Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you counsel patients on use of creatine monohydrate supplementation during a hospitalization for acute rhabdomyolysis from intense physical training?
I was a primary care doctor for the military for a few years. We regularly saw patients presenting with rhabdomyolysis from intense physical training. A standard question for all that present with this is whether supplements are being used. While there isn't a direct linkage to say that the use of c...
Should a patient on medium-dose ICS/LABA with normal PFTs, but who shows a greater than 10% decrease in FEV1 if their PFTs are done after 24 hours off their inhaler, be started on a biologic?
A little more clinical information would be useful to better answer the question. How well controlled is the patient on the LABA/ICS? What is the ACT score? The FEV1 decreased by greater than 10% (with volume >200 ml ?) when LABA/ICS was stopped for 24 hours - how quickly did it normalize when the i...
What is your approach for a primary tracheal squamous cell carcinoma?
First off as you probably know this is a randomized data-free zone. So to some extent what to do here is empiric and/or based on historic outcomes, retrospective data, and so on. But here are a few quick & dirty observations...1) Surgical patients have the best survivals/outcomes. Doing tracheal sur...
When prescribing SMART regimen for a new diagnosis of asthma, do you still prescribe rescue inhaler (i.e. SABA) if they don't have it?
When using the SMART (single maintenance and reliever therapy), I don't add an albuterol (SABA) rescue inhaler. The whole idea is to simplify things for the patient so that they maintain their asthma control and get relief with the necessary via just one inhaler. Budesonide - formoterol combinations...
How would you approach anticoagulation for a patient with acute bilateral pulmonary emboli related to malignancy, but with a concomitant cavitary lung mass experiencing episodic, small-volume hemoptysis?
This is an interesting question to which we need to apply the art of medicine, weighing the risks and benefits of treatment. The major fatal events in this exact scenario are: Recurrent PE from undertreatment. Sudden massive hemoptysis after aggressive anticoagulation. The physician's management s...
What treatment approach do you suggests for a patient with nasal polyp disease and asthma who was improved on dupilumab, but over last 2 years has begun to have increased nasal symptoms and rising eosinophil counts?
Dr. @Dr. First Last's comments are quite valuable. It might be more expedient to consider simpler options first, then progress to the less common diagnoses as needed. I very much agree that unless we know what is meant by "increased nasal symptoms", it is difficult to provide precise alternative the...
Do you consider indwelling pleural catheters in patients with refractory transudative pleural effusions?
I do as long as the risks, benefits, and possible alternatives are discussed with the patient. Frequently, these patients have refractory or end-stage heart failure, kidney failure, and liver failure. Often, they have decompensated or end-stage diseases and are not candidates for organ transplantati...
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
How do you determine whether to add abatacept or rituximab to the treatment regimen in patients with mild RA-ILD on methotrexate?
I think of many agents before rituxan for RA ILD: all in various stages of being studied MMF, Orencia/abatacept, Tocli/actemra, and even JAK inhibitors xeljanz/rinvoq. Generally, if I treat and control the joints, the lungs stabilize. 10-20% run independently from joints or extra-articular ILD witho...
Can symptomatic radiation pneumonitis ever improve spontaneously without corticosteroids?
As “pneumonitis” has always been difficult to pinpoint, and relies on “inflammatory radiologic findings” confined to XRT portals, fever, cough without positive bacterial cultures, and shortness of breath, the diagnosis is even more difficult with 3D-directed and multiple portals or mostly IMRT-deliv...