Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What factors influence your decision between dexmedetomidine and propofol for sedation in mechanically ventilated patients?
The main factor that influences this decision in my practice is the indication for mechanical ventilation. For patients in whom the main indication is airway protection, such that the patient would not otherwise require oxygenation or ventilation support, I aim for higher RASS goals (-1 to +1) and t...
How do you manage a 3 cm solitary pulmonary cryptococcoma in an asymptomatic, immunocompetent, HIV-negative host?
I will treat it with oral Fluconazole for 6-12 months. Brain MRI to R/O CNS infection.
What policies do you take regarding legalized recreational marijuana or medical marijuana use in transplant patients?
The use of THC and CBD is becoming an increasingly important topic in solid organ transplantation. Recent survey data has demonstrated that daily cannabis use is higher than daily alcohol use in the U.S. (Caulkins, PMID 38775461).Certainly, the legalization of THC use in many states has led to consi...
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
How do you decide on supportive care vs empiric antibiotics in a patient with suspected aspiration pneumonitis (i.e., witnessed macroaspiration event within the past 24 hours) but with features that could suggest pneumonia (e.g., acute respiratory distress, fever, leukocytosis, pulmonary infiltrates, etc.)?
Great question and one that comes up all the time for me. As the patient has more signs of true infection, such as those you mention with fever, leukocytosis, and respiratory distress, I am much more likely to start antibiotics. If the patient just has chest radiograph findings of opacities and some...
How do you approach managing clozapine in patients who are critically ill?
With COVID-19 disproportionately affecting those with mental illness we found an increasing number of medical admissions for those on clozapine. There are multiple domains of concern for those on clozapine who are medically ill. Clozapine levels have been shown to potentially double during periods o...
How do you use cardiac POCUS to potentially defer formal echocardiogram in patients presenting with an acute pulmonary embolism?
In patients with acute PE, cardiac ultrasound is useful in risk stratification and identification of patients at higher risk of short-term mortality and complications. Signs to look for on POCUS are: RV dilatation (RV>LV on apical 4-chamber view), McConnell Sign (hyperkinetic RV apex with hypokineti...
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 ...