Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
For a patient on appropriate treatment for invasive aspergillosis, how do you determine if and when it is acceptable to reintroduce a TNF inhibitor that likely contributed to their acquisition of the infection but is considered essential for control of their inflammatory condition?
There is no established answer to this question. The reintroduction of a TNF inhibitor must be individualized based on the clinical situation of the patient under consideration. There are two critical questions. First, how much does the patient need the inhibitor”? The more the patient is dependent ...
What is your approach to treatment of airway involvement, such as recurrent bronchial stenosis, in relapsing polychondritis?
Depending on the location of airway involvement from the subglottic area to the trachea and central airways, options include cryo-spray ablation, balloon dilation, APC/Laser ablation (less favored), Kenalog injection and airway stenting. Typically, combined modalities are more effective than single ...
How do you approach PJP prophylaxis in patients with rheumatic disease on corticosteroids?
Here is a graphic I made covering PJP Prophylaxis with Dr. @Dr. First Last if anyone is interested! As noted, one can check absolute lymphocyte count (ALC) or CD4 count as factors to further risk stratify as well.
How long do you continue rituximab in patients with ANCA associated vasculitis who have achieved remission?
My approach is to use rituximab every 6 months for remission maintenance for at least 2 years. Past that point, a lot depends on the individual patient circumstances. For patients who have already suffered substantial organ damage, for whom another flare could be catastrophic (e.g., a patient with s...
What is your hemoglobin target for PRBC transfusion in cases of acute brain injury?
At our institution, our hemoglobin goal has always been 7 except for TBI patients, in which the goal has been 8.5. The TBI goal was a bit arbitrary and really just split the difference between 7 and 10 given some of the contradictory data. Given the new HEMOTION and TRAIN trials, we are revisiting o...
In a patient with low titer +anti-SAE antibody and known ILD, but no other clinical features of dermatomyositis, how would you approach further testing or would you treat the patient as dermatomyositis associated ILD?
When someone with ILD has an isolated biomarker without other clinical features associated with that biomarker, I have to ask myself these questions: first, is the biomarker simply a false positive because I have tested a plethora of biomarkers and second, is ILD the initial or only manifestation as...
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...
What's the threshold to consider a PSG abnormal enough to preclude a MSLT the following night?
To cancel the next day MSLT, I would consider cancelling or rescheduling if AHI > 10 or 15, TST < 6 hours, poor sleep efficiency (<70%), positive drug screen, staff identification of a circadian rhythm disorder we were not aware of before, etc. I have also heard of sleep docs cancelling for a low am...
What are the potential implications of re-introduction of 'long-term responders to calcium channel blockers' in the classification of pulmonary hypertension, and how should clinicians approach the identification and management of these patients?
The purpose of reintroducing it into the definition is to identify that rare group of IPAH who would respond to CCBand perhaps their PH is likely driven by vasoconstriction rather than vasculature remodeling. They are likely to remain stable on CCB. Long-term responders are defined as those who, aft...
Do you recommend air purifier in bedrooms and office/workplaces of patients with chronic lung disease?
As with many answers within medicine, the answer is "it depends." Asthmatics or individuals with airway-related environmental triggers such as COPD overlap syndrome may benefit from air purification systems -- either as part of a central HVAC system or utilized as a portable unit used within sleepin...