WINTER 2015 Newsletter Children’s Vol 1 Issue 1 Specialty Group PulmonologySpo light on Vocal Cord Dysfunction (VCD) by Jose “Frank” Chocano, MD Both asthma and vocal cord dysfunction (VCD) can make breathing dicult. Signs and symptoms of either condition can include dyspnea, coughing, noisy breathing (stridor or wheezing), throat or chest tightness and hoarseness. Some children with asthma also develop VCD. Vocal cord dysfunction is the abnormal and in- Services voluntary paradoxical closing of the vocal cords Our practice provides evaluation, di- during inspiration. As with asthma, exposure to agnosis, management and treatment of airway irritants, an upper respiratory viral infec- diseases aecting the lungs in patients tion, gastro esophageal reux (GERD) or exer- from birth through 21 years of age. cising may trigger VCD. Although asthma and e most common conditions VCD may have similar triggers and symptoms, the we treat include the following: treatment approach for VCD is very dierent than asthma, recurrent cough or wheeze, treatments used to manage and control asthma. cystic brosis, bronchopulmonary is makes proper diagnosis essential. dysplasia, chronic lung disease, bron- chiectasis, respiratory insuciency, You may suspect VCD rather than asthma if: congenital malformations of the lung, pulmonary hemosiderosis, pulmonary • During ares your patient complains that it’s hypertension, immotile cilia disease, harder to breathe in than breathe out spine and chest wall disorders, sleep • Asthma medications don’t seem to ease the disorders and dyspnea with exercise. symptoms • Results of routine breathing (pulmonary func- Referrals to Pulmonology tion) tests for asthma are normal Please provide us with a reason why the patient is being referred to our practice. • Your patient’s symptoms are not due to a respi- ratory infection alone, something in his/her air- Normal vocal-cord abduction We also ask that you provide a list of (Top) and Severe vocal-cord ab- current medications and medication ways or another health problem duction (Bottom) during inhala- delivery devices as well as any relevant Diagnosing VCD can be challenging! is may tion. e paradoxical movement doctor’s notes, labs, and chest X-rays clearly illustrates the “diamond- that may not be accessed through lead to further tests such as spirometry with in- shaped posterior chink.” CHKD’s EHR. spiratory and expiratory ow volume loops, an ex- ercise challenge or the direct observation of vocal cord closure during (continued on next page) HIS ISSUE IN T 2 The Inside Scoop 3 Hats-Off 6 CF Newborn Screens 8 Dreams Do Come True CSG Leadership notes Special Awards Cynthia Epstein, MD Urgent Care for Kids 2 Spacer or Nebulizer 4 Places & New Faces 7 Cough in Children 8 MaRxs of Distinction Shana Crabtree, MD Division contact info Marilyn Gowen, MD Why CSG is so Special (Fold-out) Bridges: Winter 2015 Newsletter Volume 1 Issue 1 3 (cont’d) inspiration using a laryngoscope. Treatment for VCD typically involves activities that relax the throat muscles, speech therapy and deep breathing techniques. A Pulmonologist has specialized training and experience in the diagnosis, treatment and management of conditions such as asthma and VCD. to a Job Welcome to our first edition of BRIDGES! Our journey together begins.... Dr. Chocano joined CSG in 2005. He Did You Know? Well Done! I’m sure you are wondering, “why another is boarded in Pediatric Pulmonology and Sleep Medicine. When he’s not Harbor View is now open! newsletter?” providing excellent patient care, 5838 Harbour View Blvd Frank loves spending time with his family. Suffolk, VA 23435 Recently, I was asked to chair the He also enjoys watching professional soccer Patient appointments available in: marketing committee for CSG. At the and listening to the classic-rock stylings of his Allergy, Cardiology, Dermatology, Developmental Pediatrics, Gastroenterology, time, I felt like nothing in my skill set son Elliot...but not at the same time! Nephrology and Neurology. suggested that I was trained to help Resident Team Players market a practice, but I knew what Helping House Staff Dr.’s Jennifer Simmons Supporting a Great Cause grabbed me and what I would look for , was recently Dr. Bryan Greenfield Why choose a Spacer over a Peter Farrell , Nic Rister Dr. Shana Crabtree and expect from a medical practice. Reeti Kumar and for providing Spanish by Shana Crabtree, MD for working extra honored at the Brewer’s Ball: interpretation in the PICU Nebulizer? unscheduled hours in the ED by A Celebration of Hampton Roads’ Since I joined Children’s Specialty Group coming down from floor duties after midnight for a Spanish (CSG), CHKD, and EVMS fourteen years Wheezing-related illnesses are a common reason for physician visits. Some Finest young professionals. She was speaking family during children may benet from bronchodilators and inhaled corticosteroids. It is to help see patients in the given the Horizon award for raising ago, I have often worried about the ED during a particularly