Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you grade severity of OSA by AHI or RDI?
We recently changed, per AASM guidelines, to reporting both AHI3a and AHI4. Since most sleep-disordered breathing events will qualify with the 3a decision, as it includes arousals, we have stopped reporting an RDI. If there are events that don't meet the 3a hypopnea definition, we might comment on i...
Would you consider octreotide as an adjunctive therapy for patients experiencing an acute life-threatening hemorrhage, outside of standard indications such as variceal or AVM bleeding?
In very selective scenarios, when the patient is experiencing an acute life-threatening bleeding while variceal or AVM bleeding remains on the differential, yes, I would consider octreotide as an adjunctive therapy, but only as a bridge to definitive diagnosis and treatment and not as a substitute f...
In patients with ILD who are started on nerandomilast on top of background nintedanib, what monitoring is most important early in therapy?
While it may seem initially that combining antifibrotics is a bad idea due to side effect profiles, it has, in fact, been done with some success. The INJOURNEY trial combined nintedanib AND perfenidone in patients with IPF, and during the study period (12 weeks), those on combined therapy lost only ...
How do you talk with your patients regarding radiographic expectations on surveillance CT after lung SBRT?
In general, especially when I have a discussion about the 3-month follow-up scan and tell patients that the lesion may likely be stable in size, which is often normal, and not to panic. There may also be post-radiation changes that make it more difficult to initially interpret. I think this highligh...
Would you start treatment for MAC in a patient with nodular bronchiectatic disease who has demonstrated radiographic progression but remains asymptomatic and smear-negative?
My default answer would be yes; this is a sign of progressive disease that will get worse without treatment. Having said that many things could be considered while making the decision, including patient preferences. First is there another cause? Does the patient have an exacerbation of bronchiectasi...
How do you approach the decision to consult Cardiology and pursue an ischemic workup for an isolated troponin elevation attributable to a non-cardiac acute illness such as sepsis or acute respiratory failure?
This decision is much more complex than can be adequately addressed in this response, based on the information given. The demographics and clinical risk factors of the patient are important in this decision, as well as the comfort of the clinician/primary care physician caring for the patient. Does ...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS, i.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). *I don't love carbidopa/levodopa for RLS. It very often causes augmentation.
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...
Do more fractionated regimens reduce severe toxicity over SBRT in patients with ILD and early-stage NSCLC?
I personally think fewer fractions are safer, such as 30 Gy x 1 instead of 10 Gy x 5, for patients with advanced COPD or ILD. Why? It's because each time a burst of ionization events is delivered to pulmonary tissues, a wound is created that recruits an inflammatory response, which can exacerbate th...