Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your blood pressure or mean arterial pressure goal in a critically ill patient with acute kidney injury?
The current surviving sepsis guidelines recommend targeting a mean arterial pressure (MAP) of 65 mm Hg with no benefit of targeting a higher MAP in septic shock patients.
Are there clinical scenarios in which you would start empiric treatment for pulmonary TB without microbiologic confirmation?
Yes, there are a few situations. One of them being pauci-bacillary TB in which you catch TB very early on its course hence your micro/cultures will be negative. CT will demonstrate micronodules. This is a diagnosis of exclusion and requires the right clinical setting (high-risk patient, from an ende...
How would you manage a patient with ANCA associated vasculitis who has recurrent flare including pulmonary hemorrhage, persistent MPO antibody positivity while on maintenance rituximab and avacopan regimen even after induction rituximab therapy?
Probably cyclophosphamide but maybe mycophenolate or azathioprine.
Which ANCA vasculitis patients are better candidates for cyclophosphamide rather than rituximab?
Both can be used for induction in GPA/MPA vasculitis. I would use rituximab (RTX) if the patient has previously been treated with cyclophosphamide (CYC) and developed a relapse/flare and in patients who are young and with fertility concerns. In GPA/MPA, I tend to use RTX most of the time for inducti...
Are you using genomic classifiers to diagnose UIP when imaging is indeterminate or suggestive of an alternate diagnosis?
Antifibrotics are indicated for the treatment of IPF, scleroderma-ILD, and progressive pulmonary fibrosis, not specifically for "UIP," which can manifest in any of the three. When a patient presents with an indeterminate pattern on CT without suggestive features of connective tissue disease on histo...
Do you administer immunosuppression to patients with idiopathic NSIP who have normal lung function and mild to moderate respiratory symptoms?
I think it depends on whether or not it clinically seems that the idiopathic NSIP is driving the mild to moderate respiratory symptoms. If there are no other clear causes of the respiratory symptoms (pulmonary hypertension, cardiovascular disease, airways disease, etc.) and the HRCT imaging findings...
What is your approach to evaluation and diagnosis following a non-diagnostic MSLT in a patient with suspected narcolepsy type 2?
A non-diagnostic study is a good time to review technical considerations of the study a second time. Was everything performed correctly? Was the patient on any medications which may have confounded the testing? Ideally, this should be determined during the initial read of the study although we are a...
Do you consider tracheostomy for the management of continued hypercapnea despite compliance with PAP in patients with OHS and OSA?
I would try AVAPS such as trelegy machine first before considering Tracheotomy. In most circumstances with good compliance, it helps with the hypercapnic failure.
What are your top takeaways from CHEST 2024?
Many great presentations at CHEST 2024. I was impressed by the Rapid Fire sessions where the outcomes on the latest trials for Robotic Bronchoscopy were discussed. It’s very encouraging to see the needle move forward in lung cancer accuracy diagnosis. Also a great opportunity to network and meet wit...
Are there patients with granulomatosis with polyangiitis on maintenance rituximab therapy for whom you do not co-administer glucocorticoid therapy?
I think this is a great question. @Dr. First Last et al (NCT01933724) have conducted a study to answer that question (conveniently called TAPIR). In their analysis that was presented 1 week ago at the International Vasculitis Workshop, they found that patients on low-dose prednisone along with other...