Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What steroid regimen do you employ in the treatment of patients with post COVID-19 pulmonary fibrosis?
I don't use steroids for post-COVID fibrosis. Not only have I not seen steroid-responsiveness in this setting from an anecdotal standpoint, but previous data on steroids in non-COVID pulmonary fibrosis seems clear about the potential harms (e.g., PANTHER trial). If there is a large proportion of gro...
What patient related factors and hemodynamic parameters would lead you to avoid transbronchial biopsies in patients with pulmonary hypertension?
I try to avoid if INR is > 1.7 or platelet count is less than 30,000 in patients who have Grp I PAH.
Do you perform a clamp trial before removing a chest tube for pneumothorax?
Yes, almost always but depending on the indication for chest tube placement commonly encountered as below. A) If the chest tube is placed for pneumothorax, clamping a chest tube before removal is essentially simulating the same scenario when the chest tube is out. It is much better to clamp than to ...
Are there known biomarkers predictive of IRAEs?
While there are no FDA-approved biomarkers predictive of iAEs, there is a growing body of preclinic and retrospective research trying to address this important question. Eosinophilia may be a potentially useful biomarker and this is supported by several retrospective studies 1,2. It is intriguing th...
Would you give checkpoint inhibitor therapy to a cancer patient with known dermatomyositis given the association of checkpoint inhibitor associated myocarditis, myasthenia gravis, and myositis?
I think the dermatomyositis could be more paraneoplastic that would actually benefit from controlling the cancer with ICI. I would give the treatment but I would carefully follow-up the patient for any irAEs. I will also document the rheumatological assessment, CPK, and myositis panel before startin...
What are your preferred ventilatory settings/mode(s) for patients with acute hypoxic respiratory failure presenting with severe biventricular dysfunction in cardiogenic shock?
This is a great question - and, unfortunately, one that doesn't have a robust evidence base upon which to formulate a particularly informed response (at least nothing that has looked a hard outcomes like mortality or duration of mechanical ventilation). I go back, however, to the basics and a mantra...
Which hemodynamic parameters can be used to titrate positive pressure ventilation in preload dependent settings such as RV failure, cardiac tamponade, HOCM or hemodynamically significant PE?
As this question alludes, the application of positive pressure ventilation influences cardiac hemodynamics. Key principles of these cardiopulmonary interactions are outlined nicely by Alviar and colleagues (1) in a well-done review. In contemplating this question, it is important to consider the sep...
How do you approach performing EBUS TBNA in patients with latex allergy?
Nothing else besides not placing balloon, wearing non-latex gloves and ensuring that all staff is aware about latex allergy.
How do you choose between azithromycin and roflumilast in the management of a patient with severe COPD who remains symptomatic with frequent exacerbations despite maximal dose LABA/LAMA/ICS with demonstrated compliance and proper inhaler technique?
Zithromax 250 mg on Monday, Wednesday, and Friday. I would consider roflumilast only in patients who are phenotypically and physiologically chronic bronchitis patients.
Do you routinely start full dose anticoagulation in new onset atrial fibrillation in the ICU?
Case-to-case basis based on the underlying cause and bleeding risk. I don't as readily in patients where it's driven by sepsis: Walkey et al., PMID 27487456