Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you use anticoagulants in the management of patients with pulmonary veno-occlusive disease (PVOD)?
Not enough research
What is your approach to the management of a newly acquired Pseudomonas aeruginosa infection that was not eradicated with initial treatment in a patient with CF?
I think this is a situation where shared decision making with patient is required; in general, would aim for second round of eradication with different antibiotic (for example if tobramycin was used first, inhaled aztreonam would be next) or consideration of a second month; however, chances of eradi...
How do you approach management of a patient with multiple lung nodules and low titer +CCP but no active joint symptoms suggestive of RA?
In the absence of other clinical symptomatology, I would favor close observation and follow-up in this case as there is no established diagnosis and repeat CT, PFT’s in 3 to 6 months. Details of initial evaluation should include PET-CT to exclude malignancy but also to investigate other organ system...
How do you workup patients with neuropathy suspected to be secondary to sarcoid?
To answer this question, the attached paper with consensus criteria for the diagnosis of neurosarcoidosis, published in 2018, should be reviewed, Stern et al., PMID 30167654.Based on this paper, a diagnosis of probable or definite neurosarcoidosis requires unequivocal evidence of non-caseating granu...
Is there an upper threshold of pCO₂ that can cause symptomatic hypercapnia (e.g. AMS) despite metabolic compensation and normal pH?
Hi - I'm not sure about an upper threshold of pCO2 and AMS. However, even with normal pH, elevated pCO2 can cause significant increases in cerebral blood flow. Pollock et al., PMID 19406361 studied MR perfusion imaging and found that patients with a mean pCO2 of ~ 54mmHg had more than double the cer...
Are you more permissive of perioperative interruption of anticoagulation for VTE depending on the location and relative chronicity of the thrombus?
Yes - in general, I try to balance the relative urgency/importance of the procedure or surgery v. the thrombotic risk to the patient of a period of time off of anticoagulation. Location and chronicity both can feed into determining thrombotic risk. An upper extremity DVT, in general, has a lower rec...
What is your experience with transesophageal lung mass biopsies?
Thoracic lesions requiring FNA in the mediastinum are often best approached with EUS–FNA, as the sedation and airway management are less complex than the EBUS, and the needle does not need to break through cartilage rings to access the lesion. On the other hand, a lung mass would require the needle ...
How do you or your practice manage young, average-risk patients without structural lung disease referred to you or self-referred for concern of environmental mold exposure?
These individuals are generally managed by pulmonology and allergy/immunology clinics because the clinical presentation is generally more aligned with allergy-type symptoms like a chronic cough, congestion, or other symptoms associated with airway irritation. In individuals who are receiving chronic...
How long do you strictly enforce low tidal volume ventilation in ARDS?
I do not believe that there is data specifically looking at during duration of LTVV in ARDS vs shorter durations. However, there are multiple trials that argue that LTVV in ARDS and patients at risk for ARDS improves mortality outcomes with minimal negative side effects. In my practice, I try to adh...
Has your management of severe hyponatremia changed after a recent observational study described higher in-hospital mortality for sodium correction of <6 mEq/L compared to 6-10 mEq/L in the first 24 hours?
In short, no. I think the recent studies tell me two things: We need to better discriminate correction rates based on the risk of osmotic demyelination (ODS). Perhaps, do not worry so much about over-correction. They do not tell me to start rapidly correcting patients, and I guess I will summarize m...