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Specialty Areas
The following is a list of the specialty services we provide as part of the Pulmonology, Critical Care and Sleep Medicine divisions.
Medical Intensive Care Unit
The Medical Intensive Care Unit is staffed around the clock by board certified Pulmonary and Critical Care specialists and three physicians in training. Our team is complemented by some of the finest Critical Care certified nurses in the New England region, respiratory therapists, physical and occupational therapists, nutritionists, pharmacists, and social workers. The Tufts Medical Center is a regional referral center for critically ill patients.
Areas of specialization include:
- Acute and chronic respiratory failure with special interest in acute lung injury
- Asthma
- Interstitial lung disease
- Management of cardiac failure and cardiogenic shock
- Sepsis and septic shock
- Management of the unique problems in patients who are awaiting or have had solid organ or hematologic transplantation
We offer aggressive management of gastrointestinal bleeding, fulminate hepatic failure, and acute renal failure with all of the state of the art therapeutic options available.
These include:
- Specialized techniques in mechanical ventilation
- Specialized endoscopy
- Hemodialysis and CVVHD
- Vascular imaging and embolization
- Transhepatic porto-systemic shunt or TIPS
- State-of-the art surgical intervention including transplantation
Patients can be transferred to the Tufts Medical Center MICU at any time of day or night. Please call 617-636-5114 and ask for the Pulmonary and Critical Care Fellow or Attending Physician on call, if you wish to transfer a patient to the unit.
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Pulmonary Clinic
Our Pulmonary Clinic provides state-of-the-art evaluation and treatment for a wide variety of pulmonary problems. We provide outpatient care for patients with undiagnosed or general respiratory problems. Patients are seen by Tufts Medical Center faculty pulmonologists who work in close collaboration with chest radiologists, thoracic surgeons, and pulmonary pathologists at Tufts Medical Center to provide definitive diagnoses and therapeutic options across the spectrum of pulmonary medicine.
We see a wide variety of patients, many of whom have pulmonary disorders such as asthma, emphysema, and lung cancer. Many patients also present with work-related pulmonary disease and sleep disorders. Very often patients come to our clinic without a diagnosis but with symptoms such as persistent or troublesome cough, shortness of breath either at rest or with physical exertion. Difficult or unusual problems are thoroughly evaluated by drawing upon the expertise of Tufts Medical Center clinicians in other specialties. A full report is mailed promptly to referring physicians.
Please make sure you obtain a referral from your primary care doctor to be seen in the Pulmonary Clinic if needed. You may also reach us by telephone at 617-636-6377.
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Pulmonary Function Laboratory
The Pulmonary Function Laboratory (PFT lab) at Tufts Medical Center is a state-of-the art pulmonary physiology laboratory staffed by three licensed technicians. Our lab contains three Sensormedics platforms that include two nitrogen washout systems for the determination of lung volumes, one body plethysmograph and a metabolic cart to perform cardiopulmonary exercise testing. We also have a portable spirometer to do bedside studies.
The laboratory is open from 8:00 - 4:00 p.m., Monday - Friday.
Appointments can be arranged by patients or physicians by calling 617-636-6387.
Physicians must fax over a signed requisition of the tests desired. This can be done on a Pulmonary Lab Requisition Sheet which can be acquired from the Lab at your request.
We strive to offer pleasant, efficient service and are happy to answer any questions regarding your study or your patient's study. Below is a list and description of the services and studies provided by our laboratory.
These descriptions are aimed at non-pulmonary physicians to ensure that your patients have the proper test. We hope that residents, medical students, and patients will also be able learn from the information provided.
Spirometry and Post-Bronchodilator Testing
Spirometry is a basic and highly informative pulmonary function test that allows for the time dependent evaluation of lung volumes. It is also the most common test ordered in the pulmonary function laboratory. While breathing through a mouthpiece the patient is asked to take a maximal breath in and then exhale as fast as possible (the total exhaled volume is termed the “Forced Vital Capacity” (FVC)). Volumes are measured in relation to time (i.e. Forced Expiratory Volume in 1 second (FEV1)) and analyzed in relation to the FVC. Spirometry allows physicians to identify the presence of obstructive or restrictive physiology by analyzing the FVC, FEV1/FVC ratio, and flow rates (i.e. FEF25-75%).
