Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you navigate PAP approval for patients with tracheobronchomalacia or excessive dynamic airway collapse who do not have OSA?
Since there is no insurance pathway for PAP for tracheobronchomalacia, we basically perform a sleep study and hope there is a small amount of OSA to treat. Otherwise, we find ways to get a machine for the patient at low cost. While there is theoretical benefit to using PAP for TBM there isn't much e...
What is your initial treatment of choice in patients with RA and associated interstitial lung disease?
Because of the nature of the disease and to avoid unnecessary ILD treatment, it would not be appropriate to provide the 'direct answer' first. But the direct answer will appear in bold at the bottom. Of note, there is little data on therapeutics in RA-ILD. This is an important question because it hi...
What are best practices in management of severe acute infusion reaction from infliximab?
Severe infusion reactions to infliximab are not typically IgE-mediated. The presumption is that it is ‘anaphylactoid’ due to IgG antibodies directed against the mouse chimeric proteins in the molecule. Stopping the infusion is essential (at least temporarily) and administering antihistamines such as...
What strategies do you employ to prevent post-intubation hypotension in a profoundly hypoxic patient given a paralytic for intubation?
There are a few strategies I use. I choose an induction agent such as Etomidate or a ketamine which has minimal hemodynamic effects. If BP is soft to start with, I use IV fluid small bolus, use a vasopressor such as phenylephrine push if needed before sedation.
What is your approach to the evaluation and management of a suspected intrapulmonary hematoma?
I usually observe and they do tend to resolve over time.
Would you consider deferring chest tube placement in a clinically stable patient with a small empyema without signs of systemic infection?
Firstly, diagnosing empyema means the fluid has already been diagnostically tested by thoracentesis. If all the fluid was removed on the diagnostic tap, I would continue and complete the course of antibiotics with close follow-up. The duration of Antibiotics ranges from 4-6 weeks. If a significant a...
What agents do you utilize for mucociliary clearance during the index hospitalization of patients post lung transplant?
Early post-operatively bronchoscopy is the mainstay for the removal of secretions which may be quite thick and obstructive related to the sloughing of pseudomembranes (ischemic epithelium). We will transition from bronchoscopy to hypertonic saline (3% or 5%) nebulized BID with bronchodilators prior ...
Have you seen rheumatoid nodules or RA-ILD in patients with seronegative RA?
By definition, rheumatoid nodules are considered to be a highly specific manifestation of RA. Regarding the first part of the question, one should never see true rheumatoid nodules in someone who does not have seronegative RA. Though there are sporadic case reports of finding these nodules in people...
How do you clinically distinguish between group I and group III PH in patients with CTD-ILD?
The distinction between pulmonary hypertension (PH) of the group 1 (pulmonary arterial hypertension (PAH)) and group 3 (pulmonary hypertension (PH) due to lung disease and/or hypoxia) is essential since the management is different. In group 1 PH we stratify the risk and treat with a variety of PAH-s...
Do you give additional pneumococcal vaccines after a dose of PCV20 in patients with asplenia?
Assuming the patient otherwise does not have immunocompromising conditions other than asplenia, following age-appropriate vaccine schedules is appropriate. A dose of PCV20 appears to provide adequate protection. However, ongoing surveillance studies will be important to answer this question, and vac...