Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Can palliative radiation be used to treat recurrent malignant pleural effusion in NSCLC?
There has been gradual recognition of improved survival with the administration of three-dimensional radiotherapy (3D-CRT) to the primary tumor in the context of systemic chemotherapy, EGFR-TKIs, or immunotherapy in patients with stage IV non-small cell lung cancer. (Zheng et al., PMID 31040256, Arr...
How do you choose roflumilast vs ensifentrine in COPD patients with dyspnea despite adequate LABA + LAMA (+ ICS therapy where indicated)?
Hi - I don't think there is a clear answer for this. However, in my practice I rarely use roflumilast for dyspnea (mostly for exacerbation prevention). I have been trying ensifentrine in some of these dyspneic COPD patients, in part because they are wanting to "try something new". So far, I have see...
What is your preferred agent for fungal prophylaxis in a patient post lung transplant with abnormal LFTs?
Isavuconazonium tends to cause less elevations in LFTs.
What additional workup do you pursue in a patient in whom you suspect Yellow Nail Syndrome?
Mandatory pulmonology (and/or ENT for sinusitis) for comorbit workup or monitoring. Detailed ROS for eval of any underlying disease and workup as indicated. Age-appropriate cancer screenings.
In a patient with severe hyponatremia and acute kidney injury in the setting of hypovolemic shock, would fluid resuscitation take precedence over the rate at which sodium is corrected?
Normal saline, or a balanced fluid, e.g., Lactated Ringers or Plasmalye, if you are believers in balanced fluids. Shock trumps ANY concerns over rate of Na rise. Also if someone is in shock they are not going to have a water diuresis from volume.
When do you stop dantrolene in a patient with neuroleptic malignant syndrome?
Dantrolene is typically used to treat severe NMS, although the data supporting its use is mixed. The biggest risk with the therapy is hepatotoxicity. It is reasonable to discontinue dantrolene once the hyperthermia and severe muscle rigidity have resolved, or earlier if there is concern for liver in...
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).