Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How would you manage a patient with morbid obesity who presents with new symptomatic pulmonary embolism a few days after he was started on DOAC for DVT?
There are guidelines from the American Society of Hematology and The International Society of Hemostasis and Thrombosis as well as expert opinions recommending either apixaban or rivaroxaban for venous thromboembolism or pulmonary embolism in patients with BMI >40. In addition, this includes use as ...
Do you treat A0B1 rejection noted on surveillance bronchoscopy in a patient less than one year post lung transplant?
Assuming the patient is asymptomatic and has great lung function, CXR/CT would treat, but more focused on optimizing immunosuppression to full dose and likely use oral steroid taper; would also look for DSAs and encourage frequent surveillance.
How do you approach the bronchoscopic evaluation of a cavitary lesion of the lung?
I think transbronchial biopsy is very helpful in the diagnosis of a cavitary lesion of the lung. I usually send it both for pathology and culture. I also believe it should be dealt with in a multidisciplinary approach and biopsy should be offered to those whose diagnoses are not clear or straightfor...
Do you treat Candida spp isolated from a bronchoalveolar lavage?
I would only treat if there was evidence of Candida infection from another source/location (at the same time).
Are there patients who can forgo anticoagulation with asymptomatic, incidentally discovered subsegmental pulmonary embolism?
Of note, there are two ongoing clinical trials that should hopefully provide further data on the definitive management of SSPE (NCT01455818, NCT04263038).
What is your blood pressure or mean arterial pressure goal in a critically ill patient with acute kidney injury?
The current surviving sepsis guidelines recommend targeting a mean arterial pressure (MAP) of 65 mm Hg with no benefit of targeting a higher MAP in septic shock patients.
Are there clinical scenarios in which you would start empiric treatment for pulmonary TB without microbiologic confirmation?
Yes, there are a few situations. One of them being pauci-bacillary TB in which you catch TB very early on its course hence your micro/cultures will be negative. CT will demonstrate micronodules. This is a diagnosis of exclusion and requires the right clinical setting (high-risk patient, from an ende...
How would you manage a patient with ANCA associated vasculitis who has recurrent flare including pulmonary hemorrhage, persistent MPO antibody positivity while on maintenance rituximab and avacopan regimen even after induction rituximab therapy?
Probably cyclophosphamide but maybe mycophenolate or azathioprine.
Which ANCA vasculitis patients are better candidates for cyclophosphamide rather than rituximab?
Both can be used for induction in GPA/MPA vasculitis. I would use rituximab (RTX) if the patient has previously been treated with cyclophosphamide (CYC) and developed a relapse/flare and in patients who are young and with fertility concerns. In GPA/MPA, I tend to use RTX most of the time for inducti...
Are you using genomic classifiers to diagnose UIP when imaging is indeterminate or suggestive of an alternate diagnosis?
Antifibrotics are indicated for the treatment of IPF, scleroderma-ILD, and progressive pulmonary fibrosis, not specifically for "UIP," which can manifest in any of the three. When a patient presents with an indeterminate pattern on CT without suggestive features of connective tissue disease on histo...