Allergy & Pulmonary Medicine | Patient Care

Clinical expertise among division members covers the broad range of allergy and pulmonary medicine, including adverse reactions to food, allergy to penicillin and other drugs, asthma, obstructive and restrictive lung diseases, cystic fibrosis, pediatric lung transplantation, pulmonary physiology, sleep-related breathing disorders and sleep diagnostic services. Research in the division focuses on disease processes including asthma, cystic fibrosis, sleep-related breathing disorders, pneumonia, cancer and other disorders causing lung destruction. In addition, faculty are investigating general processes of lung development, inflammation, extracellular matrix turnover and transplantation biology,

Allergy and Pulmonary physicians have 10 half-day clinics each week. The division typically sees approximately 25 new allergy and pulmonary patients each week. As much as possible, the waiting period is limited to two weeks. Division physicians also provide inpatient consultation for questions regarding allergy and pulmonary, as well as being primary attendings for patients on the general pediatric wards and directing the lung transplantation unit. They also attend on the general Pediatric service. Bill Parks directs the departmental research conference and is also a unit leader for the department's Molecular and Cellular Biology group. Dr. Strunk is co-director of the Patient-Oriented Research Unit.

Asthma care and research are prominent activities of the division. Approximately 1,200 children are admitted to St. Louis Children's Hospital each year for care of acute asthma. Members of the division consult on many of these patients. Approximately 450 children with asthma are followed in Allergy and Pulmonary Medicine clinics in conjunction with their primary care physician. Six allergy and pulmonary nurses provide education about asthma and other diseases and are available for phone consultation during the day.

Drs. Strunk and Bacharier continued to provide medical supervision for the Asthma Intervention Model, in which advanced practice nurses provide care and education for some of the asthma inpatients. Drs. Strunk and Bacharier and nurses from the division participate in an Asthma Education Committee to revise and standardize asthma education materials used throughout the BJC Healthcare System. Emergency care of asthma is coordinated with Drs. David Jaffe and Sharon Smith in the Division of Emergency Medicine and to work toward a system of asthma care with the Medicaid HMOs. The Community Asthma Program continues to expand. This program focuses on asthma care in primary care settings with a purpose of reducing hospitalizations and emergency visits, as well as improving quality of life for children with asthma and their families.

These community efforts are complemented by NIH-funded asthma research, including Drs. Strunk and Bacharier's participation in the Clinical Asthma Management Program Continuation Study and the Childhood Asthma Research and Education (CARE) Network and Dr. Parks' involvement with the Washington University Asthma SCOR.

Dr. Bacharier is actively involved in Washington University School of Medicine's Masters of Science in Clinical Investigation Program.

St. Louis Children's Hospital continues to be one of the most active pediatric solid organ transplant centers in the United States. Lung and heart-lung transplantation are major factors in that success. The Washington University School of Medicine and St. Louis Children's Hospital pediatric lung transplant program was the first free-standing pediatric lung transplant program, and each year accounts for 30 to 50 percent of pediatric lung transplants. Between June 1990 and April 2004, nearly 250 lung and heart lung transplants were performed. The program remains the preeminent pediatric lung transplant program in the world. In addition to referrals from throughout North America, we have provided care for patients from Japan, Australia, Israel and Saudi Arabia. Transplant physicians in the pulmonary division, directed by Dr. Stuart Sweet with the assistance of Dr. Maite de la Morena, work closely with cardiothoracic surgeon Dr. Charles Huddleston (cardiothoracic surgeon-in-chief). Research into the etiology of obliterative bronchiolitis and other major complications of lung transplantation is a high priority in the division.

Dedicated to the treatment of patients with cystic fibrosis (CF) for more than 4 decades, the comprehensive fully-accredited Cystic Fibrosis Center at Washington University Medical Center has developed into a premier clinical and research program, and the numbers of patients seen here is steadily increasing. In 2003, the Center and affiliated programs treated more than 500 patients from several states (including Missouri, Illinois, Kansas, Kentucky, Tennessee, and Arkansas), thus making it one of the largest centers in the country.

