Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
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...
Do you prescribe bronchodilators to patients with radiographic emphysema and respiratory symptoms, but no spirometric obstruction?
Yes, I will sometimes offer a therapeutic trial of bronchodilators to symptomatic patients with radiographic emphysema, but no obstruction on spirometry. Patients with CT evidence of emphysema were not specifically studied in the RETHINC trial.
Do you perform EBUS-TBNA for staging in patients with biopsy proven malignant lung nodules with no lymphadenopathy on CT chest and PET scan?
I agree that incidence is low, but estimates for radiographically occult nodal disease range from 10-20% and the fact is there isn't great literature on this. A PET scan is a decent test, better than a regular CT, but there are still a significant minority of patients that are mis-staged when an EBU...
How do you determine the time window for which to monitor for cerebral edema development in patients with brain injury?
The type of edema definitely matters. The two big categories of cerebral edema include cytotoxic and vasogenic edema. Cytotoxic results from free water accumulation in dying cells from acute brain injury, while vasogenic edema results in disruption of the blood-brain barrier. The classic teaching is...
In patients who develop severe precapillary PH within 6–12 weeks after LT, which potentially reversible post-transplant contributors do you prioritize ruling out before escalating PAH therapy because they are most actionable and most plausibly causal in your experience?
The development of pre-capillary pulmonary artery hypertension post-liver transplant in the timeframe mentioned can be extremely serious. Obviously, the most life-threatening concern to rule out is acute pulmonary embolism, which could cause fairly dramatic hemodynamic changes and right heart dysfun...
What strategies have you found most effective for those attempting vaping cessation?
Clinicians are finding increasing success with Varencline and Nicotine Replacement Therapy (NRT) for vaping cessation. When combined with behavioral counseling, these treatments are more likely to achieve sustained abstinence than medication alone. For adolescents in particular, it is important to i...
What drug and specific dosing would you use for secondary pneumocystis prophylaxis in a patient with renal transplant, documented TMP-SMX allergy, and normal G6PD testing, who was diagnosed with moderate PJP and improved on clindamycin/primaquine and steroids?
I think the options are dapsone (which is tolerated by most patients allergic to TMP/SMX), atovaqone, and inhaled pentamidine. During my career, those choices have depended to some extent on the local practice. I have preferred inhaled pentamidine because I have worked in places with low volume and ...
Do you recommend maintaining the same monitoring interval of PFTs every 3–6 months with HRCT as indicated for patients with anti-MDA5 dermatomyositis, or do you recommend closer surveillance in this group?
Closer surveillance may be needed at diagnosis of ILD in anti-MDA5 DM at every 3 months for 1st year. But typically, in my experience, patients' symptoms progress faster than every 3 months, so rapidly progressive ILD is diagnosed clinically.