Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
How do you decide on supportive care vs empiric antibiotics in a patient with suspected aspiration pneumonitis (i.e., witnessed macroaspiration event within the past 24 hours) but with features that could suggest pneumonia (e.g., acute respiratory distress, fever, leukocytosis, pulmonary infiltrates, etc.)?
Great question and one that comes up all the time for me. As the patient has more signs of true infection, such as those you mention with fever, leukocytosis, and respiratory distress, I am much more likely to start antibiotics. If the patient just has chest radiograph findings of opacities and some...
How do you approach managing clozapine in patients who are critically ill?
With COVID-19 disproportionately affecting those with mental illness we found an increasing number of medical admissions for those on clozapine. There are multiple domains of concern for those on clozapine who are medically ill. Clozapine levels have been shown to potentially double during periods o...
How do you use cardiac POCUS to potentially defer formal echocardiogram in patients presenting with an acute pulmonary embolism?
In patients with acute PE, cardiac ultrasound is useful in risk stratification and identification of patients at higher risk of short-term mortality and complications. Signs to look for on POCUS are: RV dilatation (RV>LV on apical 4-chamber view), McConnell Sign (hyperkinetic RV apex with hypokineti...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
Do you routinely administer desmopressin to patients with intracerebral hemorrhage who are also on anti-platelet therapy?
I routinely administer desmopressin in patients presenting with ICH if they are on dual antiplatelets but not single antiplatelets. The evidence for this is limited, but it has not revealed any harm.
How would you treat an asymptomatic patient with a positive Blastomyces antibody, evidence of prior granulomatous lung disease on imaging, and who may require immunosuppression in the future?
We practice in an area with a good bit of blastomycosis and rarely see a positive Blastomyces antibody, even in patients with culture-proven blastomycosis. The newer EIA antibody that MiraVista lab is doing may be more reliable. If the prior granulomatous lung disease has been worked up with negativ...
When trying to increase infliximab for active disease (inflammatory arthritis or sarcoidosis), do you prefer to increase dosage or reduce frequency between doses?
As is often the case with rheumatology therapeutics, we are residing in a " data-free" zone. There is limited literature available from the Crohn's disease patient population where this issue was studied in a limited way. There did not appear to be any significant difference in outcome using either ...
How do you determine the severity of restrictive lung disease?
My interpretation of the latest ATS/ERS guidelines is that FEV1 should be used for "any spirometric abnormality" including restriction or mixed disorders, which is unchanged from the 2005 ERS Guidelines.That said, I tend to use FVC when grading pure restrictive disorders, habituated as a result of F...
Is there any role for using mandibular advancement splints on select nights in place of CPAP in the management of patients with OSA who have difficulty tolerating CPAP?
Oral appliances are a very good treatment for sleep apnea; however, before "substituting" one for CPAP, in anyone with moderate to severe sleep apnea, it is important to retest with the OA in place to make sure it is reducing AHI to an adequate level. If there is relative "equivalence," then it is o...