Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you counsel an otherwise healthy patient on how soon they can go back to moderate exercise after a bilateral pulmonary embolism?
Generally, the approach is to have the patient start their exercise regimen at a lower intensity and gradually increase it based on their tolerance.
What strategies do you employ to minimize the risk of cardiovascular collapse when intubating a patient with severe pulmonary hypertension?
Intubating patients with pulmonary hypertension is a challenging medical and critical care situation. Generally, I try to apply principles of right ventricular optimization of care before I proceed with endotracheal intubation. Intubating patients with pulmonary hypertension is a challenging medical...
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?
This is an excellent question, which is very based on the patient's clinical presentation as well as the resources you have available to you in your setting, particularly how long it takes for test results to come back. One aspect that should be considered in patients with advanced HIV is that they ...
What is your approach to managing rash associated with pirfenidone?
I don’t think "permanently discontinue" is the first step here. Rash commonly occurs in conjunction with sun exposure, which can be prevented with skin covering and high SPF sunscreen, but sometimes it is a different phenomenon (i.e., a true allergy, which does require discontinuation).If the photos...
Do you routinely integrate the use of a multiplex PCR panel in the evaluation and diagnosis of patients suspected of having VAP?
In our hospital, we use emperic treatment till we get the sputum culture results.
What is your approach to scheduling and then weaning nebulizers in patients admitted with acutely exacerbated asthma or COPD?
In hospitalized patients with acute asthma or COPD exacerbations, my approach to nebulizers is front-loaded and reassessment-driven. I start by gauging the severity and the patient’s ability to use an inhaler. pMDI with a spacer is preferred for most patients, but nebulizers are reasonable early on ...
Do you use anticoagulants in the management of patients with pulmonary veno-occlusive disease (PVOD)?
Not enough research
What is your approach to the management of a newly acquired Pseudomonas aeruginosa infection that was not eradicated with initial treatment in a patient with CF?
I think this is a situation where shared decision making with patient is required; in general, would aim for second round of eradication with different antibiotic (for example if tobramycin was used first, inhaled aztreonam would be next) or consideration of a second month; however, chances of eradi...
How do you approach management of a patient with multiple lung nodules and low titer +CCP but no active joint symptoms suggestive of RA?
In the absence of other clinical symptomatology, I would favor close observation and follow-up in this case as there is no established diagnosis and repeat CT, PFT’s in 3 to 6 months. Details of initial evaluation should include PET-CT to exclude malignancy but also to investigate other organ system...
Do you recommend procalcitonin to help convince other providers to stop antibiotics in patients with pneumonia in whom a non-infectious diagnosis is strongly suspected?
I have looked at both of these studies in some depth. The de Jong et al., study, called SAPS, is perhaps the more impressive of the two, but regarding either or any study on so-called "biomarkers", even the RCT studies only make recommendations or give advice. And, more often than not, the doctors d...