Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Would you stop Dupixent in an asthma patient who has good asthma control and notes improvement in loss of smell, but shows notable eosinophil elevation after 4-5 doses of the medication?
Transient eosinophilia has been reported in patients treated with Dupixent, likely related to downregulation of eotaxin and adhesion molecules resulting in impaired eosinophil migration into the tissues (Castro et al., PMID 29782217, Olaguibel et al., PMID 35522053). This phenomenon is typically see...
What is your approach to patients with chronic hypoxemic respiratory failure who have apparent higher oxygen needs during hospitalization but no clear acute/decompensated respiratory illness?
Will work them up completely for infection, PE, COPD exacerbation, heart failure/cardiac etiology. If no convincing reason for decompensation and they are stable, I will have them do a 6 min RT walk test to determine oxygen needs and have them follow up with PCP or pulmonary for further PFTs or othe...
Would you consider levofloxacin graded challenge, extended IV aztreonam, or an alternative treatment in a patient with reported anaphylaxis to penicillin, fluoroquinolones, and cefuroxime with cavitary pneumonia secondary to Klebsiella and Pseudomonas?
The first and most important thing would be to establish whether the patient had a true penicillin (as well as other antibiotic) allergy since >90% of patients who think they are sensitive to PNC really are not. If it is established that the patient does have a PCN allergy, consultation with ID is a...
How would you approach early stage NSCLC in a patient who is not an ideal surgical candidate and has pulmonary AVMs?
The standard volumes and flows of PFTs do not assess regional differences in what is perfused and ventilated. V/Q scans do, but their most common use for pulmonary embolism is their most common role. This serves to identify gas exchange near the primary as well as where the AVM’s reside. Target the ...
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...
Would you perform screening for pulmonary hypertension in a patient who has biopsy-proven Sjogren's but has a centromere antibody?
Generally, the risk of pulmonary hypertension in Sjogren's is low - about 2% in a recent study using RHC for diagnosis (Coppi et al., PMID 40058609). There have been no studies linking Raynaud's to pulmonary hypertension risk in Sjogren's, although this is true in systemic sclerosis. So the real que...
Do you recommend maintaining the same monitoring interval of PFTs every 3–6 months with HRCT as indicated for patients with anti-MDA5 dermatomyositis, or do you recommend closer surveillance in this group?
Closer surveillance may be needed at diagnosis of ILD in anti-MDA5 DM at every 3 months for 1st year. But typically, in my experience, patients' symptoms progress faster than every 3 months, so rapidly progressive ILD is diagnosed clinically.
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...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
How are you using liquid biopsy in the routine management of your patients with metastatic NSCLC?
The dramatic improvement in the prognosis of metastatic NSCLC patients harboring targetable oncogenic genetic alterations with highly effective therapy has underscored the need for tumor molecular profiling. There have been numerous studies in the past decade assessing the performance of ctDNA (here...