Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Can tacrolimus in a transplant patient be used during radiation and concurrent chemoradiation?
Patients with solid organ transplants present unique challenges in management and risk of infectious complications, among others. The short answer is that tacrolimus can be used in the lowest dose possible, along with concurrent chemoradiation and close coordination with the transplant team. If the ...
Do you routinely evaluate for PE if a DVT is found?
I would not routinely evaluate for PE in a patient with new DVT, unless they had symptoms or signs suggestive of PE diagnosis. But I would usually evaluate for DVT in a new PE patient. This is in case the patient develops leg swelling or pain in the future and DVT is found then. It's difficult, oc...
What would prompt you to consider a sleep study for narcolepsy in a child or adolescent with new-onset hallucinations?
It would depend on other elements of the history. The age of the child, the timing of the hallucinations, particularly if they are associated with sleep, onset or awakening, other hypersomnia disorder symptoms, and the child's psychiatric history. Generally, I have a very low threshold for an in-lab...
Do you recommend careful correction of serum sodium to avoid osmotic demyelination syndrome in patients who are found to have isoosmolar hyponatremia in the setting of an elevated BUN level?
Urea is an ineffective osm and so if the blood is "isoosmolar" in the setting of hyponatremia but is isoosmolar because of an elevated BUN it may be isoosmolar numerically but not physiologically. I would ignore the BUN in making my decision. I would not ignore the BG though if it were elevated.
How do you manage persistent insomnia despite ASV titration in patients with complex sleep apnea?
It is an excellent question, and I am not sure if I have a perfect answer. The first question I would have is if the insomnia pre-dated the treatment-emergent central sleep apnea. It is assumed if they are on adaptive servo-ventilation (ASV) that they already tried CPAP, had treatment-emergent centr...
Is there a role for the use of transient elastography (FibroScan) to monitor liver fibrosis in patients on long term methotrexate?
Liver elastography is a useful tool to use when assessing the potential hepatotoxicity of various drug therapies. Traditionally, methotrexate accounted for nearly all the hepatotoxicity issues that we faced; however, we can add many other drugs to that list. Virtually, every immune suppressive drug ...
Are there instances where tracheostomy alone without mechanical ventilation can be sufficient to manage neuromuscular respiratory failure?
This is a very rare circumstance in our assisted ventilation clinic. This situation usually arises because a patient underwent tracheostomy during an acute illness while they were requiring invasive ventilatory support, and were able to wean from the ventilator but had dyspnea or hypercarbia while t...
How do you determine if pulmonary hypertension is disproportionate to the severity of lung disease?
This is a question we faced on a daily basis in our PH clinic. Patients with parenchymal lung disease like COPD or ILD would get an echocardiogram that showed an elevated RVSP and/or RV dilation/dysfunction and will be referred to our clinic for PH evaluation. Alternatively, the patient already unde...
Would you add abatacept to treat active inflammatory arthritis in a patient with history of RA-ILD who is already taking mycophenolate?
Although there are no controlled trials of abatacept in RA-ILD, the current literature suggests a stabilization of ILD in RA patients and is one of my principal go-to agents for this situation. A review paper from 2021 (Vicente-Rabaneda et al., PMID 33887489) indicated abatacept was associated with ...
How do you manage PEEP in a morbidly patient with severe hypoxia who is already proned with no access to esophageal ballon?
We do not use esophageal balloons at our facility. In patients we are proning, I usually titrate the PEEP to the lower inflection point on the pressure-volume curve on their vent graphics and tweak from there based on their level of hypoxia and plateau pressures. In morbidly obese patients, higher p...