Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Would you consider levofloxacin graded challenge, extended IV aztreonam, or an alternative treatment in a patient with reported anaphylaxis to penicillin, fluoroquinolones, and cefuroxime with cavitary pneumonia secondary to Klebsiella and Pseudomonas?
The first and most important thing would be to establish whether the patient had a true penicillin (as well as other antibiotic) allergy since >90% of patients who think they are sensitive to PNC really are not. If it is established that the patient does have a PCN allergy, consultation with ID is a...
Would you perform screening for pulmonary hypertension in a patient who has biopsy-proven Sjogren's but has a centromere antibody?
Generally, the risk of pulmonary hypertension in Sjogren's is low - about 2% in a recent study using RHC for diagnosis (Coppi et al., PMID 40058609). There have been no studies linking Raynaud's to pulmonary hypertension risk in Sjogren's, although this is true in systemic sclerosis. So the real que...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
Do you still consider propranolol first-line for sinus tachycardia in thyroid storm, or have newer perspectives on beta-blocker risks altered your management?
Yes, but...Propranolol remains the first-line option for thyroid storm, but recent evidence supports that beta-1 selective agents (metoprolol, atenolol) are equally effective and may be preferred in certain clinical contexts. The choice between propranolol and cardioselective beta-blockers should be...
Is there a specific criteria that you use to determine if a patient with respiratory symptoms should have a multiplex respiratory test performed?
If the patient is being admitted to the hospital, the information provided by this test can be useful with regards to antimicrobial stewardship (potentially avoiding antibiotic therapy or targeting it) and also with regards to infection control precautions. For outpatient scenarios, if respiratory s...
What strategies do you use to prevent overcorrection of serum sodium in patients with severe hyponatremia and adrenal insufficiency when initiating glucocorticoid therapy?
Treatment of hyponatremia due to adrenal insufficiency with glucocorticoid therapy may result in overcorrection of serum sodium due to suppression of ADH and resultant water diuresis. Therefore, serum sodium, urinary osmolality and urinary output should be closely monitored. A brisk water diuresis w...
What findings on routine monitoring PFTs prompt you to pursue HRCT in your patients with SARDs?
That’s an excellent question, and the strategy might vary somewhat by the specific SARD, but in general, in any SARD patient undergoing annual PFTs, the presence of any of these should prompt an HRCT to evaluate for the development of ILD. FVC drop ≥ 10% DLCO drop ≥ 15% Moderate decline in FVC (5-9...
When do you consider PET/CT to evaluate for an occult source of infection in patients with persistent bacteremia if TTE/TEE does not show evidence of endocarditis?
Great question. Generally, I consider PET/CT to evaluate for an occult source of infection in patients with persistent bacteremia if TTE/TEE does not show evidence of endocarditis, in the following scenarios: Persistent bacteremia ≥72 hours. TEE was negative or nondiagnostic. No source identified o...
Do more fractionated regimens reduce severe toxicity over SBRT in patients with ILD and early-stage NSCLC?
I personally think fewer fractions are safer, such as 30 Gy x 1 instead of 10 Gy x 5, for patients with advanced COPD or ILD. Why? It's because each time a burst of ionization events is delivered to pulmonary tissues, a wound is created that recruits an inflammatory response, which can exacerbate th...
Would you recommend antifungal treatment or observation without therapy in an immunocompetent patient with a pulmonary nodule who underwent malignancy workup and was found to have yeast forms consistent with histoplasma on GMS stain?
We have seen a number of patients who have had a lung biopsy for a solitary pulmonary nodule to exclude the diagnosis of cancer. When histoplasmosis is identified by pathology, we obtain a urine histoplasma antigen as well as a careful history and exam, and some lab tests for immunosuppression. If n...