Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Among patients with secured subarachnoid hemorrhage who are receiving daily TCDs, what is the appropriate frequency of post operative neurological assessments?
I think a textbook might state something like "every 1-2 hours in the acute setting." However, in my opinion, the frequency of neurological examinations should be tailored to the individual patient and involves considerable clinical judgement. Factors that might influence this decision include a) se...
When pulmonary vasodilator therapy lowers PVR to transplant targets but causes systemic hypotension or worsening renal perfusion in decompensated cirrhosis, how do you adjust therapy (dose reduction, agent change, accepting higher PVR) while preserving both hemodynamic eligibility and overall transplant candidacy?
Fortunately, an uncommon problem, but when it does occur, careful dose reduction of the offending agent may help. Also, I would consider going from any offending oral medication to an inhaled prostacyclin to avoid/minimize systemic effects.
What are first-line choices for vasopressors/inotropes to use in hypotensive patients with Eisenmenger Syndrome?
The answer is that it all depends on the etiology... However, a common issue with Eisenmenger syndrome (ES) is that routine pharmacological treatments that cause peripheral vasodilatation may worsen the right to left shunting and further shock. My first patient with ES was a gentleman recovering fro...
What factors do you consider for patients on an individual basis when establishing a post-cardiac arrest MAP goal after ROSC is achieved, considering some may benefit from higher MAP goals for optimal cerebral perfusion?
I generally aim for a MAP of 70. However, I am more concerned with ensuring end organ perfusion and will track urine output, lactate, mental status, and LFTs in addition to the physical exam (cool vs warm and absence of mottling). MAP goal adjustment should also be considered in instances with a wid...
If there is trapped lung after a thoracentesis in an outpatient setting, in a patient who has stable vitals and no dyspnea, is there a role of overnight observation?
I am assuming this question came up because there was a pneumothorax post-thoracentesis, and you are suspecting entrapped lung.If you are confident that the patient has an entrapped (trapped) lung and remains completely asymptomatic, overnight observation or hospitalization is not necessary. In case...
In elderly patients with advanced melanoma and idiopathic pulmonary fibrosis receiving active antifibrotic therapy, would neoadjuvant or adjuvant immune checkpoint inhibition be preferred?
Given this scenario, it is most important to have a goal-of-care discussion. That would help sort out the optimal treatment for such patients. Always treat to relieve pain as needed.
What factors do you consider to help guide treatment for patients with high grade large cell neuroendocrine cancers of the lung?
High-grade large cell neuroendocrine carcinomas make up a small and aggressive subset of lung cancers that histologically and regarding treatment responsiveness share features with both small and non-small cell carcinomas. These shared features have been borne out in recent sequencing studies of thi...
What is your approach to managing hyperkalemia secondary to respiratory acidosis?
Since hyperkalemia in respiratory acidosis is due to transcellular shift, therapy should be directed at treating the underlying respiratory acidosis. Correction of the hypercarbia should lead to resolution of the hyperkalemia. In severe hyperkalemia due to respiratory acidosis that is not easily rev...
Are there any biomarkers, imaging, or other clinical information that can be used to better choose effective therapies for super refractory status epilepticus?
SRSE is a syndrome not a diagnosis. The key determination is if this is immune-mediated, infectious, structural, metabolic, genetic, or drug/toxic-induced. For example, if the lumbar puncture shows significant pleocytosis, in the presence of flare changes in the medial temporal lobes, especially in ...
What is your approach to volume resuscitation in patients who are third spacing fluids?
In patients with significant third-spacing (e.g., due to capillary leak in sepsis, severe pancreatitis, hypoalbuminemia, etc), we prefer balanced crystalloids (e.g., Lactated Ringer’s) as the first-line fluid for initial resuscitation in hypovolemic or septic shock with third-spacing. Typical initia...