Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your approach to withdrawal of ventilatory support at the end of life?
This is a great question with a complex answer. Both options are reasonable and in my practice, I gear compassionate extubation practices towards the patient and family wishes. In conjunction with our Palliative Care team, we have an algorithm for providing medications to ensure the patient's will n...
Do you administer prophylactic antibiotics to prevent VAP following intubation in patients with acute brain injury?
I currently do not, though this trial is interesting and the results are compelling. I think the risk of one dose of CTX is low. No clear evidence of resistance. I think moving forward, I would have a low threshold for administering one dose of ceftriaxone following intubation in my TBI patients. Ho...
How would you treat a patient with combined pre- and post-capillary pulmonary hypertension after successfully optimizing post-capillary pressures through a valvular intervention?
No good data here. First, if I'm contemplating treating this group with pulmonary vasodilators at all, I would like to see repeat RHC demonstrating precapillary pulmonary hypertension with a low wedge. Fixing the valvular disease may help with left-sided function, but many of these patients have dev...
Is there a subset of ANCA vasculitis patients for which you would try plasma exchange?
Circling back to this now that we have more data. I agree with Dr. @Dr. First Last's main conclusion that GN or the presence of concomitant anti-GBM antibodies are the primary scenarios in which there may be a role for plasma exchange patients with ANCA-associated vasculitis.Following the PEXIVAS tr...
When do you consider Balloon Pulmonary Angioplasty in patients with inoperable CTEPH?
In all patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are not surgical candidates or those with residual pulmonary hypertension after pulmonary thromboendarterectomy (PTE) surgery, balloon pulmonary angioplasty (BPA) should be considered. There are instances in which patient...
What is your approach to counseling and management of patients with severe symptomatic OSA whose PAP devices have been recalled?
Continue to use it with or without a microbiological filter. The latter is not necessarily recommended by Respironics but is an option nevertheless.
Would you start any treatment for radiation pneumonitis if there is a large area of consolidation in the irradiated lung field but the patient is asymptomatic?
If the timeline matches then for radio graphic only pneumonitis, I would favor observation with a repeat scan in a few months.
Is there a role for nintedanib in the management of patients with radiation-induced pulmonary fibrosis?
There is no phase III evidence I am aware of on the benefits of nintedanib in the prevention of radiation-induced pulmonary fibrosis so it is not a drug I use. There are a few case reports and some pre-clinical studies suggesting an effect. There is a small (34 patients) randomized phase II study th...
How would you approach a pulmonary-renal PR3+ ANCA vasculitis patient who has persistent re-narrowing of mainstem bronchus after several dilatation and stenting procedures, with other anca features well-controlled on rituximab & avacopan?
Obviously, this is going to be a very challenging management issue. Bronchial or tracheobronchial stenosis evolves independently of other organ involvement and often fails to respond to immune suppressive regimens. There is one anecdotal study from France, suggesting that cyclophosphamide may offer ...
Is there a role for repeat surveillance blood cultures in patients with prosthetic valve endocarditis without associated cardiac abscess after a 6 week course of antibiotic treatment without surgical intervention?
Compared to NVE, PVE is associated with high morbidity and in-hospital mortality (10-30%). Patients with PVIE who are medically managed have either no surgical indication or have surgical contraindications. 2023 ESC guidelines supported repeating the blood cultures within the first week of finishing...