Patient Care

The Bronx has the city’s highest incidence of asthma and COPD, as well as smoking-related lung conditions. To address this need, The Department of Pulmonary Medicine provides state-of-the-art diagnostic, management and critical care services for a broad range of pulmonary diseases, including sleep-related breathing problems, pulmonary infections and lung disorders caused by other diseases.

In 2015, we integrated the department with critical care to better serve the management of conditions that are highly prevalent in our population. This has allowed us to structure our pulmonary critical care services around the needs of our patients, providing comprehensive care that will assist with early recovery, avoid hospital re-admissions and improve their quality of life. This means rendering timely critical care, offering self-directed treatment plans for conditions like asthma, and educating patients on how they can better manage and control their conditions so they can avoid having to come to the emergency department in the middle of the night.

SBH Health System in Bronx, NY is a new addition to the Westchester Medical Center Pulmonary and Critical Care Medicine Fellowship program.

Here is a brief overview of the program:

 

SBH Pulmonary Services

 Below is a brief description of the different areas of our expertise.

 

Our team: 

Director, Dr. Miguel Robles

-Full-time Pulmonary and Critical Care Attendings: Dr. Velazquez, Dr. Fingerhood, Dr. Avula, Dr. Mediha, Dr. Robles.

– Pharmacist, Nurse Practitioner, Clerk, Nurses: Marlene, Valery, Wilma, Laren, Frances, Jackie, Ana

– Internal Medicine Residents: 2 – 3 per monthly rotation.

– Medical Students from CUNY School of Medicine and NYIT College of Medicine.

 

Outpatient Services:

1. Mondays, Wednesdays and Fridays are dedicated to our regular pulmonary and asthma clinic patients. We have morning and afternoon session, visits are face-to-face and by phone. We assist patients with multiple types of conditions: COPD, Sarcoidosis, ILD, pHTN.
2. Tuesdays and Thursdays are for Xolair/ Nucala patients. Patients with Severe Persistent Asthma get immunologic subcutaneous injections every 2 – 4 weeks. We have between 100 -150 patients that visit our clinic regularly. We are also applying for Fasenra, a new immunologic therapy.
3. The Lung Cancer Screening Program, which started in 2017, runs Tuesdays and Thursdays. Patients that meet criteria for further lung cancer investigation will be able to get EBUS and IR guided biopsy in less than 4 weeks in our center. Our yield of diagnosis is similar to other centers (60 – 80%). We have monthly Oncologist/Radiologist/CT-Surgery Tumor Board meeting. Dr. Lafaro, our Cardiothoracic surgery attending, has been working closely with us.
4. Pulmonary Function Test: We were able to accomplish the highest standard of care regarding COVID precautions. We have 3 Negative Pressure rooms with 1 room dedicated exclusively for PFT. Covid testing is done before the PFT and the Respiratory Therapist uses PAPR type Respirator. The other 2 Negative pressure rooms are used for pulmonary outpatient visits.
5. Ancillary tests: EBUS, Bronchoscopy and Thoracentesis.

 

Inpatient Services:

1. Floor consults: Residents will divide the consults and discuss with pulmonary attending.
2. Vent rounds are on our dedicated 7 floors for chronic vent dependent. We have a weaning protocol with daily discussion about ventilator management and active weaning.
3. Ancillary tests: Thoracentesis, Bronchoscopy either in our dedicated bronchoscopy room (4^th floor) or at bedside.

 

Biologic Therapy:

Alannah Garcia, an eight-year-old girl with a sweet nature, curly dark hair and glasses, rushed into Dr. Alyson Smith’s examination room bubbling over with a smile that stretched from ear to ear. She held aloft a small plastic trophy that represented an important milestone in her life.

“It was the first time she ever had perfect attendance in school,” says Dr. Smith, a pediatric allergist at SBH Health System. “She was so proud of her award.”

At two years old, Alannah was diagnosed with asthma. Medications prescribed by her pediatrician since then did little to relieve her symptoms (which included coughing, wheezing, shortness of breath, chest congestion, and chest pain).

