Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you still consider propranolol first-line for sinus tachycardia in thyroid storm, or have newer perspectives on beta-blocker risks altered your management?
Yes, but...Propranolol remains the first-line option for thyroid storm, but recent evidence supports that beta-1 selective agents (metoprolol, atenolol) are equally effective and may be preferred in certain clinical contexts. The choice between propranolol and cardioselective beta-blockers should be...
How do you use IVC caliber and collapsibility to guide decisions about diuresis?
I use IVC caliber in conjunction with my lung exam to assist with the assessment of right and left atrial pressures respectively. The IVC assessment has many caveats in different patient populations, and evaluation with POCUS can be done in two planes to better understand IVC shape.Caveats - IVC siz...
Is there a specific criteria that you use to determine if a patient with respiratory symptoms should have a multiplex respiratory test performed?
If the patient is being admitted to the hospital, the information provided by this test can be useful with regards to antimicrobial stewardship (potentially avoiding antibiotic therapy or targeting it) and also with regards to infection control precautions. For outpatient scenarios, if respiratory s...
For locally advanced NSCLC, does endobronchial tumor debulking just prior to treatment influence your decision making regarding bronchial tissue constraints/expected toxicity?
Bulky, large endobronchial lesions both bleed and obstruct. The concern should be the length and depth of the tumor. If destruction of the trachea or bronchial tumor risks bleeding and B/P fistula, it may account for some of the hazards associated with “ultra-central” location. The endobronchial deb...
What strategies do you use to prevent overcorrection of serum sodium in patients with severe hyponatremia and adrenal insufficiency when initiating glucocorticoid therapy?
Treatment of hyponatremia due to adrenal insufficiency with glucocorticoid therapy may result in overcorrection of serum sodium due to suppression of ADH and resultant water diuresis. Therefore, serum sodium, urinary osmolality and urinary output should be closely monitored. A brisk water diuresis w...
Would you offer empiric lung SBRT for two growing FDG-avid lung lesions in a patient with severe COPD on oxygen?
This is a good question! The short answer is yes, most likely. Many patients are too high-risk to receive biopsies; this is decided by surgery/pulm/IR. Unless the patient has contraindications to RT or something like severe IPF (where treatment may be worse than the disease), I would likely offer th...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
Consideration of risk factors is important. Routinely, someone without these risk factors, and if getting a short burst of steroids, the GI prophylaxis is not given. PPIs carry certain risks, including increased risk of C. Diff infection or even pneumonia. So, they should be avoided if not indicated...
If there is trapped lung after a thoracentesis in an outpatient setting, in a patient who has stable vitals and no dyspnea, is there a role of overnight observation?
I am assuming this question came up because there was a pneumothorax post-thoracentesis, and you are suspecting entrapped lung.If you are confident that the patient has an entrapped (trapped) lung and remains completely asymptomatic, overnight observation or hospitalization is not necessary. In case...
What findings on routine monitoring PFTs prompt you to pursue HRCT in your patients with SARDs?
That’s an excellent question, and the strategy might vary somewhat by the specific SARD, but in general, in any SARD patient undergoing annual PFTs, the presence of any of these should prompt an HRCT to evaluate for the development of ILD. FVC drop ≥ 10% DLCO drop ≥ 15% Moderate decline in FVC (5-9...
How has COVID-19 altered your recommendations for invasive mediastinal staging for NSCLC?
I just had this discussion with our chief of interventional pulmonolgy at MD Anderson. Some of his faculty are being asked to staff our COVID-19 patient floor. In addition, bronchoscopy procedures should be considered high-risk procedures, and are required to have at least 45 minutes in between proc...