Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
In patients with severe asthma who are candidates for biologics, do you put them on an ICS/LABA/LAMA rather than high dose ICS/LABA?
I have done both. Once I need to go to high-dose ICS/LABA or ICS/LABA/LAMA, I start looking at options for biologics. I work exclusively with children, so it depends on the age of the child and what is approved for their age. It is easier to add a LAMA under age than a biologic.
Is it acceptable to list a patient for lung transplantation who has a BMI between 30 and 35 kg/m² and is otherwise a highly suitable candidate, without first requiring weight loss to bring their BMI below 30?
Complicated decisions regarding candidacy for lung transplantation cannot, and should not, be made solely on the basis of a single numerical value. Patients with elevated BMI have been successfully transplanted, and the relationship between BMI and transplant outcomes is best described as a U-shaped...
In elderly patients with advanced melanoma and idiopathic pulmonary fibrosis receiving active antifibrotic therapy, would neoadjuvant or adjuvant immune checkpoint inhibition be preferred?
Given this scenario, it is most important to have a goal-of-care discussion. That would help sort out the optimal treatment for such patients. Always treat to relieve pain as needed.
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
What is your approach to managing high-volume, thick tracheal secretions in a patient with a tracheostomy when there is no clear evidence of pulmonary infection?
Managing airway secretions in patients with chronic tracheostomies can be very challenging, and secretion volume varies considerably in some patients from day to day or even hour to hour, often inexplicably. The tube itself is an irritant, as is frequent suctioning, so virtually every patient with a...
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 ...
How has the FLUID trial, which showed no significant difference in death or readmission rates between Lactated Ringer’s solution and normal saline, influenced your approach to IV fluid management?
The choice between normal saline and Lactated Ringer's should be individualized. Normal saline is preferred in patients with hyponatremia or metabolic alkalosis. Lactated Ringer's is preferred in patients with hyperchloremic acidosis, and it should be avoided in patients with hyponatremia since its ...
How would you manage an intermediate-risk segmental PE that is transiently provoked after a knee surgery?
Segmental suggests small PE and prob intermediate-low risk. But still look at vitals, RV/LV ratio, and clot burden. Again, clot sounds small (no lobar, main PA or saddle, but look for contrast-reflux into IVC/liver. Try to look at RV FUNCTION by echo if possible, and echo also allows ruling out a cl...
Do you seek pathologic confirmation before proceeding with empiric immunosuppressive therapy in symptomatic patients with radiographic NSIP?
In general, getting lung biopsies is needed in a minority of people who have clear evidence of NSIP on HRCT. If there is any evidence to suggest a concomitant ARD, a biopsy will not typically be needed. In our combined ILD-Rheumatology clinic, we see these patients all the time and I can think of on...
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...