Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
When attempting PEEP titration, how long do you wait after decrements or increments to assess for a change in driving pressure?
This depends on the patient level of consciousness and whether or not they are paralyzed.
What is the current recommendation for air travel after a primary spontaneous pneumothorax?
General guidelines including the British Thoracic Society recommend delaying air travel for at least 2 weeks following the radiographic resolution of a pneumothorax. However, recent studies have challenged this conservative approach. A study by Majercik et al., PMID 25494425 demonstrated that patien...
Is there any role for palliative radiation in patients who are intubated due to malignant airway obstruction?
The literature is limited, but this small series showed about 1/4 of patients can have reversal of intubation.If the patient/family is interested in attempting, it occasionally works, but my own experience is less successful than 1/4. It is unlikely to worsen the situation, so after explaining that ...
How do you counsel and manage patients who meet criteria for sleep apnea based on 3% but not 4% desaturation?
It depends on the patient's symptoms. If they have symptoms attributable to sleep apnea then I tell them they have sleep apnea. If they don't have symptoms then I don't diagnose them with sleep apnea. If the patient has an insurance plan that only accepts 4% desaturations and yet they clearly have s...
For how long do you recommend treatment for latent tuberculosis prior to initiation of anti-TNF therapy?
Some recommendations call for completing a course of treatment for latent TB prior to starting a biologic but I find most patients and referring specialists are intolerant of that strategy. This reference: Yeo et al., European Respiratory Journal 2014 is a good example of data supporting a shorter w...
What are first-line choices for vasopressors/inotropes to use in hypotensive patients with Eisenmenger Syndrome?
The answer is that it all depends on the etiology... However, a common issue with Eisenmenger syndrome (ES) is that routine pharmacological treatments that cause peripheral vasodilatation may worsen the right to left shunting and further shock. My first patient with ES was a gentleman recovering fro...
Do you use FVIII levels to differentiate between DIC and coagulopathy of liver disease?
DIC is a clinical diagnosis that is difficult to establish in the absence of bleeding or thrombosis, particularly in patients with liver disease. I do think that following DIC laboratory markers (FDP, fibrinogen, D-dimer) serially may be helpful as you would not expect them to acutely drop simply be...
Do you consider immunosuppressive agents in progressive interstitial pneumonias or pneumonitis without a clear driving etiology?
Although it's often helpful to have a clear diagnosis of an underlying connective tissue disease (CTD) or positive autoantibodies to guide therapy (or perhaps feel better about prescribing it), we more often find ourselves dealing with ambiguous cases. When pathology is available to suggest an infla...
What protective post-op measures do you recommend for a patient with scleroderma and a history of ILD, PH, Raynaud’s and digital ischemia undergoing cardiothoracic surgery?
Appropriate post-operative care in patients with scleroderma is very important. In the context of the cardiopulmonary disease, volume management is very important with close monitoring in I/O's to optimize fluid status. In a patient with a history of digital ischemia, it is important to keep the pat...
What would be your recommendation for treatment of worsening lung disease in a patient with long-standing scleroderma after long-term mycophenolate therapy which is no longer an option due to side effect/intolerance?
Someone who has been on long-term Mycophenolate for interstitial lung disease and has had stabilization or improvement in their lung function and then is unable to tolerate the medication may be able to be switched to mycophenolic acid sodium (myfortic) which is often less toxic and better able to b...