Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How would you manage an intermediate-risk segmental PE that is transiently provoked after a knee surgery?
Segmental suggests small PE and prob intermediate-low risk. But still look at vitals, RV/LV ratio, and clot burden. Again, clot sounds small (no lobar, main PA or saddle, but look for contrast-reflux into IVC/liver. Try to look at RV FUNCTION by echo if possible, and echo also allows ruling out a cl...
Do you seek pathologic confirmation before proceeding with empiric immunosuppressive therapy in symptomatic patients with radiographic NSIP?
In general, getting lung biopsies is needed in a minority of people who have clear evidence of NSIP on HRCT. If there is any evidence to suggest a concomitant ARD, a biopsy will not typically be needed. In our combined ILD-Rheumatology clinic, we see these patients all the time and I can think of on...
What is your approach to treating recurrent organizing pneumonia in patients with side effects from steroids?
The first approach is trying lower dose steroids. More is not necessarily better in many cases. If this strategy is ineffective in attenuating symptoms and making any radiographic changes, then one may consider mycophenolate mofetil (MMF), which is increasingly used as the preferred glucocorticoid-s...
How do you taper dopamine agonists for RLS in patients experiencing augmentation?
Slowly. Abrupt withdrawal from agonists can cause mood dysregulation (dopamine agonist withdrawal syndrome) and in RLS patients, would likely exacerbate RLS symptoms.Adding gabapentin to the regimen prior to slow withdrawal of the agonist would probably help avoid worsening RLS symptoms during this ...
How do you manage resistant infections that persist after stopping antibiotic therapy in patients with non-CF bronchiectasis?
In patients with non-CF bronchiectasis who continue to have infections after completing antibiotics, I first obtain repeat sputum cultures to identify the organism and check for any resistance patterns. I also review adherence to airway clearance techniques, as inadequate mucus clearance often contr...
Does your working phenotype for ‘new PAH after LT’ (occult POPH vs PAH unmasked after HPS resolution vs distinct post-LT vasculopathy) change what you actually do—specifically, who you screen more aggressively and when you initiate PAH therapy?
In pre-liver transplant patients with known hepatopulmonary syndrome (HPS), we do pay greater post-transplant attention to those considered to have "large intrapulmonary shunts," marked lung-brain uptake with technetium-99m macroaggregated albumin (⁹⁹ᵐTc-MAA) scanning (>30%) or poor response to 100%...
Do you routinely discontinue atypical coverage in community-acquired pneumonia when PCR testing (i.e., respiratory pathogen panel) is negative for atypical organisms?
In community-acquired pneumonia (CAP), here is how I approach the decision to discontinue atypical coverage (e.g., azithromycin or doxycycline) when respiratory pathogen panel PCR testing is negative for atypical organisms (most commonly, Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneum...
In patients presenting with disabling acute ischemic stroke symptoms early in the therapeutic window, would you consider anticoagulation reversal to enable administration of intravenous thrombolytics?
In short, 'no'. For patients who have a large vessel occlusion, there is the option of proceeding directly to EVT without thrombolysis. We know from the direct EVT trials that although concurrent or sequential thrombolytic drug treatment followed by EVT is better, it is better only by a small amount...
How do you approach screening for ILD in patients with a diagnosis of MCTD given the recommendation discrepancies between the most recent EULAR and ACR/CHEST guidelines?
Another excellent question! While the EULAR guidelines treat MCTD as SSc-equivalent and suggest universal screening, ACR/CHEST guidelines suggest risk-stratified screening with emphasis on symptoms, PFT abnormalities, and high-risk phenotypes.Prevalence of ILD in MCTD can be high, in the range of 30...
Do you continue Trikafta throughout pregnancy in a woman with cystic fibrosis who has adequate lung function and is in a stable clinical state, rather than discontinuing therapy out of concern for unknown fetal risk?
I think this is an area where shared decision-making is needed. My default answer tends to be continue for anybody with CF, as in general, ETI has been found to be safe, except for some increased monitoring for the infants after birth. If the pregnant person is 100% asymptomatic, has no bronchiectas...