Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you empirically administer high-dose IV thiamine to all patients admitted with sepsis and a history of alcohol use disorder, even without clinical signs of Wernicke encephalopathy?
There is little to no downside risk for thiamine administration in comparison to severe morbidity for the failure to use thiamine, as supported by a recent review (Teixeira et al., PMID 39818490).
Is it necessary to prescribe a steroid taper after two weeks of high-dose prednisone (60 mg daily)?
Interesting question. Not being an endocrinologist, I don't have the expertise to advise but the reference below makes the statement that even short-term steroids can be an issue. I suspect that if you have to stop abruptly from 60 mg daily for 2 weeks, it would probably be fine in most instances bu...
Do you obtain an MSLT or start empiric therapy with modafinil in patients with residual excessive daytime sleepiness despite optimal adherence to PAP therapy?
In this situation I would start either modafinil, armodafinil, or solriamfetol for residual EDS if the OSA was appropriately controlled without need for MSLT. We have an FDA label for these medications in this situation to support this practice. If I felt like there was concern for a combination of ...
In patients with RA on methotrexate and a TNF inhibitor who develop PJP pneumonia, how long do you hold immunosuppression before restarting therapy?
I would typically hold immunosuppression until the patient has completed therapy unless they had significant respiratory failure, in which case I would await full recovery. The patient should be placed on appropriate PJP prophylaxis prior to resuming therapy.
How do you approach a patient with recurrent VTE who develops VTE again after reduction of apixaban to 2.5 mg bid?
Several factors play into this decision for me. Is the patient obese? Obese patients tend to give me pause for dose-reduction of DOACs. As such, half-dose apixaban may have been relatively underdosed for an obese patient and I would not call it DOAC failure, rather I would increase the dose to usua...
How well does a negative non-contrast MRI of the brain exclude metastasis in a patient with squamous cell carcinoma of the lung?
I don't think the question has enough information to give a good answer. For example, if it was a T3, N2 NSCLC, or a small cell, then "yes" I'd repeat the MRI with contrast. On the other hand, if it was a T1, N0 NSCLC, then "no", I wouldn't. In other words, if I thought there was a real risk of havi...
What steroid durations do you use for the treatment of acute, chronic, and drug-induced eosinophilic pneumonia?
For acute eosinophilic pneumonia, these are often high doses of IV methyl prednisone in the hospital, and assuming that the exposure or risk is mitigated, I would taper these down over a short period of time after discharge. Chronic eosinophilic pneumonia, I treat briefly with steroids but quickly t...
What specific clinical and echocardiographic thresholds lead you to taper/de-escalate pulmonary hypertension therapy before liver transplant?
The goal in pulmonary hypertension therapy pre-transplant is to fulfill the MELD exception criteria in terms of mean pulmonary artery pressure, pulmonary vascular resistance, as well as right ventricular function by echo. Once those criteria are satisfied, maintain those PH therapy doses until the t...
Would you recommend starting tolvaptan at 7.5 mg per day, which is half the typical starting dose, to reduce the risk of overcorrection in an inpatient with SIADH and a serum sodium level of 122 mEq/L?
If it is for SIADH, I always start with 7.5 mg. See this, my fellow and I put together years ago. Dosing in SIADH: A Tale of Two Tolvaptans If it is for CHF, I would start with 15 mg as those patients are so pre-renal, their distal delivery is so impaired, and tolvaptan is limited by that. I haven't...
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 ...