Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What patient factors, if any, would lead you to extubate a patient at high risk of extubation failure to AVAPS rather than BIPAP?
Unless a patient used AVAPS/iVAPS support prior to intubation and is returning to baseline, I discourage our team from using volume-targeted pressure support in acute situations. Although the idea of having a volume target is attractive, there are many opportunities in the acute setting for unexpect...
When do you consider the use of PH specific therapies in patients with pre-capillary pulmonary hypertension associated with sickle cell disease?
Sickle cell-associated PH would be considered Group V PH. Evidence for treating sickle-associated pre-capillary PH with Pulmonary vasodilator therapies is poor. So, in a garden variety of sickle cell anemia associated with PH, I tend not to treat it with PV meds. If the PVR increases, I may sometime...
How would you manage asymptomatic osseous sarcoidosis of the lumbar spine without any other systemic involvement?
Some patients with sarcoidosis are found to have bone-related abnormalities. These are frequently incidental findings often detected as a phantom abnormality on PET or MR scan without corresponding X-ray or CT abnormality; this suggests they are foci of inflammation localized within bone marrow and ...
Is dyspnea without radiation pneumonitis a side effect of lung radiation?
Thanks for the interesting question. I would want to know: on what basis are we saying that the patient does not have radiation pneumonitis (RP)? I am going to assume that this is being stated since the imaging findings are underwhelming in this case. Assuming that this is the case, I would answer: ...
How are you approaching patients with early-stage NSCLC who progress on neoadjuvant chemo-immunotherapy and are no longer surgical candidates?
This is a good question, and we are seeing it too often these days. This question cites progression as the reason for not proceeding to surgery after neoadjuvant chemo-IO. We are also seeing patient refusal and ineligibility (i.e. N3 disease that didn't respond) as reasons. I think it's very importa...
How do you assess the use of Heimlich valves for patients who present with persistent air leaks?
I would do it for patients who have a persistent air leak and can tolerate water seal (lung is up on xray on water seal but chest tube has air leak).
How do you define an adequate EBUS when staging NSCLC?
Important question. There is a high degree of variability in the diagnostic performance of EBUS based pretest probability of disease, physician experience and skill, quality control, and evaluation skills of the cytopathologist. Nice consensus guidelines from CHEST was published a few years back det...
How do you approach management of limited stage SCLC in a patient with idiopathic pulmonary fibrosis?
I've seen a few patients with IPF and small cell. The concern is always that these patients have an underlying pro-inflammatory lung condition that makes them more prone to pneumonitis. My preference in this specific group is to give and complete chemotherapy first and then restage the patient. Sinc...
What dose and duration of steroid therapy do you use in steroid responsive ILD?
This is an extremely challenging question to answer as "steroid-responsive lung disease" encompasses a variety of formal and informal diagnoses as well as a variety of different clinical scenarios. Additionally, the dose and duration of corticosteroids would depend on patient factors and comorbid co...
What are your top takeaways from ISHLT 2024?
I had the privilege of attending ISHLT 2024, and I am delighted to share insights from three standout presentations that I believe will significantly influence our field.1. Trifecta Heart Study by Dr. Philip HalloranImpact: This presentation explored innovative blood-based techniques such as cell-fr...