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Pulmonary & Critical Fellowship Clinical Services

Pulmonary Physiology Laboratory

Protocols Followed:

  • Cold Air Challenge
  • High Altitude Stimulation
  • Standardized Pulmonary Function Test Interpretation
  • Six Minute Walk Test
  • Cardiopulmonary Exercise Stress Test
  • Body Plethysmography


2009
2008 2007
Outpatients  1,437 880 733
Inpatients  337 303 233
Total Patients
 1,774 1,183 966

Center for Sleep Medicine and Research

New York Methodist Hospital’s Center for Sleep Disorders Medicine and Research is a 6-bed facility across the street from the Hospital. The center and staff are well-equipped to evaluate a variety of patients, from pediatric and adult patients, to patients being evaluated for bariatric surgery. Various sleep disorders diagnosed and managed under the auspices of the sleep center include: obstructive sleep apnea-hypopnea syndrome, central sleep apnea including Cheyne-Stokes respiration, various parasomnias such as sleepwalking and REM behavior disorder, hypersomnias including narcolepsy utilizing multiple sleep latency testing, circadian rhythm disorders, and insomnia. Clinics associated with the sleep center include a general sleep clinic run by the center’s director and an insomnia clinic run by a sleep specialist along with a clinical psychologist specializing in insomnia and related disorders. Research is active at the center and currently includes a randomized, crossover trial evaluating measures to improve compliance with CPAP devices and a study looking at REM sleep and its effects on various subjective parameters.

  • New Director hired July 1, 2009 (formally trained at Columbia Presbyterian Medical Center, NYC)
  • Performing studies 7 days a week
  • Performed nearly 1,200 studies in 2009
  • Continue to expand on a growing research program
  • Training a staff that is poised to set new standards for professional credentials
  • Developed a long term relationship with city agencies to evaluate and treat their most safety sensitive personnel
  • Weekly Insomnia Clinic continues to grow

Sleep Studies 2009
2008
2007
Totals 1172 1345 1484

Medical Intensive Care Unit

Multidisciplinary Care to ICU Patients

  1. All admissions to the ICU are approved by the Pulmonary fellow assigned to the unit.
  2. Daily multidisciplinary rounds including physicians, nurses, respiratory therapist, and pharmacist are carried out. This approach makes for a well rounded approach to patient care.
  3. Weekly infectious disease, radiology, and nutrition rounds are carried out. Future plans including regular meetings with the health care team and family members.
  4. Monthly review of mortality data. All mortalities, complications and adverse occurrences in the medical intensive care unit are reviewed and discussed in an open forum. An M&M data sheet has been developed for all reviews.

Standardization of Care

  • Sepsis and Septic Shock
  • ARDS net guidelines
  • COPD/Asthma guidelines
  • State of art respiratory therapy equipment, including the entire gamut of modern ventilators (high frequency oscillation, high frequency persussive ventilation, APRV, NAVA, PAV, Prone protocols, and ECMO )
  • Non-invasive Positive Pressure Ventilation (NIPPV)
  • Respiratory Therapist Driven Weaning
  • Sedation/Analgesia
  • Involvement in the Institute of Healthcare Improvement and Saving 100,000 lives campaign
  • Determination of Brain Death and Apnea Testing Bedside Percutaneous Tracheostomy
  • Monitoring of Central Line Related Bloodstream Infections
  • Hypothermia in Cardiac Arrest
  • Use of Ultrasound for ICU Procedures (central lines, thoracentesis, etc). A formal ultrasound didactic and hand-on session was held in February 2009 according to the following teaching points:
    • Bedside ultrasound for procedural guidance, including central and peripheral line placement
    • Performance of basic ultrasound of the heart and inferior vena cava to evaluate global cardiac function, presence of pericardial effusion +/- tamponade, determination of volume status, and guide resuscitation efforts in critically ill patients
    • Vascular phantom lab to improve ultrasound-guided venous access skills
    • Bedside cardiac scanning of normal subjects to develop baseline skill set
    • Assessment of ones own practice for improvement, understanding limitations, learning from errors, incorporating feedback in performing bedside ultrasound

