Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What do you think about using conventional thoracic imaging methods (e.g., X-ray, CT, etc.) to determine if a pleural effusion is of adequate size to consider thoracentesis?
Generally speaking, CT would be superior as it would allow you to see more volumetric characteristics of the effusion; XR would have a hard time discerning true size, presence of loculations, or trapped lung. The real winner for this application would be bedside ultrasound. This modality would give ...
What are the potential implications of re-introduction of 'long-term responders to calcium channel blockers' in the classification of pulmonary hypertension, and how should clinicians approach the identification and management of these patients?
The purpose of reintroducing it into the definition is to identify that rare group of IPAH who would respond to CCBand perhaps their PH is likely driven by vasoconstriction rather than vasculature remodeling. They are likely to remain stable on CCB. Long-term responders are defined as those who, aft...
Would you give consolidation durvalumab to a patient who underwent chemoradiation for his stage III NSCLC and is being started on antifibrotic therapy by pulmonology for his ILD?
This is a difficult scenario. On the one hand, we know from the PACIFIC trial that there is a clear benefit to the addition of durvalumab in this setting. On the other hand, there is a higher risk of pneumonitis due to both the prior use of radiotherapy and the history of underlying ILD. I think ECO...
What is the goal oxygen saturation for patients with COPD and pulmonary hypertension?
Although an oxygen saturation target of 88–92% is commonly used in patients with COPD to reduce the risk of oxygen-induced hypercapnia, a higher saturation goal is appropriate in patients with pulmonary hypertension associated with COPD. In this population, we generally aim for an oxygen saturation ...
Would you recommend starting tolvaptan at 7.5 mg per day, which is half the typical starting dose, to reduce the risk of overcorrection in an inpatient with SIADH and a serum sodium level of 122 mEq/L?
If it is for SIADH, I always start with 7.5 mg. See this, my fellow and I put together years ago. Dosing in SIADH: A Tale of Two Tolvaptans If it is for CHF, I would start with 15 mg as those patients are so pre-renal, their distal delivery is so impaired, and tolvaptan is limited by that. I haven't...
Do you routinely use pupillometry for serial neurologic examinations in the ICU, especially for patients at risk for transtentorial herniation?
We frequently do pupillometry assessments on patients at high risk of ICP crisis. It gets rid of observer subjectivity as it is often an issue in ICUs. We have a protocol with the following indications for q1h pupillary assessments. It is not based on particular guidelines but serves as a good marke...
What is your preferred third antimicrobial agent for a patient with treatment-naive pulmonary MAC without cavitary disease and strict contraindications to utilization of rifampin or rifabutin?
There’s no clear winner yet. Inhaled liposomal amikacin solution has good potential and the data is trending this way with earlier clearance shown but the long-term outcomes, I believe are still pending. I’m relatively unconvinced or underwhelmed by moxi but as a third drug in the seemingly rare occ...
How do you plan to integrate nerandomilast into the treatment algorithm for patients with ILD?
That’s a great question and one we’re all still actively defining in real time as this new agent enters practice.First, I always start with the basics—diagnosis and disease behavior. Before starting any antifibrotic, I make sure the ILD diagnosis is solid through multidisciplinary review and that th...
What is your approach to empiric treatment of achromobacter infections?
Achromobacter is a Gram-negative bacterium in the Burkholderia order. This pathogen is significant in immunocompromised patients, such as those with cancer or Cystic fibrosis, and is seen with bacteremia or causing pneumonia. They can also be associated with foreign device infections. Typically, the...
When do you consider a trial of steroids for acute hypoxemic respiratory failure when there are no other clear indications for its use (i.e., COVID, COPD, organizing pneumonia, etc.)?
We will consider a trial of systemic corticosteroids in patients with moderate-to-severe acute respiratory distress syndrome (ARDS) within 14 days of onset—even when no other clear indications are present (such as COVID-19, COPD, or organizing pneumonia). This is supported by the 2024 American Thora...