Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you offer immunosuppression to patients with CTD-ILD with concomitant well controlled HIV?
I agree with @Dr. First Last's response, which is excellent. Primary things to consider would be control of HIV and medication interactions, but I'd also take into account the patient's history of infections, reliability of taking meds and getting monitored, etc.This is timely since it seems we may ...
How do you define severe hypoxic burden on home sleep testing?
There seem to be two questions here. First, can you measure hypoxic burden on a home sleep test? The answer is that technically it can be done without great difficulty. However, as far as I know, there are no home sleep apnea testing devices that offer hypoxic burden as an outcome measure. Thus gett...
Do you consider dual biologic therapy in patients with ABPA that remain steroid dependent despite the use of omalizumab?
The treatment of ABPA can be so challenging, but this is something that I have not seriously considered at this point. Unfortunately, in general, the evidence for biologics in the treatment of ABPA currently is heterogeneous. Furthermore, many studies are descriptive case reports/series or based on ...
How do you approach treatment of septated parapneumonic pleural effusions that do not satisfy traditional criteria for complicated effusion after diagnostic thoracentesis?
Septated effusion is a complicated effusion, whether it is empyema, parapneumonic, or malignant, and usually, they are exudative. By definition, untreated parapneumonic effusion will become empyema. Septations <4-6 week duration are usually fibrinous and can be lysed with tPa/DNase instilled through...
Do you routinely continue using TPA/Dornase for treatment of empyema, if there is accumulation of new sero-sanguinous output from the chest tube after the initial treatment?
In my practice, if there is an accumulation of serosanguinous output after initial treatment, further treatment with tPa/ dornase depends on several factors. Hct of drainage - if > 50%, will not give further dose. If a patient is coagulopathic or receiving anticoagulation for a medical condition af...
What is your approach to initial work up for a young patient with bronchiectasis?
I assume we are talking about patients in their 20s, 30s-50s who have had a HRCT with radiological bronchiectasis. It will be good to know if they have had clinical implications and symptoms of cough, infections, and mucus production. It will be good to know about multiorgan involvement like sinuses...
What is your preferred strategy for controlling bleeding after transbronchial or endobronchial biopsies?
I use all Cold Saline, Wedging and EPI. If severe bleeding side down, therapeutic bronchoscope with suctioning blood till bleeding stops. Also to assess bleeding risk prior (low PLT, hx of ASA anticoagulation use) to bronchoscopy and during bronch watching oozing and stopping further biopsy can be v...
What is your approach to management of elderly patients with cardiopulmonary comorbidities and severe pulmonary hypertension?
I generally follow the current ERS/ESC guidelines with regard to the treatment of patients with WHO group 1 PAH. I often will often start with a low dose of PDE5i and see them back within 4 weeks prior to increasing the dose. Similarly, I will see back within 4 weeks of adding an ERA to look for sid...
What is your approach to using nintedanib in patients on baseline immunosuppression?
Typically I start antifibrotic therapy in a few situations: The most common reason is ILD progression despite adequate immune suppression, defined as no extra-pulmonary disease activity (usually joint disease, but can tailor according to the patient's disease/situation, such as by presence of rash, ...
Do you start steroid therapy in a patient with pure ARDS without septic shock, or would you only consider steroids only in those with severe community acquired pneumonia?
I do not routinely start corticosteroids for pure ARDS, septic shock, or severe community-acquired pneumonia. In my mind, the DEXA-ARDS study was underpowered to answer the question. The recently published ESCAPE and CAPE-COD trials yielded conflicting results in CAP. In my mind, before adopting cor...