Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your second line therapy for patients with EGPA with mainly pulmonary and sinonasal features who did not respond to mepolizumab 300 mg/month and still require high doses of steroid?
This is an important question. Benralizumab has recently been shown to have similar efficacy to mepolizumab with a suggestion of a greater number of patients being able to fully discontinue steroids when treated with benralizumab as compared to mepolizumab. On the basis of this study I would use ben...
Are there benefits to adding IL5/IL5 receptor blockade in patients with vasculitic manifestations of EGPA?
While IL-5/IL5 receptor blockade has been shown to be efficacious in treating "eosinophilic" manifestations of EGPA, including asthma and nasal polyps, there are real-world studies that demonstrate its effectiveness in what we consider "vasculitic" manifestations of the disease as well. I personally...
Do you continue methotrexate while starting TNFi therapy in patients with refractory pulmonary sarcoidosis?
No clear data to do this in an EBM fashion in my opinion. I keep the baseline anti-inflammatory agents the same for the initial two doses of infliximab and once they are on regular dosing, I decrease the other agent/s. After steady-state, I would still keep a low dose of prednisone (2.5 or 5 mg dail...
How do you advise using Mycoplasma antibody testing to guide antibiotic selection in patients with pneumonia?
I do not. It takes several days to result, and I would not change treatment duration or choice of antibiotic based on a result. I treat all patients with pneumonia with a cell wall inhibitor like amoxicillin and something for atypical coverage like azithromycin. In patients with community-acquired p...
What is your approach to selecting and adjusting NIPPV settings in the management of patients with chronic hypercapnic respiratory failure?
In our clinic, which serves more patients with neuromuscular disease and advanced lung disease than OHS, most of our patients that have already developed hypercapnic respiratory failure have advanced lung disease or are the survivors of critical illness. We are hopefully catching patients with neuro...
What is the preferred four-drug regimen for initial treatment of pan-susceptible tuberculous meningitis, given the need to achieve optimal CNS penetration?
I will defer to the guidelines for the specific regimen. One general issue I would like to address is the idea of "CNS penetration." Since we don't routinely do brain biopsies in humans to truly assess levels of antimicrobials in the brain/spinal cord/meninges, many people think that "CSF levels = C...
What are your thoughts on using abatacept for RA-associated ILD in a patient undergoing treatment for CLL with zanubrutinib, and how would you assess the potential increased risk of infection in this context?
Zanubrutinib is an inhibitor of Bruton tyrosine kinase which is part of an important signaling pathway for B cells. BTK inhibition prevents B cell activation, proliferation, and survival. It is useful for B cell malignancies such as CLL.I have two concerns about using abatacept and zanubrutinib toge...
Do you transcutaneously pace or cardiovert patients with DNR status who have not lost pulses?
Yes, since it would not qualify as cardiopulmonary resuscitation if they maintain a pulse.
Do you consider thrombocytopenia a contraindication for fibrinolytic therapy for a massive PE?
If one has access to mechanical thrombectomy devices and operators, they should be considered before systemic thrombolytics unless the massive PE is causing imminent danger to the patient/patient is going to code/die, in which case the risk of dying from said PE is higher than potential bleeding eve...
How would you approach management of a patient with seropositive RA and UIP-ILD, with concern for active lung disease?
There is a potential benefit of adding additional immunosuppression for an RA patient with a UIP pattern on HRCT. My go-to-drugs are either abatacept or rituximab. While MMF is a standard first-line medication for many forms of ARD-ILD, it was tried for RA joint disease many years ago and the study ...