Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you routinely use pupillometry for serial neurologic examinations in the ICU, especially for patients at risk for transtentorial herniation?
We frequently do pupillometry assessments on patients at high risk of ICP crisis. It gets rid of observer subjectivity as it is often an issue in ICUs. We have a protocol with the following indications for q1h pupillary assessments. It is not based on particular guidelines but serves as a good marke...
Do you suggest using a vascular probe to assess the superficial vasculature prior to performing a bedside procedure such as paracentesis, thoracentesis, lumbar puncture, etc.?
Yes - this is now standard of care for paracentesis and thoracentesis, and we have had a couple of bleeding complications when it was not used, and then a vessel was noted on POCUS after the fact. So it really should be incorporated into standard practice and taught such that it's done consistently....
How routinely do you use POCUS to assess fluid responsiveness in patients with sepsis?
I do use this sometimes, but would recommend using it with caution and only as one piece to the puzzle - IVC ultrasound should never be used in isolation. My most recent example was a patient who initially appeared volume overloaded, then was found to have sepsis. When I looked at his IVC, it was ex...
Should long-acting subcutaneous insulin be started upfront in addition to regular insulin infusion for patients with diabetic ketoacidosis?
Current ADA guidelines suggest patients with uncomplicated mild or moderate DKA may be treated with subcutaneous rapid-acting insulin analogs every 1-2 hours as an effective alternative to IV insulin, but still only recommend IV short-acting insulin by continuous infusion for moderate-severe DKA. Ho...
When would you consider prescribing a wakefulness promoting agent for excessive daytime sleepiness from insufficient sleep?
I would never consider prescribing an alerting medication for someone with insufficient sleep. Behaviorally insufficient sleep is a diagnosis in and of itself. The treatment for excessive daytime sleepiness in the case of insufficient sleep is changing behavior to allow for more time in bed. I would...
What serologic biomarkers do you send to assess for sarcoidosis at baseline and/or during flares, in patients where it may correlate with disease activity?
Elevated ACE, dihydroxy vitamin D, and soluble IL2r levels have been shown to correlate with disease activity, but it is important to keep in mind that the sensitivity and specificity are variable and they should never be used in isolation to diagnosis or assess disease activity in sarcoidosis. The ...
Under what circumstance would you order dalbavancin instead of vancomycin or daptomycin for MRSA endocarditis?
The short answer is active/recent IV drug use. Personally, I don’t or didn’t agree with not using PICC and 6 weeks of daily IV abx. My understanding, although it may be outdated, is that there is evidence that most patients would not abuse the PICC. That had been my experience, I had only one patien...
Are there concerns with combining anti-IL5 biologics (mepolizumab or benralizumab) for severe asthma with other biologics for RA?
The question of combination biologic therapy is becoming increasingly important in our field. The main concern with combination biologic therapy is the risk of serious infections. This concern extends to IL-5 agents combined with biologics for RA. Unfortunately, there is a lack of data to guide our ...
Do you routinely use two empiric antibiotics to cover for Pseudomonas aeruginosa in the management of CF exacerbations?
Historically, two antibiotics have been used to cover Pseudomonas pulmonary exacerbations. The last guidelines were published in 2009 (Flume et al., PMID 19729669 ). At that time, the expert guidelines stated, "The CF Foundation concludes that there is insufficient evidence to recommend the use of a...
What is your second line therapy for patients with EGPA with mainly pulmonary and sinonasal features who did not respond to mepolizumab 300 mg/month and still require high doses of steroid?
This is an important question. Benralizumab has recently been shown to have similar efficacy to mepolizumab with a suggestion of a greater number of patients being able to fully discontinue steroids when treated with benralizumab as compared to mepolizumab. On the basis of this study I would use ben...