HELPING EMPHYSEMA PATIENTS BREATHE EASIER

By Mark A. Vollenweider, MD, MPH

More than 15 million Americans have some form of chronic obstructive pulmonary disease (COPD). And for the 3.5 million who suffer from emphysema — COPD’s more severe, progressive form — simply taking a breath can be a painful challenge.

Emphysema weakens and ruptures the tiny air sacs in the lungs, creating larger air spaces. When this occurs, old air becomes trapped in these damaged pockets, putting pressure on the healthy parts of the lung and on the diaphragm — making it difficult to take deep breaths. Patients may struggle with normal daily activities like bathing, getting dressed, walking or even eating without feeling breathless and tired.

Emphysema is life-threatening and currently has no cure. Initial treatments include medications such as bronchodilators, antibiotics and inhaled steroids. Pulmonary rehabilitation, nutrition therapy and supplemental oxygen are other approaches. For those with more serious cases of emphysema, highly invasive treatments such as lung volume reduction surgery or lung transplantation have been the traditional options. AN ALTERNATIVE TO LUNG SURGERY

With no surgical cutting or incisions needed, the Zephyr® Valve System is the first procedure approved by the U.S. Food and Drug Administration (FDA) to treat severe cases of emphysema that is minimally invasive.

The valve is effective for adults who have little or no collateral ventilation (where ventilation bypasses obstructed airways through other channels) in the lobes where valves will be placed. People who have breathlessness even though they are taking emphysema or COPD medicines are candidates. Other health factors also may be taken into account.

Since 2007, more than 20,000 patients have been treated with the Zephyr Valve worldwide. In June 2018, it was approved by the FDA for use in the United States. The Zephyr Valve was granted Breakthrough Device Designation by the FDA based on positive data from clinical trials, including the pivotal LIBERATE trial. Orlando Health Orlando Regional Medical Center (ORMC) was the only hospital in Florida that participated in the LIBERATE clinical trial to evaluate the effectiveness and safety of the Zephyr Endobronchial Valve in emphysema patients with little to no collateral ventilation.

During the procedure, a bronchoscope — a small, flexible tube with a camera — is inserted through the nose or mouth and down into the lungs. The Zephyr system’s one-way valves are implanted to prevent airflow into the lungs’ diseased areas while allowing trapped air and fluids to escape. By reducing the lung volume, the healthy portions of the lungs can expand, and the diaphragm has less pressure, enabling deeper breaths, less shortness of breath and increased energy levels.

While the Zephyr Valve does not cure emphysema and may not eliminate all symptoms of the disease, it does provide a revolutionary approach for improving the health and quality of life for patients with emphysema.

Orlando Health ORMC was the first hospital in Florida to offer the Zephyr valve treatment and continues to be one of only about a dozen in Florida approved by Pulmonx, maker of the Zephyr Valve, to perform the procedure. OPENING THE LUNGS’ AIRWAYS

Prior to being approved for the Zephyr Valve procedure, patients will receive a CT scan. Using the StratX® Lung Analysis Platform, a cloud-based CT analysis service, the surgeon is provided information on where the dense portions of the lung are and where the damaged portions are. The damaged portions of the lung are where valves need to be placed to obstruct airflow to those areas.

Once the 30- to 60-minute bronchoscopy procedure is underway, the StratX® findings are confirmed using the Chartis® Pulmonary Assessment System. Before any valves are put in place, catheters with balloons are inserted to obstruct the targeted lobes. The Chartis System provides precise flow and pressure readings for each specific lobe to assess the absence of collateral ventilation. For example, if I am trying to obstruct the left upper lobe, when the Chartis balloon is placed in that airway I want the air flow to go down and the pressure to go up to make sure that there are no backflow leaks, or collateral lateral ventilation. This process is an important predictor of response to the valve treatment and puts the patient’s needs at the forefront before the procedure continues.

During the procedure, anywhere from two to six one-way valves are placed in the designated airways to block off the diseased parts of the lungs, preventing air from entering those areas and becoming trapped. Keeping air from getting trapped in the diseased parts of the lung allows the healthier parts of the lungs to be more efficient — able to expand and take in more air.

As with any medical procedure some risks exist, including pneumothorax, worsening of COPD symptoms, bleeding in the airway, pneumonia and, in rare cases, death. Patients will stay in the hospital for five days for observation following the procedure.

Patients who have had the Zephyr Valve procedure may experience immediate relief. It improves quality of life by allowing patients to breathe easier, have less shortness of breath, and be more active and energetic. Whether returning to work, enjoying retirement, or celebrations in between, the outcomes can be life changing.

