Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
When would you consider prescribing a wakefulness promoting agent for excessive daytime sleepiness from insufficient sleep?
I would never consider prescribing an alerting medication for someone with insufficient sleep. Behaviorally insufficient sleep is a diagnosis in and of itself. The treatment for excessive daytime sleepiness in the case of insufficient sleep is changing behavior to allow for more time in bed. I would...
Do you recommend IV sodium bicarbonate for patients with rhabdomyolysis and AKI without metabolic alkalosis or hypocalcemia?
The primary goal of IV fluids and urine alkalinization in patients with rhabdomyolysis is to prevent AKI, not to treat established AKI. The most important factor in preventing AKI is early and vigorous fluid administration (aiming to achieve a brisk diuresis of 200-400 ml/hr), while the choice of IV...
What serologic biomarkers do you send to assess for sarcoidosis at baseline and/or during flares, in patients where it may correlate with disease activity?
Elevated ACE, dihydroxy vitamin D, and soluble IL2r levels have been shown to correlate with disease activity, but it is important to keep in mind that the sensitivity and specificity are variable and they should never be used in isolation to diagnosis or assess disease activity in sarcoidosis. The ...
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...
How would you manage cardiac sarcoid with intolerance/contraindications to methotrexate, azathioprine, and mycophenolate/mycophenolic acid and that has proven refractory to adalimumab and infliximab as determined by PET?
I think it would be important to know the doses of the medications 'failed'. Similarly to allopurinol dosing and gout prophylaxis 'failures', I find most patients I see for consultation with this story are not on high enough doses, need combo therapy, or are not on the medication long enough. Meth...
What is the rationale/evidence to support doing 4 puffs of albuterol vs. 2 puffs for a reversibility study?
The rationale per ATS in 2005 is that 4 puffs of albuterol is higher on the dose-response curve and thus would potentially avoid getting a suboptimal (< 12%, < 200 mL) response from 2 puffs. Having said that, there was a study of this issue in 240 pediatric patients showing non-inferiority of 2 puff...
Under what circumstance would you order dalbavancin instead of vancomycin or daptomycin for MRSA endocarditis?
In our practice, we consider dalbavancin as an alternative to vancomycin or daptomycin for treating MRSA endocarditis in clinically stable patients who are unable or unwilling to complete the standard 6-week course of intravenous therapy, especially among people who inject drugs.
Are there concerns with combining anti-IL5 biologics (mepolizumab or benralizumab) for severe asthma with other biologics for RA?
The question of combination biologic therapy is becoming increasingly important in our field. The main concern with combination biologic therapy is the risk of serious infections. This concern extends to IL-5 agents combined with biologics for RA. Unfortunately, there is a lack of data to guide our ...
Do you routinely use two empiric antibiotics to cover for Pseudomonas aeruginosa in the management of CF exacerbations?
Historically, two antibiotics have been used to cover Pseudomonas pulmonary exacerbations. The last guidelines were published in 2009 (Flume et al., PMID 19729669 ). At that time, the expert guidelines stated, "The CF Foundation concludes that there is insufficient evidence to recommend the use of a...