Department for Intensive Care and Intoxications - Level 3

The Department for Intensive Care and Intoxications –level III (Intensive Care Unit - ICU) is a part of Emergency Pulmonology Clinic treating critically ill patients with a dysfunction of one or more organ systems, predominantly the respiratory or cardiovascular ones.

The Department has five patient beds provided with ventilation support, noninvasive and invasive haemodynamic monitoring (blood pressure, cardiac frequency, saturation, respiration count, diuresis, body temperature). Additional routinely used equipment includes a portable echocardiography device, bronchoscope, and instruments for continual renal function substitution.

Department physicians are engaged in the Unit for Invasive Diagnostics and Treatment intended for invasive haemodynamic procedures (right heart catheterisation, pericardiocentesis, placement of ports, cava filters, cava stents, ECMO and ECOS catheters, thromboaspirations, pulmonary angiography, balloon pulmonary agioplastica, embolisation of pulmonary arteries).

The Department employs six physicians – three specialists (Assist. Prof. Jovan Matijasevic, MD. PhD, Uros Batranovic, Srdjan Gavrilovic, MD), and three physicians specialising in Internal Medicine (Vladimir Carapic, Svetislava Milic, and Ana Andrijevic), as well as 21 nurses/medical technicians. The physicians of the Department are members of the Serbian Society of Intensive Care Medicine and the European Society of Critical Care Practitioners. They went for advanced training to the States (Mayo Clinic, Rochester), to Italy and other countries. Experienced in participating in clinical trials and international projects, they are also included in the global project iCertain, involving 40 countries from all over the world, leaded by the Mayo Clinic, while the Institute for Pulmonary Diseases of Vojvodina is a coordination centre.

The Head of the Department for Intensive Care and Intoxication is Assist. Prof. Jovan Matijasevic, MD. PhD, a Specialist in Internal Medicine, and the Head Nurse is Maja Stanojevic, a graduate health care organiser.

Intensive Care Department – Level 2

The Intensive Care Department - Level 2 is a modern respiratory unit of the Emergency Pulmonology Clinic the Institute designed in compliance with recommendations of the European Society of Critical Care Practitioners. The Department has five patient beds provided with equipment for noninvasive and invasive monitoring of vital parameters, and two beds for patients with multiresistant agents of their disease requiring isolation measures to be undertaken. The Department provides treatment for critically ill pulmonary patients, in compliance with the good clinical practice of the critical care medicine.

The Department is technically equipped in compliance with European standards, providing a continual monitoring of vital parameters, including a patient’s haemodynamic profile. Noninvasive ventilation adjusted to indications and the Protocol of the European Respiratory Society is carried out at the Department.

The staff of the Intensive Care Department – Level 2 includes its Head Assist. Prof. Dusanka Obradovic; an internist-pulmonologist, and current Chief of the Internal Medicine Department of the Medical Faculty of Novi Sad, Biljana Joves, MD. PhD, an internist, Ivana Vujovic, a clinical physician, and Jelena Repic, the Head Nurse.

Department for Pulmonary Thromboembolism

The Department for Pulmonary Thromboembolism provides treatment for patients with pulmonary embolism (PE) and deep venous thrombosis (DVT). As soon as a patient is clinically examined and assessed for a potential presence of PE and DVT, diagnostic procedures are undertaken including X-ray of the lungs, blood gas analyses, ECG, echocardiography, D-dimer test, coagulation, enzyme and biochemistry status evaluation. If the obtained test findings suggest PE may be involved, the definite diagnosis is established by CTPA – computerised angiography and perfusion scintigraphy of the lungs. Concurrently with diagnosing pulmonary thromboembolism, it is attempted to detect the thrombus site of origin applying ultrasonography of the lower extremity veins. If the thrombus origin is defined, a vascular surgery or a vena cava filter insertion are considered by a vascular surgeon in order to prevent pulmonary thromboembolism to reoccur.

