Respiratory Exchange 2008 - Cleveland Clinic

Respiratory Exchange 2008 - Cleveland Clinic

Research and News for

Physicians from the Cleveland

Clinic Respiratory Institute

Raising the BAR in Lung Transplant

Also in this Issue

High Altitude


pg 4



By Gösta B. Pettersson MD, PhD, Director Lung Transplant and Heart Lung Transplant Program; Atul C. Mehta, MBBS; and the Cleveland Clinic Lung Transplant Team

Clinical Utility of

Exhaled Nitric Oxide

pg 6


Treatments for Severe


pg 12

Fall | 2008

With 72 lung transplants performed in 2007, the second highest volume in the United States,

Cleveland Clinic continues to remain one of the premier lung transplant centers in the country.

The transplant program continues to be a leader in developing and offering innovative approaches

in the field of transplantation that may impact short- and long-term outcomes.

Currently, lung transplantation continues to demonstrate mortality

of close to 50 percent at five years. Significant early complications

following single- and double-lung transplantation include airway

healing issues (necrosis, dehiscence and subsequent stenosis),

which may lead to lung infections and rejections, and contribute

to development of bronchiolitis obliterance syndrome/obliterative

bronchiolitis (BOS/OB). All these complication could

possibly directly or indirectly relate to ischemia, particularly

of the airways and the airway anastomsis.

continued on page 2

2 | Respiratory Exchange

Dear Colleagues:

Patients with complex respiratory

disorders benefit from the expertise of a

multidisciplinary team of specialists. At

Cleveland Clinic, experts in the Respiratory

Institute (Pulmonary, Allergy and Critical

Care Medicine) collaborate with specialists

in Thoracic and Cardiovascular

Surgery, Thoracic Imaging and Pulmonary

Pathology to care for these patients.

In this issue of Respiratory Exchange,

you will find articles that illustrate the

continued growth of our clinical programs,

research funding and application

of innovative technologies, particularly in

the areas of breath analysis, pulmonary

hypertension, asthma, bronchoscopy and

lung transplantation.

For additional information about our

ongoing clinical and research activities

in respiratory disorders, please visit

(current and

previous issues of Respiratory Exchange

are available here) and clevelandclinic.


We hope you’re able to spend a few

minutes reviewing Respiratory Exchange,

and that you find it valuable and informative.

Please feel free to contact us at our

toll-free number for physicians, 866.

CCF.LUNG (866.223.5864), if you have any

questions or would like to refer a patient.

As always, we welcome the opportunity to

work with you.


Herbert P. Wiedemann, MD, MBA

Chairman, Cleveland Clinic

Respiratory Institute

Standard surgical approach. Some

necrosis and ischemia is evident at

the anastomotic site one week after

transplant surgery.

BAR surgical technique. Normal

appearing tracheal anastomosis one

week after transplant surgery.

Raising the BAR in Lung Transplant continued

Currently, the standard surgical approach in lung transplantation

involves restoration of only pulmonary artery blood flow to the lungs,

but the bronchial artery blood supply is ignored. Bronchial artery

revascularization (BAR) is a surgical technique intended to restore

bronchial arterial circulation to transplanted lungs. Cleveland Clinic’s

Transplant Surgical Team currently is conducting a prospective pilot

study offering BAR at the time of transplantation with the reasoning

that by restoring bronchial blood supply both short- and long-term

outcomes in lung transplant patients may be improved.

Historically, consideration of BAR has been weighed against its technical

difficulty, its complications and potential consequences of a failed

procedure, combined with the fact that the described complications

were not that frequent and BAR might offer minimal or no benefit and

therefore unnecessary. Gösta B. Pettersson, MD, PhD, Director, Lung

and Heart Lung Transplant program, Cleveland Clinic, has the world’s

largest experience with BAR, performing this procedure in more than

100 patients while in Copenhagen.

Recently the Copenhagen lung transplant group published long-term

follow up data:

1. The overall survival for this Copenhagen patient series was better

than for any other large single center lung transplant series

2. The survival was better for the first five-year period, including all

the BAR patients than for the second.

Removal of the esophagus from the block, taking care not to damage

the retroesophageal intercostobraonchial artery.

3. Survival was better after en bloc double lungs (all performed with

BAR) than after sequential double lungs. The five- year survival after

en bloc double-lung transplantation with BAR was an impressive

75 percent and this was better than after sequential double-lung

transplantation, despite earlier date of surgery, a higher percentage

of COPD and alpha-1-deficiency patients, and older age (mean 47

years vs. 34 years). Although there were patients who had singlelung

transplantation or combined heart and lung transplantation with

BAR, the number in these groups were small. The Copenhagen clinical

experience, with 106 BAR procedures, is unique and larger than

the published BAR experience of the rest of the world combined.

Currently, we have enrolled more than 50 patients in the BAR pilot

study with 10 procedures performed (five en bloc double-lung transplants

and five single-lung transplants) since December 2007. Eight

of the nine patients had primary normal airway healing and selective

angiography demonstrating revascularization success, the tenth patient

not yet examined. One patient had evidence of airway ischemia and necrosis

and failed revascularization on angiography, but the anastomosis

still eventually healed without stenosis within 10 weeks of surgery.

Thus far, the early experience with BAR at Cleveland Clinic is promising

and comparable to the Copenhagen experience with a high success rate

associated with normal healing of the airway. Our long term hope is,

of course, to duplicate the long-term outcomes of the Copenhagen

experience in terms of BOS and better survival. At this time, this is

the only study of its kind being offered in the world and has the potential

to change the standard approach to lung transplantation.

Recommended Reading

Respiratory Exchange

Herbert P. Wiedemann, MD, Medical Editor

Megan Frankel, Marketing Manager

Ann Bungo, Managing Editor

Anne Drago, Graphic Designer

Respiratory Exchange is written for physicians

and should be relied upon for

medical education purposes only. It

does not provide a complete overview

of the topics covered and should not

replace the independent judgment of a

physician about the appropriateness or

risks of a procedure for a given patient.

© 2008 The Cleveland Clinic Foundation

Fall 2008 | 3

Burton CM, Milman N, Carlsen J, Arendrup H,

et al: The Copenhagen National Lung Transplant

Group: Survival after Single Lung, Double Lung, and

Heart-Lung Transplantation. J Heart Lung Transplant


Pettersson G, Nørgaard MA, Arendrup H, et al. Direct

bronchial artery revascularization and en bloc double

lung transplantation - Surgical techniques and early

outcome. J Heart Lung Transplant 1997;16:320-333.

Herrera JM, McNeil KD, Higgins RSD, et al.

Airway complications after lung transplantation.

Treatment and long-term outcome. Ann Thorac Surg.


Giudicelli R, Thomas P, Massard G, et al. Tracheobronchial

healing after lung and heart-lung transplantation.

Eur J Cardiothorac Surg. 1993;7:453-456.

Colquhoun IW, Gascoigne AD, Au J, et al. Airway complications

after pulmonary transplantation. Ann Thorac

Surg. 1994;57:141-145.

Wilson IC, Hasan A, Healey M. Healing of the bronchus

in pulmonary transplantation. Eur J Cardiothorac Surg.


Alvarez A, Algar J, Santos F, et al. Airway complications

after lung transplantation. A review of 151 anastomoses.

Eur J Cardiothorac Surg. 2001;19:381-387.

Kamler M, Nowak K, Bock M, Herold U, Motsch

J, Hagl S, Gebhard MM, Jakob H et al. Bronchial

Artery Revascularization Restores Peribronchial Tissue

Oxygenation After Lung Transplantation. J Heart Lung

Transplant 2004;23:763-6.

Hyytinen et al. Bronchial Artery Revascularization

Improves Tracheal Anastamotic Healing After Lung Transplantation.

Scand Cardiovasc J 34; 213-218, 2000.

Bando et al. Obliterative bronchiolitis after lung and

heart-lung transplantation. An analysis of risk factors

and management. J Thorac Cardiovasc Surg 1995;


Nørgaard et al. Revascularization of the Bronchial Arteries

in Lung Transplantation: An Overview. Ann Thorac Surg

1996; 62: 1215-21.

Nørgaard et al. Does bronchial artery revascularization

influence results concerning bronchiolitis obliterans

syndrome and/or obliterative bronchiolitis after lung transplantation?

Eur J Cardiothorac Surg 1998; 14(3): 311-8.

Daly RC et al. Routine immediate direct bronchial artery

revascularization for single-lung transplantation. Ann

Thorac Surg 1994; 57(6): 1446-52.

