Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
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...
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...