Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How might the introduction of brensocatib as a treatment option impact the use of other anti- inflammatory or antibiotic therapies currently employed in bronchiectasis management?
I would hesitate to add brensocatib in someone on asthma biologics. In the ASPEN trial for brensocatib, patients with a "primary" diagnosis of asthma were excluded from the study. I would not have any problem with adding brensocatib if they were on chronic azithromycin (around 20% of the patients re...
Are there factors that would prompt you to consider the use of methylene blue in refractory septic shock?
I usually don't consider using it unless all other options are exhausted. Although there is date that shows decrease in pressor needs, there is no data that shows any clinical improvements, and specifically no improvement in mortality. It is not part of my algorithm for refractory shock.
What is your approach to managing ILD associated with inflammatory bowel disease?
We must first convince ourselves that the "ILD" relates to the underlying IBD. Patients may be on an immunomodulating regimen that increases the risk of opportunistic infections. The regimen itself may cause diffuse pneumonitis. Environmental/occupational exposures may also play a role. Armed with c...
In massive transfusion protocol from suspected hemorrhage, is it worth obtaining a TEG to guide transfusion?
There really is no evidence (except expert opinion) on massive transfusion protocols and outcomes. There are a few trials showing that TEG or other viscoelastic tests reduce transfusion and even improve survival or other important outcomes in hemorrhage. So given the choice, if rapid point of care T...
Do you use spO2 to define ARDS in patients with darker skin pigmentation?
That's an excellent question and highlights some different approaches to define, and thus provide appropriate early treatment for, patients with ARDS.For many years, clinicians have been using a framework designed in 2012 and referred to as the Berlin Definition to define and classify ARDS (Ranieri ...
Do you ever stop tobramycin prophylaxis in a patient with chronic bronchiectasis previously colonized with pseudomonas?
Yes, I will often stop tobramycin if there are issues with tolerance, antibiotic resistance, or treatment fatigue. Further, in more mild bronchiectasis (cylindrical vs. varicoid or cystic morphologies), sputum bacterial cultures will negatively convert on chronic cycled inhaled tobramycin, and this ...
How do you manage persistent pseudomonas positive sputum a patient with non-CF bronchiectasis who has chronic sputum production but is otherwise asymptomatic?
I am assuming the Pseudomonas has persisted despite efforts to eradicate early on; if not, I would consider at least an effort at "eradication" or at least aggressive treatment. If the Pseudomonas has persisted and the person feels well other than sputum production, would aggressively pursue airway ...
What is your preferred forceps size for transbronchial biopsies, considering options ranging from 1.8 to 2.8mm?
This question depends on the clinical situation. Generally speaking, I'll use a forceps that is 1.9mm in diameter for most cases, as it has the ability to fit through any of our bronchoscopes and can usually provide adequate tissue. Occasionally, if more tissue is required, you can consider the use ...
Do you seek pathologic confirmation before proceeding with empiric immunosuppressive therapy in symptomatic patients with radiographic NSIP?
In general, getting lung biopsies is needed in a minority of people who have clear evidence of NSIP on HRCT. If there is any evidence to suggest a concomitant ARD, a biopsy will not typically be needed. In our combined ILD-Rheumatology clinic, we see these patients all the time and I can think of on...
Would you consider antifungal prophylaxis for immunocompromised patients with COVID-19 requiring mechanical ventilation, considering the high risk of invasive pulmonary aspergillosis in patients with severe COVID-19?
I don't universally add anti-mold prophylaxis in all immunocompromised patients with severe COVID-19 requiring intubation, but I am always considering it. Factors that might push me to add would be: positive fungal markers (Beta-D-Glucan or galactomannan) on BAL or blood at time of intubation, use o...