Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
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...
Does the experience level of the intubation operator affect outcomes related to pre-oxygenation with NIV versus an oxygen mask?
Operator experience is certainly associated with first-pass success rate and time from induction of anesthesia to intubation, but this is not an interaction we specifically looked for in PREOXI. I will speculate along with you that since NIV improves pre-oxygenation and prolongs the time until desat...
What are the logistical challenges and time constraints of implementing NIV for pre-oxygenation in emergency settings compared to oxygen masks?
Logistical and training challenges do exist to routine implementation of noninvasive preoxygenation. Perhaps the most challenging one is the availiability of the mechanical ventilator in the emergency setting at the time of intubation. In settings where mechanical ventilators are not routinely prese...
Does the use of NIV for pre-oxygenation delay the time to intubation?
That probably depends on how you define "time to intubation". In the study, we measured time from induction of anesthesia to intubation and % of successful intubations on the first attempt, which were nearly identical between groups (Table 3). However, I suspect the real question is whether NIV preo...
How long post operatively do you wait before transitioning from parenteral anticoagulation to oral anticoagulants after pulmonary thromboendarterectomy for CTEPH?
It depends. In straightforward cases, we are pretty aggressive with starting anticoagulation to prevent re-thrombosis after pulmonary thromboendarterectomy. These patients are started on parenteral anticoagulation (with IV heparin) on POD #0, usually within several hours after arriving in the ICU if...
Is there a role for biologics to help patients with ABPA who are steroid responsive and have removed their allergen insult, but continue to have an elevated serum IgE and incomplete resolution of symptoms return to their baseline functional status?
We have a fairly large number of ABPA patients on Omalizumab. It works great. One of the issues we frequently encounter is that ABPA patients sometimes have too high of IGE counts for the approved highest Omalizumab dosage. In these patients, we initially treat them with standard prednisone therap...
Is positive pleural fluid cytology from pleural mesothelioma considered M+?
No, positive pleural fluid cytology is not considered M1 disease based on AJCC 8th edition staging. Pleural effusion with positive cytology is often present even in early stage disease.Initially, MPM forms small, discrete nodules on the parietal pleura surfaces, convalescing into confluent sheets of...
Do you favor timely bronchoscopy for diagnostics over close surveillance in mildly symptomatic patients with CT findings suspicious for NTM infection who are not able to expectorate?
Yes, I do favor FOB to obtain BAL in symptomatic patients with suspected NTM.
Do you use steroids in the management of PJP pneumonia with severe hypoxia in HIV negative patients?
I only saw about 4 (non-HIV) patients with PJP before AIDS hit the US in 1981. Like others caring for AIDS patients in the 1980s, PJP was incredibly common I saw at least 200 cases over the years. Until AIDS, there were never enough non-HIV patients to do a RCT to look at steroids. Thanks to the wel...
Do you favor the use of maximal inspiratory/expiratory pressure measurement or supine spirometry in the evaluation of a patient with suspected respiratory muscle weakness?
In practice, we often perform both in the same session. Supine spirometry has the advantage of assessing the orthopnea that is a common complaint among my patients with neuromuscular disease. Also, many of our patients report that the MIP/MEP maneuver is difficult to perform and they feel it underes...