busy for Virginia Chapter downtime when the interpreter disconnect between the medical school, up to the physician to choose the method of delivery and educate the family. A over $10,000 phone was not available. spacer with or without a mask is an excellent option for aerosol delivery at home, overnight shift. of the Cystic Fibrosis Foundation. the hospital and the physicians. I am the oce, the emergency room and the hospital as evidence-based literature has reminded of this gap each time I think demonstrated. of my beloved friend, Dr. Don Lewis, who Multiple studies have demonstrated that albuterol can be delivered eectively via somehow was able to juggle the interests spacer. Castro-Rodriguez et al J Pediatr 2004 found six prospective randomized of each entity and kept everyone focused Great Community Teaching Attention to Detail control trials looking at albuterol delivery in the emergency department. Dr. Kent Reifschneider on what pulls us together. Meta-analysis demonstrated a decreased admission rate in moderate to severe Community Education Dr.’s Joel Brenner, David Smith, , as Chair exacerbations and improved clinical symptoms in children under 5 years of age. for recently giving and Aisha Joyce , from Sports of the Nutrition committee at CHKD, When I was asked to create a newsletter ese studies did demonstrate a wide range of four to ten pus of albuterol MDI Dr. Peter Dozier Medicine, continue to provide has worked diligently to provide for CSG, I knew I wanted it to be something to be equivalent to 2.5mg nebulized albuterol. e wide range is due to many a half day symposium at Chesapeake education to physical therapists, nutritional menus in the cafeteria that could bridge the gaps in perception, factors including the type of holding chamber and the delivery technique. A Bay Academy for the community athletic trainers, coaches, parents and inpatient setting. He also created knowledge, and communication among valved anti-static holding chamber has the highest deposition of particles. on effective behavior modification and other health care professionals in and instituted educational videos and in children with ADHD. He was also our community. They address concerns posters on how to properly measure those groups. In these times of global Regarding inhaled corticosteroids, there are no studies directly comparing the installed on the school’s Board of infants and children. Literature threats, ever-changing standards of care, delivery of budesonide via nebulizer to uticasone via meter dose inhaler. In including concussions, sports related Directors to help establish and injuries and performance enhancing indicates 70% error rate in clinics. and a multitude of health care access randomized control trials, uticasone has been demonstrated to be safe and maintain policies that provide an ecacious in preschool children (Qaqundah et al J Pediatr 2006); and uticasone substances in an effort to keep Posters available for all pediatric and utilization issues, a small newsletter optimal education for children with has improved pulmonary function and symptoms in infants with recurrent behavioral challenges. Hampton Roads athletes safe and offices. may not have world impact. However, wheeze (Mallol et al Allergol Immunopathol 2009). healthy. They have provided over we hope to provide some educational 28 community lectures in information as we highlight different Based on the above studies, spacer use has been demon- the last 12 months. subspecialties, improve patient access by strated to be safe and ecacious in infants for both bronchodilators and inhaled corticosteroids. A providing resources, phone numbers and spacer is also more ecient, convenient, faster tips, and inform you of new research, and less expensive. e neb- ulizer uses milli- projects, equipment and new faces that grams, while the MDI uses micrograms; yet equal amounts of appropri- ate size particles are part of CSG. e nebulizer is less portable than the spacer, requires electricity and is more reach the lungs. A nebuliz- er takes approxi- Dr. Shana Crabtree completed The ultimate goal is to improve the mately 10 minutes per treatment, while dicult to clean. e spacer can be cleaned with soap and water. Regarding medical school at the University of communication among our healthcare the spacer treat- ment can occur in total costs, the nebulizer is more expensive. However, insurance companies Louisville, pediatric residency at the two to three minutes. oen cover the nebulizer and require higher co-pays for spacer and MDIs. University of Virginia and fellowship community so we can all continue to at Texas Children’s Hospital. Shana joined enhance the lives of our patients, one Our CHKD pulmonology practice recommends spacer with MDI in CSG in 2013. Her interests include asthma, Bridge at a time. appropriate patients of all ages for the reasons indicated above. It would cystic brosis, pulmonary hypertension be our pleasure to work with you and your patients to provide them with and lung transplants.