Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you find that complete interlobar fissures on HRCT correlate well with decreased collateral ventilation on endoscopic balloon occlusion in the evaluation and placement of endobronchial valves for bronchoscopic lung volume reduction?
Incomplete fissures are very common and exhibit a great variation in anatomy. The reported prevalence is 17%–85% for the right major fissure, 19%–74% for the left major fissure, and 20%–90% for the minor fissure.CT scans may overestimate the completeness of the right minor fissure and underestimate ...
Do you favor the use of Fick or thermodiluation to measure cardiac output in patients with interstitial lung disease with suspected pulmonary hypertension?
Unless the patient has a left to right shunt or a metabolic cart is used to calculate direct Fick, thermodilution cardiac output (TDCO) is the preferred method of cardiac output measurement in all patients with pulmonary hypertension. This is supported by current guidelines. It's important to take t...
Do you ever initiate pirfenidone in patients with CTD-ILD?
Short answer: yes. Long answer: yes, but rarely. I don't have any reason to assume it wouldn't be effective in these patients, but the main barrier is insurance since it doesn't have FDA approval for this indication. A few patients I've started pirfenidone on with CTD-ILD are 1) progressing despite...
How frequently do you monitor LFTs and CBC after initiating endothelin receptor antagonists?
The FDA requires LFT testing before starting and every month thereafter for bosentan. For ambrisentan and macitentan, there is no requirement for monthly monitoring of LFTs due to the clinical trials data and post-marketing data demonstrating the safety of these medications. I routinely check LFTs d...
What is your preferred steroid sparing therapy in a patient experiencing a severe checkpoint inhibitor toxicity and not responding to high dose IV steroids?
There are likely two different questions here: 1) For patients who have responded to steroids, but are unable to taper off (or to a minimally acceptable chronic dose), I have favored mycophenolate as a steroid sparing agent. 2) For patients with severe pneumonitis that is refractory to steroid ther...
Would you consider PLEX for patients with DAH from SLE-associated capillaritis?
DAH is a severe life-threatening manifestation of SLE. Usually, patients who present with DAH have multi-organ involvement. DAH could be triggered by an underlying infection. Evaluating other potential causes of hemoptysis and pulmonary infiltrates (heart failure, endocarditis, malignancy, medicatio...
Do you give intrapleural lytics for complicated effusion/empyema in patients on systemic anticoagulation?
Like some people's relationship status, it's complicated. Since 2011, when the MIST II trial (1) was published by Rahman and colleagues, intrapleural tissue plasminogen activator (tpa) and DNase have been given intrapleurally to facilitate source control for pleural infection by breaking up loculati...
What is your approach to the work up and management of interstitial lung abnormalities?
ILA are incidental radiological findings (non-dependent abnormalities affecting more than 5% of any lung zone) in asymptomatic patients. We first evaluate these patients for any potential causes of ILA (i.e. connective tissue diseases, aspiration, drug-related pulmonary toxicity, etc). If an underly...
What steroid regimen do you employ prior to extubating a patient who does not have a suitable cuff leak?
Before deciding on steroids, there are many factors to be considered. Patient height and weight, ET tube size and medical history. For example, a person who is 5’ 0” with a size 8 ETT intubated for 2 days might not have a leak but be perfectly safe to extubate without steroids. Alternatively, someon...
What is your approach to volume resuscitation in patients with obvious septic shock but also with a component of suspected cardiogenic shock?
I think it comes down to clinical decision-making at bedside with the help of a combination of modalities. POCUS to evaluate the IVC size and collapsibility is one option we commonly use and is quick and easy to obtain. Additionally, in situations of unclear shock state, our practice is to float a P...