Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What strategies do you use to prevent overcorrection of serum sodium in patients with severe hyponatremia and adrenal insufficiency when initiating glucocorticoid therapy?
Treatment of hyponatremia due to adrenal insufficiency with glucocorticoid therapy may result in overcorrection of serum sodium due to suppression of ADH and resultant water diuresis. Therefore, serum sodium, urinary osmolality and urinary output should be closely monitored. A brisk water diuresis w...
When do you consider PET/CT to evaluate for an occult source of infection in patients with persistent bacteremia if TTE/TEE does not show evidence of endocarditis?
Great question. Generally, I consider PET/CT to evaluate for an occult source of infection in patients with persistent bacteremia if TTE/TEE does not show evidence of endocarditis, in the following scenarios: Persistent bacteremia ≥72 hours. TEE was negative or nondiagnostic. No source identified o...
Would you recommend antifungal treatment or observation without therapy in an immunocompetent patient with a pulmonary nodule who underwent malignancy workup and was found to have yeast forms consistent with histoplasma on GMS stain?
We have seen a number of patients who have had a lung biopsy for a solitary pulmonary nodule to exclude the diagnosis of cancer. When histoplasmosis is identified by pathology, we obtain a urine histoplasma antigen as well as a careful history and exam, and some lab tests for immunosuppression. If n...
When do you consider a trial of steroids for acute hypoxemic respiratory failure when there are no other clear indications for its use (i.e., COVID, COPD, organizing pneumonia, etc.)?
We will consider a trial of systemic corticosteroids in patients with moderate-to-severe acute respiratory distress syndrome (ARDS) within 14 days of onset—even when no other clear indications are present (such as COVID-19, COPD, or organizing pneumonia). This is supported by the 2024 American Thora...
How do you monitor for pulmonary toxicity for patients on trastuzumab deruxtecan?
Eligibility criteria for T-DXd trials were based on clinical history and not on objective findings such as PFTs or radiographic criteria. Therefore, risk for factors for T-DXd-related ILD or other pulmonary toxicity are not at all clear, although they may emerge with larger pooled safety analyses an...
What are your thoughts on trending beta-hydroxybutyrate once a diagnosis of DKA is already established?
Beta-hydroxybutyrate (BOHB) ≥3.0 mmol/L is highly sensitive and specific for diagnosing DKA and can be measured through serum or point-of-care testing. However, its role in monitoring treatment response and determining resolution remains debated. The American Diabetes Association recommends continui...
Do you routinely prescribe dry powdered inhalers over metered dose inhalers for the purpose of addressing carbon emissions?
Appreciate this question because we often forget just how inextricable the link is between human health and climate health. More specifically, carbon emissions from inhalers worsen the respiratory conditions they are intended to treat. Inhaler prescriptions filled by CMS beneficiaries in 2022 were e...
How do you distinguish portopulmonary hypertension from group 3 or mixed-etiology PH in liver transplant candidates with COPD/ILD and elevated mPAP—what additional testing (PFTs/DLCO, CT, V/Q, ABG, repeat RHC maneuvers) or hemodynamic interpretation do you rely on before listing?
Certainly, PFTS and Chest CT help decide if another (possible group 3) major issue is evolving along in the setting of suspected or proven portopulmonary hypertension (POPH) by right heart cath. In my experience, the severity of the pulmonary hypertension (mPAP and PVR) is helpful. Rarely have I see...
What is your preferred laboratory test to assess treatment response or infection resolution in patients with bacterial pneumonia?
I don't generally check a laboratory test to assess resolution. I go more by their improved clinical status and seeing them get back to baseline oxygen status. If I am trending a WBC or procal, I do like to see it trend down, but it's not the only lab I hang my hat on to decide if someone has resolv...
What minimum clinical features or risk factors drive you to obtain a baseline HRCT in a patient with RA or Sjogren's disease?
Overall, about 10% of RA patients will develop clinically significant ILD, as will 20% of those with SjD. Those are a significant number of people, and ILD should be on our radar as clinicians. Knowledge of risk factors for ILD can help us focus on people most likely to be affected. Several risk fac...