Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you approach pharmacologic treatment of sleep disturbances in perimenopausal or menopausal patients with vasomotor symptoms?
CBT-I is still the gold standard approach in this population, and sleep hygiene, relaxation, and sleep efficiency would likely be helpful whether you are also addressing vasomotor or other contributing factors. But it can be so helpful to directly treat vasomotor symptoms. I use gabapentin 100-400 m...
How do you decide whether to use pharmacologic VTE prophylaxis in hospitalized patients with decompensated cirrhosis?
For all patients, I begin by using a standard risk prediction tool to determine if the patient is appropriate for pharmacologic VTE prophylaxis. At our institution, the Padua risk prediction tool is embedded in our electronic health record/admission set. Clinical guidelines- including those from the...
How do you decide the maximum amount of volume to remove during a therapeutic thoracentesis?
Critically ill (hypotension/shock on pressors) that are not having hypoxia issues/increased FiO2 requirements, I would probably be cautious. Rest of the population, use clinical judgement based on the clinical response... Less likely to need a "hard" stop/limit.
What would be your recommendation for treatment of worsening lung disease in a patient with long-standing scleroderma after long-term mycophenolate therapy which is no longer an option due to side effect/intolerance?
Someone who has been on long-term Mycophenolate for interstitial lung disease and has had stabilization or improvement in their lung function and then is unable to tolerate the medication may be able to be switched to mycophenolic acid sodium (myfortic) which is often less toxic and better able to b...
In an ALS patient with FVC 60–70% predicted, normal daytime ABG, and normal nocturnal oximetry, but persistent orthopnea and unrefreshing sleep, do you initiate nocturnal NIV — and if so, how do you navigate the CMS coverage gap?
In our assisted ventilation clinic, we lean toward symptom-based initiation for patients with neuromuscular disease, including ALS. There are several strategies for navigating the coverage gap. We have found that performing both FVC and MIP measurements with supine positioning will often reveal that...
In a patient on chronic stable methadone or buprenorphine for OUD who develops symptomatic central sleep apnea, do you prioritize treating the CSA (CPAP → ASV if LVEF >45%, adjunct acetazolamide/O₂) or pushing the opioid team toward dose reduction? Where does loop-gain phenotyping change your sequence?
The starting point is to explore opioid dose reduction. If this is not feasible, then I would initiate CPAP, given the substantial overlap between OSA and CSA (co-morbid OSA is present in more than 2/3 of patients with CSA). If CSA persists, then I would consider adjunctive therapy with acetazolamid...
Do you empirically administer high-dose IV thiamine to all patients admitted with sepsis and a history of alcohol use disorder, even without clinical signs of Wernicke encephalopathy?
There is little to no downside risk for thiamine administration in comparison to severe morbidity for the failure to use thiamine, as supported by a recent review (Teixeira et al., PMID 39818490).
In symptomatic women with an overall AHI of <5 but REM AHI >30 and meaningful REM-related hypoxic burden, do you treat?
If the study was an HSAT, might consider a PSG or repeating the test due to night-to-night variability. You can try to appeal to the insurance company for coverage.
Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?
PCV-21 was recently approved by the FDA and supported by ACIP. At this early stage (August 2024), CDC has not finalized guidance on PCV-21, so we do not know how the vaccine schedule will be changed. An important distinction is that PCV-21 covers different serotypes of pneumococcus, as outlined in t...
What serum biomarkers are most helpful in cardiac arrest prognostication?
Neuron-specific enolase. This is checked at 24, 48, and 72 hours. It is, however, NOT to be used in isolation for prognostication, which is multimodal, including clinical exam after clearance of sedation (typically at 5 days post arrest), EEG (e.g., looking for reactivity of background), NSE, and MR...