Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
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?
Based on the MIST trials (Maskell et al., PMID 15745977, Rahman et al., PMID 21830966, and Bedawe et al., PMID 37820359), I typically complete a three-day course of intrapleural therapy before proceeding to surgical decortication. It's only three days, and the decision to proceed to surgery after th...
Under what circumstances do you recommend POCUS guidance for lumbar puncture?
If the circumstances allow for it, I would use ultrasound for guidance for LP every time a LP is performed. This allows for continued practice in identification of the landmarks and improves accuracy in POCUS when it's truly needed, as in obese patients, where landmarks are difficult to palpate. Got...
How do you screen rheumatoid arthritis patients for lung disease (modality, frequency, patient selection)?
Theoretically, we are supposed to screen these patients obtaining a baseline chest X-ray before starting DMARD therapy. As I remember, these guidelines were formulated when MTX was still blamed for MTX lung disease although presently, even the presence of underlying ILD is not necessarily a contrain...
How would you approach a stable 3 cm iatrogenic pneumothorax in an asymptomatic patient?
I think it is quite reasonable to continue to monitor in this situation. I probably would take comorbidities and reliability into consideration to decide if this is someone I would admit to the hospital VS follow up as outpatient.
Is it necessary to prescribe a steroid taper after two weeks of high-dose prednisone (60 mg daily)?
Interesting question. Not being an endocrinologist, I don't have the expertise to advise but the reference below makes the statement that even short-term steroids can be an issue. I suspect that if you have to stop abruptly from 60 mg daily for 2 weeks, it would probably be fine in most instances bu...
In patients with RA on methotrexate and a TNF inhibitor who develop PJP pneumonia, how long do you hold immunosuppression before restarting therapy?
I would typically hold immunosuppression until the patient has completed therapy unless they had significant respiratory failure, in which case I would await full recovery. The patient should be placed on appropriate PJP prophylaxis prior to resuming therapy.
How do you approach a patient with recurrent VTE who develops VTE again after reduction of apixaban to 2.5 mg bid?
Several factors play into this decision for me. Is the patient obese? Obese patients tend to give me pause for dose-reduction of DOACs. As such, half-dose apixaban may have been relatively underdosed for an obese patient and I would not call it DOAC failure, rather I would increase the dose to usua...
How well does a negative non-contrast MRI of the brain exclude metastasis in a patient with squamous cell carcinoma of the lung?
I don't think the question has enough information to give a good answer. For example, if it was a T3, N2 NSCLC, or a small cell, then "yes" I'd repeat the MRI with contrast. On the other hand, if it was a T1, N0 NSCLC, then "no", I wouldn't. In other words, if I thought there was a real risk of havi...
What steroid durations do you use for the treatment of acute, chronic, and drug-induced eosinophilic pneumonia?
For acute eosinophilic pneumonia, these are often high doses of IV methyl prednisone in the hospital, and assuming that the exposure or risk is mitigated, I would taper these down over a short period of time after discharge. Chronic eosinophilic pneumonia, I treat briefly with steroids but quickly t...
What specific clinical and echocardiographic thresholds lead you to taper/de-escalate pulmonary hypertension therapy before liver transplant?
The goal in pulmonary hypertension therapy pre-transplant is to fulfill the MELD exception criteria in terms of mean pulmonary artery pressure, pulmonary vascular resistance, as well as right ventricular function by echo. Once those criteria are satisfied, maintain those PH therapy doses until the t...