Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your stepwise approach to supporting the RV in the setting of RV failure from unrevascularized RCA disease in an unstable patient in the absence of RP impella availability?
Physiology RV infarct → preload dependent, afterload sensitive, rhythm/AV-synchrony dependent. Aim to optimize preload (not too little/not too much), reduce RV afterload, maintain perfusion pressure, preserve sinus/AV synchrony, and relieve ischemia where possible. 1) Immediate stabilization (fir...
What duration of antibiotic therapy do you use for a loculated parapneumonic effusion that does not meet criteria for empyema?
It would be great to see more prospective research in this area. I think we should be a bit more nuanced in our approach as it seems to be crude to recommend 4 to 6 weeks of IV antibiotics for every parapneumonic effusion or complicated pleural space. I think that in melding the IDSA and American As...
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 a patient does not have comorbid atopic dermatitis or nasal polyposis, how do you determine when to use the 200 mg vs 300 mg maintenance dosing for Dupixent for asthma?
One might consider the nonbiologic baseline therapy and severity of the asthma that is driving the potential initiation of a biologic like dupilumab to treat the asthma. Assuming I have decided to use dupilumab instead of a different biologic for improving management of the patient's asthma, I would...
What clinical features guide your choice between ketamine and etomidate in patients with septic shock who require rapid sequence intubation given recent data suggesting no difference in 28 day mortality?
Given the lower risk for hypotension with use of etomidate vs. ketamine, I usually use etomidate. I find the onset of action is more predictable. In our medical intensive care unit (MICU), the only time I reach for ketamine for rapid sequence intubation (RSI) is if patients have bronchospasms.
What has been your stepwise approach to oxygenation, including when to consider the use of inhaled nitric oxide or epoprostenol, in refractory hypoxemia due to cardiogenic pulmonary edema in patients who are otherwise not ECMO candidates?
Stepwise Approach to Oxygenation in Refractory Hypoxemia Due to Cardiogenic Pulmonary Edema: Initial Stabilization and Oxygen Therapy: Start with supplemental oxygen to maintain SpOâ‚‚ > 90%. Use noninvasive ventilation (NIV), such as CPAP or BiPAP, to provide positive end-expiratory pressure (PEE...
Which biologics for asthma have data regarding mucus plugging?
There have been multiple studies on biologics investigating the effects on mucus plugging (as measured by the CT mucus plug score of the number of pulmonary segments with a mucus plug, established by Dunican et al., PMID 29400693). In these studies, high mucus plug scores correlate with T2 high biom...
Do you utilize cytokine panels to guide treatment of patients with EGPA?
Whether biomarkers can guide treatment decisions or predict disease relapse is a critical area of study in ANCA associated vasculitis. However, efforts to identify biomarkers that are predictive in EGPA are at an early stage currently. There have been multiple negative studies of biomarkers being ab...
What is your preferred rescue inhaler for patients with asthma?
SMART with ICS/formoterol. I tend to think all asthma patients should be on SMART therapy (ICS/formoterol). Just don't really see the reason to not treat that way.
When have you found the Nidra TOMAC device to be helpful for refractory restless leg syndrome?
I have one patient who found it helpful with breakthrough symptoms in refractory RLS, but was unable to get enough coverage to continue using it.