Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you recommend IV sodium bicarbonate for patients with rhabdomyolysis and AKI without metabolic alkalosis or hypocalcemia?
The primary goal of IV fluids and urine alkalinization in patients with rhabdomyolysis is to prevent AKI, not to treat established AKI. The most important factor in preventing AKI is early and vigorous fluid administration (aiming to achieve a brisk diuresis of 200-400 ml/hr), while the choice of IV...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
We only use acid-suppressive medications for GI prophylaxis in patients treated with corticosteroids when they have additional risk factors for upper GI bleeding. Risk factors include concomitant NSAID or antiplatelet therapy, history of GI bleeding or peptic ulcer, age over 60 years, prednisone dos...
How soon would you repeat PET/CT in a patient with cardiac sarcoid after starting treatment with infliximab?
Very good question. There is no consensus on this answer, and it is also important to consider the medical burden on a patient to repeat such involved testing. Our approach is to follow the resolution/improvement of patient-reported cardiac-related symptoms and follow less invasive testing such as E...
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...
How do you decide when to implement a "renal diet" (i.e., restricting electrolyte and/or fluid intake) in hospitalized patients with renal impairment?
I think about this from several perspectives: First, what's the severity of the renal impairment? Generally, I consider electrolyte abnormalities like hyperkalemia and hyperphosphatemia more likely to occur when the eGFR is <60 (for hyperphosphatemia, it might be more evident when the eGFR drops bel...
How do you choose between dupilumab and mepolizumab for managing COPD in patients with eosinophilia?
I do use both agents and do not have a strong preference. I consider the patient's preference for every 4-week dosing (mepolizumab) vs. every 2-week dosing. Also, if the eosinophil count is between 150 and 300, mepolizumab may be the only option from the insurance perspective.
What is your approach to cough in hospitalized patients with pneumonia?
This is an interesting question, as we have all been paged for “something” for a patients cough by our nursing team, or faced the direct question from a patient. Cough in pneumonia is primarily managed by treating the underlying infection with appropriate antibiotics.While it is intuitive that use o...
Can sIL2-R differentiate between active sarcoidosis affecting small airways vs uncontrolled asthma and guide treatment with methotrexte vs biologics?
This is an interesting question. Just to provide a little context, I used to have a sarcoidosis-focused clinic where one day each week I would see only sarcoidosis patients. I also had a day of seeing only neurosarcoidosis patients once per month, together with neuroimmunology. To be honest, since I...
How do you determine the time window for which to monitor for cerebral edema development in patients with brain injury?
The type of edema definitely matters. The two big categories of cerebral edema include cytotoxic and vasogenic edema. Cytotoxic results from free water accumulation in dying cells from acute brain injury, while vasogenic edema results in disruption of the blood-brain barrier. The classic teaching is...
What is your approach to management of a patient with sarcoidosis who is asymptomatic, but demonstrates progressively enlarging mediastinal lymphadenopathy and rising soluble IL-2 receptor levels?
My concern here would be whether such a patient does not have 'asymptomatic sarcoidosis' but has CVID (often associated with multifocal non-caseating granulomas) with an associated B-cell lymphoma (for which such patients have a 30-fold Relative Risk) with developing mHLH (elevated sIL-2 being an as...