Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you continue methotrexate while starting TNFi therapy in patients with refractory pulmonary sarcoidosis?
No clear data to do this in an EBM fashion in my opinion. I keep the baseline anti-inflammatory agents the same for the initial two doses of infliximab and once they are on regular dosing, I decrease the other agent/s. After steady-state, I would still keep a low dose of prednisone (2.5 or 5 mg dail...
How do you advise using Mycoplasma antibody testing to guide antibiotic selection in patients with pneumonia?
I do not. It takes several days to result, and I would not change treatment duration or choice of antibiotic based on a result. I treat all patients with pneumonia with a cell wall inhibitor like amoxicillin and something for atypical coverage like azithromycin. In patients with community-acquired p...
What are your thoughts on using abatacept for RA-associated ILD in a patient undergoing treatment for CLL with zanubrutinib, and how would you assess the potential increased risk of infection in this context?
Zanubrutinib is an inhibitor of Bruton tyrosine kinase which is part of an important signaling pathway for B cells. BTK inhibition prevents B cell activation, proliferation, and survival. It is useful for B cell malignancies such as CLL.I have two concerns about using abatacept and zanubrutinib toge...
Do you consider thrombocytopenia a contraindication for fibrinolytic therapy for a massive PE?
If one has access to mechanical thrombectomy devices and operators, they should be considered before systemic thrombolytics unless the massive PE is causing imminent danger to the patient/patient is going to code/die, in which case the risk of dying from said PE is higher than potential bleeding eve...
Do you find there is any benefit to giving N-acetyl-cysteine in non-acetaminophen related acute liver failure?
Yes, we believe there is a modest benefit for non-APAP patients. The Acute Liver Failure Study Group did a placebo controlled double blind study of NAC use in non-APAP ALF. Here is the reference. This is not FDA-approved. They wanted a second study but this one took about 6 or 7 years to complete!Le...
Do you add adjunctive gentamicin and/or rifampin for treatment of prosthetic valve Staphylococcus aureus endocarditis?
No, we do not add adjunctive gentamicin for treatment of Staphylococcus aureus (SA) prosthetic valve endocarditis (PVE). The potential benefit of using an aminoglycoside in this setting is minimal, if any, and is outweighed by the risk of toxicity.With respect to using rifampin, it depends on whethe...
Do you routinely integrate telomere length testing into the evaluation of patients with ILD?
"Routine" would be a stretch, but I have dramatically increased my utilization of telomere length testing with the publication of recent studies, including this one. I do not check telomere lengths in patients when I don't think it will impact my management, but there is uncertainty surrounding best...
When do you consider Cheyne-Stokes respirations noted in download data from positive pressure machines to be normal vs abnormal requiring intervention?
I do not have great confidence in the algorithms for CSR detection in CPAP machines (both in terms of false negatives and positives). That said, I agree with Dr. @Dr. First Last that if there is an newly increased amount of central events or CSR on a CPAP report, that should prompt (at the least) a ...
Is there a role for monitoring serum ANCAs to assess ANCA associated vasculitis disease activity?
This is (and remains) a somewhat controversial question. ANCA titers do appear to rise in anticipation of disease flares and patients with persistent titers appear to have more flares. This is especially true for PR3 ANCAs. However, the proximity of flares to rising ANCA titers is not terribly close...
In cases of intermediate-risk pulmonary embolism, what factors influence your decision to pursue catheter-directed thrombolysis?
"Intermediate-risk" is a complex term. Patients with intermediate-low risk are not prognostically the same as those with intermediate-high risk (i.e., with elevated cardiac biomarkers and RV dysfunction) (Santos et al., PMID 31017472), and my threshold to intervene on intermediate-high risk patients...