Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you favor aggressive airway clearance regimens or bronchoscopy for clearing occluding mucous plugs in patients who are not in respiratory distress?
The first step is to determine the cause of the secretion issue. Is this acute or chronic? The underlying disorder that predisposes to abnormal mucus or ineffective cough? How much difficulty is this creating with ventilation and or oxygenation (ir level of urgency?). Since there is no respiratory d...
Do you recommend providing supplemental oxygen for patients with a pneumothorax in the absence of hypoxemia?
I was certainly always taught that one should give supplemental oxygen to patients to decrease the size of the pneumothorax. This is based on the "nitrogen wash-out" theory, essentially, you're trying to get the partial pressure of nitrogen down in the alveoli so that it will be resorbed from the pn...
Do you use an antibiotic with antitoxin activity for the entire duration of therapy for patients with necrotizing MSSA or MRSA pneumonia or just until definitive clinical improvement?
I misread the question. I assumed a necrotizing S. aureus infection meant a necrotizing skin and soft-tissue infection. I’m not sure how “necrotizing pneumonia” is being defined here. Regarding MRSA pneumonia with toxin-mediated tissue injury, there are data suggesting that linezolid may yield bette...
How do you weigh the risk of urinary catheter or fecal management system placement with that of soiling sacral wounds?
This question is an important question that arises for many of our bed-bound and poorly mobile patients, as sacral wounds commonly develop due to pressure injury. They become very challenging to treat due to fecal and urinary contamination, which can lead to further infection. Fecal and urinary dive...
How have the findings from DanGer Shock RCT changed your perspective on which patients presenting with acute MI complicated by cardiogenic shock would benefit from Impella for additional hemodynamic support?
First and foremost, it is notable that DanGer Shock (Møller et al., PMID 38587239) was the first randomized trial to show a mortality benefit with the use of a microaxial flow pump in acute MI-associated cardiogenic shock - a practice that proliferated based upon promising outcomes in non-randomized...
When would you recommend prescribing an asthmatic patient budesonide/salbutamol rather than budesonide/formoterol?
This is another example of two approaches to the same issue (i.e. adding inhaled steroid to a rescue B2 adrenergic agent) which is actually more theoretical than practical since no head-to-head studies have been reported. For me, there is an intrinsic value to using a rapid onset LABA (i.e. formoter...
When starting stress dose steroids for patient with primary adrenal insufficiency, how do you decide whether to start hydrocortisone 100 mg every 8 hours versus 50 mg every 6 hours?
Stress doses of steroids in patients with primary adrenal insufficiency depend on the anticipated stress. The dose of steroids can be doubled or tripled depending on the stress. For example, in cases of maximal stress such as major surgery, the dose can be similar to the dose used for an adrenal cri...
Would you continue or stop anticoagulation for a DVT/PE in a patient with active cancer who has completed 6 months of therapy?
This is an important question that we didn’t really have a clear answer for… until this year when an NEJM RCT was published! Mahé et al., PMID 40162636 In this RCT, patients with cancer-associated VTE who completed 6 months of full-dose apixaban were randomized to half-dose apixaban vs. full-dos...
How do you approach treating patients who develop psoriasis while on Dupixent?
Stop the Dupixent. These patients likely had a non-Th2 driven type of dermatitis e.g. Malassezia yeast hypersensitivity, which is Th17 driven, or stasis dermatitis with autoeczematization, or eczematous drug reaction. Revisit the Diagnostic Checklist for Generalized Dermatitis.
Are there certain clinical features that help you choose between benralizumab and mepolizumab for EGPA in clinical practice?
Given, as noted above, no significant clinical differences between benralizumab and mepolizumab, assuming there are no specific insurance differences between the two, I preferentially prescribe benralizumab because of the 8-week dosing frequency after the first three 4-week loading doses. For a few ...