Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your preferred biologic in children and adolescents with T2 high asthma?
It depends on patient age, biomarkers (IgE levels, eosinophil counts, FeNO, allergy testing results), comorbidities, what insurance will cover, and how frequently a patient can tolerate injections, adverse effects. Also, clinical outcomes such as wanting to improve FEV1 can play a role in the decisi...
Do you preferentially avoid use of piperacillin-tazobactam for empiric anti-pseudomonal coverage in hospitalized patients due to risk of nephrotoxicity?
The bulk of published data indicates that the onset of nephrotoxicity in patients receiving piperacillin-tazobactam plus vancomycin seldom occurs before 3 days of the combination. Thus, I do not object to initiation of this combination empiric therapy, but, as in all cases, therapy must be reevaluat...
How does your approach to subsegmental PE differ from segmental PE both diagnostically and therapeutically?
My approach to subsegmental PE and segmental PE generally tends to be very similar. I am aware of the CHEST guidelines which indicate patients can safely be observed with subsegmental PE, but like a recent study showed (Rouleau et al., PMID 37531107), uptake of these guidelines is slow and many pati...
Do add a macrolide for immunomodulatory effect in patients with macrolide-resistant M. abscessus?
I think using azithromycin is something that definitely can be considered, but on an individual basis; if there is significant bronchiectasis with exacerbations, then it makes sense to consider azithromycin; more likely to consider also if there are other microorganisms, especially Pseudomonas drivi...
What is your approach in differentiating IPAF (interstitial pneumonia with autoimmune features) versus "CTD ILD" in patients with serologic abnormalities but do not fulfill criteria for autoimmune disease?
Even for those of us who work in ILD clinics, this can be a challenging issue. The concept of IPAF (interstitial pneumonia with autoimmune features) was developed in 2015 jointly by the ATS and the ERS for study purposes and as such is somewhat helpful in the clinic. Much like classification criteri...
Have you incorporated the use of steroids for patients with severe community-acquired pneumonia?
Yes, the evidence is pointing toward starting steroids (hydrocortisone at 200mg total daily dose) early (in the first 24 hours) in patients with severe CAP who do NOT have influenza. In septic shock caused by CAP, steroid recs follow the septic shock guidelines. Dequin et al., PMID 36942789 showed t...
How do you monitor safety, effectiveness, and adherence to therapy when using sedative hypnotics in patients with insomnia?
Generally looking at the average sleep length and quality monthly as described by the patient; side effects are always a concern; if there is any possibility of modifying overall sleep hygiene–that would be the way to go; strength of the medicine should be the lowest possible; definitely avoiding or...
How do you approach management of adult patients with CVID and sarcoid-like syndrome?
Common variable immunodeficiency syndrome (CVID) is the most common primary immunodeficiency, and is of course, characterized by recurrent infections. This can lead to bronchiectasis due to structural damage from these recurrent infections. However, patients can also have non-infectious manifestatio...
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...
At what age do you stop LDCT chest for lung cancer screening?
One of Medicine's three priority-ordered duties is to postpone death. This also pertains to persons who have reached age 81. Lung cancer can occur longer than 15 years after cessation of smoking. Even if surgery can't be done, primary radiation of Stage 1 squamous cell lung carcinoma can result in p...