Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
When giving albumin challenge, for acute kidney injury with suspected hepatorenal syndrome, do you administer a single dose daily or split the dose of albumin?
The main concern about albumin infusions is the potential risk for pulmonary edema (China et al., PMID 33657293). Therefore, I prefer to have albumin administered in divided doses of 25 grams at a time with a max daily dose of up to 100 grams, and I tend to stop IV albumin if the serum albumin level...
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...
Do you ever consider tapering off steroid-sparing agents in patients with stable non-IPF ILD?
In short, the answer is YES—I always look for ways to reduce immunosuppression exposure over time and use the lowest effective dose required to keep a patient’s inflammatory ILD in check. I often remind myself that when these patients present with a mixture of fibrotic changes (e.g., traction bronch...
In cases of intermediate-risk pulmonary embolism, what factors influence your decision to pursue catheter-directed thrombolysis?
"Intermediate-risk" is a complex term. Patients with intermediate-low risk are not prognostically the same as those with intermediate-high risk (i.e., with elevated cardiac biomarkers and RV dysfunction) (Santos et al., PMID 31017472), and my threshold to intervene on intermediate-high risk patients...
Do you commonly observe acute erythrocytosis in patients with ILD flares being treated with supplemental oxygen and high-dose corticosteroids?
Assuming that this patient does not have erythrocytosis at baseline, my experience is that acute erythrocytosis is not typical. Erythrocytosis caused by hypoxemia typically has a lag of several weeks, even though EPO increases within 48 hours. You commonly see a moderate acute leukocytosis with high...
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...
How do you recommend incorporating B-lines on lung POCUS as part of evaluating a patient's volume status?
Great question! As you allude to in your question, it is important to address this problem holistically in the context of the patient's history, exam, labs, and other imaging. I find that this happens all of the time, and here is how I typically break them down when applying lung ultrasound. 1) 1-2 ...
How many proctored robotic assisted bronchoscopies does it take to become proficient at it?
Robotic-assisted bronchoscopy has made navigation to nodules significantly easier, and the platforms are relatively user-friendly in the sense of learning to use them. I do think that there are a ton of nuances and even after doing >500 I still learn new things. Further, and perhaps most importantly...
At what initial sodium level do you recommend strict avoidance of overcorrection (e.g., no more than 6 mEq/L in 24 hours) in patients with hyponatremia?
Less than 120.
What is your approach to follow up after embolization of pulmonary AVM in patients with HHT?
After closure of all PAVMs with feeding artery >2-3 mm diameter, I check a contrast echo (TCE) and CTA chest about 6 months later to assure that the AVM are still closed. Right-to-left shunt on TCE can be graded 0-3 using the system of Mager and colleagues. On CTA you are looking to see if all PAVM ...