Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you approach the management of patients with mildly elevated mPAP (21-24 mmHg) and PVR (2-3 WU) who may be at risk of progression, given the recent changes in the hemodynamic definition of pulmonary hypertension?
The "new" definition of PH with a cutoff of 20 mmHg is a very sensible change, based on the study by Kovacs et al., PMID 19324955, which showed that a mean PAP of 20 mmHg is already two standard deviations above the mean PAP in normals. Thus, the cut off of 20 mmHg makes more sense than 25 mmHg.To a...
Is there a role for the use of transient elastography (FibroScan) to monitor liver fibrosis in patients on long term methotrexate?
Liver elastography is a useful tool to use when assessing the potential hepatotoxicity of various drug therapies. Traditionally, methotrexate accounted for nearly all the hepatotoxicity issues that we faced; however, we can add many other drugs to that list. Virtually, every immune suppressive drug ...
How do you sequence pharmacologic treatments for primary insomnia?
First, be sure you have already addressed deficiencies in sleep hygiene: Room at 65 degrees F Wearing earplugs Complete darkness (no visible hand in front of face) No clock Golden hour before bed ETOH, nicotine, and caffeine reduction with cessation of 4 hours before bed Writing a list of worries B...
How would you manage symptomatic, bilateral subsegmental PE developed after long air travel?
I generally consider air travel to be a relatively weak provoking factor. Although the 2020 ASH guidelines do not address this, the ASH Guidelines from 2018 on management of VTE cite a 2.8-fold increased risk for VTE associated with air travel, which is roughly similar to the increased risk associat...
Are there instances where tracheostomy alone without mechanical ventilation can be sufficient to manage neuromuscular respiratory failure?
This is a very rare circumstance in our assisted ventilation clinic. This situation usually arises because a patient underwent tracheostomy during an acute illness while they were requiring invasive ventilatory support, and were able to wean from the ventilator but had dyspnea or hypercarbia while t...
How do you determine if pulmonary hypertension is disproportionate to the severity of lung disease?
This is a question we faced on a daily basis in our PH clinic. Patients with parenchymal lung disease like COPD or ILD would get an echocardiogram that showed an elevated RVSP and/or RV dilation/dysfunction and will be referred to our clinic for PH evaluation. Alternatively, the patient already unde...
What factors do you consider when deciding between monotherapy with an antipseudomonal cephalosporin and combination therapy in ICU patients with Pseudomonas aeruginosa bloodstream infection who are not in septic shock?
In a patient who is critically ill, combination therapy can be used if there is concern that there may be a drug-resistant organism. In that case, a combination regimen can be used while awaiting the susceptibility test results. The combination choice should be based on the resistance patterns of th...
Would you add abatacept to treat active inflammatory arthritis in a patient with history of RA-ILD who is already taking mycophenolate?
Although there are no controlled trials of abatacept in RA-ILD, the current literature suggests a stabilization of ILD in RA patients and is one of my principal go-to agents for this situation. A review paper from 2021 (Vicente-Rabaneda et al., PMID 33887489) indicated abatacept was associated with ...
How do you manage PEEP in a morbidly patient with severe hypoxia who is already proned with no access to esophageal ballon?
We do not use esophageal balloons at our facility. In patients we are proning, I usually titrate the PEEP to the lower inflection point on the pressure-volume curve on their vent graphics and tweak from there based on their level of hypoxia and plateau pressures. In morbidly obese patients, higher p...
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...