And Dr. Gerard A. Silvestri, FCCP

As pulmonary/critical care becomes more complex and demands on our time increase, many argue that we should not take on additional time and potential liability for procedures in the ICU. In some institutions, pulmonary/critical care physicians are not credentialed to perform tube thoracostomy or endotracheal tube intubation due to local culture, lack of training, or hospital policies. When credentialing for such procedures is based upon specialty alone rather than competence, procedural "ownership" may occur, whereby barriers to care, lack of collaboration, and duplication of services can occur (Kovitz et al. Chest. 2013;144[2]:368). We argue that by retaining procedural skills in the ICU, there are benefits to our patients and profession that should not be relinquished.

No other physician knows a patient and family as well as the intensivist in charge of their care. With such complete knowledge, issues such as fluid management, bleeding risk, sedative options, goals of care, and comorbidities can be factored into the planning and execution of procedures, thus preparing the physician to manage complications. A common conundrum occurs when we delegate procedures to other specialties, such as interventional radiology in which the ICU physician may be held hostage to international normalized ratio (INR) thresholds or platelet requirements that are not evidence-based or even achievable in some patients. The unnecessary or excess use of blood products may delay urgent procedures or even place patients at risk for transfusion reactions, acute lung injury, or infection. Sedation/analgesia choices used to facilitate procedures should be tailored to each critically ill patient, especially considering that excess use of certain sedatives in the ICU has been linked to worsened clinical outcomes and even long-term cognitive impairment (Miller et al. Semin Respir Crit Care Med. 2006;27[3]:210).

While some medical centers have surgical or airway teams on call when a chest tube or advanced airway is needed, many hospitals do not. Even in the ones that do, there may not be a guarantee of timely responsiveness (eg, emergent need for a chest tube or an airway when the surgeon or on-call anesthesiologist is preoccupied). Problems develop when the training of our country’s critical care workforce occurs in environments that do not prepare them for conditions they will encounter following graduation. Without advanced training in lifesaving skills, such as airway management, potential harm to future patients may occur when that expertise is otherwise unavailable.

The American College of Chest Physicians has recommended against a 1-year critical care fellowship for internal medicine hospitalists to obtain board certification, with skill and experience in invasive procedures, and has argued for longer training (Baumann et al. Chest. 2012;142[1]:5). These skills include standard bronchoscopic procedures that are needed for emergent or urgent diagnostic or therapeutic purposes in the ICU. These procedures should be germane to graduates of pulmonary/critical care fellowships and include bronchoscopy with therapeutic suctioning that can relieve airway obstruction.They should also include BAL to diagnose alveolar hemorrhage, Pneumocystis jiroveci pneumonia (PJP), or acute eosinophilic pneumonia. Transbronchial needle aspiration (TBNA) can be used to diagnose treatable causes of respiratory failure, such as small cell lung cancer or lymphoma; transbronchial and endobronchial biopsies are used to diagnose malignant, inflammatory, and infectious processes.

Unlike bronchoscopy requirements that are standardized for pulmonary fellowships, there is presently no specific number of endotracheal intubations that deem someone competent, and training in this skill varies widely across the United States (Joffe et al. Respir Care. 2012;57[7]:1084). As there are defined competency metrics for endotracheal tube intubation in emergency medicine, one can make a strong argument for the same in pulmonary/critical care. In fact, the American Board of Internal Medicine (ABIM) and the Accreditation Council for Graduate Medical Education (ACGME) require proficiency in emergent endotracheal intubation to graduate from pulmonary/critical care fellowships. Mayo and authors demonstrated that with proper training, which incorporates simulation, crew resource management, and adequate equipment (eg, video laryngoscope, bronchoscope, subglottic devices, etc), emergent endotracheal intubation may be performed safely by pulmonary/critical care medicine physicians (Mayo et al. J Intensive Care Med. 2011;26[1]:50).

It is a tremendous advantage for interventional pulmonologists or properly trained intensivists to perform percutaneous dilatational tracheostomies (PDT) in the ICU. Numerous studies document the comparable safety profile of PDT compared with surgical tracheostomy, along with decreased patient charge, increased efficiency, shorter procedure time, decreased bleeding, and decreased postoperative stomal infection rates (Yarmus et al. Respiration. 2012;84[2]:123). In addition, properly trained intensivists from nonsurgical specialties can perform PDT as safely as surgeons (Seder et al. Neurocrit Care. 2009;10[3]:264).