Once the suspected pulmonary thromboembolism is confirmed by basic diagnostic tests, the treatment is initiated, depending on the severity of pulmonary thromboembolism. Massive pulmonary thromboembolism is treated by fibrinolytic therapy, monitoring a patient in the Intensive Care Unit of the Emergency Pulmonary Clinic. Stabilised patients and those with non- massive PE receive anticoagulation therapy (unfractionated and low-molecular heparin. Afterwards, the patients are translated to oral anticoagulation therapy, controlling their prothrombin time. Once the therapeutic effect is achieved, further controls are performed in the Thrombosis Prevention Unit in the Policlinic of the Institute, seven to ten days after the discharge from hospital and during the first month, and afterwards, as the therapy has been well regulated, once in a month. When new oral anticoagulant drugs are not contraindicated, they are introduced in the treatment, thus reducing the hospital treatment length, performing controls in three-month intervals. In case the thrombus resolution is not achieved after the applied treatment, chronic pulmonary hypertension develops due to pulmonary thromboembolism. This condition is assessed 3-6 months following acute PE (by echocardiography, right heart catheterisation, CTPA and perfusion scintigraphy). Based on the obtained findings, endarterectomy is indicated, representing a golden standard in CTEPH management, in case major branches of the pulmonary artery are obstructed, or balloon angioplasty in case peripheral branches are occluded. The latter procedures are performed in specialised centres selected by the International CTEPH Association.

As venous thromboembolism develops as a complication of other diseases, surgeries, traumas, infections, malignancies, thrombophilia, there is a close cooperation with other clinics of the Institute and the Clinical Centre of Novi Sad, as well as with the Service for Haemostasis and Thrombosis.

The Head of the Department is Jadranka Vucicevic-Trobok, MD, a Subspecialist in Pulmonology.

Associates: Sandra Pekovic, MD, a Subspecialist in Pulmonology, Stanislava Sovilj-Gmizic, a Specialist in Internal Medicine, Milica Miric, MD, specializing in Internal Medicine.

Department for Pulmonary Hypertension and Chronic Pulmonary Heart

As an integral part of the Clinic for Emergency Pulmonology, this department is intended for emergency treatment of patients with acute/chronic respiratory failure usually due to chronic obstructive pulmonary disease (COPD), right heart decompensation, or a combined cardiorespiratory disease. These patients usually require a noninvasive mechanical ventilation in addition to other medicamentous and supportive treatment. The diagnosis and treatment of the underlying cause of the disease are further steps in patients admitted to intensive and semi intensive units and transferred to the clinical department for further treatment.

Over the last five-year period, patients with primary pulmonary hypertension (PAH) have been separately diagnosed and treated in the Department, complying to international guidelines and in cooperation with other centres in the country and abroad (the Clinical Centre of Serbia in Belgrade and AKH Clinic in Vienna). Most diagnostic procedures can be carried out in a short period of time, including the right heart catheterisation, which is a golden standard, and is carried out in the intensive care unit.

As a single referral centre for PAH in Vojvodina, due to persistent efforts and in cooperation with the Ministry of Health, we have succeeded to provide a part of the latest, specific PAH treatment for these patients. At present, two groups of drugs are available: receptor 5 phosphodiesterase inhibitors (sildenafil), and endolenyn receptor 1 antagonist (bosentan); additional combinations are also available in clinical trials with selected patients. Each drug administration is approved the Board for Pulmonary Hypertension, presided by prof. Ilija Andrijevic, MD. PhD.

Head of the Department: Prof. Ilija Andrijevic, MD. PhD.

Physicians: Stoja Krunic, MD, a Specialist in Pulmonology, Senka Milutinov, MD. PhD, a Specialist in Pulmonology

Primary activities of the Clinic are diagnosis and treatment of interstitial (most frequently idiopathic pulmonary fibrosis) and granulomatous (sarcoidosis and tuberculosis) lung diseases. Nowadays, tuberculosis takes about 15% of the Clinic’s capacity, due to a reduced incidence rate of tuberculosis in Vojvodina (14/100,000 persons) over the last 12-year period.

