Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you factor smoking history into biologic selection for asthma since the clinical trials generally excluded these patients?
This is very important clinical data depending upon the duration of smoking and whether the patient is still smoking. Confirming the underlying clinical diagnosis is the important first step. Even with a long history of documented asthma, the clinical question is whether the patient has progressed t...
How do you manage calcium and vitamin D supplementation in patients with sarcoidosis on chronic steroids?
This is a great question with very limited data to help answer it well. The first-line therapy for sarcoidosis is corticosteroids, and chronic use can lead to decreased bone mass. Of course, Vitamin D supplementation is a very important factor in rebuilding bone mass. In sarcoid patients, this issue...
When do you consider ketamine to treat nonconvulsive status epilepticus?
Ketamine is a fine agent for the management of status epilepticus (SE) and some centers use it first line instead of propofol or midazolam. Mechanistically, it makes more sense as it controls the seizures through NMDA blockade, bypassing GABA receptors, which are downregulated in the setting of SE. ...
How does the presence of interstitial lung disease affect your decision to offer SBRT for early stage NSCLC?
As opposed to interstitial lung disease (ILD) in general, the entity most described in the literature as associated with severe pulmonary toxicity after SABR has more specifically been idiopathic pulmonary fibrosis (IPF) and additionally, in the absence of a known diagnosis of IPF, CT findings consi...
When would you consider using acetazolamide to augment diuresis in patients with ADHF?
The ADVOR trial suggested that the addition of acetazolamide to a loop diuretic "upfront" in congested patients with heart failure achieves greater decongestion at 72 hours and discharge. While most would not use such a combination in "all" patients, this strategy is optimal in those demonstrating s...
In a patient with acute stroke/ICH/SDH/hyperammonemia at risk for rebound edema with new onset renal failure, do you prefer CRRT versus low and slow HD?
In the acute period (first 72-96 hours after ictus), my personal preference is CRRT due to the theoretical advantage of hourly titration of ultrafiltrate. I don't know if it really matters though. As for the frequency of laboratory evaluations, I don't find more frequent than q4 hours to be useful, ...
What is your approach to helping parents manage sleep disturbances in patients with autism spectrum disorder?
At our center, we start with sleep hygiene education, using tools such as the Autism Speaks sleep toolkit which has a printable PDF that is free for parental and clinical use. We also try to do therapy on sleep hygiene and our therapists will often try to find out what factors may exist in the home ...
What is your approach to evaluating amiodarone induced interstitial pneumonitis?
There are no definitive histopathological or radiological findings of amiodarone toxicity. For example, foamy lipid laden macrophages are reported but this reflects exposure, not injury, and these findings are present without interstitial lung disease related to amiodarone. High HUs have been report...
How do you decide whether to use lung POCUS versus CT as the next step when a chest X-ray is equivocal for pneumonia?
Lung ultrasound is a quick, safe, and inexpensive test to perform. If the patient already has a chest X-ray and it is equivocal for pneumonia, I always perform a lung ultrasound. It is useful for evaluating an inflammatory vs. non-inflammatory interstitial process. It is better than an X-ray to dete...
In which cases would you consider early transition to DOAC (within 72 hours) for hospitalized patients with intermediate or high risk PE?
Two DOACs are FDA-approved for early use (within 72 hrs), rivaroxaban and apixaban. The PEITHO-2 dabigatran cohort study included no comparison group (its authors called it a "trial"?) and required "72 hrs" parenteral anticoagulant before dabigatran but the small print in its Lancet Haematology show...