Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you give intrapleural lytics for complicated effusion/empyema in patients on systemic anticoagulation?
Like some people's relationship status, it's complicated. Since 2011, when the MIST II trial (1) was published by Rahman and colleagues, intrapleural tissue plasminogen activator (tpa) and DNase have been given intrapleurally to facilitate source control for pleural infection by breaking up loculati...
What is your approach to the work up and management of interstitial lung abnormalities?
ILA are incidental radiological findings (non-dependent abnormalities affecting more than 5% of any lung zone) in asymptomatic patients. We first evaluate these patients for any potential causes of ILA (i.e. connective tissue diseases, aspiration, drug-related pulmonary toxicity, etc). If an underly...
What steroid regimen do you employ prior to extubating a patient who does not have a suitable cuff leak?
Before deciding on steroids, there are many factors to be considered. Patient height and weight, ET tube size and medical history. For example, a person who is 5’ 0” with a size 8 ETT intubated for 2 days might not have a leak but be perfectly safe to extubate without steroids. Alternatively, someon...
What is your approach to volume resuscitation in patients with obvious septic shock but also with a component of suspected cardiogenic shock?
I think it comes down to clinical decision-making at bedside with the help of a combination of modalities. POCUS to evaluate the IVC size and collapsibility is one option we commonly use and is quick and easy to obtain. Additionally, in situations of unclear shock state, our practice is to float a P...
What steroid regimen do you employ in the treatment of patients with post COVID-19 pulmonary fibrosis?
I don't use steroids for post-COVID fibrosis. Not only have I not seen steroid-responsiveness in this setting from an anecdotal standpoint, but previous data on steroids in non-COVID pulmonary fibrosis seems clear about the potential harms (e.g., PANTHER trial). If there is a large proportion of gro...
What patient related factors and hemodynamic parameters would lead you to avoid transbronchial biopsies in patients with pulmonary hypertension?
I try to avoid if INR is > 1.7 or platelet count is less than 30,000 in patients who have Grp I PAH.
Do you perform a clamp trial before removing a chest tube for pneumothorax?
Yes, almost always but depending on the indication for chest tube placement commonly encountered as below. A) If the chest tube is placed for pneumothorax, clamping a chest tube before removal is essentially simulating the same scenario when the chest tube is out. It is much better to clamp than to ...
Are there known biomarkers predictive of IRAEs?
While there are no FDA-approved biomarkers predictive of iAEs, there is a growing body of preclinic and retrospective research trying to address this important question. Eosinophilia may be a potentially useful biomarker and this is supported by several retrospective studies 1,2. It is intriguing th...
Would you give checkpoint inhibitor therapy to a cancer patient with known dermatomyositis given the association of checkpoint inhibitor associated myocarditis, myasthenia gravis, and myositis?
I think the dermatomyositis could be more paraneoplastic that would actually benefit from controlling the cancer with ICI. I would give the treatment but I would carefully follow-up the patient for any irAEs. I will also document the rheumatological assessment, CPK, and myositis panel before startin...
What are your preferred ventilatory settings/mode(s) for patients with acute hypoxic respiratory failure presenting with severe biventricular dysfunction in cardiogenic shock?
This is a great question - and, unfortunately, one that doesn't have a robust evidence base upon which to formulate a particularly informed response (at least nothing that has looked a hard outcomes like mortality or duration of mechanical ventilation). I go back, however, to the basics and a mantra...