Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What patient factors prompt you to consider starting dupilumab in patients with COPD?
The factors I consider are recurrent exacerbations, symptoms despite triple therapy, and an eosinophil count that is greater than 300. What is unclear is the decision regarding chronic azithromycin and/or roflumilast versus dupilumab. It looks like roflumilast was not allowed in the study, and appar...
Do you grade severity of OSA by AHI or RDI?
We recently changed, per AASM guidelines, to reporting both AHI3a and AHI4. Since most sleep-disordered breathing events will qualify with the 3a decision, as it includes arousals, we have stopped reporting an RDI. If there are events that don't meet the 3a hypopnea definition, we might comment on i...
What is your approach to the use of Paxlovid for patients with risk factors for severe Covid-19 infection but who have received SARS-CoV-2 vaccines in light of the EPIC-SR trial findings?
Although EPIC-SR Trial may not have shown a significant benefit of paxlovid in standard-risk patients regardless of vaccination status, EPIC HR and real-world evidence have shown benefits in high-risk populations. Shared decision-making with the patient is always the best policy.Disclosure: I have r...
Is there an age at which you consider not starting antifibrotic therapy in a patient with IPF?
I don't have an age cutoff. In my first couple of years of practice, I was hard-pressed to prescribe octogenarian antifibrotics, but I've come to think that approach is discriminatory.There does not appear to be an age at which antifibrotics lose efficacy. The real question seems to be whether older...
Do you consider administration of nintedanib or pirfenidone via enteral tube in patients unable to take PO due to recurrent aspiration?
I have not ordered nintedanib or pirfenidone via enteral tube for any of my patients. However, in the past, I have looked into it due to some research interests and have discussed it with our local MSLs and our clinical pharmacist. Nintedanib is available only in capsule form and is not recommended ...
Are SCDs contraindicated in patients with acute DVTs?
SCDs can help prevent DVT but I'm not aware of any evidence of benefit when treating an established event. There are rare reports of pulmonary embolism following the application of SCDs in patients with asymptomatic DVTs. I don't think this constitutes an absolute contraindication, but in the absenc...
Do you ever employ the use of prolonged periods of pressure support ventilation as means of "weaning" in the management of patients with acute respiratory failure?
The evidence basis here would suggest no one mode is superior for weaning vs just putting patients on SBT. However, as a practical matter, weaning a patient from the ventilator involves letting sedatives metabolize/wear off (propofol can take days to wash out after a week of use), and testing how th...
How small of a nodule would you attempt to biopsy with robotic bronchoscopy?
There’s no right answer to this. Size is only one criteria, and may not even be the most important. Location relative to the airways is far more important than size, and you may have trouble biopsying a 2 cm nodule with no airway leading near it, as compared to a 7 mm nodule that is located near or ...
Do you perform routine interval screening for pulmonary fibrosis in individuals who have been identified through genetic testing as being at risk for developing pulmonary fibrosis but don't exhibit any signs or symptoms?
Screening for pulmonary fibrosis: Only "yes" for individuals with one or more family members with IPF and age >50 - HRCT findings of ILAs, fibrotic ILAs, or IPF will be identified in 20% of these individuals. No for all other individuals including those carrying various high-risk alleles such as M...
In light of the RECITAL study, would rituximab be a reasonable choice in a patient with PL-12 antibodies, rapidly progressive pulmonary disease with organizing pneumonia on biopsy?
The findings from the RECITAL study have confirmed the validity of our clinical approach, advocating for rituximab as the primary treatment for CTD-ILD, considering the elevated risks associated with the use of cyclophosphamide. Therefore, it is entirely justifiable to opt for rituximab in cases of ...