Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your approach to REM behavior disorder not adequately treated with melatonin and clonazepam?
If both are at their max doses, then, in addition to making sure the bedroom environment is safe, I recommend rivastigmine. HA
What are your top takeaways from ATS 2026?
I was impressed with the FROSTBITE-2 study published in JAMA!It was a well-designed study and supports the use of a 1.1 mm cryoprobe in many bronchoscopic lung biopsy settings. This is a practice-changing level of evidence for bronchoscopists and will help us get better results for our patients.
In patients with severe asthma who are candidates for biologics, do you put them on an ICS/LABA/LAMA rather than high dose ICS/LABA?
Assuming adherence to ICS/LABA, I would use high-dose ICS/LABA if FENO is high, especially if they have exacerbations. I would add Triple Rx in patients with low FENO, especially in the presence of obstruction on spirometry.
Is it still significant to denote the etiology of ILD in a patient with PPF?
Yes, absolutely! Infact, the most effective treatment in patients without IPF (PPF) is treatment of the cause. So if there is underlying autoimmune disease or exposure, primary treatment should be directed against that trigger and this has potential to stop progression and even improve lung function...
How often, if at all, do you monitor a CBC with differential to assess peripheral eosinophilia in patients with type 2 inflammatory asthma who have been started on dupilumab?
For most patients, a baseline CBC with differential followed by a recheck at approximately 3 months aligns with the observed pharmacokinetics of eosinophil rebound. GINA 2026 notes transient blood eosinophilia occurs in 4–13% of patients, with rare EGPA cases potentially unmasked following OCS reduc...
Would you offer empiric lung SBRT for two growing FDG-avid lung lesions in a patient with severe COPD on oxygen?
This is a good question! The short answer is yes, most likely. Many patients are too high-risk to receive biopsies; this is decided by surgery/pulm/IR. Unless the patient has contraindications to RT or something like severe IPF (where treatment may be worse than the disease), I would likely offer th...
In cirrhosis patients with borderline pre-transplant PVR (≈2–3 WU), what additional findings (e.g., mPAP/TPG, pulmonary artery compliance, RV strain on echo, DLCO) prompt you to treat this as higher risk and arrange closer follow-up or PH-center referral rather than reassuring the transplant team?
Agree that recent data do suggest that pulmonary vascular resistance (PVR) 2 to 3 Wood units should be followed carefully in patients who are liver transplant candidates.Using historical data and International Liver Transplant Society (ILTS) Guidelines, mean pulmonary arterial pressure (mPAP) < 35 m...
When do you consider giving IV albumin for severe hypoalbuminemia with third-spacing of fluid outside of standard indications (i.e., large-volume paracentesis, HRS, SBP, shock, etc.)?
On the wards, I do not treat the albumin number. Severe hypoalbuminemia with third spacing, by itself, is not an indication for IV albumin. The consistent signal from the literature is that albumin should not be used simply to raise serum levels or to “pull fluid back in” as an adjunct to diuretics....
Do you add empiric anti-MRSA coverage to the initial antibiotic regimen for a patient admitted with community-acquired pneumonia who has risk factors for MRSA but a negative MRSA nasal screen?
Thank you for this excellent and highly relevant clinical question. I approach this scenario by blending robust evidence-based medicine with fundamental principles of diagnostic reasoning. The short answer is generally no, you probably do not need to add empiric anti-MRSA coverage for a standard CAP...
How would you manage a patient with necrotizing pneumonia due to a susceptible Pseudomonas aeruginosa strain who continues to have significant purulent secretions and worsening imaging while receiving cefepime?
I agree, not enough information here to make a firm recommendation, but often times these necrotic pneumonias will undergo significant liquefactive necrosis, and all of that dead lung and purulence has to come out through the mouth. I tell patients that they may have a worse cough for a while, and t...