Clinical

The Division of Respirology at KHSC provides the vast majority of bronchoscopy services in the Southeastern Ontario health region. KHSC performs an average of 400 bronchoscopies per year, including close to 300 EBUS (Endobronchial Ultrasound) in addition to cryobiospy procedures.

Details of these procedures are summarized below:

Flexible Bronchoscopy

Flexible bronchoscopy is a procedure that allows physicians to examine the airways of the lungs. It is most commonly performed as a diagnostic procedure to find out more about a problem with the lungs but can also be used as a therapeutic procedure to treat a problem in the lungs.

Common reasons for performing bronchoscopy include: 1) diagnosis of symptoms related to the chest by examining the airways and taking samples of tissue (biopsies) or fluid to examine for infection or cancer; 2) examining lung collapse (atelectasis) which may reveal a blockage from thick mucous, a foreign body, or a tumour, at which point the physician can attempt to relieve the blockage; 3) facilitate special procedures in the lungs, such as performing biopsies for the evaluation of lung cancer or lung inflammation and scarring.

Endobronchial Ultrasound (EBUS)

Endobronchial ultrasound (EBUS) combines bronchoscopy with ultrasound to enhance the definition of mediastinal structures and aid in visualization of the lung and surrounding mediastinal structures. This equipment has emerged as a highly effective and minimally invasive technique for sampling peribronchial, mediastinal, and lung masses and lymph nodes for pathologic examination. It has been shown to be significantly cost-effective compared with prior gold standard techniques.

More specifically, EBUS plays a significant role in the diagnosis and staging of lung cancer, and is considered the standard of care for patients undergoing evaluation for a lung mass with mediastinal or hilar adenopathy.  EBUS is also essential in the diagnostic evaluation of endobronchial lesions as well as hilar and mediastinal adenopathy for patients with malignant and non-malignant diagnoses, which can include sarcoidosis and infectious etiologies. It provides higher diagnostic yield than routine flexible bronchoscopy and is less invasive and resource intensive than mediastinoscopy. As medical diagnosis and therapy move towards less-invasive procedures that provide results equal or superior to those of more invasive procedures, EBUS has become the standard of care and the EBUS program has grown exponentially since its launch in 2014.

Cryobiopsy

Cryobiopsy is an advanced bronchoscopic procedure for obtaining lung tissue for the diagnosis of diffuse parenchymal lung disease, such as interstitial lung disease. It involves the bronchoscopic placement of a flexible cryoprobe inside the lung parenchyma, freezing the probe, and shearing out the lung tissue frozen around the tip.  KHSC is one of only a few sites in North America providing this service.

What is the ILD Clinic:

The ILD clinic was created in May, 2013 by Dr. Onofre Moran-Mendoza, with the support and approval of Dr. Michael Fitzpatrick, then Head of the Division of Respirology and Critical Care Medicine.   Before the creation of the ILD clinic, no such clinic was in existence. 

This clinic was created due to the demand for a specialty clinic for patients suffering with interstitial lung disease (ILD) for diagnosis and management of these complex diseases.  

In 2014, the ILD clinic rapidly evolved into an Interstitial Lung Disease Program that now includes:

• ILD Clinic
• ILD Nurse
• ILD Multidisciplinary Rounds
• ILD Fellowship Program
• ILD Research Program
• ILD Program Collaborators

ILD Clinic Protocol Creation:

The ILD clinics are currently held at Hotel Dieu Hospital on Thursdays and Mondays. In order to better understand the approach and procedures for the ICD clinic, Dr. Moran Mendoza attended the ILD Program at the University of Toronto to learn the approach and procedures used by Dr. Shane Shapera, Director of their ILD program. 

All diagnostic and management protocols used in the ILD clinic are in compliance with the Guidelines for the Diagnosis and Management of Idiopathic Pulmonary Fibrosis (IPF), published by the American Thoracic Society (ATS, European Respiratory Society (ERS), Japanese Respiratory Society (JRS), and Asociacion Latino Americana de Torax (ALAT) as well as the International Guidelines for the Diagnosis of Idiopathic Interstitial Lung Diseases and the Guidelines on Bronchoalveolar Lavage (BAL) in ILDs.

The ILD clinic works collaboratively with Chest Radiology, Thoracic Surgery, Rheumatology, Palliative Care and Pulmonary Rehabilitation and several protocols for patient assessment and referrals have been created and implemented. 

