Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you treat complicated pneumonia with a drained empyema longer if Streptococcus anginosus is cultured, either in isolation or with other organisms, compared to cases in which it is not?
Targeted antimicrobial therapy for any bacterial etiology of an empyema will be individualized for each patient but a general duration of 4-6 weeks. I would not consider strep anginosus differently in this regard. What I am looking for is adequacy of drainage with clinical improvement. Radiographic ...
How do you manage hypercalcemia in sarcoidosis despite being on immunosuppressive therapy?
Let us accept, first, that the individual does not have emergent levels of elevated calcium (equal to around or greater than 14 mg/dl) and concerning symptoms of the following systems: neurological (e.g., weakness, confusion, delirium), renal (e.g., polyuria, polydipsia), gastrointestinal (e.g., los...
When would you consider glucocorticoids as adjunctive therapy for for community-acquired pneumonia outside of the ICU setting?
Thank you for bringing this new study to my attention; I hadn't seen it yet. After reviewing the article, my practice regarding steroids remains unchanged. While the trial was well-executed, and it is laudable to see such research coming out of a limited-resource setting, that environment differs si...
How would you approach treatment of latent TB for patients who cannot tolerate rifamycins or isoniazid due to allergy, intolerance, or drug-drug interactions?
Levofloxacin or moxifloxacin. Duration is 6-9 months.
When do you consider diaphragmatic pacing in patients with diaphragmatic paresis?
Diaphragmatic pacing and phrenic nerve stimulation are most typically considered in patients with chronic ventilatory failure that results from high cervical spine or brain lesions that disrupt the normal respiratory drive pathways that exist within the pons and medulla. It is also commonly used in ...
Do you favor aggressive airway clearance regimens or bronchoscopy for clearing occluding mucous plugs in patients who are not in respiratory distress?
The first step is to determine the cause of the secretion issue. Is this acute or chronic? The underlying disorder that predisposes to abnormal mucus or ineffective cough? How much difficulty is this creating with ventilation and or oxygenation (ir level of urgency?). Since there is no respiratory d...
Do you recommend providing supplemental oxygen for patients with a pneumothorax in the absence of hypoxemia?
I was certainly always taught that one should give supplemental oxygen to patients to decrease the size of the pneumothorax. This is based on the "nitrogen wash-out" theory, essentially, you're trying to get the partial pressure of nitrogen down in the alveoli so that it will be resorbed from the pn...
Do you use an antibiotic with antitoxin activity for the entire duration of therapy for patients with necrotizing MSSA or MRSA pneumonia or just until definitive clinical improvement?
I misread the question. I assumed a necrotizing S. aureus infection meant a necrotizing skin and soft-tissue infection. I’m not sure how “necrotizing pneumonia” is being defined here. Regarding MRSA pneumonia with toxin-mediated tissue injury, there are data suggesting that linezolid may yield bette...
How do you weigh the risk of urinary catheter or fecal management system placement with that of soiling sacral wounds?
This question is an important question that arises for many of our bed-bound and poorly mobile patients, as sacral wounds commonly develop due to pressure injury. They become very challenging to treat due to fecal and urinary contamination, which can lead to further infection. Fecal and urinary dive...
How have the findings from DanGer Shock RCT changed your perspective on which patients presenting with acute MI complicated by cardiogenic shock would benefit from Impella for additional hemodynamic support?
First and foremost, it is notable that DanGer Shock (Møller et al., PMID 38587239) was the first randomized trial to show a mortality benefit with the use of a microaxial flow pump in acute MI-associated cardiogenic shock - a practice that proliferated based upon promising outcomes in non-randomized...