Chronic Ventilator Unit

Standardization of Care

  • Sepsis
  • ARDS/COPD/Asthma
  • Non-invasive Positive Pressure Ventilation (NIPPV)
  • Respiratory Therapist Driven Weaning
  • Determination of Brain Death and Apnea Testing
  • Bedside Percutaneous Tracheostomy
  • Admission and discharge criteria being developed for a true 4 bedded Stepdown Units
  • Monitoring incidence of ventilator associated pneumonias
  1. All admissions to Infill 7 are approved by the Pulmonary fellow assigned to the unit.
  2. Daily multidisciplinary rounds including physicians, nurses, respiratory therapist, and pharmacist are carried out. This makes for a well rounded approach to patient care.
  3. Weekly infectious disease and nutrition rounds are carried out. Future plans including regular meetings with the health care team and family members.
  4. Monthly review of mortality data. All mortalities, complications and adverse occurrences in the respiratory care unit are reviewed and discussed in an open forum. An M&M data sheet has been developed for all reviews.

Palliative care units are carried out one morning per week.

Interventional Pulmonology

The interventional pulmonology program continues to grow and expand. New York Methodist offers a truly complete pulmonary interventional program. In 2009, the program performed more than 1,000 procedures including both diagnostic and therapeutic interventions. The IP program teams up with cardiothoracic surgeons, radiation oncologists, anesthesiologists to manage patients with complex diseases, especially lung cancer. This aspect continues to make New York Methodist Hospital the only comprehensive IP program in Brooklyn, and one of two programs in the entire New York City area. As a result, tertiary referrals increased for both inpatients and outpatients, including transfers from neighboring hospitals for critically-ill patients with airway pathologies during the year.

Click here for Types of Procedures Performed

The NYM Interventional Pulmonology program continues to draw pulmonary fellows from other programs as observers. Fellows from Interfaith Hospital have participated in four week rotations throughout the year and have the opportunity to see procedures for which they are not able to experience in their home programs. PCCM fellow rotations in Interventional Pulmonology have also come from two NYC hospitals (New York University and Beth Israel) in 2009.

Education

In 2007, we had our 1st annual course “Introduction to Pulmonary Procedures”. This course was very well received from many programs in the Brooklyn community. Faculty included Drs. Armin Ernst (Boston’s Beth Israel Deaconess Hospital), Kevin Kovitz (Chicago Chest Center), David Feller-Kopman (Johns Hopkins), and Jed Gorden (Swedish Hospital in Seattle). 

In 2008, our second pulmonary course was expanded to two days. “Current Approaches to Lung Cancer: Staging and Therapy – A Two-Day Multidisciplinary Symposium and Hands on Procedure Course” was held September 18-19, 2008 at the Downtown Conference Center in lower Manhattan. Nationally known faculty participated in this two day course which was very well received. Course participants came from a wide range of hospitals including Mount Sinai Hospital, St. Vincent’s Medical Center, Memorial Sloan Kettering, New York University Medical Center, Brooklyn Hospital, Interfaith Medical Center, Cornell, Winthrop, Cooper Hospital, and Mary Immaculate Hospital. 

2009 brought our most popular course yet, a one day program held September 11, 2009 at the Downtown Conference Center, entitled “Therapeutic Bronchoscopy” focused on many advanced interventional pulmonary procedures including rigid bronchoscopy, stent placement, argon plasma, and percutaneous tracheostomy.


Interventional Pulmonary Research

New York Methodist continues to be on a forefront of participating in national clinical trials in Interventional Pulmonology:

Study Title: A Randomized, Double-blind Study to Evaluate the Safety and Effectiveness of the Exhale® Drug-Eluting Stent in Homogeneous Emphysema Subjects with Severe Hyperinflation (2007-2009)

Sponsor: Broncus Technologies (Mountainview, California)
New York Methodist Hospital participated in an international clinical trial to investigate an important new, minimally invasive option for people with advanced widespread emphysema. The procedure being tested—airway bypass—creates pathways in the lung for trapped air to escape and, thereby relieves emphysema symptoms like shortness of breath. NYM is one of only three centers in New York City to offer the trial.

Pulmonary Hypertension Center

The division of pulmonary and critical care medicine at New York Methodist is pleased to announce the establishment of the Pulmonary Hypertension Center. Pulmonary Hypertension (PH) is an increasingly recognized disease that affects many patients from all demographics, causing many symptoms that can eventually progress to respiratory and cardiac failure. Over the past decade, much effort has been placed in the research and development of new drugs to manage this highly debilitating and often fatal disease. In concert, pulmonary physicians with expertise in the care of patients with PH are educating the medical community to heighten the awareness and recognize the spectrum of disease presentations.

