Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
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...
Do you recommend avoidance of occupational/environmental exposures in patients with pulmonary sarcoidosis?
The best assessment of occupational exposures associated with pulmonary sarcoidosis comes from A Case Controlled Etiologic Study of Sarcoidosis (ACESS). This is nicely summarized in a state-of-the-art article that lists occupations and exposures with both positive and negative associations between o...
What factors do you consider prior to offering a trial of ICS/LABA therapy versus a methacholine challenge test in patients with suspected asthma but normal pulmonary function testing?
If there is a high suspicion of asthma, have the patient obtain a portable electronic spirometer. If peak flows/FeV1 drops >15% correlate with symptoms, start Rx and follow spiro results. If low suspicion for asthma or very mild symptoms, do methacholine.
How well does a negative non-contrast MRI of the brain exclude metastasis in a patient with squamous cell carcinoma of the lung?
I don't think the question has enough information to give a good answer. For example, if it was a T3, N2 NSCLC, or a small cell, then "yes" I'd repeat the MRI with contrast. On the other hand, if it was a T1, N0 NSCLC, then "no", I wouldn't. In other words, if I thought there was a real risk of havi...
What are the next steps in the management of a patient admitted with an IPF exacerbation resistant to steroid therapy?
IPF exacerbation is associated with a poor prognosis, with an in-hospital mortality rate of up to 50% in one study (Song et al., PMID 20595144). As discussed earlier by Dr. @Dr. First Last, there are currently no established or evidence-based pharmacotherapies for managing IPF exacerbation. Aggressi...
What criteria do you use to determine when to start a steroid-sparing agent for hypersensitivity pneumonitis?
This is a very challenging question, acknowledging the difficulty in confidently establishing the diagnosis of HP, limited evidence in general to guide the treatment of HP, and recent small observational studies that conflict prior small observational studies. To attempt to answer, breaking down int...
Can palliative radiation be used to treat recurrent malignant pleural effusion in NSCLC?
There has been gradual recognition of improved survival with the administration of three-dimensional radiotherapy (3D-CRT) to the primary tumor in the context of systemic chemotherapy, EGFR-TKIs, or immunotherapy in patients with stage IV non-small cell lung cancer. (Zheng et al., PMID 31040256, Arr...
How do you choose roflumilast vs ensifentrine in COPD patients with dyspnea despite adequate LABA + LAMA (+ ICS therapy where indicated)?
Hi - I don't think there is a clear answer for this. However, in my practice I rarely use roflumilast for dyspnea (mostly for exacerbation prevention). I have been trying ensifentrine in some of these dyspneic COPD patients, in part because they are wanting to "try something new". So far, I have see...
What is your preferred agent for fungal prophylaxis in a patient post lung transplant with abnormal LFTs?
Isavuconazonium tends to cause less elevations in LFTs.
What additional workup do you pursue in a patient in whom you suspect Yellow Nail Syndrome?
Mandatory pulmonology (and/or ENT for sinusitis) for comorbit workup or monitoring. Detailed ROS for eval of any underlying disease and workup as indicated. Age-appropriate cancer screenings.