Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you favor remdesivir over nirmatrelvir/ritonavir when interaction management is complex but feasible in a high-risk outpatient with early COVID-19?
Yes. If nirmatrelvir/ritonavir interactions are complex and carry meaningful risk despite being manageable, I would favor remdesivir when IV treatment is feasible.
Do shorter door-to-balloon (D2B) times impact outcomes in STEMI, if it's already less than 90 minutes, and to what degree (i.e., 30 vs 60 minutes would have a more significant impact)?
No. Shorter door-to-balloon times have not been shown to improve survival or outcomes in STEMI. The reason is that the other variable is the time from the onset of chest pain to presentation to a medical facility. This time is beyond the control of the medical system. For example, a patient waits 4 ...
How often are you repeating screening PFTs in patients with SARDs who have 3 or more years of normal or stable PFTs?
The answer to this question is complex and needs to be tailored to the individual patient’s risk for ILD and the particular SARD.Approximately 30-40% of patients with systemic sclerosis (SSc) will develop ILD, typically within the first 5 years after the first non-Raynaud’s manifestation and rarely ...
How long do you try an inhaler before increasing the dose because it was inadequate/failed to control the patients asthma?
ICS inhalers should improve asthma control in weeks, not months, especially in steroid naive patients.
What is your approach to counseling patients regarding re-initiation of anti-TNF therapy after completion of treatment for non-disseminated pulmonary histoplasmosis?
We published a retrospective study on this topic in 2015 (Vergidis et al., PMID 25870331). We concluded that resumption of TNF-alpha antagonist therapy may be considered in individuals treated for histoplasmosis who have no evidence of residual disease and undetectable Histoplasma antigen levels. We...
What is your approach to inhaler therapy in a patient with asthma who cannot be on an inhaled corticosteroid due to ocular disease?
I use LABA/LAMA combination.
Would you initiate antifibrotic therapy in a patient with CTD-ILD experiencing worsening symptoms and declining lung function, despite no clear evidence of fibrosis on CT scans?
If the predominant findings on CT were ground glass opacities and/or nodules without any evidence of fibrosis on CT, I would not start with an antifibrotic and, instead, would start with immunosuppression as a first-line agent. Based on the American College of Rheumatology (ACR) and American Thoraci...
How have the 2026 CHEST clinical practice guidelines for biologic management in severe asthma affected your management of these patients given the conditional strength of recommendations and very low certainty supporting evidence using the GRADE approach?
I applaud the panel for their objective, comprehensive analysis of these questions. The recommendations that they made for the 7 clinically relevant questions are sensible and actionable. The challenge, even using GRADE-based recommendations, is that (appropriately based upon existing evidence) the ...
What non-pharmacological management strategies have you found particularly helpful for older adults with restless leg syndrome?
Ensure appropriate sleep opportunity (around 7 hours in older adults). Avoid certain medications when possible, including SSRIs/TCAs, dopamine antagonists, and antihistamines. Avoid alcohol, caffeine, nicotine, and large amounts of carbohydrates. Ensure regular exercise. Ensure adequate iron stores...
Do you prescribe bronchodilators to patients with radiographic emphysema and respiratory symptoms, but no spirometric obstruction?
Yes, I will sometimes offer a therapeutic trial of bronchodilators to symptomatic patients with radiographic emphysema, but no obstruction on spirometry. Patients with CT evidence of emphysema were not specifically studied in the RETHINC trial.