The Clinic employs nine physicians – one specialist in pulmonology and internal medicine respectively, four pneumophthysiologists, one physician specialising in internal medicine, and two clinicians. Three of the physicians have a PhD title, one and two of whom are a full and associate professors respectively. Twenty-three nurses work in the Clinic, including a head nurse, four section nurses, three therapists, and 15 shift nurses.

The Clinic for Granulamatous and Interstitial Lung Diseases has the capacity of 62 beds, distributed in 17 patient rooms (seven six-bed and two ten-bed rooms). Each room has its own bathroom and is equipped with a central oxygen supply and an air conditioner. In 2016, there were 1,159 patients treated in the Clinic, who made the total of 19,483 hospital days, with the mean treatment duration of 17 days.

Infectious TB Isolation Section including three patient rooms with the total capacity of nine patients was opened in October, 2014. The Section is physically separated from the rest of the Clinic and it entirely applies TB infection control measures in compliance with standard operative procedures.

“TB Control in Serbia”, a ten-year project, was being carried out until 1st April, 2015. All physicians of the Clinic participated in this project as the expert team members, supervisors, or educators. Education of all staff profiles of the Clinic has been carried out according to the plan and programme of education. Special attention has been paid to education on the measures for prevention and control of the TB bacillus-induced nosocomial infection immediately before opening the Isolation Section of the Clinic, which also included other health professional and assisting staff outside the Clinic who come in contact with the Section during their regular work practice (food serving staff, technical staff, laboratory technicians), as well as the patients themselves and their family members.

Upon termination of the TB Control in Serbia project, the physicians of the Clinic still have a leading role in the control of the disease in Vojvodina through educational seminars, workshops, supervision visits to TB treatment centres, as well as consultation services given by the Commission for Granulomatous and Interstitial Diseases at the Clinic.

The quantiFERON test (QTF) has been applied in the Institute for Pulmonary Diseases of Vojvodina since 1st January, 2015. It is used to detect a latent TB infection (LTB). Unlike the tuberculin skin test (TST), the QFT is positive only when a TB infection is chiefly induced by M. tuberculosis, but not when BCG vaccination is applied. The test is performed in the Immunology Laboratory of the Institute. The advantage of this LTB-confirming method over tuberculin skin test (TST) is in that it requires just a single visit to the laboratory unlike theTST, which requires two visits in 72 hours.

Although the Clinic has been primarily intended for diagnosis and treatment of tuberculosis, current declining trends in the number of TB patients in Serbia and Vojvodina have resulted in the Clinic’s growing orientation to the diagnosis and treatment of sarcoidosis and disorders of the lung parenchyma. The name of the Clinic itself has been accordingly amended. Significant advances in the diagnosis and treatment of these diseases have been achieved in the last decade, so the physicians of the Clinic have been increasingly interested in these fields, constantly improving their knowledge about them.

Consequently, a multidisciplinary approach in the diagnosis and treatment of interstitial lung diseases has been recognized and the Commission for granulomatous and interstitial diseases founded, which includes clinicians (pulmonologists/pneumophthysiologists) from the Clinic, a radiologist and a pathologist. The Commission makes a final decision about the diagnosis and treatment of active and latent tuberculosis, sarcoidosis and other granulomatous and interstitial lung diseases. It considers the cases of both in- and out-patients, the latter referred by a regional pulmonologist or another specialist dealing with systemic diseases which may affect the lung interstitium (immunologist, rheumatologist, etc). The Commission works on Tuesdays and Thursdays from 11 o’clock. Appointments are made by phone at the Control Examination Unit (+381 21 48 05 114).

All medical staff members of the Clinic have been permanently improving in their fields of interest through education courses, professional meetings and conferences in the country and abroad in which they take an active part, organising seminars and symposia, giving introductory lectures, oral and poster presentations.

