Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you manage daytime somnolence without a clear cause?
Throw a broad net out for the evaluation because we don't know how much has a physiological component and how much is mental/emotional. At intake, I get a moderately comprehensive set of labs. Rating Scales like HAMA, HAM-D, PHQ-9, Epworth Sleepiness Scale, and a ROS (Review of Systems) are done. I...
Do you prescribe lower dose ICS for asthma to mitigate the risk of pneumonia in patients with a history of respiratory infections or compromised immune systems?
Yes, I do, if possible. This is based on data that demonstrates that high-dose ICS negatively impacts the microbiome diversity. While not linked directly to clinical outcomes, these findings warrant caution enough to make this simple alteration. That said, more research into the clinical impact is n...
How do you manage patients with central sleep apnea due to heart failure with reduced ejection fraction?
I assume you are referring to CSA with Cheyne-Stokes respiration. Several possibilities, but first ask yourself what your treatment goal is. If the patient does NOT have symptoms (frequent awakenings, daytime sleepiness, etc.) I contend that you don't need to treat at all. We already know that there...
Are there situations where you would consider treating E faecalis or E faecium that grows from a respiratory culture?
Pretty much almost never! Enterococcus is not recognized as a pneumonia pathogen. In the setting of a lung abscess, I suppose you could consider treating it as part of a polymicrobial infection. In a heavily immunocompromised patient, it is possible that enterococcus might cause pneumonia—and it has...
How do you evaluate a suspicious, but negative pleural effusion when working up NSCLC and SCLC?
Good question and this came up in my practice very recently (NSCLC). Historically, clinical trials have required 2 negative taps for entry. The patient I had in clinic appeared to have a node negative, LLL lesion with a ton of atelectasis and had a bloody tap that was negative for malignancy. It did...
Do shorter door-to-balloon (D2B) times impact outcomes in STEMI, if it's already less than 90 minutes, and to what degree (i.e., 30 vs 60 minutes would have a more significant impact)?
No. Shorter door-to-balloon times have not been shown to improve survival or outcomes in STEMI. The reason is that the other variable is the time from the onset of chest pain to presentation to a medical facility. This time is beyond the control of the medical system. For example, a patient waits 4 ...
Can tacrolimus in a transplant patient be used during radiation and concurrent chemoradiation?
Patients with solid organ transplants present unique challenges in management and risk of infectious complications, among others. The short answer is that tacrolimus can be used in the lowest dose possible, along with concurrent chemoradiation and close coordination with the transplant team. If the ...
Do you routinely evaluate for PE if a DVT is found?
I would not routinely evaluate for PE in a patient with new DVT, unless they had symptoms or signs suggestive of PE diagnosis. But I would usually evaluate for DVT in a new PE patient. This is in case the patient develops leg swelling or pain in the future and DVT is found then. It's difficult, oc...
What would prompt you to consider a sleep study for narcolepsy in a child or adolescent with new-onset hallucinations?
It would depend on other elements of the history. The age of the child, the timing of the hallucinations, particularly if they are associated with sleep, onset or awakening, other hypersomnia disorder symptoms, and the child's psychiatric history. Generally, I have a very low threshold for an in-lab...
Do you recommend careful correction of serum sodium to avoid osmotic demyelination syndrome in patients who are found to have isoosmolar hyponatremia in the setting of an elevated BUN level?
Urea is an ineffective osm and so if the blood is "isoosmolar" in the setting of hyponatremia but is isoosmolar because of an elevated BUN it may be isoosmolar numerically but not physiologically. I would ignore the BUN in making my decision. I would not ignore the BG though if it were elevated.