The past decade has seen a new paradigm shift in the types of chest tubes placed in the ICU (Bauman et al. Chest. 2012;142[1]:536). It is no longer considered blasphemy to place smaller bore catheters (less than or equal to= 14F) for most situations, including empyema (Rahman et al. Chest. 2010;137[3]:536) and most pneumothoraces (Lin et al. Am J Emerg Med. 2010;28[4]:466). Such tubes can be safely placed via a modified Seldinger technique and do not require surgical consultation or a radiologist. Even small collections can be safely drained under ultrasound guidance. With the use of deoxyribonuclease and tissue plasminogen activator through small-bore tubes, the drainage of complex pleural infections is improved and the frequency of surgeries and the duration of the hospital stay can be reduced (Najib and Rahman. N Engl J Med. 2011;365:518).

The role of thoracic ultrasound has been instrumental in the success of pleural procedures for the nonsurgeon, and in addition to directing placement in fluid collections, bedside ultrasonography is now standard of care for detecting pneumothorax in the ICU for those with proper training. Ultrasound can detect 92% of occult pneumothoraces diagnosed with CT scan (Soldati et al. Chest. 2008;133[1]:204). In addition, it is more sensitive than chest radiography and it allows for rapid reassessment (Galbois et al. Chest. 2010;138[3]:648). It can also be used to quickly rule out pneumothorax after central line placement or transbronchial biopsy (Vezzani et al. Crit Care Med. 2010; 38[2]:533).

For the pulmonary/critical care physician trained in point-of-care echocardiography, it no longer makes sense to wait on the official results of an echocardiogram for acutely ill patients. For the intensivist, bedside echocardiography has established itself as a powerful hemodynamic tool to diagnose and treat patients with hemodynamic failure. In a matter of minutes, a therapeutic plan can be initiated and results monitored. Volume responsiveness can be assessed and acted upon in most cases without additional invasive procedures (Mayo et al. Chest. 2009; 135[4]:1050).

In conclusion, diagnostic and therapeutic procedures should only be performed by those with adequate training and experience. The use of simulation (particularly for lower frequency, higher stakes procedures) and more evidence-based modalities for assessing competence are opportunities to ensure the highest level of skill in performing ICU procedures (Kennedy et al. Crit Care Med. 2014;42[1]:169). For many, the allure of the ICU and the marriage of cognitive and procedural skills to provide timely lifesaving care to patients is the impetus to enter pulmonary/critical care. Will there be the same attraction to clinical practice in the ICU if our specialty does not maintain its procedural repertoire?

Dr. Pastis is Assistant Professor of Medicine, Department of Medicine, Division of Pulmonary and Critical Care Medicine; Dr. Silvestri is George C. and Margeret Hillenbrand Endowed Professor, Vice-Chair of Faculty Development. Division of Pulmonary and Critical Care Medicine; Medical University of South Carolina, Charleston, South Carolina.

As pulmonary/critical care becomes more complex and demands on our time increase, many argue that we should not take on additional time and potential liability for procedures in the ICU. In some institutions, pulmonary/critical care physicians are not credentialed to perform tube thoracostomy or endotracheal tube intubation due to local culture, lack of training, or hospital policies. When credentialing for such procedures is based upon specialty alone rather than competence, procedural "ownership" may occur, whereby barriers to care, lack of collaboration, and duplication of services can occur (Kovitz et al. Chest. 2013;144[2]:368). We argue that by retaining procedural skills in the ICU, there are benefits to our patients and profession that should not be relinquished.

No other physician knows a patient and family as well as the intensivist in charge of their care. With such complete knowledge, issues such as fluid management, bleeding risk, sedative options, goals of care, and comorbidities can be factored into the planning and execution of procedures, thus preparing the physician to manage complications. A common conundrum occurs when we delegate procedures to other specialties, such as interventional radiology in which the ICU physician may be held hostage to international normalized ratio (INR) thresholds or platelet requirements that are not evidence-based or even achievable in some patients. The unnecessary or excess use of blood products may delay urgent procedures or even place patients at risk for transfusion reactions, acute lung injury, or infection. Sedation/analgesia choices used to facilitate procedures should be tailored to each critically ill patient, especially considering that excess use of certain sedatives in the ICU has been linked to worsened clinical outcomes and even long-term cognitive impairment (Miller et al. Semin Respir Crit Care Med. 2006;27[3]:210).

