Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you routinely administer desmopressin to patients with intracerebral hemorrhage who are also on anti-platelet therapy?
I routinely administer desmopressin in patients presenting with ICH if they are on dual antiplatelets but not single antiplatelets. The evidence for this is limited, but it has not revealed any harm.
How would you treat an asymptomatic patient with a positive Blastomyces antibody, evidence of prior granulomatous lung disease on imaging, and who may require immunosuppression in the future?
We practice in an area with a good bit of blastomycosis and rarely see a positive Blastomyces antibody, even in patients with culture-proven blastomycosis. The newer EIA antibody that MiraVista lab is doing may be more reliable. If the prior granulomatous lung disease has been worked up with negativ...
When trying to increase infliximab for active disease (inflammatory arthritis or sarcoidosis), do you prefer to increase dosage or reduce frequency between doses?
As is often the case with rheumatology therapeutics, we are residing in a " data-free" zone. There is limited literature available from the Crohn's disease patient population where this issue was studied in a limited way. There did not appear to be any significant difference in outcome using either ...
How do you determine the severity of restrictive lung disease?
My interpretation of the latest ATS/ERS guidelines is that FEV1 should be used for "any spirometric abnormality" including restriction or mixed disorders, which is unchanged from the 2005 ERS Guidelines.That said, I tend to use FVC when grading pure restrictive disorders, habituated as a result of F...
Is there any role for using mandibular advancement splints on select nights in place of CPAP in the management of patients with OSA who have difficulty tolerating CPAP?
Oral appliances are a very good treatment for sleep apnea; however, before "substituting" one for CPAP, in anyone with moderate to severe sleep apnea, it is important to retest with the OA in place to make sure it is reducing AHI to an adequate level. If there is relative "equivalence," then it is o...
What are your top takeaways from CHEST 2025?
1. Pulmonary Hypertension: From Basics to Bedside and Theory to Therapy This postgraduate course provided an exceptional deep dive into pulmonary vascular disease through interactive, small-group learning and expert-led case discussions. The integration of hemodynamic interpretation, risk stratifica...
How do you approach the use of benzodiazepines in patients with chronic medical illnesses that may be susceptible to respiratory compromise (e.g., CHF, COPD, ILD)?
It’s a very good question and answers may vary among different specialty providers. Yes, a slow or gradual weaning of the benzodiazepines would be advisable. When they reach lower doses the taper should be even slower over weeks or longer. There is a risk for not weaning them off benzodiazepines inc...
When do you usually introduce conversations regarding tracheostomy placement in patients with refractory status epilepticus, or other conditions where one may anticipate delayed awakening?
It depends on the underlying pathology and how long the patient is expected to have impaired airway reflexes requiring prolonged mechanical ventilation. In the Setpoint 2 trial, among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy (</= 5 days), compare...
How do you decide on the timing and number of blood cultures for suspected endocarditis given the differences in recommendations between the ESC guidelines and the Duke Criteria?
Concern about differences in recommendations regarding specifics of blood culture collection between the two guidelines should be alleviated if one understands that these are guidelines, not dictates. It would help to lay out general principles. First, the focus of infection in infective endocarditi...
When you interpret a PFT officially, do you include a comparison to an older PFT on your report?
Yes, I use as much information as is readily available in my PFT interpretations. Comparison with older PFTs enables me to track changes in pulmonary function; for example, changes in FVC are particularly important in individuals with pulmonary fibrosis who are undergoing antifibrotic therapy. I als...