Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
In patients with severe asthma who are candidates for biologics, do you put them on an ICS/LABA/LAMA rather than high dose ICS/LABA?
Assuming adherence to ICS/LABA, I would use high-dose ICS/LABA if FENO is high, especially if they have exacerbations. I would add Triple Rx in patients with low FENO, especially in the presence of obstruction on spirometry.
Would you offer empiric lung SBRT for two growing FDG-avid lung lesions in a patient with severe COPD on oxygen?
This is a good question! The short answer is yes, most likely. Many patients are too high-risk to receive biopsies; this is decided by surgery/pulm/IR. Unless the patient has contraindications to RT or something like severe IPF (where treatment may be worse than the disease), I would likely offer th...
In cirrhosis patients with borderline pre-transplant PVR (≈2–3 WU), what additional findings (e.g., mPAP/TPG, pulmonary artery compliance, RV strain on echo, DLCO) prompt you to treat this as higher risk and arrange closer follow-up or PH-center referral rather than reassuring the transplant team?
Agree that recent data do suggest that pulmonary vascular resistance (PVR) 2 to 3 Wood units should be followed carefully in patients who are liver transplant candidates.Using historical data and International Liver Transplant Society (ILTS) Guidelines, mean pulmonary arterial pressure (mPAP) < 35 m...
How would you manage a patient with necrotizing pneumonia due to a susceptible Pseudomonas aeruginosa strain who continues to have significant purulent secretions and worsening imaging while receiving cefepime?
I agree, not enough information here to make a firm recommendation, but often times these necrotic pneumonias will undergo significant liquefactive necrosis, and all of that dead lung and purulence has to come out through the mouth. I tell patients that they may have a worse cough for a while, and t...
How do you taper dopamine agonists for RLS in patients experiencing augmentation?
Slowly. Abrupt withdrawal from agonists can cause mood dysregulation (dopamine agonist withdrawal syndrome) and in RLS patients, would likely exacerbate RLS symptoms.Adding gabapentin to the regimen prior to slow withdrawal of the agonist would probably help avoid worsening RLS symptoms during this ...
What factors would encourage you to choose abatacept vs tocilizumab in a patient with RA-ILD with a UIP pattern of pulmonary fibrosis?
The available literature on abatacept and tocilizumab in RA-ILD does not provide a definitive answer and hopefully with the general increase in interest in ILD we will have more definitive data in the near future. My review of the current literature suggests that abatacept has a slightly higher perc...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
For locally advanced NSCLC, does endobronchial tumor debulking just prior to treatment influence your decision making regarding bronchial tissue constraints/expected toxicity?
Bulky, large endobronchial lesions both bleed and obstruct. The concern should be the length and depth of the tumor. If destruction of the trachea or bronchial tumor risks bleeding and B/P fistula, it may account for some of the hazards associated with “ultra-central” location. The endobronchial deb...
How do you manage a cytology-negative pleural effusion that develops after lung RT?
I think most times you can just watch them as long as they are stable and not symptomatic. I see them not infrequently after RT, especially lung SBRT, and find they often find a size they feel comfortable with and don't change much over time. I wonder about their physiology... my impression is there...
How do you counsel eligible patients on lung cancer screening who are hesitant because of the cancer risk from CT scans?
This is simple. The risk of lung cancer in patients who have smoked for >20 years is orders of magnitude higher than the theoretical risk of medical X-ray-induced cancers from low-dose CT (LDCT) screening. A typical LDCT scan exposes patients to approximately 1.5 mSv of radiation, equivalent to abou...