Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Have you noticed poor response to Tyvaso DPI compared to the nebulized form in PH-ILD?
I find that patients with PH-ILD who have symptoms of dry cough at baseline do better when initiated on Tyvaso nebulizer. I have found the nebulized form of the medication easier to initiate, with better toleration of titration. I often transition my patients to the DPI formulation for convenience o...
How do you complete brain death testing in patients who cannot tolerate apnea testing and are unable to transport for ancillary testing?
The short answer is that you cannot. Brain death diagnosis requires the presence of 3 conditions: persistent coma, absence of brainstem reflexes, and lack of ability to breathe independently. If portions of the clinical exam or apnea test cannot be performed, ancillary testing is necessary to make t...
What is your approach to tapering therapy in patients with pulmonary sarcoidosis who are asymptomatic with stable pulmonary function and imaging?
We generally do not use weight-based dosing for treating sarcoidosis but often will use 20 mg daily (0.25 mg/kg) as a starting point. If a patient is newly started on prednisone, then we may use a gradual taper 20 mg daily for 1 month, then 15 mg daily for 1 month, then 10 mg daily until they are re...
What postural change in FVC is suggestive of respiratory muscle weakness?
In our practice, an assisted ventilation clinic which is enriched with patients who have diagnosed neuromuscular disease and/or chronic respiratory failure of unclear etiology, we often use 12% or 200cc simply by analogy to the criteria we use to assess bronchodilator responsiveness during PFTs. Alt...
How do you manage an adult primary rhabdomyosarcoma of the lung/mediastinum?
COG trials include all patients <50 years old. The 5-year OS of patients treated in the most recent COG trials is over 70%. So, I would recommend you treat the adult patients per COG protocols if you do not enroll your patients in the COG trials. To manage rhabdomyosarcoma, we need to know the risk ...
What is your approach to de-escalation of asthma inhaler therapy in the setting of negative bronchoprovocation testing when patients are averse to deprescribing?
I discuss the reason we are doing the bronchoprovacation test and what the results would mean. This makes it easier for patients to de-escalate therapy and seek an alternative diagnosis for their symptoms.
How do you approach medication management in biopsy-proven pulmonary sarcoidosis with disease stable for over 2 years on hydroxychloroquine and low dose prednisone?
Epidemiologic studies in sarcoidosis show that the majority of sarcoid cases are benign. Some patients can have disease remission, and therefore are able to come off of therapy. Most of this data is in pulmonary sarcoidosis and the data is less clear when there is other organ involvement. The diseas...
What is your approach to prescribing RIPE for 6 month vs rifapentine/moxifloxacin for 4 months in the treatment of drug sensitive TB in the US?
There are many things that have to be taken into consideration before deciding on using the rifapentine-moxifloxacin regimen instead of the standard RIPE regimen for drug-susceptible TB. The regimen is only recommended for people with pulmonary TB at this time. People with extra pulmonary TB were no...
In what clinical scenarios do you utilize post-cardiac arrest targeted temperature management (TTM)?
There still is a role for TTM in post-cardiac arrest patients. The Targeted Temperature Management After Cardiac Arrest: A Systematic Review was a systematic review of six randomized clinical trials with a total of 3870 participants that were examined. Of these, 2,767 participants were treated with ...
What is your approach to management of pulmonary fibrosis in patients with a history of microscopic polyangiitis who do not have other active organ involvement?
ILD is an important organ manifestation in AAV, typically seen in patients with MPO-ANCA where ~20% of patients have ILD which often precedes the diagnosis of AAV. The most common radiographic pattern is UIP. ILD has been associated with a higher risk of mortality in AAV in multiple series including...