Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What specific clinical and echocardiographic thresholds lead you to taper/de-escalate pulmonary hypertension therapy before liver transplant?
The goal in pulmonary hypertension therapy pre-transplant is to fulfill the MELD exception criteria in terms of mean pulmonary artery pressure, pulmonary vascular resistance, as well as right ventricular function by echo. Once those criteria are satisfied, maintain those PH therapy doses until the t...
Would you recommend starting tolvaptan at 7.5 mg per day, which is half the typical starting dose, to reduce the risk of overcorrection in an inpatient with SIADH and a serum sodium level of 122 mEq/L?
If it is for SIADH, I always start with 7.5 mg. See this, my fellow and I put together years ago. Dosing in SIADH: A Tale of Two Tolvaptans If it is for CHF, I would start with 15 mg as those patients are so pre-renal, their distal delivery is so impaired, and tolvaptan is limited by that. I haven't...
Do you accept a decline in eGFR during aggressive diuresis for heart failure if the patient is successfully decongesting, given data suggesting modest eGFR decline with improved congestion may still be associated with lower mortality?
Yes, I accept a modest decline in eGFR during diuresis in patients with heart failure. Previous studies of patients hospitalized with acute decompensated heart failure have shown that mortality and readmission rates are reduced by effective decongestion even if the creatinine rises. The study by Oka...
How has the FLUID trial, which showed no significant difference in death or readmission rates between Lactated Ringer’s solution and normal saline, influenced your approach to IV fluid management?
The choice between normal saline and Lactated Ringer's should be individualized. Normal saline is preferred in patients with hyponatremia or metabolic alkalosis. Lactated Ringer's is preferred in patients with hyperchloremic acidosis, and it should be avoided in patients with hyponatremia since its ...
What is the goal oxygen saturation for patients with COPD and pulmonary hypertension?
Although an oxygen saturation target of 88–92% is commonly used in patients with COPD to reduce the risk of oxygen-induced hypercapnia, a higher saturation goal is appropriate in patients with pulmonary hypertension associated with COPD. In this population, we generally aim for an oxygen saturation ...
What is your approach to empiric treatment of achromobacter infections?
Achromobacter is a Gram-negative bacterium in the Burkholderia order. This pathogen is significant in immunocompromised patients, such as those with cancer or Cystic fibrosis, and is seen with bacteremia or causing pneumonia. They can also be associated with foreign device infections. Typically, the...
Do you perform routine screening for latent tuberculosis in a patient who resides in the United States, has frequent, 1-2 week trips to see family in a highly endemic country, but who otherwise has no significant risk factors or high risk exposure activities?
If an individual has qualifying risk factors for latent TB, including frequent travel with relatively prolonged stays to TB endemic regions, I do offer and perform testing for latent TB. This is an opportunity to identify individuals with latent TB and offer treatment. Failing to screen is a missed ...
Would you consider leaving fever untreated in patients with sepsis to potentially enhance immune responses and antimicrobial efficacy?
In light of the review article attached (Tilanus et al., PMID 41113323), there is some data reviewed supporting that fever is actually therapeutic. Four articles are of special interest in the review. Two are from the 70s, before sepsis was defined as it is today. Two are in the last 15 years, but o...
Do you generally recommend device exchange/removal in patients with gram positive bacteremia in the setting of intra-aortic balloon bump or other mechanical circulatory devices?
I am assuming in this case that the patient has a mechanical circulatory support device such as an LVAD, IABP, or another implantable device, and has developed gram-positive bacteremia. No further details about the device type or clinical scenario are provided. In such cases, device removal is recom...
Do you routinely hold anticoagulation (including pharmacologic VTE prophylaxis) for bedside procedures such as paracentesis, thoracentesis, and central venous catheter placement?
We do not hold anticoagulation of any kind for paracentesis. I also do not hold anticoagulation of any kind of thoracentesis, though some places will still ask things like Plavix or DOAC to be held. We do hold ppx and anticoagulation for LP due to the risk of epidural hematoma. I do not hold for the...