Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Is there a role for antifibrotic therapy in post COVID-19 pulmonary fibrosis?
As you may know from working with these patients in the acute and post-infection (PASC - post-acute sequelae of COVID-19) settings, there is a spectrum of lung injuries that can ensue after infection with SARS-CoV-2. This spectrum is composed of mild GGOs to organizing pneumonia to fibrosis (or, fre...
Do you de-escalate airway clearance therapies in patients with CF who experience an improvement in mucus production and clearance after CFTR modulator therapy is started?
De-escalation of airway clearance therapy, and even mucolytic therapy, is a frequently encountered question since the introduction of highly effective modulator therapy. Since the majority of patients no longer have cough or sputum production, the necessity of such therapy is often questioned and it...
Do you routinely continue airway clearance therapies in the setting of mild to moderate hemoptysis in a patient with CF?
I typically hold it temporarily until hemoptysis resolves or decreases.
Is there a role for the use of inhaled corticosteroids in patients with pulmonary sarcoidosis who have stage II or III disease with abnormal lung function but only mild respiratory symptoms?
There are several older studies that have tried to answer this question.Du Bois et al., PMID 10445610: 44 stage II or III patients randomized to placebo or fluticasone 2mg/day, showed no statistically significant difference in symptom scores, PEFR, or FEV1 over 6 months (although trend towards impro...
How do you treat patients with sarcoid who have persistent symptoms after an initial 6 week course of corticosteroids?
The answer to this question depends on what organ(s) you are treating and how severe the manifestation(s) is/are because you must balance the risk of the treatment itself, and the risk of flare with an aggressive steroid taper. 6 weeks of steroids is not appropriate for cardiac sarcoidosis that over...
Do you consider EBUS TBNA in the diagnostic evaluation of patients with mediastinal lymphadenopathy with concern for lymphoma?
Yes, very commonly. The traditional thought is that histological architecture is needed to diagnose lymphoma. However, with flow-cytometry, we can diagnose all types of NHL. We always try to get a lot of aspirations (more than 7-10 passes) from the lymph nodes or mediastinal masses to prepare a good...
Do you recommend the use of endobronchial valves in the management of patients with spontaneous pneumothorax with persistent air leak?
Patients with primary spontaneous pneumothorax and persistent air leak or recurrent pneumothorax should be considered for surgery (typically VATS) with bleb resection and pleurodesis in order to prevent a recurrence. I believe bronchial valves in this setting have a little role since they are not de...
Do you routinely use donor derived cell free DNA levels to guide surveillance bronchoscopies in lung transplant recipients?
Donor-derived cell-free DNA is becoming more available but is not as helpful as in the other solid organ transplant recipient, so there is no clear consensus at this time to guide surveillance bronchoscopies in lung transplant recipients.
Do you employ the use of extracorporeal photopheresis in the management of patients with progressive BOS following lung transplantation?
Yes, extracorpeal photopheresis (ECP) is employed for BOS in certain situations. There may be insurance barriers (Medicare) that will be prohibitive. Any changes to the immunosuppression strategies should be done in the earlier stages to have beneficial effects. Hence to start ECP in stage 3 BOS if ...
Do you employ the use of external chest compression with sandbags in the management of patients with severe ARDS who are not candidates for proning?
The short answer is while there is a physiologic rationale to support the beneficial effects of supine chest wall compression, the best method and clinical impact of such maneuvers have not been studied. In addition, there may be potential untoward consequences to sustained chest wall compression th...