Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you extend the duration of maintenance therapy past 24 months for patients with ANCA glomerulonephritis who have multiple organ involvement?
The duration of maintenance therapy in patients with AAV depends on many factors and should be individualized. Some factors that are associated with a higher risk of relapse include PR3 positivity, seroconversion from negative to positive, ENT disease, use of a tailored approach to RTX dosing, and u...
How do you risk stratify patients with different WHO groups of pulmonary hypertension prior to non-cardiac surgeries?
First, I would direct the audience to recent AHA guidelines on the perioperative management of PH in non-cardiac surgery. Rajagopal et al., PMID 36924225In general, the severity of pulmonary hypertension and relevant comorbidities are likely more important than the WHO group. In patients with CTEPH,...
What is your approach to de-escalation of asthma therapy if patients have remained clinically stable on triple inhaler therapy and a biologic agent?
Since the reason most folks need biologics is prednisone and considering the side effects, getting patients down to the lowest dose is beneficial.
How do you treat CTD-associated organizing pneumonia?
The approach to CTD-associated organizing pneumonia is similar to that of CTD-associated NSIP and involves treatment with glucocorticoids and steroid-sparing agents. The evidence for the choice of steroid-sparing agents is extrapolated from clinical trial and observational data from systemic scleros...
Do you use any drugs prophylactically to reduce the risk of radiation pneumonitis in lung SBRT?
I have not although there are varying levels of evidence to support each of these agents. I think it points to a broader failure as a field to develop radioprotective strategies that could enhance our therapeutic ratio. RTOG 0123 made an attempt at a prospective evaluation of captopril to reduce rad...
When do you screen for pulmonary hypertension in ILD patients?
Pulmonary hypertension (PH) is a frequent finding in patients with advanced interstitial lung disease (ILD) and its presence is associated with worse morbidity and mortality. The prevalence of PH will depend on the severity of ILD, ranging from around 10% at diagnosis and about 60% of patients with ...
Is the adage “If GCS <8, intubate” still relevant for non-TBI patients?
It's a challenging area. NICO does lead credence to withholding intubation among patients that are comatose from acute poisoning with improvements in "composite end point of in-hospital death, length of ICU stay, and length of hospital stay."Practically speaking, I've never liked hard and fast rules...
When would you consider biopsy for an incidentally noted, PET negative, solid, solitary pulmonary nodule that is >8mm in size?
No, probably not. The whole point of a PET scan is to use it for its negative predictive value (which is very high for a nodule that is solid, and large enough). I'd like to know just how large it is because smaller nodules (e.g. just at or above the 8 mm size threshold we all perseverate on) can be...
What steroid regimen do you use in patients with both septic shock and ARDS?
Personally, I have used Hydrocortisone 50mg q6h for patients with refractory shock, regardless of the presence of absence of ARDS. I have not been an adopter of Steroids in ARDS.
What is your approach to treatment for MDA5 dermatomyositis patients with rapidly progressive ILD?
Rapidly progressive ILD is a temporal term, describing rapidly declining lung function within weeks (usually defined as 3 months). Therefore, we commonly use this term when the patient is already hospitalized with respiratory failure. The majority of the data stem from Japan and China, where they en...