Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
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?
The answer is yes; thinking outside of transplant, CF or not CF, this tends to be a serious gram-negative bacteria with some caveats on genomovar about how virulent they can be; however, if they cause frequent exacerbations, then chronic suppression can be considered to prevent them; what to use is ...
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.
Have you incorporated the use of linezolid in lieu of vancomycin plus clindamycin for empiric treatment of necrotizing fasciitis?
Clindamycin (with beta-lactam) vs linezolid use debate exists for severe invasive GAS infections like necrotizing fasciitis cases. Both inhibit protein synthesis via the 50s ribosome subunit, inhibiting translation and, thus, toxin production. The concern is rising clindamycin resistance in GAS isol...
Is there a role for the use of biologics as steroid sparing agents in treating patients with ABPA who are intolerant to prednisone?
Treatment for ABPA is generally guided by IgE levels and corticosteroids remain the main drug therapy regardless of classification in both people with cystic fibrosis (CF) and without. Limited treatment with antifungal therapy (itraconazole or voriconazole) is considered usually first in individuals...
Can intra-abdominal pressure serve as a surrogate for pleural pressure to titrate PEEP in obese patients or those with intra-abdominal hypertension?
No. Duomarco and Rimini in 1947 clearly established the presence of regional abdominal pressures.
Is there increased risk with lung SBRT in a patient who has a mild asymptomatic pneumothorax in the field after CT-guided needle biopsy?
I'd be curious what others thought but my quick thought is probably not. If I can extrapolate (i.e., make up) what might be the course of events and what you might want to consider... You send a patient for bx to confirm malignancy and see them right after for sim. The patient is noted by IR to have...
How do you approach biologic initiation in patients with inflammatory arthritis and repeatedly indeterminate Quantiferon?
This is an unusual but anxiety-inducing situation. Remember that an "indeterminate" Quantiferon is not an "intermediate" Quantiferon. It's not half-positive, it's uninterpretable. The result provides absolutely no reason to be more or less concerned that the patient has lTB, latent or otherwise. I a...
How do you approach the treatment of indeterminate UIP on HRCT with grossly positive MPO antibody and no other features consistent with AAV?
We see these patients in our combined ILD/Rheumatology and would treat with immunosuppressive therapy. The indeterminant UIP is likely NSIP although UIP is not an uncommon pattern seen in these patients. ILD can be the presenting manifestation in ANCA-ILD in 14-85% of ANCA vasculitis patients depend...