Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What are first-line choices for vasopressors/inotropes to use in hypotensive patients with Eisenmenger Syndrome?
The answer is that it all depends on the etiology... However, a common issue with Eisenmenger syndrome (ES) is that routine pharmacological treatments that cause peripheral vasodilatation may worsen the right to left shunting and further shock. My first patient with ES was a gentleman recovering fro...
If there is trapped lung after a thoracentesis in an outpatient setting, in a patient who has stable vitals and no dyspnea, is there a role of overnight observation?
I am assuming this question came up because there was a pneumothorax post-thoracentesis, and you are suspecting entrapped lung.If you are confident that the patient has an entrapped (trapped) lung and remains completely asymptomatic, overnight observation or hospitalization is not necessary. In case...
What factors do you consider to help guide treatment for patients with high grade large cell neuroendocrine cancers of the lung?
High-grade large cell neuroendocrine carcinomas make up a small and aggressive subset of lung cancers that histologically and regarding treatment responsiveness share features with both small and non-small cell carcinomas. These shared features have been borne out in recent sequencing studies of thi...
Are there any biomarkers, imaging, or other clinical information that can be used to better choose effective therapies for super refractory status epilepticus?
SRSE is a syndrome not a diagnosis. The key determination is if this is immune-mediated, infectious, structural, metabolic, genetic, or drug/toxic-induced. For example, if the lumbar puncture shows significant pleocytosis, in the presence of flare changes in the medial temporal lobes, especially in ...
Do you obtain routine blood cultures in a non-immunocompromised patient with community-acquired pneumonia who does not meet criteria for severe CAP?
Fabre et al., PMID 31942949, categorizes "non-severe community-acquired pneumonia" as low yield for bacteremia and therefore less critical and potentially wasteful/poor stewardship to obtain blood cultures, however do note that severe community-acquired pneumonia (CAP) falls into a moderate pre-test...
How do you decide when to initiate antibiotics for superimposed bacterial pneumonia in patients with influenza?
Antibiotic therapy should not be routinely prescribed for patients with influenza and should instead be reserved for those with a specific clinical concern for secondary bacterial pneumonia. This diagnosis is best identified by clinical trajectory. Key triggers include initial improvement followed b...
How do you approach tapering high dose continuous infusions for status epilepticus in patients experiencing serious medication-related toxicity?
The short answer is as quickly as possible. How you do it will somewhat depend on the need for ongoing continuous infusion of a sedative for treatment of status epilepticus. Probably the most severe toxicity syndrome is Propofol-Related Infusion Syndrome (PRIS), which if not recognized early, can le...
When reviewing right heart catheterization numbers in obese individuals, what adjustments or caveats do you routinely apply to your interpretation?
I use the principles outlined in Kovacs et al., PMID 24869464. The respiratory pressure swings are mainly a problem for knowing absolute values of, say, mean pulmonary arterial pressure (mPAP) or pulmonary capillary wedge pressure (PCWP). More commonly, we care about determining if there is evidence...
Would you give consolidation durvalumab to a patient who underwent chemoradiation for his stage III NSCLC and is being started on antifibrotic therapy by pulmonology for his ILD?
This is a difficult scenario. On the one hand, we know from the PACIFIC trial that there is a clear benefit to the addition of durvalumab in this setting. On the other hand, there is a higher risk of pneumonitis due to both the prior use of radiotherapy and the history of underlying ILD. I think ECO...
What guides your decision whether to complete a full course of intrapleural alteplase-dornase versus proceeding to surgical decortication when a patient continues to worsen or does not adequately improve with intrapleural therapy?
This decision is typically individualized, based on the patient's clinical trajectory and radiographic findings. My practice is to initiate treatment with a lower dose of tPA, as supported by current literature. If the patient does not demonstrate an adequate response within the first 1 to 2 doses, ...