Patient Flow in ILD Clinic:

All patients attending the ILD clinic undergo the following standardized assessments to properly investigate the most common groups of ILDs: Hypersensitivity pneumonitis, Connective Tissues Diseases (CTD), and drugs, as  per guidelines:

Questionnaires: 

As per the ILD protocol, patients with either clinical or laboratory abnormalities suggestive of a connective tissues disease are referred to Dr. Clements-Baker in the Division of Rheumatology who assess the ILD patients within 2-4 weeks to determine if their ILD is related to a CTD. 

Patients who have, as per the American College of Chest Physicians questionnaire, environmental exposures associated with hypersensitivity pneumonitis or have exposure to drugs reported to cause ILD, are routinely offered bronchoscopy with bronchealveolar lavage +/- transbronchial biopsies.

Once diagnosis is established, if anti-fibrotic treatment is required, patients are re-scheduled in clinic to discuss pros and cons of treatment, as well as the need to refer them to:

• Dyspnea Clinic to be assessed and managed by Dr. Ingrid Harle, Palliative Care, who has agreed to collaborate with the ILD clinic and manage the dyspnea patient population. 
• Pulmonary Rehabilitation Program with Dr. Denis O’Donnell, to assess suitability for enrollment in the rehabilitation program at Providence Care. 
• Lung Transplant Programin Toronto: Eligible patients diagnosed with IPF or with another advanced or progressive ILD despite treatment are referred to the lung transplant program in Toronto

After diagnosis and treatment are established, ILD patients are followed by the clinic every 3-6 months depending on the severity of their disease or presentation and progression.

Nursing Support for the ILD Clinic:

In 2015 the ILD clinic hired nursing support (Mrs. Lynda McCarthy).

Roles of the ILD Nurse:

• Before each appointment the ILD nurse ensures patients have the appropriate chest CT, Pulmonary Function Tests, and blood work.  
• As patients arrive to clinic the ILD nurse collects information from all questionnaires that have been mailed to patients before their appointment, reviews all tests, updates medication lists etc. 
• Post-appointment the nursing support enters all clinically relevant information into an electronic research database
• The ILD nurse also provides patients with the ILD Clinic Patient Recommendations form and anti-gastroesophageal reflux disease measures. The patient recommendations address environmental exposures of risk that patients should avoid, as well as the monitoring and proper titration of their oxygen (if applicable).

To refer to the ILD Clinic please fax your referral to: 613 549-1459

Purpose:

This program coordinates the care for patients being worked up for possible lung malignancies. This includes patients who are being assessed for possible lung cancer and those with diagnosed lung cancer for whom treatment or further diagnostic decisions are made.

Contact:

Lung Diagnostic Assessment Program (LDAP) Referral Form 

Please fax completed form and CT chest report along with any other pertinent information (i.e. other imaging, PFTs, blood work)

Patient Navigator: Christine Noseworthy, RN

Tel: 613.544.3400 ext 2474

Toll Free: 855.544.3400 ext 2474

Fax: 613.546.8225

Email: Christine.Noseworthy@KingstonHSC.ca

DAP Administrative Assistant:  Abigail Murano

Admin Tel: 613.544.3400 ext 2410

Toll Free: 855.544.3400 ext 2410

Fax: 613.546.8225

Email: Abigail.Murano@KingstonHSC.ca

Instructions to Patients:

The LDAP Patient Navigator, Christine Noseworthy, will be in contact with you. If you have not been contacted, please contact her at 1 (613) 544-3400 ext 2474

The Cystic Fibrosis (CF) Program is a multi-disciplinary program which provides comprehensive care to patients with CF. The team includes a pediatrician (pediatric program) and respiratory physician (adult program), nurse coordinator, physiotherapist, dietician, social worker, pharmacist, pulmonary function technologist and (for the pediatric program) a child life worker. The CF Program provides ambulatory care in separate Pediatric and Adult Clinics, provides inpatient services for hospitalized patients, and participates in CF research. The CF Clinics are accredited by the Canadian Cystic Fibrosis Foundation.

Patients with suspected cystic fibrosis may be referred directly to the appropriate physician for evaluation. Patients with confirmed CF are enrolled in the CF Program and followed regularly by all members of the team in either the Pediatric or Adult CF Clinic, in keeping with current practice guidelines. Patients typically enter the Adult Clinic at about age 18. Routine follow-up visits occur approximately every 3 months. Patients may be seen between regularly scheduled appointments for acaute illnesses. Consultative services are provided to hospitalized patients as required. Patients in the CF Program may be invited to participate in ongoing research studies. Currently, we are participating in several multi-centre CCFF-funded studies, including a genetics study (children and adults) and osteoporosis study (adults only).

