Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you transcutaneously pace or cardiovert patients with DNR status who have not lost pulses?
Yes, since it would not qualify as cardiopulmonary resuscitation if they maintain a pulse.
Do you consider thrombocytopenia a contraindication for fibrinolytic therapy for a massive PE?
If one has access to mechanical thrombectomy devices and operators, they should be considered before systemic thrombolytics unless the massive PE is causing imminent danger to the patient/patient is going to code/die, in which case the risk of dying from said PE is higher than potential bleeding eve...
How would you approach management of a patient with seropositive RA and UIP-ILD, with concern for active lung disease?
There is a potential benefit of adding additional immunosuppression for an RA patient with a UIP pattern on HRCT. My go-to-drugs are either abatacept or rituximab. While MMF is a standard first-line medication for many forms of ARD-ILD, it was tried for RA joint disease many years ago and the study ...
When can we consider deferring an insulin drip in patients with hypertriglyceridemia-induced pancreatitis?
Serum triglyceride levels >500 mg/dL (5.6 mmol/L) are required for hypertriglyceridemia to be considered the underlying etiology of acute pancreatitis (UpToDate).For patients with severe hypertriglyceridemic pancreatitis, such as those serum triglyceride levels >1000 mg/dL plus lipase >3 times the u...
Do you find there is any benefit to giving N-acetyl-cysteine in non-acetaminophen related acute liver failure?
Yes, we believe there is a modest benefit for non-APAP patients. The Acute Liver Failure Study Group did a placebo controlled double blind study of NAC use in non-APAP ALF. Here is the reference. This is not FDA-approved. They wanted a second study but this one took about 6 or 7 years to complete!Le...
How do you decide which IV opioid to use for symptom relief at the end of life?
For patients at the end of life who need IV medications for symptom relief, I choose morphine, hydromorphone, or fentanyl depending on the patient's baseline opioid tolerance, symptom burden, and their kidney and liver function. Morphine is the lowest potency of these three options and is a good cho...
Do you add adjunctive gentamicin and/or rifampin for treatment of prosthetic valve Staphylococcus aureus endocarditis?
No, we do not add adjunctive gentamicin for treatment of Staphylococcus aureus (SA) prosthetic valve endocarditis (PVE). The potential benefit of using an aminoglycoside in this setting is minimal, if any, and is outweighed by the risk of toxicity.With respect to using rifampin, it depends on whethe...
How do you counsel patients who are concerned that discontinuation of certain chronic medications may actually perpetuate suffering at the end of life?
Great question, and it’s very nuanced. I’ll share how I typically approach this based on my experience. In the end-of-life care setting, when I review a medication list, I go through every single one and ask: “What is the purpose of this medication in this particular case?” For example, anticoagul...
When, if ever, would you consider methotrexate over prednisone for first line therapy in patients with pulmonary sarcoidosis?
The PREDMETH trial supports the use of methotrexate for initial therapy for sarcoidosis. Future studies may identify subgroups that may benefit from the concurrent use of prednisone initially; it is unclear how soon methotrexate may provide symptomatic relief compared to the ability of an appropriat...
Do you find consumer grade wrist actigraphy useful in measuring sleep quality and duration?
Consumer wearables are advancing quickly, and there is a lot of variation in their performance, particularly in those with sleep disorders. Unfortunately, there is a wide variation in the performance of devices, even ones using the same signals to calculate sleep/wake. Additionally, orthosomnia is a...