Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you routinely perform genetic testing in patients presenting with pulmonary fibrosis who endorse a family history of fibrotic lung disease?
I receive this question frequently when I hear from other clinicians and I think it is a very thought-provoking question. We know that patients with pulmonary fibrosis (PF) commonly have first-degree relatives with interstitial lung disease (ILD). Some studies quote numbers as high as 20% so it is d...
How do you approach treating mild hypercalcemia in patients with sarcoidosis?
This may seem like a straightforward query, but like many issues surrounding sarcoidosis, it is actually deceptively complex. For a more complete discussion, I refer the readers to an excellent review by Lower and Saidenberg-Kermanac’h (2019). In and of itself, asymptomatic “mild” hypercalcemia does...
Do you consider pulmonary hypertension related to sarcoidosis to be an indication to start steroids?
Pulmonary hypertension (PH) associated with sarcoidosis presents a complex clinical challenge. The decision to use corticosteroids in sarcoidosis-associated pulmonary hypertension depends on several factors: Underlying Cause of PH: It's crucial to determine whether the pulmonary hypertension is dir...
Is it safe to combine mycophenolate and adalimumab for management of pulmonary sarcoidosis in a patient that could not tolerate methotrexate?
Combination therapy is often required in patients with sarcoidosis. Combination of adalimumab with other immunosuppressants, such as methotrexate, leflunomide, azathioprine, or mycophenolate, can be used, with close monitoring of labs (CBC, CMP) and for infections.
What is your approach to withdrawal of ventilatory support at the end of life?
This is a great question with a complex answer. Both options are reasonable and in my practice, I gear compassionate extubation practices towards the patient and family wishes. In conjunction with our Palliative Care team, we have an algorithm for providing medications to ensure the patient's will n...
Do you administer prophylactic antibiotics to prevent VAP following intubation in patients with acute brain injury?
I currently do not, though this trial is interesting and the results are compelling. I think the risk of one dose of CTX is low. No clear evidence of resistance. I think moving forward, I would have a low threshold for administering one dose of ceftriaxone following intubation in my TBI patients. Ho...
How would you treat a patient with combined pre- and post-capillary pulmonary hypertension after successfully optimizing post-capillary pressures through a valvular intervention?
No good data here. First, if I'm contemplating treating this group with pulmonary vasodilators at all, I would like to see repeat RHC demonstrating precapillary pulmonary hypertension with a low wedge. Fixing the valvular disease may help with left-sided function, but many of these patients have dev...
Is there a subset of ANCA vasculitis patients for which you would try plasma exchange?
Circling back to this now that we have more data. I agree with Dr. @Dr. First Last's main conclusion that GN or the presence of concomitant anti-GBM antibodies are the primary scenarios in which there may be a role for plasma exchange patients with ANCA-associated vasculitis.Following the PEXIVAS tr...
When do you consider Balloon Pulmonary Angioplasty in patients with inoperable CTEPH?
In all patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are not surgical candidates or those with residual pulmonary hypertension after pulmonary thromboendarterectomy (PTE) surgery, balloon pulmonary angioplasty (BPA) should be considered. There are instances in which patient...
What is your approach to counseling and management of patients with severe symptomatic OSA whose PAP devices have been recalled?
Continue to use it with or without a microbiological filter. The latter is not necessarily recommended by Respironics but is an option nevertheless.