Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Which biomarkers or diagnostic tools do you prioritize to support the decision to start antifungal treatment in septic patients with no clear source of infection but at high risk for fungal infections?
In general terms we do not use biomarkers to decide to start antifungals in a septic patient. We use them to confirm or rule out the infection once the antifungals were started based on clinical suspicion/presentation. BDG in particular has very good negative predictive value for candidemia, but due...
Do you routinely recommend a sleep study in patients with clinical history of REM-sleep behavior disorder?
I do routinely recommend and perform in lab sleep testing for patients with suspected REM behavior disorder (RBD). The finding of REM sleep without atonia (RSWA) is supportive of a diagnosis of RBD, as atonia is normally presented in individuals (without RBD) during REM sleep. RBD can be a tricky di...
What features on PFT or flow-volume loops do you look at to suspect small airway dysfunction?
I would strongly advise against using the flow-volume loop to diagnose small airway dysfunction. It is difficult if not impossible to visually distinguish between small airway dysfunction and normal aging (I would point out that part of normal aging involves changes in small airway function). Althou...
Do you monitor CBCs to assess for drug toxicity in patients on nintedanib?
Not typically. I've never been advised to check these, but it's worth re-examining whether it's worthwhile. Looking at the side effect profile in INBUILD and INPULSIS doesn't reveal any major cytopenias. It doesn't appear to be on the FDA prescription information, either. I think this question arise...
Do you hold anticoagulation prior to performing bronchoalveolar lavage?
Can do BAL on anticoagulation. Anticoagulation does not increase the risk of bleeding for BAL.
Would a metal endobronchial stent within the treatment field change your radiation treatment plan for a thoracic malignancy?
No, a stent placement within an airway would not alter either the appropriateness or the planning of radiotherapy for a thoracic tumor. That said, I would discuss the long-term implications of a stent in an irradiated field and would follow the patient closely with pulmonary medicine to discuss the ...
How do you determine which patients with ANCA associated vasculitis may be good candidates for reduced dose glucocorticoid tapering?
This is an important question. Currently there are several groups of patients that benefit from reduced dose glucocorticoids: The largest group are patients who are receiving avacopan for remission induction. The ADVOCATE trial demonstrated that avacopan can markedly reduce the dose of glucocorticoi...
How do you read a PFT with restrictive type spirometry but normal lung volumes?
Non-specific pattern. Initially, NEJM papers showed that these patients develop obstructive patterns in the long term but follow-up papers have shown that patients can stay in that pattern (non-specific) or develop restrictive or obstructive patterns.
Is there a role for dual antibiotic treatment with ethambutol and macrolide only, as opposed to three-drug antibiotic therapy, in the treatment of treatment-naive pulmonary MAC without cavitary disease?
That is a great question, as the role of rifampin (or rifabutin) regarding its relative contribution to the treatment of MAC is not overly clear. Historic data that is a few decades old raised the possibility of better activity when a rifamycin is combined with ethambutol (at least in vitro and furt...
What dose and duration of steroid therapy do you employ while starting mycophenolate in an outpatient with relatively stable CTD-ILD?
This is a great question since it raises some important concepts about treatment response in this patient population. Providers often talk about the presence or absence of a steroid-responsive process, and if so, whether a steroid-sparing agent would be beneficial. My bias is to avoid steroids in an...