Published on January 14th, 2014
St. Luke’s University Health Network Forges Comprehensive Approach to Pulmonary Care
The Pulmonary Medicine Department at St. Luke’s University Health Network couples comprehensive care for pulmonary diseases with a state-of-the-art approach that optimizes diagnosis and treatment and enhances patient outcomes.
When patients enter St. Luke’s Pulmonary & Critical Care Associates, fellowship-trained pulmonologists compile an extensive history that may illuminate risk factors that contribute to chronic obstructive pulmonary disease (COPD), asthma, pulmonary hypertension or interstitial lung disease. Livia Bratis, D.O., Section Chief of Pulmonary and Critical Care Medicine at St. Luke’s University Health Network, explains that many times, a patient’s symptomatology and history may fit diagnostic criteria for multiple diseases, so effective treatment begins with a detailed history supplemented by diagnostic imaging tests to confirm a diagnosis and rule out secondary causes. Pulmonary lung function tests are conducted to determine how well the lungs perform. One of the most common tests is spirometry, measuring how much and how quickly air moves through the lungs.
“Often our patients are smokers, so chest X-rays may find a lung tumor, signs of congestive heart failure or some other reason why patients may be short of breath,” Dr. Bratis says. “The chest X-ray excludes other causes, and spirometry definitively identifies COPD.”
Care for Chronic Lung Disease
COPD comprises chronic bronchitis and emphysema, according to the National Heart, Lung, and Blood Institute (NHLBI). More than 12 million Americans have been diagnosed with COPD, the third leading cause of death in the United States, according to the American Lung Association.
After spirometry tests identify COPD, Dr. Bratis explains, pulmonologists work with patients to evaluate the severity of the disease and construct individually tailored treatment plans, which may consist of medical therapy, oxygen therapy, pulmonary rehabilitation and potential inclusion in clinical trials. Smoking is the leading cause of COPD, so counseling patients on quitting is an important adjuvant component in St. Luke’s University Health Network’s treatment of the disease.
Determining patients’ history of infections and hospital admissions, as well as what types of coughs they experience, enables Dr. Bratis to assess the need for short- or long-term corticosteroids or bronchodilators.
“After starting patients on inhalers, we go through an action plan, which includes educating them about symptoms they can expect and what signs indicate they’re having a flare-up, so they can take action before symptoms grow so bad they require hospitalization,” Dr. Bratis notes. “When that happens, we can escalate their therapy to prevent such flare-ups.”
Because COPD can cause low blood oxygen levels — below 90 percent, according to the NHLBI — pulmonologists may recommend oxygen therapy. Dr. Bratis explains that tests performed while patients are either at rest or walking on a treadmill monitor the amount of oxygen in patients’ blood. If oxygenation drops below 88 percent, at-home oxygen therapy can help patients breathe more easily and restore oxygenation to healthy levels.
Finding the Best Path for Asthma Treatment
Unlike COPD, Dr. Bratis says, asthma usually isn’t detected by pulmonary function tests unless a patient is contemporaneously suffering an exacerbation. Therefore, in addition to gathering a thorough patient history, pulmonologists may administer a methacholine challenge test — in which they induce an asthma attack with an airway irritant — to allow definitive diagnosis.
Once the disease is identified, medical therapies, including aggressive inhaled corticosteroids and bronchodilators, can be prescribed to help control asthma. Deborah Stahlnecker, D.O., Director of Critical Care at St. Luke’s University Health Network’s Anderson Campus, board-certified in pulmonary and critical care medicine, explains that other medications for allergy management must be prescribed as well because allergies can exacerbate asthma.
In tandem with allergy medications, moderate to severe asthmatics with allergies may benefit from Xolair injections once or twice per month as needed, Dr. Stahlnecker says.
The Future of Asthma Treatment
In addition, this summer, St. Luke’s Pulmonary Medicine Department welcomes a leading-edge treatment that significantly improves asthma patients’ ability to participate fully in everyday activities. Dr. Stahlnecker says minimally invasive bronchial thermoplasty prevents frequent exacerbations for patients whose conditions have not been managed well by medicine, and it reduces the amount of work, school or other pursuits missed due to asthma attacks.
Dr. Bratis explains that the innovative therapy represents a groundbreaking option for asthmatics.
“This procedure can make a huge difference in our patients’ quality of life,” she says. “We’ve never been able to do anything like this before.”
Provided in three outpatient appointments spaced approximately three weeks apart, bronchial thermoplasty has demonstrated five years of maintained therapeutic benefits, says Dr. Bratis. Pulmonologists use a bronchoscope to deliver controlled therapeutic radiofrequency energy to the smooth muscle in the airway. Heating the muscle prevents it from contracting, which Dr. Stahlnecker explains is a major underlying problem associated with asthma.
Minimally invasive bronchial thermoplasty aims to free patients with asthma from being tethered to their inhalers.
“The hope is that patients will achieve an overall reduction in exacerbation rates,” says Dr. Stahlnecker. “We think patients will require less rescue medication and perhaps even fewer maintenance medications after the third visit, when they’ll reach their maximum benefit.”
Although many of these diseases require significant levels of care and multidisciplinary expertise, some diseases may be treated effectively without hospitalization. Pulmonary rehabilitation may reverse the disease process in certain cases and eliminate the need for more intensive treatment.
Owing to pulmonary rehabilitation’s preventive nature, John Kintzer, M.D., FCCP, pulmonary critical care specialist at St. Luke’s University Health Network, board-certified in pulmonary and critical care medicine, considers it a vital adjunct to the Pulmonary Medicine Department’s armamentarium of innovative treatments.
“Pulmonary rehabilitation is an important component in treatment of patients with chronic lung disease,” Dr. Kintzer notes. “Medications do have a role, but when someone’s short of breath and having increased pulmonary difficulty, we often find an answer by looking into different areas. Pulmonary rehabilitation is a practical solution that has demonstrated efficacy.”
Initially, respiratory therapists assess each patient with a six-minute walking test and then tailor rehabilitation programs according to measured oxygen and exertion levels. During the four- to six-week program, the therapists work individually with patients, primarily using treadmill exercises at different steepness grades, speeds and times — and sometimes enhancing the workout with light free weights — to improve endurance levels, Dr. Kintzer says.
He adds that many patients who enter the program assume they cannot exercise because of their restricted breathing. However, one-on-one work with pulmonary therapists, who teach patients appropriate exercises, and meetings with pulmonary support groups, where patients are educated about stress management techniques and better nutrition, improve patients’ overall condition and provide a psychological boost.
St. Luke’s University Health Network pulmonologists work diligently across disciplines to successfully treat pulmonary diseases that are wide-ranging in their severity. Cardiologists perform right heart catheterization procedures that measure pulmonary artery pressure and help diagnose pulmonary hypertension, and cardiothoracic surgeons may assist by performing lung biopsies on patients with suspected interstitial lung disease.
When imaging studies reveal potential cancers or lung nodules, pulmonologists present the findings at weekly multidisciplinary forums, during which pulmonologists, thoracic surgeons, radiation oncologists and medical oncologists construct the most appropriate courses of treatment.
“We take the multidisciplinary approach seriously,” Dr. Bratis explains. “This ensures we look at the patient’s disease from all angles so we miss nothing from diagnostic or treatment standpoints.”
For more information about St. Luke’s University Health Network’s Pulmonary Medicine Department, please visit www.sluhn.org or call 484-526-3890.