While some medical centers have surgical or airway teams on call when a chest tube or advanced airway is needed, many hospitals do not. Even in the ones that do, there may not be a guarantee of timely responsiveness (eg, emergent need for a chest tube or an airway when the surgeon or on-call anesthesiologist is preoccupied). Problems develop when the training of our country’s critical care workforce occurs in environments that do not prepare them for conditions they will encounter following graduation. Without advanced training in lifesaving skills, such as airway management, potential harm to future patients may occur when that expertise is otherwise unavailable.

The American College of Chest Physicians has recommended against a 1-year critical care fellowship for internal medicine hospitalists to obtain board certification, with skill and experience in invasive procedures, and has argued for longer training (Baumann et al. Chest. 2012;142[1]:5). These skills include standard bronchoscopic procedures that are needed for emergent or urgent diagnostic or therapeutic purposes in the ICU. These procedures should be germane to graduates of pulmonary/critical care fellowships and include bronchoscopy with therapeutic suctioning that can relieve airway obstruction.They should also include BAL to diagnose alveolar hemorrhage, Pneumocystis jiroveci pneumonia (PJP), or acute eosinophilic pneumonia. Transbronchial needle aspiration (TBNA) can be used to diagnose treatable causes of respiratory failure, such as small cell lung cancer or lymphoma; transbronchial and endobronchial biopsies are used to diagnose malignant, inflammatory, and infectious processes.

Unlike bronchoscopy requirements that are standardized for pulmonary fellowships, there is presently no specific number of endotracheal intubations that deem someone competent, and training in this skill varies widely across the United States (Joffe et al. Respir Care. 2012;57[7]:1084). As there are defined competency metrics for endotracheal tube intubation in emergency medicine, one can make a strong argument for the same in pulmonary/critical care. In fact, the American Board of Internal Medicine (ABIM) and the Accreditation Council for Graduate Medical Education (ACGME) require proficiency in emergent endotracheal intubation to graduate from pulmonary/critical care fellowships. Mayo and authors demonstrated that with proper training, which incorporates simulation, crew resource management, and adequate equipment (eg, video laryngoscope, bronchoscope, subglottic devices, etc), emergent endotracheal intubation may be performed safely by pulmonary/critical care medicine physicians (Mayo et al. J Intensive Care Med. 2011;26[1]:50).

It is a tremendous advantage for interventional pulmonologists or properly trained intensivists to perform percutaneous dilatational tracheostomies (PDT) in the ICU. Numerous studies document the comparable safety profile of PDT compared with surgical tracheostomy, along with decreased patient charge, increased efficiency, shorter procedure time, decreased bleeding, and decreased postoperative stomal infection rates (Yarmus et al. Respiration. 2012;84[2]:123). In addition, properly trained intensivists from nonsurgical specialties can perform PDT as safely as surgeons (Seder et al. Neurocrit Care. 2009;10[3]:264).

The past decade has seen a new paradigm shift in the types of chest tubes placed in the ICU (Bauman et al. Chest. 2012;142[1]:536). It is no longer considered blasphemy to place smaller bore catheters (less than or equal to= 14F) for most situations, including empyema (Rahman et al. Chest. 2010;137[3]:536) and most pneumothoraces (Lin et al. Am J Emerg Med. 2010;28[4]:466). Such tubes can be safely placed via a modified Seldinger technique and do not require surgical consultation or a radiologist. Even small collections can be safely drained under ultrasound guidance. With the use of deoxyribonuclease and tissue plasminogen activator through small-bore tubes, the drainage of complex pleural infections is improved and the frequency of surgeries and the duration of the hospital stay can be reduced (Najib and Rahman. N Engl J Med. 2011;365:518).

The role of thoracic ultrasound has been instrumental in the success of pleural procedures for the nonsurgeon, and in addition to directing placement in fluid collections, bedside ultrasonography is now standard of care for detecting pneumothorax in the ICU for those with proper training. Ultrasound can detect 92% of occult pneumothoraces diagnosed with CT scan (Soldati et al. Chest. 2008;133[1]:204). In addition, it is more sensitive than chest radiography and it allows for rapid reassessment (Galbois et al. Chest. 2010;138[3]:648). It can also be used to quickly rule out pneumothorax after central line placement or transbronchial biopsy (Vezzani et al. Crit Care Med. 2010; 38[2]:533).

