Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Should a patient on medium-dose ICS/LABA with normal PFTs, but who shows a greater than 10% decrease in FEV1 if their PFTs are done after 24 hours off their inhaler, be started on a biologic?
A little more clinical information would be useful to better answer the question. How well controlled is the patient on the LABA/ICS? What is the ACT score? The FEV1 decreased by greater than 10% (with volume >200 ml?) when LABA/ICS was stopped for 24 hours - how quickly did it normalize when the in...
Is there a role for dual antibiotic treatment with ethambutol and macrolide only, as opposed to three-drug antibiotic therapy, in the treatment of treatment-naive pulmonary MAC without cavitary disease?
That is a great question, as the role of rifampin (or rifabutin) regarding its relative contribution to the treatment of MAC is not overly clear. Historic data that is a few decades old raised the possibility of better activity when a rifamycin is combined with ethambutol (at least in vitro and furt...
Would you offer lung SBRT in a patient with Pulmonary Langerhans Cell Histiocytosis (PLCH)?
Langerhans cell histiocytosis (LCH) is a clonal proliferation of Langerhans cells (dendritic cells), part of the mononuclear-phagocytic system. Some patients present with unifocal disease, often in bone. A variety of treatments are acceptable for unifocal disease, including radiation therapy. Very l...
Would you recommend anti-fungal treatment for aspergillus infection for a patient with an incidental finding of worsening ground glass opacities and enlarging nodules on CT chest with positive BAL galactomannan, elevated aspergillus IgE and IgG in an otherwise immunocompetent host with no respiratory symptoms?
No, I would not recommend antifungal treatment in this case. The patient, as described, does not seem to have invasive aspergillosis, chronic necrotizing aspergillosis, or allergic bronchopulmonary aspergillosis, so I don't believe antifungal treatment is indicated. There may be other details of the...
Do you obtain an MSLT or start empiric therapy with modafinil in patients with residual excessive daytime sleepiness despite optimal adherence to PAP therapy?
In this situation I would start either modafinil, armodafinil, or solriamfetol for residual EDS if the OSA was appropriately controlled without need for MSLT. We have an FDA label for these medications in this situation to support this practice. If I felt like there was concern for a combination of ...
How could POCUS be useful in the initial evaluation of a severely ill patient in whom infectious endocarditis is suspected?
I love this question. POCUS is very useful in this patient population, both in diagnosis and management, though data are mostly limited to case reports and case series (López Palmero et al., PMID 41016280). Remember that transthoracic echo (TTE) is not as sensitive for infectious endocarditis as tra...
What is your approach to REM behavior disorder not adequately treated with melatonin and clonazepam?
Rule out comorbidities like sleep apnea or medications causing RBD. Optimize doses for melatonin and clonazepam, and consider dual therapy with these. Other options are gabapentin or pramipexole. Thanks,Sam Morkous
How aggressively do you screen the menopausal patient presenting with new or worsening insomnia for OSA, and what is your threshold for in-lab PSG after a negative HSAT in this population?
I would treat the insomnia and do actigraphy or obtain data from an Apple Watch, or even repeat HST before doing an in-lab. At least once in a while, there is someone scheduled in the sleep lab who cannot sleep and leaves in the middle of the night.
What dose of methotrexate do you typically continue to prevent antibody formation when adding infliximab for sarcoidosis?
Infliximab is a chimeric molecule that contains approximately 25% murine protein, so it can be immunogenic in some individuals.Development of anti-infliximab antibodies (ATI) has been reported in various autoimmune diseases treated with infliximab.Around 10 to 50% of individuals with rheumatoid arth...
Do you recommend that your patients with COPD avoid gabapentin or pregabalin entirely, given the increased rate of exacerbations noted in patients on these medications?
No, I don't exclude gabapentin or pregabalin as therapeutic options for patients with COPD. The study of Rahman is a cohort study that suggests an interesting association but has limitations, including residual confounding variables and a lack of smoking information on the study population. The issu...