Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you manage daytime somnolence without a clear cause?
I have a cohort of probably 5-10 patients now, mostly female in their late teens to early twenties, who report needing 10-14 hours of sleep per day and still not feeling refreshed. Excessive daytime somnolence (falling asleep in class or while driving). I tried modafinil and stimulants with modest s...
How do you weigh the risk of urinary catheter or fecal management system placement with that of soiling sacral wounds?
This question is an important question that arises for many of our bed-bound and poorly mobile patients, as sacral wounds commonly develop due to pressure injury. They become very challenging to treat due to fecal and urinary contamination, which can lead to further infection. Fecal and urinary dive...
Should a biologic be started for prevention of asthma-related exacerbations and hospitalizations if these are infrequent and patient is well controlled outside of flares, but is also on prednisone that they cannot get off indefinitely due to adrenal insufficiency?
Biologics have transformed the management of severe asthma by reducing symptoms, decreasing exacerbation rates, improving lung function, and, in selected patients, reducing or eliminating the need for maintenance oral corticosteroids. In the scenario you describe, however, the patient is already rec...
Do you treat patients with culture positive mycobacterium abscessus if they are asymptomatic and do not have progression on imaging?
Treating NTM, particularly M. abscessus, is a complex and challenging process that is prolonged - regardless of the response to therapy. Further, M. abscessus, particularly M. abscessus abscessus, has a high relapse or recurrence rate in addition to a higher likelihood of developing of multi-drug re...
How do you approach management of new onset ILD in a patient with RA who is otherwise well controlled on methotrexate or leflunomide?
We do not have any randomized controlled trials for DMARDs in RA-ILD. Most of the data is case series or retrospective analysis. Nonetheless, we can use current data to at least make clinical decisions until we receive more direction from high-quality clinical trials. We now know that in general met...
For a patient on appropriate treatment for invasive aspergillosis, how do you determine if and when it is acceptable to reintroduce a TNF inhibitor that likely contributed to their acquisition of the infection but is considered essential for control of their inflammatory condition?
There is no established answer to this question. The reintroduction of a TNF inhibitor must be individualized based on the clinical situation of the patient under consideration. There are two critical questions. First, how much does the patient need the inhibitor”? The more the patient is dependent ...
What is your approach to treatment of airway involvement, such as recurrent bronchial stenosis, in relapsing polychondritis?
Depending on the location of airway involvement from the subglottic area to the trachea and central airways, options include cryo-spray ablation, balloon dilation, APC/Laser ablation (less favored), Kenalog injection and airway stenting. Typically, combined modalities are more effective than single ...
How do you approach PJP prophylaxis in patients with rheumatic disease on corticosteroids?
Here is a graphic I made covering PJP Prophylaxis with Dr. @Dr. First Last if anyone is interested! As noted, one can check absolute lymphocyte count (ALC) or CD4 count as factors to further risk stratify as well.
What is your hemoglobin target for PRBC transfusion in cases of acute brain injury?
At our institution, our hemoglobin goal has always been 7 except for TBI patients, in which the goal has been 8.5. The TBI goal was a bit arbitrary and really just split the difference between 7 and 10 given some of the contradictory data. Given the new HEMOTION and TRAIN trials, we are revisiting o...
In a patient with low titer +anti-SAE antibody and known ILD, but no other clinical features of dermatomyositis, how would you approach further testing or would you treat the patient as dermatomyositis associated ILD?
When someone with ILD has an isolated biomarker without other clinical features associated with that biomarker, I have to ask myself these questions: first, is the biomarker simply a false positive because I have tested a plethora of biomarkers and second, is ILD the initial or only manifestation as...