Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do more fractionated regimens reduce severe toxicity over SBRT in patients with ILD and early-stage NSCLC?
I personally think fewer fractions are safer, such as 30 Gy x 1 instead of 10 Gy x 5, for patients with advanced COPD or ILD. Why? It's because each time a burst of ionization events is delivered to pulmonary tissues, a wound is created that recruits an inflammatory response, which can exacerbate th...
In patients with severe asthma who are candidates for biologics, do you put them on an ICS/LABA/LAMA rather than high dose ICS/LABA?
Similarly to Dr. @Dr. First Last, I usually trial them on ICS/LABA/LAMA if possible, rather than high dose ICS/LABA with the anticipation that biologic may be added next. My preference is for ICS/LABA/LAMA over high-dose ICS/LABA, but unfortunately, I have been running into insurance coverage issues...
What is your approach for a primary tracheal squamous cell carcinoma?
First off as you probably know this is a randomized data-free zone. So to some extent what to do here is empiric and/or based on historic outcomes, retrospective data, and so on. But here are a few quick & dirty observations...1) Surgical patients have the best survivals/outcomes. Doing tracheal sur...
When prescribing SMART regimen for a new diagnosis of asthma, do you still prescribe rescue inhaler (i.e. SABA) if they don't have it?
When using the SMART (single maintenance and reliever therapy), I don't add an albuterol (SABA) rescue inhaler. The whole idea is to simplify things for the patient so that they maintain their asthma control and get relief with the necessary via just one inhaler. Budesonide - formoterol combinations...
For septic patients with borderline heart failure, how do you individualize the decision about additional fluid boluses after the initial resuscitation?
For septic patients with borderline heart failure, the decision about additional fluid boluses after the initial resuscitation requires careful observation and monitoring. My approach has been to administer 500 cc-1 liter of fluid, and then assess volume status (physical exam, JVP, or POCUS, which i...
How would you approach anticoagulation for a patient with acute bilateral pulmonary emboli related to malignancy, but with a concomitant cavitary lung mass experiencing episodic, small-volume hemoptysis?
This is an interesting question to which we need to apply the art of medicine, weighing the risks and benefits of treatment. The major fatal events in this exact scenario are: Recurrent PE from undertreatment. Sudden massive hemoptysis after aggressive anticoagulation. The physician's management s...
What treatment approach do you suggests for a patient with nasal polyp disease and asthma who was improved on dupilumab, but over last 2 years has begun to have increased nasal symptoms and rising eosinophil counts?
Dr. @Dr. First Last's comments are quite valuable. It might be more expedient to consider simpler options first, then progress to the less common diagnoses as needed. I very much agree that unless we know what is meant by "increased nasal symptoms", it is difficult to provide precise alternative the...
Is it still significant to denote the etiology of ILD in a patient with PPF?
Yes, absolutely! Infact, the most effective treatment in patients without IPF (PPF) is treatment of the cause. So if there is underlying autoimmune disease or exposure, primary treatment should be directed against that trigger and this has potential to stop progression and even improve lung function...
Do you consider indwelling pleural catheters in patients with refractory transudative pleural effusions?
I do as long as the risks, benefits, and possible alternatives are discussed with the patient. Frequently, these patients have refractory or end-stage heart failure, kidney failure, and liver failure. Often, they have decompensated or end-stage diseases and are not candidates for organ transplantati...
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...