Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your approach in differentiating IPAF (interstitial pneumonia with autoimmune features) versus "CTD ILD" in patients with serologic abnormalities but do not fulfill criteria for autoimmune disease?
Even for those of us who work in ILD clinics, this can be a challenging issue. The concept of IPAF (interstitial pneumonia with autoimmune features) was developed in 2015 jointly by the ATS and the ERS for study purposes and as such is somewhat helpful in the clinic. Much like classification criteri...
Have you incorporated the use of steroids for patients with severe community-acquired pneumonia?
Yes, the evidence is pointing toward starting steroids (hydrocortisone at 200mg total daily dose) early (in the first 24 hours) in patients with severe CAP who do NOT have influenza. In septic shock caused by CAP, steroid recs follow the septic shock guidelines. Dequin et al., PMID 36942789 showed t...
How do you monitor safety, effectiveness, and adherence to therapy when using sedative hypnotics in patients with insomnia?
Generally looking at the average sleep length and quality monthly as described by the patient; side effects are always a concern; if there is any possibility of modifying overall sleep hygiene–that would be the way to go; strength of the medicine should be the lowest possible; definitely avoiding or...
How do you approach management of adult patients with CVID and sarcoid-like syndrome?
Common variable immunodeficiency syndrome (CVID) is the most common primary immunodeficiency, and is of course, characterized by recurrent infections. This can lead to bronchiectasis due to structural damage from these recurrent infections. However, patients can also have non-infectious manifestatio...
What is your approach to counseling patients regarding re-initiation of anti-TNF therapy after completion of treatment for non-disseminated pulmonary histoplasmosis?
We published a retrospective study on this topic in 2015 (Vergidis et al., PMID 25870331). We concluded that resumption of TNF-alpha antagonist therapy may be considered in individuals treated for histoplasmosis who have no evidence of residual disease and undetectable Histoplasma antigen levels. We...
At what age do you stop LDCT chest for lung cancer screening?
One of Medicine's three priority-ordered duties is to postpone death. This also pertains to persons who have reached age 81. Lung cancer can occur longer than 15 years after cessation of smoking. Even if surgery can't be done, primary radiation of Stage 1 squamous cell lung carcinoma can result in p...
How do you approach treating and monitoring sarcoidosis manifested by maxillary bone/teeth loss without other symptoms?
I'm very curious how this was determined to be sarcoidosis. Has a PET been done to determine whether this is the only site? Other entities evaluated for like CRMO? Obviously, neoplasm and infection are also important to rule out before immunosuppressive treatment. Conversely, with our limited "tool ...
What steroid sparing agent do you use for treatment of cardiac sarcoidosis?
Recognizing that corticosteroids will be needed to acutely stabilize cardiac sarcoidosis, a steroid sparing agent is usually a reasonable choice early. My choice of secondary agents depends on the other manifestations of sarcoidosis present at the time of diagnosis. I have rarely seen cardiac sarcoi...
How do you manage MAT for opioid use disorder in lung transplant patients during the peri/postoperative period?
There is currently no evidence regarding mOUD in lung transplants. Available research represents generally a weak quality of evidence regarding opioid use for pain control before and after lung transplant. Non-opioid analgesic interventions, including thoracic epidural anesthesia and intercostal ner...
How do you manage concurrent non-life-threatening hemoptysis and acute pulmonary embolism?
Hemoptysis can occur with PE when there is pulmonary infarction. However, the majority of pulm embolism cases have pleuritic chest pain without infarction. Significant hemoptysis is very rare in these cases and anticoagulation is nearly always safe. When hemoptysis continues or the volume is concern...