Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What strategies do you employ to prevent post-intubation hypotension in a profoundly hypoxic patient given a paralytic for intubation?
There are a few strategies I use. I choose an induction agent such as Etomidate or a ketamine which has minimal hemodynamic effects. If BP is soft to start with, I use IV fluid small bolus, use a vasopressor such as phenylephrine push if needed before sedation.
What is your approach to the evaluation and management of a suspected intrapulmonary hematoma?
I usually observe and they do tend to resolve over time.
Would you consider deferring chest tube placement in a clinically stable patient with a small empyema without signs of systemic infection?
Firstly, diagnosing empyema means the fluid has already been diagnostically tested by thoracentesis. If all the fluid was removed on the diagnostic tap, I would continue and complete the course of antibiotics with close follow-up. The duration of Antibiotics ranges from 4-6 weeks. If a significant a...
What agents do you utilize for mucociliary clearance during the index hospitalization of patients post lung transplant?
Early post-operatively bronchoscopy is the mainstay for the removal of secretions which may be quite thick and obstructive related to the sloughing of pseudomembranes (ischemic epithelium). We will transition from bronchoscopy to hypertonic saline (3% or 5%) nebulized BID with bronchodilators prior ...
Have you seen rheumatoid nodules or RA-ILD in patients with seronegative RA?
By definition, rheumatoid nodules are considered to be a highly specific manifestation of RA. Regarding the first part of the question, one should never see true rheumatoid nodules in someone who does not have seronegative RA. Though there are sporadic case reports of finding these nodules in people...
How do you clinically distinguish between group I and group III PH in patients with CTD-ILD?
The distinction between pulmonary hypertension (PH) of the group 1 (pulmonary arterial hypertension (PAH)) and group 3 (pulmonary hypertension (PH) due to lung disease and/or hypoxia) is essential since the management is different. In group 1 PH we stratify the risk and treat with a variety of PAH-s...
Do you give additional pneumococcal vaccines after a dose of PCV20 in patients with asplenia?
Assuming the patient otherwise does not have immunocompromising conditions other than asplenia, following age-appropriate vaccine schedules is appropriate. A dose of PCV20 appears to provide adequate protection. However, ongoing surveillance studies will be important to answer this question, and vac...
What is your approach to a patient who has a cardiac PET scan suggestive of sarcoid but no other supporting evidence of a diagnosis of sarcoid?
The diagnosis of cardiac sarcoidosis (CS) can be challenging, as non-necrotizing granulomatous inflammation is frequently patchy, and as a result, may not be present on endomyocardial biopsy even in the setting of active cardiac disease. Many institutions, including ours, attempt to avoid endomyocar...
When is it considered inappropriate to omit pathological mediastinal lymph node staging for non-small cell lung cancer?
This is a very good question often debated by thoracic radiation oncologists with their thoracic surgery colleagues and can get complicated. The best way to look at it, in my opinion, is to understand the sensitivity and specificity of FDG PET/CT to detect true mediastinal nodal disease. For example...
Is there still a role for direct laryngoscopy in the intubation of patients in the ICU?
I believe you have to be proficient in many techniques in case you need alternatives when performing a procedure. This applies to DL. Video intubation has facilitated intubation greatly but the technique is different and if it fails the default is DL.