Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Are there any biomarkers, imaging, or other clinical information that can be used to better choose effective therapies for super refractory status epilepticus?
SRSE is a syndrome not a diagnosis. The key determination is if this is immune-mediated, infectious, structural, metabolic, genetic, or drug/toxic-induced. For example, if the lumbar puncture shows significant pleocytosis, in the presence of flare changes in the medial temporal lobes, especially in ...
How do you approach tapering high dose continuous infusions for status epilepticus in patients experiencing serious medication-related toxicity?
This is done with continuous EEG monitoring. It depends on how long the patient has been on these infusions and what doses they are at, if there is sufficient coverage with non-infusion ASMs (either IV or oral). There is no one particular strategy, but what is typically done is reducing by up to 25%...
When reviewing right heart catheterization numbers in obese individuals, what adjustments or caveats do you routinely apply to your interpretation?
I use the principles outlined in Kovacs et al., PMID 24869464. The respiratory pressure swings are mainly a problem for knowing absolute values of, say, mean pulmonary arterial pressure (mPAP) or pulmonary capillary wedge pressure (PCWP). More commonly, we care about determining if there is evidence...
Would you give consolidation durvalumab to a patient who underwent chemoradiation for his stage III NSCLC and is being started on antifibrotic therapy by pulmonology for his ILD?
This is a difficult scenario. On the one hand, we know from the PACIFIC trial that there is a clear benefit to the addition of durvalumab in this setting. On the other hand, there is a higher risk of pneumonitis due to both the prior use of radiotherapy and the history of underlying ILD. I think ECO...
What guides your decision whether to complete a full course of intrapleural alteplase-dornase versus proceeding to surgical decortication when a patient continues to worsen or does not adequately improve with intrapleural therapy?
Based on the MIST trials (Maskell et al., PMID 15745977, Rahman et al., PMID 21830966, and Bedawe et al., PMID 37820359), I typically complete a three-day course of intrapleural therapy before proceeding to surgical decortication. It's only three days, and the decision to proceed to surgery after th...
Under what circumstances do you recommend POCUS guidance for lumbar puncture?
If the circumstances allow for it, I would use ultrasound for guidance for LP every time a LP is performed. This allows for continued practice in identification of the landmarks and improves accuracy in POCUS when it's truly needed, as in obese patients, where landmarks are difficult to palpate. Got...
How would you approach a stable 3 cm iatrogenic pneumothorax in an asymptomatic patient?
I think it is quite reasonable to continue to monitor in this situation. I probably would take comorbidities and reliability into consideration to decide if this is someone I would admit to the hospital VS follow up as outpatient.
Is it necessary to prescribe a steroid taper after two weeks of high-dose prednisone (60 mg daily)?
Interesting question. Not being an endocrinologist, I don't have the expertise to advise but the reference below makes the statement that even short-term steroids can be an issue. I suspect that if you have to stop abruptly from 60 mg daily for 2 weeks, it would probably be fine in most instances bu...
In patients with RA on methotrexate and a TNF inhibitor who develop PJP pneumonia, how long do you hold immunosuppression before restarting therapy?
I would typically hold immunosuppression until the patient has completed therapy unless they had significant respiratory failure, in which case I would await full recovery. The patient should be placed on appropriate PJP prophylaxis prior to resuming therapy.
How do you approach a patient with recurrent VTE who develops VTE again after reduction of apixaban to 2.5 mg bid?
Several factors play into this decision for me. Is the patient obese? Obese patients tend to give me pause for dose-reduction of DOACs. As such, half-dose apixaban may have been relatively underdosed for an obese patient and I would not call it DOAC failure, rather I would increase the dose to usua...