Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you manage recurrent inflammatory pleural effusions in lupus pleuritis?
I'll stick to the immunomodulatory treatments and not discuss thoracentesis and pleurodesis for large and recurrent effusions. (These are rarely needed anyway, and I'd get the help of a pulmonologist). There really are no large study, or evidence-based proven therapies for pleural effusions and pleu...
What patient characteristics would lead you to opt for triple therapy versus double therapy in newly diagnosed PAH?
When treating patients with PAH it is essential to assess their mortality risk. Risk assessment is done using 2 tools that include the a) European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines (Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hyp...
What workup do you do for patients who have PL-7 elevation when screening for myopathy?
In the literature, the PL-7 antibody has been associated with the antisynthetase syndrome and aside from myositis, interstitial lung disease (ILD). Patients with PL-7 autoantibodies are at high risk of ILD. Referral to pulmonary should be considered. One would also consider assessing pulmonary funct...
In a patient with history of pneumonectomy would you consider SBRT for treatment of a new tumor in the remaining lung?
I've been pulled into this a few times and it is tricky. I think I've posted a few of my misadventures about this before (central tumor in a patient with pneumonectomy that died from SOB related to mechanical changes). However, I have done it successfully several other times and so I believe it's do...
Do you consider the use of bevacizumab in patients with HHT who have high output cardiac failure related to liver AVMs who also have cerebral AVMs?
Liver and cerebral AVMs are common manifestations in patients with HHT. Treatment of these manifestations should be considered and managed independently. Guideline recommendations to effectively eliminate the future risk of cerebral hemorrhage in patients with cerebral AVMs is consultation with HHT ...
Do you often see clinical improvement that is significant enough to de-list patients with CF for transplant after the initiation of CFTR modulator therapy?
Yes, this is actually very common and has led to a dramatic decrease in lung transplants and referrals for persons with CF. Here is a paper from France that shows this more systematically Burgel et al., PMID 33600738. There is also a follow-up paper, which I cannot find right now. Denis Hadjiliaids
Do you find that complete interlobar fissures on HRCT correlate well with decreased collateral ventilation on endoscopic balloon occlusion in the evaluation and placement of endobronchial valves for bronchoscopic lung volume reduction?
Incomplete fissures are very common and exhibit a great variation in anatomy. The reported prevalence is 17%–85% for the right major fissure, 19%–74% for the left major fissure, and 20%–90% for the minor fissure.CT scans may overestimate the completeness of the right minor fissure and underestimate ...
Do you favor the use of Fick or thermodiluation to measure cardiac output in patients with interstitial lung disease with suspected pulmonary hypertension?
Unless the patient has a left to right shunt or a metabolic cart is used to calculate direct Fick, thermodilution cardiac output (TDCO) is the preferred method of cardiac output measurement in all patients with pulmonary hypertension. This is supported by current guidelines. It's important to take t...
Do you ever initiate pirfenidone in patients with CTD-ILD?
Short answer: yes. Long answer: yes, but rarely. I don't have any reason to assume it wouldn't be effective in these patients, but the main barrier is insurance since it doesn't have FDA approval for this indication. A few patients I've started pirfenidone on with CTD-ILD are 1) progressing despite...
How frequently do you monitor LFTs and CBC after initiating endothelin receptor antagonists?
Endothelin-1 is a potent vasoconstrictor involved in vascular remodeling. There are three FDA-approved endothelin receptor antagonists (ERA) in the market for the treatment of pulmonary arterial hypertension (PAH), including bosentan, ambrisentan and macitentan. ERAs are used in PAH to improve exerc...