Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do the results of FIBRONEER-ILD change your approach to antifibrotic treatment in patients with sarcoidosis related PPF?
According to the FIBRONEER-PPF data, no sarcoidosis-specific outcomes have been reported, and one can only infer that the sarcoidosis-related PPF subpopulation has tracked similarly to the other ILD subtypes, which is a big assumption. It is important to remember that in the INBUILD study, which exa...
When would you consider using acetazolamide to augment diuresis in patients with ADHF?
The ADVOR trial suggested that the addition of acetazolamide to a loop diuretic "upfront" in congested patients with heart failure achieves greater decongestion at 72 hours and discharge. While most would not use such a combination in "all" patients, this strategy is optimal in those demonstrating s...
In routine clinical practice, how do you operationally define ‘progression despite therapy’ in PPF to justify escalation to combination treatment?
ILD patients undergo regular monitoring with intervals based on concern for progression. In addition to symptom review, objective testing includes PFTs with spirometry and DLCO, 6-minute walk testing that provides information on distance walked, symptoms experienced, and whether or not the patient d...
How long do you continue rituximab in patients with ANCA associated vasculitis who have achieved remission?
My approach is to use rituximab every 6 months for remission maintenance for at least 2 years. Past that point, a lot depends on the individual patient circumstances. For patients who have already suffered substantial organ damage, for whom another flare could be catastrophic (e.g., a patient with s...
How do you incorporate positive respiratory viral testing and/or low procalcitonin into antibiotic de-escalation when chest imaging still suggests pneumonia in a hospitalized patient?
Pneumonia is not a radiographic diagnosis, and an infiltrate does not tell us the pathogen. Chest radiographic abnormalities overlap substantially between viral and bacterial pneumonia; in the EPIC pediatric cohort, for example, consolidation was present in 74% of typical bacterial infections but al...
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 ...
What is your approach to a patient with undetectable MMR titers checked prior to or during immunosuppression and a history of MMR vaccination in childhood?
MMR titers are good correlates of protection. If any titer is undetectable it could be one of these situations: Primary failure. The components of the MMR have different efficacy. Two doses of appropriately given MMR will have 96+% against measles, but only 88% for mumps. Thus 1 in 10 appropriately...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
Do you find consumer grade wrist actigraphy useful in measuring sleep quality and duration?
Consumer wearables are advancing quickly, and there is a lot of variation in their performance, particularly in those with sleep disorders. Unfortunately, there is a wide variation in the performance of devices, even ones using the same signals to calculate sleep/wake. Additionally, orthosomnia is a...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.