Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
How are you using liquid biopsy in the routine management of your patients with metastatic NSCLC?
The dramatic improvement in the prognosis of metastatic NSCLC patients harboring targetable oncogenic genetic alterations with highly effective therapy has underscored the need for tumor molecular profiling. There have been numerous studies in the past decade assessing the performance of ctDNA (here...
How do you counsel patients who are hesitant to try behavioral therapies for insomnia instead of starting a sleep medication?
I try to be very understanding of the desire to have an easier solution to sleep difficulties, which are so common. It is challenging that our gold standard and best strategies to help people sleep better require a lot of effort on the patient's part. Starting with that validation can be very helpfu...
How do you balance diagnostic stewardship and high value cost-conscious care when working up a patient with newly diagnosed HIV/AIDS admitted to the ICU with shortness of breath who most likely has PJP pneumonia or cryptococcal infection but is at risk of multiple other pathogens?
Multiple concurrent OIs are common in individuals with advanced HIV and contribute significantly to morbidity. Because several infections can emerge simultaneously in the setting of profound immunosuppression, recognizing the likelihood of multiple coexisting pathogens is critical. Early identificat...
What is your approach to management of a patient with sarcoidosis who is asymptomatic, but demonstrates progressively enlarging mediastinal lymphadenopathy and rising soluble IL-2 receptor levels?
There are no diagnostic or prognostic biomarkers specific for sarcoidosis, and proposed surrogate markers for tracking disease activity, including soluble IL-2, serum angiotensin-converting enzyme (ACE), and even the presence of fluorodeoxyglucose (FDG)-avid lesions, have limited predictive value. F...
What criteria do you use to decide when to perform a BAL in hypersensitivity pneumonitis?
Short answer: When the vibes are right. I know that's a flippant answer, but that's an honest-to-God real answer. Long answer: This is really complicated and personally, I'm frustrated by our guidelines and the level of evidence we have for diagnosing HP. To answer the question, it's worth delineati...
How would you approach anticoagulation for a patient with acute bilateral pulmonary emboli related to malignancy, but with a concomitant cavitary lung mass experiencing episodic, small-volume hemoptysis?
This is an interesting question to which we need to apply the art of medicine, weighing the risks and benefits of treatment. The major fatal events in this exact scenario are: Recurrent PE from undertreatment. Sudden massive hemoptysis after aggressive anticoagulation. The physician's management s...
Do you transcutaneously pace or cardiovert patients with DNR status who have not lost pulses?
Yes, since it would not qualify as cardiopulmonary resuscitation if they maintain a pulse.
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
From a rheumatology perspective, I would be mindful that there is accumulating data that like other viral infections, but perhaps even more so, COVID-19 can be a significant "epigenetic hit" to immunologic homeostasis, with the triggering of nascent autoimmune disease not uncommon. Profound fatigue ...