Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you use isavuconazole for treatment of moderate to severe histoplasmosis in patients with co-morbidities, acute or chronic renal failure, or other features that increase the risk of side effects of itraconazole or amphotericin?
No. I would not routinely use isavuconazole as initial therapy for moderate to severe histoplasmosis. For severe disease, liposomal amphotericin B remains the recommended first-line induction treatment, followed by step-down oral therapy, traditionally itraconazole. In patients with renal dysfunctio...
What are your vaccine recommendations while patients are on biologics?
Live vaccines are best completed at least a month before initiation of biologics when these are appropriate (e.g., MMR, chickenpox, yellow fever). The data on non-live vaccines is limited. I personally think that some degree of protection is better than none. I will not interrupt biological therapy ...
What is the goal oxygen saturation for patients with COPD and pulmonary hypertension?
Although an oxygen saturation target of 88–92% is commonly used in patients with COPD to reduce the risk of oxygen-induced hypercapnia, a higher saturation goal is appropriate in patients with pulmonary hypertension associated with COPD. In this population, we generally aim for an oxygen saturation ...
What is your approach when a patient has concomitant acute decompensated heart failure and rapid atrial fibrillation?
Is the patient stable? If not stable, then I would move towards immediate cardioversion. If stable (good BP) but poor oxygenation, then diuretic with consideration of metoprolol, digoxin, or amiodarone. If unable to tolerate BB due to lower BP, then would lean towards amiodarone or digoxin. Anticoa...
How long after initiating mycophenolate do you wait before tapering prednisone off in patients with myositis-associated ILD?
Taper Pred after 6 weeks MMF tapering to prednisone 20 mg/day and hold this dose for 6-8 weeks monitoring for relapses. If no relapse, taper to Prednisone 10 mg/day.
Does screening for sleep apnea in asymptomatic patients reduce long-term dementia risk?
Obstructive sleep apnea (OSA) is common, underdiagnosed, and increasingly recognized as a potentially modifiable contributor to late-life cognitive decline. Observational studies consistently report associations between OSA, intermittent hypoxemia, sleep fragmentation, cerebrovascular injury, Alzhei...
Do you monitor CBCs to assess for drug toxicity in patients on nintedanib?
Not typically. I've never been advised to check these, but it's worth re-examining whether it's worthwhile. Looking at the side effect profile in INBUILD and INPULSIS doesn't reveal any major cytopenias. It doesn't appear to be on the FDA prescription information, either. I think this question arise...
In drawing blood cultures from a central line to evaluate for CLABSI, do you advise drawing separate blood cultures from each port in case of dual or triple lumen line?
You don't need to use the central line to draw those cultures. Using the line to draw blood can in it by itself pose risk of introducing a microorganisms. NHSN CLABSi definition does not call for blood culture to be done from a line.
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...
How do you approach a patient with sarcoidosis who cannot tolerate steroids and who is developing ILD?
As with most questions about sarcoidosis, clear understanding of the relevant clinical context should first be established. While interstitial lung disease (ILD) is a common manifestation of sarcoidosis, it often can be safely monitored without treatment, and so radiologically identified sarcoid ILD...