4 | Respiratory Exchange

High Altitude Survival

How the biology of Tibetans may help find new treatments

for hypoxia-related diseases

By Cynthia Beall, PhD, and Serpil Erzurum, MD

Hemodynamics and oxygen delivery among Tibetan and sea level populations. (A and B) Tibetan forearm

blood flow (A) and oxygen delivery (B) were greater than sea level controls. (C) The greater forearm blood

flow of Tibetans compared with the sea level population accounts for the greater oxygen delivery (R 2 = 0.96

and P < 0.001). (D) Higher hemoglobin concentrations of Tibetans as compared with sea level population

contributes modestly to greater oxygen delivery (R 2 = 0.13 and P < 0.001).

For 20,000 years, people have been thriving in their rugged and unforgiving

mountainous terrain, the Tibetan Plateau, nearly three miles above sea

level where oxygen levels are low. Despite their oxygen-starved environment,

Tibetans are healthy and do not develop altitude-related sickness. Researchers

at Cleveland Clinic and Case Western Reserve University have uncovered the

unique biology that protects Tibetans from high-altitude sickness, which may

lead to new clinical treatments for hypoxia-related diseases.

The low barometric pressure at high altitude

causes lower arterial oxygen content among

Tibetan highlanders, who somehow maintain

normal levels of oxygen use as indicated by

basal and maximal oxygen consumption levels

that are consistent with sea level predictions.

In our study, we investigated how Tibetans

offset physiological hypoxia and achieve

normal oxygen delivery. We discovered that

Tibetans have higher blood flow in their

systemic circulation, which is achieved by

higher levels of production of nitric oxide (NO),

the main endothelial factor regulating blood

flow and vascular resistance.

The natural experimental study design compared

Tibetans at 4200m and U.S. residents

at 206m. Forearm blood flow, an indicator

of systemic blood flow, was measured noninvasively

using plethysmography at rest, after

breathing supplemental oxygen, and after

exercise. The Tibetans had more than double

the forearm blood flow of low-altitude residents,

resulting in even greater than sea level

oxygen delivery to tissues. Strikingly, Tibetans

had more than 10-fold higher circulating

concentrations of NO.

The findings, which are reported in the

article, “Higher Blood Flow and Circulating

NO Products Offset High Altitude Hypoxia among Tibetans,” published in the November

6, 2007, Proceedings of the National Academy of Sciences, describe this newly discov-

ered, distinctive and different adaptation

to high-altitude hypoxia that is character-

ized by blood flow and oxygen delivery

rates substantially higher than any reported

previously. Natural experiments such as this

one that extend the known range of healthy

human biological variation provide important

and fundamental knowledge about general

patterns and mechanisms of oxygen delivery

in human biology.

The next step in this research is to find out

how Tibetans produce so much NO. The

metabolic pathways and genetic features

that allow Tibetans to produce high levels

of NO will be investigated next.

Knowing how NO offsets hypoxia may lead

to new treatment methods for patients who

suffer from hypoxia-related diseases such

as heart disease, pulmonary hypertension,

cystic fibrosis, chronic obstructive pulmonary

disease and sleep apnea.

Dr. Serpil Erzurum, Chairman of Pathobiology

and a member of the Respiratory Institute,

collaborated with colleague Cynthia M. Beall,

PhD, a professor of physical anthropology

at Case Western Reserve University on this

research. Dr. Erzurum can be reached at

216.445.5764 or

Searching for Answers in IPF

By Jeffrey T. Chapman, MD

Given the complexity of the immunopathologic

process in idiopathic

pulmonary fibrosis (IPF), a multi-pronged

attack with several medications and

novel therapeutic approaches may be

required. Currently being tested is an

empirical clinical strategy to treat IPF

with a combination of agents having

low toxicity and cost that might retard

progression of this illness.

We have recently joined the National Institutes

of Health-funded IPF Clinical Research Network

(“IPF-Net”), a group of 11 sites throughout the

U.S. formed to evaluate multi-drug therapeutic

trials for stabilizing the disease. As a new member

of the IFP-Net, we will soon begin enrollment in

these trials for patients with newly diagnosed IPF.

Cleveland Clinic has recently

been accepted into the

NHLBI-sponsored Idiopathic

Pulmonary Fibrosis Research

Network. Dr. Chapman is the

site Principal Investigator.

The IPF Network conducts

clinical trials, and related

pathophysiology studies,

related to IPF. The IPF

Network is similar to other

NHLBI networks that we are

participating in, including

networks for ARDS, severe

asthma, and COPD (long-

term oxygen therapy).

One of these upcoming trials is the Sildenafil Trial

of Exercise Performance in Idiopathic Pulmonary

Fibrosis (STEP-IPF trial), for late-stage disease.

This trial has been designed for patients with moderate to severe lung disease. In the

24-week study, eligible patients will receive either sildenafil or placebo for the first 12

weeks, followed by sildenafil for the next 12 weeks. The study expects to enroll about

200 patients beginning later this year.

We also will be enrolling patients for the Evaluating the Effectiveness of Prednisone,

Azathioprine, and N-Acetylcysteine in People With Idiopathic Pulmonary Fibrosis

(PANTHER study). This study will evaluate the effectiveness of the antioxidant

N-acetylcysteine (NAC), alone and in combination with an established IPF medication

regimen, at preventing the loss of lung function in people with early-stage IPF.

These trials will be a valuable option for our patients with IPF in our growing

interstitial lung disease program.

Dr. Jeffrey Chapman is a Cleveland Clinic pulmonologist and the local PI

for the IPF Clinical Research Network. He can be reached at 216.444.4222


Fall 2008 | 5

6 | Respiratory Exchange

Clinical Utility of Exhaled Nitric Oxide (FENO)

By Raed A. Dweik, MD, FCCP

Nitric oxide (NO) is endogenously synthesized by nitric oxide synthases

(NOSs) that are widely expressed in various tissues including the lungs.

Once produced, NO is freely diffusible and enters target cells activating

soluble guanylate cyclase to produce guanosine 3’, 5’-cyclic monophosphate

(cGMP) that mediates the majority of NO effects. The functions and effects

of NO in the lung/airways reflect its key roles as a vasodilator, bronchodilator,

neurotransmitter and inflammatory mediator. The unique lung anatomy

allows NO produced in the airways to be detected in exhaled breath. This was

accomplished in the early 1990s with the advent of chemiluminescence analyzers

that could detect low levels of NO in the parts per billion (ppb) range.

Interestingly, patients with asthma have high

levels of exhaled NO in their exhaled breath

that returns to normal levels after treatment

with corticosteroids, making exhaled NO a potentially

useful marker of airway inflammation.

Although these findings clearly suggest a role

for NO in asthma pathogenesis, the exact role

of NO in asthma and airway reactivity remains

elusive despite intense research in this area.

Whether NO is beneficial through its bronchodilator

and antioxidant effects or harmful by

inducing inflammation remains unclear. It also

is possible that it may play both roles depending

on the level and the airway milieu in a

particular patient or at a particular stage of

the disease. In either case, measuring exhaled

NO has shown clinical utility in monitoring the

inflammatory component of asthma.

The use of exhaled NO in monitoring asthma

is promising for several reasons. It is noninvasive,

it can be performed repeatedly,

and it can be used in children and patients

with severe airflow obstruction where other

techniques are difficult or not possible to perform.

Exhaled NO may also be more sensitive

than currently available tests in detecting

airway inflammation, which may allow more

optimum therapy.

Several issues, however, needed to be addressed

before exhaled NO could become a

useful clinical tool in routine asthma monitoring

and management. First, a better understanding

of the role of NO in asthma pathogenesis was

needed. Second, the methods and equipment

for measuring NO needed to be standardized.

Third, large population studies were needed to

determine the normal range of exhaled NO levels

and the effect of confounding factors. Last,

but not least, interpretative strategies needed

to be devised and put in place for the different

potential uses and applications. While the

answers have not always been straightforward

and simple, most of these issues have either

already been addressed or are currently under

investigation, allowing exhaled NO measurement

to make the transition from the research

to the clinical arena.

The American Thoracic Society (ATS) has published

standards for performing measurements

of exhaled NO. The guidelines recommend the

use of the term FENO (the fractional exhaled

NO concentration) to describe levels of NO in

exhaled breath. FENO is expressed in parts

per billion, which is equivalent to nanoliters

per liter (nl/L). Several commercial analyzers

are available to measure NO levels in exhaled

breath based on the ATS guidelines. One such

device was approved by the FDA in 2003.

The standardization of FENO measurement

was followed by several large clinical and

population studies demonstrating that FENO

levels can be useful in the diagnosis of asthma

and in monitoring disease activity/airway

inflammation and response to therapy. These

studies have also identified various possible

confounders that affect FENO including age,

gender, weight, height, diurnal variation,

and food intake, among others. Observations

that have been consistent in the literature,

however, are that atopic individuals tend to

have higher FENO while smokers tend to

have lower FENO.

