Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What postural change in FVC is suggestive of respiratory muscle weakness?
In our practice, an assisted ventilation clinic which is enriched with patients who have diagnosed neuromuscular disease and/or chronic respiratory failure of unclear etiology, we often use 12% or 200cc simply by analogy to the criteria we use to assess bronchodilator responsiveness during PFTs. Alt...
How do you manage an adult primary rhabdomyosarcoma of the lung/mediastinum?
COG trials include all patients <50 years old. The 5-year OS of patients treated in the most recent COG trials is over 70%. So, I would recommend you treat the adult patients per COG protocols if you do not enroll your patients in the COG trials. To manage rhabdomyosarcoma, we need to know the risk ...
What is your approach to de-escalation of asthma inhaler therapy in the setting of negative bronchoprovocation testing when patients are averse to deprescribing?
I discuss the reason we are doing the bronchoprovacation test and what the results would mean. This makes it easier for patients to de-escalate therapy and seek an alternative diagnosis for their symptoms.
How do you approach medication management in biopsy-proven pulmonary sarcoidosis with disease stable for over 2 years on hydroxychloroquine and low dose prednisone?
Epidemiologic studies in sarcoidosis show that the majority of sarcoid cases are benign. Some patients can have disease remission, and therefore are able to come off of therapy. Most of this data is in pulmonary sarcoidosis and the data is less clear when there is other organ involvement. The diseas...
What is your approach to prescribing RIPE for 6 month vs rifapentine/moxifloxacin for 4 months in the treatment of drug sensitive TB in the US?
There are many things that have to be taken into consideration before deciding on using the rifapentine-moxifloxacin regimen instead of the standard RIPE regimen for drug-susceptible TB. The regimen is only recommended for people with pulmonary TB at this time. People with extra pulmonary TB were no...
In what clinical scenarios do you utilize post-cardiac arrest targeted temperature management (TTM)?
There still is a role for TTM in post-cardiac arrest patients. The Targeted Temperature Management After Cardiac Arrest: A Systematic Review was a systematic review of six randomized clinical trials with a total of 3870 participants that were examined. Of these, 2,767 participants were treated with ...
What is your approach to management of pulmonary fibrosis in patients with a history of microscopic polyangiitis who do not have other active organ involvement?
ILD is an important organ manifestation in AAV, typically seen in patients with MPO-ANCA where ~20% of patients have ILD which often precedes the diagnosis of AAV. The most common radiographic pattern is UIP. ILD has been associated with a higher risk of mortality in AAV in multiple series including...
How do you approach management of osteoporosis in patients post lung transplant?
Osteoporosis in patients with lung transplants is essentially glucocorticoid-induced osteoporosis. Most patients with severe lung disease have a long history of glucocorticoid exposure. Post-transplant, these patients are often on long-term glucocorticoids. The primary pathophysiology of chronic glu...
What is your approach to treatment in a patient with radiographic UIP but pathologic evidence of both fibrotic NSIP and UIP?
Depends on the underlying etiology and progression. I will most likely use antifibrotics, particularly for IPF or progressive fibrosis, but include immune suppression for autoimmune-related ILD.
Should methotrexate be categorically avoided in RA patients with COPD or RA-ILD?
Thanks for raising a very important question. It is something that every practicing Rheumatologist comes across several times during their career.The traditional teaching has always been to avoid using Methotrexate in patients with underlying pulmonary conditions due to the associated risk of Hypers...