Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What are first-line choices for vasopressors/inotropes to use in hypotensive patients with Eisenmenger Syndrome?
The answer is that it all depends on the etiology... However, a common issue with Eisenmenger syndrome (ES) is that routine pharmacological treatments that cause peripheral vasodilatation may worsen the right to left shunting and further shock. My first patient with ES was a gentleman recovering fro...
What factors do you consider for patients on an individual basis when establishing a post-cardiac arrest MAP goal after ROSC is achieved, considering some may benefit from higher MAP goals for optimal cerebral perfusion?
I generally aim for a MAP of 70. However, I am more concerned with ensuring end organ perfusion and will track urine output, lactate, mental status, and LFTs in addition to the physical exam (cool vs warm and absence of mottling). MAP goal adjustment should also be considered in instances with a wid...
If there is trapped lung after a thoracentesis in an outpatient setting, in a patient who has stable vitals and no dyspnea, is there a role of overnight observation?
I am assuming this question came up because there was a pneumothorax post-thoracentesis, and you are suspecting entrapped lung.If you are confident that the patient has an entrapped (trapped) lung and remains completely asymptomatic, overnight observation or hospitalization is not necessary. In case...
What factors do you consider to help guide treatment for patients with high grade large cell neuroendocrine cancers of the lung?
High-grade large cell neuroendocrine carcinomas make up a small and aggressive subset of lung cancers that histologically and regarding treatment responsiveness share features with both small and non-small cell carcinomas. These shared features have been borne out in recent sequencing studies of thi...
Are there any biomarkers, imaging, or other clinical information that can be used to better choose effective therapies for super refractory status epilepticus?
SRSE is a syndrome not a diagnosis. The key determination is if this is immune-mediated, infectious, structural, metabolic, genetic, or drug/toxic-induced. For example, if the lumbar puncture shows significant pleocytosis, in the presence of flare changes in the medial temporal lobes, especially in ...
What is your approach to volume resuscitation in patients who are third spacing fluids?
In patients with significant third-spacing (e.g., due to capillary leak in sepsis, severe pancreatitis, hypoalbuminemia, etc), we prefer balanced crystalloids (e.g., Lactated Ringer’s) as the first-line fluid for initial resuscitation in hypovolemic or septic shock with third-spacing. Typical initia...
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...
How do you decide when to initiate antibiotics for superimposed bacterial pneumonia in patients with influenza?
Antibiotic therapy should not be routinely prescribed for patients with influenza and should instead be reserved for those with a specific clinical concern for secondary bacterial pneumonia. This diagnosis is best identified by clinical trajectory. Key triggers include initial improvement followed b...
How do you approach tapering high dose continuous infusions for status epilepticus in patients experiencing serious medication-related toxicity?
The short answer is as quickly as possible. How you do it will somewhat depend on the need for ongoing continuous infusion of a sedative for treatment of status epilepticus. Probably the most severe toxicity syndrome is Propofol-Related Infusion Syndrome (PRIS), which if not recognized early, can le...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...