Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you approach management of ILD in the presence of weakly positive RF and ANA but no other objective systemic findings of connective tissue disease?
This issue comes up frequently in our combined ILD/Rheumatology clinic and my pulmonary colleagues are typically looking at me for an answer as to whether I think the biomarkers are relevant to the patient's ILD. Low-level ANAs and RFs are not uncommon in the general population and can result in ove...
Do you feel high dose Symbicort or Dulera is appropriate to use for SMART despite these doses not being studied in clinical trials?
One of the primary purposes of SMART therapy is to provide extra doses of ICS to patients inadequately controlled enough to use rescue inhalers. The other major purpose is to do this with a single inhaler instead of 2 or 3. So if the patient's baseline asthma is severe enough to require high-dose Sy...
How would you manage a patient with HbSS and severe pulmonary hypertension on home oxygen?
This patient should be referred to a specialist in pulmonary hypertension in sickle cell disease for right heart catheterization and aggressive management of the pulmonary hypertension. As described, the patient is not a good candidate for lung transplant or gene therapy.
What are your top takeaways in Thoracic Cancers from ASCO 2022?
1. Abst 8502 - Quality metrics and survival after lung cancer surgery: More efficient work-ups and consistently high quality resections will likely do more to improve lung cancer survival than any adjuvant or neo-adjuvant therapy we can come up with. This is low-hanging, low-cost fruit. 2. Abst 9007...
What blood pressure targets do you enforce in the first 24-48 hours in a patient who develops an intracranial hemorrhage after mechanical thrombectomy?
Typically post-thrombectomy you encounter hemorrhagic transformation of an ischemic infarct. In this setting, I adjust the SBP goal to the classification of hemorrhagic transformation (HI-1, HI-2, PH-1 or PH-2). HI-1: No specific parameter; SBP goal adjusted according to TICI score. HI-2: SBP 120-...
Do you use bronchodilator response to distinguish between asthma, COPD, or asthma-COPD overlap?
Combined with eosinophil count and other pertinent history that supports a diagnosis of asthma or asthma/COPD overlap.
What strategies do you use to prevent overcorrection of serum sodium in patients with severe hyponatremia and adrenal insufficiency when initiating glucocorticoid therapy?
Treatment of hyponatremia due to adrenal insufficiency with glucocorticoid therapy may result in overcorrection of serum sodium due to suppression of ADH and resultant water diuresis. Therefore, serum sodium, urinary osmolality and urinary output should be closely monitored. A brisk water diuresis w...
How do you adjust your management strategy to address the unique needs of anuric end-stage kidney disease patients when treating diabetic ketoacidosis?
There is no osmotic diuresis, and they do not need IVFluid, the opposite is true they may appear intravascularly overloaded, and will respond to insulin alone, they do not need HD for this. They will not be K deficient, do not give K. Their potassium will likely respond to insulin alone, and should...
Will you incorporate ensifentrine in the treatment regimen of patients with COPD on baseline dual or triple inhaler therapy?
Novel bronchodilator. ENHANCE 1 and 2 showed improvement of lung function but cost can be a factor. $2,950 per month.
What is the upper limit of blood glucose target in hyperglycemic critically ill patients?
I don't think there's much data that argues that setting the upper limit between 180 and 200 will make much of a mortality difference. The SCCM guidelines center around initiation of insulin infusions, and doesn't seem to say that we should start insulin infusions for BG>180, but tolerate it up to 2...