Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you choose between oral and IV cyclophosphamide for the treatment of ANCA-associated vasculitis?
When considering cyclophosphamide for induction in severe AAV, both oral and IV regimens are reasonable routes of administration. In the CYCLOPS trial (DeGroot, Ann Int Med, 2009), oral cyclophosphamide 2mg/kg/d was compared with IV CYC 15mg/kg q 2 weeks for the first three pulses, then every 3 week...
How do you approach patients with ANCA vasculitis who had partial response, but continue to have disease activity on q 6 month maintenance rituximab and remain on steroids?
This question raises some fundamental issues about the management of patients with ANCA-associated vasculitis (as well as other vasculitides or chronic inflammatory disorders), including i) the need to consider the potential contribution of comorbidities to clinical signs or symptoms suggestive of v...
What indicators do you use to identify patients with CTD-ILD who do not have potential to improve from continued immunosuppressive therapy?
This is an interesting question. We need to clarify what this phrase means "who do not have potential to improve". It may be easier to identify patients who may benefit from therapy.ILD physicians work under the motto, 'stability is success'. Thus, improvement may mean 'did not deteriorate'. Minimal...
What are your recommendations regarding methotrexate usage in patients with persistent chest CT changes post COVID pneumonia?
With the raging pandemic and the steady stream of post-COVID inflammatory/fibrotic patients, we are bound to encounter patients with such abnormalities who are on potentially pneumotoxic drugs (or need initiation).With minimal concrete data, any recommendation is purely based on experience.Methotrex...
How would you approach treatment for fulminant RA-associated ILD?
Even though this hypothetical patient has tolerated methotrexate (MTX), I would probably stop it since MTX can directly scar lung parenchyma and continuation of it may confuse the clinical picture. The data for adverse lung toxicity with TNFi drugs is less clear, so I would consider maintaining it. ...
What strategies can be employed to manage interstitial lung disease seen with trastuzumab deruxtecan?
Educating clinic staff and patients/family members is key. Any reports of worsening respiratory symptoms such as worsening cough or SOB should be carefully worked up and managed. Always check for saturation at clinic visits and (actively) look for interstitial findings at every scan (the patient cou...
What are best practices for engaging with multidisciplinary colleagues to ensure patients with earlier stage NSCLC are being appropriately considered for novel adjuvant therapies?
Treatment of early stage or locally advanced stage NSCLC truly requires a cohesive multidisciplinary team and consistent messaging. Many, if not all, of these cases should be discussed prospectively at a multidisciplinary tumor board. It is also important to set expectations with patients up front a...
Would you offer adjuvant chemotherapy, osimertinib, or both to a patient with Stage IB EGFR mutated lung adenocarcinoma found in the lung explant pathology after bilateral lung transplant?
This is such a rare and individualized case that there will likely be no correct answer. My understanding of the facts is that stage IB lung adenocarcinoma was found on the removed explanted lung after a lung transplant. The question posed is what is the role of adjuvant systemic therapy? Ignoring t...
Would you advise a patient with quiescent vasculitis who flared with the first Covid mRNA vaccine to obtain an additional dose?
There is still much we don't know about mRNA vaccines, including the true risk of vasculitis relapse and the risk of relapses occurring with vaccine re-challenge. Relapses of vasculitis after COVID vaccination have only been reported in case report form to date. Therefore it's not possible to tell w...
What is your approach to treatment for a patient with progressive ILD (UIP pattern) with high titer RF but no articular symptoms?
Hello and thank you for this question. It is very important. But I need more facts to safely answer this question. My very first thought is that assessment (i.e., a thorough history and physical exam) is highly operator-dependent. In most cases, the historical and exam findings of systemic autoimmun...