Pulmonary and Critical Care Medicine Fellowship Program

Special Programs

Bronchoscopy and Pulmonary Physiology Suites

Diagnostic Bronchoscopy:

Photo: Doctors perfoming a bedside bronchoscopy

Dr. Hasday and Dr. Abdelhady, a pulmonary fellow, perform a bedside bronchoscopy

The Pulmonary and Critical Care division performs over 500 bronchoscopy procedures each year. Dedicated bronchoscopy suites with fluoroscopy equipment are available at the University hospital and the VA.

Our large volume enables fellows to become proficient in all aspects of the procedure. A particular focus of the division is diagnostic and staging transbronchial needle aspiration (TBNA).

This service is supported by referrals from the Thoracic Oncology Program of the Greenebaum Cancer Center and private physicians from around the state. Fellows begin performing TBNA early in the first clinical year and learn to apply the technique for biopsy of mediastinal and hilar lymphadenopathy as well as peripheral masses and "coin" lesions using fluoroscopic guidance. TBNA is generally underutilized in the community because of inadequate training in many fellowship programs. The large volume of TBNA procedures performed at the University of Maryland is truly one of the fellowship's strengths.

CT-guided Bronchoscopy:

Airway preparation is administered in the pulmonary procedure area.

Although our extensive experience with TBNA increases the diagnostic accuracy for cases of malignancy and invasive infection, some lesions are too small to visualize with routine fluoroscopy or are in technically difficult locations.

At most centers these lesions are approached with surgery or percutaneous biopsy which have higher complication rates than bronchoscopy.

The University of Maryland is one of a few centers with the capability to perform bronchoscopy with TBNA under CT fluoroscopic guidance. Faculty and fellows within our division have published this experience and presented data at international meetings. The procedure is performed with the patient in the CT suite. Using CT fluoroscopy, real time trans-axial imaging is obtained and used to direct the biopsy materials to the target lesion. Nodules as small as 8 mm have been biopsied successfully. We are also investigating other diagnostic and therapeutic uses for this technique.

The airway preparation is administered in the pulmonary procedure area. The patient is then transferred to the CT suite and placed on the floating gantry which can be moved in and out of the CT ring by hand. Bronchoscopy with a complete airway exam is performed in the usual manner using conscious sedation with assistance from a nurse and an endoscopy technician.

Interventional Bronchoscopy:

The University of Maryland is a major lung cancer treatment center with an active clinical trials program. Patients with advanced local disease are common and may need palliative therapy. Interventional therapies are available through the combined efforts of the Pulmonary and Critical Care, Thoracic Surgery, Radiation Oncology and Interventional Radiology divisions.

Pulmonary fellows have the opportunity to use the latest interventional tools including metal stents, argon plasma coagulation and brachytherapy, all through the flexible bronchoscope in the endoscopy suite. They also are invited to spend time in the operating room with the thoracic surgeons to learn more about rigid bronchoscopy.

Bronchoscopy training at the University of Maryland:

Bronchoscopy Training during the Pulmonary Fellowship:

Training begins with practice and instruction in basic skills using latex models and using the "virtual reality bronchoscopy simulator" developed here at the University of Maryland in cooperation with a in Gaithersburg Maryland. Fellows and training can expect to be fully involved in the evaluation of patients for and performance of >500 diagnostic fiber-optic bronchoscopies undertaken yearly on the consultation service at University hospital.

The case mix is drawn from the needs of physicians caring for patients with lung cancer in our comprehensive lung cancer program. This program involves cooperative efforts of: thoracic surgeons, radiotherapists and oncologist, diagnostic radiologists and pulmonologists in a large combined modality program utilizing the latest clinical trials and techniques.

The diagnostic bronchoscopy program also supports the evaluation of patients with pulmonary infections and complications of the largest renal transplant program country (> 365 kidney transplants yearly), and in active bone marrow transplant, heart, lung and liver transplant programs, and in one of the largest combined kidney and pancreas transplant programs and country.

A large capitated HIV population also requires a substantial input are our diagnostic services. The division maintains its own bronchoscopic facility and staff, maintaining a library of instruments and fluoroscopic capability. As part of the renovation of University hospital, new facilities are in the active design phase.

During the second and third years of fellowship training, fellows maintain their skills by performing diagnostic fiber-optic bronchoscopy on their own patients seen in the faculty referral clinics. Approximately 35 percent of bronchoscopies are outpatient, derived from the resident clinics and faculty practices.

An additional 200 fiber-optic examinations are undertaken yearly at the Baltimore Veterans Administration medical Center, where a weekly "lung mass clinic" generates a large volume of diagnostic lung cancer worked.

In addition to our own bronchoscopy suite, we have active and flow cooperative access to the CAT scan fluoroscopy resources of the department radiology at University hospital, where interdepartmental pioneering working and CT fluoroscopy aided diagnostic fiber-optic bronchoscopy has been undertaken.

Fellows graduating from this program leave here as exceptionally skilled fiber-optic bronchoscopists, well versed in the art of awake cooperative fiber-optic bronchoscopy.

Chest Tube Placement and Pleural Biopsy:

Pulmonary fellows are encouraged to become proficient at tube thoracostomy for the management of pneumothorax, empyema and malignant pleural effusions. We routinely place traditional large-bore chest tubes at the bedside in the intensive care unit.

Our procedure suites with fluoroscopy also allow us to place image guided small-bore tubes with much less trauma and discomfort for the patients. Pleural biopsies are also performed in the procedure suites when indicated.

Right Heart Catheterization:

The Pulmonary and Critical Care division has an active pulmonary hypertension program. Patients with Primary Pulmonary Hypertension and other forms of pulmonary arterial hypertension are treated with the latest vasodilator therapies including prostacyclin infusions and oral endothelin antagonists.

Patients are able to remain within the University system for complete evaluation and treatment including lung or heart-lung transplantation if necessary. Pulmonary fellows learn to perform right heart catheterization for the evaluation of pulmonary hypertension in our procedure suite using fluoroscopic guidance. These procedures routinely include trials of vasodilator responsiveness.

Sleep Disorders Center

The recently established sleep disorders center at the University of Maryland is a multidisciplinary center performing comprehensive clinical and laboratory evaluation of patients with a variety of sleep disorders.

Under the direction of Dr. Scharf, a board certified pulmonary and sleep specialist, specialists from diverse fields including ENT, Psychiatry, Dentistry, Neurology and Pediatrics, evaluate and manage a wide variety of pulmonary and non-pulmonary sleep disorders. The center maintains an outpatient clinic and a sleep laboratory.

Fellows are invited to rotate through the center, engage in research projects linked to sleep disorders and develop clinical skills necessary for the management of sleep disordered breathing within the framework of a pulmonary medicine practice.

Introduction to Basic Research at UMB

The course consists of two weeks of half-day classes (9 am to noon), followed by lunch with a different faculty member each day, and is held just prior to the short "Introduction to Clinical Research" course offered by the Department of Epidemiology and Preventative Medicine.

The course is designed for Fellows, senior residents, and clinicians who would like to include basic research in their studies, as well as clinicians who would like to improve their ability to critically review basic science literature and the impact of basic science on clinical research.

The goal of this course is not to provide hands-on training in basic science techniques, but instead to provide an overview to the core scientific resources that are available to your scientists at UMB.

In addition, lectures will also deal with the concepts of experimental design, data analysis, balancing effort versus impact when beginning new research projects, research portfolio building, and time management for the physician-scientist. The course is run by Dr. Fenton.

This page was last updated on: October 10, 2007.

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