Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What factors do you consider when determining whether to perform a biopsy for the diagnosis of organizing pneumonia?
If there are known risk factors such as autoimmune disease, biopsy is usually not necessary in that circumstance. If it's truly cryptogenic in nature, or the appearance on CT imaging is not typical, then biopsy can be helpful. Direct tissue sampling also increases the yield for culture in case it is...
What are some immunosuppression regimens to consider in a patient with refractory cardiac sarcoidosis?
Unfortunately, there is no high quality data at this point to directly answer this question but here are some options. For patients who have only been treated with oral steroids, I would first consider the addition of weekly methotrexate at a dose of between 10 - 20 mg WEEKLY with supplemental folic...
When would you consider referring a patient with suspected cardiac sarcoidosis based on PET and MRI for endomyocardial biopsy given degree of patchy involvement, as opposed to initiating empiric immunosuppressive therapies?
I would avoid initiating empiric immunosuppressive therapies without a firm diagnosis of sarcoidosis. I will mention however that the latest Japanese Circulation Society criteria for the diagnosis of sarcoidosis do include criterion for the non-invasive diagnosis of likely cardiac sarcoidosis based ...
Do you utilize soluble IL-2 receptor or ACE levels as serum biomarkers to monitor disease activity in pulmonary sarcoidosis?
I use ACE levels to monitor disease activity in patients who demonstrate elevated ACE levels at diagnosis of confirmed sarcoidosis and for which there is no other explanation for elevation of ACE. ACE normalizes with treatment and will increase again if/when the disease relapses. The literature indi...
What criteria do you use to determine if a change is clinically significant while evaluating PFTs?
This can be determined using various criteria, including whether or not a measurement has dropped below certain severity thresholds and/or if the observed change is greater than one might expect through general variability. Various professional societies have recommended using the lower limit of nor...
Will you incorporate the use of tirzepatide in the management of patients with OSA?
Yes! However, the best methods to incorporate GLP-1s into the practice of Sleep Medicine have yet to be determined. Hopefully, our professional organizations can provide us with clinical practice guidelines to better direct our practice in this area.For those that have not had a chance to review, SU...
How do you approach dyspnea in a patient with seropositive rheumatoid arthritis with normal imaging findings but abnormal PFT findings (restriction, reduced DLCO)?
Pulmonary pathophysiological abnormalities are common in individuals with rheumatoid arthritis (RA) and respiratory symptoms. In individuals without respiratory symptoms, abnormalities may even be detected by lung function testing or high-resolution CT imaging. Any compartment of the lungs may be in...
If PFTs are done on different machines or different places, are the comparisons valid?
Pulmonary function test results might differ slightly when performed at different facilities due to staff engagement and coaching during respiratory maneuvers and machine calibration. Another important consideration is there may be differences due to use of body box plethysmography versus helium dil...
What’s your approach to an asymptomatic, hemodynamically stable patient with moderate spontaneous pneumomediastinum without pneumothorax and normal esophagogram?
Terrific question and, fortunately, an unusual occurrence with an estimated 1 in 30,000 hospital admissions (Barroso et al., PMID 37965408). The true incidence is likely higher as underdiagnosis may be related to individuals with mild symptoms who do not seek medical care, symptoms misdiagnosed and ...
How do you approach a patient with a solitary brain metastasis from small cell lung cancer s/p resection with otherwise limited thoracic disease?
This is rather an uncommon situation but can happen if a patient presents with a synchronous solitary brain metastasis (with or w/o symptom) and undergoes craniotomy and resection only to find out that it is small cell lung cancer. Additional information is needed on the volume of intra-thoracic dis...