Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
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...
How do you titrate opioids for pain and breathlessness in patients with a DNR/DNI code status, but who otherwise still wish to pursue life-prolonging treatments?
Carefully! But let's be very clear about this situation: the DNR/DNI status shouldn't really affect your management if the patient wants full treatment otherwise. In fact, even if someone opts for a hospice care plan and does not want full treatment nor resuscitation, we can still have the same gene...
What are your top takeaways from ATS 2026?
I was impressed with the FROSTBITE-2 study published in JAMA!It was a well-designed study and supports the use of a 1.1 mm cryoprobe in many bronchoscopic lung biopsy settings. This is a practice-changing level of evidence for bronchoscopists and will help us get better results for our patients.
In cirrhosis patients with borderline pre-transplant PVR (≈2–3 WU), what additional findings (e.g., mPAP/TPG, pulmonary artery compliance, RV strain on echo, DLCO) prompt you to treat this as higher risk and arrange closer follow-up or PH-center referral rather than reassuring the transplant team?
Agree that recent data do suggest that pulmonary vascular resistance (PVR) 2 to 3 Wood units should be followed carefully in patients who are liver transplant candidates.Using historical data and International Liver Transplant Society (ILTS) Guidelines, mean pulmonary arterial pressure (mPAP) < 35 m...
How would you manage a patient with necrotizing pneumonia due to a susceptible Pseudomonas aeruginosa strain who continues to have significant purulent secretions and worsening imaging while receiving cefepime?
I agree, not enough information here to make a firm recommendation, but often times these necrotic pneumonias will undergo significant liquefactive necrosis, and all of that dead lung and purulence has to come out through the mouth. I tell patients that they may have a worse cough for a while, and t...
What factors would encourage you to choose abatacept vs tocilizumab in a patient with RA-ILD with a UIP pattern of pulmonary fibrosis?
The available literature on abatacept and tocilizumab in RA-ILD does not provide a definitive answer and hopefully with the general increase in interest in ILD we will have more definitive data in the near future. My review of the current literature suggests that abatacept has a slightly higher perc...
For locally advanced NSCLC, does endobronchial tumor debulking just prior to treatment influence your decision making regarding bronchial tissue constraints/expected toxicity?
Bulky, large endobronchial lesions both bleed and obstruct. The concern should be the length and depth of the tumor. If destruction of the trachea or bronchial tumor risks bleeding and B/P fistula, it may account for some of the hazards associated with “ultra-central” location. The endobronchial deb...
How do you manage a cytology-negative pleural effusion that develops after lung RT?
I think most times you can just watch them as long as they are stable and not symptomatic. I see them not infrequently after RT, especially lung SBRT, and find they often find a size they feel comfortable with and don't change much over time. I wonder about their physiology... my impression is there...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
How do you balance diagnostic stewardship and high value cost-conscious care when working up a patient with newly diagnosed HIV/AIDS admitted to the ICU with shortness of breath who most likely has PJP pneumonia or cryptococcal infection but is at risk of multiple other pathogens?
Multiple concurrent OIs are common in individuals with advanced HIV and contribute significantly to morbidity. Because several infections can emerge simultaneously in the setting of profound immunosuppression, recognizing the likelihood of multiple coexisting pathogens is critical. Early identificat...