Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
Would you offer lung SBRT in a patient with Pulmonary Langerhans Cell Histiocytosis (PLCH)?
Langerhans cell histiocytosis (LCH) is a clonal proliferation of Langerhans cells (dendritic cells), part of the mononuclear-phagocytic system. Some patients present with unifocal disease, often in bone. A variety of treatments are acceptable for unifocal disease, including radiation therapy. Very l...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
Would you recommend anti-fungal treatment for aspergillus infection for a patient with an incidental finding of worsening ground glass opacities and enlarging nodules on CT chest with positive BAL galactomannan, elevated aspergillus IgE and IgG in an otherwise immunocompetent host with no respiratory symptoms?
No, I would not recommend antifungal treatment in this case. The patient, as described, does not seem to have invasive aspergillosis, chronic necrotizing aspergillosis, or allergic bronchopulmonary aspergillosis, so I don't believe antifungal treatment is indicated. There may be other details of the...
Do you obtain an MSLT or start empiric therapy with modafinil in patients with residual excessive daytime sleepiness despite optimal adherence to PAP therapy?
In this situation I would start either modafinil, armodafinil, or solriamfetol for residual EDS if the OSA was appropriately controlled without need for MSLT. We have an FDA label for these medications in this situation to support this practice. If I felt like there was concern for a combination of ...
Do you feel high dose Symbicort or Dulera is appropriate to use for SMART despite these doses not being studied in clinical trials?
One of the primary purposes of SMART therapy is to provide extra doses of ICS to patients inadequately controlled enough to use rescue inhalers. The other major purpose is to do this with a single inhaler instead of 2 or 3. So if the patient's baseline asthma is severe enough to require high-dose Sy...
How has COVID-19 altered your recommendations for invasive mediastinal staging for NSCLC?
I just had this discussion with our chief of interventional pulmonolgy at MD Anderson. Some of his faculty are being asked to staff our COVID-19 patient floor. In addition, bronchoscopy procedures should be considered high-risk procedures, and are required to have at least 45 minutes in between proc...
How could POCUS be useful in the initial evaluation of a severely ill patient in whom infectious endocarditis is suspected?
I would broaden the question to incorporate principles of diagnostic reasoning: how does a given test, in this case, point-of-care ultrasound (POCUS), adjust the probability of infective endocarditis (IE) in a severely ill patient?IE is a difficult diagnosis, and clinicians should be cautious about ...
What is your approach to REM behavior disorder not adequately treated with melatonin and clonazepam?
Rule out comorbidities like sleep apnea or medications causing RBD. Optimize doses for melatonin and clonazepam, and consider dual therapy with these. Other options are gabapentin or pramipexole. Thanks,Sam Morkous
How aggressively do you screen the menopausal patient presenting with new or worsening insomnia for OSA, and what is your threshold for in-lab PSG after a negative HSAT in this population?
I would treat the insomnia and do actigraphy or obtain data from an Apple Watch, or even repeat HST before doing an in-lab. At least once in a while, there is someone scheduled in the sleep lab who cannot sleep and leaves in the middle of the night.