Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your approach for a primary tracheal squamous cell carcinoma?
First off as you probably know this is a randomized data-free zone. So to some extent what to do here is empiric and/or based on historic outcomes, retrospective data, and so on. But here are a few quick & dirty observations...1) Surgical patients have the best survivals/outcomes. Doing tracheal sur...
When prescribing SMART regimen for a new diagnosis of asthma, do you still prescribe rescue inhaler (i.e. SABA) if they don't have it?
When using the SMART (single maintenance and reliever therapy), I don't add an albuterol (SABA) rescue inhaler. The whole idea is to simplify things for the patient so that they maintain their asthma control and get relief with the necessary via just one inhaler. Budesonide - formoterol combinations...
What treatment approach do you suggests for a patient with nasal polyp disease and asthma who was improved on dupilumab, but over last 2 years has begun to have increased nasal symptoms and rising eosinophil counts?
Dr. @Dr. First Last's comments are quite valuable. It might be more expedient to consider simpler options first, then progress to the less common diagnoses as needed. I very much agree that unless we know what is meant by "increased nasal symptoms", it is difficult to provide precise alternative the...
Do you consider indwelling pleural catheters in patients with refractory transudative pleural effusions?
I do as long as the risks, benefits, and possible alternatives are discussed with the patient. Frequently, these patients have refractory or end-stage heart failure, kidney failure, and liver failure. Often, they have decompensated or end-stage diseases and are not candidates for organ transplantati...
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
How do you determine whether to add abatacept or rituximab to the treatment regimen in patients with mild RA-ILD on methotrexate?
I think of many agents before rituxan for RA ILD: all in various stages of being studied MMF, Orencia/abatacept, Tocli/actemra, and even JAK inhibitors xeljanz/rinvoq. Generally, if I treat and control the joints, the lungs stabilize. 10-20% run independently from joints or extra-articular ILD witho...
Can symptomatic radiation pneumonitis ever improve spontaneously without corticosteroids?
As “pneumonitis” has always been difficult to pinpoint, and relies on “inflammatory radiologic findings” confined to XRT portals, fever, cough without positive bacterial cultures, and shortness of breath, the diagnosis is even more difficult with 3D-directed and multiple portals or mostly IMRT-deliv...
How do you counsel older adults regarding the use, dosing, and safety of CBD-containing products for insomnia?
When counseling older adults on CBD use for insomnia, I usually explain that evidence for safety and effectiveness is limited. Most products are not FDA-approved, and their labeling, purity, and dosing can be inconsistent. It’s important to review the patient’s comorbidities and medications closely,...
Do you utilize D-dimer to inform anticoagulation duration in the treatment of VTE?
I had developed a policy during my last eight or ten years of practice evaluating how long patients should be treated after a thrombosis and I'd like to share some impressions over these years as well as conclusions that I reached. These conclusions formed the basis of my approach to this problem. I...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....