Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
In routine clinical practice, how do you operationally define ‘progression despite therapy’ in PPF to justify escalation to combination treatment?
ILD patients undergo regular monitoring with intervals based on concern for progression. In addition to symptom review, objective testing includes PFTs with spirometry and DLCO, 6-minute walk testing that provides information on distance walked, symptoms experienced, and whether or not the patient d...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
How do you approach the decision to consult Cardiology and pursue an ischemic workup for an isolated troponin elevation attributable to a non-cardiac acute illness such as sepsis or acute respiratory failure?
This decision is much more complex than can be adequately addressed in this response, based on the information given. The demographics and clinical risk factors of the patient are important in this decision, as well as the comfort of the clinician/primary care physician caring for the patient. Does ...
In patients treated with infliximab, do rates of immunogenicity vary based on underlying disease (RA, IBD, sarcoidosis, etc) and/or baseline disease activity?
Yes, rates of infliximab immunogenicity appear to vary based on underlying disease, with evidence showing higher rates for RA than IBD and spondyloarthritis, and tend to increase with higher baseline disease activity. Most patients tend to develop anti-drug antibodies within the first year, but this...
In patients with ILD who are started on nerandomilast on top of background nintedanib, what monitoring is most important early in therapy?
I do not use combined therapy often, and I usually stop nintedanib to start nerandomilast. This does depend on how long they've been on nintedanib. If it's within the first three months, lab monitoring as required for nintedanib is important. Otherwise, it's really just side effects. Obviously, from...
Do the results of FIBRONEER-ILD change your approach to antifibrotic treatment in patients with sarcoidosis related PPF?
It changes my thinking somewhat, but I would be careful not to overinterpret the sarcoidosis results. FIBRONEER-ILD supports the broader concept that once different non-IPF ILDs develop a progressive fibrotic phenotype, targeting fibrosis may be beneficial regardless of the original diagnostic label...
Would you start treatment for MAC in a patient with nodular bronchiectatic disease who has demonstrated radiographic progression but remains asymptomatic and smear-negative?
My default answer would be yes; this is a sign of progressive disease that will get worse without treatment. Having said that many things could be considered while making the decision, including patient preferences. First is there another cause? Does the patient have an exacerbation of bronchiectasi...
Do you commonly arrange home nocturnal oxygen at discharge for hospitalized patients with incidental nocturnal hypoxemia vs recommend an outpatient sleep study?
I'd say this is one of the more forward questions. I would place an order for an outpatient sleep study. If it's only happening at night while the patient is asleep, the most common cause is OSA, and nocturnal oxygen does not fix the pathophysiologic mechanism. This is consistent with the American A...
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
How do you counsel patients on the potential benefits of nerandomilast for PPF?
Nerandomilast is an inhibitor of phosphodiesterase 4 (PDE4), which leads to elevated intracellular cAMP, which reduces the expression of profibrotic cytokines and growth factors. It has both antifibrotic and immunomodulatory activity and may be useful in active inflammatory ILD based on these charac...