Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you distinguish portopulmonary hypertension from group 3 or mixed-etiology PH in liver transplant candidates with COPD/ILD and elevated mPAP—what additional testing (PFTs/DLCO, CT, V/Q, ABG, repeat RHC maneuvers) or hemodynamic interpretation do you rely on before listing?
Certainly, PFTS and Chest CT help decide if another (possible group 3) major issue is evolving along in the setting of suspected or proven portopulmonary hypertension (POPH) by right heart cath. In my experience, the severity of the pulmonary hypertension (mPAP and PVR) is helpful. Rarely have I see...
What is your preferred laboratory test to assess treatment response or infection resolution in patients with bacterial pneumonia?
I don't generally check a laboratory test to assess resolution. I go more by their improved clinical status and seeing them get back to baseline oxygen status. If I am trending a WBC or procal, I do like to see it trend down, but it's not the only lab I hang my hat on to decide if someone has resolv...
What minimum clinical features or risk factors drive you to obtain a baseline HRCT in a patient with RA or Sjogren's disease?
Overall, about 10% of RA patients will develop clinically significant ILD, as will 20% of those with SjD. Those are a significant number of people, and ILD should be on our radar as clinicians. Knowledge of risk factors for ILD can help us focus on people most likely to be affected. Several risk fac...
How do you approach management of chronic cough in patients with ILD?
By the time an individual presents with ILD and cough, and fibrotic therapy has started, there’s almost no use for increasing the dose to treat cough instead of a neural modulator such as gabapentin, and if cough is interrupting sleep, low-dose narcotics. The spinoff is that narcotics may reduce dia...
Are there instances when you recommend central line access when treating a patient using 3% sodium chloride for management of severe hyponatremia?
At UCLA, our hospital policy allows for the administration of 3% sodium chloride via a peripheral intravenous catheter at infusion rates up to 50 mL/hr (Perez & Figueroa, PMID 28471928, Jones et al., PMID 27965228, Mesghali et al., PMID 30745195). Moreover, a prospective, observational study demonst...
What is the specificity of dynamic air bronchograms for bacterial pneumonia?
Dynamic air bronchograms on lung ultrasound for bacterial pneumonia have a specificity estimate around 95% (Lichtenstein et al., PMID 19225063 and Haaksma et al., PMID 34582414). This high specificity reflects the presence of patent, transiently air-filled bronchi within consolidation characteristic...
How do you suggest using POCUS to detect or confirm a pneumothorax?
Great question - yes, there are mimickers of "lung point" (known as pseudo-lung point) such as pleural-based blebs, anatomical junction between heart/lung or between two lobes, focal adhesions - to name a few. On top of this, searching for a lung point in a deteriorating patient can delay interventi...
Do you prescribe empiric antibiotics to patients with CAP who test positive for a respiratory virus?
I do not start antibiotics when there is a detected viral etiology. And I tend to stop them if they were started. Obviously, this changes if the symptoms worsen and/or I suspect a bacterial superinfection. Another caveat would be in a patient with underlying COPD where Azithromycin may play a role i...
Are there best practices for integrating pollen, wildfire smoke, and AQI data into asthma/allergic rhinitis action plans?
Living in northern Calif, we frequently incorporate this topic into our patient discussions. We advise virtually all of our asthmatic pts to have a high-quality HEPA air purifier available because they frequently become hard to get when the air quality decreases.
In suspected portopulmonary hypertension with high cardiac output where mPAP is elevated but PVR is acceptable, do you base liver transplant candidacy primarily on PVR (and RV function) rather than mPAP, and how do you operationalize that in your listing decisions?
The short answer is yes. The key parameters of PVR and right heart function by transthoracic echo (mainly RV free wall strain, Fractional area change, and TAPSE in combination) are discussed by pulmonary and anesthesia colleagues at our selection conference. Specifically, we follow the current Inter...