Is Your Online Reputation Costing You Patients?

By Sonda Eunus, MHA, CMPE

What does your online reputation say about your practice? If you have a negative online reputation, you are missing out on new patients every day. Most medical practices now get the majority of their new patients through Google and other search engine queries, such as “Pediatrician in Orlando”. If your practice appears in these searches, the most common next step for a potential new patient would be to check out your reviews – what are other patients saying about your practice? It has been reported that 90% of consumers read online reviews before visiting a business and that online reviews influence 67% of purchasing decisions (Bright Local). For this reason, it is incredibly important to pay attention to the rating and reviews that your practice has on search engines, social media platforms, and local online business directories.

However, despite the importance of cultivating a positive online reputation, only 33% of businesses report actively collecting and asking for reviews (1). One great process to set in place at your practice is asking for patient reviews after each patient visit. It can be as simple as training your front office staff to ask each patient how their visit went while checking them out, and if they receive favorable feedback then they can ask the patient to please leave a review on Google or Facebook about their experience. If they receive negative feedback, this feedback should be taken very seriously, and management should be notified as soon as possible so that the issue can be mitigated before the patient decides to post a negative review.

Setting up an automated text or email campaign that asks each patient for their feedback after their appointment is also a great way to improve your online reputation as well as to correct any issues that may be occurring at your practice. When you receive feedback from patients, you are then able to prompt them to leave a public review on Facebook, Google, Yelp, Healthgrades, or other applicable review platforms. However, you must be aware that legally, you are not allowed to only direct people with favorable feedback to leave reviews, which is known as review-gating – so if you are implementing an automated system like this, just make sure that you are aware of this limitation. There are online reputation management platforms which allow you to customize the messages that people see when they leave negative feedback as opposed to positive feedback, but both of those messages must still offer the option to leave a public review. However, if you create your message in such a way as to communicate to the patient who may leave negative feedback that you are working hard on resolving the issue and that someone will be in touch shortly, that may prevent them from leaving a public negative review.

When you receive a public review on Google, Facebook, or other review sites, make sure that you respond to it – either by thanking them for a good review or by asking them to contact you to discuss how you can improve their experience. Do not argue or try to defend yourself online – try to speak about it with them privately, fix the issue, and ask them to remove the review if possible. When you receive great reviews, make sure to cross-share them on your various social media platforms. You should also create a “Reviews” page on your website and add all great reviews to this page. This instantly adds credibility to your website.

Finally, make sure that when you look over the feedback and reviews that you receive, you are paying attention to what the negative reviews are saying – this is a great opportunity to identify current process challenges and improve your patients’ experience at your practice. Need help managing your practice’s online reputation? Visit www.lms-plus.com to see how Leading Marketing Solutions can help.

Sonda Eunus is the CEO of Leading Marketing Solutions, a Marketing Agency working with Medical Practices and other Businesses to help them identify the best marketing strategies for their business, create a strong online presence, and automate their marketing processes for a better return on their Marketing budget. Learn more about Leading Marketing Solutions at www.lms-plus.com. 

Mark A. Vollenweider, MD, MPH, is a board-certified interventional pulmonologist with Orlando Health Medical Group

Pulmonary and Sleep Medicine. His research interests include complicated airway management and pleural malignancies,

and he is skilled in the use of several innovative technologies to diagnose and treat benign and malignant airway and pul-

monary lesions. Dr. Vollenweider was the Principal Investigator in Orlando Health Orlando Regional Medical Center’s

participation in the LIBERATE clinical trial to evaluate the effectiveness and safety of the Zephyr® Endobronchial Valve

and co-authored the study published in the American Journal of Respiratory and Critical Care Medicine. 

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Pediatric Limb Length Discrepancies

By: Jason Malone, DO

Q: HOW COMMON ARE PEDIATRIC LIMB LENGTH DISCREPANCIES?

A: Limb length discrepancies are very common. Up to twothirds of the population have a leg length difference of less than 2 cm (0.79 inch). Luckily, most people do not have symptoms unless the difference is greater than 2 cm.

Q: WHAT ARE CAUSES OF LIMB LENGTH DISCREPANCIES?

A: Limb length discrepancies can be categorized into two major groups: congenital and acquired.

Congenital causes range from longitudinal deficiencies such as congenital short femurs, proximal focal femoral deficiencies, tibia hemimelia, fibular hemimelia, hemihypertrophy, unilateral clubfoot, skeletal dysplasias, and hip dysplasia. Acquired causes range from idiopathic, paralytic disorders such as cerebral palsy or polio and physeal injury from trauma, infection or tumors.

