Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
In a patient with low titer +anti-SAE antibody and known ILD, but no other clinical features of dermatomyositis, how would you approach further testing or would you treat the patient as dermatomyositis associated ILD?
When someone with ILD has an isolated biomarker without other clinical features associated with that biomarker, I have to ask myself these questions: first, is the biomarker simply a false positive because I have tested a plethora of biomarkers and second, is ILD the initial or only manifestation as...
How long do you continue surveillance with imaging and sputum cultures in a patient with NTM with no indications for treatment?
Since NTM lung disease typically develops over years, it is reasonable to monitor the patient with periodic HRCTs, even if the patient is relatively asymptomatic. I typically do this every 12 months in an otherwise stable patient. The reason for this is because we know that in up to 2/3 of patients,...
What is the minimum daily duration of supplemental oxygen therapy you recommend to patients with chronic hypoxic respiratory failure?
I think the REDOX trial has changed the landscape of long-term oxygen therapy, and I would now advise most patients to use oxygen a minimum of 15 hours/day. In patients with particularly severe hypoxemia, e.g., patients whose PO2 on room air is in the 30's, I would advise them to use oxygen for as c...
Which class of biologic agent do you use first in a patient with asthma who may qualify for multiple drugs?
This is a situation where shared decision making with the family is best. It would be helpful to discuss what the patient's and families' goals or priorities are. For instance, if the patient is on chronic steroids or receives multiple courses, studies have shown that mepolizumab, benralizumab, and...
What is your preferred regimen for remission induction and maintenance in EGPA with cardiac involvement?
Cardiac involvement in EGPA is associated with a poor prognosis and is an independent predictor of mortality. Therefore, it needs to be treated aggressively. Depending on the study, between 15-30% of EGPA patients present with or develop cardiac manifestations. The manifestations are highly variable...
How do you approach induction immunosuppression in patients with high PRA undergoing lung transplantation?
At my institution, if PRA >30%, we perform preoperative plasma exchange and administer preop eculizumab along with our standard preop basiliximab and methylprednisolone. If the crossmatch is positive, we subsequently perform daily plasma exchange followed by eculizumab for the next four days. Then, ...
Do you use intrapleural tPA/dornase in loculated effusions that are not due to infection?
The use of tPA ONLY has been reported in patients with a complicated pleural fluid collection, not due to infection (Heimes et al., PMID 28616283). The dose was 6 mg in 50 mL of normal saline instilled via a pleural chest tube. However, lower doses have been used (Thomas et al., PMID 25742001).
Which biomarkers or diagnostic tools do you prioritize to support the decision to start antifungal treatment in septic patients with no clear source of infection but at high risk for fungal infections?
In general terms we do not use biomarkers to decide to start antifungals in a septic patient. We use them to confirm or rule out the infection once the antifungals were started based on clinical suspicion/presentation. BDG in particular has very good negative predictive value for candidemia, but due...
Do you routinely recommend a sleep study in patients with clinical history of REM-sleep behavior disorder?
I do routinely recommend and perform in lab sleep testing for patients with suspected REM behavior disorder (RBD). The finding of REM sleep without atonia (RSWA) is supportive of a diagnosis of RBD, as atonia is normally presented in individuals (without RBD) during REM sleep. RBD can be a tricky di...
What features on PFT or flow-volume loops do you look at to suspect small airway dysfunction?
I would strongly advise against using the flow-volume loop to diagnose small airway dysfunction. It is difficult if not impossible to visually distinguish between small airway dysfunction and normal aging (I would point out that part of normal aging involves changes in small airway function). Althou...