Pulmonary Medicine

The diagnostic and interventional minimally invasive procedures offered are as follows:

• Laser Bronchoscopy for tumor destruction
  Laser Bronchoscopy uses laser to destroy airway tumors or lesions as well as eliminate obstructions in the bronchial tubes that cause shortness of breath.
• Airway stent placement for narrowing of the airway
  Stents are small cylindrical expandable tubes, very similar to the types used by cardiologists to open up arteries in the heart. They are used to open bronchial tubes that are occluded or narrowed due to infection, tumors or scar tissues.
• Electrocautery bronchoscopy for destruction of lesions and removal of polyps
  Electrocautery bronchoscopy uses electric currents to destroy benign and malignant tumors in the bronchial tubes. It also helps to open up obstructed airways and to stop bleeding.
• Argon plasma coagulation
  Argon plasma coagulation uses mild electric currents to destroy benign and malignant tumors in bronchial tubes, open up obstructed airways, and stop bleeding.
• Balloon dilation for tracheal and bronchial stenosis
  Balloon dilation for tracheal and bronchial stenosis uses small balloons to dilate bronchial tubes. The procedure passes the balloons through small bronchoscopes. The procedure is similar to angioplasties performed by cardiologists, except that it is done on the bronchial tubes.
• Autofluorescence bronchoscopy
  Autofluorescence bronchoscopy is a special light that is used inside the lung through our small scope. This light is able to detect suspicious areas of possible cancer in the bronchia tubes that are not clearly seen by standard bronchoscopy.
• Endobronchial ultrasound (EBUS)
  EBUS is a technique where a special, very small scope, with a tiny ultrasound at the tip of the scope, allows the pulmonologist to perform biopsies in multiple areas. This allows the specialist to minimize the risk of puncturing a blood vessel and allows for better accuracy, since we can see that the needle is placed inside the abnormality with the ultrasound.
• Esophageal ultrasound (EUS)
  EUS is a special technique, where a special, scope, with a tiny ultrasound at the tip of the scope allows the physician to perform biopsies in multiple areas. This allows the specialist to minimize the risk of puncturing a blood vessel and allows for better accuracy, since we can see that the needle is placed inside the lesion with the ultrasound.
• Transbronchial Needle Aspiration Biopsy
  Transbronchial Needle Aspiration Biopsy uses a small scope to go to distant areas in the lung where a small biopsy forceps is used to remove tiny pieces of lung to make the accurate diagnosis of lung conditions in the outpatient setting.
• Transtracheal Needle Aspiration Biopsy
  EUS is a technique where a special, very small-sized scope, with a tiny ultrasound at the tip of the scope, allows the pulmonologist to perform biopsies in multiple areas. The lesion is visualized by fluoroscopy (live ex-ray) or by bronchoscopy. This allows the specialist to minimize the risk of puncturing a blood vessel and allows for better accuracy, since we can see that the needle is placed inside the area of concern with the ultrasound.
• Flexible Biopsy Techniques
  Biopsy procedures are performed with very small scopes using sedation techniques that keep patients very comfortable and asleep.
• Percutaneous Needle Biopsy
  Chest radiologists perform computerized guided biopsy of tumors at multiple areas in the chest reducing the need for surgical biopsies to make a diagnosis. Those procedures are done on an outpatient basis with the patient going home the same day.
• Photodynamic therapy
  Photodynamic therapy uses an injection of a special chemical in the blood that is absorbed by cancer cells in the lungs. After the chemical is given, special light is used to activate the chemical absorbed inside the tumor cell, destroying the tumor cell but not affecting the healthy ones. This can be very useful in early stages of cancer to prevent further growth.
• Pleuroscopy
  Pleuroscopy is a procedure similar to laparoscopy but when performed in the chest is called pleuroscopy or video thoracoscopy. It is a small instrument with a camera that is inserted into the chest cavity through a very small incision allowing the physician to do diagnostic and therapeutic procedures inside the chest.
• Ultrasound Guided Thoracentesis
  Ultrasound Guided Thoracentesis removes abnormal fluid from the pleural space between the lung and the chest wall using ultrasound.
• PleurX catheter placement
  Placement of a pig-tail catheter in the pleural spare when fluid continues to re-accumulate, especially in patients with malignant pleural effusions.
• Brachytherapy
  Brachytherapy places a small catheter in the lung so radiation can be given inside the bronchial tube. This is utilized in patients with central tumors or tumors inside the airway, as well as patients who have received large doses of external radiation.
• Cryotherapy
  Cryotherapy uses cold energy and freezing temperatures to treat bronchial lesions.
• Foreign body aspiration or inhalation and removal
  Foreign body aspiration and removal removes accidentally inhaled foreign bodies such as food, insects and others from the airway with little baskets or other tools.