For the pulmonary/critical care physician trained in point-of-care echocardiography, it no longer makes sense to wait on the official results of an echocardiogram for acutely ill patients. For the intensivist, bedside echocardiography has established itself as a powerful hemodynamic tool to diagnose and treat patients with hemodynamic failure. In a matter of minutes, a therapeutic plan can be initiated and results monitored. Volume responsiveness can be assessed and acted upon in most cases without additional invasive procedures (Mayo et al. Chest. 2009; 135[4]:1050).

In conclusion, diagnostic and therapeutic procedures should only be performed by those with adequate training and experience. The use of simulation (particularly for lower frequency, higher stakes procedures) and more evidence-based modalities for assessing competence are opportunities to ensure the highest level of skill in performing ICU procedures (Kennedy et al. Crit Care Med. 2014;42[1]:169). For many, the allure of the ICU and the marriage of cognitive and procedural skills to provide timely lifesaving care to patients is the impetus to enter pulmonary/critical care. Will there be the same attraction to clinical practice in the ICU if our specialty does not maintain its procedural repertoire?

Dr. Pastis is Assistant Professor of Medicine, Department of Medicine, Division of Pulmonary and Critical Care Medicine; Dr. Silvestri is George C. and Margeret Hillenbrand Endowed Professor, Vice-Chair of Faculty Development. Division of Pulmonary and Critical Care Medicine; Medical University of South Carolina, Charleston, South Carolina.

As pulmonary/critical care becomes more complex and demands on our time increase, many argue that we should not take on additional time and potential liability for procedures in the ICU. In some institutions, pulmonary/critical care physicians are not credentialed to perform tube thoracostomy or endotracheal tube intubation due to local culture, lack of training, or hospital policies. When credentialing for such procedures is based upon specialty alone rather than competence, procedural "ownership" may occur, whereby barriers to care, lack of collaboration, and duplication of services can occur (Kovitz et al. Chest. 2013;144[2]:368). We argue that by retaining procedural skills in the ICU, there are benefits to our patients and profession that should not be relinquished.

No other physician knows a patient and family as well as the intensivist in charge of their care. With such complete knowledge, issues such as fluid management, bleeding risk, sedative options, goals of care, and comorbidities can be factored into the planning and execution of procedures, thus preparing the physician to manage complications. A common conundrum occurs when we delegate procedures to other specialties, such as interventional radiology in which the ICU physician may be held hostage to international normalized ratio (INR) thresholds or platelet requirements that are not evidence-based or even achievable in some patients. The unnecessary or excess use of blood products may delay urgent procedures or even place patients at risk for transfusion reactions, acute lung injury, or infection. Sedation/analgesia choices used to facilitate procedures should be tailored to each critically ill patient, especially considering that excess use of certain sedatives in the ICU has been linked to worsened clinical outcomes and even long-term cognitive impairment (Miller et al. Semin Respir Crit Care Med. 2006;27[3]:210).

While some medical centers have surgical or airway teams on call when a chest tube or advanced airway is needed, many hospitals do not. Even in the ones that do, there may not be a guarantee of timely responsiveness (eg, emergent need for a chest tube or an airway when the surgeon or on-call anesthesiologist is preoccupied). Problems develop when the training of our country’s critical care workforce occurs in environments that do not prepare them for conditions they will encounter following graduation. Without advanced training in lifesaving skills, such as airway management, potential harm to future patients may occur when that expertise is otherwise unavailable.

The American College of Chest Physicians has recommended against a 1-year critical care fellowship for internal medicine hospitalists to obtain board certification, with skill and experience in invasive procedures, and has argued for longer training (Baumann et al. Chest. 2012;142[1]:5). These skills include standard bronchoscopic procedures that are needed for emergent or urgent diagnostic or therapeutic purposes in the ICU. These procedures should be germane to graduates of pulmonary/critical care fellowships and include bronchoscopy with therapeutic suctioning that can relieve airway obstruction.They should also include BAL to diagnose alveolar hemorrhage, Pneumocystis jiroveci pneumonia (PJP), or acute eosinophilic pneumonia. Transbronchial needle aspiration (TBNA) can be used to diagnose treatable causes of respiratory failure, such as small cell lung cancer or lymphoma; transbronchial and endobronchial biopsies are used to diagnose malignant, inflammatory, and infectious processes.

