Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
When would you start antiepileptic drugs in a critically ill patient who develops myoclonic jerks but has not yet had an EEG?
Treatment depends on the setting in which these myoclonic jerks are seen. In a non-cardiac arrest patient, such myoclonic jerks are often due to medications, organ dysfunction (e.g., uremia, etc), electrolyte imbalance, or non-convulsive seizures, etc, and workup for this is recommended with labs, h...
Under what circumstances would you choose the 1-month 1HP treatment over a 3-4 month regimen for latent TB?
I tend to favor the 1-month daily isoniazid–rifapentine regimen (1HP) in very specific clinical and programmatic contexts, rather than as a default option. Its main advantage is speed i.e. when there is a narrow window to complete latent TB treatment such as prior to imminent immunosuppression (e.g....
In patients with anoxic brain injury who have a tracheostomy, but “liberated” from the ventilator, and appear to be able to protect their airway, but have no meaningful neurological function, is there a role for decannulation?
Unfortunately, in patients with such severe brain injury that they have no meaningful neurologic function, decannulation would come at significant risk. Often, patients in these situations do not manage their secretion well and are at high risk for aspiration. With the trach in place, suctioning and...
Do you have any pearls for how to manage OSA with CPAP in older adults with cognitive impairment?
I try to involve a partner or other family member in the process, including getting a sleep study in the first place. If the study shows moderate or severe sleep apnea, especially with substantial oxygen desaturation, I remind the patient and partner that use of CPAP will help the patient's memory. ...
What is the best alternative oral therapy for treatment of non-severe pulmonary nocardiosis in an immunocompetent patient with sulfa allergy?
We have been using linezolid for this indication, based on a paper from ARUP Labs.Schlaberg et al., PMID 24247124
Do you prefer using end-expiratory or mean pulmonary artery wedge pressure obtained during diagnostic right heart catheterization for the classification of precapillary vs postcapillary PH?
I use end-expiratory wedge pressure (and all hemodynamics for that matter at end-expiratory pressure) most of the time which is supported by current guidelines. The confounder is in patients with wide transthoracic pressure swings (i.e., exercise, severe COPD, severe obesity). This is just something...
Do you ever consider continuing annual LDCT chest for lung cancer screening in patients who quit smoking more than 15 years ago?
The 15 years is now 20 years but keep in mind the “Guidelines” may not apply to the patient in front of you. Did anyone else notice that 2nd hand smoke is not in the eligibility criteria?
What factors do you consider for patients on an individual basis when establishing a post-cardiac arrest MAP goal after ROSC is achieved, considering some may benefit from higher MAP goals for optimal cerebral perfusion?
I generally aim for a MAP of 70. However, I am more concerned with ensuring end organ perfusion and will track urine output, lactate, mental status, and LFTs in addition to the physical exam (cool vs warm and absence of mottling). MAP goal adjustment should also be considered in instances with a wid...
In what circumstances would you consider monotherapy for empiric treatment of unresectable nontuberculous mycobacterial lymphadenitis?
NTM lymphadenitis is rather uncommon, and I personally have little experience with it and did not see it much even at NJH. However, extrapolating from how I treat any NTM disease in general, I would shy away from monotherapy in any NTM disease, preferring at least two active agents. Perhaps one scen...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...