Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you consider administration of nintedanib or pirfenidone via enteral tube in patients unable to take PO due to recurrent aspiration?
I have not ordered nintedanib or pirfenidone via enteral tube for any of my patients. However, in the past, I have looked into it due to some research interests and have discussed it with our local MSLs and our clinical pharmacist. Nintedanib is available only in capsule form and is not recommended ...
Are SCDs contraindicated in patients with acute DVTs?
SCDs can help prevent DVT but I'm not aware of any evidence of benefit when treating an established event. There are rare reports of pulmonary embolism following the application of SCDs in patients with asymptomatic DVTs. I don't think this constitutes an absolute contraindication, but in the absenc...
Do you ever employ the use of prolonged periods of pressure support ventilation as means of "weaning" in the management of patients with acute respiratory failure?
The evidence basis here would suggest no one mode is superior for weaning vs just putting patients on SBT. However, as a practical matter, weaning a patient from the ventilator involves letting sedatives metabolize/wear off (propofol can take days to wash out after a week of use), and testing how th...
How small of a nodule would you attempt to biopsy with robotic bronchoscopy?
There’s no right answer to this. Size is only one criteria, and may not even be the most important. Location relative to the airways is far more important than size, and you may have trouble biopsying a 2 cm nodule with no airway leading near it, as compared to a 7 mm nodule that is located near or ...
Do you perform routine interval screening for pulmonary fibrosis in individuals who have been identified through genetic testing as being at risk for developing pulmonary fibrosis but don't exhibit any signs or symptoms?
Screening for pulmonary fibrosis: Only "yes" for individuals with one or more family members with IPF and age >50 - HRCT findings of ILAs, fibrotic ILAs, or IPF will be identified in 20% of these individuals. No for all other individuals including those carrying various high-risk alleles such as M...
In light of the RECITAL study, would rituximab be a reasonable choice in a patient with PL-12 antibodies, rapidly progressive pulmonary disease with organizing pneumonia on biopsy?
The findings from the RECITAL study have confirmed the validity of our clinical approach, advocating for rituximab as the primary treatment for CTD-ILD, considering the elevated risks associated with the use of cyclophosphamide. Therefore, it is entirely justifiable to opt for rituximab in cases of ...
In patients being evaluated for brain death, which abnormal movements are definitively known to still be consistent with brain death and which are possibly consistent with brain death but lack definitive evidence?
This is indeed a challenging question, one that I continue to grapple with as a neurointensivist. Fortunately, most brain-dead patients do not exhibit any movements in response to noxious stimuli, but some case series report reflexive movement in up to 75% of cases. The classic teaching is that only...
Would bag-mask ventilation with a PEEP valve be a reasonable alternative to NIV for pre-oxygenation prior to intubation in settings where NIV is not easily accessible?
The PREOXI trial does not inform the use of a bag-mask device with a PEEP valve. Many invasive mechanical ventilators are capable of delivering noninvasive ventilation using the same mask that the bag-mask device uses.
How do you identify which patients are at highest risk for decompensation and most likely to benefit from NIV for pre-oxygenation prior to intubation?
Prior to this study, I would periodically use NIV pre-oxygenation for patients not already on NIV for respiratory failure if they were requiring high levels of FiO2 (>50% FiO2 on HFNC, or >6-8L nasal cannula/face mask), were very obese, or had other predictors of a difficult airway.In the PREOXI stu...
Is there a subset of patients in whom pre-oxygenation with NRB or BVM could be safely pursued?
Preoxygenation using an oxygen mask that does not provide positive pressure may be appropriate in patients who have a contraindication to noninvasive ventilation such as patients with active emesis. However, one of the key findings of the PREOXI trial was that preoxygenation with noninvasive ventila...