Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your approach to counseling a patient with exertional hypoxia, but normal resting oxygen saturation, who is hesitant to use supplemental oxygen therapy?
Many of these patients are not only hesitant but actually reluctant. Considering that the hard evidence to support this application is weak at best, as long as the desaturation is transient, not associated with much in the way of symptoms, and bounces back fairly quickly when the exertion ceases, I ...
What is your approach to the monitoring and management of a never-smoker with respiratory symptoms and a nonspecific ventilatory pattern on pulmonary function testing?
In the RETHINC trial, inhaled dual bronchodilator therapy did not decrease respiratory symptoms in symptomatic tobacco-exposed people. We still do not know how best to address symptomatic people with PRISm or those with or without a smoking history and respiratory symptoms without obstruction on spi...
How do you manage a stenotic airway following SBRT or hypofractionated radiation to a central lung tumor?
I haven't read much about this in the literature and my quick search doesn't reveal much about it either. So, I'll give you my clinical wisdom on it and you can take it with a bunch of grains of salt. The issues that I've faced with a stenotic airway have been in the context of shortness of breath a...
How do you approach a thoracic lymph node that is highly suspicious on CT and PET but negative on EBUS in patients with NSCLC?
Our institution is very privileged in having a very large, highly expert team of interventional pulmonologists. In the cases where we are conflicted over how to interpret imaging of concerning lymph nodes, and where we have had the chance for a deep dive at tumor board and accompanying expert radiol...
Do you adjust immunosuppression in lung transplant recipients diagnosed with COVID-19?
Adjustment of immunosuppression in the setting of infection is center dependent after transplant. At our center, we typically only adjust if needed, other centers will empirically stop Mycophenolate. We typically monitor the white blood count and Prograf levels daily. If the patient we adjust the Pr...
Is there a role for immunosuppression in addition to standard PAH therapy in the management of pulmonary hypertension associated with primary Sjogrens syndrome?
In short: maybe. Pulmonary hypertension is quite uncommon in Sjogren’s. When I find it, I look for other causes of pulmonary hypertension, especially ILD, and for systemic sclerosis. I also consider other potential indications for immunosuppressive therapy such as inflammatory joint pain. There is, ...
What criteria do you use to consider pleurodesis vs indwelling tunneled catheters in patients with malignant pleural effusion?
There are typically three approaches that are used for the management of recurrent malignant pleural effusions. The first approach is to perform repeated thoracentesis. This may be acceptable if there is a significant duration of time between recurrent symptomatic pleural effusions. The other two ap...
How do you counsel patients regarding prognosis following a diagnosis of IPF?
Are you using NAC in lieu of hypertonic saline amidst the current shortage of hypertonic saline in patients with either CF or non-CF bronchiectasis?
The Mogayzel and colleagues guidelines for maintenance of lung health do not recommend for or against NAC in the treatment of CF Lung disease. In contrast, they do recommend the chronic use of HTS. Mogayzel Jr et al., PMID 23540878In CF and Non-CF bronchiectasis, my first choice is inhaled hypertoni...
Would you consider the use of dual antifibrotic therapy (nintedanib and pirfenidone together) for progressive fibrosing ILD?
Pirfenidone and Nintedanib have different antifibrotic mechanisms of action, and emerging data suggests that these complex molecules may possess previously unknown pleiotropic properties. It is unclear whether a synergistic effect might be realized from combination therapy with these agents, and ind...