Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you routinely use sweat tests if you are going to titrate a CF patient onto a lower dose of ETI for any reason (allergy, mental health, etc) to assess the severity of their response to the lower dose?
No, we don't use it routinely. Sweat test can be a good biomarker of response and has been used in research. I do not believe adjusted dose has been looked upon for any response in clinical practice.
What is your approach to the management of a patient with PAH who is resistant to contraception and planning a pregnancy?
PAH in pregnancy is associated with high maternal mortality despite the advanced therapies we now have available. Therefore, my first step is counseling the patient so she is aware of all the potential risks associated with a pregnancy. If she is already pregnant, I then discuss the option of termin...
What is your approach to steroid sparing therapy in patients with suspected CTD-ILD?
It depends on numerous factors: What's the underlying CTD? Has the patient been trialed on immunomodulatory agents before? What's the risk of therapy in this patient? And many others. It's a big topic. To delve into some of the above by bullet point: Most guidance for immune suppression is driven by...
What is your preferred management for diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH)?
The management of patients with DIPNECH is predominantly symptomatic but DIPNECH is a chronic disease, often with significant respiratory symptoms such as dyspnea and cough but the severity of the symptoms varies over time.I recommend involving pulmonary medicine early on as the management can resem...
How would you manage immune check point inhibitor induced capillary leak syndrome refractory to IVIG monotherapy?
There is no great evidence and only case reports. Diuretics and supportive management. Stopping the ICIs is likely essential at this point because we do not know how to safely rechallenge yet. There is a discussion of possible using anti IL-6 therapy for capillary leak if IVIG and corticosteroids do...
Does your approach to the management of a patient with an acute exacerbation of CPFE where the ILD is attributed to IPF differ from the management of a patient with an exacerbation of IPF alone?
In general, once an extensive workup to exonerate alternative causes of ILD in patients with presumed CPFE has been performed, I tend to treat the interstitial component of these two entities similarly, whether in the chronic phase or during an acute exacerbation. Smoking is a well-known risk facto...
What is your threshold to start triple therapy in mild to moderate asthma/COPD overlap with minimal functional limitation?
The question is vague as it does not define functional limitations. If the patient has frequent exacerbations (not defined by the question), Triple therapy would be recommended. If she just has minimal SOB for instance an exercise induced type picture SABA/LAMA prn with LABA ICS (w/o LAMA) would be ...
Do you continue CFTR modulator therapy in patients with extra-pulmonary manifestations of CF after lung transplant?
Yes, we do continue CFTR modulators in post-transplant patients for benefits to other organs like sinuses, GI tract, pancreas and perhaps liver. We have to modify and adjust for transplant medication for dosing and interactions. Unfortunately, there is not a large evidence base supporting this pract...
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...