Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Which patient characteristics or scenarios drive you to choose tezepelumab over dupilumab for asthma?
I typically put adult patients with T2 high, and allergic phenotype on dupilumab whereas those that are T2 high only or T2 low are on tezepelumab. Additionally, if the patient has nasal polyps or AD, then I would prefer dupilumab over tezepelumab. I always have a discussion with the patient regardin...
How do you manage persistent insomnia despite ASV titration in patients with complex sleep apnea?
It is an excellent question, and I am not sure if I have a perfect answer. The first question I would have is if the insomnia pre-dated the treatment-emergent central sleep apnea. It is assumed if they are on adaptive servo-ventilation (ASV) that they already tried CPAP, had treatment-emergent centr...
Is there a role for the use of transient elastography (FibroScan) to monitor liver fibrosis in patients on long term methotrexate?
Liver elastography is a useful tool to use when assessing the potential hepatotoxicity of various drug therapies. Traditionally, methotrexate accounted for nearly all the hepatotoxicity issues that we faced; however, we can add many other drugs to that list. Virtually, every immune suppressive drug ...
How do you sequence pharmacologic treatments for primary insomnia?
First, be sure you have already addressed deficiencies in sleep hygiene: Room at 65 degrees F Wearing earplugs Complete darkness (no visible hand in front of face) No clock Golden hour before bed ETOH, nicotine, and caffeine reduction with cessation of 4 hours before bed Writing a list of worries B...
How would you manage symptomatic, bilateral subsegmental PE developed after long air travel?
I generally consider air travel to be a relatively weak provoking factor. Although the 2020 ASH guidelines do not address this, the ASH Guidelines from 2018 on management of VTE cite a 2.8-fold increased risk for VTE associated with air travel, which is roughly similar to the increased risk associat...
Are there instances where tracheostomy alone without mechanical ventilation can be sufficient to manage neuromuscular respiratory failure?
This is a very rare circumstance in our assisted ventilation clinic. This situation usually arises because a patient underwent tracheostomy during an acute illness while they were requiring invasive ventilatory support, and were able to wean from the ventilator but had dyspnea or hypercarbia while t...
How do you determine if pulmonary hypertension is disproportionate to the severity of lung disease?
This is a question we faced on a daily basis in our PH clinic. Patients with parenchymal lung disease like COPD or ILD would get an echocardiogram that showed an elevated RVSP and/or RV dilation/dysfunction and will be referred to our clinic for PH evaluation. Alternatively, the patient already unde...
Would you add abatacept to treat active inflammatory arthritis in a patient with history of RA-ILD who is already taking mycophenolate?
Although there are no controlled trials of abatacept in RA-ILD, the current literature suggests a stabilization of ILD in RA patients and is one of my principal go-to agents for this situation. A review paper from 2021 (Vicente-Rabaneda et al., PMID 33887489) indicated abatacept was associated with ...
How do you manage PEEP in a morbidly patient with severe hypoxia who is already proned with no access to esophageal ballon?
We do not use esophageal balloons at our facility. In patients we are proning, I usually titrate the PEEP to the lower inflection point on the pressure-volume curve on their vent graphics and tweak from there based on their level of hypoxia and plateau pressures. In morbidly obese patients, higher p...
Would you offer lung SBRT in a patient with Pulmonary Langerhans Cell Histiocytosis (PLCH)?
Langerhans cell histiocytosis (LCH) is a clonal proliferation of Langerhans cells (dendritic cells), part of the mononuclear-phagocytic system. Some patients present with unifocal disease, often in bone. A variety of treatments are acceptable for unifocal disease, including radiation therapy. Very l...