Q: WHAT TECHNIQUES DO YOU USE TO TREAT THESE PATIENTS?

A: Symptomatic leg length differences less than 1 cm can be treated with a shoe insert. A difference greater than 1 cm can be addressed with nonsurgical treatment with a customized shoe lift. However, some patients or families do not wish to use a brace or shoe insert for the rest of their life.

Leg differences can be treated with a shortening procedure on the long side or a lengthening procedure on the short side or a combination of the two. Shortening procedures are smaller surgeries that are quicker to recover from but do lead shorter stature. Lengthening procedures are classically done for differences greater than 5 cm but many deformity specialists are now treating smaller leg length differences down to 3 cm in skeletally mature patients. done for leg difference of 2-5 cm.

Q: HOW LONG DOES THE PROCESS

TAKE?

A: Distraction osteogenesis is a long process. After the initial surgery we wait about a week for the bony callus or regenerate to develop. We then lengthen 1 mm per day. Then the bone takes about 8-12 weeks to fully heal the regenerate. A large 5 cm lengthening can take about 100 days to fully heal.

Q: WHAT ARE THE POTENTIAL COMPLICATIONS INVOLVED?

A: Distraction osteogenesis is safe if performed and monitored by an experienced physician, but it can also be associated with multitude problems. The bones, tendons, muscles and neurovascular structures are growing faster than the body is used to growing, so patients can develop joint contractures, joint dislocations and nerve stretch. We combat this by using nighttime braces, starting physical therapy right away, and stopping the lengthening process if any major complication develops. We can also lengthen more in the future. You also have your standard complication that can happen with any orthopedic procedure such as infection, nonunion, malunion or hardware failure.

An epiphysiodesis can also have its complications such as fracture at the physis, continue growth, angular deformity if the entire growth plate is not fully removed and continues to grow, not timing the surgery right and not achieving the desired correction or even overcorrecting and needing to perform an epiphysiodesis on the contralateral side.

Q: WHEN SHOULD A CHILD SEE A SPECIALIST TO ADDRESS THE

DISCREPANCY?

Q: HOW DOES THE PROCESS WORK?

A: Limb Lengthening procedures were first described by Dr. Gavriil Ilizarov in the 1950s. He called the process distraction osteogenesis. The process entails making a fracture in a bone, having the patient rest for 5-7 days, then distracting the bone ends about 1 mm per day. The bones can be distracted with an external fixator, a mechanical intramedullary nail, and soon with an expanding plate. We can safely lengthen a bone about 5 cm per treatment.

External fixators are better for legs that have an associated large deformity or children with open growth plates. Intramedullary nails are better tolerated but can only be placed in the femur of children at least 8 years old once the growth plate is closed in the tibia. The new lengthening plates that should be out in the summer of 2021 will allow us to lengthen internally even when a child has an open growth plate.

Shortening procedures usually are done in growing children. This is done through a timed epiphysiodesis. I prefer to perform a percutaneous epiphysiodesis as it leaves small scars and is associated with less complications than other techniques. This is

A: A child should see a pediatric orthopedic surgeon specialized in deformity correction when they have a congenital leg length difference, when they have a physeal injury, or an idiopathic leg length difference that is symptomatic or over 2 cm.

Q: ARE YOU CURRENTLY DOING ANY RESEARCH IN THE FIELD?

A: I just finished a research paper looking through a nationwide database from 1997-2016 on trends in femoral lengthenings in pediatric patients. What we found are that most of the surgeries are performed in large urban teaching hospitals. The South does more lengthenings than any other region in the country. The surgery has become safer over the years with shorter hospital stays but like most of medicine, the costs have risen substantially through the years. We currently have the paper submit for publication.

Jason Malone, DO, is a fellowship-trained pediatric orthopedic surgeon at Nemours Children’s Health who specializes in treating limb length discrepancies and

deformities. Call (407) 650-7715 for more information. 

9-year-old boy had a physeal injury to his left tibia. He sustained a 5 cm leg length difference with a flexion deformity of his knee. He had a projected leg length difference 9.6 cm. He was treated with a hexapod external fixator to lengthen his leg 5 cm and correct his deformity. The tibia is now healed right before the external fixator is removed.

16-year-old boy with an idiopathic 4 cm leg length difference, right genu valgum and an osteochondroma.

He was treated with a lengthening intramedullary nail, acute correction of his knee dormity and excision of his osteochondroma.