Diseases commonly diagnosed and treated by our Interventional Pulmonary Service include:

• Lung cancer
• Lung nodule and Lung Mass
• Mediastinal Adenopathy / enlarged lymph nodes
• Abnormal Chest x-ray
• Blood in sputum (hemoptysis)
• Malignant Pleural Effusion (fluid in the pleural space)
• Benign Pleural Effusion
• Tracheal stenosis
• Bronchial stenosis
• Complications of tracheostomy and intubation
• Tracheobronchomalacia
• Relapsing polychondritis
• Amyloidosis
• Wegener’s granulomatosis

The Interventional Pulmonology Program at Cleveland Clinic Florida was founded in 2001 by Dr. Eduardo Oliveira. It is one of the top interventional programs in the state of Florida, providing a full spectrum of diagnostic and therapeutic services for lung cancer and other benign conditions of the lung. Our academic institution is able to provide cutting edge treatment in pulmonary medicine, by highly qualified and trained professionals.

We offer primary and second opinion outpatient consultations, as well as surgical and procedural evaluations for complex chest diseases. Our patients come from all parts of Florida and surrounding states. We provide consultation to international patients from South America, the Caribbean and Central America. Appointments for international patients are arranged through our International Patient Services department. Our section works in collaboration with multiple specialists at Cleveland Clinic Florida as well as the Pulmonary and Thoracic institutes at Cleveland Clinic in Ohio.

Our multidisciplinary team includes:

• Interventional Pulmonology
• General Pulmonology
• Critical Care specialists
• Thoracic Surgery
• Oncologists
• Radiation Oncologists
• Gastroenterologists specializing in EUS
• Radiologists and interventional radiologists
• Respiratory therapists
• Outpatient Nursing team

At the end of 2006, Cleveland Clinic Florida launched new comprehensive Multidisciplinary Thoracic Oncology program. The multidisciplinary team is composed of a thoracic surgeon, pulmonologists, medical and radiation oncologists, radiologists, pathologists, gastroenterologists, and numerous support staff. Together they specialize in the diagnosis and treatment of lung and esophageal cancer as well as other thoracic malignancies such as chest wall tumors, thymic tumors, and lymphoma.

With a minimally-invasive approach, patients that require surgery benefit from smaller incisions, less postoperative pain, and shorter hospital stays. Patients undergoing thoracoscopic surgery better tolerate postoperative treatments such as chemotherapy compared to those having more traditional “open” surgery.

We are pleased to offer our patients new, innovative treatments such as photodynamic therapy (PDT). For patients with cancer in the main airways or in the esophagus who cannot undergo surgical resection, PDT is an endoscopic (no incisions) light-based treatment used to destroy the tumor. This typically involves a few outpatient treatments over one week and allows patients to breathe or swallow easier depending on the location of the tumor.

In conjunction with the Interventional Pulmonary service, tracheobronchial stenting can be used when there is airway obstruction from a variety of causes.

Other new thoracic surgical services include:

• Thoracoscopic lung biopsy for interstitial lung disease with an average length of stay of less than 24 hours.
• Thoracoscopic sympathectomy for hyperhidrosis. This is performed on an outpatient basis.
• Thoracoscopic decortication for empyema or parapneumonic effusion.
• Thoracoscopic first rib resection for thoracic outlet syndrome.
• Thoracoscopic resection of mediastinal masses including thymectomy for myasthenia gravis.

For patients with tumors in the major airways, a lung-sparing procedure called “sleeve lobectomy” may be utilized to preserve pulmonary function. In the past, the surgical alternative would have been a pneumonectomy—the removal of the entire lung.

