Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What are your go-to options for managing ICU delirium in patients with contraindications to antipsychotics?
Evidence for Ramelteon (Yu et al., PMID 36726202)Delirium with behavioral disturbances Depakote Clonidine Propranolol, especially with TBI Non pharmacological Make sure they're closer to the nursing station. Constant re-orientation. Shades open during the day and close at night. Bring anything they ...
Do you use an antibiotic with antitoxin activity for the entire duration of therapy for patients with necrotizing MSSA or MRSA pneumonia or just until definitive clinical improvement?
I misread the question. I assumed a necrotizing S. aureus infection meant a necrotizing skin and soft-tissue infection. I’m not sure how “necrotizing pneumonia” is being defined here. Regarding MRSA pneumonia with toxin-mediated tissue injury, there are data suggesting that linezolid may yield bette...
Would you continue or stop anticoagulation for a DVT/PE in a patient with active cancer who has completed 6 months of therapy?
This is an important question that we didn’t really have a clear answer for… until this year when an NEJM RCT was published! Mahé et al., PMID 40162636 In this RCT, patients with cancer-associated VTE who completed 6 months of full-dose apixaban were randomized to half-dose apixaban vs. full-dos...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
We only use acid-suppressive medications for GI prophylaxis in patients treated with corticosteroids when they have additional risk factors for upper GI bleeding. Risk factors include concomitant NSAID or antiplatelet therapy, history of GI bleeding or peptic ulcer, age over 60 years, prednisone dos...
Do you continue calcium channel blocker monotherapy in a patient with idiopathic PAH who had an acute vasoreactive response at diagnosis and achieved WHO functional class I or II at 12 months, or would you still add disease modifying therapy with sotatercept?
This is a data-free zone. However, given that many patients who are calcium channel blocker responsive often normalize or near-normalize their hemodynamics, there often is no need to add additional therapies. Most PH clinicians would increase the calcium channel dose prior to switching or adding cla...
How do you approach treatment in a patient with +anti-CCP antibodies, negative RF and no current evidence of active inflammatory arthritis, but progression of NSIP?
In these cases, observing a positive CCP suggests some form of an immunologic or autoimmune driven porcess responsible for the NSIP. The result may justify the use of immunosuppressive therapies, including corticosteroids and other drugs, to treat the lung disease. Anecdotally, the CCP positivity co...
How do you plan to integrate nerandomilast into the treatment algorithm for patients with ILD?
That’s a great question and one we’re all still actively defining in real time as this new agent enters practice.First, I always start with the basics—diagnosis and disease behavior. Before starting any antifibrotic, I make sure the ILD diagnosis is solid through multidisciplinary review and that th...
Do you continue voriconazole beyond the minimum recommended duration in a patient with invasive pulmonary aspergillosis who is clinically improved but has persistent radiographic abnormalities on CT?
The "recommended" duration is based on expert opinion, rather than trials. The immune status of the patient counts. When I was taught how to treat invasive aspergillosis at the National Cancer Institute (this was before voriconazole was available), the recommendation was to continue treatment until ...
Do you use isavuconazole for treatment of moderate to severe histoplasmosis in patients with co-morbidities, acute or chronic renal failure, or other features that increase the risk of side effects of itraconazole or amphotericin?
No. I would not routinely use isavuconazole as initial therapy for moderate to severe histoplasmosis. For severe disease, liposomal amphotericin B remains the recommended first-line induction treatment, followed by step-down oral therapy, traditionally itraconazole. In patients with renal dysfunctio...
What are your vaccine recommendations while patients are on biologics?
Live vaccines are best completed at least a month before initiation of biologics when these are appropriate (e.g., MMR, chickenpox, yellow fever). The data on non-live vaccines is limited. I personally think that some degree of protection is better than none. I will not interrupt biological therapy ...