Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
When starting stress dose steroids for patient with primary adrenal insufficiency, how do you decide whether to start hydrocortisone 100 mg every 8 hours versus 50 mg every 6 hours?
Stress doses of steroids in patients with primary adrenal insufficiency depend on the anticipated stress. The dose of steroids can be doubled or tripled depending on the stress. For example, in cases of maximal stress such as major surgery, the dose can be similar to the dose used for an adrenal cri...
Are there certain clinical features that help you choose between benralizumab and mepolizumab for EGPA in clinical practice?
Given, as noted above, no significant clinical differences between benralizumab and mepolizumab, assuming there are no specific insurance differences between the two, I preferentially prescribe benralizumab because of the 8-week dosing frequency after the first three 4-week loading doses. For a few ...
Is there any role for adjusting how long to hold anticoagulation perioperatively based on DOAC dose?
The PAUSE trial evaluated perioperative management of DOACs. However, only 20% and 16% of patients were on prophylactic doses of apixaban and rivaroxaban, respectively. It was suggested to hold the drugs for two days, and one day before high-risk and low-risk procedures. A useful review of this appr...
How do you approach pre-operative risk assessment and optimization in a patient with interstitial lung disease?
Surgery in patients with interstitial lung disease (ILD) is not a decision we take lightly! At our center, we start with general risk tools like the ARISCAT score but layer in ILD-specific factors—such as DLCO below 60% and declining trends in PFTs or 6MWT testing. We also screen for comorbidities l...
What is your approach to tapering anesthetic drips for refractory status epilepticus after achieving burst suppression?
Ensure adequate oral/IV ASMs are on board, targeting the receptors appropriately based on the type of status- generalized, focal (e.g., GABA, Na channel, glutamate, etc.). These would include the first, second, and third line as per status protocols. Check levels to ensure adequacy. At least 24 hou...
What do you think about using conventional thoracic imaging methods (e.g., X-ray, CT, etc.) to determine if a pleural effusion is of adequate size to consider thoracentesis?
Generally speaking, CT would be superior as it would allow you to see more volumetric characteristics of the effusion; XR would have a hard time discerning true size, presence of loculations, or trapped lung. The real winner for this application would be bedside ultrasound. This modality would give ...
Do you routinely use pupillometry for serial neurologic examinations in the ICU, especially for patients at risk for transtentorial herniation?
We frequently do pupillometry assessments on patients at high risk of ICP crisis. It gets rid of observer subjectivity as it is often an issue in ICUs. We have a protocol with the following indications for q1h pupillary assessments. It is not based on particular guidelines but serves as a good marke...
Do you suggest using a vascular probe to assess the superficial vasculature prior to performing a bedside procedure such as paracentesis, thoracentesis, lumbar puncture, etc.?
Yes - this is now standard of care for paracentesis and thoracentesis, and we have had a couple of bleeding complications when it was not used, and then a vessel was noted on POCUS after the fact. So it really should be incorporated into standard practice and taught such that it's done consistently....
How routinely do you use POCUS to assess fluid responsiveness in patients with sepsis?
I do use this sometimes, but would recommend using it with caution and only as one piece to the puzzle - IVC ultrasound should never be used in isolation. My most recent example was a patient who initially appeared volume overloaded, then was found to have sepsis. When I looked at his IVC, it was ex...
Should long-acting subcutaneous insulin be started upfront in addition to regular insulin infusion for patients with diabetic ketoacidosis?
Current ADA guidelines suggest patients with uncomplicated mild or moderate DKA may be treated with subcutaneous rapid-acting insulin analogs every 1-2 hours as an effective alternative to IV insulin, but still only recommend IV short-acting insulin by continuous infusion for moderate-severe DKA. Ho...