Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your approach to a patient who has a cardiac PET scan suggestive of sarcoid but no other supporting evidence of a diagnosis of sarcoid?
The diagnosis of cardiac sarcoidosis (CS) can be challenging, as non-necrotizing granulomatous inflammation is frequently patchy, and as a result, may not be present on endomyocardial biopsy even in the setting of active cardiac disease. Many institutions, including ours, attempt to avoid endomyocar...
When is it considered inappropriate to omit pathological mediastinal lymph node staging for non-small cell lung cancer?
This is a very good question often debated by thoracic radiation oncologists with their thoracic surgery colleagues and can get complicated. The best way to look at it, in my opinion, is to understand the sensitivity and specificity of FDG PET/CT to detect true mediastinal nodal disease. For example...
Is there still a role for direct laryngoscopy in the intubation of patients in the ICU?
I believe you have to be proficient in many techniques in case you need alternatives when performing a procedure. This applies to DL. Video intubation has facilitated intubation greatly but the technique is different and if it fails the default is DL.
How do you manage diarrhea in a patient with CTD-ILD on MMF who was recently started on full dose nintedanib?
It is important to keep in mind that immunomodulator therapy is also frequently associated with gi toxicity (MMF, methotrexate, leflunomide, azathioprine, etc.). Given this, it is important to begin one therapy at a time in order to mitigate side effects and do understand which agent is responsible....
Do you continue to prone patients with severe ARDS after initiation of VV-ECMO?
Not routinely - although we have occasionally proned VV ECMO patients at our center. Reasons for not proning include: Cannula dislodgement/displacement risk (although Roca et al, PMID 34461971 reviews the literature on proning with VV ECMO and the risk of major line complications is small). Generall...
What else do you consider in the differential diagnosis for pulmonary-renal syndromes if there is low clinical and serologic evidence of AAV, Goodpasture's or other rheumatologic disease (SLE, RA, APS, Scleroderma)?
Endocarditis can mimic vasculitis and can have pulmonary hemorrhage. You CANNOT miss that one. Sarcoidosis is I suppose a pulmonary renal syndrome. Renal vein thrombosis from MGN with a pulmonary embolus is I suppose a pulmonary-renal syndrome.
Do you routinely perform genetic testing in patients presenting with pulmonary fibrosis who endorse a family history of fibrotic lung disease?
I receive this question frequently when I hear from other clinicians and I think it is a very thought-provoking question. We know that patients with pulmonary fibrosis (PF) commonly have first-degree relatives with interstitial lung disease (ILD). Some studies quote numbers as high as 20% so it is d...
How do you approach treating mild hypercalcemia in patients with sarcoidosis?
This may seem like a straightforward query, but like many issues surrounding sarcoidosis, it is actually deceptively complex. For a more complete discussion, I refer the readers to an excellent review by Lower and Saidenberg-Kermanac’h (2019). In and of itself, asymptomatic “mild” hypercalcemia does...
Do you consider pulmonary hypertension related to sarcoidosis to be an indication to start steroids?
Pulmonary hypertension (PH) associated with sarcoidosis presents a complex clinical challenge. The decision to use corticosteroids in sarcoidosis-associated pulmonary hypertension depends on several factors: Underlying Cause of PH: It's crucial to determine whether the pulmonary hypertension is dir...
Is it safe to combine mycophenolate and adalimumab for management of pulmonary sarcoidosis in a patient that could not tolerate methotrexate?
Combination therapy is often required in patients with sarcoidosis. Combination of adalimumab with other immunosuppressants, such as methotrexate, leflunomide, azathioprine, or mycophenolate, can be used, with close monitoring of labs (CBC, CMP) and for infections.