Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your approach to managing rash associated with pirfenidone?
I don’t think "permanently discontinue" is the first step here. Rash commonly occurs in conjunction with sun exposure, which can be prevented with skin covering and high SPF sunscreen, but sometimes it is a different phenomenon (i.e., a true allergy, which does require discontinuation).If the photos...
Do you routinely integrate the use of a multiplex PCR panel in the evaluation and diagnosis of patients suspected of having VAP?
In our hospital, we use emperic treatment till we get the sputum culture results.
What is your approach to scheduling and then weaning nebulizers in patients admitted with acutely exacerbated asthma or COPD?
In hospitalized patients with acute asthma or COPD exacerbations, my approach to nebulizers is front-loaded and reassessment-driven. I start by gauging the severity and the patient’s ability to use an inhaler. pMDI with a spacer is preferred for most patients, but nebulizers are reasonable early on ...
Do you use anticoagulants in the management of patients with pulmonary veno-occlusive disease (PVOD)?
Not enough research
What is your approach to the management of a newly acquired Pseudomonas aeruginosa infection that was not eradicated with initial treatment in a patient with CF?
I think this is a situation where shared decision making with patient is required; in general, would aim for second round of eradication with different antibiotic (for example if tobramycin was used first, inhaled aztreonam would be next) or consideration of a second month; however, chances of eradi...
How do you approach management of a patient with multiple lung nodules and low titer +CCP but no active joint symptoms suggestive of RA?
In the absence of other clinical symptomatology, I would favor close observation and follow-up in this case as there is no established diagnosis and repeat CT, PFT’s in 3 to 6 months. Details of initial evaluation should include PET-CT to exclude malignancy but also to investigate other organ system...
How do you workup patients with neuropathy suspected to be secondary to sarcoid?
To answer this question, the attached paper with consensus criteria for the diagnosis of neurosarcoidosis, published in 2018, should be reviewed, Stern et al., PMID 30167654.Based on this paper, a diagnosis of probable or definite neurosarcoidosis requires unequivocal evidence of non-caseating granu...
Is there an upper threshold of pCO₂ that can cause symptomatic hypercapnia (e.g. AMS) despite metabolic compensation and normal pH?
Hi - I'm not sure about an upper threshold of pCO2 and AMS. However, even with normal pH, elevated pCO2 can cause significant increases in cerebral blood flow. Pollock et al., PMID 19406361 studied MR perfusion imaging and found that patients with a mean pCO2 of ~ 54mmHg had more than double the cer...
Are you more permissive of perioperative interruption of anticoagulation for VTE depending on the location and relative chronicity of the thrombus?
Yes - in general, I try to balance the relative urgency/importance of the procedure or surgery v. the thrombotic risk to the patient of a period of time off of anticoagulation. Location and chronicity both can feed into determining thrombotic risk. An upper extremity DVT, in general, has a lower rec...
What is your experience with transesophageal lung mass biopsies?
Thoracic lesions requiring FNA in the mediastinum are often best approached with EUS–FNA, as the sedation and airway management are less complex than the EBUS, and the needle does not need to break through cartilage rings to access the lesion. On the other hand, a lung mass would require the needle ...