Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you choose roflumilast vs ensifentrine in COPD patients with dyspnea despite adequate LABA + LAMA (+ ICS therapy where indicated)?
Hi - I don't think there is a clear answer for this. However, in my practice I rarely use roflumilast for dyspnea (mostly for exacerbation prevention). I have been trying ensifentrine in some of these dyspneic COPD patients, in part because they are wanting to "try something new". So far, I have see...
What is your preferred agent for fungal prophylaxis in a patient post lung transplant with abnormal LFTs?
Isavuconazonium tends to cause less elevations in LFTs.
What additional workup do you pursue in a patient in whom you suspect Yellow Nail Syndrome?
Mandatory pulmonology (and/or ENT for sinusitis) for comorbit workup or monitoring. Detailed ROS for eval of any underlying disease and workup as indicated. Age-appropriate cancer screenings.
How do you manage resistant infections that persist after stopping antibiotic therapy in patients with non-CF bronchiectasis?
It depends on what is meant by resistant infections; if this means multi-drug resistant bacteria that remain present after treatment ends and when symptoms have returned to baseline, there are many things to consider. First, has the person had many exacerbations before? Or do they have minimal sympt...
How do you plan to integrate sotatercept into the current treatment algorithm for PAH, particularly in patients who are stable on existing therapies?
Sotatercept gained FDA approval to increase exercise capacity, improve WHO functional class, and reduce the risk of clinical worsening events e.g., hospitalization for worsening PAH. The pivotal clinical trials enrolled a subset of Group 1 PAH patients who were stable for an extended period on PAH t...
Do you adhere to the standard 5-day minimum treatment duration for community-acquired pneumonia, or have you used shorter courses for certain low-risk patients?
This is a question addressing a shorter duration of antibiotic therapy than the current IDSA guidelines for community-acquired pneumonia (CAP) recommend. It has been the topic of several studies, for example, 3-day treatment (Richard T. Ellison III, MD, reviewing Dinh et al., PMID 33773631; Niederma...
In a patient with severe hyponatremia and acute kidney injury in the setting of hypovolemic shock, would fluid resuscitation take precedence over the rate at which sodium is corrected?
Normal saline, or a balanced fluid, e.g., Lactated Ringers or Plasmalye, if you are believers in balanced fluids. Shock trumps ANY concerns over rate of Na rise. Also if someone is in shock they are not going to have a water diuresis from volume.
When do you stop dantrolene in a patient with neuroleptic malignant syndrome?
Dantrolene is typically used to treat severe NMS, although the data supporting its use is mixed. The biggest risk with the therapy is hepatotoxicity. It is reasonable to discontinue dantrolene once the hyperthermia and severe muscle rigidity have resolved, or earlier if there is concern for liver in...
What is your approach to the management of persistent hydropneumothorax due to a non expandable lung?
This depends on the clinical scenario and really, relating to patient factors. For instance, if a patient is young without many co-morbidities and the non-expandable lung is related to a 'benign' etiology (i.e. empyema that has resolved and is now a transudative effusion), then surgical consultation...
Based on findings of the INCREASE trial, are you routinely prescribing inhaled treprostinil to patients with group 3 pulmonary hypertension secondary to interstitial lung disease?
As a brief background, the INCREASE trial (Waxman et al., PMID 33440084) was a randomized trial in patients with pulmonary hypertension due to interstitial lung disease (PH-ILD) assessing the effect of inhaled treprostinil versus placebo on change in 6-minute walk distance at 16 weeks. The study enr...