Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you perform EBUS-TBNA for staging in patients with biopsy proven malignant lung nodules with no lymphadenopathy on CT chest and PET scan?
I agree that incidence is low, but estimates for radiographically occult nodal disease range from 10-20% and the fact is there isn't great literature on this. A PET scan is a decent test, better than a regular CT, but there are still a significant minority of patients that are mis-staged when an EBU...
What strategies have you found most effective for those attempting vaping cessation?
Clinicians are finding increasing success with Varencline and Nicotine Replacement Therapy (NRT) for vaping cessation. When combined with behavioral counseling, these treatments are more likely to achieve sustained abstinence than medication alone. For adolescents in particular, it is important to i...
What drug and specific dosing would you use for secondary pneumocystis prophylaxis in a patient with renal transplant, documented TMP-SMX allergy, and normal G6PD testing, who was diagnosed with moderate PJP and improved on clindamycin/primaquine and steroids?
I think the options are dapsone (which is tolerated by most patients allergic to TMP/SMX), atovaqone, and inhaled pentamidine. During my career, those choices have depended to some extent on the local practice. I have preferred inhaled pentamidine because I have worked in places with low volume and ...
Do you perform routine screening for latent tuberculosis in a patient who resides in the United States, has frequent, 1-2 week trips to see family in a highly endemic country, but who otherwise has no significant risk factors or high risk exposure activities?
Absolutely. I perform annual screening on persons with the described exposures. The screen is fast, safe, and easy for the patient. A goal is to eliminate all new cases of tuberculosis in this country. To accomplish this, we must identify all potential cases and treat them accordingly.
What is your approach to selecting and adjusting NIPPV settings in the management of patients with chronic hypercapnic respiratory failure?
In our clinic, which serves more patients with neuromuscular disease and advanced lung disease than OHS, most of our patients that have already developed hypercapnic respiratory failure have advanced lung disease or are the survivors of critical illness. We are hopefully catching patients with neuro...
When should we suspect ‘climate-amplified’ rhinitis/asthma versus poor control from other causes?
Before labeling rhinitis or asthma as “climate-amplified,” we must first exclude common causes of poor control: adherence issues, suboptimal controller dosing, inhaler technique, indoor allergen exposure, occupational triggers, and comorbidities (GERD, CRS, OSA, obesity). These remain far more commo...
Do you prefer awake ECMO as a bridge to lung transplantation in a spontaneously breathing patient with end-stage lung disease who is deteriorating on the waitlist, rather than proceeding to intubation and mechanical ventilation?
Yes. Avoiding intubation and maintaining muscular strength and avoiding intubation is key element to successful outcome post transplant.
Is it acceptable to list a patient for lung transplantation who has a BMI between 30 and 35 kg/m² and is otherwise a highly suitable candidate, without first requiring weight loss to bring their BMI below 30?
Complicated decisions regarding candidacy for lung transplantation cannot, and should not, be made solely on the basis of a single numerical value. Patients with elevated BMI have been successfully transplanted, and the relationship between BMI and transplant outcomes is best described as a U-shaped...
In elderly patients with advanced melanoma and idiopathic pulmonary fibrosis receiving active antifibrotic therapy, would neoadjuvant or adjuvant immune checkpoint inhibition be preferred?
Given this scenario, it is most important to have a goal-of-care discussion. That would help sort out the optimal treatment for such patients. Always treat to relieve pain as needed.
What is your approach to managing high-volume, thick tracheal secretions in a patient with a tracheostomy when there is no clear evidence of pulmonary infection?
Managing airway secretions in patients with chronic tracheostomies can be very challenging, and secretion volume varies considerably in some patients from day to day or even hour to hour, often inexplicably. The tube itself is an irritant, as is frequent suctioning, so virtually every patient with a...