Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you use sitting vs supine spirometry to consider tracheostomy in a patient with Amyotrophic Lateral Sclerosis?
The decision to pursue tracheostomy is becoming less of a choice altogether in our practice. However, to answer your question once my patients are on NIPPV I don't routinely subject patients to supine spirometry for prognostic follow-up, given the high risk-benefit ratio of transferring a patient wi...
Is there any role for prophylactic bronchial artery embolization in immunocompromised patients with invasive pulmonary aspergillosis?
Bronchial artery embolization is NOT without complications. Although the bleeding risk is very high in invasive pulmonary aspergillosis, empirical embolization is not well supported either by data or clinical practice. It probably should be a case-by-case decision.
Is there a risk of hepatitis C activation with rituximab in a patient who has a history of HCV treated with antivirals and who is in sustained viral response?
In general, the risk of HCV flare with immunosuppression in general including rituximab must be viewed as minimal for those who have achieved a sustained virologic response (Undetectable HCV RNA ≥12 weeks after treatment completion) and does not influence my therapeutic decision-making if the patien...
Would you give T-DXd to patients with resolved drug-induced ILD from other agents such as prior chemo/targeted therapy/immunotherapy?
Depending on the pathophysiology and prior offending agent, I would consider treating such patients with TDxd. Ado-trastuzumab emtansine has been rarely associated with ILD; in this particular case, ILD caused by another HER2-targeting ADC, unless it was grade 1, I may not consider challenging the p...
Do you wait until serum anti-GBM antibody titers are undetectable before hospital discharge in a patient with anti-GBM antibody disease with renal involvement who is receiving daily plasmapheresis, cyclophosphamide, and steroids?
If such a patient is responding to treatment, titers are declining, is otherwise doing well, and does not have extra-renal issues that would require hospitalization, for example, an ongoing oxygen requirement for lung involvement, they could be managed as an outpatient if pheresis can be arranged. I...
Have you adopted the use of low dose morphine for treatment of cough in patients with IPF?
Yes, I selectively use low-dose morphine for the treatment of chronic cough (lasting more than 8 weeks) in certain patients with idiopathic pulmonary fibrosis (IPF).This includes individuals who demonstrate somewhat preserved lung function (specifically, a forced vital capacity [FVC] of 45% or more ...
Should the RSV vaccine be administered to pregnant mothers even if it is not seasonally circulating but they are 32-36 weeks pregnant?
Here is the official CDC/ACIP recommendation (accessed 3/30/2025): "CDC recommends one dose of Pfizer’s Abrysvo for women who are 32 0/7 weeks’ through 36 6/7 weeks’ gestation. Pregnant women who are more than 36 weeks 6 days pregnant should not be vaccinated, as it is unlikely there will be enough ...
Do you consider extensive clot burden as a factor in determining whether patients with submassive PE may be appropriate for thrombolytic therapy?
I don't either. I think it is fairly clear that mortality in PE correlates to hemodynamic effect and RV function, rather than clot burden (see Hariharan et al., PMID 27742425; Furlan et al., PMID 22993221), likely related to acute pulmonary hypertension caused by endogenous elaboration of such media...
Do you routinely check an Allen's test before placing a radial arterial line?
If for whatever reason, both radials cannot safely be cannulated, the next best site would be femoral. If either femoral sites are not accessible, brachial and axillary would be the less than ideal. You are correct, the data regarding Allen’s test utilization is not robust.
How will you use tocilizumab in the treatment algorithm for SSc-ILD, given its recent FDA approval?
I am excited that we finally have evidence for an effective therapy to treat SSc- ILD. Scleroderma is among the most challenging diseases facing the rheumatologist and over the years we have failed in our efforts to identify potentially effective treatment options for patients, especially those with...