Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
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 ...
Is there any role for adjusting how long to hold anticoagulation perioperatively based on DOAC dose?
The PAUSE trial evaluated perioperative management of DOACs. However, only 20% and 16% of patients were on prophylactic doses of apixaban and rivaroxaban, respectively. It was suggested to hold the drugs for two days, and one day before high-risk and low-risk procedures. A useful review of this appr...
Would you biopsy calcified lung nodules and or lymphadenopathy that have shown stability over a 2-year period, in a bid to rule out sarcoidosis?
No. Certainly not without a comprehensive occupational and other exposure history. Follow "the rules" for the assessment of any sarcoidosis suspect. Do a physical exam to look for extrapulmonary signs of sarcoidosis. Order an eye exam to assess for ocular sarcoidosis. Obtain baseline MTB testing and...
How do you approach pre-operative risk assessment and optimization in a patient with interstitial lung disease?
Surgery in patients with interstitial lung disease (ILD) is not a decision we take lightly! At our center, we start with general risk tools like the ARISCAT score but layer in ILD-specific factors—such as DLCO below 60% and declining trends in PFTs or 6MWT testing. We also screen for comorbidities l...
Do you routinely give combination antifungal therapy for invasive mold infections?
The data on triazole single agent versus triazole plus echinocandin for the treatment of invasive aspergillosis are limited. I do not have a standard approach. I generally use a triazole alone, but will use the combination for initial treatment in patients with severe and/or rapidly progressive dise...
What is your preferred rescue inhaler for patients with asthma?
SMART with ICS/formoterol. I tend to think all asthma patients should be on SMART therapy (ICS/formoterol). Just don't really see the reason to not treat that way.
Is there any evidence to support further uptitration of dobutamine beyond 5mcg/kg/min for patients with advanced HF and/or cardiogenic shock, or should further investigation into potential MCS be considered at that point?
When a patient with acutely decompensated heart failure and shock is exhibiting insufficient perfusion in spite of a given level of support, whether pharmacologic or mechanical, it is appropriate to pause and ask why. Options at this point could include an escalation of inotropic therapy (dose escal...
What is your stepwise approach to supporting the RV in the setting of RV failure from unrevascularized RCA disease in an unstable patient in the absence of RP impella availability?
Physiology RV infarct → preload dependent, afterload sensitive, rhythm/AV-synchrony dependent. Aim to optimize preload (not too little/not too much), reduce RV afterload, maintain perfusion pressure, preserve sinus/AV synchrony, and relieve ischemia where possible. 1) Immediate stabilization (fir...
Among patients with secured subarachnoid hemorrhage who are receiving daily TCDs, what is the appropriate frequency of post operative neurological assessments?
I think a textbook might state something like "every 1-2 hours in the acute setting." However, in my opinion, the frequency of neurological examinations should be tailored to the individual patient and involves considerable clinical judgement. Factors that might influence this decision include a) se...