Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Should methotrexate be categorically avoided in RA patients with COPD or RA-ILD?
Thanks for raising a very important question. It is something that every practicing Rheumatologist comes across several times during their career.The traditional teaching has always been to avoid using Methotrexate in patients with underlying pulmonary conditions due to the associated risk of Hypers...
Should MTX be avoided in RA patients with asymptomatic lung nodules?
It is well established that in some RA patients, methotrexate does cause accelerated nodulosis predominantly in the hands which improves after stopping the medication. That does not mean having pulmonary nodules is a contraindication to use methotrexate. I recommend doing frequent chest x-rays for m...
How do you treat multisystem sarcoidosis refractory to methotrexate, humira, and remicade?
There are many layers to this question because there are many possible explanations for treatment failure. The first issue to consider is whether the specific features of sarcoidosis being treated are best addressed through an immunosuppressive approach. Some manifestations of sarcoidosis may be ind...
Would you consider prophylactic antifungal treatment prior to immunosuppressive therapies in a patient with previously treated pulmonary coccidiomycosis and residual parenchymal changes?
If the pulmonary coccidiomycosis was treated in the past, I would not necessarily prescribe prophylaxis, but that also depends on the meaning of "residual parenchymal changes.” If you’re referring to post-inflammatory fibrotic changes, then prophylaxis likely is unnecessary. If you’re referring to c...
When do you consider the use of steroids in the management of acute exacerbations in patients with cystic fibrosis?
Steroids have been shown to improve FEV1 and decrease hospitalizations when used as a maintenance treatment regimen in Cystic fibrosis patients. But due to the long-term adverse effects, steroids are recommended for daily use (Mogayzel et al., PMID 23540878).Small Pilot projects showed no statistica...
Do you consider bronchoscopic lung volume reduction in patients with homogenous emphysema?
The short answer to whether I consider bronchoscopic lung volume reduction (BLVR) in homogenous emphysema is yes. However, there is certainly some nuance.BLVR is gaining traction as a safer modality for lung volume reduction than a surgical intervention. Rather than undergo a partial lung resection,...
What is your approach to treatment of patients with fulminant C difficile infection who required ileostomy creation or colectomy?
Great question. If the entire colon has been removed, I do not see a role for oral vancomycin.
Is there a role for chronic suppressive oral or inhaled therapy for recurrent Burkholderia cepacia pneumonia causing frequent hospitalizations in a patient with severe bronchiectasis with or without underlying cystic fibrosis?
In certain cases, certainly, suppression may be the optimal role but in conjunction with modification to the immunosuppression. Generally, the immunosuppression will need to be lowered to allow for cellular immunity to combat the infection. Other factors include whether the gemovar is a more aggress...
What would be your approach to percutaneous intervention for acute plaque rupture and cardiogenic shock for a patient with cirrhosis and severe thrombocytopenia?
Thrombocytopenia is not an absolute contraindication to indicated percutaneous coronary intervention (PCI) and the antiplatelet therapy which it obligates. In a scenario such as this one -- cardiogenic shock complicating an acute myocardial infarction -- PCI is indicated as a life-saving procedure. ...
Do you routinely obtain a CXR or CT after identifying an etiology for dyspnea on POCUS?
Sometimes, it depends on the patient. I usually do a POCUS in a patient with dyspnea or respiratory failure. If I think there is an ILD or another disorder causing dyspnea, then I would get a CT.