Unlike bronchoscopy requirements that are standardized for pulmonary fellowships, there is presently no specific number of endotracheal intubations that deem someone competent, and training in this skill varies widely across the United States (Joffe et al. Respir Care. 2012;57[7]:1084). As there are defined competency metrics for endotracheal tube intubation in emergency medicine, one can make a strong argument for the same in pulmonary/critical care. In fact, the American Board of Internal Medicine (ABIM) and the Accreditation Council for Graduate Medical Education (ACGME) require proficiency in emergent endotracheal intubation to graduate from pulmonary/critical care fellowships. Mayo and authors demonstrated that with proper training, which incorporates simulation, crew resource management, and adequate equipment (eg, video laryngoscope, bronchoscope, subglottic devices, etc), emergent endotracheal intubation may be performed safely by pulmonary/critical care medicine physicians (Mayo et al. J Intensive Care Med. 2011;26[1]:50).

It is a tremendous advantage for interventional pulmonologists or properly trained intensivists to perform percutaneous dilatational tracheostomies (PDT) in the ICU. Numerous studies document the comparable safety profile of PDT compared with surgical tracheostomy, along with decreased patient charge, increased efficiency, shorter procedure time, decreased bleeding, and decreased postoperative stomal infection rates (Yarmus et al. Respiration. 2012;84[2]:123). In addition, properly trained intensivists from nonsurgical specialties can perform PDT as safely as surgeons (Seder et al. Neurocrit Care. 2009;10[3]:264).

The past decade has seen a new paradigm shift in the types of chest tubes placed in the ICU (Bauman et al. Chest. 2012;142[1]:536). It is no longer considered blasphemy to place smaller bore catheters (less than or equal to= 14F) for most situations, including empyema (Rahman et al. Chest. 2010;137[3]:536) and most pneumothoraces (Lin et al. Am J Emerg Med. 2010;28[4]:466). Such tubes can be safely placed via a modified Seldinger technique and do not require surgical consultation or a radiologist. Even small collections can be safely drained under ultrasound guidance. With the use of deoxyribonuclease and tissue plasminogen activator through small-bore tubes, the drainage of complex pleural infections is improved and the frequency of surgeries and the duration of the hospital stay can be reduced (Najib and Rahman. N Engl J Med. 2011;365:518).

The role of thoracic ultrasound has been instrumental in the success of pleural procedures for the nonsurgeon, and in addition to directing placement in fluid collections, bedside ultrasonography is now standard of care for detecting pneumothorax in the ICU for those with proper training. Ultrasound can detect 92% of occult pneumothoraces diagnosed with CT scan (Soldati et al. Chest. 2008;133[1]:204). In addition, it is more sensitive than chest radiography and it allows for rapid reassessment (Galbois et al. Chest. 2010;138[3]:648). It can also be used to quickly rule out pneumothorax after central line placement or transbronchial biopsy (Vezzani et al. Crit Care Med. 2010; 38[2]:533).

For the pulmonary/critical care physician trained in point-of-care echocardiography, it no longer makes sense to wait on the official results of an echocardiogram for acutely ill patients. For the intensivist, bedside echocardiography has established itself as a powerful hemodynamic tool to diagnose and treat patients with hemodynamic failure. In a matter of minutes, a therapeutic plan can be initiated and results monitored. Volume responsiveness can be assessed and acted upon in most cases without additional invasive procedures (Mayo et al. Chest. 2009; 135[4]:1050).

In conclusion, diagnostic and therapeutic procedures should only be performed by those with adequate training and experience. The use of simulation (particularly for lower frequency, higher stakes procedures) and more evidence-based modalities for assessing competence are opportunities to ensure the highest level of skill in performing ICU procedures (Kennedy et al. Crit Care Med. 2014;42[1]:169). For many, the allure of the ICU and the marriage of cognitive and procedural skills to provide timely lifesaving care to patients is the impetus to enter pulmonary/critical care. Will there be the same attraction to clinical practice in the ICU if our specialty does not maintain its procedural repertoire?

Dr. Pastis is Assistant Professor of Medicine, Department of Medicine, Division of Pulmonary and Critical Care Medicine; Dr. Silvestri is George C. and Margeret Hillenbrand Endowed Professor, Vice-Chair of Faculty Development. Division of Pulmonary and Critical Care Medicine; Medical University of South Carolina, Charleston, South Carolina.