Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your experience with transesophageal lung mass biopsies?
Thoracic lesions requiring FNA in the mediastinum are often best approached with EUS–FNA, as the sedation and airway management are less complex than the EBUS, and the needle does not need to break through cartilage rings to access the lesion. On the other hand, a lung mass would require the needle ...
How do you counsel and manage cough as a side effect when initiating inhaled treprostinil in a patient with IPF?
At the present time, since it is prescribed in ILD-PH, I try to ensure that they are euvolemic and have precapillary pulmonary arterial hypertension (PAH). Most patients say it makes the throat dry; they do drink water before and after. I will have them do an albuterol inhaler or an albuterol and st...
In patients with connective tissue disease-associated interstitial lung disease (CTD-ILD) who have achieved clinical and physiologic stability after successful discontinuation of prednisone while on mycophenolate mofetil, how do you typically approach tapering or discontinuing the mycophenolate?
Unfortunately, there are no high-quality, evidence-based guidelines that specifically address tapering or discontinuing mycophenolate mofetil (MMF) in CTD-ILD after achieving clinical stability. The available literature strongly favors prolonged maintenance therapy rather than early discontinuation,...
How do you determine whether to add abatacept or rituximab to the treatment regimen in patients with mild RA-ILD on methotrexate?
I think of many agents before rituxan for RA ILD: all in various stages of being studied MMF, Orencia/abatacept, Tocli/actemra, and even JAK inhibitors xeljanz/rinvoq. Generally, if I treat and control the joints, the lungs stabilize. 10-20% run independently from joints or extra-articular ILD witho...
How do you approach a patient on anti-TNF with positive Quantiferon (previously negative) with negative chest x-ray and no symptoms?
Prior to routine screening for latent TB for patients receiving or about to receive TNF inhibitor therapy, there were reports of miliary TB developing after initiation of TNF inhibitors. Therefore, one cannot say that a negative chest x-ray and no symptoms means the patient is not at risk for develo...
What is your pharmacologic approach to treating insomnia comorbid with sleep apnea?
I do not usually treat any insomnia, regardless of comorbidities, with any targeted medication for the insomnia itself. If the patient is getting over 5 hours of sleep, then I use CBT-I as this is guideline-recommended (AASM) first-line treatment for insomnia and has efficacy lasting over a year out...
How do you manage hypercalcemia in sarcoidosis despite being on immunosuppressive therapy?
Let us accept, first, that the individual does not have emergent levels of elevated calcium (equal to around or greater than 14 mg/dl) and concerning symptoms of the following systems: neurological (e.g., weakness, confusion, delirium), renal (e.g., polyuria, polydipsia), gastrointestinal (e.g., los...
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...
Would you recommend starting tolvaptan at 7.5 mg per day, which is half the typical starting dose, to reduce the risk of overcorrection in an inpatient with SIADH and a serum sodium level of 122 mEq/L?
If it is for SIADH, I always start with 7.5 mg. See this, my fellow and I put together years ago. Dosing in SIADH: A Tale of Two Tolvaptans If it is for CHF, I would start with 15 mg as those patients are so pre-renal, their distal delivery is so impaired, and tolvaptan is limited by that. I haven't...
Do you start inhaled treprostinil outside a pulmonary hypertension indication in a patient with IPF and ongoing FVC decline despite antifibrotic therapy?
The phase 3 data show efficacy with a high discontinuation rate. Of course, it's not FDA-approved, so I wouldn't start it until the FDA approves it.