Pulmonary Hypertension is clinically defined by a mean pulmonary artery pressure (PAP) >25 mmHg at rest or >30 mmHg with exercise during right heart catheterization. Due to the broad spectrum of patients at risk for and diagnosed with pulmonary arterial hypertension, the disease is categorized into five groups1:

  •  Group 1 includes idiopathic PAH, familial PAH, PAH associated with connective tissue diseases, congenital heart disease, portal hypertension, HIV, sickle cell, drugs and toxins.
  • Group 2 includes PH associated with left heart disease.
  • Group 3 includes PH associated with respiratory diseases such as COPD.
  • Group 4 includes PH associated with chronic thrombotic or embolic disease.
  • Group 5 includes PH associated with miscellaneous diseases.

Although PH may manifest in various ways, the following patients should be considered for referral:

  • Known elevation (>40 mm Hg) of peak pulmonary artery pressures on the ECHO
  • Severe shortness of breath without a clearly definable cardiac or pulmonary cause
  • Severe pulmonary fibrosis
  • Enlarged pulmonary arteries on CXR or CT scan
  • Any of the conditions grouped above accompanied by shortness of breath at rest or with exertion, fatigue or decreased oxygen saturation.

Final diagnosis of Pulmonary Hypertension is made after the patient undergoes a right heart catheterization. During the right heart catheterization an adenosine challenge may be given to the patient in an attempt to see if the patient is a candidate for calcium channel blockers or if other medications will be prescribed as the first line of therapy.

The Pulmonary Hypertension Center at NYM is the only center in Brooklyn with a comprehensive and integrated approach to the diagnosis and disease management of PH. Our plan of care offers:

  • A dedicated pulmonary hypertension outpatient clinic held on Wednesday afternoons, to consult with initial referrals and subsequent follow-ups, as these patients require close monitoring following the initiation of therapies.
  • Due to the disease complexity and difficulty in approval of medications, a dedicated PH nurse will work exclusively with patients in both the inpatient and outpatient settings. From the initial intake after a patient is referred, medical history and initial work-up is reviewed. The patient will then undergo a streamlined and complete work-up, including blood tests, pulmonary physiological tests, thoracic imaging including collaborations with nuclear medicine and advanced cardiac imaging.
  • For the appropriately selected patients, a right heart catheterization will be performed in collaboration with the division of cardiology, for definitive stratification and classification of the disease.
  • A thorough management plan is discussed with the patient and the referring physician. A comprehensive report is generated to communicate closely with the referring physician.
  • Follow-up clinic visits every 1-3 months, monitoring of appropriate labs and access to supports systems specifically for PH patients.

1 http://www.guideline.gov/summary/summary.aspx?doc_id=6467


Pulmonary Rehabilitation

The fellows receive training at Columbia University’s pulmonary rehab program and the newly established NYM pulmonary rehab program.

2009 also brought the initiation of an outpatient pulmonary rehabilitation program. The pulmonary rehabilitation is performed in conjunction with Metro SportsMed, the hospital’s rehabilitation center conveniently located across the street from the main hospital campus. The usual duration of rehab is approximately 8 weeks. All patients who complain of shortness of breath and who have a pulmonary or neuromuscular problem are eligible for screening. Patients who have angina, irregular heart beat or other cardiac conditions should not be considered for rehab.


The process of screening includes the following:

A detailed five page evaluation (including utilization of four subjective and objective questionnaires including the Eastern Cooperative Oncology Group Performance Scale; the Karnofsky Performance Status Scale which measures the patient’s ability to carry out activities of daily living; the Borg Dyspnea Index, ; and the BODE Index for COPD, which uses variables and points values used for the computation of Body mass Index, degree of airflow Obstruction and Dyspnea, and Exercise Capacity (BODE) are carried out. 

A cardiopulmonary exercise stress test and six minute walk test is also performed as part of the evaluation.

  • Based upon the evaluation and pulmonary exercise stress test, a prescription for pulmonary rehab will be written
  • Patients are then prioritized and referred to Metro SportsMed with the relevant patient information for evaluation.
  • After the rehab is completed, a follow up consult visit where the benefits of pulmonary rehab in the patient will be drawn up and a report sent to the referring physician.