A more difficult problem to address in the NO

field has been the establishment of normal

healthy population values for FENO. While

several studies have tried to address this issue

of normative values, they were done in different

populations, addressed different potential

confounders, and reported their results in different

ways. Furthermore, “reference values”

derived from a “normal” population may not

be applicable in patients with asthma. This

raises the question whether normal values are

at all useful when it comes to the use of FENO

in asthma. Thus, defining different cut points

for different clinical settings may be more clinically

useful than normative values.

Combined with the fact that there is con-

siderable overlap in FENO between healthy

individuals and asthmatics, it is very clear

from reviewing the literature that the FENO

value by itself is not sufficient. FENO value

should be taken within the clinical context:

Was the measurement obtained in someone

who has symptoms or in an asymptomatic

individual? Was it performed as a screening

or to aid in the diagnosis? Is the individual

known to have asthma? And if so is he/she

on therapy? Do they have previous levels and

how does this level compare? Once the clinical

setting is taken into consideration, certain

cut points become very useful: FENO levels

above 45-50 ppb predict steroid responsiveness

while levels below 35 ppb suggest

optimal asthma control in an asthmatic

on therapy. FENO levels above 20-25 ppb

suggest the presence of asthma in a steroidnaive

individual with symptoms while lower

levels are not likely to be associated with

airway inflammation.

Thus, advances in technology and standardization

made FENO measurement simple and

allowed us to easily perform it in different

settings from diagnosis, to monitoring, to

screening, and possibly others. In order for

this simple yet powerful tool to achieve its

potential, however, we need to understand

what FENO levels mean in different clinical

settings. While some tests are difficult to perform

and easy to interpret, others like FENO

are easy to perform but may need considerable

skill to interpret.

New guidelines on FENO interpretation are

forthcoming from the American Thoracic

Society, expected out early 2009.

Dr. Raed Dweik serves as Chairman of the

ATS committee charged with writing the

guidelines for the interpretation of FENO

in clinical practice and is Director of the

Pulmonary Vascular Program within Cleveland

Clinic’s Respiratory Institute. Contact him

at 216.445.5763 or

Recommended Reading

Grob, N. M., and R. A. Dweik. 2008. Exhaled nitric oxide

in asthma. From diagnosis, to monitoring, to screening: are

we there yet? Chest 133(4):837-9.

Dweik, R. A. 2007. The lung in the balance: arginine,

methylated arginines, and nitric oxide. Am J Physiol Lung

Cell Mol Physiol 292(1):L15-7.

Gill, M., G. R. Graff, A. J. Adler, and R. A. Dweik. 2006.

Validation study of fractional exhaled nitric oxide measurements

using a handheld monitoring device. J Asthma


Akpinar-Elci, M., K. J. Stemple, O. C. Elci, R. A. Dweik, K.

Kreiss, and P. L. Enright. 2006. Exhaled nitric oxide measurement

in workers in a microwave popcorn production

plant. Int J Occup Environ Health 12(2):106-10.

Dweik, R. A. 2005. Nitric oxide, hypoxia, and superoxide:

the good, the bad, and the ugly! Thorax 60(4):265-7.

Khatri, S. B., J. Hammel, M. S. Kavuru, S. C. Erzurum,

and R. A. Dweik. 2003. Temporal association of nitric

oxide levels and airflow in asthma after whole lung allergen

challenge. J Appl Physiol 95(1):436-40; discussion 435.

Dweik, R. A. 2002. Nitric oxide production in the lung and

its regulation by oxygen. In N. Marczin and M. H. Yacoub,

editors. Disease Markers in Exhaled Breath: basic mechanisms

and clinical applications (NATO Science Series). IOS

press, Amsterdam, Netherlands. 11-17.

Ozkan, M., and R. A. Dweik. 2001. Nitric Oxide and Airway

Reactivity. Clinical Pulmonary Medicine 8(4):199-206.

Khatri, S. B., M. Ozkan, K. McCarthy, D. Laskowski,

J. Hammel, R. A. Dweik, and S. C. Erzurum. 2001.

Alterations in exhaled gas profile during allergen-induced

asthmatic response. Am J Respir Crit Care Med 164(10 Pt


Dweik, R. A., S. A. Comhair, B. Gaston, F. B. Thunnissen,

C. Farver, M. J. Thomassen, M. Kavuru, J. Hammel, H.

M. Abu-Soud, and S. C. Erzurum. 2001. NO chemical

events in the human airway during the immediate and late

antigen-induced asthmatic response. Proc Natl Acad Sci U

S A 98(5):2622-7.

Dweik, R. A. 2001. The promise and reality of nitric oxide

in the diagnosis and treatment of lung disease. Cleve Clin J

Med 68(6):486, 488, 490, 493.

2005. (Dweik RA, contributing author). ATS/ERS

Recommendations for Standardized Procedures for

the Online and Offline Measurement of Exhaled Lower

Respiratory Nitric Oxide and Nasal Nitric Oxide, 2005.

Am J Respir Crit Care Med 171(8):912-930.

Fall 2008 | 7

Jean Wall Bennett

Chair for Emphysema

Research Established

James K. Stoller, MD, MS, Head,

Section of Respiratory Therapy,

Department of Pulmonary and

Critial Care Medicine, is the first

to hold the Jean Wall Bennett Chair

for Emphysema Research.

This endowed chair is a gift of Mr. Joseph

Bennett in memory of his late wife, Jean

Wall Bennett, who suffered from the

disease and was treated by Dr. Stoller.

The new chair will advance emphysema

research at Cleveland Clinic. Dr. Stoller’s

interests include emphysema in general

and also Alpha-1-Antitrypsin Deficiency,

a genetic form of the disease. Active

research in both areas is underway.

One current study with Alpha-1-

Antitrypsin Deficiency is examining

the role of CT as a way to measure the

lung disease progression in emphysema

as an alternative to breathing tests.

Dr. Stoller is also Cleveland Clinic’s site

PI for the largest randomized clinical

trial of the effectiveness and safety of

long-term home oxygen therapy for

COPD (chronic obstructive pulmonary

disease). The results will help Medicare

decide whether to extend coverage for

home oxygen treatment to patients with

moderate disease. Currently, Medicare

limits coverage of home oxygen therapy

to beneficiaries with severe COPD (very

low blood oxygen levels while resting).

8 | Respiratory Exchange

Women’s Menstrual Cycles Could Offer

Clues to Lung Disease Therapies

By Kewal Asosingh, PhD, and Samar Farha, MD

The changes that a woman's body

undergoes during her monthly

menstrual cycle could offer clues

into potential therapies for people

who have advanced lung diseases

and need ways to improve how they

absorb oxygen.

During a portion of the menstrual cycle, a

woman’s ovaries and the lining of her uterus

become enriched with blood vessels in preparation

for possible reproduction. But if there is

no fertilized egg, the uterine lining is discarded

as the menstrual flow. The uterus returns to

its normal state until the process starts again

the following month.

Scientists have studied different factors that

control blood vessel formation and regression

in the uterus. Among these are hormones such

as estrogen; proteins that control blood vessel

growth such as vascular endothelial growth

factor; and adult stem cells, derived from bone

Lung tissues from ovariectomized female mice exposed to estrogen (B, D, E) or placebo (A, C) for 2 wk. A

marrow that circulates in the blood, called

and B: lungs of estrogen-exposed mice have greater numbers of vessels as identified by endothelial cells that

are positive (brown staining) for von Willebrand factor but smaller alveoli than control ovariectomized female endothelial progenitor cells (or EPC).

mice. Arrowheads identify microvessels. Magnification x 400. C and D: alveolar capillary unit from the lungs of

ovariectomized mice exposed to estrogen compared with placebo. Immunopositivity for von Willebrand factor The question was do these factors also en-

identifies endothelial cells. Magnification x 1,000. E: capillaries containing erythrocytes are identified as they

courage blood vessel formation in the lungs?

traverse through alveolar walls. Magnification x 1,500. a, Alveolar spaces; open arrowheads, capillary lining;

black arrowheads, red blood cells.

As part of a team of pathologists and pul-

Farha, S. et al. J Appl Physiol 103: 1789-1795 2007. Used with permission.

monologists, we found that microscopic blood

vessels in the lung increase and decrease

in the same rhythm as a woman’s uterine lining changes. These blood vessels are critical to

pulmonary gas transfer – the exchange of oxygen for carbon dioxide that occurs in the lungs

with each breath we take. The study monitored and tested 10 healthy, non-smoking women

in their early 30s during their menstrual cycles (four healthy, non-smoking males were used

as a control group). We also looked at blood vessels in mice receiving estrogen or placebo.

