Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How are you navigating approval of CPAP for patients with a high suspicion for OSA on chronic oxygen who are unable to complete an in-lab PSG?
This is a challenging situation for both patient and healthcare provider. The physician is to be applauded for making efforts to get this patient appropriate care despite the very difficult situation to navigate. Of course, the best outcome will occur if we can find a way to get this patient in for ...
Is a larger bore percutaneous chest tube sufficient to adequately drain a hemothorax, or is a surgical chest tube required?
A pigtail is frequently sufficient for hemothorax. There are studies suggesting there was no obvious advantage of larger chest tubes over smaller size chest tubes in hemothorax. There are also studies to support the use of tPA in hemothorax to facilitate the drainage.
Do you routinely use hypertonic saline for pulmonary toileting in patients with non-CF bronchiectasis?
We routinely use hypertonic saline (3% or 7%) inhaled twice daily with oscillatory PEP therapy in non-CF bronchiectasis. The Aerobika device is helpful as the saline can be directly administered through the device with an Aeroeclipse nebulizer, which many patients find more beneficial. I have found ...
Do you perform spontaneous breathing trials on higher levels of PEEP with extubation to positive pressure ventilation in patients intubated for obesity hypoventilation syndrome?
Yes. But like anything patient selection is key and the rationale for the use of higher levels of PEEP (e.g. improve oxygenation vs prevention of atelectasis for simplicity sake) factors into the decision (as do co-morbidities -heart failure, pulm HTN, etc). The literature nor weaning guideline do ...
Do you assess telomere length in all patients with IPF prior to lung transplant?
I do not check telomere length before lung transplants. I also do not check telomere length while evaluating causes of diffuse parenchymal lung disease. I do look for clinical evidence of short telomeres when evaluating patients for lung transplants with fibrotic lung disease or evaluating diffuse l...
If a PET/CT scan is positive for mediastinal lymph node involvement, is a mediastinoscopy or EBUS still required for NSCLC staging?
The gold standard for mediastinal staging is still mediastinoscopy. You can have 15 to 20 percent false positive PET findings in mediastinum and for these patients surgery should not be excluded based on PET findings alone.
Do you recommend the use of indwelling pleural catheters in the management of patients with hepatic hydrothorax requiring frequent drainage?
The use of an indwelling pleural catheter (IPC) in hepatic hydrothorax (HH) is a nuanced question. One must weigh the benefit of frequent drainage versus the morbidity associated with the catheter as well as the clinical context of the patient.There are somewhat limited data regarding the use of IPC...
For patients with suspected complement-mediated TMA, are there specific clinical or laboratory parameters that can help guide the decision for starting empirical treatment (e.g., eculizumab) while awaiting the results of complement testing?
I just want to point out that hemolytic microangiopathy (as seen on the peripheral smear by our Hematology colleague) is paramountly important in determining the presence of TMA. Laboratory parameters may be misleading. I have seen even ADAMT13 levels very low in sepsis and DIC process. Therefore lo...
What criteria do you use on echocardiogram and PFT to determine who needs further evaluation for CTD-associated pulmonary hypertension?
PFTs are often obtained in patients with systemic sclerosis to evaluate for interstitial lung disease. Low DLCO on PFTs can signify an increased probability of PH, but it is by no means specific. Echocardiograms are readily available, offer additional information about possible causes of PH (e.g. LV...
Are there certain subsets of ANCA vasculitis patients for whom you would consider life long maintenance therapy?
Overall the field is moving towards longer, and sometimes indefinite maintenance therapy. This is because multiple studies have demonstrated that relapse risk increases when maintenance therapy is stopped. I consider indefinite maintenance therapy for the following patients: 1. Frequent relapsers - ...