Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How would you manage an intermediate-risk segmental PE that is transiently provoked after a knee surgery?
_*]:min-w-0 gap-3"> _*]:min-w-0 gap-3"> Full anticoagulation of very recent (1 to 5 days) total knee replacement, for example, is high-risk for bleeding complications of a surgery that already takes 3 to 6 months to recover from without complications. _*]:min-w-0 gap-3"> Instead, start intravenous (IV) unfractionated heparin (UFH) drip without bolus, ...
Do you seek pathologic confirmation before proceeding with empiric immunosuppressive therapy in symptomatic patients with radiographic NSIP?
In general, getting lung biopsies is needed in a minority of people who have clear evidence of NSIP on HRCT. If there is any evidence to suggest a concomitant ARD, a biopsy will not typically be needed. In our combined ILD-Rheumatology clinic, we see these patients all the time and I can think of on...
What is your approach to treating recurrent organizing pneumonia in patients with side effects from steroids?
The first approach is trying lower dose steroids. More is not necessarily better in many cases. If this strategy is ineffective in attenuating symptoms and making any radiographic changes, then one may consider mycophenolate mofetil (MMF), which is increasingly used as the preferred glucocorticoid-s...
How do you taper dopamine agonists for RLS in patients experiencing augmentation?
Slowly. Abrupt withdrawal from agonists can cause mood dysregulation (dopamine agonist withdrawal syndrome) and in RLS patients, would likely exacerbate RLS symptoms.Adding gabapentin to the regimen prior to slow withdrawal of the agonist would probably help avoid worsening RLS symptoms during this ...
Does your working phenotype for ‘new PAH after LT’ (occult POPH vs PAH unmasked after HPS resolution vs distinct post-LT vasculopathy) change what you actually do—specifically, who you screen more aggressively and when you initiate PAH therapy?
In pre-liver transplant patients with known hepatopulmonary syndrome (HPS), we do pay greater post-transplant attention to those considered to have "large intrapulmonary shunts," marked lung-brain uptake with technetium-99m macroaggregated albumin (⁹⁹ᵐTc-MAA) scanning (>30%) or poor response to 100%...
In patients presenting with disabling acute ischemic stroke symptoms early in the therapeutic window, would you consider anticoagulation reversal to enable administration of intravenous thrombolytics?
In short, 'no'. For patients who have a large vessel occlusion, there is the option of proceeding directly to EVT without thrombolysis. We know from the direct EVT trials that although concurrent or sequential thrombolytic drug treatment followed by EVT is better, it is better only by a small amount...
Do you continue Trikafta throughout pregnancy in a woman with cystic fibrosis who has adequate lung function and is in a stable clinical state, rather than discontinuing therapy out of concern for unknown fetal risk?
I think this is an area where shared decision-making is needed. My default answer tends to be continue for anybody with CF, as in general, ETI has been found to be safe, except for some increased monitoring for the infants after birth. If the pregnant person is 100% asymptomatic, has no bronchiectas...
What is your stepwise approach to supporting the RV in the setting of RV failure from unrevascularized RCA disease in an unstable patient in the absence of RP impella availability?
Physiology RV infarct → preload dependent, afterload sensitive, rhythm/AV-synchrony dependent. Aim to optimize preload (not too little/not too much), reduce RV afterload, maintain perfusion pressure, preserve sinus/AV synchrony, and relieve ischemia where possible. 1) Immediate stabilization (fir...
What duration of antibiotic therapy do you use for a loculated parapneumonic effusion that does not meet criteria for empyema?
It would be great to see more prospective research in this area. I think we should be a bit more nuanced in our approach as it seems to be crude to recommend 4 to 6 weeks of IV antibiotics for every parapneumonic effusion or complicated pleural space. I think that in melding the IDSA and American As...
When a patient does not have comorbid atopic dermatitis or nasal polyposis, how do you determine when to use the 200 mg vs 300 mg maintenance dosing for Dupixent for asthma?
One might consider the nonbiologic baseline therapy and severity of the asthma that is driving the potential initiation of a biologic like dupilumab to treat the asthma. Assuming I have decided to use dupilumab instead of a different biologic for improving management of the patient's asthma, I would...