Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
Do you utilize cytokine panels to guide treatment of patients with EGPA?
Whether biomarkers can guide treatment decisions or predict disease relapse is a critical area of study in ANCA associated vasculitis. However, efforts to identify biomarkers that are predictive in EGPA are at an early stage currently. There have been multiple negative studies of biomarkers being ab...
Do you use isavuconazole for treatment of moderate to severe histoplasmosis in patients with co-morbidities, acute or chronic renal failure, or other features that increase the risk of side effects of itraconazole or amphotericin?
No. I would not routinely use isavuconazole as initial therapy for moderate to severe histoplasmosis. For severe disease, liposomal amphotericin B remains the recommended first-line induction treatment, followed by step-down oral therapy, traditionally itraconazole. In patients with renal dysfunctio...
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.
When have you found the Nidra TOMAC device to be helpful for refractory restless leg syndrome?
I have one patient who found it helpful with breakthrough symptoms in refractory RLS, but was unable to get enough coverage to continue using it.
Do you recommend procalcitonin to help convince other providers to stop antibiotics in patients with pneumonia in whom a non-infectious diagnosis is strongly suspected?
I have looked at both of these studies in some depth. The de Jong et al., study, called SAPS, is perhaps the more impressive of the two, but regarding either or any study on so-called "biomarkers", even the RCT studies only make recommendations or give advice. And, more often than not, the doctors d...
What is your approach to REM behavior disorder not adequately treated with melatonin and clonazepam?
Rule out comorbidities like sleep apnea or medications causing RBD. Optimize doses for melatonin and clonazepam, and consider dual therapy with these. Other options are gabapentin or pramipexole. Thanks,Sam Morkous
When a patient does not have comorbid atopic dermatitis or nasal polyposis, how do you determine when to use the 200 mg vs 300 mg maintenance dosing for Dupixent for asthma?
One might consider the nonbiologic baseline therapy and severity of the asthma that is driving the potential initiation of a biologic like dupilumab to treat the asthma. Assuming I have decided to use dupilumab instead of a different biologic for improving management of the patient's asthma, I would...
Do you adhere to the standard 5-day minimum treatment duration for community-acquired pneumonia, or have you used shorter courses for certain low-risk patients?
This is a question addressing a shorter duration of antibiotic therapy than the current IDSA guidelines for community-acquired pneumonia (CAP) recommend. It has been the topic of several studies, for example, 3-day treatment (Richard T. Ellison III, MD, reviewing Dinh et al., PMID 33773631; Niederma...
How do you approach management of an ICU patient with brief potentially ictal rhythmic discharges (BIRDs) on EEG?
This is a very challenging question, and the clinical importance of BIRDs, besides being associated with an increased frequency of seizures (Yoo et al., PMID 24535702 ), is unclear. I am a neurointensivist, and in general, I do not escalate therapy for intermittent BIRDs unless we identify concomita...