Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
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...
When reviewing right heart catheterization numbers in obese individuals, what adjustments or caveats do you routinely apply to your interpretation?
I use the principles outlined in Kovacs et al., PMID 24869464. The respiratory pressure swings are mainly a problem for knowing absolute values of, say, mean pulmonary arterial pressure (mPAP) or pulmonary capillary wedge pressure (PCWP). More commonly, we care about determining if there is evidence...
Would you give consolidation durvalumab to a patient who underwent chemoradiation for his stage III NSCLC and is being started on antifibrotic therapy by pulmonology for his ILD?
This is a difficult scenario. On the one hand, we know from the PACIFIC trial that there is a clear benefit to the addition of durvalumab in this setting. On the other hand, there is a higher risk of pneumonitis due to both the prior use of radiotherapy and the history of underlying ILD. I think ECO...
What clinical features guide your choice between ketamine and etomidate in patients with septic shock who require rapid sequence intubation given recent data suggesting no difference in 28 day mortality?
For most, short of compelling evidence favoring one medication over another, the choice of induction agent for intubation is influenced by the comfort and familiarity one has with a particular agent. This is likely the case for most, given the recent article demonstrating no mortality difference in ...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
How often are you repeating screening PFTs in patients with SARDs who have 3 or more years of normal or stable PFTs?
The answer to this question is complex and needs to be tailored to the individual patient’s risk for ILD and the particular SARD.Approximately 30-40% of patients with systemic sclerosis (SSc) will develop ILD, typically within the first 5 years after the first non-Raynaud’s manifestation and rarely ...
What guides your decision whether to complete a full course of intrapleural alteplase-dornase versus proceeding to surgical decortication when a patient continues to worsen or does not adequately improve with intrapleural therapy?
This decision is typically individualized, based on the patient's clinical trajectory and radiographic findings. My practice is to initiate treatment with a lower dose of tPA, as supported by current literature. If the patient does not demonstrate an adequate response within the first 1 to 2 doses, ...
What is your approach to managing high-volume, thick tracheal secretions in a patient with a tracheostomy when there is no clear evidence of pulmonary infection?
Managing airway secretions in patients with chronic tracheostomies can be very challenging, and secretion volume varies considerably in some patients from day to day or even hour to hour, often inexplicably. The tube itself is an irritant, as is frequent suctioning, so virtually every patient with a...
Under what circumstances do you recommend POCUS guidance for lumbar puncture?
I agree with Dr. @Dr. First Last. As with many other skills in medicine, repetition is key to mastering POCUS skills. So, if available, I always use ultrasound to assist with lumbar punctures. You are improving your skills and increasing your success rate at the first needle pass, improving patient ...