Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you approach the use of benzodiazepines in patients with chronic medical illnesses that may be susceptible to respiratory compromise (e.g., CHF, COPD, ILD)?
It’s a very good question and answers may vary among different specialty providers. Yes, a slow or gradual weaning of the benzodiazepines would be advisable. When they reach lower doses the taper should be even slower over weeks or longer. There is a risk for not weaning them off benzodiazepines inc...
When do you usually introduce conversations regarding tracheostomy placement in patients with refractory status epilepticus, or other conditions where one may anticipate delayed awakening?
It depends on the underlying pathology and how long the patient is expected to have impaired airway reflexes requiring prolonged mechanical ventilation. In the Setpoint 2 trial, among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy (</= 5 days), compare...
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...
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.
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...