Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What's the threshold to consider a PSG abnormal enough to preclude a MSLT the following night?
To cancel the next day MSLT, I would consider cancelling or rescheduling if AHI > 10 or 15, TST < 6 hours, poor sleep efficiency (<70%), positive drug screen, staff identification of a circadian rhythm disorder we were not aware of before, etc. I have also heard of sleep docs cancelling for a low am...
What are the potential implications of re-introduction of 'long-term responders to calcium channel blockers' in the classification of pulmonary hypertension, and how should clinicians approach the identification and management of these patients?
The purpose of reintroducing it into the definition is to identify that rare group of IPAH who would respond to CCBand perhaps their PH is likely driven by vasoconstriction rather than vasculature remodeling. They are likely to remain stable on CCB. Long-term responders are defined as those who, aft...
Do you recommend air purifier in bedrooms and office/workplaces of patients with chronic lung disease?
As with many answers within medicine, the answer is "it depends." Asthmatics or individuals with airway-related environmental triggers such as COPD overlap syndrome may benefit from air purification systems -- either as part of a central HVAC system or utilized as a portable unit used within sleepin...
For septic patients with borderline heart failure, how do you individualize the decision about additional fluid boluses after the initial resuscitation?
For septic patients with borderline heart failure, the decision about additional fluid boluses after the initial resuscitation requires careful observation and monitoring. My approach has been to administer 500 cc-1 liter of fluid, and then assess volume status (physical exam, JVP, or POCUS, which i...
What is your approach to managing hyperkalemia secondary to respiratory acidosis?
Since hyperkalemia in respiratory acidosis is due to transcellular shift, therapy should be directed at treating the underlying respiratory acidosis. Correction of the hypercarbia should lead to resolution of the hyperkalemia. In severe hyperkalemia due to respiratory acidosis that is not easily rev...
How would you approach failure of maintenance therapy (Azathioprine) for PR3 positive, c-ANCA positive, pulmonary–renal vasculitis previously induced with cyclophosphamide, with a history of anaphylaxis to rituximab?
This is a challenging clinical situation with several appropriate treatment approaches as follows: Desensitization to rituximab - this would need to be done in the ICU but is effective for patients who are willing to undergo the process for whom other maintenance regimen options are suboptimal. Avac...
For post-LT patients who improve on PAH therapy, what objective criteria do you require before attempting medication withdrawal, and how do you structure a safe de-escalation plan?
At month 4 post-liver transplant, we routinely repeat a transthoracic echocardiogram to look at the right size and right ventricular function parameters and compare to pre-transplant echoes. We focus on reducing/discontinuing IV prostacyclin medications 1st. The final decision to stop IV prostacycli...
Would you consider combination mycophenolate and JAKi in a patient with RA-ILD?
I have minimal experience combining a JAKi with mycophenolate. A patient with RA-ILD whose joints were well controlled with tofacitinib but whose ILD was progressing had MMF added to their regimen by their ILD pulmonologist. Unfortunately, after 4 months, the patient developed significant leukopenia...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
How do you plan to integrate sotatercept into the current treatment algorithm for PAH, particularly in patients who are stable on existing therapies?
Sotatercept gained FDA approval to increase exercise capacity, improve WHO functional class, and reduce the risk of clinical worsening events e.g., hospitalization for worsening PAH. The pivotal clinical trials enrolled a subset of Group 1 PAH patients who were stable for an extended period on PAH t...