Pulmonology Offers Multidisciplinary Approach to Best Serve Pediatric Patients

Providing holistic care for each patient at Arkansas Children's Hospital (ACH) in Little Rock starts with a multidisciplinary approach, which the Pulmonology Clinic has perfected. One of seven nationally-ranked programs by U.S. News & World Report, ACH pulmonology provides comprehensive care for a variety of disorders, including cystic fibrosis, chronic cough, asthma and other causes of wheezing, aspiration/dysphagia-related lung disease and chronic lung disease of prematurity (bronchopulmonary dysplasia). Innovative services provided in pulmonology include:

  • State-of-the-art bronchoscopy
  • Outstanding Pulmonary Function Laboratories (PFL) and respiratory care services
  • Fully-accredited Pediatric Sleep Center
  • The only accredited Pediatric Cystic Fibrosis Center in Arkansas
  • The Arkansas Center for Respiratory Technology Dependent Children (ACRTDC)
  • Specialized care for asthma, bronchopulmonary dysplasia (BPD) and pulmonary complications of neurological and neuromuscular disorders.
  • Primary Ciliary Disease (PCD) Accreditation
Matthew Pertzborn, M.D., a pediatric pulmonologist at ACH and assistant professor of Pediatrics in the Division of Pediatric Pulmonology at the University of Arkansas for Medical Sciences (UAMS), said a multidisciplinary approach helps specialists focus on the whole picture of patient care.

"Sometimes we can get into a silo in terms of our specific organ system, what we're focusing on," Pertzborn said. "The different organ systems don't operate in complete isolation. It helps to communicate better between subspecialties, especially when you are facing challenging medical decisions and making big changes. Making the best decisions is hard if you only think about one organ system."

Neonatology, Pulmonology and BPD Care

As the only children's hospital in the state, ACH is a leader in neonatology, developing expertise in caring for babies with bronchopulmonary dysplasia (BPD), a chronic lung disease impacting newborns. Happening often in premature babies, BPD damages the lungs and airways and destruction of the tissue in the lung's air sacs.

In recent years, a weekly care coordination conference has provided comprehensive care for these babies using a multidisciplinary approach. David Matlock, M.D., neonatologist at ACH and assistant professor of pediatrics in the division of neonatology at UAMS, said the team demonstrated an improvement in provider perceptions in provided care with 89 percent improvement in developing long-term, well-coordinated plans for patients with severe BPD.   

"Our pulmonary and complex care clinics coordinate care for these babies all over the state. It's impressive how they get these babies on a trajectory towards healing and recovery from this disease," Matlock said. "We love to hear about their success - weaning their baby off oxygen or a ventilator, hearing their first words, or having their tracheostomies removed. That's what makes us tear up, come to work every day and give everything we have to these babies and families." 

Pediatric Pulmonologist Amit Agarwal, M.D., FAAP, medical director of the chronic ventilator program at ACH and associate professor of pediatrics in the division of pulmonary medicine at UAMS, is a member of the BPD care team, working in collaboration with neonatology to guide care from initial diagnosis and continuation of care.

"At Arkansas Children's, our mission is to serve BPD patients and families with leading-edge research, innovation, and compassion. There are about 70 to 80 new BPD patients annually, with about 80% who have a severe form of this disease," Agarwal said. "Our program has excellent inpatient coordinated BPD care. We work with the neonatologist in a multidisciplinary approach and are working to establish a dedicated BPD clinic for these patients."

Clinical and translational research are priorities for the program. ACH participates in local and multicenter studies to improve BPD and chronic respiratory failure disease outcomes.

"Our team is participating in a recorded home oximetry program, an evidence-based remote patient monitoring program that facilitates safe and effective weaning of home oxygen in premature infants. We are part of a BPD collaborative, a multi-institutional setup with 28 centers across the U.S., Canada and Sweden. They are dedicated to improving the outcomes of children's BPD, and fostering interdisciplinary care, collaboration and innovation in identifying and treating these children," Agarwal said. "We are currently involved in several projects, including developing a registry of severe BPD; weaning supplemental oxygen at home; patient use of in-home telemedicine; and improving out-patient care of severe BPD by transitioning these children to home ventilators and weaning them off a ventilator safely. Our team is also utilizing Neurally-Assisted Ventilatory Assist (NAVA) technology in mechanically-ventilated patients with severe BPD with Dr. Matlock."

Pulmonary Involvement in the Fontan Clinic

Within four years, ACH has performed over 80 Fontan procedures, an open-heart surgery typically meant for children 18 to 36 months old.

The surgical technique directs systemic venous blood flow through the lungs without it being pushed forward by a ventricle of the heart. This surgery is typically done when a person is born without a heart that has two adequately working ventricles. This allows the one ventricle that is working to focus on pumping blood to the rest of the body.

This surgery is typically done when a person is born without a heart that has two adequately working ventricles. This allows the one ventricle that is working to focus on pumping blood to the rest of the body. It has proven effective in treating complex congenital heart disease patients born with this single ventricle physiology. Fontan patients require close, specialized care due to higher rates of arrhythmias, chronic liver disease, heart and renal failure and other conditions as they grow.

Because the heart and lungs are closely intertwined and can create a vicious cycle of complications, earlier care is vital for healthier outcomes.

"We're staying on the cutting edge of care. We are keeping up with the leaders in the pack when it comes to management of Fontans," Pertzborn said.

One way the clinic stays forward-focused is by educating patients and families on the latest data that encourages exercise, as tolerated, for Fontan patients.

"There's this old way of thinking that if you have a Fontan, you have to restrict your exercise because you don't have that other side of the heart working. New data shows that's not true," Pertzborn said. "You need to exercise like everyone else, to the point you're able to tolerate, of course, because that helps the heart and lungs. Dr. Dala Zakaria and I have worked hard to educate families on this. In terms of preventative medicine, we've made a lot of progress here."

Pertzborn added that a multidisciplinary approach has allowed cardiologists and pulmonologists to make key findings in overall patient care.

"We've concluded that many people need more workup than what they have previously had done with regard to the function and pressures within their Fontan. We've gotten patients in for those procedures, screened those patients that really needed that procedure way sooner than they otherwise would have been screened," Pertzborn said. "That's helped because we can say, 'OK, maybe there's some sleep apnea here that we need to address that's causing those pressures in the Fontan to go higher than they should be. Maybe we need to treat the sleep apnea or add some medication to help with those pressures.' We've moved the needle getting those specific issues identified and addressed sooner to help improve patient's long-term health."

This type of preventative care can help increase the longevity of a patient’s Fontan and the amount of time they can have their Fontan without needing a transplant.

Sickle Cell

Sickle cell disease impacts every organ in the body, making its collaboration with pulmonology vital. It is the most common genetic disorder in the U.S., and Arkansas Children's is the only health system in the state to comprehensively diagnose, evaluate and treat children who have it.

Sickle cell patients can develop acute chest syndrome from a respiratory infection or pain crisis. It is also common to develop pulmonary hypertension secondary to sickle cell disease.

The bi-monthly stable pulmonary clinic meets in the same space, allowing subspecialist physicians to discuss a care plan together with the patient's caregivers. Beyond the logistics, the camaraderie with the staff is exemplary.

Pertzborn said many sickle cell patients have reactive airways, sleep apnea or other breathing problems that can worsen the disease. Having multidisciplinary visits can help manage these other illnesses and better control the impact of sickle cell.

"We're making a difference in helping patients control their sickle cell disease," Pertzborn said. "Because poorly controlled lung diseases such as asthma, even asthma that is slightly less controlled than is ideal, can be a big problem when it comes to sickle cell disease."

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