Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
When would you consider biopsy for an incidentally noted, PET negative, solid, solitary pulmonary nodule that is >8mm in size?
No, probably not. The whole point of a PET scan is to use it for its negative predictive value (which is very high for a nodule that is solid, and large enough). I'd like to know just how large it is because smaller nodules (e.g. just at or above the 8 mm size threshold we all perseverate on) can be...
What steroid regimen do you use in patients with both septic shock and ARDS?
Personally, I have used Hydrocortisone 50mg q6h for patients with refractory shock, regardless of the presence of absence of ARDS. I have not been an adopter of Steroids in ARDS.
What is your approach to treatment for MDA5 dermatomyositis patients with rapidly progressive ILD?
Rapidly progressive ILD is a temporal term, describing rapidly declining lung function within weeks (usually defined as 3 months). Therefore, we commonly use this term when the patient is already hospitalized with respiratory failure. The majority of the data stem from Japan and China, where they en...
Would you treat a sputum culture positive for Aspergillus niger despite an atypical CT chest and a negative serum galactomannan in an immunosuppressed patient who is too high risk for bronchoscopy?
Do you consider surgical thrombectomy in patients with a large, obstructive pulmonary venous thrombosis after lung transplant?
The occurrence of pulmonary embolism after a lung transplant is well-reported (Kahan et al., PMID 17403474). Consequences of large PE can include immediate life-threatening circulatory compromise, hypoxia and the potential for pulmonary infarction. I will weigh in on both the immediate life-threaten...
When do you begin antifibrotic therapy for a patient with newly diagnosed ILD that is not IPF?
The evidence behind starting anti-fibrotic therapy for non-IPF ILD is largely based on the results of the INBUILD trial where patients who have non-IPF ILD who demonstrate progression (based on at least a 10% decline in FVC or a 5% decline in FVC with worsening symptoms or radiologic progression) ha...
What factors do you consider while selecting high risk patients for prophylactic NIV after planned extubation?
I use prophylactic NIV in severe Cardiomyopathy/CHF, severe COPD, and Obesity hypoventilation.
When do you consider the use of corticosteroids in patients diagnosed with EVALI?
If they have ground glass opacities on CT which is considered to be secondary to EVALI.
How would you approach medication de-escalation in a patient with a history of rapidly progressive CTD-ILD who responded to and is currently on mycophenolate 3 grams daily and IVIG 2mg/kg monthly infusions and has been stable for two years?
This is an excellent question with the very little data to go by. We spend most of our time studying escalation of therapy and very little time discussing de-escalation. It has been my experience as a rheumatologist for almost 37 years that many autoimmune diseases initially can be quite immunologic...
How do you approach management of a patient with idiopathic PAH and +ANA, but no other current symptoms/signs of active rheumatologic disease?
(1) Of note, abnormal nail fold capillaroscopy is associated with PAH in several systemic immune diseases: This is famously true for systemic sclerosis, but there are also publications reporting this association for other diseases, notably those in the “lupus family“ like SLE and dermatomyositis. As...