Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What are the next steps in the management of a patient admitted with an IPF exacerbation resistant to steroid therapy?
IPF exacerbation is associated with a poor prognosis, with an in-hospital mortality rate of up to 50% in one study (Song et al., PMID 20595144). As discussed earlier by Dr. @Dr. First Last, there are currently no established or evidence-based pharmacotherapies for managing IPF exacerbation. Aggressi...
What criteria do you use to determine when to start a steroid-sparing agent for hypersensitivity pneumonitis?
This is a very challenging question, acknowledging the difficulty in confidently establishing the diagnosis of HP, limited evidence in general to guide the treatment of HP, and recent small observational studies that conflict prior small observational studies. To attempt to answer, breaking down int...
Can palliative radiation be used to treat recurrent malignant pleural effusion in NSCLC?
There has been gradual recognition of improved survival with the administration of three-dimensional radiotherapy (3D-CRT) to the primary tumor in the context of systemic chemotherapy, EGFR-TKIs, or immunotherapy in patients with stage IV non-small cell lung cancer. (Zheng et al., PMID 31040256, Arr...
How do you choose roflumilast vs ensifentrine in COPD patients with dyspnea despite adequate LABA + LAMA (+ ICS therapy where indicated)?
Hi - I don't think there is a clear answer for this. However, in my practice I rarely use roflumilast for dyspnea (mostly for exacerbation prevention). I have been trying ensifentrine in some of these dyspneic COPD patients, in part because they are wanting to "try something new". So far, I have see...
What is your preferred agent for fungal prophylaxis in a patient post lung transplant with abnormal LFTs?
Isavuconazonium tends to cause less elevations in LFTs.
What additional workup do you pursue in a patient in whom you suspect Yellow Nail Syndrome?
Mandatory pulmonology (and/or ENT for sinusitis) for comorbit workup or monitoring. Detailed ROS for eval of any underlying disease and workup as indicated. Age-appropriate cancer screenings.
How do you manage resistant infections that persist after stopping antibiotic therapy in patients with non-CF bronchiectasis?
It depends on what is meant by resistant infections; if this means multi-drug resistant bacteria that remain present after treatment ends and when symptoms have returned to baseline, there are many things to consider. First, has the person had many exacerbations before? Or do they have minimal sympt...
How do you plan to integrate sotatercept into the current treatment algorithm for PAH, particularly in patients who are stable on existing therapies?
Sotatercept gained FDA approval to increase exercise capacity, improve WHO functional class, and reduce the risk of clinical worsening events e.g., hospitalization for worsening PAH. The pivotal clinical trials enrolled a subset of Group 1 PAH patients who were stable for an extended period on PAH t...
Do you adhere to the standard 5-day minimum treatment duration for community-acquired pneumonia, or have you used shorter courses for certain low-risk patients?
This is a question addressing a shorter duration of antibiotic therapy than the current IDSA guidelines for community-acquired pneumonia (CAP) recommend. It has been the topic of several studies, for example, 3-day treatment (Richard T. Ellison III, MD, reviewing Dinh et al., PMID 33773631; Niederma...
In a patient with severe hyponatremia and acute kidney injury in the setting of hypovolemic shock, would fluid resuscitation take precedence over the rate at which sodium is corrected?
Normal saline, or a balanced fluid, e.g., Lactated Ringers or Plasmalye, if you are believers in balanced fluids. Shock trumps ANY concerns over rate of Na rise. Also if someone is in shock they are not going to have a water diuresis from volume.