Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you talk with your patients regarding radiographic expectations on surveillance CT after lung SBRT?
In general, especially when I have a discussion about the 3-month follow-up scan and tell patients that the lesion may likely be stable in size, which is often normal, and not to panic. There may also be post-radiation changes that make it more difficult to initially interpret. I think this highligh...
What is the goal oxygen saturation for patients with COPD and pulmonary hypertension?
Although an oxygen saturation target of 88–92% is commonly used in patients with COPD to reduce the risk of oxygen-induced hypercapnia, a higher saturation goal is appropriate in patients with pulmonary hypertension associated with COPD. In this population, we generally aim for an oxygen saturation ...
What is your approach when a patient has concomitant acute decompensated heart failure and rapid atrial fibrillation?
Is the patient stable? If not stable, then I would move towards immediate cardioversion. If stable (good BP) but poor oxygenation, then diuretic with consideration of metoprolol, digoxin, or amiodarone. If unable to tolerate BB due to lower BP, then would lean towards amiodarone or digoxin. Anticoa...
How long after initiating mycophenolate do you wait before tapering prednisone off in patients with myositis-associated ILD?
Taper Pred after 6 weeks MMF tapering to prednisone 20 mg/day and hold this dose for 6-8 weeks monitoring for relapses. If no relapse, taper to Prednisone 10 mg/day.
Do you screen for interstitial lung disease in patients with newly diagnosed polymyositis or dermatomyositis in the absence of respiratory symptoms?
I do screen all newly diagnosed IIM patients with PFTs and chest CT. This has a double purpose: establishing a baseline of lung function and, screening for lung cancer. While the patient might not have lung symptoms on presentation, respiratory involvement can manifest later on the course of the d...
Does screening for sleep apnea in asymptomatic patients reduce long-term dementia risk?
Obstructive sleep apnea (OSA) is common, underdiagnosed, and increasingly recognized as a potentially modifiable contributor to late-life cognitive decline. Observational studies consistently report associations between OSA, intermittent hypoxemia, sleep fragmentation, cerebrovascular injury, Alzhei...
Do you monitor CBCs to assess for drug toxicity in patients on nintedanib?
Not typically. I've never been advised to check these, but it's worth re-examining whether it's worthwhile. Looking at the side effect profile in INBUILD and INPULSIS doesn't reveal any major cytopenias. It doesn't appear to be on the FDA prescription information, either. I think this question arise...
In drawing blood cultures from a central line to evaluate for CLABSI, do you advise drawing separate blood cultures from each port in case of dual or triple lumen line?
You don't need to use the central line to draw those cultures. Using the line to draw blood can in it by itself pose risk of introducing a microorganisms. NHSN CLABSi definition does not call for blood culture to be done from a line.
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...
How do you approach a patient with sarcoidosis who cannot tolerate steroids and who is developing ILD?
As with most questions about sarcoidosis, clear understanding of the relevant clinical context should first be established. While interstitial lung disease (ILD) is a common manifestation of sarcoidosis, it often can be safely monitored without treatment, and so radiologically identified sarcoid ILD...