Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you add empiric anti-MRSA coverage to the initial antibiotic regimen for a patient admitted with community-acquired pneumonia who has risk factors for MRSA but a negative MRSA nasal screen?
Thank you for this excellent and highly relevant clinical question. I approach this scenario by blending robust evidence-based medicine with fundamental principles of diagnostic reasoning. The short answer is generally no, you probably do not need to add empiric anti-MRSA coverage for a standard CAP...
How do you screen rheumatoid arthritis patients for lung disease (modality, frequency, patient selection)?
Theoretically, we are supposed to screen these patients obtaining a baseline chest X-ray before starting DMARD therapy. As I remember, these guidelines were formulated when MTX was still blamed for MTX lung disease although presently, even the presence of underlying ILD is not necessarily a contrain...
What factors would encourage you to choose abatacept vs tocilizumab in a patient with RA-ILD with a UIP pattern of pulmonary fibrosis?
The available literature on abatacept and tocilizumab in RA-ILD does not provide a definitive answer and hopefully with the general increase in interest in ILD we will have more definitive data in the near future. My review of the current literature suggests that abatacept has a slightly higher perc...
What is your approach to treatment in a patient with radiographic UIP but pathologic evidence of both fibrotic NSIP and UIP?
Depends on the underlying etiology and progression. I will most likely use antifibrotics, particularly for IPF or progressive fibrosis, but include immune suppression for autoimmune-related ILD.
What would be your approach to percutaneous intervention for acute plaque rupture and cardiogenic shock for a patient with cirrhosis and severe thrombocytopenia?
This is a risk benefit ratio question and the benefits of PCI far outweigh the bleeding (and paradoxically, thrombotic) risk. ASA and ADP antagonists last the lifespan of the platelet for the most part, so after the early stage of DAPT with ASA and a potent P2Y12 inhibitor, d/c’ing ASA may reduce ov...
How do you approach patients who identify so strongly with being sick or with a particular diagnostic label that it makes up a significant portion of their identity?
In many cases, the point at which this question is being asked is one at which the train has already left the station, and sickness as a way of life/career has set in. Unfortunately, with functional somatic syndromes, there is data suggesting that self-rated quality of life and functioning are lower...
Would you consider octreotide as an adjunctive therapy for patients experiencing an acute life-threatening hemorrhage, outside of standard indications such as variceal or AVM bleeding?
In very selective scenarios, when the patient is experiencing an acute life-threatening bleeding while variceal or AVM bleeding remains on the differential, yes, I would consider octreotide as an adjunctive therapy, but only as a bridge to definitive diagnosis and treatment and not as a substitute f...
Do more fractionated regimens reduce severe toxicity over SBRT in patients with ILD and early-stage NSCLC?
I personally think fewer fractions are safer, such as 30 Gy x 1 instead of 10 Gy x 5, for patients with advanced COPD or ILD. Why? It's because each time a burst of ionization events is delivered to pulmonary tissues, a wound is created that recruits an inflammatory response, which can exacerbate th...
How do you use IVC caliber and collapsibility to guide decisions about diuresis?
I use IVC caliber in conjunction with my lung exam to assist with the assessment of right and left atrial pressures respectively. The IVC assessment has many caveats in different patient populations, and evaluation with POCUS can be done in two planes to better understand IVC shape.Caveats - IVC siz...
Do you continue PJP prophylaxis indefinitely in patients on rituximab maintenance therapy?
Risk for PJP infection is usually in the context of moderate-high dose corticosteroid therapy or low T cell counts.