Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is the role of inebilizumab in the maintenance treatment of IgG4-related disease?
Inebilizumab may play an important role in the maintenance treatment of IgG4-related disease (IgG4-RD), particularly in patients at high risk for relapse. These are typically patients with multi-organ involvement and elevated serum IgG4 levels who initially respond well to corticosteroids but tend t...
For patients with definite UIP and MPO-ANCA-associated vasculitis limited to the lungs (without systemic manifestations), what is the role of immunosuppression?
I think in these subjects (as opposed to UIP in RA), immune suppression would be my first agent. The data are limited; there is some suggestion on biopsy that they have significant inflammation (Arnold et al., PMID 38574743). I would start with immunosuppression and have a low threshold to add anti-...
Do you de-escalate back to medium-dose ICS after starting dupilumab in a patient whose uncontrolled severe asthma had not responded adequately to high-dose ICS?
Yes, I will often de-escalate if patients are well controlled after adding a biologic. In fact, I have had times when patients decrease the frequency of their dose or even stop their controller inhalers (on their own) after a good response to biologic therapy. In these cases, it can sometimes be a c...
Do you have patients with recurrent nephrolithiasis temporarily hold potassium citrate when prescribed acetazolamide for altitude sickness prevention?
I haven’t encountered this situation before. I can see the theoretical disadvantage of combining the two medications. For short-term use of acetazolamide, I doubt there would be a problem. For longer-term use, I would monitor electrolytes and reduce or stop the potassium citrate as appropriate.
Has the FROSTBITE-2 trial changed how you choose between cryoprobe and forceps for transbronchial biopsy in your practice?
FROSTBITE - 2 trial suggested that cryobiopsy was associated with a high diagnostic yield and a satisfactory safety profile. Overall, cryobiopsy using the 1.1 mm cryoprobe for nodules, ILD, and post-transplant biopsy would be my first choice.
Would you recommend early empirical anti-mold therapy for patients with severe influenza pneumonia admitted to the ICU to reduce the incidence of influenza-associated pulmonary aspergillosis?
Although this is a known complication, I would not place someone on mold prophylaxis given the lack of supporting data, the rarity of the complication, and the fact that—when considered early—it can usually be identified based on signs and symptoms suggestive of invasive mold infection. Prophylaxis ...
How often do you recommend ophthalmologic screening exams for patients with sarcoidosis?
The American Academy of Ophthalmology has guidelines for routine eye exams for an asymptomatic, healthy individual (not someone with sarcoidosis). These guidelines include a complete, dilated eye exam at age 40, interim exams at the discretion of the patient and one's ophthalmologist, and an exam ev...
Do you use bronchodilator response to distinguish between asthma, COPD, or asthma-COPD overlap?
Combined with eosinophil count and other pertinent history that supports a diagnosis of asthma or asthma/COPD overlap.
Do you favor timely bronchoscopy for diagnostics over close surveillance in mildly symptomatic patients with CT findings suspicious for NTM infection who are not able to expectorate?
Yes, I do favor FOB to obtain BAL in symptomatic patients with suspected NTM.
Do you recommend providing supplemental oxygen for patients with a pneumothorax in the absence of hypoxemia?
I was certainly always taught that one should give supplemental oxygen to patients to decrease the size of the pneumothorax. This is based on the "nitrogen wash-out" theory, essentially, you're trying to get the partial pressure of nitrogen down in the alveoli so that it will be resorbed from the pn...