Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Would you give checkpoint inhibitor therapy to a cancer patient with known dermatomyositis given the association of checkpoint inhibitor associated myocarditis, myasthenia gravis, and myositis?
I think the dermatomyositis could be more paraneoplastic that would actually benefit from controlling the cancer with ICI. I would give the treatment but I would carefully follow-up the patient for any irAEs. I will also document the rheumatological assessment, CPK, and myositis panel before startin...
What are your preferred ventilatory settings/mode(s) for patients with acute hypoxic respiratory failure presenting with severe biventricular dysfunction in cardiogenic shock?
This is a great question - and, unfortunately, one that doesn't have a robust evidence base upon which to formulate a particularly informed response (at least nothing that has looked a hard outcomes like mortality or duration of mechanical ventilation). I go back, however, to the basics and a mantra...
Which hemodynamic parameters can be used to titrate positive pressure ventilation in preload dependent settings such as RV failure, cardiac tamponade, HOCM or hemodynamically significant PE?
As this question alludes, the application of positive pressure ventilation influences cardiac hemodynamics. Key principles of these cardiopulmonary interactions are outlined nicely by Alviar and colleagues (1) in a well-done review. In contemplating this question, it is important to consider the sep...
How do you approach performing EBUS TBNA in patients with latex allergy?
Nothing else besides not placing balloon, wearing non-latex gloves and ensuring that all staff is aware about latex allergy.
How do you choose between azithromycin and roflumilast in the management of a patient with severe COPD who remains symptomatic with frequent exacerbations despite maximal dose LABA/LAMA/ICS with demonstrated compliance and proper inhaler technique?
Zithromax 250 mg on Monday, Wednesday, and Friday. I would consider roflumilast only in patients who are phenotypically and physiologically chronic bronchitis patients.
Do you routinely start full dose anticoagulation in new onset atrial fibrillation in the ICU?
Yes. (Based on CHADS2 + Absence of absolute contraindications, i.e., active uncontrolled bleeding or coagulopathy.)
What is your threshold to start stress dose steroids in the management of patients with septic shock?
Absent long-term use at baseline, I do not routinely start stress dose steroids for patients with septic shock. I reserve steroids for patients with a persistent vasopressor requirement despite adequate volume resuscitation and treatment of the underlying source of infection.
What are your top takeaways from CHEST 2022?
Presentations: Pulmonary literature update Asthma and OSA Inhaled antibiotics in non-CF bronchiectasis Use of LAMA in Asthma Key takeaways: Inhaled steroids predispose people to NTM Inhaled steroids can worsen OSA Inhaled antibiotics can be used for VAP Inhaled aztreonam is not recommended for ...
Is there a role of everolimus or capecitabine and temozolomide in diffuse idiopathic pulmonary neuroendocrine cell hyperplasia in patients already on octreotide?
The key question is why there is a reason to change the treatment... Is it for worsening symptoms or progressive disease with overt lung NET development or progression of known lung NET?In a retrospective study of 55 patients with DIPNECH, only 18% had a progression to a lung NET (typical carcinoid)...
Is there any PFT criteria that you use in guiding decision making to offer transbronchial lung cryobiopsy to patients with interstitial lung disease?
We really don't have any specific PFT criteria to identify the need for cryobiopsy, but apply the same guidelines to determine the need for open lung biopsy in the decision-making process. Even with the risk of bleeding, cryobiopsy is safe. Unless someone is at high risk for ventilator dependence, o...