Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you integrate inhaled colistimethate sodium into existing treatment regimens for patients with bronchiectasis and PSAR infection?
I agree with Dr. @Dr. First Last. I also consider inhaled colistimethate sodium in addition to tobramycin and aztreonam when developing treatment regimens. Of note, while the inhaled route of antibiotics can decrease the risk of side effects in other parts of the body (nephrotoxicity, ototoxicity, e...
Do you start immunosuppression for enlarging pulmonary nodules without symptoms, impaired pulmonary function, or extra-pulmonary disease in a patient with sarcoidosis?
First consider whether further diagnostic workup is necessary, to increase your confidence that enlarging nodules, changing pulmonary function, or extrapulmonary disease is due to sarcoidosis. Sarcoidosis patients have an increased risk of cancer in the early peri-diagnostic period, likely due to th...
Is there a role for biologic therapies in asthma-COPD overlap syndrome with evidence of type 2 inflammation?
While there are ongoing studies regarding the potential role of biologics in COPD care, to date, the data remains unclear. The whole issue of COPD/ asthma overlap syndrome remains controversial and I know of no clear data defining a role of biologics. However, I would suggest that the stronger the a...
Do you routinely use milrinone to augment RV function in patients with massive pulmonary emboli on vasoactive support?
Recent data in experimental acute PE suggest that levosimendan and milrinone showed similar and beneficial hemodynamic profiles – reducing RV afterload and improving RV function without increasing RV mechanical work. (Dobutamine increased CO, but at the cost of an increase in RV afterload and RV mec...
What is your approach to PEEP titration in the management of a morbidly obese patient with ARDS?
Unfortunately, there is no definitive evidence on how to best adjust positive end-expiratory pressure (PEEP) in morbidly obese patients with acute respiratory distress syndrome (ARDS) as patients with a body mass index (BMI) of greater than 35 kg/m2 were excluded from most of the large clinical tria...
Do you routinely perform echocardiography in patients with Staphylococcus aureus bacteremia deemed low risk for metastatic infection, or do you selectively omit it based on specific clinical criteria?
A limitation of the applicability of this study is that no isolates of MRSA were detected. Thus, there would be no strains, such as USA300-like strains, with both virulence and resistance mechanisms. In this situation, the goal is to avoid morbidity and mortality from a uniformly deadly disease: S. ...
How do you follow pulmonary embolism patients who have completed anticoagulation?
3 months after sustaining an acute PE, I asked the patients if they were back to their pre-PE level of functional capacity. If they are not, i.e. if they remain dyspneic, I get an echocardiogram and a VQ scan. If the echo during the acute PE shows RV strain or evidence of pulmonary hypertension, I r...
What is the current practice regarding the use of GLP-1 agonists in patients listed for lung transplant and in the post-transplant period?
The current practice regarding GLP-1 RA use is not standardized in the field of lung transplantation. This is mainly due to a lack of adequate data at this point. Various institutions use recommendations from the American Society of Anesthesiologists (ASA) and the American Gastroenterological Associ...
How do you integrate dd-cfDNA into the evaluation and management of ACR in lung transplant recipients?
We have been using dd-cfDNA in the context of a clinical investigation during the first-year post-transplant. We haven't yet used it outside this context but we are planning to after our institution sets up a payment mechanism to do so. We have been obtaining dd-cfDNA at 3 mo intervals during the fi...
Do you favor transthoracic needle biopsy or navigational biopsy for diagnosis of intermediate risk pulmonary nodules?
I prefer navigational bronchoscopy if it is available. This is supported by a recent NEJM article (May 18, 2025) that reported that navigational bronchoscopy was non-inferior for diagnosis and safer in terms of pneumothorax.