Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you routinely use milrinone to augment RV function in patients with massive pulmonary emboli on vasoactive support?
Recent data in experimental acute PE suggest that levosimendan and milrinone showed similar and beneficial hemodynamic profiles – reducing RV afterload and improving RV function without increasing RV mechanical work. (Dobutamine increased CO, but at the cost of an increase in RV afterload and RV mec...
What is your approach to PEEP titration in the management of a morbidly obese patient with ARDS?
Unfortunately, there is no definitive evidence on how to best adjust positive end-expiratory pressure (PEEP) in morbidly obese patients with acute respiratory distress syndrome (ARDS) as patients with a body mass index (BMI) of greater than 35 kg/m2 were excluded from most of the large clinical tria...
Do you treat patients with culture positive mycobacterium abscessus if they are asymptomatic and do not have progression on imaging?
If by "symptomatic," the assumption is that patients have a productive cough, malaise, fatigue, and weight loss, they should be treated per protocol. We usually proceed with "shared decision making" discussing the nuances of untreated versus treated scenarios.
Do you routinely perform echocardiography in patients with Staphylococcus aureus bacteremia deemed low risk for metastatic infection, or do you selectively omit it based on specific clinical criteria?
A limitation of the applicability of this study is that no isolates of MRSA were detected. Thus, there would be no strains, such as USA300-like strains, with both virulence and resistance mechanisms. In this situation, the goal is to avoid morbidity and mortality from a uniformly deadly disease: S. ...
How do you follow pulmonary embolism patients who have completed anticoagulation?
3 months after sustaining an acute PE, I asked the patients if they were back to their pre-PE level of functional capacity. If they are not, i.e. if they remain dyspneic, I get an echocardiogram and a VQ scan. If the echo during the acute PE shows RV strain or evidence of pulmonary hypertension, I r...
What is the current practice regarding the use of GLP-1 agonists in patients listed for lung transplant and in the post-transplant period?
We currently bring all potential recipients on our lung transplant list off GLP-1 agonists prior to listing, and we confirm a normal solid gastric emptying scan at the time of listing, about 1 month after being off the drugs. We have used G: P-1 agonists to facilitate weight loss to our target listi...
How do you integrate dd-cfDNA into the evaluation and management of ACR in lung transplant recipients?
We have been using dd-cfDNA in the context of a clinical investigation during the first-year post-transplant. We haven't yet used it outside this context but we are planning to after our institution sets up a payment mechanism to do so. We have been obtaining dd-cfDNA at 3 mo intervals during the fi...
Do you favor transthoracic needle biopsy or navigational biopsy for diagnosis of intermediate risk pulmonary nodules?
I agree as well. The Veritas trial just published in the NEJM confirms that navigational bronchoscopy is non-inferior to CT guided needle biopsy (with some limitations) even without the use of intra-operative cone beam CT or cryobiopsy which increase the diagnostic yield even further and would likel...
Do you favor ETI (Trikafta) or VTD (Alyftrek) for patients with CF eligible for either drug?
For patients eligible for both medications who have not started either, I currently have equipoise; VZD appears to be slightly better in a mechanistic way (better sweat test on trials) and is once daily; however, ETI has 5.5 years of experience after approval, so we know what to expect; I suspect ov...
What is your approach to radiographically suspicious lung nodules for which initial biopsy was negative for malignancy?
It depends on how suspicious the nodule is for malignancy clinically and on the biopsy. The following criteria play into my decision-making: If the kinetics (steady growth over multiple scans) and morphology (solid and spiculated) on CT as well as hypermetabolism on PET-CT are highly suggestive of ...