Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What do you think about using conventional thoracic imaging methods (e.g., X-ray, CT, etc.) to determine if a pleural effusion is of adequate size to consider thoracentesis?
Generally speaking, CT would be superior as it would allow you to see more volumetric characteristics of the effusion; XR would have a hard time discerning true size, presence of loculations, or trapped lung. The real winner for this application would be bedside ultrasound. This modality would give ...
What are the potential implications of re-introduction of 'long-term responders to calcium channel blockers' in the classification of pulmonary hypertension, and how should clinicians approach the identification and management of these patients?
The purpose of reintroducing it into the definition is to identify that rare group of IPAH who would respond to CCBand perhaps their PH is likely driven by vasoconstriction rather than vasculature remodeling. They are likely to remain stable on CCB. Long-term responders are defined as those who, aft...
Do you routinely use pupillometry for serial neurologic examinations in the ICU, especially for patients at risk for transtentorial herniation?
We frequently do pupillometry assessments on patients at high risk of ICP crisis. It gets rid of observer subjectivity as it is often an issue in ICUs. We have a protocol with the following indications for q1h pupillary assessments. It is not based on particular guidelines but serves as a good marke...
What is your preferred third antimicrobial agent for a patient with treatment-naive pulmonary MAC without cavitary disease and strict contraindications to utilization of rifampin or rifabutin?
There’s no clear winner yet. Inhaled liposomal amikacin solution has good potential and the data is trending this way with earlier clearance shown but the long-term outcomes, I believe are still pending. I’m relatively unconvinced or underwhelmed by moxi but as a third drug in the seemingly rare occ...
How do you plan to integrate nerandomilast into the treatment algorithm for patients with ILD?
That’s a great question and one we’re all still actively defining in real time as this new agent enters practice.First, I always start with the basics—diagnosis and disease behavior. Before starting any antifibrotic, I make sure the ILD diagnosis is solid through multidisciplinary review and that th...
Do you suggest using a vascular probe to assess the superficial vasculature prior to performing a bedside procedure such as paracentesis, thoracentesis, lumbar puncture, etc.?
Yes - this is now standard of care for paracentesis and thoracentesis, and we have had a couple of bleeding complications when it was not used, and then a vessel was noted on POCUS after the fact. So it really should be incorporated into standard practice and taught such that it's done consistently....
How routinely do you use POCUS to assess fluid responsiveness in patients with sepsis?
I do use this sometimes, but would recommend using it with caution and only as one piece to the puzzle - IVC ultrasound should never be used in isolation. My most recent example was a patient who initially appeared volume overloaded, then was found to have sepsis. When I looked at his IVC, it was ex...
How do you approach management of an ICU patient with brief potentially ictal rhythmic discharges (BIRDs) on EEG?
This is a very challenging question, and the clinical importance of BIRDs, besides being associated with an increased frequency of seizures (Yoo et al., PMID 24535702 ), is unclear. I am a neurointensivist, and in general, I do not escalate therapy for intermittent BIRDs unless we identify concomita...
Should long-acting subcutaneous insulin be started upfront in addition to regular insulin infusion for patients with diabetic ketoacidosis?
Current ADA guidelines suggest patients with uncomplicated mild or moderate DKA may be treated with subcutaneous rapid-acting insulin analogs every 1-2 hours as an effective alternative to IV insulin, but still only recommend IV short-acting insulin by continuous infusion for moderate-severe DKA. Ho...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...