Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Will you incorporate the use of tirzepatide in the management of patients with OSA?
Yes! However, the best methods to incorporate GLP-1s into the practice of Sleep Medicine have yet to be determined. Hopefully, our professional organizations can provide us with clinical practice guidelines to better direct our practice in this area.For those that have not had a chance to review, SU...
How do you approach dyspnea in a patient with seropositive rheumatoid arthritis with normal imaging findings but abnormal PFT findings (restriction, reduced DLCO)?
Pulmonary pathophysiological abnormalities are common in individuals with rheumatoid arthritis (RA) and respiratory symptoms. In individuals without respiratory symptoms, abnormalities may even be detected by lung function testing or high-resolution CT imaging. Any compartment of the lungs may be in...
If PFTs are done on different machines or different places, are the comparisons valid?
Pulmonary function test results might differ slightly when performed at different facilities due to staff engagement and coaching during respiratory maneuvers and machine calibration. Another important consideration is there may be differences due to use of body box plethysmography versus helium dil...
What’s your approach to an asymptomatic, hemodynamically stable patient with moderate spontaneous pneumomediastinum without pneumothorax and normal esophagogram?
Terrific question and, fortunately, an unusual occurrence with an estimated 1 in 30,000 hospital admissions (Barroso et al., PMID 37965408). The true incidence is likely higher as underdiagnosis may be related to individuals with mild symptoms who do not seek medical care, symptoms misdiagnosed and ...
How do you approach a patient with a solitary brain metastasis from small cell lung cancer s/p resection with otherwise limited thoracic disease?
This is rather an uncommon situation but can happen if a patient presents with a synchronous solitary brain metastasis (with or w/o symptom) and undergoes craniotomy and resection only to find out that it is small cell lung cancer. Additional information is needed on the volume of intra-thoracic dis...
Do you prescribe lower dose ICS for asthma to mitigate the risk of pneumonia in patients with a history of respiratory infections or compromised immune systems?
Yes, I do, if possible. This is based on data that demonstrates that high-dose ICS negatively impacts the microbiome diversity. While not linked directly to clinical outcomes, these findings warrant caution enough to make this simple alteration. That said, more research into the clinical impact is n...
How do you manage patients with central sleep apnea due to heart failure with reduced ejection fraction?
I assume you are referring to CSA with Cheyne-Stokes respiration. Several possibilities, but first ask yourself what your treatment goal is. If the patient does NOT have symptoms (frequent awakenings, daytime sleepiness, etc.) I contend that you don't need to treat at all. We already know that there...
Are there situations where you would consider treating E faecalis or E faecium that grows from a respiratory culture?
Pretty much almost never! Enterococcus is not recognized as a pneumonia pathogen. In the setting of a lung abscess, I suppose you could consider treating it as part of a polymicrobial infection. In a heavily immunocompromised patient, it is possible that enterococcus might cause pneumonia—and it has...
What is the best approach to determine whether antiviral post-exposure prophylaxis for influenza is appropriate in an elderly immunocompromised patient who has been vaccinated?
This is purely a matter of clinical judgement. The studies showing the benefits of post-exposure prophylaxis did not use any laboratory data, but it is believed that starting prophylaxis within 48h of exposure is important. The risk of severe complications or death in the hypothetical is unknown, bu...
How do you evaluate a suspicious, but negative pleural effusion when working up NSCLC and SCLC?
Good question and this came up in my practice very recently (NSCLC). Historically, clinical trials have required 2 negative taps for entry. The patient I had in clinic appeared to have a node negative, LLL lesion with a ton of atelectasis and had a bloody tap that was negative for malignancy. It did...