Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you routinely repeat imaging for PE after anticoagulation treatment to establish a new baseline?
We only do imaging if the patient is symptomatic still after a few weeks or has persistent chest pain or clinical signs of pulmonary hypertension. Rarely I have seen recurrent or progressive thromboembolic disease on anticoagulation. Another possible reason if the patient needs to go to surgery in t...
Do you recommend avoidance of occupational/environmental exposures in patients with pulmonary sarcoidosis?
The best assessment of occupational exposures associated with pulmonary sarcoidosis comes from A Case Controlled Etiologic Study of Sarcoidosis (ACESS). This is nicely summarized in a state-of-the-art article that lists occupations and exposures with both positive and negative associations between o...
Can symptomatic radiation pneumonitis ever improve spontaneously without corticosteroids?
As “pneumonitis” has always been difficult to pinpoint, and relies on “inflammatory radiologic findings” confined to XRT portals, fever, cough without positive bacterial cultures, and shortness of breath, the diagnosis is even more difficult with 3D-directed and multiple portals or mostly IMRT-deliv...
How do you counsel an otherwise healthy patient on how soon they can go back to moderate exercise after a bilateral pulmonary embolism?
Generally, the approach is to have the patient start their exercise regimen at a lower intensity and gradually increase it based on their tolerance.
How do you counsel eligible patients on lung cancer screening who are hesitant because of the cancer risk from CT scans?
This is simple. The risk of lung cancer in patients who have smoked for >20 years is orders of magnitude higher than the theoretical risk of medical X-ray-induced cancers from low-dose CT (LDCT) screening. A typical LDCT scan exposes patients to approximately 1.5 mSv of radiation, equivalent to abou...
Do you use an antibiotic with antitoxin activity for the entire duration of therapy for patients with necrotizing MSSA or MRSA pneumonia or just until definitive clinical improvement?
I misread the question. I assumed a necrotizing S. aureus infection meant a necrotizing skin and soft-tissue infection. I’m not sure how “necrotizing pneumonia” is being defined here. Regarding MRSA pneumonia with toxin-mediated tissue injury, there are data suggesting that linezolid may yield bette...
Do you continue calcium channel blocker monotherapy in a patient with idiopathic PAH who had an acute vasoreactive response at diagnosis and achieved WHO functional class I or II at 12 months, or would you still add disease modifying therapy with sotatercept?
This is a data-free zone. However, given that many patients who are calcium channel blocker responsive often normalize or near-normalize their hemodynamics, there often is no need to add additional therapies. Most PH clinicians would increase the calcium channel dose prior to switching or adding cla...
How do you approach treatment in a patient with +anti-CCP antibodies, negative RF and no current evidence of active inflammatory arthritis, but progression of NSIP?
In these cases, observing a positive CCP suggests some form of an immunologic or autoimmune driven porcess responsible for the NSIP. The result may justify the use of immunosuppressive therapies, including corticosteroids and other drugs, to treat the lung disease. Anecdotally, the CCP positivity co...
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 continue voriconazole beyond the minimum recommended duration in a patient with invasive pulmonary aspergillosis who is clinically improved but has persistent radiographic abnormalities on CT?
The "recommended" duration is based on expert opinion, rather than trials. The immune status of the patient counts. When I was taught how to treat invasive aspergillosis at the National Cancer Institute (this was before voriconazole was available), the recommendation was to continue treatment until ...