Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you utilize the bronchiectasis severity index (BSI) in your approach to managing non-CF bronchiectasis?
I calculate it for academic reasons in my bronchiectasis clinic. It perhaps affects the frequency of visits in the clinic. Otherwise, not much practical application. I respond to daily cough and secretion management with stepping up airway clearance, and to frequency bronchiectasis exacerbations wit...
What alternative, low-effort airway clearance strategies do you use in frail neuromuscular patients who are unable to tolerate or fail manual chest physiotherapy (e.g., oscillating PEP devices, high-frequency chest wall oscillation vests, or mechanical insufflation-exsufflation/cough assist)?
Airway clearance is key to quality of life and prolonged survival in frail NMD patients, sometimes adding decades, depending on the particular NMD and other factors (luck and prayers don't hurt). Most tolerate manual techniques (i.e., quad coughing) reasonably well, so I wouldn't wait for them to no...
How do you treat idiopathic hypersomnia inadequately responding to modafinil?
I agree with @Dr. First Last. I usually start my patients on modafinil or armodafinil. If those do not work, I will try solriamfetol. I will supplement with as needed amphetamines as well. I do not often go straight to sodium oxybate/low-sodium oxybate, as you need the right patient for this medicat...
How do you characterize pleural effusions on POCUS between trace, small, moderate, and large?
Assuming the effusion is free-flowing and not loculated, there are a few equations out there that can help quantify pleural effusion volume based on whether the patient is supine at max inspiration, supine at end-expiration, or sitting upright. In my hospitalist practice, I don't usually calculate b...
Do you recommend the use of portable high-efficiency particulate absolute air cleaners to former smokers with moderate to severe COPD?
This is a regional decision that is based upon ambient air pollution, such as wildfire smoke in the Southwest, and can be trialed before purchase to evaluate symptomatic efficacy. The CLEAN AIR STUDY (Hansel et al., PMID 34449285) did not validate improvement in total St George's Respiratory Questio...
Do you have any strategies for increasing yield while doing bronchoscopic biopsy with EBUS?
Well, there are multiple factors that can help with improved yield, ranging from the skills of the team (NOT just the bronchopist), ROSE and even sample processing and the cytopathologist reading the sample. It will be a whole book chapter to go through all factors. I will just focus on the number o...
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.
How important is a severely diminished diffusion capacity in determining whether to offer a lung cancer patient radiotherapy?
Conventionally, Pulmonary function tests (PFTs) are considered essential before considering thoracic surgery and by extension this rule has applied to definitive radiation. This is because baseline pulmonary function (PF) can predict the risk of pulmonary complications after thoracotomy, and patient...
What findings on routine monitoring PFTs prompt you to pursue HRCT in your patients with SARDs?
I don't think there is a way to set specific recommendations for this. Declines in physiology without other explanation, with or without symptoms, prompt me to get imaging. This is taking into consideration other things that affect the FVC and DLCO, but any significant decline (5% or greater?) would...
How have you improved your serious illness conversation skills over the course of your career?
I surely hope that my communication skills have improved over the course of my career (in the same way that being a doctor has improved). However, improvement as a clinician doesn't just happen. One has to be intentional about it. Things that will help: Take a course. VitalTalk runs a number of edu...