Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you or your practice manage young, average-risk patients without structural lung disease referred to you or self-referred for concern of environmental mold exposure?
These individuals are generally managed by pulmonology and allergy/immunology clinics because the clinical presentation is generally more aligned with allergy-type symptoms like a chronic cough, congestion, or other symptoms associated with airway irritation. In individuals who are receiving chronic...
How long do you strictly enforce low tidal volume ventilation in ARDS?
I do not believe that there is data specifically looking at during duration of LTVV in ARDS vs shorter durations. However, there are multiple trials that argue that LTVV in ARDS and patients at risk for ARDS improves mortality outcomes with minimal negative side effects. In my practice, I try to adh...
Has your management of severe hyponatremia changed after a recent observational study described higher in-hospital mortality for sodium correction of <6 mEq/L compared to 6-10 mEq/L in the first 24 hours?
In short, no. I think the recent studies tell me two things: We need to better discriminate correction rates based on the risk of osmotic demyelination (ODS). Perhaps, do not worry so much about over-correction. They do not tell me to start rapidly correcting patients, and I guess I will summarize m...
Would you treat Scedosporium growth in expectorated sputum in a patient with COPD, pulmonary hypertension, and bronchiectasis, who has chronic dyspnea with exertion, thick sputum production, negative bacterial cultures, and no signs of mold infection on a high resolution CT scan, with no other clinical symptoms of infection?
In persons with bronchiectasis, almost anything that grows can be a pathogen, but it is tough to know. If the patient has COPD and no other immunocompromising conditions, I would not expect typical invasive fungal infection findings. Having said that, scedosporium is not the first common pathogen th...
When do you recommend limited or targeted respiratory pathogen testing versus a full respiratory pathogen panel in a patient presenting with URI symptoms?
I think we’re asking the wrong group of people. How infectious disease physicians use respiratory pathogen panels is not the same as how emergency medicine or urgent care clinicians use them. For stewards of diagnostics, especially ID providers, the test often doesn’t change management. In many sett...
How do you manage anticoagulation for patients with DVT/PE who have brain metastases?
Not all brain metastases pose the same risk to patients. Rapid, numerous (even if tiny), new onset metastases from RCC or melanoma (especially BRAF mutant) can go from asymptomatic to life threatening hemorrhage within 1-2 weeks and I would strongly caution anti-coagulation in these patients. If the...
How do you approach a positive Quantiferon/PPD test result in a patient for whom testing is sent without a clinical indication and who does not have a risk factor for TB exposure nor TB reactivation?
If a test for TB infection such as a Quantiferon or PPD is done without TB exposure risk factor or clincial indication and is positive, a chest X-ray and good history for symptom assessment and exam should be done. I will assess to see if there is an increased risk of developing TB such as an immuno...
What factors influence your decision between dexmedetomidine and propofol for sedation in mechanically ventilated patients?
The main factor that influences this decision in my practice is the indication for mechanical ventilation. For patients in whom the main indication is airway protection, such that the patient would not otherwise require oxygenation or ventilation support, I aim for higher RASS goals (-1 to +1) and t...
How do you manage a 3 cm solitary pulmonary cryptococcoma in an asymptomatic, immunocompetent, HIV-negative host?
I will treat it with oral Fluconazole for 6-12 months. Brain MRI to R/O CNS infection.
What policies do you take regarding legalized recreational marijuana or medical marijuana use in transplant patients?
The use of THC and CBD is becoming an increasingly important topic in solid organ transplantation. Recent survey data has demonstrated that daily cannabis use is higher than daily alcohol use in the U.S. (Caulkins, PMID 38775461).Certainly, the legalization of THC use in many states has led to consi...