Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you routinely use vasopressin in the management of RV failure leading to shock state in the absence of an obvious treatable cause such as infarction or PE?
It seems that there is a vasopressin dose-dependent effect on PA pressures. The doses we usually use for septic shock (0.03 or less) have some degree of pulmonary vasodilation (for example, Tsuneyoshi et al., PMID 11373409). Higher doses may have the opposite effect (Leather et al., PMID 12441768). ...
What is your approach to pulmonary vasodilator therapy in patients with COPD and Severe Group 3 Pulmonary Hypertension?
I'd like to first acknowledge that there are no large randomized controlled trials specifically in patients with severe COPD-PH to guide practice. Before I consider PH-specific treatment, I like to exclude other causes of PH namely CTEPH, LHD, and CTD-PH which would influence treatment options. Seco...
What is your approach to therapy for pulmonary sarcoidosis resistant to methotrexate?
The first question I ask myself in any situation dealing with "refractory" sarcoidosis is "Am I sure active inflammation from sarcoidosis is the cause of their symptoms?". Oftentimes, I will see patients referred for refractory disease who end up having other causes of their symptoms. If I am confid...
Do you consider the duration of lung/lobar atelectasis in your decision making while offering airway stents for malignant central airway obstruction?
Yes, always. We review old imaging to determine when there is a post obstructive pneumonia or collapsed lobe/lung secondary to endobronchial obstruction (extrinsic or intrinsic). The old teaching was that, if a lobe is down for more than two months, it is unlikely to be salvaged, even after the endo...
What is your perspective on the role of respiratory therapists in managing a patient who is dyssynchronous on their current mode of mechanical ventilation?
Yes, it’s in the scope of their practice to adjust vent settings for various reasons. At my practice, I work with them closely so I am aware of the changes being made. And this goes both ways. If I end up making changes, I make it a point to let the RTs know what changes I made.
Do you use prednisone in the management of patients with persistent respiratory symptoms following acute COVID-19 infection?
No, unless I note bronchial hyperresponsiveness on follow-up Pulmonary function tests (PFTs). What I've noted is a significantly high percentage of undiagnosed asthmatics who come into the light because of a more severe clinical course from covid. Use anti-fibrotics occasionally for fibrosis dependi...
Do you offer immunosuppression to patients with CTD-ILD with concomitant well controlled HIV?
With the widespread use of highly active antiretroviral therapy (HAART), we have definitely seen an increase in long-term HIV patients who now live long enough and with enough functional immunity to develop CTD-ILD or autoimmune ILD warranting the use of immunosuppression. However, these patients re...
How do you define severe hypoxic burden on home sleep testing?
There seem to be two questions here. First, can you measure hypoxic burden on a home sleep test? The answer is that technically it can be done without great difficulty. However, as far as I know, there are no home sleep apnea testing devices that offer hypoxic burden as an outcome measure. Thus gett...
Do you consider dual biologic therapy in patients with ABPA that remain steroid dependent despite the use of omalizumab?
The treatment of ABPA can be so challenging, but this is something that I have not seriously considered at this point. Unfortunately, in general, the evidence for biologics in the treatment of ABPA currently is heterogeneous. Furthermore, many studies are descriptive case reports/series or based on ...
How do you approach treatment of septated parapneumonic pleural effusions that do not satisfy traditional criteria for complicated effusion after diagnostic thoracentesis?
Septated effusion is a complicated effusion, whether it is empyema, parapneumonic, or malignant, and usually, they are exudative. By definition, untreated parapneumonic effusion will become empyema. Septations <4-6 week duration are usually fibrinous and can be lysed with tPa/DNase instilled through...