Clinical conference on management dilemmas: progressive infiltrates and respiratory failure.

P ulmonary clinicians are often faced with management problems for which there are no answers at hand, either because there is no literature that definitely gives answers, because there are conflicting data in the literature, or because the circumstances surrounding the clinical cases are unusual enough to prevent the application of existing scientific knowledge. When faced with these problems, clinicians are forced to make decisions based on a logical extension of their scientific knowledge into uncharted clinical waters. They are forced to make judgments based on the conviction of their speculations and on prior experiences. This case conference addresses difficult management problems without singularly correct decisions; its object is not necessarily to seek consensus. Defining the exact issues, formulating rationales for decision making, and committing to the decisions themselves are all equally important in this presentation. This is a real case in which the decisions were made by the “treating pulmonologist” or “treating intensivist” without input from the other participants. The “responses of pulmonary experts” are given only with the knowledge of the case presentation up to the moment at which each expert gave his or her decision and without the knowledge of any of the other opinions rendered. The last “commentary” opinions are given only with the knowledge of the “case presentation” and the remarks of the “treating pulmonologist (or intensivist)” but without the knowledge of any of the other opinions rendered. Although the “commentary” opinions are the last in the sequence of this presentation, they are not necessarily offered as definitive solutions to the problems posed in the case. The reader is the ultimate arbiter in this presentation of decisionmaking alternatives.