The Clinic for Obstructive Pulmonary Diseases and Acute Pneumopathies has the capacity of 74 hospital beds distributed in 20 patient rooms (10, two and eight of which are two-bed, three-bed and six-bed rooms respectively); seven of the rooms are equipped with an air conditioner.

About 2,000 patients are treated at the Clinic in a year, suffering from acute low respiratory infections, asthma, chronic obstructive pulmonary disease (COPD), respiratory insufficiency, cystic fibrosis, rare pulmonary diseases, or undiagnosed lesions of the pulmonary thoracic area.

The Clinic is equipped with modern medical equipment, hotair and positive pressure inhalers and a central oxygen supply, installed in all rooms. Diagnostic and treatment procedures are carried out in compliance with the latest principles of the good clinical practice, as well as with national and international guidelines. Physicians of the Clinic have at disposal modern laboratory assays of biochemical and inflammation markers, diagnostic immunology and microbiology tests, histopathology analyses, radiologic and other imaging diagnostic procedures, as well as lung function tests (spirometry, plethysmography, diffuse capacity, exercise tests), blood gas analysis, induced sputum analysis, specific bronchial challenge tests, in-vivo and in-vitro allergy tests.

Education and training of the Clinic’s medical staff is carried out permanently, keeping constantly informed about the latest diagnostic and therapeutic achievements. One of our chief goals is to educate our patients about the nature of their disease, recommended life styles, instruct them how to use inhalers and make them aware of the importance of having their disease treated regularly. To achieve these goals, numerous pamphlets and handbooks have been published, intended for both the physicians and patients of the Clinic. We are very proud of the good cooperation we have with the physicians from other centres throughout Serbia and from surrounding countries: Montenegro, the Serbian Republic, Bosnia and Herzegovina, Croatia, Slovenia, Macedonia. It is not unusual that foreign patients are also referred to the Clinic for further diagnosing and treatment.

Department for Acute Pneumopathies

(Head Prof Mirna Djuric, MD, PhD; Physicians: Dusan Skrbic, MD, Marija Zdrnja MD.)

The patients most frequently treated in the Department for Acute Pneumopathies suffer from acute respiratory infections of bacterial, viral or obscure aetiology, bronchiectases, pleural effusions and infiltrative lung lesions of unclarified aetiology. In addition to basic laboratory analyses, contemporary inflammation markers, X-ray and CT screening of the chest, microbiological diagnostics (bacteriological, virologic, immunological and mycological analyses of the serum, sputum, bronchoaspiration and broncholavage samples) are utilised in the routine every-day practice of the Department, and when necessary, preparation for invasive diagnostic procedures (bronchoscopy, video-assisted thoracoscopy and thoracotomy) is also carried out. In cooperation with other departments and institutions, the Department carries out a regular monitoring of the isolated agents of severe community-acquired low respiratory infections in the city of Novi Sad and throughout the district of South Backa.

The Department also has a specific unit for care and treatment of adult patients with cystic fibrosis which, as recommended by the European Cystic Fibrosis Society, requires the inhalatory antibiotic treatment, respiratory rehabilitation and education, including a multidisciplinary approach in either the pharmacologic or nonpharmacologic therapy.

Department for Chronic Obstructive Pulmonary Diseases

(Head: Lidija Vrtunski-More, MD. MSc; Physicians: Jelena Papovic, MD, Olivera Maksimovic, MD. MSc.

The Department for Chronic Obstructive Pulmonary Diseases (COPD) admits patients with an acute exacerbation of COPD to be treated with the latest bronchodilatory and anti-inflammatory therapy, as well as with substitution oxygen treatment in case of pulmonary gas exchange disorder. The presence of comorbidities is investigated and the adequate treatment initiated. All COPD patients are included in the respiratory rehabilitation programme which contributes to a faster and better recuperation. The adequate treatment of COPD exacerbations reduces their frequency and severity, improving patients’ life quality and survival. An important segment of the treatment is education of the patients about the disease - its character, severity, prognosis and prevention, adequate inhaler use, importance of smoking cessation and other nonmedicamentous treatment measures. The selected cases are evaluated for an interventional surgical procedure in terms of the pulmonary parenchyma reduction or bullectomy.

