Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
For patients with suspected complement-mediated TMA, are there specific clinical or laboratory parameters that can help guide the decision for starting empirical treatment (e.g., eculizumab) while awaiting the results of complement testing?
I just want to point out that hemolytic microangiopathy (as seen on the peripheral smear by our Hematology colleague) is paramountly important in determining the presence of TMA. Laboratory parameters may be misleading. I have seen even ADAMT13 levels very low in sepsis and DIC process. Therefore lo...
What criteria do you use on echocardiogram and PFT to determine who needs further evaluation for CTD-associated pulmonary hypertension?
PFTs are often obtained in patients with systemic sclerosis to evaluate for interstitial lung disease. Low DLCO on PFTs can signify an increased probability of PH, but it is by no means specific. Echocardiograms are readily available, offer additional information about possible causes of PH (e.g. LV...
Are there certain subsets of ANCA vasculitis patients for whom you would consider life long maintenance therapy?
Overall the field is moving towards longer, and sometimes indefinite maintenance therapy. This is because multiple studies have demonstrated that relapse risk increases when maintenance therapy is stopped. I consider indefinite maintenance therapy for the following patients: 1. Frequent relapsers - ...
How would you manage a patient with radiation pneumonitis who remains symptomatic on steroids?
Engage your Pulmonology colleagues to assist in these difficult cases. Important to rule out other causes of persistent symptoms including infectious processes. Rebronch can be helpful for infectious work up and/or determining the nature of the inflammatory process that is ongoing (for example, the ...
Is an early chest tube and tPA/Dornase therapy for a loculated and complex pleural effusion that is not an empyema or hemothorax helpful in reducing the rate of developing trapped lung?
We always keep a low threshold for adding TPA/DNase therapy, if chest tube output starts decreasing, while the radiological infiltrate is not resolving concurrently. The fact to keep in mind is that NO diagnostic workup is 100% sensitive for diagnosing infectious triggers/organizing paranamonic pro...
Do you perform PEEP titration while patients are proned?
Once a patient is proned- we don't use the PEEP: FIO2 ratio tables because you want to continue optimal recruitment. So we monitor driving pressures and maintain PEEP for optimal driving pressures. Also remember as the chest wall compliance decreases with proning, for a given plateau pressure, your ...
What patient factors, if any, would lead you to extubate a patient at high risk of extubation failure to AVAPS rather than BIPAP?
Unless a patient used AVAPS/iVAPS support prior to intubation and is returning to baseline, I discourage our team from using volume-targeted pressure support in acute situations. Although the idea of having a volume target is attractive, there are many opportunities in the acute setting for unexpect...
When do you consider the use of PH specific therapies in patients with pre-capillary pulmonary hypertension associated with sickle cell disease?
Sickle cell-associated PH would be considered Group V PH. Evidence for treating sickle-associated pre-capillary PH with Pulmonary vasodilator therapies is poor. So, in a garden variety of sickle cell anemia associated with PH, I tend not to treat it with PV meds. If the PVR increases, I may sometime...
How would you manage asymptomatic osseous sarcoidosis of the lumbar spine without any other systemic involvement?
Some patients with sarcoidosis are found to have bone-related abnormalities. These are frequently incidental findings often detected as a phantom abnormality on PET or MR scan without corresponding X-ray or CT abnormality; this suggests they are foci of inflammation localized within bone marrow and ...
Is dyspnea without radiation pneumonitis a side effect of lung radiation?
Thanks for the interesting question. I would want to know: on what basis are we saying that the patient does not have radiation pneumonitis (RP)? I am going to assume that this is being stated since the imaging findings are underwhelming in this case. Assuming that this is the case, I would answer: ...