Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Can transudative pleural effusions lead to trapped lung?
Yes. I’ve seen it many times especially in patients with longstanding CHF and/or CKD. With a persistent effusion of any type, the pleura can respond by forming a peel resulting in a non expanding lung.
Do you use absolute random cortisol levels or delta cortisol levels after ACTH stimulation to diagnose adrenal insufficiency in the critically ill?
As reviewed recently by Dr. Teblick et al., PMID 35358303, this is still a controversial and complex issue. Based on many studies, it would be preferable to avoid ACTH stimulation unless there is rapid availability of free cortisol. Random total cortisol is probably the better alternative.
Do you attempt more aggressive PEEP titration to improve the P/F ratio prior to proceeding with proning in patients with ARDS and P/F <150?
Aggressive PEEP titration is a loaded term. Do these patients need higher PEEPs? Yes, if they are recruitable. You need to understand the lung mechanics and the concept of stress and strain to make sure that you are optimizing the inflation pressure these lungs are exposed to. This can be achieved b...
What is the expected timeframe one would expect to see paroxysmal sympathetic hyperactivity/sympathetic storming persist post-traumatic brain injury?
I've personally seen as long as 30+ days but usually less.
How do you navigate PAP approval for patients with tracheobronchomalacia or excessive dynamic airway collapse who do not have OSA?
Since there is no insurance pathway for PAP for tracheobronchomalacia, we basically perform a sleep study and hope there is a small amount of OSA to treat. Otherwise, we find ways to get a machine for the patient at low cost. While there is theoretical benefit to using PAP for TBM there isn't much e...
What is your initial treatment of choice in patients with RA and associated interstitial lung disease?
Because of the nature of the disease and to avoid unnecessary ILD treatment, it would not be appropriate to provide the 'direct answer' first. But the direct answer will appear in bold at the bottom. Of note, there is little data on therapeutics in RA-ILD. This is an important question because it hi...
What are best practices in management of severe acute infusion reaction from infliximab?
Severe infusion reactions to infliximab are not typically IgE-mediated. The presumption is that it is ‘anaphylactoid’ due to IgG antibodies directed against the mouse chimeric proteins in the molecule. Stopping the infusion is essential (at least temporarily) and administering antihistamines such as...
What strategies do you employ to prevent post-intubation hypotension in a profoundly hypoxic patient given a paralytic for intubation?
There are a few strategies I use. I choose an induction agent such as Etomidate or a ketamine which has minimal hemodynamic effects. If BP is soft to start with, I use IV fluid small bolus, use a vasopressor such as phenylephrine push if needed before sedation.
What is your approach to the evaluation and management of a suspected intrapulmonary hematoma?
I usually observe and they do tend to resolve over time.
Would you consider deferring chest tube placement in a clinically stable patient with a small empyema without signs of systemic infection?
Firstly, diagnosing empyema means the fluid has already been diagnostically tested by thoracentesis. If all the fluid was removed on the diagnostic tap, I would continue and complete the course of antibiotics with close follow-up. The duration of Antibiotics ranges from 4-6 weeks. If a significant a...