Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Would you stop Dupixent in an asthma patient who has good asthma control and notes improvement in loss of smell, but shows notable eosinophil elevation after 4-5 doses of the medication?
Transient eosinophilia has been reported in patients treated with Dupixent, likely related to downregulation of eotaxin and adhesion molecules resulting in impaired eosinophil migration into the tissues (Castro et al., PMID 29782217, Olaguibel et al., PMID 35522053). This phenomenon is typically see...
How would you approach early stage NSCLC in a patient who is not an ideal surgical candidate and has pulmonary AVMs?
The standard volumes and flows of PFTs do not assess regional differences in what is perfused and ventilated. V/Q scans do, but their most common use for pulmonary embolism is their most common role. This serves to identify gas exchange near the primary as well as where the AVM’s reside. Target the ...
Do you recommend doxycycline over azithromycin as first-line treatment for outpatient community-acquired pneumonia in otherwise healthy adults, given rising macrolide resistance rates?
Yes - our county antibiogram shows >50% resistance of Streptococcus pneumoniae to azithromycin, and thus if there is a true concern for bacterial infection, I recommend doxycycline.
For hospitalized patients with confirmed viral respiratory infections who clinically improve but remain PCR-positive, how long do you maintain isolation precautions?
This is a great question and one that routinely comes up for patients, their families, and staff. Precautions should be continued until symptoms improve and for a minimum of 14 days after the onset of signs and symptoms. This is especially important for patients who can spread virus to individuals t...
Have you used Karius to work up fevers in the hospital when the source remains unknown?
This is a tricky question because Karius is an expensive test, which many experts believe should not be used for its negative predictive value (and I have anecdotally seen negative results where infection was still present, and infections/organisms detected of very unclear significance). I like to u...
Do you recommend treating Candida albicans on urine culture from an indwelling catheter in a patient with septic shock?
In a patient with septic shock, one is typically obligated to treat all things until further culture data is back, etc. If there are other clear causes of shock, I would not treat the candida (though I would try to change the catheter ASAP). If the patient is extremely ill and no other sources of in...
What are the best techniques to reduce POCUS artifact and increase the diagnostic accuracy of lung ultrasound?
It is important to first clarify that essentially all of lung ultrasound is artifact, and this is a great illustration of how artifact can actually help us to make a diagnosis rather than obscuring it. When we see B-lines, for example, that is an artifact that does not represent a similarly appearin...
Which biologics for asthma have data regarding mucus plugging?
There have been multiple studies on biologics investigating the effects on mucus plugging (as measured by the CT mucus plug score of the number of pulmonary segments with a mucus plug, established by Dunican et al., PMID 29400693). In these studies, high mucus plug scores correlate with T2 high biom...
Do elevated neutrophils in the bronchoalveolar lavage of patients with sarcoidosis have any prognostic value?
Neutrophils in the alveolar space are uncommon in healthy non-smoking individuals, accounting for around 1% of cells in bronchoalveolar lavage (BAL). Macrophages compose 80–90% of the cells policing the alveolar surface, with the remaining cells being lymphocytes, rare eosinophils, and basophils. A ...
How do you manage moderately severe RLS in a patient with advanced CKD (eGFR 15–30) who has developed dopaminergic augmentation on a dopamine agonist, given that standard gabapentinoid replacement agents carry significant accumulation risk at this level of renal impairment?
This is a challenging picture. I suggest slow tapering of the dopamine agonist while proceeding to the next therapy. I propose the following steps. Check ferritin/TSAT → give iron if low, IV iron may be needed. Start low-dose gabapentin or pregabalin (renal dosing). Titrate cautiously. Severe persis...