Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you decide whether to use lung POCUS versus CT as the next step when a chest X-ray is equivocal for pneumonia?
Lung ultrasound is a quick, safe, and inexpensive test to perform. If the patient already has a chest X-ray and it is equivocal for pneumonia, I always perform a lung ultrasound. It is useful for evaluating an inflammatory vs. non-inflammatory interstitial process. It is better than an X-ray to dete...
In which cases would you consider early transition to DOAC (within 72 hours) for hospitalized patients with intermediate or high risk PE?
Two DOACs are FDA-approved for early use (within 72 hrs), rivaroxaban and apixaban. The PEITHO-2 dabigatran cohort study included no comparison group (its authors called it a "trial"?) and required "72 hrs" parenteral anticoagulant before dabigatran but the small print in its Lancet Haematology show...
How might the introduction of brensocatib as a treatment option impact the use of other anti- inflammatory or antibiotic therapies currently employed in bronchiectasis management?
I would hesitate to add brensocatib in someone on asthma biologics. In the ASPEN trial for brensocatib, patients with a "primary" diagnosis of asthma were excluded from the study. I would not have any problem with adding brensocatib if they were on chronic azithromycin (around 20% of the patients re...
Are there factors that would prompt you to consider the use of methylene blue in refractory septic shock?
I usually don't consider using it unless all other options are exhausted. Although there is date that shows decrease in pressor needs, there is no data that shows any clinical improvements, and specifically no improvement in mortality. It is not part of my algorithm for refractory shock.
What is your approach to managing ILD associated with inflammatory bowel disease?
We must first convince ourselves that the "ILD" relates to the underlying IBD. Patients may be on an immunomodulating regimen that increases the risk of opportunistic infections. The regimen itself may cause diffuse pneumonitis. Environmental/occupational exposures may also play a role. Armed with c...
In massive transfusion protocol from suspected hemorrhage, is it worth obtaining a TEG to guide transfusion?
There really is no evidence (except expert opinion) on massive transfusion protocols and outcomes. There are a few trials showing that TEG or other viscoelastic tests reduce transfusion and even improve survival or other important outcomes in hemorrhage. So given the choice, if rapid point of care T...
Do you use spO2 to define ARDS in patients with darker skin pigmentation?
That's an excellent question and highlights some different approaches to define, and thus provide appropriate early treatment for, patients with ARDS.For many years, clinicians have been using a framework designed in 2012 and referred to as the Berlin Definition to define and classify ARDS (Ranieri ...
Do you ever stop tobramycin prophylaxis in a patient with chronic bronchiectasis previously colonized with pseudomonas?
Yes, I will often stop tobramycin if there are issues with tolerance, antibiotic resistance, or treatment fatigue. Further, in more mild bronchiectasis (cylindrical vs. varicoid or cystic morphologies), sputum bacterial cultures will negatively convert on chronic cycled inhaled tobramycin, and this ...
How do you manage persistent pseudomonas positive sputum a patient with non-CF bronchiectasis who has chronic sputum production but is otherwise asymptomatic?
I am assuming the Pseudomonas has persisted despite efforts to eradicate early on; if not, I would consider at least an effort at "eradication" or at least aggressive treatment. If the Pseudomonas has persisted and the person feels well other than sputum production, would aggressively pursue airway ...
What is your preferred forceps size for transbronchial biopsies, considering options ranging from 1.8 to 2.8mm?
This question depends on the clinical situation. Generally speaking, I'll use a forceps that is 1.9mm in diameter for most cases, as it has the ability to fit through any of our bronchoscopes and can usually provide adequate tissue. Occasionally, if more tissue is required, you can consider the use ...