Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
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...
How do you approach pharmacologic treatment of sleep disturbances in perimenopausal or menopausal patients with vasomotor symptoms?
CBT-I is still the gold standard approach in this population, and sleep hygiene, relaxation, and sleep efficiency would likely be helpful whether you are also addressing vasomotor or other contributing factors. But it can be so helpful to directly treat vasomotor symptoms. I use gabapentin 100-400 m...
Are there benefits to adding IL5/IL5 receptor blockade in patients with vasculitic manifestations of EGPA?
While IL-5/IL5 receptor blockade has been shown to be efficacious in treating "eosinophilic" manifestations of EGPA, including asthma and nasal polyps, there are real-world studies that demonstrate its effectiveness in what we consider "vasculitic" manifestations of the disease as well. I personally...
When do you recommend limited or targeted respiratory pathogen testing versus a full respiratory pathogen panel in a patient presenting with URI symptoms?
I think we’re asking the wrong group of people. How infectious disease physicians use respiratory pathogen panels is not the same as how emergency medicine or urgent care clinicians use them. For stewards of diagnostics, especially ID providers, the test often doesn’t change management. In many sett...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in the setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
How do you decide whether to use pharmacologic VTE prophylaxis in hospitalized patients with decompensated cirrhosis?
For all patients, I begin by using a standard risk prediction tool to determine if the patient is appropriate for pharmacologic VTE prophylaxis. At our institution, the Padua risk prediction tool is embedded in our electronic health record/admission set. Clinical guidelines- including those from the...
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
How do you decide the maximum amount of volume to remove during a therapeutic thoracentesis?
Critically ill (hypotension/shock on pressors) that are not having hypoxia issues/increased FiO2 requirements, I would probably be cautious. Rest of the population, use clinical judgement based on the clinical response... Less likely to need a "hard" stop/limit.
What are your go-to options for managing ICU delirium in patients with contraindications to antipsychotics?
Evidence for Ramelteon (Yu et al., PMID 36726202)Delirium with behavioral disturbances Depakote Clonidine Propranolol, especially with TBI Non pharmacological Make sure they're closer to the nursing station. Constant re-orientation. Shades open during the day and close at night. Bring anything they ...