed positive for a nodule of 4 to 6 mm stands at 0.5%, increasing the threshold to 6 mm might act to increase the PPV by a factor of 1.8 (7.2% at 6 mm vs 3.8% at 4 mm) without significantly affecting the sensitivity to detect cancer. Given that the average risk of cancer in solid nodules smaller than 6 mm in patients at high risk is less than 1%, it is reasonable to assume an even lower risk in a patient with low clinical risk.

According to the risk categories proposed by the American College of Chest Physicians (ACCP), low risk, which corresponds to an estimated risk of cancer of less than 5%, is associated with young age, less smoking, smaller nodule size, regular margins, and location in an area other than the upper lobe.

CT screening for lung cancer: alternative definitions of positive test result based on the national lung screening trial and international early lung cancer action program databases. Yip R1, Henschke CI, Yankelevitz DF, Smith JP. Radiology. 2014 Nov;273(2):591-6. 2014 Jun 19

Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e93S-e120S. doi:10.1378/chest.12-2351

Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017

Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017

National Lung Screening Trial Research Team Aberle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365:395-409

Performance of ACR Lung-RADS in a Clinical CT Lung Screening Program McKee, Brady J. et al. Journal of the American College of Radiology, Volume 12, Issue 3, 273 - 276
 
Performance of ACR Lung-RADS in a Clinical CT Lung Screening Program McKee, Brady J. et al. Journal of the American College of Radiology, Volume 12, Issue 3, 273-276

Sarcoidosis is a multisystemic disease with heterogenous clinical presentations. Diagnosis of sarcoidosis is often challenging because of the lack of reliable biomarkers and other gold standard tests. Unusually high serum angiotensin converting enzyme (ACE) is present in up to 75 percent of untreated patients. However, testing for high serum ACE level has been repeatedly demonstrated to have a poor sensitivity, insufficient specificity (including a false positive rate of around 10 percent) and inconsistent correlation with disease severity. As such, its general clinical utility is limited.

Diagnosis and Management of Sarcoidosis. Natalia Soto-Gomez, md; Jay I. Peters, MD; and Anoop m. Nambiar, MD, University of Texas Health Science Center, San Antonio, Texas Am Fam Physician. 2016 May 15;93(10):840- 850

Diagnostic Utility of Angiotensin-Converting Enzyme in Sarcoidosis: A Population-Based Study. Ungprasert P, Carmona EM, Crowson CS, Matteson EL Lung. 2016 Feb;194(1):91-5. Epub 2015 Nov 13

Serum angiotensin converting enzyme in sarcoidosis--its value in present clinical practice. Studdy PR, Bird R Ann Clin Biochem. 1989;26 (Pt 1):13

Pulmonary sarcoidosis. Baughman RP Clin Chest Med. 2004;25(3):521