Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Would you start octreotide in a patient with suspected sulfonyurea overdose but without frank hypoglycemia?
The data in the literature supports treating with Octreotide once hypoglycemia is present. Otherwise, a watchful, waiting period would be employed. It is reasonable to have a low threshold for its use once indicated, given how prolonged and profound the hypoglycemia can be in this situation.
How do you decide between neoadjuvant or perioperative chemoimmunotherapy, as per Checkmate 816 or KEYNOTE-671, for early-stage NSCLC?
All of us caring for patients with a lung cancer diagnosis face a very challenging “now what” scenario following publications of many studies demonstrating benefits of a neoadjuvant and/or perioperative approach for the treatment of patients with resectable NSCLC with already 2 FDA approvals of the ...
Have you used Karius to aid in the diagnosis of a non-resolving pneumonia, with negative bronchoscopy, biopsy, and other infectious work up in an immunocompetent patient?
Culture-negative hospital-acquired pneumonia is approximately 50%. Positive cultures are complicated by having to correlate results clinically as organisms may contaminate specimens (even if from a protected brush) and include an organism that doesn't even cause pneumonia, such as Enterococcus spp. ...
Do you routinely use 3% sodium chloride and desmopressin to correct hypovolemic hyponatremia in an asymptomatic patient with serum sodium of less than 120 mEq/L?
The challenge with hypovolemic hyponatremia lies in the fact that, upon correcting volume depletion, the kidney's capacity to excrete dilute urine returns, potentially leading to a rapid excretion of large volumes of dilute urine. In the case of an asymptomatic patient with a sodium level of 120 mEq...
What immunosuppression regimens do you use in patients with progressive RB-ILD despite smoking cessation and prednisone?
In patients with progressive RB-ILD who continue to worsen despite quitting tobacco use and prednisone, treatment options are very limited. Since there are no RCTs specifically studying immunosuppressive treatment in RB-ILD, most available evidence comes from observational studies, and most recommen...
What is your approach to bronchiolocentric interstitial pneumonia patterns observed on histology?
This histologic pattern involves fibrosis or other nonspecific inflammation involving the bronchioles and adjacent alveolar interstitium. It is important to point out that "bronchiolocentric interstitial pneumonia" is really not a distinct clinical entity but requires taking a variety of tools out o...
When would you consider initiating antibiotic sinus rinses for recurrent sinus infections, assuming no other underlying pathology and normal infunction?
Antibiotic sinus rinses are a great alternative to antibiotics by mouth. If indicated, I would favor the rinses after sinus surgery when there is better access to the sinuses. One commonly used preparation is Bactroban or bacitracin in a 45 ml Ocean nasal spray bottle.
How do you approach ongoing screening for TB in patients with a history of treated latent TB, but who have ongoing use of DMARDs and/or biologics given Quantiferon testing and PPD can remain positive?
Interferon-release assays (such as Quantiferon) and PPD testing do not discriminate between infection, reinfection, and prior infection with TB. However, in most developed countries, the likelihood that a patient who has once been treated for LTBI becomes reinfected and develops LTBI again is low, i...
What are your first-line vasopressors of choice for the management of acute severe aortic regurgitation and persistent hypotension/shock?
Clinically, it's a surgical emergency, but I would reach for norepinephrine in the acute setting for hypotension, keeping a lower MAP target to manage after load as best as possible.
What is the duration of steroids that you prescribe for organizing pneumonia?
The recommended duration of corticosteroid therapy for organizing pneumonia is typically 6-12 months, as supported by clinical studies and expert guidelines: Reference 1: American Journal of Respiratory and Critical Care Medicine suggests prolonged steroid therapy, often lasting 6-12 months, to redu...