Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you use bronchodilator response to distinguish between asthma, COPD, or asthma-COPD overlap?
Combined with eosinophil count and other pertinent history that supports a diagnosis of asthma or asthma/COPD overlap.
How do you adjust your management strategy to address the unique needs of anuric end-stage kidney disease patients when treating diabetic ketoacidosis?
There is no osmotic diuresis, and they do not need IVFluid, the opposite is true they may appear intravascularly overloaded, and will respond to insulin alone, they do not need HD for this. They will not be K deficient, do not give K. Their potassium will likely respond to insulin alone, and should...
Will you incorporate ensifentrine in the treatment regimen of patients with COPD on baseline dual or triple inhaler therapy?
Novel bronchodilator. ENHANCE 1 and 2 showed improvement of lung function but cost can be a factor. $2,950 per month.
What is the upper limit of blood glucose target in hyperglycemic critically ill patients?
I don't think there's much data that argues that setting the upper limit between 180 and 200 will make much of a mortality difference. The SCCM guidelines center around initiation of insulin infusions, and doesn't seem to say that we should start insulin infusions for BG>180, but tolerate it up to 2...
Is methacholine challenge on its way out?
I have not needed to order the challenge test for a long time now. I see the need for this test is declining.
Do you perform routine interval lung cancer screening in non-smokers who are 1st degree relatives of patients with non-smoking related lung cancers with known EGFR mutations?
I would not. Although there may be a measurable increase in the risk of lung cancer detected in population studies, the absolute risk is probably far below the equivalent of even a low-risk, current or former tobacco user. This is a hard conversation to have with people who believe their risk to be ...
What is your approach to therapy in patients with progressive Scedosporium pulmonary infection who are not candidates for surgical debridement?
Scedosporium species are increasingly common clinical isolates in patients with bronchiectasis (both CF and NCFBE). There are precious few publications describing these infections in immune-competent hosts, but it seems that these infections tend to be symptomatic (rather than asymptomatic colonizat...
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...
Do you recommend automatically starting CRRT anticoagulation when initiating CRRT if there are no medical contraindications to anticoagulation?
Great question. My practice is that we don't. However, I wonder if we should. In any case, it is not unreasonable not to give it at the beginning and start it if the patient clots daily or more often. I think bleeding episodes tend to be very dramatic at times and result in clouding our judgement a ...
How would you approach the workup and management of isolated inflammatory subglottic stenosis in a young previously healthy patient that is steroid responsive with a completely negative serologic autoimmune workup?
This is a relatively unusual situation in that idiopathic subglottic stenosis is typically not managed with systemic immunosuppression. The typical therapies are endoscopic and include dilatation (+/- intralesional corticosteroids), endoscopic resection, and cricotracheal resection. A recent large t...