Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
How do you determine whether to add abatacept or rituximab to the treatment regimen in patients with mild RA-ILD on methotrexate?
I think of many agents before rituxan for RA ILD: all in various stages of being studied MMF, Orencia/abatacept, Tocli/actemra, and even JAK inhibitors xeljanz/rinvoq. Generally, if I treat and control the joints, the lungs stabilize. 10-20% run independently from joints or extra-articular ILD witho...
Can symptomatic radiation pneumonitis ever improve spontaneously without corticosteroids?
As “pneumonitis” has always been difficult to pinpoint, and relies on “inflammatory radiologic findings” confined to XRT portals, fever, cough without positive bacterial cultures, and shortness of breath, the diagnosis is even more difficult with 3D-directed and multiple portals or mostly IMRT-deliv...
How do you counsel older adults regarding the use, dosing, and safety of CBD-containing products for insomnia?
When counseling older adults on CBD use for insomnia, I usually explain that evidence for safety and effectiveness is limited. Most products are not FDA-approved, and their labeling, purity, and dosing can be inconsistent. It’s important to review the patient’s comorbidities and medications closely,...
Do you use MRSA nares PCR to influence antibiotic selection for non-respiratory infections?
BLUF: Yes, I use a MRSA nares PCR for early de-escalation in the stable patient with a non-purulent, non-respiratory infection. Mergenhagen et al., PMID 31573026 retrospectively examined nearly half a million clinical cultures and compared them to MRSA nares results. Among all infections, the NPVs w...
Do you utilize D-dimer to inform anticoagulation duration in the treatment of VTE?
I had developed a policy during my last eight or ten years of practice evaluating how long patients should be treated after a thrombosis and I'd like to share some impressions over these years as well as conclusions that I reached. These conclusions formed the basis of my approach to this problem. I...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
When pulmonary vasodilator therapy lowers PVR to transplant targets but causes systemic hypotension or worsening renal perfusion in decompensated cirrhosis, how do you adjust therapy (dose reduction, agent change, accepting higher PVR) while preserving both hemodynamic eligibility and overall transplant candidacy?
Fortunately, an uncommon problem, but when it does occur, careful dose reduction of the offending agent may help. Also, I would consider going from any offending oral medication to an inhaled prostacyclin to avoid/minimize systemic effects.
Would you recommend anti-fungal treatment for aspergillus infection for a patient with an incidental finding of worsening ground glass opacities and enlarging nodules on CT chest with positive BAL galactomannan, elevated aspergillus IgE and IgG in an otherwise immunocompetent host with no respiratory symptoms?
No, I would not recommend antifungal treatment in this case. The patient, as described, does not seem to have invasive aspergillosis, chronic necrotizing aspergillosis, or allergic bronchopulmonary aspergillosis, so I don't believe antifungal treatment is indicated. There may be other details of the...
When would you start antiepileptic drugs in a critically ill patient who develops myoclonic jerks but has not yet had an EEG?
Treatment depends on the setting in which these myoclonic jerks are seen. In a non-cardiac arrest patient, such myoclonic jerks are often due to medications, organ dysfunction (e.g., uremia, etc), electrolyte imbalance, or non-convulsive seizures, etc, and workup for this is recommended with labs, h...