Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
In patients who develop severe precapillary PH within 6–12 weeks after LT, which potentially reversible post-transplant contributors do you prioritize ruling out before escalating PAH therapy because they are most actionable and most plausibly causal in your experience?
The development of pre-capillary pulmonary artery hypertension post-liver transplant in the timeframe mentioned can be extremely serious. Obviously, the most life-threatening concern to rule out is acute pulmonary embolism, which could cause fairly dramatic hemodynamic changes and right heart dysfun...
Do you commonly arrange home nocturnal oxygen at discharge for hospitalized patients with incidental nocturnal hypoxemia vs recommend an outpatient sleep study?
I'd say this is one of the more forward questions. I would place an order for an outpatient sleep study. If it's only happening at night while the patient is asleep, the most common cause is OSA, and nocturnal oxygen does not fix the pathophysiologic mechanism. This is consistent with the American A...
What is your approach to giving sleep aids to patients who will not address their sleep hygiene habits or contributing comorbidities?
Always suggest CBT-I but also do brief CBT in the office. Sometimes it hits home, and they realize what they’re doing is self-detrimental, but often times they just want a pill to solve the problem. If you can get them motivated enough to go back to school or get a job, then that can help in rearran...
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 ...
Do you offer dupilumab to patients with COPD and eosinophilia who are not on inhaled triple therapy?
I recently tried this due to inhaler/nebulizer intolerance in such a patient and it was refused by insurance. It makes sense from a pathophysiological perspective, and is why I do not tend to wean biologics off my asthma patients if they achieve clinical stability on it. But I do not think most insu...
In patients treated with infliximab, do rates of immunogenicity vary based on underlying disease (RA, IBD, sarcoidosis, etc) and/or baseline disease activity?
Yes, rates of infliximab immunogenicity appear to vary based on underlying disease, with evidence showing higher rates for RA than IBD and spondyloarthritis, and tend to increase with higher baseline disease activity. Most patients tend to develop anti-drug antibodies within the first year, but this...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in the setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
Do you screen for interstitial lung disease in patients with newly diagnosed polymyositis or dermatomyositis in the absence of respiratory symptoms?
I do screen all newly diagnosed IIM patients with PFTs and chest CT. This has a double purpose: establishing a baseline of lung function and, screening for lung cancer. While the patient might not have lung symptoms on presentation, respiratory involvement can manifest later on the course of the d...
How do you decide whether to empirically cover Pseudomonas for pneumonia in hospitalized patients?
The decision to empirically cover Pseudomonas aeruginosa in pneumonia among hospitalized patients depends on the pneumonia type (community-acquired pneumonia, CAP vs. hospital-acquired pneumonia, HAP), disease severity, etiology, and specific risk factors. For Community-Acquired Pneumonia (CAP) Pa...
Do you use particular cutoffs of troponin and BNP that you deem indicative of a hemodynamically significant/high-risk PE, or do you see any abnormal value as indicative?
Biomarkers are contributory variables in a multivariable assessment of any patient with pulmonary embolism. In light of the multiple factors that influence biomarker levels in a given patient, it is challenging to define one-size-fits-all cut points for meaning. It is also important to recognize tha...