Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
How would you approach anticoagulation for a patient with acute bilateral pulmonary emboli related to malignancy, but with a concomitant cavitary lung mass experiencing episodic, small-volume hemoptysis?
This is an interesting question to which we need to apply the art of medicine, weighing the risks and benefits of treatment. The major fatal events in this exact scenario are: Recurrent PE from undertreatment. Sudden massive hemoptysis after aggressive anticoagulation. The physician's management s...
What is your approach to volume resuscitation in patients who are third spacing fluids?
In patients with significant third-spacing (e.g., due to capillary leak in sepsis, severe pancreatitis, hypoalbuminemia, etc), we prefer balanced crystalloids (e.g., Lactated Ringer’s) as the first-line fluid for initial resuscitation in hypovolemic or septic shock with third-spacing. Typical initia...
When do you consider giving IV albumin for severe hypoalbuminemia with third-spacing of fluid outside of standard indications (i.e., large-volume paracentesis, HRS, SBP, shock, etc.)?
On the wards, I do not treat the albumin number. Severe hypoalbuminemia with third spacing, by itself, is not an indication for IV albumin. The consistent signal from the literature is that albumin should not be used simply to raise serum levels or to “pull fluid back in” as an adjunct to diuretics....
Do you utilize the bronchiectasis severity index (BSI) in your approach to managing non-CF bronchiectasis?
I calculate it for academic reasons in my bronchiectasis clinic. It perhaps affects the frequency of visits in the clinic. Otherwise, not much practical application. I respond to daily cough and secretion management with stepping up airway clearance, and to frequency bronchiectasis exacerbations wit...
What alternative, low-effort airway clearance strategies do you use in frail neuromuscular patients who are unable to tolerate or fail manual chest physiotherapy (e.g., oscillating PEP devices, high-frequency chest wall oscillation vests, or mechanical insufflation-exsufflation/cough assist)?
Airway clearance is key to quality of life and prolonged survival in frail NMD patients, sometimes adding decades, depending on the particular NMD and other factors (luck and prayers don't hurt). Most tolerate manual techniques (i.e., quad coughing) reasonably well, so I wouldn't wait for them to no...
How do you treat idiopathic hypersomnia inadequately responding to modafinil?
I agree with @Dr. First Last. I usually start my patients on modafinil or armodafinil. If those do not work, I will try solriamfetol. I will supplement with as needed amphetamines as well. I do not often go straight to sodium oxybate/low-sodium oxybate, as you need the right patient for this medicat...
How do you characterize pleural effusions on POCUS between trace, small, moderate, and large?
Assuming the effusion is free-flowing and not loculated, there are a few equations out there that can help quantify pleural effusion volume based on whether the patient is supine at max inspiration, supine at end-expiration, or sitting upright. In my hospitalist practice, I don't usually calculate b...
Do you recommend the use of portable high-efficiency particulate absolute air cleaners to former smokers with moderate to severe COPD?
This is a regional decision that is based upon ambient air pollution, such as wildfire smoke in the Southwest, and can be trialed before purchase to evaluate symptomatic efficacy. The CLEAN AIR STUDY (Hansel et al., PMID 34449285) did not validate improvement in total St George's Respiratory Questio...
Do you have any strategies for increasing yield while doing bronchoscopic biopsy with EBUS?
Rapidly advancing the needle forward during agitation while performing EBUS can improve sample quantity. Tumor cells are often very sticky, so keeping the needle on the same plane allows it to first shear the cells from the surrounding tissue. The repeated back-and-forth motion, combined with suctio...