Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS, i.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). *I don't love carbidopa/levodopa for RLS. It very often causes augmentation.
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...
Should thunderstorm asthma be incorporated into asthma action plans?
Thank you for the ongoing dialogue around thunderstorm-associated respiratory events. These episodes represent not just allergen exposure but a combined aeroallergen–irritant phenomenon involving pollen fragmentation, fungal spore surges, PM2.5 downdrafts, ozone shifts, and the priming effects of pr...
Is it still significant to denote the etiology of ILD in a patient with PPF?
Yes, absolutely! Infact, the most effective treatment in patients without IPF (PPF) is treatment of the cause. So if there is underlying autoimmune disease or exposure, primary treatment should be directed against that trigger and this has potential to stop progression and even improve lung function...
What is your working definition of "CPAP failure" - number of weeks, mask trials, structured adherence intervention - before you move a patient to HGNS, OAT, or pharmacotherapy?
I have a hard time with this because my personal definition is not the current definition for payment. However, I try to determine what the patient is willing to accept for therapy before even testing them. I work at the VA, and a lot of the patients have claustrophobia and are, therefore, averse to...
Do you routinely recommend peak flow meters for asthma in your practice?
Always helpful for engaging patient in their own care, and managing exacerbations or fluctuations. Even if patient does not "need" it at first, good to have one on hand, have been trained, and establish good habit.
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
Would you biopsy calcified lung nodules and or lymphadenopathy that have shown stability over a 2-year period, in a bid to rule out sarcoidosis?
No. Certainly not without a comprehensive occupational and other exposure history. Follow "the rules" for the assessment of any sarcoidosis suspect. Do a physical exam to look for extrapulmonary signs of sarcoidosis. Order an eye exam to assess for ocular sarcoidosis. Obtain baseline MTB testing and...
Under what circumstances would you consider treating obstructive sleep apnea in an older adult who has few or no daytime symptoms?
I always treat OSA if severe with respect to the level of hypoxemia or of fragmentation of sleep (which can be approximated by the AHI). Even if there are no symptoms of daytime sleepiness, I would treat it if there are nighttime symptoms (e.g., middle-of-the-night insomnia, nocturia, or waking too ...
What is your approach to radiographically suspicious lung nodules for which initial biopsy was negative for malignancy?
It depends on how suspicious the nodule is for malignancy clinically and on the biopsy. The following criteria play into my decision-making: If the kinetics (steady growth over multiple scans) and morphology (solid and spiculated) on CT as well as hypermetabolism on PET-CT are highly suggestive of ...