Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is the current recommendation for air travel after a primary spontaneous pneumothorax?
General guidelines including the British Thoracic Society recommend delaying air travel for at least 2 weeks following the radiographic resolution of a pneumothorax. However, recent studies have challenged this conservative approach. A study by Majercik et al., PMID 25494425 demonstrated that patien...
Is there any role for palliative radiation in patients who are intubated due to malignant airway obstruction?
The literature is limited, but this small series showed about 1/4 of patients can have reversal of intubation.If the patient/family is interested in attempting, it occasionally works, but my own experience is less successful than 1/4. It is unlikely to worsen the situation, so after explaining that ...
How do you counsel and manage patients who meet criteria for sleep apnea based on 3% but not 4% desaturation?
It depends on the patient's symptoms. If they have symptoms attributable to sleep apnea then I tell them they have sleep apnea. If they don't have symptoms then I don't diagnose them with sleep apnea. If the patient has an insurance plan that only accepts 4% desaturations and yet they clearly have s...
For how long do you recommend treatment for latent tuberculosis prior to initiation of anti-TNF therapy?
Some recommendations call for completing a course of treatment for latent TB prior to starting a biologic but I find most patients and referring specialists are intolerant of that strategy. This reference: Yeo et al., European Respiratory Journal 2014 is a good example of data supporting a shorter w...
Do you use FVIII levels to differentiate between DIC and coagulopathy of liver disease?
DIC is a clinical diagnosis that is difficult to establish in the absence of bleeding or thrombosis, particularly in patients with liver disease. I do think that following DIC laboratory markers (FDP, fibrinogen, D-dimer) serially may be helpful as you would not expect them to acutely drop simply be...
Do you consider immunosuppressive agents in progressive interstitial pneumonias or pneumonitis without a clear driving etiology?
Although it's often helpful to have a clear diagnosis of an underlying connective tissue disease (CTD) or positive autoantibodies to guide therapy (or perhaps feel better about prescribing it), we more often find ourselves dealing with ambiguous cases. When pathology is available to suggest an infla...
What protective post-op measures do you recommend for a patient with scleroderma and a history of ILD, PH, Raynaud’s and digital ischemia undergoing cardiothoracic surgery?
Appropriate post-operative care in patients with scleroderma is very important. In the context of the cardiopulmonary disease, volume management is very important with close monitoring in I/O's to optimize fluid status. In a patient with a history of digital ischemia, it is important to keep the pat...
Would you stop azathioprine in a patient with ANCA vasculitis who has been in long term remission on azathioprine, but has a new diagnosis of lung cancer requiring initiation of immunotherapy?
Data about the effect of immunosuppression on the efficacy of immune checkpoint inhibitors suggests that there is a negative of effect of being on immunosuppression at the time of ICI initiation on tumor response. So if the patient really has been clinically stable for a long time there are a few op...
Is there a role for nocturnal supplemental oxygen as opposed to no therapy in patients with OSA who are unable to tolerate PAP therapy?
I do not use supplemental oxygen as a sole therapy for sleep-disordered breathing (SDB). Treatment with Positive Airway Pressure (PAP) is the initial treatment of choice for SDB. There is no indication to use supplemental oxygen for patients who do not accept or tolerate PAP therapy. Instead, oxygen...
How do you approach determining appropriateness for extubation in a patient with acute respiratory failure in the setting of known chronic neuromuscular disease?
This can be a very challenging situation in the ICU. I first discuss the options with the patient (if possible) and caregivers before considering extubation. I consider baseline/pre-illness data if available such as prior FVC or NIF/MIP, need for NIV, etc. Also, it is important to consider why they ...