The Cystic Fibrosis Center at Washington University Medical Center is under the direction of Dr. Thomas Ferkol. Located at the St. Louis Children's Hospital, the Pediatric Cystic Fibrosis Clinical Center currently cares for more than 230 patients. An additional 80 CF children from across the United States have been referred for or have survived lung or liver transplantation and are followed by the Pediatric Transplantation programs. The long-established Adult Cystic Fibrosis Clinical Center at Barnes-Jewish Hospital, directed by Dr. Daniel Rosenbluth, follows more than 170 patients, including CF patients who have undergone lung transplantation. The Center is well-supported by nurses and ancillary health personnel, and has adult and pediatric subspecialty consultants available.

The CF research programs at Washington University School of Medicine have expanded, and close collaborative relationships between the Cystic Fibrosis Center and investigators in clinical and basic science departments have allowed us to consider questions fundamental to our understanding of the disease. The clinical research program has rapidly grown, especially following our inclusion to the Cystic Fibrosis Foundation Therapeutics Development Network (TDN). Moreover, Washington Univer-sity and St Louis Children’s Hospital are involved in a number of quality improvement programs, and participated as one of the sites for the National Initiative for Children's Healthcare Quality (NICHQ) "Breakthrough Series" project to improve the quality of CF care.

Patients with CF under 21 years of age receive their care at St. Louis Children’s Hospital. The Cystic Fibrosis Center Clinics are regularly scheduled in the Pediatric Ambulatory Clinics. Individual physi-cians, who have primary responsibility for their patients, attend the clinic with CF nurses, dieticians, clinical social workers, pharmacist, and physical therapist. When necessary, children with CF are hospi-talized in the St. Louis Children’s Hospital pediatric wards, under the care of pediatric residents and pediatric pulmonology fellows with attending supervision from the Division of Pediatric Allergy and Pulmonary Medicine.

Management of children with allergies is an important part of the division. Faculty physicians see a large number of children with rhinitis, sinusitis, otitis, asthma, eczema, urticaria and other disorders with allergic pathogenesis. In addition, the division offers penicillin and food allergy diagnostic services.

In addition to the areas discussed above, less common diseases treated in the division include a variety of restrictive and obstructive lung disorders, Swyer-James syndrome, alveolar proteinosis, tuberculosis, pulmonary hemosiderosis, bronchopulmonary dysplasia, bronchiolitis obliterans, lymphocytic interstitial pneumonitis, dysmotile cilia syndrome, laryngo, tracheal and bronchomalacia, vocal cord dysfunction, aspiration disorders, hypersensitivity pneumonitis, and a variety of lung diseases associated with neuromuscular disorders. Because of the division's large referral base for lung transplantation, its physicians see an extreme variety of end-stage lung disease.

Our physicians are expert at flexible fiberoptic bronchoscopy (FOB). As a group, they perform more than 400 FOBs per year, the majority with transbronchial lung biopsies. This most likely represents more procedures and certainly more biopsies than any other pediatric pulmonary division. The large number of procedures is directly related to our involvement in lung transplantation, but having this expertise allows us to more aggressively and definitively diagnose a variety of infectious and non-infectious lung disease in children of all ages.

The Pediatric Pulmonary Function Lab has been a crucial key to the success of the Division of Allergy and Pulmonary Medicine. The chief technologist of the laboratory is Deborah K. White, R.P.F.T., R.R.T., and she is joined by four other pulmonary function technologists dedicated to providing the highest quality pulmonary function testing possible. The laboratory offers a full range of lung function tests for clinical and research patients, from infancy into early adulthood. In addition to standard tests of lung mechanics (including spirometry, lung volume determination, diffusion capacity), the lab conducts specialized tests including exercise and resting metabolics, and protocols that evoke airway reactivity (methacholine, exercise, cold air challenges). The lab also performs state-of-the-art infant pulmonary function testing including plethysmographic measurements of lung volume and raised-volume forced flows.

Sleep diagnostic services are offered in the division. Full-scale polysomnography services are available in a two-bedroom suite. Nap studies are also done during the day. Dr. Elizabeth Uong is medical director of the sleep diagnostic service. The service has two full-time staff that are both certified respiratory therapists and certified polysomnography technicians. Together, they provide both day and night coverage. The service has completed nearly 400 studies yearly since 2000.