Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Would you recommend anti-fungal treatment for aspergillus infection for a patient with an incidental finding of worsening ground glass opacities and enlarging nodules on CT chest with positive BAL galactomannan, elevated aspergillus IgE and IgG in an otherwise immunocompetent host with no respiratory symptoms?
No, I would not recommend antifungal treatment in this case. The patient, as described, does not seem to have invasive aspergillosis, chronic necrotizing aspergillosis, or allergic bronchopulmonary aspergillosis, so I don't believe antifungal treatment is indicated. There may be other details of the...
What is the optimal duration of biologic therapy before assessing for non-response and initiating a switch in patients with uncontrolled asthma?
I generally wait 3-6 months before changing biologic class to allow for the medications to get to a steady state. I will monitor eNO and will not wean steroids prior to 3 months.
When would you start antiepileptic drugs in a critically ill patient who develops myoclonic jerks but has not yet had an EEG?
Treatment depends on the setting in which these myoclonic jerks are seen. In a non-cardiac arrest patient, such myoclonic jerks are often due to medications, organ dysfunction (e.g., uremia, etc), electrolyte imbalance, or non-convulsive seizures, etc, and workup for this is recommended with labs, h...
In patients with anoxic brain injury who have a tracheostomy, but “liberated” from the ventilator, and appear to be able to protect their airway, but have no meaningful neurological function, is there a role for decannulation?
Unfortunately, in patients with such severe brain injury that they have no meaningful neurologic function, decannulation would come at significant risk. Often, patients in these situations do not manage their secretion well and are at high risk for aspiration. With the trach in place, suctioning and...
Do you have any pearls for how to manage OSA with CPAP in older adults with cognitive impairment?
I try to involve a partner or other family member in the process, including getting a sleep study in the first place. If the study shows moderate or severe sleep apnea, especially with substantial oxygen desaturation, I remind the patient and partner that use of CPAP will help the patient's memory. ...
What is the best alternative oral therapy for treatment of non-severe pulmonary nocardiosis in an immunocompetent patient with sulfa allergy?
We have been using linezolid for this indication, based on a paper from ARUP Labs.Schlaberg et al., PMID 24247124
Do you prefer using end-expiratory or mean pulmonary artery wedge pressure obtained during diagnostic right heart catheterization for the classification of precapillary vs postcapillary PH?
I use end-expiratory wedge pressure (and all hemodynamics for that matter at end-expiratory pressure) most of the time which is supported by current guidelines. The confounder is in patients with wide transthoracic pressure swings (i.e., exercise, severe COPD, severe obesity). This is just something...
Do you ever consider continuing annual LDCT chest for lung cancer screening in patients who quit smoking more than 15 years ago?
The 15 years is now 20 years but keep in mind the “Guidelines” may not apply to the patient in front of you. Did anyone else notice that 2nd hand smoke is not in the eligibility criteria?
How do you weigh the benefit of urinary catheter placement for strict I/O measurement with the risk of avoidable CAUTI?
Our hospital's approach, which is consistent with CDC guidance, limits urinary catheters (UC) for I/O measurement to critically ill patients. We clarify that the information from the UC should be used at least q1-2 hours, otherwise it can be obtained in other ways (noninvasive collection, bladder sc...
How do you treat idiopathic hypersomnia inadequately responding to modafinil?
I agree with @Dr. First Last. I usually start my patients on modafinil or armodafinil. If those do not work, I will try solriamfetol. I will supplement with as needed amphetamines as well. I do not often go straight to sodium oxybate/low-sodium oxybate, as you need the right patient for this medicat...