Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your approach to counseling patients regarding re-initiation of anti-TNF therapy after completion of treatment for non-disseminated pulmonary histoplasmosis?
We published a retrospective study on this topic in 2015 (Vergidis et al., PMID 25870331). We concluded that resumption of TNF-alpha antagonist therapy may be considered in individuals treated for histoplasmosis who have no evidence of residual disease and undetectable Histoplasma antigen levels. We...
At what age do you stop LDCT chest for lung cancer screening?
One of Medicine's three priority-ordered duties is to postpone death. This also pertains to persons who have reached age 81. Lung cancer can occur longer than 15 years after cessation of smoking. Even if surgery can't be done, primary radiation of Stage 1 squamous cell lung carcinoma can result in p...
How do you approach treating and monitoring sarcoidosis manifested by maxillary bone/teeth loss without other symptoms?
I'm very curious how this was determined to be sarcoidosis. Has a PET been done to determine whether this is the only site? Other entities evaluated for like CRMO? Obviously, neoplasm and infection are also important to rule out before immunosuppressive treatment. Conversely, with our limited "tool ...
What steroid sparing agent do you use for treatment of cardiac sarcoidosis?
Recognizing that corticosteroids will be needed to acutely stabilize cardiac sarcoidosis, a steroid sparing agent is usually a reasonable choice early. My choice of secondary agents depends on the other manifestations of sarcoidosis present at the time of diagnosis. I have rarely seen cardiac sarcoi...
How do you manage MAT for opioid use disorder in lung transplant patients during the peri/postoperative period?
There is currently no evidence regarding mOUD in lung transplants. Available research represents generally a weak quality of evidence regarding opioid use for pain control before and after lung transplant. Non-opioid analgesic interventions, including thoracic epidural anesthesia and intercostal ner...
How do you manage concurrent non-life-threatening hemoptysis and acute pulmonary embolism?
Hemoptysis can occur with PE when there is pulmonary infarction. However, the majority of pulm embolism cases have pleuritic chest pain without infarction. Significant hemoptysis is very rare in these cases and anticoagulation is nearly always safe. When hemoptysis continues or the volume is concern...
What is your protocol for transitioning to oral anticoagulation post-thrombolysis for pulmonary embolism?
My answer has multiple parts."Thrombolysis" is not all the same. As studied in stroke treatment, alteplase causes marked fibrinogen depletion and coagulopathy (prolonged PT, aPTT), whereas tenecteplase doesn't so much (Huang et al., PMID 26514192).So, if alteplase was used (systemic or reduced cathe...
Do you recommend early oral nutrition when managing diabetic ketoacidosis?
There are many benefits to starting enteral feedings in patients undergoing treatment for DKA. Once insulin is being infused, the use of enteral nutrition will help suppress ongoing ketosis. Also, restarting nutrition will help prevent weight loss during recovery. Of course, some patients have condi...
Does your institution have formal policies or work flows to reduce unnecessary IGRAs ordered for patients on biologics?
We have developed a multi-specialty working group to implement this as a lot of unnecessary testing is getting done. This will include having a 2-3 question screening pre start of biologics, and then annually to asses risk, that we hope will be incorporated into the visit or an order set.
Is there a role for biologics to improve lung function in patients who have severe asthma with daily symptoms and reduced lung function but do not experience frequent exacerbations?
Biologic therapy in severe asthma not only reduce exacerbation but also improve lung function based on several RCT.