Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Under what circumstances would you initiate antibiotics in adults hospitalized with RSV and a suspected bacterial co-infection?
Bacterial co-infection in patients hospitalized with RSV ranges between 8% and 29% (Karlsen et al., PMID 41488696). The American Thoracic Society 2025 guidelines recommend prescribing empiric antibiotics to all hospitalized patients with clinical and imaging evidence of community-acquired pneumonia ...
How frequently do you monitor CT scans, PFTs, and TTEs in patients with ILA or mild ILD?
Typically, I want my patients with ILD to be seen in clinic every 3-4 months, but of course, that depends a great deal on individual circumstances (e.g., disease severity, what we're doing for their disease, etc.). My typical approach is to have my patients perform spiro, DLCO, and 6MWT Q 3-4 months...
Should a patient who requires definitive treatment for prostate cancer as a pre-transplant requirement be strictly required to complete their course prior to transplant/initiation of immunosuppression?
To help address this complex question, I would like to call your attention to a review of the topic by Al-Adra et al., PMID 32969590. It covers several types of malignancies, including prostate cancer (Table 4). Treating this patient will require close collaboration with the transplant surgeon, urol...
Should a patient on medium-dose ICS/LABA with normal PFTs, but who shows a greater than 10% decrease in FEV1 if their PFTs are done after 24 hours off their inhaler, be started on a biologic?
A little more clinical information would be useful to better answer the question. How well controlled is the patient on the LABA/ICS? What is the ACT score? The FEV1 decreased by greater than 10% (with volume >200 ml ?) when LABA/ICS was stopped for 24 hours - how quickly did it normalize when the i...
What is your approach for a primary tracheal squamous cell carcinoma?
First off as you probably know this is a randomized data-free zone. So to some extent what to do here is empiric and/or based on historic outcomes, retrospective data, and so on. But here are a few quick & dirty observations...1) Surgical patients have the best survivals/outcomes. Doing tracheal sur...
When prescribing SMART regimen for a new diagnosis of asthma, do you still prescribe rescue inhaler (i.e. SABA) if they don't have it?
When using the SMART (single maintenance and reliever therapy), I don't add an albuterol (SABA) rescue inhaler. The whole idea is to simplify things for the patient so that they maintain their asthma control and get relief with the necessary via just one inhaler. Budesonide - formoterol combinations...
What treatment approach do you suggests for a patient with nasal polyp disease and asthma who was improved on dupilumab, but over last 2 years has begun to have increased nasal symptoms and rising eosinophil counts?
Dr. @Dr. First Last's comments are quite valuable. It might be more expedient to consider simpler options first, then progress to the less common diagnoses as needed. I very much agree that unless we know what is meant by "increased nasal symptoms", it is difficult to provide precise alternative the...
Do you consider indwelling pleural catheters in patients with refractory transudative pleural effusions?
I do as long as the risks, benefits, and possible alternatives are discussed with the patient. Frequently, these patients have refractory or end-stage heart failure, kidney failure, and liver failure. Often, they have decompensated or end-stage diseases and are not candidates for organ transplantati...
Can symptomatic radiation pneumonitis ever improve spontaneously without corticosteroids?
As “pneumonitis” has always been difficult to pinpoint, and relies on “inflammatory radiologic findings” confined to XRT portals, fever, cough without positive bacterial cultures, and shortness of breath, the diagnosis is even more difficult with 3D-directed and multiple portals or mostly IMRT-deliv...
How do you counsel older adults regarding the use, dosing, and safety of CBD-containing products for insomnia?
When counseling older adults on CBD use for insomnia, I usually explain that evidence for safety and effectiveness is limited. Most products are not FDA-approved, and their labeling, purity, and dosing can be inconsistent. It’s important to review the patient’s comorbidities and medications closely,...