Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What recommendations do you have regarding the use of dronabinol to prevent cannabis withdrawal in an inpatient medical or psychiatric setting?
I routinely use dronabinol in patients who are heavy/daily cannabis users and are having a hard time as inpatients with any degree of withdrawal and cravings. It can be a good anxiolytic as well as antiemetic and orexigenic in this situation. Depending on their preferences, it can be scheduled with ...
Which images do you routinely request when ordering a HRCT chest?
The images I tend to request depends in part on the clinical scenario. In general, I find it helpful to obtain a traditional "ILD protocol" when I meet an ILD patient for the first time, especially when the diagnosis is unclear. This includes both prone and supine images with 1-1.5 mm cuts, in addit...
Have you observed adverse mental health side effects in patients who start montelukast?
A female patient with anxiety but no history of depression or suicidal tendencies developed suicidal ideation with intrusive thoughts while taking montelukast. These were resolved within days of stopping the medication. I also treated a child brought in by his parents for extreme and sometimes viole...
For patients with newly diagnosed VTE on IV heparin planned for transition to DOAC, would you start at the loading or maintenance DOAC dose?
Agree with Dr. @Dr. First Last. In the clinical trials that led to rivaroxaban and apixaban approval, many patients had 2 days of injected anticoagulant first to arrive at successful outcomes leading to DOAC approval. I suggest IV heparin until hemodynamically normal (for PE), sq LMWH for a dose or ...
Do you obtain an echocardiogram as a part of risk stratification in all patients hospitalized with an acute pulmonary embolism?
I agree with Dr. @Dr. First Last! The echo offers a “functional view” that we can’t obtain by CTA, as well as the opportunity to diagnose clot-in-transit. However, if a formal echo cannot be quickly obtained, a bedside echo may offer key information. All critical care and ED clinicians should have a...
What is the interpretation of two IGRAs with negative mitogen wells, in the absence of immunosuppression?
If I understand this case correctly, the patient is actively ill and the patient's doctors are considering tuberculosis as a possible etiology of the patient's illness. In that scenario, IGRAs and PPDs have a limited to no role. Epidemiology, family history, and other possible exposures do. In your ...
What are your preferred treatments for disrupted nighttime sleep in elderly patients with narcolepsy already taking sodium oxybate?
The treatment depends on what is causing the disruption. Before I consider any medication, I recommend a thorough investigation of possible causes of the disruption. For example, has sleep apnea been ruled out? Is the patient taking alerting substances close to bedtime? What is the sleep environment...
What factors do you consider when determining whether to perform a biopsy for the diagnosis of organizing pneumonia?
If there are known risk factors such as autoimmune disease, biopsy is usually not necessary in that circumstance. If it's truly cryptogenic in nature, or the appearance on CT imaging is not typical, then biopsy can be helpful. Direct tissue sampling also increases the yield for culture in case it is...
What are some immunosuppression regimens to consider in a patient with refractory cardiac sarcoidosis?
Unfortunately, there is no high quality data at this point to directly answer this question but here are some options. For patients who have only been treated with oral steroids, I would first consider the addition of weekly methotrexate at a dose of between 10 - 20 mg WEEKLY with supplemental folic...
When would you consider referring a patient with suspected cardiac sarcoidosis based on PET and MRI for endomyocardial biopsy given degree of patchy involvement, as opposed to initiating empiric immunosuppressive therapies?
I would avoid initiating empiric immunosuppressive therapies without a firm diagnosis of sarcoidosis. I will mention however that the latest Japanese Circulation Society criteria for the diagnosis of sarcoidosis do include criterion for the non-invasive diagnosis of likely cardiac sarcoidosis based ...