Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your diagnostic approach to patients referred for central sleep apnea on PSG but normal overnight EEG and MRI?
In lab titration study, starting with CPAP (first-line treatment, can work in many cases). If remains, BiPAP-S titration is next (usually same night) with minimum EPAP titrated to prevent apneas and IPAP to prevent hypopneas but care as to avoid too much pressure support and over ventilation. Failur...
What has been your stepwise approach to oxygenation, including when to consider the use of inhaled nitric oxide or epoprostenol, in refractory hypoxemia due to cardiogenic pulmonary edema in patients who are otherwise not ECMO candidates?
Stepwise Approach to Oxygenation in Refractory Hypoxemia Due to Cardiogenic Pulmonary Edema: Initial Stabilization and Oxygen Therapy: Start with supplemental oxygen to maintain SpOâ‚‚ > 90%. Use noninvasive ventilation (NIV), such as CPAP or BiPAP, to provide positive end-expiratory pressure (PEE...
What is the optimal frequency and duration of post-operative radiological surveillance following resection of a solitary fibrous tumor?
Partly depends on the subset of SFT. The classic variant is low-grade, indolent clinical behavior and can recur late (several years later) requiring (maybe less frequent) but long-term follow-up for 10 years or even beyond. The malignant SFTs have a shorter natural history and typical sarcoma follow...
Do you generally recommend starting nintedanib prior to immunosuppressive therapy in a patient with CTD-ILD?
Patients with autoimmune disease-associated ILDs such as those with rheumatoid arthritis-related ILD, Sjogren and inflammatory myositis-related ILD are usually on background DMARD/immunosuppressive therapy already at the time the ILD is detected. These therapies are also important in helping to redu...
What is your hemoglobin target for PRBC transfusion in cases of acute brain injury?
At our institution, our hemoglobin goal has always been 7 except for TBI patients, in which the goal has been 8.5. The TBI goal was a bit arbitrary and really just split the difference between 7 and 10 given some of the contradictory data. Given the new HEMOTION and TRAIN trials, we are revisiting o...
How long do you recommend that a patient wear a mask when resuming biologic infusions following a recent upper respiratory infection?
Patients who have acquired an upper respiratory tract infection in the COVID, RSV, influenza era should wear masks as long as they are deemed contagious. The CDC makes recommendations concerning the duration of masking and the type to use. For COVID the current suggestion is 10 days after the cessat...
Do you routinely discontinue atypical coverage in community-acquired pneumonia when PCR testing (i.e., respiratory pathogen panel) is negative for atypical organisms?
In community-acquired pneumonia (CAP), here is how I approach the decision to discontinue atypical coverage (e.g., azithromycin or doxycycline) when respiratory pathogen panel PCR testing is negative for atypical organisms (most commonly, Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneum...
What is your approach to differentiating RA-ILD from medication toxicity (I.e. from methotrexate)?
RA-ILD occurs in about 7-10% of patient with RA. It is more common in males and in those with a history of smoking. Most are seropositive. The typical pattern on HRCT in 50-60% of RA-ILD patients is a UIP pattern followed by NSIP, OP, and even LIP is some cases. An experienced clinician with the hel...
Do you routinely perform a pre-extubation bronchoscopy for secretion clearance during the index hospitalization in patients following lung transplantation?
Yes, this is routinely done on post-op day 1 and frequently repeated if the patient is not extubated on the first post-operative day after lung transplantation. This is typically necessary and done early in the post-op phase to clear out blood or debris from the airway that often accumulates in the ...
Is Metformin contraindicated in patients using long term oxygen therapy at home?
If a patient is stable at home without hypoxia on oxygen and eGFR is over 30 cc/min, I would be comfortable with prescribing metformin at a dose appropriate to the eGFR. Metformin should be stopped for any pulmonary decompensation or hospital admission.