Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Can long-standing or previously treated sarcoidosis manifest as progressive airway stenosis with extensive circumferential calcification without active mucosal nodularity on bronchoscopy?
In general, endobronchial stenosis in sarcoidosis is uncommon but can occur at any Scadding stage of the disease. Calcification around the stenotic bronchus occurs in longer-standing disease and usually accompanies distal fibrocystic disease. Endobronchial biopsies show granulomatous involvement at ...
Among patients with secured subarachnoid hemorrhage who are receiving daily TCDs, what is the appropriate frequency of post operative neurological assessments?
I think a textbook might state something like "every 1-2 hours in the acute setting." However, in my opinion, the frequency of neurological examinations should be tailored to the individual patient and involves considerable clinical judgement. Factors that might influence this decision include a) se...
Do you routinely discontinue atypical coverage in community-acquired pneumonia when PCR testing (i.e., respiratory pathogen panel) is negative for atypical organisms?
In community-acquired pneumonia (CAP), here is how I approach the decision to discontinue atypical coverage (e.g., azithromycin or doxycycline) when respiratory pathogen panel PCR testing is negative for atypical organisms (most commonly, Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneum...
Is there any evidence to support further uptitration of dobutamine beyond 5 mcg/kg/min for patients with advanced HF and/or cardiogenic shock, or should further investigation into potential MCS be considered at that point?
When a patient with acutely decompensated heart failure and shock is exhibiting insufficient perfusion in spite of a given level of support, whether pharmacologic or mechanical, it is appropriate to pause and ask why. Options at this point could include an escalation of inotropic therapy (dose escal...
How do you decide when to initiate antibiotics for superimposed bacterial pneumonia in patients with influenza?
Antibiotic therapy should not be routinely prescribed for patients with influenza and should instead be reserved for those with a specific clinical concern for secondary bacterial pneumonia. This diagnosis is best identified by clinical trajectory. Key triggers include initial improvement followed b...
When giving albumin challenge, for acute kidney injury with suspected hepatorenal syndrome, do you administer a single dose daily or split the dose of albumin?
The main concern about albumin infusions is the potential risk for pulmonary edema (China et al., PMID 33657293). Therefore, I prefer to have albumin administered in divided doses of 25 grams at a time with a max daily dose of up to 100 grams, and I tend to stop IV albumin if the serum albumin level...
How do you decide when to test for Legionella in patients with pneumonia, given periodic outbreaks and risk for delayed diagnosis?
Legionella testing is really a question of pretest probability, not a reflex order on every CAP admission, and that distinction matters practically, since the ATS/IDSA 2019 CAP guideline explicitly moves away from routine testing toward a targeted strategy.The clearest indication is severity. Any pa...
For patients with severe eosinophilic asthma who continue to have exacerbations on benralizumab due to a viral/bacterial etiology, is azithromycin a reasonable add on therapy?
I would reassess the effectiveness of the biologic. Are they developing breakthrough eosinophilia during these exacerbations, thereby suggesting that the drug may not be as effective and consider switching the biologic? Consider repeating biomarkers like FeNO, and eosinophils to assess if there is a...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
How would you manage a patient with HbSS and severe pulmonary hypertension on home oxygen?
This patient should be referred to a specialist in pulmonary hypertension in sickle cell disease for right heart catheterization and aggressive management of the pulmonary hypertension. As described, the patient is not a good candidate for lung transplant or gene therapy.