Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
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 ...
How do you mitigate the risk of inadverdent under or over diagnosis of COPD in certain populations with transition to race-neutral spirometry reference equations?
Hi - I use the GOLD guidelines of fixed (rather than % predicted) FEV1/FVC ratio of < 0.7 to define obstruction for COPD. Most of the major studies in forming COPD treatment have used the fixed ratio. There is a risk of overdiagnosis in an older population with the fixed ratio, but in an older indiv...
Do you choose an antibiotic with CSF penetration, such as nafcillin over cefazolin, in the setting of MSSA endocarditis with septic emboli to the brain (assuming no concomitant meningitis or brain abscess)?
The prevailing theory that cefazolin has poor CNS penetration is really based on 3-4 studies performed in the 1980s (Nolan & Ulmer, PMID 7365282) where they were extrapolating data from studies looking at cephalothin concentration in CSF. Another study looking specifically at cefazolin concentration...
What is the role of mechanical circulatory support in mixed cardiogenic vasodilatory shock?
To structure management for any individual patient with "mixed" shock, it is prerequisite to define the nature, sequence and contributors to the admixture of circulatory derangements. Temporary mechanical circulatory support (tMCS) provides hemodynamic value for patients with a critical insufficienc...
What factors influence your decision to initiate antifungal treatment in asymptomatic lung transplant recipients colonized with Aspergillus?
My main driver for using Aspergillus treatment/prophylaxis for asymptomatic colonized patients is their level of immunosuppression; if they have received augmentation for rejection or because of a treatment for cancer, I would strongly consider treatment; another reason would be if they are listed f...