Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
When do you usually introduce conversations regarding tracheostomy placement in patients with refractory status epilepticus, or other conditions where one may anticipate delayed awakening?
It depends on the underlying pathology and how long the patient is expected to have impaired airway reflexes requiring prolonged mechanical ventilation. In the Setpoint 2 trial, among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy (</= 5 days), compare...
After starting high-dose SMART, what maximum total daily inhalations are appropriate?
From GINA: "For MART with beclometasone-formoterol, GINA suggests patients can use up to 12 inhalations total in one day temporarily if needed based on extensive formoterol safety data, including from studies of budesonide-formoterol".
What is the interpretation of two IGRAs with negative mitogen wells, in the absence of immunosuppression?
If I understand this case correctly, the patient is actively ill and the patient's doctors are considering tuberculosis as a possible etiology of the patient's illness. In that scenario, IGRAs and PPDs have a limited to no role. Epidemiology, family history, and other possible exposures do. In your ...
How do you approach caring for patients admitted with decompensated CHF, but who also exhibit hypotension and do not have overt signs of hypervolemia on exam?
This is a case where you might be concerned about the patient sliding into cardiogenic shock. Remember that in the context of chronic heart failure, cardiogenic shock tends to present more insidiously because these patients are typically compensated at low or borderline low cardiac output (Abraham e...
For cancer patients with suspected PE, how should the HYDRA trial--which proposes using the YEARS algorithm is as safe as a CTPA-only approach--change the diagnostic workup?
The YEARS algorithm was originally developed to determine which adults with suspected pulmonary embolism (PE) can safely avoid computed tomographic pulmonary angiography (CTPA). It uses three criteria — clinical signs of deep-vein thrombosis, hemoptysis, and PE judged the most likely diagnosis — com...
What is the rationale/evidence to support doing 4 puffs of albuterol vs. 2 puffs for a reversibility study?
The rationale per ATS in 2005 is that 4 puffs of albuterol is higher on the dose-response curve and thus would potentially avoid getting a suboptimal (< 12%, < 200 mL) response from 2 puffs. Having said that, there was a study of this issue in 240 pediatric patients showing non-inferiority of 2 puff...
How do you approach the management of patients with mildly elevated mPAP (21-24 mmHg) and PVR (2-3 WU) who may be at risk of progression, given the recent changes in the hemodynamic definition of pulmonary hypertension?
The "new" definition of PH with a cutoff of 20 mmHg is a very sensible change, based on the study by Kovacs et al., PMID 19324955, which showed that a mean PAP of 20 mmHg is already two standard deviations above the mean PAP in normals. Thus, the cut off of 20 mmHg makes more sense than 25 mmHg.To a...
How do you decide if a patient should get follow-up perfusion imaging after acute PE when they are minimally symptomatic?
I practice essentially as reflected in the most recent AHA/ACC/ACCP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Diagnosis and Management of Acute Pulmonary Embolism in Adults.Figure 8. Evaluating Ongoing Symptoms Following Acute PE - concisely outlines the workup of patients with ongoing symptoms f...
How often, if at all, do you monitor a CBC with differential to assess peripheral eosinophilia in patients with type 2 inflammatory asthma who have been started on dupilumab?
For most patients, a baseline CBC with differential followed by a recheck at approximately 3 months aligns with the observed pharmacokinetics of eosinophil rebound. GINA 2026 notes transient blood eosinophilia occurs in 4–13% of patients, with rare EGPA cases potentially unmasked following OCS reduc...
How do you counsel women with cystic fibrosis on when pregnancy is reasonably safe after lung transplant?
Unfortunately, pregnancy after lung transplantation is never safe; what we usually mean by 'safe' is a close to 100% chance of a healthy baby and a healthy mother, and in the current era we cannot be certain of such odds. Having said that, there are situations where the risk of complications is lowe...