“For years, we’d bring her to the emergency room or she would need to be hospitalized, especially during the winter when her asthma was worse,” says her mother, Ashley. “Using the asthma pumps and giving her medication when her asthma flared up didn’t work. She wasn’t living a normal childhood.”

It was about a year ago that Dr. Smith prescribed what is known as biologic therapy, a treatment SBH offers adults and children with persistent and severe asthma with conditions that are not controlled by inhaled corticosteroids alone or in combination with long-acting bronchodilators or leukotriene pathway inhibitors. In conjunction with traditional treatment, Alannah now receives an intramuscular injection every two or three weeks.
A Chronic Disease

 Asthma, a chronic disease of the airways, affects an estimated 300 million children and adults worldwide. The rates of asthma in the communities surrounding the hospital are staggering –eight times the national average, affecting 8.3 percent of children. These patients are sensitive to allergens like dust mites, cockroaches, mice, mold, and certain pollens as well as pollution that come with living in the South and Central Bronx.

Alannah’s positive response to biologic therapy is not unique among patients seen at SBH. The therapy has been shown to dramatically decrease the number of asthma attacks in patients with severe and difficult to treat asthma (which constitutes up to 10 percent of all asthma patients according to a recent article in The New England Journal of Medicine).

The use of the drug omalizumab (Xolair) works on children and adults who manufacture too much of a protein called IgE antibody. This overproduction can result in the development of such allergic conditions as allergic rhinitis (hay fever), allergic asthma, or a food or drug allergy. Clinical studies have shown that the addition of a biologic agent that targets the IgE pathway can significantly reduce exacerbations and improve asthma control.

“It is very exciting that we now have something to offer these really sick asthma patients who don’t respond to typical asthma treatment,” says Dr. Smith. “Before, our patients were told to use daily inhalers and pills but we would continue to see our patients in the emergency room and hospital all the time. I would frequently have kids on adult dose medications and their asthma symptoms were still not controlled. Now, we can finally offer something that works for these patients and allows them to live a normal life.”

Biologic therapy targets different molecules in the body that contribute to asthma. Other medications, in addition to Xolair, include the newer biologic therapies Nucala (mepolizumab) and Fasenra (benralizumab), which are medications for patients with eosinophilic asthma that work by reducing the number of eosinophils in the blood.

“It’s about identifying which type of mediator the particular asthma patient may have and then trying to block these specific mediators,” says Dr. Miguel Robles, interim director, Division of ICU/Pulmonology at SBH. “It leads to the concept of what we call personalized medicine in asthma.”

Xolair, as an example, is subcutaneously injected every two to four weeks into the fat where it can be fully absorbed by patients as young as six years old. It works by binding to the IgE allergic antibody in the blood stream and blocking its actions.

“What has changed is recognizing that there are clinical phenotypes, meaning clinical characteristics of a particular patient, that when identified and treated with specific drugs can make a big difference in their outcomes,” says Dr. Robles. “What we have found at SBH (among the approximately 100 patients who have to date received this therapy), which is very similar to other clinical studies, is a marked improvement in the asthma control of a number of patients to the point that they are no longer using or now use a very low dose of systemic steroid or steroid bursts when they have asthma exacerbations and so end up spending less time in the emergency room or being hospitalized.”

Biological agents need to be administered subcutaneously in the asthma / allergy clinic (located in the CCC) every two to four weeks and patients need to be monitored for about 15 to 30 minutes. Patients are evaluated by the asthma or allergy specialist before each dose of the medication is given. This gives additional opportunities for the patient to review asthma control and use of inhalers, and ensure that asthma does not affect their work or school.

Side effects of the treatment are infrequent and minimal, he says. Medicaid and most insurance carriers cover the cost of the medication, which is expensive. The therapy must be done in a hospital setting.

While studies show that most asthmatics can be controlled by the gold standard of treatment, biologic therapy is changing the lives of patients like Alannah.

“Over the past year, she’s been able to run and take swim classes,” says her mom. “She has a life now. She’s a normal kid.”