Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you recommend the use of endobronchial valves in the management of patients with spontaneous pneumothorax with persistent air leak?
Patients with primary spontaneous pneumothorax and persistent air leak or recurrent pneumothorax should be considered for surgery (typically VATS) with bleb resection and pleurodesis in order to prevent a recurrence. I believe bronchial valves in this setting have a little role since they are not de...
Do you routinely use donor derived cell free DNA levels to guide surveillance bronchoscopies in lung transplant recipients?
Donor-derived cell-free DNA is becoming more available but is not as helpful as in the other solid organ transplant recipient, so there is no clear consensus at this time to guide surveillance bronchoscopies in lung transplant recipients.
Do you employ the use of extracorporeal photopheresis in the management of patients with progressive BOS following lung transplantation?
Yes, extracorpeal photopheresis (ECP) is employed for BOS in certain situations. There may be insurance barriers (Medicare) that will be prohibitive. Any changes to the immunosuppression strategies should be done in the earlier stages to have beneficial effects. Hence to start ECP in stage 3 BOS if ...
Do you employ the use of external chest compression with sandbags in the management of patients with severe ARDS who are not candidates for proning?
The short answer is while there is a physiologic rationale to support the beneficial effects of supine chest wall compression, the best method and clinical impact of such maneuvers have not been studied. In addition, there may be potential untoward consequences to sustained chest wall compression th...
What is your approach to counseling a patient with exertional hypoxia, but normal resting oxygen saturation, who is hesitant to use supplemental oxygen therapy?
Many of these patients are not only hesitant but actually reluctant. Considering that the hard evidence to support this application is weak at best, as long as the desaturation is transient, not associated with much in the way of symptoms, and bounces back fairly quickly when the exertion ceases, I ...
What is your approach to the monitoring and management of a never-smoker with respiratory symptoms and a nonspecific ventilatory pattern on pulmonary function testing?
In the RETHINC trial, inhaled dual bronchodilator therapy did not decrease respiratory symptoms in symptomatic tobacco-exposed people. We still do not know how best to address symptomatic people with PRISm or those with or without a smoking history and respiratory symptoms without obstruction on spi...
How do you manage a stenotic airway following SBRT or hypofractionated radiation to a central lung tumor?
I haven't read much about this in the literature and my quick search doesn't reveal much about it either. So, I'll give you my clinical wisdom on it and you can take it with a bunch of grains of salt. The issues that I've faced with a stenotic airway have been in the context of shortness of breath a...
How do you approach a thoracic lymph node that is highly suspicious on CT and PET but negative on EBUS in patients with NSCLC?
Our institution is very privileged in having a very large, highly expert team of interventional pulmonologists. In the cases where we are conflicted over how to interpret imaging of concerning lymph nodes, and where we have had the chance for a deep dive at tumor board and accompanying expert radiol...
Do you adjust immunosuppression in lung transplant recipients diagnosed with COVID-19?
Adjustment of immunosuppression in the setting of infection is center dependent after transplant. At our center, we typically only adjust if needed, other centers will empirically stop Mycophenolate. We typically monitor the white blood count and Prograf levels daily. If the patient we adjust the Pr...
Is there a role for immunosuppression in addition to standard PAH therapy in the management of pulmonary hypertension associated with primary Sjogrens syndrome?
In short: maybe. Pulmonary hypertension is quite uncommon in Sjogren’s. When I find it, I look for other causes of pulmonary hypertension, especially ILD, and for systemic sclerosis. I also consider other potential indications for immunosuppressive therapy such as inflammatory joint pain. There is, ...