Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your approach to counseling severely frail older adults regarding their planning for invasive life-sustaining therapy?
My approach is pragmatic, evidence-based, and bi-directional. Patients/family make the decision, but I ensure they are fully informed about the pros and cons and provide them time to think through.
When reviewing right heart catheterization numbers in obese individuals, what adjustments or caveats do you routinely apply to your interpretation?
I use the principles outlined in Kovacs et al., PMID 24869464. The respiratory pressure swings are mainly a problem for knowing absolute values of, say, mean pulmonary arterial pressure (mPAP) or pulmonary capillary wedge pressure (PCWP). More commonly, we care about determining if there is evidence...
Would you give consolidation durvalumab to a patient who underwent chemoradiation for his stage III NSCLC and is being started on antifibrotic therapy by pulmonology for his ILD?
This is a difficult scenario. On the one hand, we know from the PACIFIC trial that there is a clear benefit to the addition of durvalumab in this setting. On the other hand, there is a higher risk of pneumonitis due to both the prior use of radiotherapy and the history of underlying ILD. I think ECO...
What guides your decision whether to complete a full course of intrapleural alteplase-dornase versus proceeding to surgical decortication when a patient continues to worsen or does not adequately improve with intrapleural therapy?
Based on the MIST trials (Maskell et al., PMID 15745977, Rahman et al., PMID 21830966, and Bedawe et al., PMID 37820359), I typically complete a three-day course of intrapleural therapy before proceeding to surgical decortication. It's only three days, and the decision to proceed to surgery after th...
Under what circumstances do you recommend POCUS guidance for lumbar puncture?
If the circumstances allow for it, I would use ultrasound for guidance for LP every time a LP is performed. This allows for continued practice in identification of the landmarks and improves accuracy in POCUS when it's truly needed, as in obese patients, where landmarks are difficult to palpate. Got...
How do you screen rheumatoid arthritis patients for lung disease (modality, frequency, patient selection)?
Theoretically, we are supposed to screen these patients obtaining a baseline chest X-ray before starting DMARD therapy. As I remember, these guidelines were formulated when MTX was still blamed for MTX lung disease although presently, even the presence of underlying ILD is not necessarily a contrain...
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS, i.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). *I don't love carbidopa/levodopa for RLS. It very often causes augmentation.
Would you consider using steroids in patients with respiratory failure caused by aspiration pneumonitis?
For aspiration pneumonitis alone, typically no. If there are other indications for steroids, for example, acute COPD or asthma exacerbation, then I would. I would also focus on addressing the aspiration to prevent future events. I have also seen providers use antibiotics if aspiration pneumonia vers...
What serum biomarkers are most helpful in cardiac arrest prognostication?
Neuron-specific enolase. This is checked at 24, 48, and 72 hours. It is, however, NOT to be used in isolation for prognostication, which is multimodal, including clinical exam after clearance of sedation (typically at 5 days post arrest), EEG (e.g., looking for reactivity of background), NSE, and MR...
How would you approach a stable 3 cm iatrogenic pneumothorax in an asymptomatic patient?
I think it is quite reasonable to continue to monitor in this situation. I probably would take comorbidities and reliability into consideration to decide if this is someone I would admit to the hospital VS follow up as outpatient.