Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
What is your approach to volume resuscitation in patients who are third spacing fluids?
In patients with significant third-spacing (e.g., due to capillary leak in sepsis, severe pancreatitis, hypoalbuminemia, etc), we prefer balanced crystalloids (e.g., Lactated Ringer’s) as the first-line fluid for initial resuscitation in hypovolemic or septic shock with third-spacing. Typical initia...
How do you weigh the benefit of urinary catheter placement for strict I/O measurement with the risk of avoidable CAUTI?
Our hospital's approach, which is consistent with CDC guidance, limits urinary catheters (UC) for I/O measurement to critically ill patients. We clarify that the information from the UC should be used at least q1-2 hours, otherwise it can be obtained in other ways (noninvasive collection, bladder sc...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
How do you treat idiopathic hypersomnia inadequately responding to modafinil?
I agree with @Dr. First Last. I usually start my patients on modafinil or armodafinil. If those do not work, I will try solriamfetol. I will supplement with as needed amphetamines as well. I do not often go straight to sodium oxybate/low-sodium oxybate, as you need the right patient for this medicat...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
Do you treat complicated pneumonia with a drained empyema longer if Streptococcus anginosus is cultured, either in isolation or with other organisms, compared to cases in which it is not?
Targeted antimicrobial therapy for any bacterial etiology of an empyema will be individualized for each patient but a general duration of 4-6 weeks. I would not consider strep anginosus differently in this regard. What I am looking for is adequacy of drainage with clinical improvement. Radiographic ...
How do you manage hypercalcemia in sarcoidosis despite being on immunosuppressive therapy?
Let us accept, first, that the individual does not have emergent levels of elevated calcium (equal to around or greater than 14 mg/dl) and concerning symptoms of the following systems: neurological (e.g., weakness, confusion, delirium), renal (e.g., polyuria, polydipsia), gastrointestinal (e.g., los...
When would you consider glucocorticoids as adjunctive therapy for for community-acquired pneumonia outside of the ICU setting?
Thank you for bringing this new study to my attention; I hadn't seen it yet. After reviewing the article, my practice regarding steroids remains unchanged. While the trial was well-executed, and it is laudable to see such research coming out of a limited-resource setting, that environment differs si...
In elderly patients with advanced melanoma and idiopathic pulmonary fibrosis receiving active antifibrotic therapy, would neoadjuvant or adjuvant immune checkpoint inhibition be preferred?
I'd be very careful with the use of immunotherapy in an elderly patient with any sort of autoimmune disease, especially when receiving disease-modifying therapy. Having said that, there is no such contraindication to giving immunotherapy in such patients. Neoadjuvant setting: It is always preferred ...