Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
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...
In a patient with occupational coal mine dust exposure, how do you interpret the presence of non-necrotizing granulomas in a lung biopsy specimen with respect to a possible diagnosis of coal workers’ pneumoconiosis (CWP)? Does this finding favor CWP, make it less likely, or is it nonspecific?
The finding of non-necrotizing granulomas is atypical of the histology of coal workers' pneumoconiosis (CWP) and could be indicative of co-incident sarcoidosis, especially if there are other features of sarcoidosis, such as bilateral hilar adenopathy, etc. It could also be a manifestation of a co-ex...
Do you recommend treating Candida albicans on urine culture from an indwelling catheter in a patient with septic shock?
In a patient with septic shock, one is typically obligated to treat all things until further culture data is back, etc. If there are other clear causes of shock, I would not treat the candida (though I would try to change the catheter ASAP). If the patient is extremely ill and no other sources of in...
Do you plan to use benralizumab to treat acute exacerbations of asthma or COPD associated with eosinophilia?
Currently, I do not use benralizumab for acute exacerbations of asthma or COPD, even with eosinophilia. Its role is in long-term maintenance for severe eosinophilic asthma, not in the acute setting where rapid-acting therapies are required. I’ll reconsider if emerging data support the benefit in exa...
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...
What factors do you consider when deciding between monotherapy with an antipseudomonal cephalosporin and combination therapy in ICU patients with Pseudomonas aeruginosa bloodstream infection who are not in septic shock?
In a patient who is critically ill, combination therapy can be used if there is concern that there may be a drug-resistant organism. In that case, a combination regimen can be used while awaiting the susceptibility test results. The combination choice should be based on the resistance patterns of th...
Do you ever consider tapering off steroid-sparing agents in patients with stable non-IPF ILD?
In short, the answer is YES—I always look for ways to reduce immunosuppression exposure over time and use the lowest effective dose required to keep a patient’s inflammatory ILD in check. I often remind myself that when these patients present with a mixture of fibrotic changes (e.g., traction bronch...
What factors do you consider for patients on an individual basis when establishing a post-cardiac arrest MAP goal after ROSC is achieved, considering some may benefit from higher MAP goals for optimal cerebral perfusion?
I generally aim for a MAP of 70. However, I am more concerned with ensuring end organ perfusion and will track urine output, lactate, mental status, and LFTs in addition to the physical exam (cool vs warm and absence of mottling). MAP goal adjustment should also be considered in instances with a wid...
How has the FLUID trial, which showed no significant difference in death or readmission rates between Lactated Ringer’s solution and normal saline, influenced your approach to IV fluid management?
The choice between normal saline and Lactated Ringer's should be individualized. Normal saline is preferred in patients with hyponatremia or metabolic alkalosis. Lactated Ringer's is preferred in patients with hyperchloremic acidosis, and it should be avoided in patients with hyponatremia since its ...
How do you decide which IV opioid to use for symptom relief at the end of life?
For patients at the end of life who need IV medications for symptom relief, I choose morphine, hydromorphone, or fentanyl depending on the patient's baseline opioid tolerance, symptom burden, and their kidney and liver function. Morphine is the lowest potency of these three options and is a good cho...