Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you decide on the timing and number of blood cultures for suspected endocarditis given the differences in recommendations between the ESC guidelines and the Duke Criteria?
Concern about differences in recommendations regarding specifics of blood culture collection between the two guidelines should be alleviated if one understands that these are guidelines, not dictates. It would help to lay out general principles. First, the focus of infection in infective endocarditi...
When you interpret a PFT officially, do you include a comparison to an older PFT on your report?
Yes, I use as much information as is readily available in my PFT interpretations. Comparison with older PFTs enables me to track changes in pulmonary function; for example, changes in FVC are particularly important in individuals with pulmonary fibrosis who are undergoing antifibrotic therapy. I als...
Do you recommend that your patients with COPD avoid gabapentin or pregabalin entirely, given the increased rate of exacerbations noted in patients on these medications?
No, I don't exclude gabapentin or pregabalin as therapeutic options for patients with COPD. The study of Rahman is a cohort study that suggests an interesting association but has limitations, including residual confounding variables and a lack of smoking information on the study population. The issu...
What duration of antibiotic therapy do you use for a loculated parapneumonic effusion that does not meet criteria for empyema?
It would be great to see more prospective research in this area. I think we should be a bit more nuanced in our approach as it seems to be crude to recommend 4 to 6 weeks of IV antibiotics for every parapneumonic effusion or complicated pleural space. I think that in melding the IDSA and American As...
How do you approach PJP prophylaxis in patients with rheumatic disease on corticosteroids?
Here is a graphic I made covering PJP Prophylaxis with Dr. @Dr. First Last if anyone is interested! As noted, one can check absolute lymphocyte count (ALC) or CD4 count as factors to further risk stratify as well.
What factors do you consider to help guide treatment for patients with high grade large cell neuroendocrine cancers of the lung?
High-grade large cell neuroendocrine carcinomas make up a small and aggressive subset of lung cancers that histologically and regarding treatment responsiveness share features with both small and non-small cell carcinomas. These shared features have been borne out in recent sequencing studies of thi...
Do you routinely treat pregnant patients for latent tuberculosis or delay treatment until 2-3 months post-partum?
Guidelines from CDC, WHO, ATS/IDSA recommend delaying the treatment of latent TB in pregnancy until 2-3 months postpartum unless there is a high risk of progression to TB disease e.g. HIV co-infection. This is because the risk of hepatotoxicity from isoniazid is higher during pregnancy and in the ea...
When might you soften the post-thrombolysis monitoring requirements for patients receiving TPA for acute stroke?
The recent study by Anderson et al., PMID 40412428, suggests that a pattern of reduced monitoring after tPA was noninferior to standard monitoring in patients with initial NIHSS < 10, treated within 2 hours of symptom onset. This is suggestive that the reduced monitoring protocol is safe in patients...
How do you decide between oral vs nasal route of entry for bronchoscopy with BAL with moderate sedation?
I trained in the early 90s. Where I trained the nasal route of entry was preferred. My experience is that patients cough less, require less sedation, and the scope is easier to guide and direct from the "stable" base of a nasal insertion. With proper nasal preparation complications related to nasal ...
What is your preferred mechanism for venting the left ventricle in patients on VA-ECMO?
Based on recent studies and evidence in the literature, my preferred approach for venting the left ventricle in patients on VA-ECMO would be guided by the individual patient's clinical scenario, with a cautious inclination towards using the intra-aortic balloon pump (IABP) over Impella. This prefere...