Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you perform routine interval screening for pulmonary fibrosis in individuals who have been identified through genetic testing as being at risk for developing pulmonary fibrosis but don't exhibit any signs or symptoms?
Screening for pulmonary fibrosis: Only "yes" for individuals with one or more family members with IPF and age >50 - HRCT findings of ILAs, fibrotic ILAs, or IPF will be identified in 20% of these individuals. No for all other individuals including those carrying various high-risk alleles such as M...
In light of the RECITAL study, would rituximab be a reasonable choice in a patient with PL-12 antibodies, rapidly progressive pulmonary disease with organizing pneumonia on biopsy?
The findings from the RECITAL study have confirmed the validity of our clinical approach, advocating for rituximab as the primary treatment for CTD-ILD, considering the elevated risks associated with the use of cyclophosphamide. Therefore, it is entirely justifiable to opt for rituximab in cases of ...
In patients being evaluated for brain death, which abnormal movements are definitively known to still be consistent with brain death and which are possibly consistent with brain death but lack definitive evidence?
This is indeed a challenging question, one that I continue to grapple with as a neurointensivist. Fortunately, most brain-dead patients do not exhibit any movements in response to noxious stimuli, but some case series report reflexive movement in up to 75% of cases. The classic teaching is that only...
Would bag-mask ventilation with a PEEP valve be a reasonable alternative to NIV for pre-oxygenation prior to intubation in settings where NIV is not easily accessible?
The PREOXI trial does not inform the use of a bag-mask device with a PEEP valve. Many invasive mechanical ventilators are capable of delivering noninvasive ventilation using the same mask that the bag-mask device uses.
How do you identify which patients are at highest risk for decompensation and most likely to benefit from NIV for pre-oxygenation prior to intubation?
Prior to this study, I would periodically use NIV pre-oxygenation for patients not already on NIV for respiratory failure if they were requiring high levels of FiO2 (>50% FiO2 on HFNC, or >6-8L nasal cannula/face mask), were very obese, or had other predictors of a difficult airway.In the PREOXI stu...
Is there a subset of patients in whom pre-oxygenation with NRB or BVM could be safely pursued?
Preoxygenation using an oxygen mask that does not provide positive pressure may be appropriate in patients who have a contraindication to noninvasive ventilation such as patients with active emesis. However, one of the key findings of the PREOXI trial was that preoxygenation with noninvasive ventila...
Does the experience level of the intubation operator affect outcomes related to pre-oxygenation with NIV versus an oxygen mask?
Operator experience is certainly associated with first-pass success rate and time from induction of anesthesia to intubation, but this is not an interaction we specifically looked for in PREOXI. I will speculate along with you that since NIV improves pre-oxygenation and prolongs the time until desat...
What are the logistical challenges and time constraints of implementing NIV for pre-oxygenation in emergency settings compared to oxygen masks?
Logistical and training challenges do exist to routine implementation of noninvasive preoxygenation. Perhaps the most challenging one is the availiability of the mechanical ventilator in the emergency setting at the time of intubation. In settings where mechanical ventilators are not routinely prese...
Does the use of NIV for pre-oxygenation delay the time to intubation?
That probably depends on how you define "time to intubation". In the study, we measured time from induction of anesthesia to intubation and % of successful intubations on the first attempt, which were nearly identical between groups (Table 3). However, I suspect the real question is whether NIV preo...
How long post operatively do you wait before transitioning from parenteral anticoagulation to oral anticoagulants after pulmonary thromboendarterectomy for CTEPH?
It depends. In straightforward cases, we are pretty aggressive with starting anticoagulation to prevent re-thrombosis after pulmonary thromboendarterectomy. These patients are started on parenteral anticoagulation (with IV heparin) on POD #0, usually within several hours after arriving in the ICU if...