Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How would you approach medication de-escalation in a patient with a history of rapidly progressive CTD-ILD who responded to and is currently on mycophenolate 3 grams daily and IVIG 2mg/kg monthly infusions and has been stable for two years?
This is an excellent question with the very little data to go by. We spend most of our time studying escalation of therapy and very little time discussing de-escalation. It has been my experience as a rheumatologist for almost 37 years that many autoimmune diseases initially can be quite immunologic...
How do you approach management of a patient with idiopathic PAH and +ANA, but no other current symptoms/signs of active rheumatologic disease?
(1) Of note, abnormal nail fold capillaroscopy is associated with PAH in several systemic immune diseases: This is famously true for systemic sclerosis, but there are also publications reporting this association for other diseases, notably those in the “lupus family“ like SLE and dermatomyositis. As...
In which patients do you prefer daily standard three-drug therapy for non-cavitary pulmonary MAC as opposed to three times a week dosing?
Generally, if non-cavitary disease I favor thrice weekly therapy. However, if widespread non cavitary disease or immunosuppressed, I may choose daily dosing.
Do you consider the use of antifibrotics at presentation in patients with a radiographic UIP pattern of pulmonary fibrosis in the presence of positive serologies without any symptoms of CTD who have not yet demonstrated evidence of a progressive phenotype?
I really like this question, because it succinctly encapsulates several areas of clinical uncertainty that we are routinely forced to address in our ILD clinics! Let’s unravel some of the subtleties here. For starters, if the radiographic pattern is convincingly that of UIP, our patient will technic...
Do you administer calcium to patients with K > 6.5 without EKG changes?
No. But our ER does as a reflex and I don't have a problem with that. It used to drive me nuts bc it sent the wrong message, as though Ca lowers [K] level (of course it does not, it just decreases cardiac effect). But you don't know how fast they are being seen, how fast they will get treated, so I ...
When attempting PEEP titration, how long do you wait after decrements or increments to assess for a change in driving pressure?
This depends on the patient level of consciousness and whether or not they are paralyzed.
What is the current recommendation for air travel after a primary spontaneous pneumothorax?
General guidelines including the British Thoracic Society recommend delaying air travel for at least 2 weeks following the radiographic resolution of a pneumothorax. However, recent studies have challenged this conservative approach. A study by Majercik et al., PMID 25494425 demonstrated that patien...
Is there any role for palliative radiation in patients who are intubated due to malignant airway obstruction?
The literature is limited, but this small series showed about 1/4 of patients can have reversal of intubation.If the patient/family is interested in attempting, it occasionally works, but my own experience is less successful than 1/4. It is unlikely to worsen the situation, so after explaining that ...
How do you counsel and manage patients who meet criteria for sleep apnea based on 3% but not 4% desaturation?
It depends on the patient's symptoms. If they have symptoms attributable to sleep apnea then I tell them they have sleep apnea. If they don't have symptoms then I don't diagnose them with sleep apnea. If the patient has an insurance plan that only accepts 4% desaturations and yet they clearly have s...
For how long do you recommend treatment for latent tuberculosis prior to initiation of anti-TNF therapy?
Some recommendations call for completing a course of treatment for latent TB prior to starting a biologic but I find most patients and referring specialists are intolerant of that strategy. This reference: Yeo et al., European Respiratory Journal 2014 is a good example of data supporting a shorter w...