Contacts:

Links:
Canadian Cystic Fibrosis Foundation
http://www.ccff.ca

Cysctic Fibrosis Foundation:
http://www.ccff.org

The Lung Diagnostic Assessment Program (LDAP) is a patient- and family-centred program, developed to improve the experience of diagnostic care for patients with suspected lung cancer.

Patients who are referred to the Lung DAP are first triaged by the Nurse Navigator, in preparation for their first clinic visit with either Respirology or Thoracic Surgery. The Nurse Navigator support the patient  throughout the course of the diagnostic work-up, provides ongoing care and education. Referrals to the LDAP are accepted by a central fax (1 (613) 546-8225). Respirologists and Thoracic Surgeons see patients at the Hotel Dieu Hospital or Kingston General Hospital, and the Oncologists see patients at the Cancer Centre of Southeastern Ontario. The LDAP coordinates diagnostic investigations, maintains contact with the patient and the clinician’s/ consultant’s office for discussions about the diagnosis and related issues. The LDAP also oversees timely staging investigations and/or referral to surgery or oncology.

The Lung Disease Site Group meets weekly as the Lung Multidisciplinary Cancer Conference (Dr. R. Gregg, chair; Dr. K. Reid, co-chair) to discuss patient cases, treatment, diagnostic and therapeutic issues.

Contacts:
Christine Noseworthy, Lung DAP Nurse Navigator
Phone: 613.544.3400 x2474
Fax: 1.613.546.8225 

Links

Cancer Care Ontario (CCO):
http://www.cancercare.on.ca

Cancer Care Ontario (CCO): Diagnostic Assessment Programs
https://www.cancercare.on.ca/pcs/diagnosis/diagprograms/

Cancer Care Ontario (CCO): Lung Disease Pathway Management
https://www.cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=253765

Canadian Cancer Society:
http://www.cancer.ca

American Cancer Society:
http://www.cancer.org/docroot/home/index.asp

This is a supervised, multidisciplinary rehabilitation program for patients with ventilatory insufficiency. Patient referrals are accepted from physicians and the COPD Education Centre. Typical patients for referral include those who remain symptomatic despite pharmacotherapy, who do not have significant co-morbid illness interfering with their ability to exercise (i.e., who do not have significant ischemic heart disease or musculoskeletal problems that limit their ability to participate), who preferably are non-smoking (although exceptions are made), and who are able to arrange transportation to this multi-modality exercise endurance training program. The 3 week inpatient program is for patients who meet entry criteria, but who are geographically displaced. The outpatient program is an 8 week program where patients attend clinic on three afternoons a week (Monday, Wednesday and Friday), and begin a customized, individualized exercise training program of various exercises including walking stair climbing, treadmill exercise, stationery bicycle, strength training, breathing exercises, stretching, etc. There is also an educational component, which comprises of eight lectures.

The aim of the program is to maximize functional capacity in patients with respiratory impairment so as to improve shortness of breath, exercise performance, and quality of life. Patients leaving the program enter a home-based program where they will continue regular exercises. Multidisciplinary services are also available for selected individuals, i.e., psychology, nutritional support, social work, pharmacy, as well as instruction from specialized COPD educators. This rehab program interfaces with the Better Breathing program, which helps people to continue home-based training, as well as avail of the exercise facilities at St. Mary’s of the Lake Hospital. 

Contacts:

Patients are referred to the Kingston General Hospital, Sleep Disorders Office via fax (613-549-1459) from their Family doctor, medical specialist or from a medical doctor at a walk-in clinic or ER.

SLEEP REFERAL FORM -     http://deptmed.queensu.ca/assets/Sleep Referral Feb2013.pdf

The referrals are prioritized by a sleep specialist. Typically, patients are scheduled to be seen in clinic by a sleep specialist physician at Hotel Dieu Hospital (HDH) before being scheduled for an overnight sleep study at Kingston General Hospital, Sleep lab.   Appointments are mailed to patients from the Sleep Disorders Office or may be scheduled by phone.

The Sleep Disorders Laboratory has six private bedrooms and is located at KGH on Kidd 6, Rm 22-6-005. Sleep studies are conducted by registered polysomnographic technologists (RPSGT). Overnight sleep study appointments are for arrival times between 8 PM and 11 PM with departure in the morning usually between 6 AM and 7 AM. When ordered by a sleep specialist, daytime test may be conducted either immediately after the overnight study, or for 8 AM arrival time.

Contact:

Secretary: Maureen Obreiter    Phone: 613-548-2382 and Fax: 613-549-1459

Sleep Technologists at the KGH Sleep Laboratory             Phone: 613-549-6666 x3347

Info here