Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you routinely continue using TPA/Dornase for treatment of empyema, if there is accumulation of new sero-sanguinous output from the chest tube after the initial treatment?
In my practice, if there is an accumulation of serosanguinous output after initial treatment, further treatment with tPa/ dornase depends on several factors. Hct of drainage - if > 50%, will not give further dose. If a patient is coagulopathic or receiving anticoagulation for a medical condition af...
What is your approach to initial work up for a young patient with bronchiectasis?
I assume we are talking about patients in their 20s, 30s-50s who have had a HRCT with radiological bronchiectasis. It will be good to know if they have had clinical implications and symptoms of cough, infections, and mucus production. It will be good to know about multiorgan involvement like sinuses...
What is your preferred strategy for controlling bleeding after transbronchial or endobronchial biopsies?
I use all Cold Saline, Wedging and EPI. If severe bleeding side down, therapeutic bronchoscope with suctioning blood till bleeding stops. Also to assess bleeding risk prior (low PLT, hx of ASA anticoagulation use) to bronchoscopy and during bronch watching oozing and stopping further biopsy can be v...
What is your approach to management of elderly patients with cardiopulmonary comorbidities and severe pulmonary hypertension?
I generally follow the current ERS/ESC guidelines with regard to the treatment of patients with WHO group 1 PAH. I often will often start with a low dose of PDE5i and see them back within 4 weeks prior to increasing the dose. Similarly, I will see back within 4 weeks of adding an ERA to look for sid...
What is your approach to using nintedanib in patients on baseline immunosuppression?
Typically I start antifibrotic therapy in a few situations: The most common reason is ILD progression despite adequate immune suppression, defined as no extra-pulmonary disease activity (usually joint disease, but can tailor according to the patient's disease/situation, such as by presence of rash, ...
Do you start steroid therapy in a patient with pure ARDS without septic shock, or would you only consider steroids only in those with severe community acquired pneumonia?
I do not routinely start corticosteroids for pure ARDS, septic shock, or severe community-acquired pneumonia. In my mind, the DEXA-ARDS study was underpowered to answer the question. The recently published ESCAPE and CAPE-COD trials yielded conflicting results in CAP. In my mind, before adopting cor...
What is your approach to the use of acetazolamide in patients with OSA?
I do not believe, at this time, there is very good evidence suggesting that acetazolamide should be used as primary therapy for OSA. There is a company, Desitin, that is trying to advance a different carbonic anhydrase inhibitor, sulthiame, to treat OSA, but it has not been approved to date. That be...
Do you transfuse platelets prior to central line placement in patients with platelet counts less than 50,000?
It depends. Bedside assessment is more reliable than objective data when it comes to platelets COUNT and platelet FUNCTION. We don't use a threshold number for triggering a platelet transfusion, rather base it on overall picture and bedside coagulopathy risk assessment.
Would you place an IVC filter in a patient with an acute intermediate risk PE and a proximal DVT who is on anticoagulation?
No. The only role for IVC filter use is in patients who can not tolerate anticoagulation (Marron et al., PMID 32795479).
Do you recommend transfer to an institution with a PE response team for a patient with an intermediate risk PE?
This is an interesting and difficult question. It depends on the case of a high intermediate-risk submassive PE that we have. Whenever there is a debate on the approach, a relative contraindication for certain forms of anticoagulation, different approaches on a catheter-directed intervention, or a ...