Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
When do you usually introduce conversations regarding tracheostomy placement in patients with refractory status epilepticus, or other conditions where one may anticipate delayed awakening?
It depends on the underlying pathology and how long the patient is expected to have impaired airway reflexes requiring prolonged mechanical ventilation. In the Setpoint 2 trial, among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy (</= 5 days), compare...
For patients with definite UIP and MPO-ANCA-associated vasculitis limited to the lungs (without systemic manifestations), what is the role of immunosuppression?
I think in these subjects (as opposed to UIP in RA), immune suppression would be my first agent. The data are limited; there is some suggestion on biopsy that they have significant inflammation (Arnold et al., PMID 38574743). I would start with immunosuppression and have a low threshold to add anti-...
When would you consider using acetazolamide to augment diuresis in patients with ADHF?
The ADVOR trial suggested that the addition of acetazolamide to a loop diuretic "upfront" in congested patients with heart failure achieves greater decongestion at 72 hours and discharge. While most would not use such a combination in "all" patients, this strategy is optimal in those demonstrating s...
After starting high-dose SMART, what maximum total daily inhalations are appropriate?
From GINA: "For MART with beclometasone-formoterol, GINA suggests patients can use up to 12 inhalations total in one day temporarily if needed based on extensive formoterol safety data, including from studies of budesonide-formoterol".
Are there instances when you recommend central line access when treating a patient using 3% sodium chloride for management of severe hyponatremia?
At UCLA, our hospital policy allows for the administration of 3% sodium chloride via a peripheral intravenous catheter at infusion rates up to 50 mL/hr (Perez & Figueroa, PMID 28471928, Jones et al., PMID 27965228, Mesghali et al., PMID 30745195). Moreover, a prospective, observational study demonst...
What is the interpretation of two IGRAs with negative mitogen wells, in the absence of immunosuppression?
If I understand this case correctly, the patient is actively ill and the patient's doctors are considering tuberculosis as a possible etiology of the patient's illness. In that scenario, IGRAs and PPDs have a limited to no role. Epidemiology, family history, and other possible exposures do. In your ...
How do you approach caring for patients admitted with decompensated CHF, but who also exhibit hypotension and do not have overt signs of hypervolemia on exam?
This is a case where you might be concerned about the patient sliding into cardiogenic shock. Remember that in the context of chronic heart failure, cardiogenic shock tends to present more insidiously because these patients are typically compensated at low or borderline low cardiac output (Abraham e...
For cancer patients with suspected PE, how should the HYDRA trial--which proposes using the YEARS algorithm is as safe as a CTPA-only approach--change the diagnostic workup?
The YEARS algorithm was originally developed to determine which adults with suspected pulmonary embolism (PE) can safely avoid computed tomographic pulmonary angiography (CTPA). It uses three criteria — clinical signs of deep-vein thrombosis, hemoptysis, and PE judged the most likely diagnosis — com...
What is the rationale/evidence to support doing 4 puffs of albuterol vs. 2 puffs for a reversibility study?
The rationale per ATS in 2005 is that 4 puffs of albuterol is higher on the dose-response curve and thus would potentially avoid getting a suboptimal (< 12%, < 200 mL) response from 2 puffs. Having said that, there was a study of this issue in 240 pediatric patients showing non-inferiority of 2 puff...
How do you approach treating patients who develop psoriasis while on Dupixent?
Stop the Dupixent. These patients likely had a non-Th2 driven type of dermatitis e.g. Malassezia yeast hypersensitivity, which is Th17 driven, or stasis dermatitis with autoeczematization, or eczematous drug reaction. Revisit the Diagnostic Checklist for Generalized Dermatitis.