Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
When can we consider deferring an insulin drip in patients with hypertriglyceridemia-induced pancreatitis?
Serum triglyceride levels >500 mg/dL (5.6 mmol/L) are required for hypertriglyceridemia to be considered the underlying etiology of acute pancreatitis (UpToDate).For patients with severe hypertriglyceridemic pancreatitis, such as those serum triglyceride levels >1000 mg/dL plus lipase >3 times the u...
Do you find there is any benefit to giving N-acetyl-cysteine in non-acetaminophen related acute liver failure?
Yes, we believe there is a modest benefit for non-APAP patients. The Acute Liver Failure Study Group did a placebo controlled double blind study of NAC use in non-APAP ALF. Here is the reference. This is not FDA-approved. They wanted a second study but this one took about 6 or 7 years to complete!Le...
How do you decide which IV opioid to use for symptom relief at the end of life?
For patients at the end of life who need IV medications for symptom relief, I choose morphine, hydromorphone, or fentanyl depending on the patient's baseline opioid tolerance, symptom burden, and their kidney and liver function. Morphine is the lowest potency of these three options and is a good cho...
Do you add adjunctive gentamicin and/or rifampin for treatment of prosthetic valve Staphylococcus aureus endocarditis?
No, we do not add adjunctive gentamicin for treatment of Staphylococcus aureus (SA) prosthetic valve endocarditis (PVE). The potential benefit of using an aminoglycoside in this setting is minimal, if any, and is outweighed by the risk of toxicity.With respect to using rifampin, it depends on whethe...
How do you counsel patients who are concerned that discontinuation of certain chronic medications may actually perpetuate suffering at the end of life?
Great question, and it’s very nuanced. I’ll share how I typically approach this based on my experience. In the end-of-life care setting, when I review a medication list, I go through every single one and ask: “What is the purpose of this medication in this particular case?” For example, anticoagul...
Do you find consumer grade wrist actigraphy useful in measuring sleep quality and duration?
Consumer wearables are advancing quickly, and there is a lot of variation in their performance, particularly in those with sleep disorders. Unfortunately, there is a wide variation in the performance of devices, even ones using the same signals to calculate sleep/wake. Additionally, orthosomnia is a...
Do you routinely integrate telomere length testing into the evaluation of patients with ILD?
"Routine" would be a stretch, but I have dramatically increased my utilization of telomere length testing with the publication of recent studies, including this one. I do not check telomere lengths in patients when I don't think it will impact my management, but there is uncertainty surrounding best...
When do you consider Cheyne-Stokes respirations noted in download data from positive pressure machines to be normal vs abnormal requiring intervention?
I do not have great confidence in the algorithms for CSR detection in CPAP machines (both in terms of false negatives and positives). That said, I agree with Dr. @Dr. First Last that if there is an newly increased amount of central events or CSR on a CPAP report, that should prompt (at the least) a ...
Is there a role for monitoring serum ANCAs to assess ANCA associated vasculitis disease activity?
This is (and remains) a somewhat controversial question. ANCA titers do appear to rise in anticipation of disease flares and patients with persistent titers appear to have more flares. This is especially true for PR3 ANCAs. However, the proximity of flares to rising ANCA titers is not terribly close...
How do you decide on the speed and target of blood pressure reduction for spontaneous intracranial hemorrhage?
I think the target and speed of blood pressure reduction in ICH depend on several variables, including initial SBP, clinical stability, hematoma size, and renal function. For patients presenting with SBP >220, I typically aim to lower the pressure to around SBP 160 over the first 12 hours, then grad...