Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How long after initiating mycophenolate do you wait before tapering prednisone off in patients with myositis-associated ILD?
Taper Pred after 6 weeks MMF tapering to prednisone 20 mg/day and hold this dose for 6-8 weeks monitoring for relapses. If no relapse, taper to Prednisone 10 mg/day.
If PFTs are done on different machines or different places, are the comparisons valid?
Comparisons of PFT between equipment and locations are valid if they are consistent with the underlying condition and the caveats mentioned by Dr. @Dr. First Last are taken into account. Lung volume measured by nitrogen washout would have the same issue as helium dilution, as both would miss very po...
What’s your approach to an asymptomatic, hemodynamically stable patient with moderate spontaneous pneumomediastinum without pneumothorax and normal esophagogram?
Terrific question and, fortunately, an unusual occurrence with an estimated 1 in 30,000 hospital admissions (Barroso et al., PMID 37965408). The true incidence is likely higher as underdiagnosis may be related to individuals with mild symptoms who do not seek medical care, symptoms misdiagnosed and ...
How do you approach a patient with a solitary brain metastasis from small cell lung cancer s/p resection with otherwise limited thoracic disease?
This is rather an uncommon situation but can happen if a patient presents with a synchronous solitary brain metastasis (with or w/o symptom) and undergoes craniotomy and resection only to find out that it is small cell lung cancer. Additional information is needed on the volume of intra-thoracic dis...
Do you prescribe bronchodilators to patients with radiographic emphysema and respiratory symptoms, but no spirometric obstruction?
Yes, I will sometimes offer a therapeutic trial of bronchodilators to symptomatic patients with radiographic emphysema, but no obstruction on spirometry. Patients with CT evidence of emphysema were not specifically studied in the RETHINC trial.
How do you manage daytime somnolence without a clear cause?
Throw a broad net out for the evaluation because we don't know how much has a physiological component and how much is mental/emotional. At intake, I get a moderately comprehensive set of labs. Rating Scales like HAMA, HAM-D, PHQ-9, Epworth Sleepiness Scale, and a ROS (Review of Systems) are done. I...
What's the threshold to consider a PSG abnormal enough to preclude a MSLT the following night?
We use an AHI > 14 but it is up to the referring physician to determine so if it is close, we have the tech call and confirm. We still use the AASM recommended time for the PSG of > 6 hours sleep time.
Do you prescribe lower dose ICS for asthma to mitigate the risk of pneumonia in patients with a history of respiratory infections or compromised immune systems?
Yes, I do, if possible. This is based on data that demonstrates that high-dose ICS negatively impacts the microbiome diversity. While not linked directly to clinical outcomes, these findings warrant caution enough to make this simple alteration. That said, more research into the clinical impact is n...
How do you manage patients with central sleep apnea due to heart failure with reduced ejection fraction?
I assume you are referring to CSA with Cheyne-Stokes respiration. Several possibilities, but first ask yourself what your treatment goal is. If the patient does NOT have symptoms (frequent awakenings, daytime sleepiness, etc.) I contend that you don't need to treat at all. We already know that there...
Are there situations where you would consider treating E faecalis or E faecium that grows from a respiratory culture?
Pretty much almost never! Enterococcus is not recognized as a pneumonia pathogen. In the setting of a lung abscess, I suppose you could consider treating it as part of a polymicrobial infection. In a heavily immunocompromised patient, it is possible that enterococcus might cause pneumonia—and it has...