Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you add empiric anti-MRSA coverage to the initial antibiotic regimen for a patient admitted with community-acquired pneumonia who has risk factors for MRSA but a negative MRSA nasal screen?
Thank you for this excellent and highly relevant clinical question. I approach this scenario by blending robust evidence-based medicine with fundamental principles of diagnostic reasoning. The short answer is generally no, you probably do not need to add empiric anti-MRSA coverage for a standard CAP...
Do you perform EBUS-TBNA for staging in patients with biopsy proven malignant lung nodules with no lymphadenopathy on CT chest and PET scan?
I agree that incidence is low, but estimates for radiographically occult nodal disease range from 10-20% and the fact is there isn't great literature on this. A PET scan is a decent test, better than a regular CT, but there are still a significant minority of patients that are mis-staged when an EBU...
How do you determine the time window for which to monitor for cerebral edema development in patients with brain injury?
The type of edema definitely matters. The two big categories of cerebral edema include cytotoxic and vasogenic edema. Cytotoxic results from free water accumulation in dying cells from acute brain injury, while vasogenic edema results in disruption of the blood-brain barrier. The classic teaching is...
In patients who develop severe precapillary PH within 6–12 weeks after LT, which potentially reversible post-transplant contributors do you prioritize ruling out before escalating PAH therapy because they are most actionable and most plausibly causal in your experience?
The development of pre-capillary pulmonary artery hypertension post-liver transplant in the timeframe mentioned can be extremely serious. Obviously, the most life-threatening concern to rule out is acute pulmonary embolism, which could cause fairly dramatic hemodynamic changes and right heart dysfun...
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...
What strategies have you found most effective for those attempting vaping cessation?
Clinicians are finding increasing success with Varencline and Nicotine Replacement Therapy (NRT) for vaping cessation. When combined with behavioral counseling, these treatments are more likely to achieve sustained abstinence than medication alone. For adolescents in particular, it is important to i...
What drug and specific dosing would you use for secondary pneumocystis prophylaxis in a patient with renal transplant, documented TMP-SMX allergy, and normal G6PD testing, who was diagnosed with moderate PJP and improved on clindamycin/primaquine and steroids?
I think the options are dapsone (which is tolerated by most patients allergic to TMP/SMX), atovaqone, and inhaled pentamidine. During my career, those choices have depended to some extent on the local practice. I have preferred inhaled pentamidine because I have worked in places with low volume and ...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
When do you consider giving IV albumin for severe hypoalbuminemia with third-spacing of fluid outside of standard indications (i.e., large-volume paracentesis, HRS, SBP, shock, etc.)?
On the wards, I do not treat the albumin number. Severe hypoalbuminemia with third spacing, by itself, is not an indication for IV albumin. The consistent signal from the literature is that albumin should not be used simply to raise serum levels or to “pull fluid back in” as an adjunct to diuretics....
Do you recommend maintaining the same monitoring interval of PFTs every 3–6 months with HRCT as indicated for patients with anti-MDA5 dermatomyositis, or do you recommend closer surveillance in this group?
Closer surveillance may be needed at diagnosis of ILD in anti-MDA5 DM at every 3 months for 1st year. But typically, in my experience, patients' symptoms progress faster than every 3 months, so rapidly progressive ILD is diagnosed clinically.