Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
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 ...
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 to empiric treatment of achromobacter infections?
Achromobacter is a Gram-negative bacterium in the Burkholderia order. This pathogen is significant in immunocompromised patients, such as those with cancer or Cystic fibrosis, and is seen with bacteremia or causing pneumonia. They can also be associated with foreign device infections. Typically, the...
Do you perform routine screening for latent tuberculosis in a patient who resides in the United States, has frequent, 1-2 week trips to see family in a highly endemic country, but who otherwise has no significant risk factors or high risk exposure activities?
Absolutely. I perform annual screening on persons with the described exposures. The screen is fast, safe, and easy for the patient. A goal is to eliminate all new cases of tuberculosis in this country. To accomplish this, we must identify all potential cases and treat them accordingly.
Would you consider leaving fever untreated in patients with sepsis to potentially enhance immune responses and antimicrobial efficacy?
In light of the review article attached (Tilanus et al., PMID 41113323), there is some data reviewed supporting that fever is actually therapeutic. Four articles are of special interest in the review. Two are from the 70s, before sepsis was defined as it is today. Two are in the last 15 years, but o...
Do you generally recommend device exchange/removal in patients with gram positive bacteremia in the setting of intra-aortic balloon bump or other mechanical circulatory devices?
I am assuming in this case that the patient has a mechanical circulatory support device such as an LVAD, IABP, or another implantable device, and has developed gram-positive bacteremia. No further details about the device type or clinical scenario are provided. In such cases, device removal is recom...
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 ...
Do you recommend doxycycline over azithromycin as first-line treatment for outpatient community-acquired pneumonia in otherwise healthy adults, given rising macrolide resistance rates?
Yes - our county antibiogram shows >50% resistance of Streptococcus pneumoniae to azithromycin, and thus if there is a true concern for bacterial infection, I recommend doxycycline.
For hospitalized patients with confirmed viral respiratory infections who clinically improve but remain PCR-positive, how long do you maintain isolation precautions?
This is a great question and one that routinely comes up for patients, their families, and staff. Precautions should be continued until symptoms improve and for a minimum of 14 days after the onset of signs and symptoms. This is especially important for patients who can spread virus to individuals t...