Among our findings:

• Mice that received estrogen had a greater number of microvessels and more and smaller

alveoli. Together the smaller alveoli and the rich networks of new blood vessels increase the

surface area available for transferring gases.

• Circulating EPCs clearly are related to changes in gas exchange in lung tissues.

• The lung-diffusing capacity in women increased by 10 percent when the blood vessel

formation was at its peak during the menstrual cycle, demonstrating improved gas transfer.

The research also might lead to new

understanding of episodic airflow

obstruction, such as asthma, which

may worsen in some women around

the time of their menstrual cycle.

It’s clear that the same factors that cause blood vessel development

in the uterus and ovaries during a menstrual cycle are critical factors

to how well lungs transfer gases. This understanding of what governs

gas transfer in the lung could lead to therapies that encourage blood

vessel formation in the lungs of patients with advanced lung diseases.

Any way we can improve or augment oxygen intake by these patients

will be a step forward in their care.

The research also might lead to new understanding of episodic airflow

obstruction, such as asthma, which may worsen in some women

around the time of their menstrual cycle.

Understanding what underlies the cause of these diseases can help us

to treat the symptoms better. We are currently recruiting participants

for an ongoing study to understand pulmonary arterial hypertension.

Women are particularly predisposed to diseases of the arteries and

veins within the lungs. These diseases might involve the same causes

that we revealed in our research. This gives us hope that we can identify

new therapies for women with these types of diseases.

Other collaborators on the project were Serpil Erzurum, MD, Daniel

Laskowski, Lauren Licina and Raed Dweik, MD, all of Pathobiology;

Herbert Wiedemann, MD, Chairman, Cleveland Clinic Respiratory

Institute; and Haruki Sekigushi and Douglas Losordo, MD, both of the

Northwestern Memorial Hospital Division of Cardiology in Chicago. The

report appeared in the Journal of Applied Physiology (;

2007 103: 1789-1795). It was supported by the National

Institutes of Health’s National Heart, Lung, and Blood Institute.

Dr. Kewal Asosingh is a member of the Pathobiology Department

in Lerner Research Institute. Contact him at 216.445.7191

or Dr. Samar Farha is a pulmonologist in the

Cleveland Clinic Respiratory Institute and was the lead researcher

on the project. Contact her at 216.444.3229 or

Recent Awards

Team Receives $3.8 Million

3rd Frontier Grant from State of Ohio

Fall 2008 | 9

A multi-institutional team led by Raed Dweik, MD, was

awarded in June one of six Ohio Biomedical and Research

Commercialization Partnership 3rd Frontier Grants.

The $3.8 million grant awarded to Cleveland Clinic, in

collaboration with NASA Glenn Research Center, The

Ohio State University, Case Western Reserve University,

and Makel Engineering, Inc., was to develop a nitric oxide

sensor that will enable asthma patients to monitor their

asthma at home. The proposal aims to re-develop a sensor

used in the aerospace industry, and the project’s emphasis

will be on testing and commercializing sensors already

produced in Ohio.

Serpil Erzurum, MD, is a collaborating investigator, and

other Cleveland Clinic staff include Daniel Laskowski,

RPFT, Metin Aytekin, PhD, and Jennie Newman.

2008 Howard Hughes Medical Institute

Physician-Scientist Early Career Award

Fred Hsieh, MD, of the Section of Allergy/Immunology, is

the recipient of a 2008 Howard Hughes Medical Institute

Physician-Scientist Early Career Award.

This award provides a total of $375,000 ($75,000 per year) to

support Dr. Hsieh's research over five years (August 1, 2008

July 31, 2013).

Dr. Hsieh’s work focuses on the immune system’s mast

cells, which play a central role in asthma. They release

histamine and other factors that lead to inflammation and

constriction in the lungs. Dr. Hsieh thinks that people with

asthma might produce more stem cells that can develop

into inflammatory cells like mast cells than healthy people.

He hopes to find out by examining how, when, and why

stem cells develop into mast cells by studying mouse

models and people with asthma.

Dr. Hsieh already has found that some blood-forming stem

cells can produce mast cells in asthmatic lungs. Now he

wants to find out if endothelial stem cells – found in the lining

of the lungs – also can produce mast cells and whether

they overproduce those cells in people with asthma.

10 | Respiratory Exchange

Changes in bioenergetics of IPAH endothelial cells uncovered

By Weiling Xu, MD, Donald Neumann, MD*, Frank DiFilippo, PhD*, and Serpil C. Erzurum, MD

Cleveland Clinic researchers have identified a metabolic abnormality in the lungs of patients with idiopathic pulmonary

arterial hypertension (IPAH), which could lead to new therapies and improved care of this rare but deadly disease.

IPAH primarily strikes young adults and is about twice as common in women than in men.

Idiopathic pulmonary arterial hypertension

(IPAH) is a fatal disease of unknown etiol-

ogy characterized by a progressive increase

in pulmonary artery pressure and vascular

growth. Symptoms include dyspnea, fatigue,

syncope, edema and dizziness. Chronic liver

disease, some rheumatologic disorders, or

congenital heart malformations also can

result in an associated pulmonary hypertension.

There is evidence from animal models

of pulmonary hypertension, mice genetically

deficient in endothelial NO synthase, and

complementation studies with gene transfer

of NO Synthases for the concept that NO is

a critical determinant of pulmonary vascular

tone. We and others have shown that levels

of NO are lower in lungs of patients with

IPAH as compared to healthy controls.

Separate from its vasodilatory effects, NO

binds to several targets within the mitochondrial

respiratory chain. For example,NO

competes with oxygen for binding to complex

IV in the mitochondrial respiratory chain

of oxygenated cells. Recently, NO was also

found to trigger mitochondrial biogenesis

in cells. Previous studies have identified

abnormal mitochondrial function, basically

site-specific defects in electron transport

chain, in avian idiopathic pulmonary hypertension

that lead to lower respiratory chain

coupling and inefficient use of oxygen, which

in turn contribute to the development of

pulmonary hypertension syndrome in chickens.

Similarly, Fawn Hooded rats (FHR), a

spontaneously pulmonary hypertensive strain,

have abnormal mitochondria with reduced

expression of electron transport chain components.

In a recent study, we questioned

whether abnormal energy metabolism might

* Nuclear Medicine, Cleveland Clinic

be present in the human IPAH. We hypothesized

that in the low NO state of IPAH that

pulmonary artery endothelial cells may have

an altered cellular metabolic energy pathway.

To test this, we measured the oxygen

consumption, ATP content, glycolytic rate

and mitochondrial morphology, activity and

expression of mitochondrial complexes of

pulmonary artery endothelial cells isolated

from IPAH lungs in comparison to pulmonary

artery endothelial cells from healthy controls.

Our research findings, “Alterations of cellular

bioenergetics in pulmonary artery endothelial

cells,” were published in the Jan. 16, 2007,

issue of the Proceedings of the National

Academy of Sciences.

A significant decrease of oxygen consumption

was found in IPAH cells as compared with

healthy controls. Glucose metabolism was

subserving the primary role for energy-requirements

of IPAH cells as shown by the measure

of nearly 3-fold greater glycolytic rate of IPAH

cells as compared to healthy control cells.

Positron emission tomography (PET) scan

with 18 F- fluoro-deoxy-D-glucose (FDG) was

used to evaluate the glucose metabolism in

the lungs of IPAH patients in comparison

to healthy controls. FDG PET scan revealed

higher glucose metabolic activities in lungs of

IPAH patients than in controls, confirming that

the glycolytic rate was also higher in vivo, and

that relative uptake of FDG in patient’s lungs

may have promise as a marker of IPAH disease

activity, or in the diagnosis of the disease.

Overall, this study supports that there is a

fundamental alteration in cellular bioenergetics

in IPAH, linking the human disease to

avian and murine forms of PAH, species in

which inefficient cellular use of oxygen has

been shown to predispose to development

of pulmonary hypertension. The next step in

the research is to understand the molecular

mechanisms that lead to these alterations, so

that we can develop new drug therapies to

improve mitochondrial function.

Contact Dr. Serpil C. Erzurum at

216.445.5764 or

PET/CT image of

IPAH patient, with

PET image on the

right and CT image

on the left. FDG

standardized uptake

in IPAH lung is higher

than in healthy lung

(not shown).

Lung Transplant Center of Excellence

The year 2007 brought continued

growth for the Cleveland Clinic Lung

and Heart/Lung Transplant Program,

one of the most active in the country.

