Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
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.
How do you approach screening for ILD in patients with a diagnosis of MCTD given the recommendation discrepancies between the most recent EULAR and ACR/CHEST guidelines?
Another excellent question! While the EULAR guidelines treat MCTD as SSc-equivalent and suggest universal screening, ACR/CHEST guidelines suggest risk-stratified screening with emphasis on symptoms, PFT abnormalities, and high-risk phenotypes.Prevalence of ILD in MCTD can be high, in the range of 30...
How do you decide between neoadjuvant or perioperative chemoimmunotherapy, as per Checkmate 816 or KEYNOTE-671, for early-stage NSCLC?
All of us caring for patients with a lung cancer diagnosis face a very challenging “now what” scenario following publications of many studies demonstrating benefits of a neoadjuvant and/or perioperative approach for the treatment of patients with resectable NSCLC with already 2 FDA approvals of the ...
How would you manage symptomatic, bilateral subsegmental PE developed after long air travel?
I generally consider air travel to be a relatively weak provoking factor. Although the 2020 ASH guidelines do not address this, the ASH Guidelines from 2018 on management of VTE cite a 2.8-fold increased risk for VTE associated with air travel, which is roughly similar to the increased risk associat...
How do you decide on the timing and number of blood cultures for suspected endocarditis given the differences in recommendations between the ESC guidelines and the Duke Criteria?
Concern about differences in recommendations regarding specifics of blood culture collection between the two guidelines should be alleviated if one understands that these are guidelines, not dictates. It would help to lay out general principles. First, the focus of infection in infective endocarditi...
Which patient characteristics or scenarios drive you to choose tezepelumab over dupilumab for asthma?
I typically put adult patients with T2 high, and allergic phenotype on dupilumab whereas those that are T2 high only or T2 low are on tezepelumab. Additionally, if the patient has nasal polyps or AD, then I would prefer dupilumab over tezepelumab. I always have a discussion with the patient regardin...
How would you approach management of a patient with seropositive RA and UIP-ILD, with concern for active lung disease?
There is a potential benefit of adding additional immunosuppression for an RA patient with a UIP pattern on HRCT. My go-to-drugs are either abatacept or rituximab. While MMF is a standard first-line medication for many forms of ARD-ILD, it was tried for RA joint disease many years ago and the study ...
What are your go-to options for managing ICU delirium in patients with contraindications to antipsychotics?
Evidence for Ramelteon (Yu et al., PMID 36726202)Delirium with behavioral disturbances Depakote Clonidine Propranolol, especially with TBI Non pharmacological Make sure they're closer to the nursing station. Constant re-orientation. Shades open during the day and close at night. Bring anything they ...
How do you manage resistant infections that persist after stopping antibiotic therapy in patients with non-CF bronchiectasis?
It depends on what is meant by resistant infections; if this means multi-drug resistant bacteria that remain present after treatment ends and when symptoms have returned to baseline, there are many things to consider. First, has the person had many exacerbations before? Or do they have minimal sympt...
Do you obtain routine blood cultures in a non-immunocompromised patient with community-acquired pneumonia who does not meet criteria for severe CAP?
Fabre et al., PMID 31942949, categorizes "non-severe community-acquired pneumonia" as low yield for bacteremia and therefore less critical and potentially wasteful/poor stewardship to obtain blood cultures, however do note that severe community-acquired pneumonia (CAP) falls into a moderate pre-test...