Pulmonary

The Pediatric Pulmonary division has the ability to perform flexible fiberoptic bronchoscopy in infants and children of any age. This can usually be done on an ambulatory basis. Working with the Department of Anesthesiology, these are performed under conditions felt to be safest for the patient, yet allowing the child to breathe spontaneously and improve the diagnostic yield of the procedure.

The flexible bronchoscope has the advantage of being able to go deeper into the airways than the rigid bronchoscope; to be able to be turned to go into the segmental bronchi for a deeper look at these airways and beyond; and to not require general anesthesia. Bronchoscopy is an important tool in the evaluation of children with chronic or persistent wheeze or stridor; with recurrent or persistent pneumonia; with any other persisting or recurring abnormalities on the chest radiograph; or in the child with an unusual breathing pattern or breathing noises which cannot be explained. In the Pediatric chapter in a Textbook of Bronchoscopy, Dr. Bye points out the frequency with which flexible bronchoscopy can give an etiology to the child with airway noises that don't sound like asthma, or don't respond to asthma therapy.

Through flexible bronchoscope, we can get a window into the activities and problems in the lung. Bronchoalveolar lavage has become an increasingly important tool to assess the activity or disorders in the airways, alveoli and the interstitium. This simply involves insertion of the bronchoscope into the airways until it becomes wedged into the wall of a subsegmental bronchus. We then instill normal saline into the area, allow for dwell time, and then suction the fluid back. This was first used, and its major use in children still is, to look for infecting organisms in the lungs. Dr. Bye was one of the first to describe its use in detecting lung disease in children with AIDS. This is also useful for children with other immunocompromising disorders and lung disease; for children with pneumonia who are not getting better; for children who have undergone lung transplantation; and for children with Cystic Fibrosis, in whom the bacteria in the airways cannot otherwise be detected.

We are one of the few centers in the Metropolitan area able to measure and monitor lung function in children of any age. Obviously, an infant cannot do the maneuvers necessary for normal pulmonary function testing, so machinery had to be devised for them. For infants, we place a mask over the nose and mouth to make sure we collect all the air coming out. We then place a jacket around the chest and abdomen. After the baby takes a deep breath, the jacket inflates to measure how much air the baby has in the lungs, and how fast it comes out. Originally purchased as a research tool, this equipment was recently updated and is now a vital clinical tool. It is used by the Pulmonary division to assess their patients; by the Department of Orthopedics, with their interest in repairing chest wall anomalies of infants; and by divisions whose young patients are at risk of developing lung disease.

Standard pulmonary function testing can be done in many children over the age of 5, and most over the age of 6. These routine tests can measure the speed at which air comes out of the lung, important in the assessment of asthma and Cystic Fibrosis; the size of the lungs, important in children with asthma and in children with or at risk for other lung disorders; and how the air gets across from the lung into the blood vessels. This is all done noninvasively. We can measure the changes in lung function over time, or with chronic therapy; or any immediate response to medications in children with asthma. There are children who are at risk of lung disease (cancer survivors, children with abnormal immune function, children with neuromuscular disease, children with anomalies of the chest wall, children with lupus, sickle cell disease and others) who benefit from frequent assessment of their lung function. Since the lung is affected by these and/or their therapy, it might be helpful for the physician to know that the lung is becoming effective.

We are one of very few centers in the area with an exercise laboratory dedicated to children and adolescents. The expertise in this lab is such that we have adults referred to us for evaluation, coming from all over the country. An exercise test is helpful in the evaluation of children with symptoms during exercise; in children with heart or lung disorders, to assess the response to exercise, with the potential for rehabilitation suggestions if the response is abnormal; and for children with any disorder that puts them at risk for problems with exercise, to ensure the safety of exercise for these children. The exercise test is done either on a bicycle or treadmill. Pulmonary function tests are done before the exercise. During exercise we monitor heart rate, blood pressure, blood oxygen levels and monitor the air and gases breathed in and out. All this is done noninvasively. In some patients, especially those with lung disease, pulmonary functions are often repeated after the exercise test, during recovery.