The Transplant Program completed its 626th

transplant since the program’s inception

in 1990, and in 2007, performed 72 lung

transplants, including three heart/lung

transplants and the first lung-liver transplant

in Ohio, reinforcing Cleveland Clinic’s position

among the leading lung transplantation

programs, both in Ohio and nationally. More

than 415 end-stage lung disease patients

were evaluated from all across the country

and the world by the transplant team.

The Transplant Program continues a

reputation for accepting and transplanting

challenging, complex patients. Cleveland

Clinic’s Lung Transplant Team is involved

in a series of multicenter trials aimed at

therapy of primary graft dysfunction, acute

rejection and induction therapy. In addition,

our surgeons have pioneered certain

transplant surgical techniques, including

bronchial artery revascularization, which

may improve outcomes further by reducing

ischemic injury (see lead article in this issue

of Respiratory Exchange).

The average waiting time for a graft in our

program remains stable despite the new Lung

Allocation Score (LAS). Currently, our average

waiting time is 75 days. The Transplant

Program has achieved very strong survival

rates that are at or above the national average.

Median and long-term outcomes continue

to improve, with a one-year survival rate of

86 percent and two-year survival rate of 74

percent. A continued emphasis on quality

assurance and quality improvement remains

central to the program, reflected by the decrease

in post-transplant length of stay to

an average of 13 days.

Number of transplants in 2002–2007





Lung Transplant Survival Rate










12 Months 24 Months

In 2007, the U.S. Department of Health and

Human Services identified Cleveland Clinic as

one of six “high performing” centers for lung

transplantation, based on volume, growth

and clinical outcomes. (HHS Final Report.

“Transplant Center Growth and Management

Collaborative: Best Practices Evaluation,”

Sept. 2007.)

To refer a patient for consideration for

lung transplant or heart/lung transplant,

please call our transplant coordinator at

216.444.8282, option 3.

65 64 65

2002 2003 2004 2005 2006 2007


Fall 2008 | 11


Any wait-listed transplant candidates

within a 1,000-mile radius of Cleveland

Clinic can wait at home until a donor is

located. Once a donor is found, patients

are transported within hours via private

plane to Cleveland.

For continuity of care, we follow our patients

for the life of their transplant along with

local physicians. Our transplant physicians

are committed to helping the transplanted

patients receive as much care as possible

close to their homes. The goal is to return

each transplant patient to his or her primary

care physician or referring physician

within three to six months after transplant.

12 | Respiratory Exchange

IBV Valve by Spiration, Inc.

Zephyr EBV Valve by Emphasys


Bronchial bypass by Broncus


Animal image of fibrin plug for

biologic lung volume reduction by

Aeris Therapeutics Inc.

Bronchoscopic Techniques May Provide New

Treatments for Severe Emphysema Patients

By Thomas Gildea, MD, Michael Machuzak, MD, and Atul Mehta, MD

Emphysema is a serious health issue that afflicts about 3 million people in

the U.S., causing nearly 14,000 deaths every year. Current medical treatment

for emphysema includes medication and/or supplemental oxygen,

pulmonary rehabilitation and, in rare cases, lung volume reduction surgery

(LVRS) or lung transplantation.

Although LVRS is an effective procedure, it is associated with a morbidity rate of 40 percent

and a mortality rate of 10 percent to 15 percent two years post-surgery (even in an appropriate

patient group). For this reason, researchers have developed novel, investigational endobronchial

valve devices that allow air to exit from the lung parenchyma, but not to re-enter, potentially

leading to less volume that occurs following LVRS. Researchers hope the endobronchial valves

may achieve the benefits of LVRS, but without its surgical risks and complications.


Over the last few years, Cleveland Clinic pulmonologists have been participating in several

multicenter trials to assess the efficacy and safety of bronchoscopic treatments for patients

with severe emphysema.

One such device is manufactured by Spiration Inc., Redmond, Wash. The IBV ® valve is an

umbrella-shaped nitinol framed prosthesis with a synthetic polymer cover. The flexible nitinol

frame enables the valve to maintain contact with the airway wall and prevent air from passing

into the diseased portions of the lungs while allowing for mucus and air to escape. This creates

a one-way valve effect and redirects inspired air from the diseased upper lobes to the healthier

lower lobes.

While the patient is under anesthesia, the valve is inserted through the working channel of a

flexible bronchoscope. The calibrated balloon determines the size of the valve for a preselected

airway segment. Under direct vision, the valve deployment device is passed through the working

channel of the bronchoscope and installed. The valves are intended to be permanent but

they can be removed via a minimally invasive procedure.

In the first human pilot study (Wood et al Journal of Thoracic and Cardiovascular Surgery

2007, Jan:133(1):65-73), 30 patients received IBV valves at five centers, including Cleveland

Clinic. Although the clinical trial was not designed to establish the efficacy of the valves, data

was collected to provide guidance for future studies. A majority of patients experienced significant

improvements in health-related quality of life as measured by the St George’s Respiratory

Questionnaire with an improvement of 9.8 (+/-9.6), 6.9 (+/- 12.9) and 6.8 (+/- 14.3) at

one, three and six months, respectively. Nevertheless, the physiological tests did not show

statistically significant improvements.

The pilot study continued to include 98 patients and is being published soon. The most common

procedure complication was bronchospasm in eight cases. These all resolved but one

was serious and two severe. Pneumothorax was the most common device complication and

occured in eight cases. Two cases did not require intervention but one episode was a tension

pneumothorax with death. Pneumothorax likely results from greater

lung volume changes than are necessary for significant improvement,

so the treatment pattern was revised.

The improved health-related quality of life outcomes might have been

due to a placebo effect among patients participating in a pilot study,

and so Spiration is sponsoring a larger research trial that is expected

to recruit more than 300 patients at 29 centers, including Cleveland

Clinic. This IBV valve study, currently under way, is a randomized,

blinded trial, which is expected to eliminate the placebo effect and

help investigators determine the physiological efficacy and safety of

the IBV valve. Patients will be selected based on strict inclusion and

exclusion criteria to reduce the risks for complications.


The Zephyr ® EBV valve from Emphasys Medical, Redwood City, Calif.,

has completed a multicenter clinical trial and is before the FDA for

review. Investigators at Cleveland Clinic have case by case permission

to use this valve in compassionate use protocols for persistent bronchopleural

fistula, treatment for severe emphysema and giant bullae.


Another trial currently enrolling at Cleveland Clinic is the EASE (Exhale

Airway Stents for Emphysema) trial sponsored by Broncus Technologies,

Mountain View, Calif. This is a randomized, double-blind study to

evaluate the safety and effectiveness of the Exhale ® drug-eluting

stent in patients with homogeneous emphysema and severe hyperinflation.

This technique involves creating artificial airways, or “airway

bypasses”, across the wall of poorly functioning existing airways.

Airway bypass is done in the operating room under general anesthesia.

A bronchoscopy is performed where a Doppler probe is used to

identify safe areas to place stents. A needle with a balloon is first used

to perforate the airway and dilate the opening. A balloon loaded with

the drug-eluting stent is then deployed across the airway wall. Trapped

air is now able to pass out of the areas of emphysema without getting

blocked by the diseased airways characteristic of COPD/emphysema.

Pilot trials of this device have been conducted internationally with

these airway bypass stents (Cardoso et al Journal of Thoracic and

Cardiovascular Surgery 2007 Oct;134(4):974-81). Thirty-five patients

received the airway bypass procedure with a median of eight stents

implanted per patient. At one-month follow-up, differences in lung

function tests of hyperinflation, modified Medical Research Council

scale, six-minute walk, and St George's Respiratory Questionnaire were

observed. At the six-month follow-up, statistically significant improvements

were demonstrated in residual volume and dyspnea. One death

occurred due to bleeding during the procedure.


Fall 2008 | 13

Researchers hope the endobronchial valves

may achieve the benefits of LVRS, but without

its surgical risks and complications.

Yet another procedure in trials has been developed, biologic lung vol-

ume reduction, sponsored by Aeris Therapeutics Inc., Woburn, Mass.

A process of instilling biologic chemical reagents into targeted areas

of the lung results in scar tissue collapsing areas of diseased lung,

improving lung mechanics.

Biologic lung volume reduction (BLVR) is performed by selecting

targeted subsegments. A double lumen catheter is advanced out deep

into the lung. A mixture of chemicals and a form of fibrin glue is rapidly

instilled and allowed to gel in place. The process is repeated in

several segments based on the protocol.

Phase I of the study (Reilly J et al Chest. 2007 Apr;131(4):1108-13)

enrolled six patients with advanced heterogeneous emphysema. Three

patients received unilateral treatment at two pulmonary subsegments

and three patients received unilateral treatment at four pulmonary

subsegments. BLVR was not associated with any serious complications.