Asthma Department

(Head: Prof. Biljana Zvezdim, MD. PhD; Physicians: Violeta Kolarov, MD. PhD,Vesna Kosjerina Ostric, MD. MSc, Branislav Tusek, MD.)

The Department is intended for diagnosis and treatment of patients suffering from bronchial asthma and its acute exacerbation, carried out in compliance with the latest recommendations of the Global Initiative for Asthma accepted worldwide. The achieved asthma control is evaluated analysing all factors which may contribute to an unsatisfactory disease control. Comorbid conditions (rhinitis, sinusitis, gastro-oesophageal reflux, vocal cords dysfunction, depression, anxiety, osteoporosis, etc.) are considered and respective specialists consulted to confirm the diagnosis and initiate treatment. Asthmatic patients are daily educated about their disease, instructed how to apply inhalation therapy, adjust their life style, avoid risk factors, recognize first exacerbation symptoms which may be fatal, and informed about the importance of regular control examinations.

Our goal is to provide the best possible level of medical care, diagnosis and treatment for each individual patient, based on the multidisciplinary approach.

Department for Semi-Intensive Care of COPD and Allergy

(Head: Sanja Hromis, MD. PhD; Physicians: Srdjan Stefanovic, MD, Jelena Crnobrnja, MD, Tatjana Petrovic, MD.

Noninvasive Ventilation Unit 2 and Excessive COPD Exacerbation Unit

These units of the Department for Semi-Intensive Care of COPD and Allergy are intended for patients with severe chronic respiratory failure due to asthma and COPD exacerbations, as well as for patients suffering from severe asthma and allergic lung diseases. Great attention is paid to the detection and treatment of comorbidities and patients’ education on the importance of properly administered medication and sufficiently long treatment, timely recognition of symptoms of the disease and its exacerbations, proper inhaler handling, rehabilitation, vaccination and other nonpharmacological treatment measures.

By the Development Plan of the Institute, the Department is intended to be renovated and include a modern, semi-intensive care unit equipped with four appliances for noninvasive ventilation and four monitors, with a modern accompanying kit. Noninvasive mechanical ventilation is the initial therapy measure applied in patients with acute respiratory insufficiency accompanied with respiratory acidosis, reducing mortality, the need for invasive mechanical and hospital treatment duration, and improving patients’ survival. According to the latest treatment guidelines recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD- http://goldcopd.org/), this treatment modality is qualified as 1А level guideline.

Allergy Unit

As assessed by the World Health Organisation, allergic diseases represent a huge health issue nowadays, threatening to become a pandemic. Only in Europe, about 150 million people suffer from allergy, and taking into account the current increasing tendency of allergic diseases, it has been assessed that almost one half of the entire European population will develop at least one allergic manifestation in the future 15-year period. Quite often, these patients have a severe form of these diseases which significantly affect their life quality, professional and personal prosperity, representing at the same time a great burden for the health system budgeting.

Allergic diseases of the respiratory tract constitute the most important category of these diseases, allergic rhinitis and asthma doubtlessly being the most common ones. Respiratory manifestations may occur in patients with allergy to pollens (grass, weeds, trees), house dust mites, fungi, allergens of domestic animals, insects, drugs, food and additives; respiratory symptoms may also be associated with anaphylactic reactions, skin lesions, gastro intestinal symptoms, or may manifest as a poorly controlled severe asthma or persisting rhinosinusitis.

