Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How long do you strictly enforce low tidal volume ventilation in ARDS?
I do not believe that there is data specifically looking at during duration of LTVV in ARDS vs shorter durations. However, there are multiple trials that argue that LTVV in ARDS and patients at risk for ARDS improves mortality outcomes with minimal negative side effects. In my practice, I try to adh...
Do you maintain a strict platelet threshold of >50k when performing a lumbar puncture, or are there situations in which you feel comfortable with a lower threshold?
Our institution still uses 50k as a best practice guideline, though many of our proceduralists are comfortable performing the procedure with platelets slightly lower than 50k, and will have a risk/benefit discussion with the patient/team about the bleeding risk prior to proceeding; I myself would be...
Has your management of severe hyponatremia changed after a recent observational study described higher in-hospital mortality for sodium correction of <6 mEq/L compared to 6-10 mEq/L in the first 24 hours?
In short, no. I think the recent studies tell me two things: We need to better discriminate correction rates based on the risk of osmotic demyelination (ODS). Perhaps, do not worry so much about over-correction. They do not tell me to start rapidly correcting patients, and I guess I will summarize m...
Would you treat Scedosporium growth in expectorated sputum in a patient with COPD, pulmonary hypertension, and bronchiectasis, who has chronic dyspnea with exertion, thick sputum production, negative bacterial cultures, and no signs of mold infection on a high resolution CT scan, with no other clinical symptoms of infection?
In persons with bronchiectasis, almost anything that grows can be a pathogen, but it is tough to know. If the patient has COPD and no other immunocompromising conditions, I would not expect typical invasive fungal infection findings. Having said that, scedosporium is not the first common pathogen th...
Would you perform screening for pulmonary hypertension in a patient who has biopsy-proven Sjogren's but has a centromere antibody?
Generally, the risk of pulmonary hypertension in Sjogren's is low - about 2% in a recent study using RHC for diagnosis (Coppi et al., PMID 40058609). There have been no studies linking Raynaud's to pulmonary hypertension risk in Sjogren's, although this is true in systemic sclerosis. So the real que...
When do you recommend limited or targeted respiratory pathogen testing versus a full respiratory pathogen panel in a patient presenting with URI symptoms?
I think we’re asking the wrong group of people. How infectious disease physicians use respiratory pathogen panels is not the same as how emergency medicine or urgent care clinicians use them. For stewards of diagnostics, especially ID providers, the test often doesn’t change management. In many sett...
How do you manage anticoagulation for patients with DVT/PE who have brain metastases?
Not all brain metastases pose the same risk to patients. Rapid, numerous (even if tiny), new onset metastases from RCC or melanoma (especially BRAF mutant) can go from asymptomatic to life threatening hemorrhage within 1-2 weeks and I would strongly caution anti-coagulation in these patients. If the...
How do you approach a positive Quantiferon/PPD test result in a patient for whom testing is sent without a clinical indication and who does not have a risk factor for TB exposure nor TB reactivation?
If a test for TB infection such as a Quantiferon or PPD is done without TB exposure risk factor or clincial indication and is positive, a chest X-ray and good history for symptom assessment and exam should be done. I will assess to see if there is an increased risk of developing TB such as an immuno...
Would you consider leaving fever untreated in patients with sepsis to potentially enhance immune responses and antimicrobial efficacy?
In light of the review article attached (Tilanus et al., PMID 41113323), there is some data reviewed supporting that fever is actually therapeutic. Four articles are of special interest in the review. Two are from the 70s, before sepsis was defined as it is today. Two are in the last 15 years, but o...
What factors influence your decision between dexmedetomidine and propofol for sedation in mechanically ventilated patients?
The main factor that influences this decision in my practice is the indication for mechanical ventilation. For patients in whom the main indication is airway protection, such that the patient would not otherwise require oxygenation or ventilation support, I aim for higher RASS goals (-1 to +1) and t...