Improvements were observed in mean vital capacity (+7.2 +/- 9.5%;

range, -2% to +19%), mean residual volume (RV) (-7.8 +/- 8.5%;

range, +1% to -22%), mean RV/total lung capacity ratio (-6.6

+/- 4.7%; range, -1% to -15%), mean 6-min walk distance (+14.5

+/- 18.5%; range, 0 to +51%), and in mean dyspnea score.

Cleveland Clinic participated in two Phase II multicenter trials, one for

patients with homogenous disease and the other for patients with heterogeneous

disease. Results of these trials have not yet been published.

Cleveland Clinic is preparing for the BLVR Phase III clinical trial.

Specific inclusion/exclusion criteria have not yet been set.

Cleveland Clinic doctors involved in these trials are Atul C. Mehta,

MD, Thomas R. Gildea, MD, and Michael Machuzak, MD.

Patient recruitment for these studies is under way. For more

information, please call Yvonne Meli, RN, BC, at 216.445.4215


ease Summit

l Care Medicine

Innovations in Pulmonary, Allergy and Critical Care Medicine

April 12, 2007

InterContinental Hotel and Bank of America Conference Center

Cleveland, Ohio

te Member ID#_____________________________

ealth System Physician’s Organization Member

/Nurse/Respiratory Therapist

be received in our office prior to the summit to register.

bus, Continental Breakfast, breaks and lunch.

Asthma Summit 2007

o admittance to the Summit. Purchase orders are not accepted.

online, please do not mail or fax in a registration form.

ly health centers, and CCHS community hospital employees

ysicians) should register online at the above web address.

f registering by mail or fax:

The Cleveland Clinic Foundation

Center for Continuing Education TR17

9500 Euclid Avenue

Cleveland, OH 44195

First Name Ml Degree

State Zip



arged $_______________________________

e Cleveland Clinic Educational Foundation

� Visa � MasterCard � American Express � Discover

ature) 3 Digit V-Code,on back of card

and Clinic Educational Foundation

31653 • Cleveland, OH 44193-1082



U.S. Postage


Berea, OH

Permit No. 296

14 | Respiratory Exchange

Summit 011465 • Office Use Only

Fee __________ Date ___________

M.O.P. ________ CXL/Fee ________ Asthma Center


InterContinental Hotel and Bank of America

Asthma Summit 2007

Conference Center

9801 Carnegie Avenue

Innovations in Pulmonary, Allergy and Critical Care Medicine Cleveland, OH 44106


Free Major parking is available Airway in the 100 Disease Summit

Innovations in Pulmonary and Critical Care Medicine

Department of Pulmonary, Allergy, and Critical Care Medicine

Phone: 216-707-4100 or 877-707-8999 Fax:


Hotel Accommodations:

A block of rooms has been reserved at The

InterContinental Hotel until October 11, 2007.

To make your reservations, contact the Hotel

Reservations Department at 216-707-4100 or

1-877-707-8999. Please identify yourself as

being with the Cleveland Clinic Pulmonary

Hypertension 2007 Summit, (online code

x36) for a special rate of $189 single/double plus

tax. The hotel and conference center is located on

the campus of The Cleveland Clinic.

Ground Transportation:

Taxi service is available from Cleveland Hopkins

April 12, International 2007 Airport to the InterContinental Hotel

InterContinental and Bank Hotel of America and Conference Center. As

Bank of America Conference an alternative, Center take the rapid transit train from

Cleveland, the airport to Ohio the Terminal Tower in downtown

Cleveland and from there take a taxi to the

InterContinental Hotel and Bank of America

Conference Center.

Breath Analysis Summit 2007:

April 13, 2007

Clinical Applications of Breath Testing

InterContinental Hotel and

Bank of America Conference Center

Scientific Meeting of the International Association for Breath Research (IABR)

Cleveland, Ohio

November 1 - 3, 2007 | Cleveland, Ohio

InterContinental Hotel and Bank of America Conference Center

This Summit will be this year’s scientific meeting of the International Association for

Breath Research (IABR). The meeting will be held in collaboration with the National

Aeronautics and Space Administration (NASA), the Environmental Protection Agency

(EPA), the Monell Chemical Senses Center, and the Electrochemical Society (ECS).

Proceedings will be published in the newly established Journal of Breath Research (JBR).

This Summit will bring industry executives, entrepreneurs, and investors together with

scientists, environmentalists, and clinicians to discuss key trends, future directions,

and upcoming technologies in breath analysis and medicine.

The major focus this year will be on medical applications in addition to

environmental and bioterrorism issues.

Information: For further information about this

summit, contact UNITECH Communications® at:

Local: 216-297-7330 Toll Free: 800-238-6750

Web Address:

Topics to be covered will include:

• nitric oxide • exhaled breath condensate • electronic nose and sensor arrays

• mass spectrometry and benchtop instrumentation

• cutting edge sensor technologies

For questions about registering online, call

Medical applications will include:


If you have any special needs that require

additional assistance, please call us. Requests

• asthma, COPD, pulmonary hypertension, and other respiratory diseases

• gastrointestinal diseases • occupational diseases • critical care • cancer

must be received at least 2 weeks prior to the


For emergency phone calls during the summit,


Submission deadline: on or before September 1, 2007

please call 216-707-4100 and ask for the

Cleveland Clinic Registration Desk.

For complete abstract submission details and Summit information, please visit:

Registration and Cancellation:

Pre-registrations are accepted by fax or online

until 4:00 pm EST November 15, 2007.

To register after this date you must do so on-site.

In case of cancellation, a full refund will be made

Summit Directors:

Raed A. Dweik, Cleveland Clinic

International Organizing Committee:

Anton Amann, Austria

Hotel Accommodations:

Guests need to make their reservations directly

if canceled by November 7, 2007.

Gary W. Hunter, NASA

Raed Dweik, USA

with Hotel Reservations no later than 5:00 PM

After November 7, 2007, a $50 cancellation

Jörg Ingo Baumbach, Germany

(Eastern Time) on October 1, 2007, by calling

fee will be deducted from your refund. Written

notification of your cancellation is required in

order to process your refund. NO REFUNDS


Local Organizing Committee:

Terence Risby, USA

Raed A. Dweik, Cleveland Clinic

Jochen Schubert, Germany

Serpil C. Erzurum, Cleveland Clinic

David Smith, United Kingdom

Alan Gelperin, Monell Chemical Senses Center Patrik Spanel, Czech Republic

Gary W. Hunter, NASA

Hideo Ueda, Japan

Dan Laskowski, Cleveland Clinic

(216) 707-4000 or toll free (877) 707-8999.

Please identify yourself as being with the

Cleveland Clinic Breath Analysis Summit

2007 (online code Y26) for a special rate

of $119 single/double plus tax. The hotel and

conference center is located on the campus of

Joachim Pleil, EPA

General Information

The Cleveland Clinic.

Exp: Date

Location: InterContinental Hotel & Bank of

America Conference Center

9801 Carnegie Avenue

Cleveland, OH 44106

Phone: 216-707-4100 or 877-707-8999

Fax: 216-707-4101

Register Today!

th Street

Visitor’s Parking Garage. Bring your parking ticket

to the summit registration desk for validation (selfpark

only). Valet parking is available at the hotel

for an additional charge.


The Cleveland Clinic Foundation Center for

Continuing Education is accredited by the

Accreditation Council for Continuing Medical

Education to provide continuing medical education

for physicians.

The Cleveland Clinic Foundation Center for

Continuing Education designates this educational

activity for a maximum of 15.75 AMA PRA

Category 1 Credit(s) TM Registration Form

Pulmonary Hypertension

Summit 2007

November 16 – 17, 2007

. Physicians should only

claim credit commensurate with the extent of their

participation in the activity.

This activity may be submitted for American

Osteopathic Association Continuing Medical

Education credit in Category 2.

Cleveland Clinic (OH-045) is an approved

provider of continuing education by the Ohio

Nurses Association, an accredited approver

by the American Nurses Credentialing Center’s

Commission on Accreditation (OBN-001-91).

Provider status valid through 10-1-09.


Course 011463 • Office Use Only

q $150.00 Physician

Fee __________ Date ___________

q $100.00 Nurse/Physician Assistant

M.O.P. ________ CXL/Fee ________

q $100.00 Resident/Fellow*

*(Letter from program director must be received in our office prior to the course.)

Patients are invited to attend at no charge. Seating is limited.

Please call 216-445-5763 to register before November 16, 2007


Once you register online, please do not mail or fax in a registration form.

CCF main campus, family health centers, and CCHS community hospital employees

(physicians and non-physicians) should register online at the above web address.

