Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How would you manage immune check point inhibitor induced capillary leak syndrome refractory to IVIG monotherapy?
There is no great evidence and only case reports. Diuretics and supportive management. Stopping the ICIs is likely essential at this point because we do not know how to safely rechallenge yet. There is a discussion of possible using anti IL-6 therapy for capillary leak if IVIG and corticosteroids do...
Does your approach to the management of a patient with an acute exacerbation of CPFE where the ILD is attributed to IPF differ from the management of a patient with an exacerbation of IPF alone?
In general, once an extensive workup to exonerate alternative causes of ILD in patients with presumed CPFE has been performed, I tend to treat the interstitial component of these two entities similarly, whether in the chronic phase or during an acute exacerbation. Smoking is a well-known risk facto...
What is your threshold to start triple therapy in mild to moderate asthma/COPD overlap with minimal functional limitation?
The question is vague as it does not define functional limitations. If the patient has frequent exacerbations (not defined by the question), Triple therapy would be recommended. If she just has minimal SOB for instance an exercise induced type picture SABA/LAMA prn with LABA ICS (w/o LAMA) would be ...
Do you continue CFTR modulator therapy in patients with extra-pulmonary manifestations of CF after lung transplant?
Yes, we do continue CFTR modulators in post-transplant patients for benefits to other organs like sinuses, GI tract, pancreas and perhaps liver. We have to modify and adjust for transplant medication for dosing and interactions. Unfortunately, there is not a large evidence base supporting this pract...
Do you routinely use vasopressin in the management of RV failure leading to shock state in the absence of an obvious treatable cause such as infarction or PE?
It seems that there is a vasopressin dose-dependent effect on PA pressures. The doses we usually use for septic shock (0.03 or less) have some degree of pulmonary vasodilation (for example, Tsuneyoshi et al., PMID 11373409). Higher doses may have the opposite effect (Leather et al., PMID 12441768). ...
What is your approach to pulmonary vasodilator therapy in patients with COPD and Severe Group 3 Pulmonary Hypertension?
I'd like to first acknowledge that there are no large randomized controlled trials specifically in patients with severe COPD-PH to guide practice. Before I consider PH-specific treatment, I like to exclude other causes of PH namely CTEPH, LHD, and CTD-PH which would influence treatment options. Seco...
What is your approach to therapy for pulmonary sarcoidosis resistant to methotrexate?
The first question I ask myself in any situation dealing with "refractory" sarcoidosis is "Am I sure active inflammation from sarcoidosis is the cause of their symptoms?". Oftentimes, I will see patients referred for refractory disease who end up having other causes of their symptoms. If I am confid...
Do you consider the duration of lung/lobar atelectasis in your decision making while offering airway stents for malignant central airway obstruction?
Yes, always. We review old imaging to determine when there is a post obstructive pneumonia or collapsed lobe/lung secondary to endobronchial obstruction (extrinsic or intrinsic). The old teaching was that, if a lobe is down for more than two months, it is unlikely to be salvaged, even after the endo...
What is your perspective on the role of respiratory therapists in managing a patient who is dyssynchronous on their current mode of mechanical ventilation?
Yes, it’s in the scope of their practice to adjust vent settings for various reasons. At my practice, I work with them closely so I am aware of the changes being made. And this goes both ways. If I end up making changes, I make it a point to let the RTs know what changes I made.
Do you use prednisone in the management of patients with persistent respiratory symptoms following acute COVID-19 infection?
No, unless I note bronchial hyperresponsiveness on follow-up Pulmonary function tests (PFTs). What I've noted is a significantly high percentage of undiagnosed asthmatics who come into the light because of a more severe clinical course from covid. Use anti-fibrotics occasionally for fibrosis dependi...