Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What would be your recommendation for treatment of worsening lung disease in a patient with long-standing scleroderma after long-term mycophenolate therapy which is no longer an option due to side effect/intolerance?
Someone who has been on long-term Mycophenolate for interstitial lung disease and has had stabilization or improvement in their lung function and then is unable to tolerate the medication may be able to be switched to mycophenolic acid sodium (myfortic) which is often less toxic and better able to b...
How often are you repeating screening PFTs in patients with SARDs who have 3 or more years of normal or stable PFTs?
The answer to this question is complex and needs to be tailored to the individual patient’s risk for ILD and the particular SARD.Approximately 30-40% of patients with systemic sclerosis (SSc) will develop ILD, typically within the first 5 years after the first non-Raynaud’s manifestation and rarely ...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
In an ALS patient with FVC 60–70% predicted, normal daytime ABG, and normal nocturnal oximetry, but persistent orthopnea and unrefreshing sleep, do you initiate nocturnal NIV — and if so, how do you navigate the CMS coverage gap?
In our assisted ventilation clinic, we lean toward symptom-based initiation for patients with neuromuscular disease, including ALS. There are several strategies for navigating the coverage gap. We have found that performing both FVC and MIP measurements with supine positioning will often reveal that...
In a patient on chronic stable methadone or buprenorphine for OUD who develops symptomatic central sleep apnea, do you prioritize treating the CSA (CPAP → ASV if LVEF >45%, adjunct acetazolamide/O₂) or pushing the opioid team toward dose reduction? Where does loop-gain phenotyping change your sequence?
The starting point is to explore opioid dose reduction. If this is not feasible, then I would initiate CPAP, given the substantial overlap between OSA and CSA (co-morbid OSA is present in more than 2/3 of patients with CSA). If CSA persists, then I would consider adjunctive therapy with acetazolamid...
Do you empirically administer high-dose IV thiamine to all patients admitted with sepsis and a history of alcohol use disorder, even without clinical signs of Wernicke encephalopathy?
There is little to no downside risk for thiamine administration in comparison to severe morbidity for the failure to use thiamine, as supported by a recent review (Teixeira et al., PMID 39818490).
Do you recommend IV sodium bicarbonate for patients with rhabdomyolysis and AKI without metabolic alkalosis or hypocalcemia?
The primary goal of IV fluids and urine alkalinization in patients with rhabdomyolysis is to prevent AKI, not to treat established AKI. The most important factor in preventing AKI is early and vigorous fluid administration (aiming to achieve a brisk diuresis of 200-400 ml/hr), while the choice of IV...
In symptomatic women with an overall AHI of <5 but REM AHI >30 and meaningful REM-related hypoxic burden, do you treat?
If the study was an HSAT, might consider a PSG or repeating the test due to night-to-night variability. You can try to appeal to the insurance company for coverage.
Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?
PCV-21 was recently approved by the FDA and supported by ACIP. At this early stage (August 2024), CDC has not finalized guidance on PCV-21, so we do not know how the vaccine schedule will be changed. An important distinction is that PCV-21 covers different serotypes of pneumococcus, as outlined in t...
What serum biomarkers are most helpful in cardiac arrest prognostication?
Neuron-specific enolase. This is checked at 24, 48, and 72 hours. It is, however, NOT to be used in isolation for prognostication, which is multimodal, including clinical exam after clearance of sedation (typically at 5 days post arrest), EEG (e.g., looking for reactivity of background), NSE, and MR...