Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Would you treat a sputum culture positive for Aspergillus niger despite an atypical CT chest and a negative serum galactomannan in an immunosuppressed patient who is too high risk for bronchoscopy?
Do you consider surgical thrombectomy in patients with a large, obstructive pulmonary venous thrombosis after lung transplant?
The occurrence of pulmonary embolism after a lung transplant is well-reported (Kahan et al., PMID 17403474). Consequences of large PE can include immediate life-threatening circulatory compromise, hypoxia and the potential for pulmonary infarction. I will weigh in on both the immediate life-threaten...
When do you begin antifibrotic therapy for a patient with newly diagnosed ILD that is not IPF?
The evidence behind starting anti-fibrotic therapy for non-IPF ILD is largely based on the results of the INBUILD trial where patients who have non-IPF ILD who demonstrate progression (based on at least a 10% decline in FVC or a 5% decline in FVC with worsening symptoms or radiologic progression) ha...
What factors do you consider while selecting high risk patients for prophylactic NIV after planned extubation?
I use prophylactic NIV in severe Cardiomyopathy/CHF, severe COPD, and Obesity hypoventilation.
When do you consider the use of corticosteroids in patients diagnosed with EVALI?
If they have ground glass opacities on CT which is considered to be secondary to EVALI.
How would you approach medication de-escalation in a patient with a history of rapidly progressive CTD-ILD who responded to and is currently on mycophenolate 3 grams daily and IVIG 2mg/kg monthly infusions and has been stable for two years?
This is an excellent question with the very little data to go by. We spend most of our time studying escalation of therapy and very little time discussing de-escalation. It has been my experience as a rheumatologist for almost 37 years that many autoimmune diseases initially can be quite immunologic...
How do you approach management of a patient with idiopathic PAH and +ANA, but no other current symptoms/signs of active rheumatologic disease?
(1) Of note, abnormal nail fold capillaroscopy is associated with PAH in several systemic immune diseases: This is famously true for systemic sclerosis, but there are also publications reporting this association for other diseases, notably those in the “lupus family“ like SLE and dermatomyositis. As...
In which patients do you prefer daily standard three-drug therapy for non-cavitary pulmonary MAC as opposed to three times a week dosing?
Generally, if non-cavitary disease I favor thrice weekly therapy. However, if widespread non cavitary disease or immunosuppressed, I may choose daily dosing.
Do you consider the use of antifibrotics at presentation in patients with a radiographic UIP pattern of pulmonary fibrosis in the presence of positive serologies without any symptoms of CTD who have not yet demonstrated evidence of a progressive phenotype?
I really like this question, because it succinctly encapsulates several areas of clinical uncertainty that we are routinely forced to address in our ILD clinics! Let’s unravel some of the subtleties here. For starters, if the radiographic pattern is convincingly that of UIP, our patient will technic...
Do you administer calcium to patients with K > 6.5 without EKG changes?
No. But our ER does as a reflex and I don't have a problem with that. It used to drive me nuts bc it sent the wrong message, as though Ca lowers [K] level (of course it does not, it just decreases cardiac effect). But you don't know how fast they are being seen, how fast they will get treated, so I ...