Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is your approach to a patient with undetectable MMR titers checked prior to or during immunosuppression and a history of MMR vaccination in childhood?
MMR titers are good correlates of protection. If any titer is undetectable it could be one of these situations: Primary failure. The components of the MMR have different efficacy. Two doses of appropriately given MMR will have 96+% against measles, but only 88% for mumps. Thus 1 in 10 appropriately...
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...
What clinical features push you to add dupilumab instead of escalating ICS dose in a patient with biomarker-high asthma and recurrent exacerbations?
The Phase 3 QUEST study addressed this question and found that adding dupilumab to medium-dose ICS/LABA provided significantly better control than placebo plus high-dose ICS. However, this study did not look at actual dose escalation of the ICS prior to instituting the biologic. They also found no s...
Would you advise mobility restrictions in a patient with Protein S deficiency and acute upper extremity DVTs but contraindications to anticoagulation (e.g., acute GI bleed) to reduce the risk of thrombus embolization?
This question is an interesting one and an incredibly specific scenario. I'll try to broaden the answer to cover a few more scenarios. So, the question gets at three elements: 1) Patient has an acute VTE, 2) Patient has a hypercoagulable state, 3) Patient has a contraindication to anticoagulation. S...
Can sIL2-R differentiate between active sarcoidosis affecting small airways vs uncontrolled asthma and guide treatment with methotrexte vs biologics?
Not exactly, and probably not with enough compelling precision to use it clinically. sIL-2R cannot reliably differentiate active small-airway sarcoidosis from uncontrolled asthma, nor can it independently select methotrexate versus biologic therapy. It is a marker of systemic T-lymphocyte/granuloma ...
How do you incorporate positive respiratory viral testing and/or low procalcitonin into antibiotic de-escalation when chest imaging still suggests pneumonia in a hospitalized patient?
De-escalation of antibiotic use is a key part of antimicrobial stewardship. Respiratory illnesses are one of the most common reasons for hospitalization, and bacterial pneumonia is frequently the major concern in these patients. However, there is evidence that we overdiagnose and treat bacterial pne...
How do you determine the severity of restrictive lung disease?
My interpretation of the latest ATS/ERS guidelines is that FEV1 should be used for "any spirometric abnormality" including restriction or mixed disorders, which is unchanged from the 2005 ERS Guidelines.That said, I tend to use FVC when grading pure restrictive disorders, habituated as a result of F...
Do the results of FIBRONEER-ILD change your approach to antifibrotic treatment in patients with sarcoidosis related PPF?
According to the FIBRONEER-PPF data, no sarcoidosis-specific outcomes have been reported, and one can only infer that the sarcoidosis-related PPF subpopulation has tracked similarly to the other ILD subtypes, which is a big assumption. It is important to remember that in the INBUILD study, which exa...
How will you incorporate nerandomilast into your treatment algorithm for autoimmune ILD with progression, particularly relative to sequencing with immunosuppression?
The sequencing of therapy in CTD-related PPF remains unclear. Recent data suggest that immunosuppression may not alter clinical outcomes in fibrotic ILDs, including those associated with systemic autoimmune disorders (Pugashetti et al., PMID 42432856). In the FIBRONEER-ILD study, nerandomilast impro...
Which biologic do you prefer for severe eosinophilic asthma?
I prefer Fasenra for severe eosinophilic asthma. Its efficacy, safety record, and extended dosing interval are some of the reasons. It also works well if the severe asthma is part of an underlying condition such as EGPA, HES, etc. If the severe asthma is mixed eosinophilic and allergic phenotype, I ...