Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your approach to tapering anesthetic drips for refractory status epilepticus after achieving burst suppression?
Ensure adequate oral/IV ASMs are on board, targeting the receptors appropriately based on the type of status- generalized, focal (e.g., GABA, Na channel, glutamate, etc.). These would include the first, second, and third line as per status protocols. Check levels to ensure adequacy. At least 24 hou...
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...
Do you recommend air purifier in bedrooms and office/workplaces of patients with chronic lung disease?
As with many answers within medicine, the answer is "it depends." Asthmatics or individuals with airway-related environmental triggers such as COPD overlap syndrome may benefit from air purification systems -- either as part of a central HVAC system or utilized as a portable unit used within sleepin...
How do you decide the maximum amount of volume to remove during a therapeutic thoracentesis?
Critically ill (hypotension/shock on pressors) that are not having hypoxia issues/increased FiO2 requirements, I would probably be cautious. Rest of the population, use clinical judgement based on the clinical response... Less likely to need a "hard" stop/limit.
How do you approach a patient on anti-TNF with positive Quantiferon (previously negative) with negative chest x-ray and no symptoms?
Prior to routine screening for latent TB for patients receiving or about to receive TNF inhibitor therapy, there were reports of miliary TB developing after initiation of TNF inhibitors. Therefore, one cannot say that a negative chest x-ray and no symptoms means the patient is not at risk for develo...
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...
What do you think about using conventional thoracic imaging methods (e.g., X-ray, CT, etc.) to determine if a pleural effusion is of adequate size to consider thoracentesis?
Generally speaking, CT would be superior as it would allow you to see more volumetric characteristics of the effusion; XR would have a hard time discerning true size, presence of loculations, or trapped lung. The real winner for this application would be bedside ultrasound. This modality would give ...
What are the potential implications of re-introduction of 'long-term responders to calcium channel blockers' in the classification of pulmonary hypertension, and how should clinicians approach the identification and management of these patients?
The purpose of reintroducing it into the definition is to identify that rare group of IPAH who would respond to CCBand perhaps their PH is likely driven by vasoconstriction rather than vasculature remodeling. They are likely to remain stable on CCB. Long-term responders are defined as those who, aft...
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 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 ...