Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What are your top takeaways in Thoracic Cancers from ASCO 2022?
1. Abst 8502 - Quality metrics and survival after lung cancer surgery: More efficient work-ups and consistently high quality resections will likely do more to improve lung cancer survival than any adjuvant or neo-adjuvant therapy we can come up with. This is low-hanging, low-cost fruit. 2. Abst 9007...
What blood pressure targets do you enforce in the first 24-48 hours in a patient who develops an intracranial hemorrhage after mechanical thrombectomy?
Typically post-thrombectomy you encounter hemorrhagic transformation of an ischemic infarct. In this setting, I adjust the SBP goal to the classification of hemorrhagic transformation (HI-1, HI-2, PH-1 or PH-2). HI-1: No specific parameter; SBP goal adjusted according to TICI score. HI-2: SBP 120-...
Do you use bronchodilator response to distinguish between asthma, COPD, or asthma-COPD overlap?
Combined with eosinophil count and other pertinent history that supports a diagnosis of asthma or asthma/COPD overlap.
How do you adjust your management strategy to address the unique needs of anuric end-stage kidney disease patients when treating diabetic ketoacidosis?
There is no osmotic diuresis, and they do not need IVFluid, the opposite is true they may appear intravascularly overloaded, and will respond to insulin alone, they do not need HD for this. They will not be K deficient, do not give K. Their potassium will likely respond to insulin alone, and should...
Will you incorporate ensifentrine in the treatment regimen of patients with COPD on baseline dual or triple inhaler therapy?
Novel bronchodilator. ENHANCE 1 and 2 showed improvement of lung function but cost can be a factor. $2,950 per month.
What is the upper limit of blood glucose target in hyperglycemic critically ill patients?
I don't think there's much data that argues that setting the upper limit between 180 and 200 will make much of a mortality difference. The SCCM guidelines center around initiation of insulin infusions, and doesn't seem to say that we should start insulin infusions for BG>180, but tolerate it up to 2...
Is methacholine challenge on its way out?
I have not needed to order the challenge test for a long time now. I see the need for this test is declining.
Do you perform routine interval lung cancer screening in non-smokers who are 1st degree relatives of patients with non-smoking related lung cancers with known EGFR mutations?
I would not. Although there may be a measurable increase in the risk of lung cancer detected in population studies, the absolute risk is probably far below the equivalent of even a low-risk, current or former tobacco user. This is a hard conversation to have with people who believe their risk to be ...
What is your approach to therapy in patients with progressive Scedosporium pulmonary infection who are not candidates for surgical debridement?
Scedosporium species are increasingly common clinical isolates in patients with bronchiectasis (both CF and NCFBE). There are precious few publications describing these infections in immune-competent hosts, but it seems that these infections tend to be symptomatic (rather than asymptomatic colonizat...
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...