Fee includes: Syllabus, continental breakfast, two lunches, refreshment breaks, and reception.

Payment must be received prior to admittance to the summit. Purchase orders are not accepted.

Complete the information below if registering by mail or fax:


Faculty Disclosure:

The Cleveland Clinic Foundation Center for

Continuing Education has implemented a policy

to comply with the current Accreditation Council

for Continuing Medical Education Standards for

Last Name First Name Ml Degree

Commercial Support requiring resolution of all

faculty conflicts of interest. Faculty declaring a

relevant commercial interest will be identified in

the activity syllabus.


City State Zip

Phone Fax

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Total amount enclosed or to be charged $_______________________________

MAIL Make check payable to: The Cleveland Clinic Educational Foundation

or charge the following account: q Visa q MasterCard q American Express q Discover

The Cleveland Clinic Educational Foundation Center for Continuing Education

acknowledges educational grants for partial support of the summit from:

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MAILING ADDRESS The Cleveland Clinic Educational Foundation

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U.S. Postage


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Major Airway Disease Summit

The Cleveland Clinic Foundation

Center for Continuing Education TR17

9500 Euclid Avenue

Cleveland, OH 44195

Innovations in Pulmonary and Critical Care Medicine

April 13, 2007

InterContinental Hotel and Bank of America Conference Center

Cleveland, Ohio


The Asthma Summit focused on research and clinical care advances

by global leaders in asthma. The meeting highlighted perspectives on

future research that will influence the practice of asthma care, and

described the most up to date diagnostic tools, asthma educational

programs and new insights into clinical care. More than 175 attendees

from around the world were provided detailed information on recent

innovations in asthma and potential interface with new technology.


The Major Airway Disease Summit in April 2007 focused on the

interfaces among innovative technology, research, and clinical care.

The summit provided a unique perspective on cutting-edge technologies

that will influence the future management of patients with major

airway disease.



Educational Summit Recap

This summit in May 2007 addressed the issues of supply of RTs,

demand for their services and manpower in respiratory care today.

Key issues in managing a respiratory therapy group, current issues

regarding new modes and optimal strategies of mechanical ventilation,

and optimal aerosol delivery were addressed.

Respiratory Institute Dedicated to Helping Professionals Continue to Develop



U.S. Postage Paid

Berea, OH

Permit No. 296

The Cleveland Clinic Foundation

Center for Continuing Education TR17

9500 Euclid Avenue

Cleveland, Ohio 44195

Pulmonary Hypertension

Summit 2007

November 16 – 17, 2007 | Cleveland, Ohio

InterContinental Hotel and Bank of America Conference Center

Register online at

Department of Pulmonary, Allergy, and Critical Care Medicine

Pulmonary Hypertension

Summit 2007

Translating Discoveries Into Patient Care

November 16 – 17, 2007 | Cleveland, Ohio



InterContinental Hotel and Bank of America Conference Center

Cleveland Clinic Respiratory Institute is committed to offering forums for renowned researchers in pulmonary diseases

to present their latest findings and providing professionals with insights they can integrate into their clinical practice.

The Respiratory Institute was proud to sponsor five innovation summits in 2007.

In November 2007, the Respiratory Institute hosted the first

“International Breath Analysis Summit”, which was also the third

Scientific Meeting of the International Association for Breath Research

(IABR). Directed by Raed A. Dweik, MD, the summit was held in

collaboration with NASA, the U.S. EPA, the Monell Chemical Senses

Center and the Electrochemical Society. Participants in the two

and a half day summit came from 22 countries and 18 states and

discussed key trends, future directions and upcoming technologies in

breath analysis and medicine.


The Pulmonary Hypertension Summit 2007, on November 16 and

17, attracted more than 220 participants from 20 states and five

countries to hear presentations by about 40 distinguished Cleveland

Clinic and visiting faculty. The next Pulmonary Hypertension

Symposium will be Nov. 8, 2008, and the next Pulmonary

Hypertension Summit will be in Fall 2009.


Data Available

Respirator y


The latest outcomes data from Cleveland

Clinic departments involved in the

treatment of respiratory diseases are

available. Our outcomes booklet offers

Outcomes | 2007


summary reviews of medical and surgical

trends and approaches. Charts, graphs

and data illustrate the scope and volume of procedures performed in our

departments each year. To view outcomes booklets for respiratory diseases

as well as many other Cleveland Clinic medical and surgical disciplines,


Online Access

to Your Patient’s

Treatment Progress

Whether you are referring from near or

far, our new eCleveland Clinic service,

DrConnect, can streamline communication

from Cleveland Clinic physicians

to your office. This new online tool offers

you secure access to your patient’s treatment progress at Cleveland Clinic.

With one-click convenience, you can track your patient’s care using the

secure DrConnect Web site. To establish a DrConnect account, visit or e-mail

Cleveland Clinic Ranked

One of America’s Top Hospitals

Cleveland Clinic is ranked among the top hospitals in the country, according

to the latest U.S.News & World Report’s annual survey of “America’s

Best Hospitals.” In the Respiratory Disorders category, Cleveland Clinic

is ranked #5. For details, visit

CME Calendar

Fall 2008 | 15

Physicians are welcome to attend the

following upcoming symposia:

Obesity Summit 2008 | Sept. 10-12

InterContinental Hotel and Bank of America

Conference Center, Cleveland Clinic

Cleveland, Ohio

The 5th Annual Pulmonary Arterial

Hypertension Symposium 2008 | Nov. 8

InterContinental Hotel and Bank of America

Conference Center, Cleveland Clinic

Cleveland, Ohio

Biologic Therapies in Special Populations –

Infections, Malignancies, Cardiovascular

Disease, and Other Comorbidities

May 7-9, 2009

Featuring: Mini-symposium on 'Managing

Complex Cases in Biologic Therapies'

InterContinental Hotel and Bank of America

Conference Center, Cleveland Clinic

Cleveland, Ohio

17th World Congress for Bronchology,

and the 17th World Congress for

Bronchoesophagology | June 16-19, 2012

Cleveland, Ohio

For more information about the

above events, call the Cleveland Clinic

Department of Continuing Education

at 216.444.5696 or 800.762.8173,

or visit

16 | Respiratory Institute | Staff Directory 2008

Department of Pulmonary, Allergy

and Critical Care Medicine

Herbert P. Wiedemann, MD, MBA

Chairman, Respiratory Institute


Specialty Interests: critical care

(including adult respiratory distress

syndrome and sepsis), general

pulmonary medicine, exercise testing

(dyspnea evaluation)

Loutfi Aboussouan, MD


Specialty Interests: general pulmonary

medicine, neuromuscular diseases, sleep

medicine, long-term ventilator care

Muzaffar Ahmad, MD


Specialty Interests: pulmonary function

lab, diagnostic techniques including

fiberoptic bronchoscopy, asthma, lung


Rendell Ashton, MD


Specialty Interests: critical care, lung

cancer, physician education

Marie Budev, DO, MPH

Associate Medical Director,

Lung Transplantation


Specialty Interests: lung transplantation,

pulmonary hypertension, gender specific

pulmonary issues

Robert Castele, MD


Specialty Interest: general

pulmonary medicine

Jeffrey T. Chapman, MD

Director, Interstitial Lung

Disease Program


Specialty Interests: interstitial

lung disease, pulmonary hypertension,

lung transplantation

Daniel Culver, DO

Director, Sarcoidosis Program


Specialty Interests: sarcoidosis,

interstitial lung disease, hypersensitivity


Raed A. Dweik, MD

Director, Pulmonary Vascular

Disease Program; Joint Appointment

with Pathobiology


Specialty Interests: asthma, pulmonary

hypertension, chronic beryllium disease,

critical care, bronchoscopy, nitric oxide

in lung physiology and disease, exhaled

markers in lung disease

Serpil C. Erzurum, MD

Chairman, Department of

Pathobiology, Lerner Research Institute;

Director, Cleveland Clinic General

Clinical Research Center; Co-Director

Asthma Center


Specialty Interests: asthma,

pulmonary vascular disease,

respiratory physiology, lung cancer

Samar Farha, MD


Specialty Interests: critical care,

pulmonary hypertension

Andrew Garrow, MD


Specialty Interests: critical care medicine,

sleep medicine

Thomas R. Gildea, MD

Co-Director, Center for

Major Airway Diseases


Specialty Interests: pulmonary hypertension,

interventional bronchology, lung


Jorge Guzman, MD

Head, Section of Critical

Care Medicine


Specialty Interests: critical care,

sepsis, shock

David Holden, MD


Specialty Interest:

general pulmonary medicine

Constance A. Jennings, MD


Specialty Interests: pulmonary hypertension,

pulmonary thromboembolism,

interstitial lung disease, advanced lung


Michael Machuzak, MD


Specialty Interests: rigid and flexible

bronchoscopy, endobronchial ultrasound,

laser, electrocautery, stent placement,

bronchoscopic lung volume reduction,

transtracheal oxygen catheter placement;

lung cancer, pleural diseases, COPD

Peter Mazzone, MD, MPH

Director, Lung Cancer Program;

