Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you favor the use of maximal inspiratory/expiratory pressure measurement or supine spirometry in the evaluation of a patient with suspected respiratory muscle weakness?
In practice, we often perform both in the same session. Supine spirometry has the advantage of assessing the orthopnea that is a common complaint among my patients with neuromuscular disease. Also, many of our patients report that the MIP/MEP maneuver is difficult to perform and they feel it underes...
Do you use or recommend clinical severity scores or other parameters in helping prognostication in patients with refractory status epilepticus?
I do not find prognostication scores in status epilepticus to be particularly helpful in driving care and discussing prognosis with families. We track the "Status Epilepticus Severity Score” (STESS) for quality improvement only to determine presentation severity. For prognosis, the refractoriness of...
Do you utilize phrenic nerve EMG in patients with diaphragmatic issues?
Diaphragm muscle needle EMG is definitely a useful tool to assess patients with suspected respiratory muscle weakness/paralysis. It can differentiate neurogenic from myopathic disorders and it can help with prognostication. However, many providers, including myself, are not very comfortable with "bl...
What are some important considerations for use of ACE inhibition in scleroderma renal crisis patients who require dialysis?
Yes, captopril is dialyzable with about ~35% of the drug being removed during intermittent hemodialysis. It is not recommended to be used if an AN69 hemofilter is used for iHD, as it is associated with anaphylaxis with that particular filter. There does not appear to be any contraindications to usi...
Should checking a urinalysis with reflex to culture be part of the standard work up for fever in an ICU patient with a urinary catheter?
Yes, as part of a broad workup for infectious and non-infectious causes of fever, and with many caveats. Patients in the ICU are at high risk for diagnosis with CAUTI, yet as I think you are applying, this is a difficult diagnosis to make given the inability of many patients to give a history (or fo...
How would you manage subclinical ILD associated with MDA-5 Dermatomyositis?
Subclinical ILD in anti-MDA5 is like a time bomb waiting to explode. Would do aggressive monitoring for ILD symptoms/tests and give at least 1st line immunosuppression with CellCept or tacrolimus.
How would you manage a patient with morbid obesity who presents with new symptomatic pulmonary embolism a few days after he was started on DOAC for DVT?
There are guidelines from the American Society of Hematology and The International Society of Hemostasis and Thrombosis as well as expert opinions recommending either apixaban or rivaroxaban for venous thromboembolism or pulmonary embolism in patients with BMI >40. In addition, this includes use as ...
Do you treat A0B1 rejection noted on surveillance bronchoscopy in a patient less than one year post lung transplant?
Assuming the patient is asymptomatic and has great lung function, CXR/CT would treat, but more focused on optimizing immunosuppression to full dose and likely use oral steroid taper; would also look for DSAs and encourage frequent surveillance.
When do you start steroids for radiation pneumonitis?
Great question on a relevant clinical topic. It's very important to remember that pneumonitis is a diagnosis of exclusion. Sometimes, if the timing is right and the patient's presentation is typical, there is a tendency to move quickly to the conclusion that the symptoms are caused by pneumonitis. R...
How do you approach the bronchoscopic evaluation of a cavitary lesion of the lung?
I think transbronchial biopsy is very helpful in the diagnosis of a cavitary lesion of the lung. I usually send it both for pathology and culture. I also believe it should be dealt with in a multidisciplinary approach and biopsy should be offered to those whose diagnoses are not clear or straightfor...