In addition, spirometry can be used to determine if a patient’s pulmonary function improves with the use of bronchodilator medication. Following baseline spirometry,the patient is given a bronchodilator treatment following which the spirometry is repeated. Taking into account inhearant variability, if the FEV1 or FVC increase by 12% and at least 200 ml the patient is considered to have “reversible” obstructive physiology.
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Static Lung Volume Determination - Helium Dilution Method
Static lung volume determination differs from spirometry in that lung volumes are measured independent of time. In addition, lung volume determination allows for the measurement of the total lung capacity (TLC) which includes volume within the lung not measured by spirometry (residual volume (RV)). During this measurement, the patient begins to breathe pure oxygen. Then, with each successive breath the decreasing nitrogen concentration is measured. This happens because the nitrogen left in the lung (and some in solution of the tissues) is being exhaled with no nitrogen to replace it.
A curve of the exhaled nitrogen concentration is plotted and the area under the curve represents the volume of the lung at the end of tidal breathing (FRC). The inspiratory capacity is added to the FRC to obtain the TLC and then RV is calculated by subtracting the VC from the TLC. Static lung volume measurement is useful in identifying restrictive physiology, hyperinflation, and air trapping, and is useful in monitoring response to therapy.
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Static Lung Volume Determination - Plethysmography “Body Box” Method
As opposed to the nitrogen washout method of measuring lung volumes which measures the lung volume in communication with the spirometer, body plethysmography uses Boyle’s law (PV=NRT) to measure the total thoracic volume. Thus it is useful in discriminating ventilated areas of lung from areas of the lung where air is trapped. To perform this test the patient is asked to sit in a chamber about the size of a telephone booth. With the patient breathing through a mouthpiece connected to a monitor outside the body box the patient will perform a few simple breathing maneuvers. Since the change in pressure within the box is known, this test measures the total volume of gas in the chest and also measures the resistance to flow in your airways.
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Diffusion Capacity
The diffusion capacity for carbon monoxide (DLCO) is a sensitive measure of the gas exchanging surface of the lung. Unlike oxygen which is limited in its ability to diffuse across the alveolar capillary membrane surface by perfusion and the intrinsic properties of the membrane, carbon monoxide (CO) is limited almost exclusively by the latter. Therefore, any limitation in carbon dioxide diffusion into the lung is due to an abnormality in the gas-exchanging surface of the lung. Although it is often believed that a reduced DLCO is pathonomonic with interstitial inflammation, in reality, a reduced DLCO is non-specific. Hence, there are a number of factors which affect the DLCO, including pulmonary blood volume (pulmonary congestion), lung volume (total surface area), pulmonary vascular surface area, anemia, and endogenous carbon monoxide levels (due to smoking). There are a number of techniques used to measure the DLCO, however, most laboratories including ours use the single breath method (Dsb).
While breathing through a mouthpiece the patient will be asked to exhale, and then inhale to total lung capacity and hold his or her breath for 10 seconds. During the inhalation, the patient breaths .03% CO gas. At the end of 10 seconds the patient will exhale and the air is collected and analyzed for the amount of CO absorbed into the lung. The milliliters of CO absorbed per minute per millimeter of atmospheric pressure (ml/min/mmHg) are reported. Since both the surface area (lung volume) and lung blood volume (hematocrit) can affect the Dsb and can be measured at the time of the maneuver, most laboratories also report Dsb values adjusted for; hematocrit (Dsb (adj)), Lung volume (D/VA), and both (D/VA (adj)). Although these values are useful in identifying the contribution of lung volume and red cell volume to the diffusion capacity, when in the normal predicted range should not be misconstrued to suggest that the diffusion capacity is normal. The Dsb (adj), D/VA, and D/VA (adj) help in understanding the relative contribution the alveolar-capillary membrane, total surface area, and lung red cell volume make to an abnormal diffusion capacity.
