Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you manage diarrhea in a patient with CTD-ILD on MMF who was recently started on full dose nintedanib?
It is important to keep in mind that immunomodulator therapy is also frequently associated with gi toxicity (MMF, methotrexate, leflunomide, azathioprine, etc.). Given this, it is important to begin one therapy at a time in order to mitigate side effects and do understand which agent is responsible....
Do you continue to prone patients with severe ARDS after initiation of VV-ECMO?
Not routinely - although we have occasionally proned VV ECMO patients at our center. Reasons for not proning include: Cannula dislodgement/displacement risk (although Roca et al, PMID 34461971 reviews the literature on proning with VV ECMO and the risk of major line complications is small). Generall...
What else do you consider in the differential diagnosis for pulmonary-renal syndromes if there is low clinical and serologic evidence of AAV, Goodpasture's or other rheumatologic disease (SLE, RA, APS, Scleroderma)?
Endocarditis can mimic vasculitis and can have pulmonary hemorrhage. You CANNOT miss that one. Sarcoidosis is I suppose a pulmonary renal syndrome. Renal vein thrombosis from MGN with a pulmonary embolus is I suppose a pulmonary-renal syndrome.
Do you routinely perform genetic testing in patients presenting with pulmonary fibrosis who endorse a family history of fibrotic lung disease?
I receive this question frequently when I hear from other clinicians and I think it is a very thought-provoking question. We know that patients with pulmonary fibrosis (PF) commonly have first-degree relatives with interstitial lung disease (ILD). Some studies quote numbers as high as 20% so it is d...
How do you approach treating mild hypercalcemia in patients with sarcoidosis?
This may seem like a straightforward query, but like many issues surrounding sarcoidosis, it is actually deceptively complex. For a more complete discussion, I refer the readers to an excellent review by Lower and Saidenberg-Kermanac’h (2019). In and of itself, asymptomatic “mild” hypercalcemia does...
Do you consider pulmonary hypertension related to sarcoidosis to be an indication to start steroids?
Pulmonary hypertension (PH) associated with sarcoidosis presents a complex clinical challenge. The decision to use corticosteroids in sarcoidosis-associated pulmonary hypertension depends on several factors: Underlying Cause of PH: It's crucial to determine whether the pulmonary hypertension is dir...
Is it safe to combine mycophenolate and adalimumab for management of pulmonary sarcoidosis in a patient that could not tolerate methotrexate?
Combination therapy is often required in patients with sarcoidosis. Combination of adalimumab with other immunosuppressants, such as methotrexate, leflunomide, azathioprine, or mycophenolate, can be used, with close monitoring of labs (CBC, CMP) and for infections.
What is your approach to withdrawal of ventilatory support at the end of life?
This is a great question with a complex answer. Both options are reasonable and in my practice, I gear compassionate extubation practices towards the patient and family wishes. In conjunction with our Palliative Care team, we have an algorithm for providing medications to ensure the patient's will n...
Do you administer prophylactic antibiotics to prevent VAP following intubation in patients with acute brain injury?
I currently do not, though this trial is interesting and the results are compelling. I think the risk of one dose of CTX is low. No clear evidence of resistance. I think moving forward, I would have a low threshold for administering one dose of ceftriaxone following intubation in my TBI patients. Ho...
How would you treat a patient with combined pre- and post-capillary pulmonary hypertension after successfully optimizing post-capillary pressures through a valvular intervention?
No good data here. First, if I'm contemplating treating this group with pulmonary vasodilators at all, I would like to see repeat RHC demonstrating precapillary pulmonary hypertension with a low wedge. Fixing the valvular disease may help with left-sided function, but many of these patients have dev...