About 3,000 first- and another-visit examinations are performed in the Allergy Unit of the Institute in a year, including the patients who suffer from asthma, chronic cough, unclarified bronchial obstruction and suspected allergy, as well as over 500 skin allergy tests. The Unit employs well educated and trained professionals with great experience in treating asthma and allergic diseases. The staff includes seven physicians, three of whom are subspecialists in asthma and allergology. The services provided at the Allergy Unit are coordinated with those provided in already existing subspecialist units in the territory of Novi Sad, for example the Allergy Office of the Dermatovenerology Clinic of the Clinical Centre of Vojvodina in Novi Sad, as well as the Rhinology and Phoniatry Units of the ENT Clinic of the Clinical Centre of Vojvodina in Novi Sad.

The following diagnostic and treatment procedures are performed in the Allergy Unit:

Skin prick tests are considered to be a reliable method for the diagnosis of IgE-mediated
allergic disease in patients with rhinoconjunctivitis, asthma, urticaria, anaphylaxis, atopical dermatitis and suspected food and drug allergy. The method is minimally invasive and cheap, providing immediate results immediately and having a high reproducibility if properly applied and interpreted.

Prick testing to inhalant allergens: respiratory allergy is the most common allergic disease and about 25% of the total population are sensitised to inhalant allergens.. Prick testing to inhalant allergens have currently been carried out in compliance with the Global Allergy and Asthma European Network, including the standard European test panel (modified with two allergens in compliance with the aerobiological situation in Serbia) with 17 allergens (hazel tree, alder, birch, plane tree, cypress, juniper tree, European ash, grass mixture, absinthe, ambrosia, alternaria, cladosporium, aspergillus, cat and dog hair, European house dust mite, cockroach), including a positive and negative control test. The testing is carried out as recommended by the European Academy for Allergology and Clinical Immunology.

Prick testing to food allergens, using commercial preparations produced by the Torlak Institute.
“Prick to prick“ tests: skin prick tests used to investigate the sensitivity to fresh food allergens (fruit, vegetables, wheat, hard-shelled fruit), represent ting the most common procedure in evaluating the food allergy. The number of allergens which may be examined in this way is not limited and the procedure sensitivity is very high, amounting to 85% for the oral allergic syndrome.

Nasal lavage, a diagnostic method enabling quantification of the type and stage of the nasal mucosa inflammation, which is used in order to investigate the seasonal and perennial allergic and infectious rhinitis.

Oesinophil nasal swab, is a simple and cheap procedure determining the presence of oesinophils in the nasal mucosa.

Allergen-specific immunotherapy – Immunotherapy is a single causal treatment of allergy resulting in the so called immunological tolerance, i.e. bearableness. Symptoms of the disease become reduced in most treated patients, accompanied with reduced medication and reduced risk of new sensitisations and allergic disease. Sublingual immunotherapy (SLIT) is also carried out in the Unit, using the allergens (house dust mites and pollens) produced by the Torlak Institute, in compliance with the European Academy for Allergy and Clinical Immunology guidelines.

Lung function tests are indicated and evaluated at the Unit, including spirometry, plethysmography, bronchodilation test, nonspecific indirect and direct bronchial challenge, specific bronchial challenge, induced sputum.

By development plans of the Clinic and the Allergy Unit, additional diagnostic procedures are to be introduced, thus extending and supplementing investigation for some specific types of asthma, as well as to introduce investigations for other allergic pulmonary and extrapulmonary diseases.

Work Schedule

Monday:    

Sanja Hromis, MD. PhD, Specialist in Pulmonology, Subspecialist in Allergology

Tuesday:           

Lidija Vrtunski-More, MD. MSc, Specialist in Pulmonology
Jelena Papovic, MD, Specialist in Pulmonology

Wednesday

Prof. Biljana Zvezdin, Specialist in Pulmonology

Thursday:       

Violeta Kolarov, MD. PhD, Specialist in Pulmonology, Subspecialist in Allergology
Dusica Stanojev , MD.PhD, Specialist in Pulmonology

Friday:            

Mirjana Jovancevic-Drvenica, MD, PhD, Specialist in Pulmonology, Subspecialist in Allergology
Olivera Maksimovic, MD. MSc, Specialist in Pulmonology