Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your approach for a symptomatic inpatient with locally advanced NSCLC who cannot have a PET?
These are tough cases. While we ideally aspire to have full (and congruent) staging information, this is not always possible.There are therefore competing pressures. Factors that favor AP/PA, 3 Gy fractions include 1) the need to initiate treatment rapidly given symptomatic burden and 2) the desire ...
Would you use inhaled steroids with or without oral steroids for the treatment of radiation pneumonitis?
I have not tried inhaled steroids instead of oral steroids for symptomatic radiation pneumonitis much in my practice. Many patients are already on inhaled steroids at baseline, and many who develop pneumonitis have severe symptoms. That being said, avoiding oral steroids could be particularly import...
What immunosuppressive agents aside from steroids would you use to treat bronchiolitis obliterans in a patient with long-standing seropositive RA?
There is little doubt that bronchiolitis obliterans can be a devastating lung disease. Corticosteroids remain the primary anchor therapy, however, virtually all patients will require an additional agent. Rituximab has become the primary choice and there is evidence, though mostly anecdotal, that it ...
How do you approach the management of SSc-ILD in a patient on immune checkpoint therapy?
If the oncologist thinks immune checkpoint inhibitor therapy is the best treatment for the patient's cancer, we try to facilitate this. We obtain baseline pulmonary function tests and CT scans. Repeat every three months while on therapy. Usually, these patients have pulmonary involved also, in parti...
How do you choose between oral and IV cyclophosphamide for the treatment of ANCA-associated vasculitis?
When considering cyclophosphamide for induction in severe AAV, both oral and IV regimens are reasonable routes of administration. In the CYCLOPS trial (DeGroot, Ann Int Med, 2009), oral cyclophosphamide 2mg/kg/d was compared with IV CYC 15mg/kg q 2 weeks for the first three pulses, then every 3 week...
How do you approach patients with ANCA vasculitis who had partial response, but continue to have disease activity on q 6 month maintenance rituximab and remain on steroids?
This question raises some fundamental issues about the management of patients with ANCA-associated vasculitis (as well as other vasculitides or chronic inflammatory disorders), including i) the need to consider the potential contribution of comorbidities to clinical signs or symptoms suggestive of v...
What indicators do you use to identify patients with CTD-ILD who do not have potential to improve from continued immunosuppressive therapy?
This is an interesting question. We need to clarify what this phrase means "who do not have potential to improve". It may be easier to identify patients who may benefit from therapy.ILD physicians work under the motto, 'stability is success'. Thus, improvement may mean 'did not deteriorate'. Minimal...
What are your recommendations regarding methotrexate usage in patients with persistent chest CT changes post COVID pneumonia?
With the raging pandemic and the steady stream of post-COVID inflammatory/fibrotic patients, we are bound to encounter patients with such abnormalities who are on potentially pneumotoxic drugs (or need initiation).With minimal concrete data, any recommendation is purely based on experience.Methotrex...
How would you approach treatment for fulminant RA-associated ILD?
Even though this hypothetical patient has tolerated methotrexate (MTX), I would probably stop it since MTX can directly scar lung parenchyma and continuation of it may confuse the clinical picture. The data for adverse lung toxicity with TNFi drugs is less clear, so I would consider maintaining it. ...
What strategies can be employed to manage interstitial lung disease seen with trastuzumab deruxtecan?
Educating clinic staff and patients/family members is key. Any reports of worsening respiratory symptoms such as worsening cough or SOB should be carefully worked up and managed. Always check for saturation at clinic visits and (actively) look for interstitial findings at every scan (the patient cou...