Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
If PFTs are done on different machines or different places, are the comparisons valid?
Pulmonary function test results might differ slightly when performed at different facilities due to staff engagement and coaching during respiratory maneuvers and machine calibration. Another important consideration is there may be differences due to use of body box plethysmography versus helium dil...
What’s your approach to an asymptomatic, hemodynamically stable patient with moderate spontaneous pneumomediastinum without pneumothorax and normal esophagogram?
Terrific question and, fortunately, an unusual occurrence with an estimated 1 in 30,000 hospital admissions (Barroso et al., PMID 37965408). The true incidence is likely higher as underdiagnosis may be related to individuals with mild symptoms who do not seek medical care, symptoms misdiagnosed and ...
How do you approach a patient with a solitary brain metastasis from small cell lung cancer s/p resection with otherwise limited thoracic disease?
This is rather an uncommon situation but can happen if a patient presents with a synchronous solitary brain metastasis (with or w/o symptom) and undergoes craniotomy and resection only to find out that it is small cell lung cancer. Additional information is needed on the volume of intra-thoracic dis...
How do you manage daytime somnolence without a clear cause?
Throw a broad net out for the evaluation because we don't know how much has a physiological component and how much is mental/emotional. At intake, I get a moderately comprehensive set of labs. Rating Scales like HAMA, HAM-D, PHQ-9, Epworth Sleepiness Scale, and a ROS (Review of Systems) are done. I...
What's the threshold to consider a PSG abnormal enough to preclude a MSLT the following night?
We use an AHI > 14 but it is up to the referring physician to determine so if it is close, we have the tech call and confirm. We still use the AASM recommended time for the PSG of > 6 hours sleep time.
Do you prescribe lower dose ICS for asthma to mitigate the risk of pneumonia in patients with a history of respiratory infections or compromised immune systems?
Yes, I do, if possible. This is based on data that demonstrates that high-dose ICS negatively impacts the microbiome diversity. While not linked directly to clinical outcomes, these findings warrant caution enough to make this simple alteration. That said, more research into the clinical impact is n...
How do you manage patients with central sleep apnea due to heart failure with reduced ejection fraction?
I assume you are referring to CSA with Cheyne-Stokes respiration. Several possibilities, but first ask yourself what your treatment goal is. If the patient does NOT have symptoms (frequent awakenings, daytime sleepiness, etc.) I contend that you don't need to treat at all. We already know that there...
Are there situations where you would consider treating E faecalis or E faecium that grows from a respiratory culture?
Pretty much almost never! Enterococcus is not recognized as a pneumonia pathogen. In the setting of a lung abscess, I suppose you could consider treating it as part of a polymicrobial infection. In a heavily immunocompromised patient, it is possible that enterococcus might cause pneumonia—and it has...
How do you evaluate a suspicious, but negative pleural effusion when working up NSCLC and SCLC?
Good question and this came up in my practice very recently (NSCLC). Historically, clinical trials have required 2 negative taps for entry. The patient I had in clinic appeared to have a node negative, LLL lesion with a ton of atelectasis and had a bloody tap that was negative for malignancy. It did...
Do shorter door-to-balloon (D2B) times impact outcomes in STEMI, if it's already less than 90 minutes, and to what degree (i.e., 30 vs 60 minutes would have a more significant impact)?
No. Shorter door-to-balloon times have not been shown to improve survival or outcomes in STEMI. The reason is that the other variable is the time from the onset of chest pain to presentation to a medical facility. This time is beyond the control of the medical system. For example, a patient waits 4 ...