In conjunction with the Division of Radiation Oncology, stereotactic radiosurgery is used to treat certain thoracic malignancies. This new modality provides great accuracy and precision in the delivery of radiation to the planned target with fewer treatment sessions than more traditional external beam radiation.

Corroborating with the Division of Interventional Radiology, radiofrequency ablation may be used to treat lung tumors in patients who are not candidates for surgery. This allows for a minimally invasive approach to the treatment of primary and metastatic lung cancers.

The Section of Thoracic Surgery is pleased to offer these latest advances in the management of chest disorders to the patients of South Florida. Approximately 90% of our procedures are performed minimally invasively with a relatively brief hospitalization.

When the patient is in distress, at times, it is necessary to insert a tube into the airways to assist the patient with breathing. Usually this procedure is performed by direct visualization and insertion of the endotracheal tube. Our pulmonologists use special scopes to insert endotracheal tubes resulting in 100% success rate in intubation, with less trauma to the patient and decreased need for sedation.

A longstanding or difficult to control cough or shortness of breath that is not responsive to commonly tried medications may be due to diseases of the lungs that are unusual and difficult to diagnose. Special expertise and technology may be required to diagnose and treat these disorders. A multidisciplinary approach is used as indicated involving pulmonologists, thoracic surgeons, radiologist and pathologists to provide state-of-the-art care of patients with unusual interstitial pneumonitis, pulmonary fibrosis, sarcoidosis, atypical mycobacteria such as M. avium or MAC and related illnesses.

Pulmonary Hypertension refers to increased pressure in the pulmonary vasculature. A multitude of reasons exist for this increase in pressure, resulting in a complex and demanding condition. We, at the Clinic are committed to providing our patients with state of the art attentive care, advanced medical therapy, education and screening for opportunities of enrollment in clinical trials.

The Pulmonary Hypertension Clinic benefits from comprehensive support services provided by the outstanding staff of the Cleveland Clinic Florida. We will work with drug companies, purveyors and insurance companies to assure that our patients receive the most efficacious treatment regimens available. We are committed to help other medical practitioners with expert evaluation and treatment of Pulmonary Hypertensions in their patient’s. We seek to create close ties with area physicians to jointly care for this aspect of their patients’ treatment. Reports of all activities will be sent to the referring physician, maintaining an open line of communication. Call (954) 659-5802 to schedule a consultation.

Services Offered

• Meticulous evaluation to elucidate the history of the disease, establish the diagnosis and accurate classification
• Advanced Cardiopulmonary Diagnostic Services performed by expert and highly trained personnel, to obtain meaningful understanding of the state of the disease: · Echocardiogram · Pulmonary Function Test · High resolution computed tomography (HRCT) · CT Angiogram/Cardiac MRI · Ventilation-perfusion (V/Q) scintigraphy · Right/Left Heart Catheterization
• Inhaled nitric oxide (NO) for Vasoreactivity Testing to select optimal treatment. (Lowest risk)
• Evaluation of Sleep Apnea by our Certified Sleep Disorders Center to exclude sleep disorders as a source of Pulmonary Hypertension
• Patients can receive follow up visits at our West Palm Beach facility with the PH specialist once a month.
• Comprehensive treatment plan with the most advanced drug therapy from evidence-based clinical research
• Commitment to close and dedicated follow-up
• Aid in handling insurance coverage and copayment for pulmonary hypertension medications
• Pioneering Shared Medical Appointment Program, in which multiple patients meet simultaneously with the medical provider, to improve patient access and quality of care, while providing a support group environment to address the educational and emotional needs of the pulmonary hypertension patients and their families.
• Pulmonary Rehabilitation Program designed to improve the health and quality of life of our patients.
• Active involvement in Clinical Research with a Research Fellowship Program · Pulmonary Hypertension Specialized Home Care with home dietary consultation, physical therapy and nurse visits.

