Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Is there a role for the use of biologics as steroid sparing agents in treating patients with ABPA who are intolerant to prednisone?
Treatment for ABPA is generally guided by IgE levels and corticosteroids remain the main drug therapy regardless of classification in both people with cystic fibrosis (CF) and without. Limited treatment with antifungal therapy (itraconazole or voriconazole) is considered usually first in individuals...
Can intra-abdominal pressure serve as a surrogate for pleural pressure to titrate PEEP in obese patients or those with intra-abdominal hypertension?
No. Duomarco and Rimini in 1947 clearly established the presence of regional abdominal pressures.
Is there increased risk with lung SBRT in a patient who has a mild asymptomatic pneumothorax in the field after CT-guided needle biopsy?
I'd be curious what others thought but my quick thought is probably not. If I can extrapolate (i.e., make up) what might be the course of events and what you might want to consider... You send a patient for bx to confirm malignancy and see them right after for sim. The patient is noted by IR to have...
How do you approach biologic initiation in patients with inflammatory arthritis and repeatedly indeterminate Quantiferon?
This is an unusual but anxiety-inducing situation. Remember that an "indeterminate" Quantiferon is not an "intermediate" Quantiferon. It's not half-positive, it's uninterpretable. The result provides absolutely no reason to be more or less concerned that the patient has lTB, latent or otherwise. I a...
How do you approach the treatment of indeterminate UIP on HRCT with grossly positive MPO antibody and no other features consistent with AAV?
We see these patients in our combined ILD/Rheumatology and would treat with immunosuppressive therapy. The indeterminant UIP is likely NSIP although UIP is not an uncommon pattern seen in these patients. ILD can be the presenting manifestation in ANCA-ILD in 14-85% of ANCA vasculitis patients depend...
How often do you monitor pulmonary function tests in patients with fibrotic lung disease?
For IPF patients and those on IS meds, every 4 months, I obtain Spirometry and DLCO. I obtain six-minute walk tests every 4-6 months.
What is your approach for disease activity monitoring in patients with sarcoidosis?
Disease activity monitoring is useful in managing therapy and prognostication in sarcoidosis. Since the disease activity can vary across different organ systems, it can be a challenge. Broadly, good bio-markers of overall disease activity are lacking in this disease.ACE level lacks the sensitivity b...
What patient factors prompt you to consider starting dupilumab in patients with COPD?
The factors I consider are recurrent exacerbations, symptoms despite triple therapy, and an eosinophil count that is greater than 300. What is unclear is the decision regarding chronic azithromycin and/or roflumilast versus dupilumab. It looks like roflumilast was not allowed in the study, and appar...
What is your approach to the use of Paxlovid for patients with risk factors for severe Covid-19 infection but who have received SARS-CoV-2 vaccines in light of the EPIC-SR trial findings?
Although EPIC-SR Trial may not have shown a significant benefit of paxlovid in standard-risk patients regardless of vaccination status, EPIC HR and real-world evidence have shown benefits in high-risk populations. Shared decision-making with the patient is always the best policy.Disclosure: I have r...
Is there an age at which you consider not starting antifibrotic therapy in a patient with IPF?
I don't have an age cutoff. In my first couple of years of practice, I was hard-pressed to prescribe octogenarian antifibrotics, but I've come to think that approach is discriminatory.There does not appear to be an age at which antifibrotics lose efficacy. The real question seems to be whether older...