Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What treatment approach do you suggests for a patient with nasal polyp disease and asthma who was improved on dupilumab, but over last 2 years has begun to have increased nasal symptoms and rising eosinophil counts?
Dr. @Dr. First Last's comments are quite valuable. It might be more expedient to consider simpler options first, then progress to the less common diagnoses as needed. I very much agree that unless we know what is meant by "increased nasal symptoms", it is difficult to provide precise alternative the...
Do you consider indwelling pleural catheters in patients with refractory transudative pleural effusions?
I do as long as the risks, benefits, and possible alternatives are discussed with the patient. Frequently, these patients have refractory or end-stage heart failure, kidney failure, and liver failure. Often, they have decompensated or end-stage diseases and are not candidates for organ transplantati...
How do you counsel older adults regarding the use, dosing, and safety of CBD-containing products for insomnia?
When counseling older adults on CBD use for insomnia, I usually explain that evidence for safety and effectiveness is limited. Most products are not FDA-approved, and their labeling, purity, and dosing can be inconsistent. It’s important to review the patient’s comorbidities and medications closely,...
Do you utilize D-dimer to inform anticoagulation duration in the treatment of VTE?
I had developed a policy during my last eight or ten years of practice evaluating how long patients should be treated after a thrombosis and I'd like to share some impressions over these years as well as conclusions that I reached. These conclusions formed the basis of my approach to this problem. I...
When would you start antiepileptic drugs in a critically ill patient who develops myoclonic jerks but has not yet had an EEG?
Treatment depends on the setting in which these myoclonic jerks are seen. In a non-cardiac arrest patient, such myoclonic jerks are often due to medications, organ dysfunction (e.g., uremia, etc), electrolyte imbalance, or non-convulsive seizures, etc, and workup for this is recommended with labs, h...
What is the optimal duration of biologic therapy before assessing for non-response and initiating a switch in patients with uncontrolled asthma?
I generally wait 3-6 months before changing biologic class to allow for the medications to get to a steady state. I will monitor eNO and will not wean steroids prior to 3 months.
In patients with anoxic brain injury who have a tracheostomy, but “liberated” from the ventilator, and appear to be able to protect their airway, but have no meaningful neurological function, is there a role for decannulation?
Unfortunately, in patients with such severe brain injury that they have no meaningful neurologic function, decannulation would come at significant risk. Often, patients in these situations do not manage their secretion well and are at high risk for aspiration. With the trach in place, suctioning and...
Do you have any pearls for how to manage OSA with CPAP in older adults with cognitive impairment?
I try to involve a partner or other family member in the process, including getting a sleep study in the first place. If the study shows moderate or severe sleep apnea, especially with substantial oxygen desaturation, I remind the patient and partner that use of CPAP will help the patient's memory. ...
What is the best alternative oral therapy for treatment of non-severe pulmonary nocardiosis in an immunocompetent patient with sulfa allergy?
We have been using linezolid for this indication, based on a paper from ARUP Labs.Schlaberg et al., PMID 24247124
Do you prefer using end-expiratory or mean pulmonary artery wedge pressure obtained during diagnostic right heart catheterization for the classification of precapillary vs postcapillary PH?
I use end-expiratory wedge pressure (and all hemodynamics for that matter at end-expiratory pressure) most of the time which is supported by current guidelines. The confounder is in patients with wide transthoracic pressure swings (i.e., exercise, severe COPD, severe obesity). This is just something...