Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Is it clinically necessary to provide supplemental oxygen to patients with mild, asymptomatic hypoxemia only during activity while they are recovering from an acute respiratory illness?
My practice is to withhold supplemental oxygen in patients with mild, asymptomatic hypoxemia during exertion when the underlying condition is expected to improve. I am not aware of strong evidence supporting the benefit in these cases, and I believe the potential harms generally outweigh any theoret...
Do you target a lower goal driving pressure in older patients with ARDS?
I target the lowest possible driving pressure to maintain adequate ventilation. This includes decreasing tidal volumes within physiologic range as well as PEEP titration. I use a modified “Brazilian” method described by Amato. important to consider when doing the titration that you may need to abort...
Is the combination of a negative BAL PJP PCR and normal fungitell enough to rule out PJP pneumonia in an at-risk non-HIV patient?
Yes
Do you ever consider close clinical monitoring over antifibrotic therapy in patients ascribed an MDD diagnosis of IPF who have normal lung function and are asymptomatic?
Idiopathic pulmonary fibrosis is by definition a progressive disease with high mortality, thus, clinical practice guidelines would recommend treatment at diagnosis. Based on US and UK epidemiologic studies, IPF has an average life expectancy of 3-4 years without antifibrotic treatment. Furthermore, ...
Do you always stop dexamethasone at discharge for patients admitted with COVID requiring respiratory support (as done in the RECOVERY trial), or are there situations in which you will prescribe it to complete a 10-day course?
Great question. Generally, I don't continue dexamethasone if they are no longer wheezing or generally feeling back to their baseline. Sometimes, I will extend the course if the patient has been in the hospital several times for COPD, just to see if I can keep them out of the hospital longer. But the...
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, ...