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Methacholine Challenge Test
Methacholine challenge testing is used to identify patients with reactive airways that are prone to bronchoconstriction. It is used most commonly on patients with chronic cough, or shortness of breath who have normal spirometry, lung volumes, and physical exam. When abnormal it indicates the patient is prone to bronchospasm and may suggest an underlying airway disorder such as asthma. After performing spirometry (see above) the patient is given an aerosol of methacholine to breathe for 2 minutes. Subsequently, the spirometry is repeated.
This process is repeated with increasing doses of methacholine, and if the FEV1 drops by 20% or more from their baseline, the test is terminated. A test is considered positive if the dose required to induce a 20% reduction in FEV1 is less than 8mg/ml of methacholine. As mentioned above, a positive test is suggestive of hyper-reactive airways and although not specific, in patients with symptoms of intermittent shortness of breath or cough (high pre-test probability), the positive predictive value is quite good. If the study is normal it essentially excludes the diagnosis of reactive airways disease.
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Cardiopulmonary Exercise Testing
Cardiopulmonary exercise testing has a few different indications. The most common indication is to evaluate patients for shortness of breath (dyspnea) who do not have a readily discernable cause upon routine testing. (PFT’s, echocardiogram and hematocrit). It also can be useful in the evaluation of borderline candidates for thoracic surgery, disability evaluations, initial tests are also done for patients in pulmonary rehabilitation programs to help determine exercise prescriptions or to monitor the progression or response to therapy of interstitial lung disease.
The patient will pedal a bike while breathing through a mouthpiece attached to a metabolic cart which measures minute ventilation, tidal volume, respiratory rate, oxygen consumption and CO2 production. The patient also has continual ECG recording, oxygen saturation monitor and, in cases where information is needed for pulmonary vascular problems, a radial arterial line is placed to draw serial ABG’s during the study. In patients with unexplained dyspnea, in can be determined whether the patient has a pulmonary or cardiac limitation to exercise and help guide subsequent work-up.
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Pulmonary Rehab Service
The Pulmonary Rehab Service provides evaluation and treatment for patients with advanced lung disease and for those patients recovering from an acute illness. Patients are seen by faculty pulmonologists who work in close collaboration with nurses, physical and respiratory therapists, occupational therapists, social workers, pharmacists, and dieticians.
Weaning patients from dependence on mechanical ventilation is a major aspect of the pulmonary rehabilitation service at both of these sites.
The goal is to help the patient understand and cope with the disease and function more comfortably and independently at home. Patients are taught to control the symptoms and avoid some of the complications of respiratory disorders and diseases. This is accomplished through breathing retraining and relaxation techniques, and exercising to increase strength and endurance. Any questions that patients and family members may have are addressed in detail.
The Pulmonary Rehabilitation Service is provided by the New England Sinai Hospital and Rehabilitation Center and is located at two sites:
The Sinai Inpatient Satellite Boston site
T: 617-636-1069
Patients can be moved easily to the 30 bed unit following their stay at Tufts Medical Center. The site is directed by Barry Fanburg MD and is staffed by members of the Pulmonary, Critical Care and Sleep Division. Preeti Kaur, MD is the current staff member with primary responsibility to this unit, but all staff members are involved with the unit.
New England Sinai Hospital and Rehabilitation Center
This is located 45 minutes by car south west of Boston. Physicians (both fellows and attendings) from the Pulmonary, Critical Care and Sleep Division from Tufts Medical Center run an inpatient pulmonary rehabilitation unit at the campus. Nicholas Hill, MD runs an outpatient pulmonary rehabilitation program on Monday afternoons at this campus. This multidisciplinary clinic provides state-of-the-art outpatient pulmonary rehabilitation for patients with chronic pulmonary disease.
Educational topics include:
- Effective cough techniques
- Energy conservation
- Breathing & relaxation techniques
- Inhaler and oxygen use
- Nutrition
- Stress management
- Living with COPD
- Staying in shape
- Traveling with a lung disease
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