Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
For hospitalized patients with confirmed viral respiratory infections who clinically improve but remain PCR-positive, how long do you maintain isolation precautions?
This is a great question and one that routinely comes up for patients, their families, and staff. Precautions should be continued until symptoms improve and for a minimum of 14 days after the onset of signs and symptoms. This is especially important for patients who can spread virus to individuals t...
Do you recommend treating Candida albicans on urine culture from an indwelling catheter in a patient with septic shock?
In a patient with septic shock, one is typically obligated to treat all things until further culture data is back, etc. If there are other clear causes of shock, I would not treat the candida (though I would try to change the catheter ASAP). If the patient is extremely ill and no other sources of in...
What are the best techniques to reduce POCUS artifact and increase the diagnostic accuracy of lung ultrasound?
It is important to first clarify that essentially all of lung ultrasound is artifact, and this is a great illustration of how artifact can actually help us to make a diagnosis rather than obscuring it. When we see B-lines, for example, that is an artifact that does not represent a similarly appearin...
Do elevated neutrophils in the bronchoalveolar lavage of patients with sarcoidosis have any prognostic value?
Neutrophils in the alveolar space are uncommon in healthy non-smoking individuals, accounting for around 1% of cells in bronchoalveolar lavage (BAL). Macrophages compose 80–90% of the cells policing the alveolar surface, with the remaining cells being lymphocytes, rare eosinophils, and basophils. A ...
How do you manage moderately severe RLS in a patient with advanced CKD (eGFR 15–30) who has developed dopaminergic augmentation on a dopamine agonist, given that standard gabapentinoid replacement agents carry significant accumulation risk at this level of renal impairment?
This is a challenging picture. I suggest slow tapering of the dopamine agonist while proceeding to the next therapy. I propose the following steps. Check ferritin/TSAT → give iron if low, IV iron may be needed. Start low-dose gabapentin or pregabalin (renal dosing). Titrate cautiously. Severe persis...
When, if ever, would you consider methotrexate over prednisone for first line therapy in patients with pulmonary sarcoidosis?
The PREDMETH trial supports the use of methotrexate for initial therapy for sarcoidosis. Future studies may identify subgroups that may benefit from the concurrent use of prednisone initially; it is unclear how soon methotrexate may provide symptomatic relief compared to the ability of an appropriat...
In what circumstances would you consider monotherapy for empiric treatment of unresectable nontuberculous mycobacterial lymphadenitis?
NTM lymphadenitis is rather uncommon, and I personally have little experience with it and did not see it much even at NJH. However, extrapolating from how I treat any NTM disease in general, I would shy away from monotherapy in any NTM disease, preferring at least two active agents. Perhaps one scen...
What would be your second pressor of choice if patients with LVOT obstruction remain persistently hypotensive on phenylephrine?
In patients with LVOT obstruction who remain hypotensive despite treatment with phenylephrine, choosing an appropriate second pressor requires careful consideration of the hemodynamic goals and the specific pharmacologic properties of available agents. Here are a few points: While the specific liter...
Would you recommend early empirical anti-mold therapy for patients with severe influenza pneumonia admitted to the ICU to reduce the incidence of influenza-associated pulmonary aspergillosis?
Although this is a known complication, I would not place someone on mold prophylaxis given the lack of supporting data, the rarity of the complication, and the fact that—when considered early—it can usually be identified based on signs and symptoms suggestive of invasive mold infection. Prophylaxis ...
How do you manage erythrocytosis secondary to sotatercept for patients with PAH?
I have not done that yet, but I have let Hgb drift up to 18-19 and monitor the patient closely. I lower the dose to 0.5 or even 0.3, if Hgb is high at baseline, then start and stay at 0.3 before I increase. I will consider phlebotomy if the above options are not available.