Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What factors prompt you to consider revision vs removal of endobronchial valves in patients who do not develop atelectasis after BLVR?
Usually, when patients don’t have symptomatic improvement, especially when they feel worse. I would use PFT as a reference, but not the only criteria. Discussing with the patient is also important.
Do you have any strategies to increase yield while doing a BAL?
The key is not to rush. Obtain good topical anesthesia around the bronchial segment selected for BAL to minimize coughing during the procedure and maintain a good seal. Administer lavage fluid slowly and gently, advancing the scope during infusion to "tighten" the seal. Have the therapist/nurse slow...
Do you consider early belatacept based immunosuppression in lung transplant recipients?
Belatacept is not always easy to obtain and utilize; in addition, it is not as effective as usual triple immunosuppression (Tac, MMF, Pred or other equivalents) in order to replace any of the meds; I usually do not consider as an additional medication. In exceptional circumstances, where there many ...
In drawing blood cultures from a central line to evaluate for CLABSI, do you advise drawing separate blood cultures from each port in case of dual or triple lumen line?
You don't need to use the central line to draw those cultures. Using the line to draw blood can in it by itself pose risk of introducing a microorganisms. NHSN CLABSi definition does not call for blood culture to be done from a line.
Do you use hypercapnia as an exclusion criteria in all patients that are being assessed for bronchoscopic lung volume reduction?
I have been utilizing a PaCO2 threshold exceeding 60 mmHg in arterial blood gas (ABG) analysis as one of the exclusion criteria for evaluating COPD patients for Endobronchial Valve (EBV) insertion. It may not always be imperative to conduct an ABG test. Some practitioners may opt to use bicarbonate ...
How do you factor smoking history into biologic selection for asthma since the clinical trials generally excluded these patients?
This is very important clinical data depending upon the duration of smoking and whether the patient is still smoking. Confirming the underlying clinical diagnosis is the important first step. Even with a long history of documented asthma, the clinical question is whether the patient has progressed t...
How do you manage calcium and vitamin D supplementation in patients with sarcoidosis on chronic steroids?
This is a great question with very limited data to help answer it well. The first-line therapy for sarcoidosis is corticosteroids, and chronic use can lead to decreased bone mass. Of course, Vitamin D supplementation is a very important factor in rebuilding bone mass. In sarcoid patients, this issue...
When do you consider ketamine to treat nonconvulsive status epilepticus?
Ketamine is a fine agent for the management of status epilepticus (SE) and some centers use it first line instead of propofol or midazolam. Mechanistically, it makes more sense as it controls the seizures through NMDA blockade, bypassing GABA receptors, which are downregulated in the setting of SE. ...
How does the presence of interstitial lung disease affect your decision to offer SBRT for early stage NSCLC?
As opposed to interstitial lung disease (ILD) in general, the entity most described in the literature as associated with severe pulmonary toxicity after SABR has more specifically been idiopathic pulmonary fibrosis (IPF) and additionally, in the absence of a known diagnosis of IPF, CT findings consi...
When would you consider using acetazolamide to augment diuresis in patients with ADHF?
The ADVOR trial suggested that the addition of acetazolamide to a loop diuretic "upfront" in congested patients with heart failure achieves greater decongestion at 72 hours and discharge. While most would not use such a combination in "all" patients, this strategy is optimal in those demonstrating s...