Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you suggest using POCUS to detect or confirm a pneumothorax?
Great question - yes, there are mimickers of "lung point" (known as pseudo-lung point) such as pleural-based blebs, anatomical junction between heart/lung or between two lobes, focal adhesions - to name a few. On top of this, searching for a lung point in a deteriorating patient can delay interventi...
Do you prescribe empiric antibiotics to patients with CAP who test positive for a respiratory virus?
I do not start antibiotics when there is a detected viral etiology. And I tend to stop them if they were started. Obviously, this changes if the symptoms worsen and/or I suspect a bacterial superinfection. Another caveat would be in a patient with underlying COPD where Azithromycin may play a role i...
Are there best practices for integrating pollen, wildfire smoke, and AQI data into asthma/allergic rhinitis action plans?
Living in northern Calif, we frequently incorporate this topic into our patient discussions. We advise virtually all of our asthmatic pts to have a high-quality HEPA air purifier available because they frequently become hard to get when the air quality decreases.
In suspected portopulmonary hypertension with high cardiac output where mPAP is elevated but PVR is acceptable, do you base liver transplant candidacy primarily on PVR (and RV function) rather than mPAP, and how do you operationalize that in your listing decisions?
The short answer is yes. The key parameters of PVR and right heart function by transthoracic echo (mainly RV free wall strain, Fractional area change, and TAPSE in combination) are discussed by pulmonary and anesthesia colleagues at our selection conference. Specifically, we follow the current Inter...
Under what circumstances would you initiate antibiotics in adults hospitalized with RSV and a suspected bacterial co-infection?
Bacterial co-infection in patients hospitalized with RSV ranges between 8% and 29% (Karlsen et al., PMID 41488696). The American Thoracic Society 2025 guidelines recommend prescribing empiric antibiotics to all hospitalized patients with clinical and imaging evidence of community-acquired pneumonia ...
How frequently do you monitor CT scans, PFTs, and TTEs in patients with ILA or mild ILD?
Typically, I want my patients with ILD to be seen in clinic every 3-4 months, but of course, that depends a great deal on individual circumstances (e.g., disease severity, what we're doing for their disease, etc.). My typical approach is to have my patients perform spiro, DLCO, and 6MWT Q 3-4 months...
Should a patient who requires definitive treatment for prostate cancer as a pre-transplant requirement be strictly required to complete their course prior to transplant/initiation of immunosuppression?
To help address this complex question, I would like to call your attention to a review of the topic by Al-Adra et al., PMID 32969590. It covers several types of malignancies, including prostate cancer (Table 4). Treating this patient will require close collaboration with the transplant surgeon, urol...
When should we suspect ‘climate-amplified’ rhinitis/asthma versus poor control from other causes?
Before labeling rhinitis or asthma as “climate-amplified,” we must first exclude common causes of poor control: adherence issues, suboptimal controller dosing, inhaler technique, indoor allergen exposure, occupational triggers, and comorbidities (GERD, CRS, OSA, obesity). These remain far more commo...
How do you counsel patients on use of creatine monohydrate supplementation during a hospitalization for acute rhabdomyolysis from intense physical training?
I was a primary care doctor for the military for a few years. We regularly saw patients presenting with rhabdomyolysis from intense physical training. A standard question for all that present with this is whether supplements are being used. While there isn't a direct linkage to say that the use of c...
Should a patient on medium-dose ICS/LABA with normal PFTs, but who shows a greater than 10% decrease in FEV1 if their PFTs are done after 24 hours off their inhaler, be started on a biologic?
A little more clinical information would be useful to better answer the question. How well controlled is the patient on the LABA/ICS? What is the ACT score? The FEV1 decreased by greater than 10% (with volume >200 ml ?) when LABA/ICS was stopped for 24 hours - how quickly did it normalize when the i...