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Defenders of the Pulmonary Artery Catheter

1988; Elsevier BV; Volume: 93; Issue: 5 Linguagem: Inglês

10.1378/chest.93.5.1061-a

1931-3543

Joseph M. Civetta,

Healthcare Technology and Patient Monitoring

To the Editor:In evaluating the paper, “A Community-Wide Assessment of the Use of Pulmonary Artery Catheters in Patients with Acute Myocardial Infarction” by Gore and associates, the authors recognize the obvious problem of selection bias inherent in a retrospective comparison of patients separated by clinicians because of perceived illness. Dr. Robin's commentaries have gone beyond the considered observations included in his earlier editorial, “A Critical Look at Critical Care” (Crit Care Med 1983; 11:144-48) to an expressed fear that “masses of patients have been harmed or died” by this clinical selection and use of the pulmonary artery catheter.Why should the use of a monitoring device be expected in and of itself to improve outcome as measured by mortality? Clearly, there is a clinical process of many steps linking a device with outcome: physicians do select only certain patients to be monitored, the monitoring system must produce accurate numbers, abnormal values need to be recognized, pathophysiologic causes have to be identified, the need for therapy appreciated, a specific form of therapy selected and administered appropriately, the patient must respond, and this response must improve the clinical condition sufficiently to augment survival. Yet the device alone, as some amulet, is now questioned for failing to improve survival. Despite the careful wording of possible errors by Gore and his associates in their article, the expression of fear (not fact) by Robin and the disclaimer printed in Chest, the message has already been considerably distorted. In the San Francisco Examiner, the headline read: “Diagnostic Tool May Be Fatal; study suggests use of catheter doubles chance of death.”It, in fact, seems appropriate that mortality rates are higher in patients deemed sicker by the clinician (who responds by choosing a higher level of monitoring). What if mortality rates had been higher in nonmonitored patients? Would clinicians have been guilty of not using pulmonary artery catheters? Let us stop short of a pendulum swinging too far to the other extreme. We must identify a role for monitoring devices and evaluate the application of the information by the physicians, as well as the eight other steps in the process of care. To suggest otherwise seems to be throwing out the baby with the bath water. A better question might be: since the inability to estimate hemodynamic parameters is well established, why don't objective hemodynamic data facilitate clinical care, replacing the uncertainty of “clinical judgement”? To the Editor: In evaluating the paper, “A Community-Wide Assessment of the Use of Pulmonary Artery Catheters in Patients with Acute Myocardial Infarction” by Gore and associates, the authors recognize the obvious problem of selection bias inherent in a retrospective comparison of patients separated by clinicians because of perceived illness. Dr. Robin's commentaries have gone beyond the considered observations included in his earlier editorial, “A Critical Look at Critical Care” (Crit Care Med 1983; 11:144-48) to an expressed fear that “masses of patients have been harmed or died” by this clinical selection and use of the pulmonary artery catheter. Why should the use of a monitoring device be expected in and of itself to improve outcome as measured by mortality? Clearly, there is a clinical process of many steps linking a device with outcome: physicians do select only certain patients to be monitored, the monitoring system must produce accurate numbers, abnormal values need to be recognized, pathophysiologic causes have to be identified, the need for therapy appreciated, a specific form of therapy selected and administered appropriately, the patient must respond, and this response must improve the clinical condition sufficiently to augment survival. Yet the device alone, as some amulet, is now questioned for failing to improve survival. Despite the careful wording of possible errors by Gore and his associates in their article, the expression of fear (not fact) by Robin and the disclaimer printed in Chest, the message has already been considerably distorted. In the San Francisco Examiner, the headline read: “Diagnostic Tool May Be Fatal; study suggests use of catheter doubles chance of death.” It, in fact, seems appropriate that mortality rates are higher in patients deemed sicker by the clinician (who responds by choosing a higher level of monitoring). What if mortality rates had been higher in nonmonitored patients? Would clinicians have been guilty of not using pulmonary artery catheters? Let us stop short of a pendulum swinging too far to the other extreme. We must identify a role for monitoring devices and evaluate the application of the information by the physicians, as well as the eight other steps in the process of care. To suggest otherwise seems to be throwing out the baby with the bath water. A better question might be: since the inability to estimate hemodynamic parameters is well established, why don't objective hemodynamic data facilitate clinical care, replacing the uncertainty of “clinical judgement”? Defenders of the Pulmonary Artery CatheterCHESTVol. 93Issue 5PreviewAs originally conceived, one objective of this column is to provide a platform for contrary opinions. Another (unstated) objective is to provide a written historic record of current medical thinking about certain issues in chest medicine. A recent editorial of mine on the dangers of the pulmonary artery catheter has evoked a number of contrary responses defending the use of the catheter My column this month reproduces these criticisms. As the medical literature has scarcely been starved for favorable comments concerning the use of the instrument, I have taken the liberty of discussing each critical letter My comments appear in italics. Full-Text PDF