Director, Pulmonary and Critical

Care Fellowship Program


Specialty Interests: lung cancer, critical

care, physician education

Atul C. Mehta, MD

Vice Chairman, Department of

Pulmonary, Allergy and Critical Care

Medicine; Medical Director, Lung

Transplantation; Head, Section

of Bronchology


Specialty Interests: lung transplantation,

lung volume reduction surgery, endobronchial

and bronchoscopic procedures and

interventions, transtracheal oxygen therapy

Omar A. Minai, MD


Specialty Interests: pulmonary

hypertension, interstitial lung diseases,

lung cancer, COPD, sleep apnea

Thomas Olbrych, MD


Specialty Interests:

general pulmonary medicine,

cystic fibrosis

Beverly V. O’Neill, MD


Specialty Interests:

general pulmonary medicine,

long-term ventilator patients

Joseph G. Parambil, MD


Specialty Interests: interstitial lung disease,

pulmonary hypertension, general

pulmonary medicine

Anita Reddy, MD


Specialty Interests: critical care, acute

lung injury, interstitial lung disease, lung


Hina Sahi, MD


Specialty Interests: general pulmonary


Madhu Sasidhar, MD


Specialty Interests: critical care, lung

cancer, general pulmonary medicine

James K. Stoller, MD, MS

Head, Section of Respiratory Therapy;

Executive Director, Leadership



Specialty Interests: clinical epidemiology,

alpha1-antitrypsin deficiency,

respiratory therapy

Section of Allergy

and Clinical Immunology

David M. Lang, MD

Head, Section of Allergy

and Clinical Immunology


Specialty Interests:

asthma, allergic disorders,

sinusitis, urticaria, anaphylaxis,

latex allergy, aspirin sensitivity

Mark A. Aronica, MD

Joint Appointment with Pathobiology


Specialty Interests: asthma,

allergic disorders

Sandra Hong, MD


Specialty Interests:

allergy, asthma

Fall 2008 | 17

Fred H. Hsieh, MD

Joint Appointment with Pathobiology


Specialty Interests: asthma, allergic

disorders, mast cell function

Rachel Koelsch, MD


Specialty Interests: pediatric and adult

allergic rhinitis, asthma, food allergies,

bee and wasp sting allergy, eczema,

medication allergies, hives

Lily C. Pien, MD


Specialty Interests: allergic rhinitis,

asthma, drug allergies, latex allergy,

medical education

Cristine Radojicic, MD


Specialty Interests: pediatric and

adult allergic rhinitis, asthma

Department of Diagnostic Radiology

Section of Thoracic Imaging

Moulay Meziane, MD

Head, Section of Thoracic Imaging


Specialty Interests: thoracic radiology,

CT, transthoracic chest biopsies, occupational

lung diseases, lung cancer

Ruffin J. Graham, MD


Specialty Interests: pulmonary

thromboembolism, lung cancer

and thromboembolic disease

18 | Respiratory Institute | Staff Directory 2008

Department of

Pulmonary Pathology

Jeffrey P. Kanne, MD


Specialty Interests: hematopoietic stem

cell transplantation, interstitial lung disease,

lung transplantation, occupational

lung diseases, congenital disorders of

the heart and lungs

Omar Lababede, MD


Specialty Interest: thoracic imaging

Tan-Lucien H. Mohammed, MD


Specialty Interests: cardiopulmonary

imaging/transplantation imaging,

interstitial lung disease, upper

airway disease

Barbara Risius, MD


Specialty Interest:

thoracic radiology

Carol F. Farver, MD

Director, Pulmonary Pathology


Specialty Interest:

pulmonary pathology

Andrea Arrossi, MD


Specialty Interests: pathology of

interstitial lung disease, and pleural and

pulmonary tumors

Department of Thoracic

and Cardiovascular Surgery

Charles V. Biscotti, MD


Specialty Interests: cytopathology,

gynecologic pathology

Gösta Pettersson, MD, PhD

Vice Chairman, Thoracic and

Cardiovascular Surgery; Surgical

Director, Lung Transplantation


Specialty Interests: lung and

heart-lung transplantation

Gonzalo Gonzalez-Stawinski, MD


Specialty Interests: heart transplantation,

lung transplantation,

transplant immunology, reoperative

adult cardiac surgery

Nicholas G. Smedira, MD

Surgical Director, Kaufman Center

for Heart Failure


Specialty Interests: lung and

heart-lung transplantation;

pulmonary thromboendarterectomy

Section of General Thoracic Surgery

Thomas W. Rice, MD

Head, Section of

General Thoracic Surgery


Specialty Interests: esophageal,

pulmonary, mediastinal, chest

wall and diaphragm surgery;

minimally invasive (laparoscopic

and thoracoscopic) and pediatric

general thoracic surgery; lung volume

reduction surgery

David Mason, MD


Specialty Interests: general thoracic

surgery, lung transplantation, minimally

invasive thoracoscopic and laparaoscopic

surgery, lung cancer, esophageal cancer,

malignant mesothelioma

Sudish Murthy, MD, PhD

Surgical Director, Center for

Major Airway Diseases


Specialty Interests: esophageal,

pulmonary, mediastinal, chest wall and

diaphragm surgery; minimally invasive

lung volume reduction surgery; lung

transplant surgery

leveland Clinic Facilities


General Patient Referral

24/7 hospital transfers or physician consults




Pulmonary Appointments/Referrals

216.444.6503 or 800.223.2273,

ext. 46503

Allergy Appointments/Referrals

216.444.3386 or 800.223.2273,

ext. 43386

On the Web at

Lake Erie







Cleveland Clinic


Cleveland Clinic


Cleveland Clinic



Main Campus

9500 Euclid Avenue / A90

Cleveland, OH 44195

Beachwood Family Health

and Surgery Center

26900 Cedar Road

Beachwood, OH 44122

Pulmonary and Allergy: 216.839.3800

Brunswick Family Health Center

3724 Center Road, Suite 100

Brunswick, OH 44212

Pulmonary: 330.225.8886

Euclid Hospital

Medical Office Building

99 Northline Circle, Suite 235

Euclid, OH 44119

Pulmonary: 216.692.7848

Hillcrest Hospital Atrium

6780 Mayfield Road

Mayfield Heights, OH 44124

Pulmonary: 440.312.7140



Cleveland Clinic

Cleveland Clinic

Willoughby Hills

Cleveland Clinic




Hillcrest Hospital





Fall 2008 | 19

Independence Family Health Center

5001 Rockside Road

Crown Center II

Independence, OH 44131

Pulmonary and Allergy: 216.986.4000

Strongsville Family Health

and Surgery Center

16761 SouthPark Center

Strongsville, OH 44136

Pulmonary and Allergy: 440.878.2500

Westlake Family Health Center

30033 Clemens Road

Westlake, OH 44145

Allergy: 440.899.5555

Willoughby Hills Family Health Center

2570 SOM Center Road

Willoughby Hills, OH 44094

Allergy: 440.943.2500

The Cleveland Clinic Foundation

Respiratory Institute / AC311

9500 Euclid Avenue

Cleveland, OH 44195



Introducing the

Future of Healthcare

Innovative new buildings improve

patient access, experience.

This fall, Cleveland Clinic is introducing

the future of healthcare with the opening

of the Sydell and Arnold Miller Family

Pavilion and the Glickman Tower.

These buildings, which represent the largest

construction and philanthropy project

in Cleveland Clinic history, embody the

pioneering spirit and commitment to quality

that define Cleveland Clinic. These structures

are a tangible expression of institutes,

our new model of care that organizes

patient services by organ and disease.

At 1 million square feet, the Miller Family

Pavilion is the country’s largest single-use

facility for heart and vascular care. The

12-story Glickman Tower, new home to the

Glickman Urological & Kidney Institute, is

the tallest building on Cleveland Clinic’s

main campus.

Both will help us improve patient experience

by increasing our capacity and by consolidating

services, so patients can stay in one

location for their care.

With 278 private patient rooms, more

than 90 ICU beds and a combined total of

nearly 200 exam rooms and more than 90

procedure rooms, patients will have faster

access to Cleveland Clinic cardiac and

urological services.

For details, including a virtual tour, please



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