Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
At what age do you stop LDCT chest for lung cancer screening?
One of Medicine's three priority-ordered duties is to postpone death. This also pertains to persons who have reached age 81. Lung cancer can occur longer than 15 years after cessation of smoking. Even if surgery can't be done, primary radiation of Stage 1 squamous cell lung carcinoma can result in p...
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 hypercoaguable state, 3) Patient has a contraindication to anticoagulation. S...
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 strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
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...
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 role of inebilizumab in the maintenance treatment of IgG4-related disease?
Inebilizumab may play an important role in the maintenance treatment of IgG4-related disease (IgG4-RD), particularly in patients at high risk for relapse. These are typically patients with multi-organ involvement and elevated serum IgG4 levels who initially respond well to corticosteroids but tend t...
For patients with definite UIP and MPO-ANCA-associated vasculitis limited to the lungs (without systemic manifestations), what is the role of immunosuppression?
I think in these subjects (as opposed to UIP in RA), immune suppression would be my first agent. The data are limited; there is some suggestion on biopsy that they have significant inflammation (Arnold et al., PMID 38574743). I would start with immunosuppression and have a low threshold to add anti-...
Do you de-escalate back to medium-dose ICS after starting dupilumab in a patient whose uncontrolled severe asthma had not responded adequately to high-dose ICS?
Yes, I will often de-escalate if patients are well controlled after adding a biologic. In fact, I have had times when patients decrease the frequency of their dose or even stop their controller inhalers (on their own) after a good response to biologic therapy. In these cases, it can sometimes be a c...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...