Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Would you stop azathioprine in a patient with ANCA vasculitis who has been in long term remission on azathioprine, but has a new diagnosis of lung cancer requiring initiation of immunotherapy?
Data about the effect of immunosuppression on the efficacy of immune checkpoint inhibitors suggests that there is a negative of effect of being on immunosuppression at the time of ICI initiation on tumor response. So if the patient really has been clinically stable for a long time there are a few op...
Is there a role for nocturnal supplemental oxygen as opposed to no therapy in patients with OSA who are unable to tolerate PAP therapy?
I do not use supplemental oxygen as a sole therapy for sleep-disordered breathing (SDB). Treatment with Positive Airway Pressure (PAP) is the initial treatment of choice for SDB. There is no indication to use supplemental oxygen for patients who do not accept or tolerate PAP therapy. Instead, oxygen...
How do you approach determining appropriateness for extubation in a patient with acute respiratory failure in the setting of known chronic neuromuscular disease?
This can be a very challenging situation in the ICU. I first discuss the options with the patient (if possible) and caregivers before considering extubation. I consider baseline/pre-illness data if available such as prior FVC or NIF/MIP, need for NIV, etc. Also, it is important to consider why they ...
Do you ever start a ketogenic diet in patients who present with status epilepticus admitted to the ICU?
A ketogenic diet can be considered in super-refractory status epilepticus. There are a handful of small studies and case series that are mostly pediatric, but also a few adult papers (Camões et al., PMID 35081248, Katz et al., PMID 33671485, and Cai et al., Acta Epileptologica 2022), which suggest t...
Do you start PAP in patients who have an overall AHI of less than 5 but demonstrate significant apneas/hypopneas in REM sleep?
The issue of REM AHI is fascinating. While we often find increased "scorable" events during REM, this often reflects a more pronounced desaturation for a given decrease in alveolar ventilation. There is no conclusive evidence that the upper airway is more compliant during REM sleep. The compliance o...
Do you use acetazolamide to aid diuresis in patients with acute on chronic respiratory acidosis with significantly elevated serum bicarbonate levels?
The real question is do you use acetazolamide when there is a simultaneous primary metabolic alkalosis with a respiratory acidosis so that the pH is not low enough to give you a respiratory drive. It is usually from diuretics that create the metabolic alkalosis so using acetazolamide may reverse the...
Can transudative pleural effusions lead to trapped lung?
Yes. I’ve seen it many times especially in patients with longstanding CHF and/or CKD. With a persistent effusion of any type, the pleura can respond by forming a peel resulting in a non expanding lung.
Do you use absolute random cortisol levels or delta cortisol levels after ACTH stimulation to diagnose adrenal insufficiency in the critically ill?
As reviewed recently by Dr. Teblick et al., PMID 35358303, this is still a controversial and complex issue. Based on many studies, it would be preferable to avoid ACTH stimulation unless there is rapid availability of free cortisol. Random total cortisol is probably the better alternative.
Do you attempt more aggressive PEEP titration to improve the P/F ratio prior to proceeding with proning in patients with ARDS and P/F <150?
Aggressive PEEP titration is a loaded term. Do these patients need higher PEEPs? Yes, if they are recruitable. You need to understand the lung mechanics and the concept of stress and strain to make sure that you are optimizing the inflation pressure these lungs are exposed to. This can be achieved b...
What is the expected timeframe one would expect to see paroxysmal sympathetic hyperactivity/sympathetic storming persist post-traumatic brain injury?
I've personally seen as long as 30+ days but usually less.