Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What would prompt you to consider a sleep study for narcolepsy in a child or adolescent with new-onset hallucinations?
It would depend on other elements of the history. The age of the child, the timing of the hallucinations, particularly if they are associated with sleep, onset or awakening, other hypersomnia disorder symptoms, and the child's psychiatric history. Generally, I have a very low threshold for an in-lab...
Do you recommend careful correction of serum sodium to avoid osmotic demyelination syndrome in patients who are found to have isoosmolar hyponatremia in the setting of an elevated BUN level?
Urea is an ineffective osm and so if the blood is "isoosmolar" in the setting of hyponatremia but is isoosmolar because of an elevated BUN it may be isoosmolar numerically but not physiologically. I would ignore the BUN in making my decision. I would not ignore the BG though if it were elevated.
Which patient characteristics or scenarios drive you to choose tezepelumab over dupilumab for asthma?
I typically put adult patients with T2 high, and allergic phenotype on dupilumab whereas those that are T2 high only or T2 low are on tezepelumab. Additionally, if the patient has nasal polyps or AD, then I would prefer dupilumab over tezepelumab. I always have a discussion with the patient regardin...
How do you manage persistent insomnia despite ASV titration in patients with complex sleep apnea?
It is an excellent question, and I am not sure if I have a perfect answer. The first question I would have is if the insomnia pre-dated the treatment-emergent central sleep apnea. It is assumed if they are on adaptive servo-ventilation (ASV) that they already tried CPAP, had treatment-emergent centr...
How do you approach the management of patients with mildly elevated mPAP (21-24 mmHg) and PVR (2-3 WU) who may be at risk of progression, given the recent changes in the hemodynamic definition of pulmonary hypertension?
The "new" definition of PH with a cutoff of 20 mmHg is a very sensible change, based on the study by Kovacs et al., PMID 19324955, which showed that a mean PAP of 20 mmHg is already two standard deviations above the mean PAP in normals. Thus, the cut off of 20 mmHg makes more sense than 25 mmHg.To a...
Is there a role for the use of transient elastography (FibroScan) to monitor liver fibrosis in patients on long term methotrexate?
Liver elastography is a useful tool to use when assessing the potential hepatotoxicity of various drug therapies. Traditionally, methotrexate accounted for nearly all the hepatotoxicity issues that we faced; however, we can add many other drugs to that list. Virtually, every immune suppressive drug ...
How do you sequence pharmacologic treatments for primary insomnia?
First, be sure you have already addressed deficiencies in sleep hygiene: Room at 65 degrees F Wearing earplugs Complete darkness (no visible hand in front of face) No clock Golden hour before bed ETOH, nicotine, and caffeine reduction with cessation of 4 hours before bed Writing a list of worries B...
How would you manage symptomatic, bilateral subsegmental PE developed after long air travel?
I generally consider air travel to be a relatively weak provoking factor. Although the 2020 ASH guidelines do not address this, the ASH Guidelines from 2018 on management of VTE cite a 2.8-fold increased risk for VTE associated with air travel, which is roughly similar to the increased risk associat...
Are there instances where tracheostomy alone without mechanical ventilation can be sufficient to manage neuromuscular respiratory failure?
This is a very rare circumstance in our assisted ventilation clinic. This situation usually arises because a patient underwent tracheostomy during an acute illness while they were requiring invasive ventilatory support, and were able to wean from the ventilator but had dyspnea or hypercarbia while t...
How do you determine if pulmonary hypertension is disproportionate to the severity of lung disease?
This is a question we faced on a daily basis in our PH clinic. Patients with parenchymal lung disease like COPD or ILD would get an echocardiogram that showed an elevated RVSP and/or RV dilation/dysfunction and will be referred to our clinic for PH evaluation. Alternatively, the patient already unde...