Ongoing Clinical Trials

Currently participating in multi-center Clinical Trials and conducting clinical research in:

• Sitaxsentan Trials
• Compass 3 Trial
• Athena 1 Trial
• Artemis – PH Trial
• Imatinib in Pulmonary Hypertension Trial
• Cicletanine Trial
• Group visits in Pulmonary Hypertension
• Role of CT angiography in identifying cardiac versus non-cardiac etiology of PH

Our Sleep Disorders Center, founded in 1996 by Dr. L.A. Smolley, is one of only six fully accredited sleep disorders centers in the tri-county region. We recently expanded the lab to 6 beds and relocated our modern equipment to the Marriott Hotel in Weston. By moving to a hotel setting, we provide an extremely comfortable environment more conducive to sleep.

Our diagnostic sleep laboratory is supervised by two Sleep Board certified physicians. We use a multidisciplinary approach involving sleep specialists, pulmonologists, ear-nose-throat specialists and psychologists or psychiatrists to diagnose and treat problems related to daytime sleepiness, snoring, trouble staying asleep, headaches in the morning, difficult to treat hypertension, etc., which could be due to obstructive sleep apnea or other sleep related problems.

Our comprehensive Pulmonary Function lab is equipped with state-of-the-art equipment that allows more accurate lung volume measurements, and allows for flight simulation in patients with borderline respiratory status pre-flight.

Special services include:

• Flight simulation
• Complete Pulmonary function testing
• ABG
• Methacholine challenge test
• 6 min walk test/ Oxygen level assessment during walking
• Alpha-1 Antitrypsin testing
• Overnight Saturation Study

Aside from applying the latest in technology, our ICU uses the following state-of-the-art and innovative technologies and programs:

• Scientific evidence-based clinical protocols and care pathways.
• Use of ultrasound guidance in all ICU procedures, including thoracentesis and central line placement.
• Multidisciplinary rounds with the collaboration of an extensive ICU team: Board certified ICU attending, medical residents, interns, medical students, respiratory therapists, ICU nurses, nursing students, pharmacists, pharmacy students, case managers, and dietitians. This group approach improves decision-making and facilitates collaborative execution of the plans.
• The academic residency programs, in conjunction with cardiology, gastroenterology, and renal fellowships drive excellence: as repeatedly demonstrated, hospitals with academic programs have an overall decrease in mortality.
• Continuing education of the nursing staff by medical educators.

Cleveland Clinic Florida specialists offer patients with chronic lung disease an accessible outpatient service to help them develop a healthier lifestyle and increase their levels of activity. Through comprehensive exercise programs, effective treatments, and educational resources, we help South Florida patients with pulmonary conditions return to an optimal level of respiratory function.

Pulmonary Education

The Department of Pulmonary Medicine supports an active rehabilitation and exercise program for patients with lung disease. In conjunction with the rehabilitation educators, we are offering a unique blend of pulmonary education services in the clinic. They include:

• Disease state teaching in Chronic Obstructive Pulmonary (COPD), emphysema, and asthma
• Inhaler, peak flow, spacer teaching
• Asthma action plan and COPD contingency planning
• Pulmonary rehabilitation evaluation
• Smoking cessation clinic, using state of the art techniques
• Pre-operative deep breathing instruction (Incentive Spirometry) to decrease complications following surgery

Pulmonary Rehabilitation

Pulmonary Rehabilitation has traditionally focused on patients with COPD, Chronic Obstructive Pulmonary Disease. With our Comprehensive Pulmonary Rehabilitative Program, we focus on many more pulmonary diagnoses such as:

• Asthma
• Bronchiectasis
• Pulmonary Hypertension
• Cystic Fibrosis
• Lung Cancer
• Interstitial Lung Disease

Our program is structured through accurate diagnosis, therapy, emotional support and education, resulting in a more stable physical and emotional state. We strive to return the patient to a higher quality of life and functional capacity.

The specific benefits of Pulmonary Rehabilitation are as follows:

• Reduce hospitalizations which reduces cost
• Improve quality of life
• Reduce respiratory symptoms
• Improve psychosocial symptoms
• Increase knowledge of pulmonary disease and its management
• Increase exercise tolerance and performance
• Enhance ability to perform activities of daily living
• Increased survival of some patients
• Return to work for some patients

Pulmonary rehabilitation, asthma action plans and disease state teachings have all been shown to decrease morbidity of pulmonary diseases.