Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Should in-office oscillometry for lung function measurements be utilized in pediatric patients who are unable to reliably perform spirometry?
We don't use oscillometry right now in our office, but the current issue of Annals has several outstanding editorials and reviews looking at oscillometry and how to implement it in your practice. I highly recommend looking at these papers:Link to whole issueEditorials: Oscillometry-determined small ...
Is it clinically necessary to provide supplemental oxygen to patients with mild, asymptomatic hypoxemia only during activity while they are recovering from an acute respiratory illness?
My practice is to withhold supplemental oxygen in patients with mild, asymptomatic hypoxemia during exertion when the underlying condition is expected to improve. I am not aware of strong evidence supporting the benefit in these cases, and I believe the potential harms generally outweigh any theoret...
Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?
PCV-21 was recently approved by the FDA and supported by ACIP. At this early stage (August 2024), CDC has not finalized guidance on PCV-21, so we do not know how the vaccine schedule will be changed. An important distinction is that PCV-21 covers different serotypes of pneumococcus, as outlined in t...
Do you target a lower goal driving pressure in older patients with ARDS?
I target the lowest possible driving pressure to maintain adequate ventilation. This includes decreasing tidal volumes within physiologic range as well as PEEP titration. I use a modified “Brazilian” method described by Amato. important to consider when doing the titration that you may need to abort...
Is the combination of a negative BAL PJP PCR and normal fungitell enough to rule out PJP pneumonia in an at-risk non-HIV patient?
Yes
Do you ever consider close clinical monitoring over antifibrotic therapy in patients ascribed an MDD diagnosis of IPF who have normal lung function and are asymptomatic?
Idiopathic pulmonary fibrosis is by definition a progressive disease with high mortality, thus, clinical practice guidelines would recommend treatment at diagnosis. Based on US and UK epidemiologic studies, IPF has an average life expectancy of 3-4 years without antifibrotic treatment. Furthermore, ...
What is your approach to a patient with undetectable MMR titers checked prior to or during immunosuppression and a history of MMR vaccination in childhood?
MMR titers are good correlates of protection. If any titer is undetectable it could be one of these situations: Primary failure. The components of the MMR have different efficacy. Two doses of appropriately given MMR will have 96+% against measles, but only 88% for mumps. Thus 1 in 10 appropriately...
Do you always stop dexamethasone at discharge for patients admitted with COVID requiring respiratory support (as done in the RECOVERY trial), or are there situations in which you will prescribe it to complete a 10-day course?
Great question. Generally, I don't continue dexamethasone if they are no longer wheezing or generally feeling back to their baseline. Sometimes, I will extend the course if the patient has been in the hospital several times for COPD, just to see if I can keep them out of the hospital longer. But the...
How do you manage steroid-refractory immune checkpoint inhibitor induced pneumonitis?
Steroid-refractory immune checkpoint inhibitor (ICI)-induced pneumonitis is managed with high-dose steroids plus an additional immunosuppressive agent, like infliximab or intravenous immunoglobulin (IVIG) among others. I recommend early immunomodulatory escalation as multiple studies have shown that...
How do you approach the workup of subcentimeter contralateral nodules in cases of locally advanced NSCLC?
These are often challenging questions/issues in our multimodality discussions. A couple of "general" principles/considerations. I would try, if at all possible to prove the presence of metastatic disease, however in the case of sub cm contralateral nodules, this is, as the question alludes to, not a...