Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your approach to the management of persistent hydropneumothorax due to a non expandable lung?
This depends on the clinical scenario and really, relating to patient factors. For instance, if a patient is young without many co-morbidities and the non-expandable lung is related to a 'benign' etiology (i.e. empyema that has resolved and is now a transudative effusion), then surgical consultation...
Based on findings of the INCREASE trial, are you routinely prescribing inhaled treprostinil to patients with group 3 pulmonary hypertension secondary to interstitial lung disease?
As a brief background, the INCREASE trial (Waxman et al., PMID 33440084) was a randomized trial in patients with pulmonary hypertension due to interstitial lung disease (PH-ILD) assessing the effect of inhaled treprostinil versus placebo on change in 6-minute walk distance at 16 weeks. The study enr...
Are there instances when you recommend initiation of hemodialysis for patients with severe symptomatic hypercalcemia?
In reality, there are so many treatments for hypercalcemia nowadays that the answer to the question is no. However, I can imagine if a patient is already on the cusp of needing dialysis and is hypercalcemic then I may initiate dialysis a little earlier to fix the hypercalcemia sooner.
When interpreting pulmonary function tests, do you routinely distinguish between hyperinflation and gas trapping?
Hyperinflation refers to elevated TLC (>ULN, sometimes >120% predicted). Air trapping refers to elevated RV (>ULN, sometimes >120% predicted) and/or elevated RV/TLC (same criteria).
What is your diagnostic approach to patients referred for central sleep apnea on PSG but normal overnight EEG and MRI?
In lab titration study, starting with CPAP (first-line treatment, can work in many cases). If remains, BiPAP-S titration is next (usually same night) with minimum EPAP titrated to prevent apneas and IPAP to prevent hypopneas but care as to avoid too much pressure support and over ventilation. Failur...
What is the optimal frequency and duration of post-operative radiological surveillance following resection of a solitary fibrous tumor?
Partly depends on the subset of SFT. The classic variant is low-grade, indolent clinical behavior and can recur late (several years later) requiring (maybe less frequent) but long-term follow-up for 10 years or even beyond. The malignant SFTs have a shorter natural history and typical sarcoma follow...
Do you generally recommend starting nintedanib prior to immunosuppressive therapy in a patient with CTD-ILD?
Patients with autoimmune disease-associated ILDs such as those with rheumatoid arthritis-related ILD, Sjogren and inflammatory myositis-related ILD are usually on background DMARD/immunosuppressive therapy already at the time the ILD is detected. These therapies are also important in helping to redu...
How long do you recommend that a patient wear a mask when resuming biologic infusions following a recent upper respiratory infection?
Patients who have acquired an upper respiratory tract infection in the COVID, RSV, influenza era should wear masks as long as they are deemed contagious. The CDC makes recommendations concerning the duration of masking and the type to use. For COVID the current suggestion is 10 days after the cessat...
What is your approach to differentiating RA-ILD from medication toxicity (I.e. from methotrexate)?
RA-ILD occurs in about 7-10% of patient with RA. It is more common in males and in those with a history of smoking. Most are seropositive. The typical pattern on HRCT in 50-60% of RA-ILD patients is a UIP pattern followed by NSIP, OP, and even LIP is some cases. An experienced clinician with the hel...
Do you routinely perform a pre-extubation bronchoscopy for secretion clearance during the index hospitalization in patients following lung transplantation?
Yes, this is routinely done on post-op day 1 and frequently repeated if the patient is not extubated on the first post-operative day after lung transplantation. This is typically necessary and done early in the post-op phase to clear out blood or debris from the airway that often accumulates in the ...