Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you routinely discontinue atypical coverage in community-acquired pneumonia when PCR testing (i.e., respiratory pathogen panel) is negative for atypical organisms?
In community-acquired pneumonia (CAP), here is how I approach the decision to discontinue atypical coverage (e.g., azithromycin or doxycycline) when respiratory pathogen panel PCR testing is negative for atypical organisms (most commonly, Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneum...
What is your approach to differentiating RA-ILD from medication toxicity (I.e. from methotrexate)?
RA-ILD occurs in about 7-10% of patient with RA. It is more common in males and in those with a history of smoking. Most are seropositive. The typical pattern on HRCT in 50-60% of RA-ILD patients is a UIP pattern followed by NSIP, OP, and even LIP is some cases. An experienced clinician with the hel...
Do you routinely perform a pre-extubation bronchoscopy for secretion clearance during the index hospitalization in patients following lung transplantation?
Yes, this is routinely done on post-op day 1 and frequently repeated if the patient is not extubated on the first post-operative day after lung transplantation. This is typically necessary and done early in the post-op phase to clear out blood or debris from the airway that often accumulates in the ...
Is Metformin contraindicated in patients using long term oxygen therapy at home?
If a patient is stable at home without hypoxia on oxygen and eGFR is over 30 cc/min, I would be comfortable with prescribing metformin at a dose appropriate to the eGFR. Metformin should be stopped for any pulmonary decompensation or hospital admission.
Would you start octreotide in a patient with suspected sulfonyurea overdose but without frank hypoglycemia?
The data in the literature supports treating with Octreotide once hypoglycemia is present. Otherwise, a watchful, waiting period would be employed. It is reasonable to have a low threshold for its use once indicated, given how prolonged and profound the hypoglycemia can be in this situation.
How do you decide between neoadjuvant or perioperative chemoimmunotherapy, as per Checkmate 816 or KEYNOTE-671, for early-stage NSCLC?
All of us caring for patients with a lung cancer diagnosis face a very challenging “now what” scenario following publications of many studies demonstrating benefits of a neoadjuvant and/or perioperative approach for the treatment of patients with resectable NSCLC with already 2 FDA approvals of the ...
Have you used Karius to aid in the diagnosis of a non-resolving pneumonia, with negative bronchoscopy, biopsy, and other infectious work up in an immunocompetent patient?
Culture-negative hospital-acquired pneumonia is approximately 50%. Positive cultures are complicated by having to correlate results clinically as organisms may contaminate specimens (even if from a protected brush) and include an organism that doesn't even cause pneumonia, such as Enterococcus spp. ...
Do you routinely use 3% sodium chloride and desmopressin to correct hypovolemic hyponatremia in an asymptomatic patient with serum sodium of less than 120 mEq/L?
The challenge with hypovolemic hyponatremia lies in the fact that, upon correcting volume depletion, the kidney's capacity to excrete dilute urine returns, potentially leading to a rapid excretion of large volumes of dilute urine. In the case of an asymptomatic patient with a sodium level of 120 mEq...
What immunosuppression regimens do you use in patients with progressive RB-ILD despite smoking cessation and prednisone?
In patients with progressive RB-ILD who continue to worsen despite quitting tobacco use and prednisone, treatment options are very limited. Since there are no RCTs specifically studying immunosuppressive treatment in RB-ILD, most available evidence comes from observational studies, and most recommen...
What is your approach to bronchiolocentric interstitial pneumonia patterns observed on histology?
This histologic pattern involves fibrosis or other nonspecific inflammation involving the bronchioles and adjacent alveolar interstitium. It is important to point out that "bronchiolocentric interstitial pneumonia" is really not a distinct clinical entity but requires taking a variety of tools out o...