Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you manage steroid-refractory immune checkpoint inhibitor induced pneumonitis?
Steroid-refractory immune checkpoint inhibitor (ICI)-induced pneumonitis is managed with high-dose steroids plus an additional immunosuppressive agent, like infliximab or intravenous immunoglobulin (IVIG) among others. I recommend early immunomodulatory escalation as multiple studies have shown that...
How do you approach the workup of subcentimeter contralateral nodules in cases of locally advanced NSCLC?
These are often challenging questions/issues in our multimodality discussions. A couple of "general" principles/considerations. I would try, if at all possible to prove the presence of metastatic disease, however in the case of sub cm contralateral nodules, this is, as the question alludes to, not a...
Is there any utility to trending Histoplasma serology titers to guide duration of therapy or treatment response for pulmonary histoplasmosis with negative urine antigen?
Serology unfortunately is not useful to monitor response to therapy as the fall in titers is often very slow. In immunocompetent individuals, titers will often take a few years to show a significant drop in the antibody titer after successful treatment. The treatment duration should be guided by the...
When do you consider switching from another biologic to benralizumab in patients with severe eosinophilic asthma with a history of suboptimal response to previous biologic agents?
Hi - I would consider after a few months. I personally have had considerable success with benralizumab in patients with severe eosinophilic asthma and it is generally my first line agent.
What is your approach to evaluation and management of GERD in a patient with IPF?
When evaluating GERD in a patient with idiopathic pulmonary fibrosis (IPF), I prioritize obtaining a detailed history of GERD symptoms, as this aids in guiding both diagnostic and management decisions. Many IPF patients may not exhibit classic GERD symptoms like heartburn or regurgitation. Instead, ...
Do you have any strategies for increasing yield while doing bronchoscopic biopsy with EBUS?
Rapidly advancing the needle forward during agitation while performing EBUS can improve sample quantity. Tumor cells are often very sticky, so keeping the needle on the same plane allows it to first shear the cells from the surrounding tissue. The repeated back-and-forth motion, combined with suctio...
Do you consider the use of tocilizumab in patients with COVID pneumonia who have had an improvement in supplemental O2 requirements but have significantly elevated inflammatory markers after day two of remdesivir and dexamethasone?
I don’t use tocilizumab if the clinical condition is improving.
Do you integrate inhaled colistimethate sodium into existing treatment regimens for patients with bronchiectasis and PSAR infection?
I agree with Dr. @Dr. First Last. I also consider inhaled colistimethate sodium in addition to tobramycin and aztreonam when developing treatment regimens. Of note, while the inhaled route of antibiotics can decrease the risk of side effects in other parts of the body (nephrotoxicity, ototoxicity, e...
Do you start immunosuppression for enlarging pulmonary nodules without symptoms, impaired pulmonary function, or extra-pulmonary disease in a patient with sarcoidosis?
First consider whether further diagnostic workup is necessary, to increase your confidence that enlarging nodules, changing pulmonary function, or extrapulmonary disease is due to sarcoidosis. Sarcoidosis patients have an increased risk of cancer in the early peri-diagnostic period, likely due to th...
Is there a role for biologic therapies in asthma-COPD overlap syndrome with evidence of type 2 inflammation?
While there are ongoing studies regarding the potential role of biologics in COPD care, to date, the data remains unclear. The whole issue of COPD/ asthma overlap syndrome remains controversial and I know of no clear data defining a role of biologics. However, I would suggest that the stronger the a...