Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you feel high dose Symbicort or Dulera is appropriate to use for SMART despite these doses not being studied in clinical trials?
One of the primary purposes of SMART therapy is to provide extra doses of ICS to patients inadequately controlled enough to use rescue inhalers. The other major purpose is to do this with a single inhaler instead of 2 or 3. So if the patient's baseline asthma is severe enough to require high-dose Sy...
How has COVID-19 altered your recommendations for invasive mediastinal staging for NSCLC?
I just had this discussion with our chief of interventional pulmonolgy at MD Anderson. Some of his faculty are being asked to staff our COVID-19 patient floor. In addition, bronchoscopy procedures should be considered high-risk procedures, and are required to have at least 45 minutes in between proc...
How could POCUS be useful in the initial evaluation of a severely ill patient in whom infectious endocarditis is suspected?
I love this question. POCUS is very useful in this patient population, both in diagnosis and management, though data are mostly limited to case reports and case series (López Palmero et al., PMID 41016280). Remember that transthoracic echo (TTE) is not as sensitive for infectious endocarditis as tra...
What is your approach to REM behavior disorder not adequately treated with melatonin and clonazepam?
Rule out comorbidities like sleep apnea or medications causing RBD. Optimize doses for melatonin and clonazepam, and consider dual therapy with these. Other options are gabapentin or pramipexole. Thanks,Sam Morkous
How aggressively do you screen the menopausal patient presenting with new or worsening insomnia for OSA, and what is your threshold for in-lab PSG after a negative HSAT in this population?
I would treat the insomnia and do actigraphy or obtain data from an Apple Watch, or even repeat HST before doing an in-lab. At least once in a while, there is someone scheduled in the sleep lab who cannot sleep and leaves in the middle of the night.
What are your thoughts on patients presenting with hyponatremia receiving IV fluids before urine studies are collected and the etiology is fully characterized?
Whenever possible, I try to obtain serum osmolality, urine osmolality, and urine sodium before giving IV fluids. A urine specimen requires only a small volume and can usually be collected at the same time as the initial bloodwork without meaningfully delaying care. That said, treatment should never ...
What is the role of inebilizumab in the maintenance treatment of IgG4-related disease?
Inebilizumab may play an important role in the maintenance treatment of IgG4-related disease (IgG4-RD), particularly in patients at high risk for relapse. These are typically patients with multi-organ involvement and elevated serum IgG4 levels who initially respond well to corticosteroids but tend t...
What dose of methotrexate do you typically continue to prevent antibody formation when adding infliximab for sarcoidosis?
Infliximab is a chimeric molecule that contains approximately 25% murine protein, so it can be immunogenic in some individuals.Development of anti-infliximab antibodies (ATI) has been reported in various autoimmune diseases treated with infliximab.Around 10 to 50% of individuals with rheumatoid arth...
Do you recommend that your patients with COPD avoid gabapentin or pregabalin entirely, given the increased rate of exacerbations noted in patients on these medications?
No, I don't exclude gabapentin or pregabalin as therapeutic options for patients with COPD. The study of Rahman is a cohort study that suggests an interesting association but has limitations, including residual confounding variables and a lack of smoking information on the study population. The issu...
Have you used Karius to work up fevers in the hospital when the source remains unknown?
This is a tricky question because Karius is an expensive test, which many experts believe should not be used for its negative predictive value (and I have anecdotally seen negative results where infection was still present, and infections/organisms detected of very unclear significance). I like to u...