Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your approach to selecting and adjusting NIPPV settings in the management of patients with chronic hypercapnic respiratory failure?
In our clinic, which serves more patients with neuromuscular disease and advanced lung disease than OHS, most of our patients that have already developed hypercapnic respiratory failure have advanced lung disease or are the survivors of critical illness. We are hopefully catching patients with neuro...
When should we suspect ‘climate-amplified’ rhinitis/asthma versus poor control from other causes?
Before labeling rhinitis or asthma as “climate-amplified,” we must first exclude common causes of poor control: adherence issues, suboptimal controller dosing, inhaler technique, indoor allergen exposure, occupational triggers, and comorbidities (GERD, CRS, OSA, obesity). These remain far more commo...
Do you prefer awake ECMO as a bridge to lung transplantation in a spontaneously breathing patient with end-stage lung disease who is deteriorating on the waitlist, rather than proceeding to intubation and mechanical ventilation?
Yes. Avoiding intubation and maintaining muscular strength and avoiding intubation is key element to successful outcome post transplant.
How often do you recommend ophthalmologic screening exams for patients with sarcoidosis?
The American Academy of Ophthalmology has guidelines for routine eye exams for an asymptomatic, healthy individual (not someone with sarcoidosis). These guidelines include a complete, dilated eye exam at age 40, interim exams at the discretion of the patient and one's ophthalmologist, and an exam ev...
How would you manage cardiac sarcoid with intolerance/contraindications to methotrexate, azathioprine, and mycophenolate/mycophenolic acid and that has proven refractory to adalimumab and infliximab as determined by PET?
In an article by the Yale group, Gallegos et al., PMID 33997256 give a nice summary of the literature cited options for managing cardiac sarcoidosis (Non-steroidal treatment of cardiac sarcoidosis: A systematic review.Options cited here that have not been discussed include cyclophosphamide, cyclospo...
In patients with severe asthma who are candidates for biologics, do you put them on an ICS/LABA/LAMA rather than high dose ICS/LABA?
I have done both. Once I need to go to high-dose ICS/LABA or ICS/LABA/LAMA, I start looking at options for biologics. I work exclusively with children, so it depends on the age of the child and what is approved for their age. It is easier to add a LAMA under age than a biologic.
Is it acceptable to list a patient for lung transplantation who has a BMI between 30 and 35 kg/m² and is otherwise a highly suitable candidate, without first requiring weight loss to bring their BMI below 30?
Complicated decisions regarding candidacy for lung transplantation cannot, and should not, be made solely on the basis of a single numerical value. Patients with elevated BMI have been successfully transplanted, and the relationship between BMI and transplant outcomes is best described as a U-shaped...
In elderly patients with advanced melanoma and idiopathic pulmonary fibrosis receiving active antifibrotic therapy, would neoadjuvant or adjuvant immune checkpoint inhibition be preferred?
Given this scenario, it is most important to have a goal-of-care discussion. That would help sort out the optimal treatment for such patients. Always treat to relieve pain as needed.
What is your approach to managing high-volume, thick tracheal secretions in a patient with a tracheostomy when there is no clear evidence of pulmonary infection?
Managing airway secretions in patients with chronic tracheostomies can be very challenging, and secretion volume varies considerably in some patients from day to day or even hour to hour, often inexplicably. The tube itself is an irritant, as is frequent suctioning, so virtually every patient with a...
How would you approach early stage NSCLC in a patient who is not an ideal surgical candidate and has pulmonary AVMs?
The standard volumes and flows of PFTs do not assess regional differences in what is perfused and ventilated. V/Q scans do, but their most common use for pulmonary embolism is their most common role. This serves to identify gas exchange near the primary as well as where the AVM’s reside. Target the ...