Pulmonology

Pulmonologist

A complete view of the respiratory system. (Click to enlarge).
Occupation
Names	Doctor, Medical Specialist
Activity sectors	Medicine
Description
Education required	Doctor of Medicine, Doctor of Osteopathic Medicine

In medicine, pulmonology (aka pneumology) is the specialty that deals with diseases of the respiratory tract and respiratory disease.^[1] It is called chest medicine and respiratory medicine in some countries and areas. Pulmonology is generally considered a branch of internal medicine, although it is closely related to intensive care medicine (aka critical care medicine) when dealing with patients requiring mechanical ventilation. Chest medicine is not a specialty in itself but is an inclusive term which pertains to the treatment of diseases of the chest and contains the fields of pulmonology, thoracic surgery, and intensive care medicine.

Background

In the United Kingdom, Ireland, South Africa and Australia the term "respiratory physician" is used rather than pulmonologist to distinguish a physician that practices pulmonology. In Canada, respirology and respirologist are used. Surgery of the respiratory tract is generally performed by specialists in cardiothoracic surgery (or thoracic surgery), though minor procedures may be performed by pulmonologists. As mentioned above, pulmonology is closely related to critical care medicine when dealing with patients that require mechanical ventilation. As a result, many pulmonologists are certified to practice critical care medicine in addition to pulmonary medicine. There are fellowship programs that allow physicians to become board certified in pulmonary and critical care medicine simultaneously. Interventional pulmonology is a relatively new field within pulmonary medicine that deals with the use of procedures such as bronchoscopy to treat several pulmonary diseases. Interventional pulmonology is not its own specialty.^[2]

History of pulmonology

One of the first major discoveries relevant to the field of pulmonology was the discovery of pulmonary circulation. Originally, it was thought that blood reaching the right side of the heart passed through small 'pores' in the septum into the left side to be oxygenated, as theorized by Galen; however, the discovery of pulmonary circulation disproves this theory, which had previously been accepted since the second century. Thirteenth century anatomist and physiologist Ibn Al-Nafis accurately theorized that there was no 'direct' passage between the two sides (ventricles) of the heart. He believed that the blood must have passed through the pulmonary artery, through the lungs, and back into the heart to be pumped around the body. This is believed by many to be the first scientific description of pulmonary circulation.^[3]

Although pulmonary medicine only began to evolve as a medical specialty in the 1950's, William Welch and William Osler founded the 'parent' organization of the American Thoracic Society, the National Association for the Study and Prevention of Tuberculosis. When the specialty did begin to evolve, several discoveries were being made linking the respiratory system and the measurement of arterial blood gases, attracting more and more physicians and researchers to the developing field.^[4]

Diagnosis

The pulmonologist begins the diagnostic process with a general review focusing on:

• hereditary diseases affecting the lungs (cystic fibrosis, alpha 1-antitrypsin deficiency)
• exposure to toxins (tobacco smoke, asbestos, exhaust fumes, coal mining fumes)
• exposure to infectious agents (certain types of birds, malt processing)
• an autoimmune diathesis that might predispose to certain conditions (pulmonary fibrosis, pulmonary hypertension)

Physical diagnostics are as important as in the other fields of medicine.

• Inspection of the hands for signs of cyanosis or clubbing, chest wall, and respiratory rate.
• Palpation of the cervical lymph nodes, trachea and chest wall movement.
• Percussion of the lung fields for dullness or hyperresonance.
• Auscultation (with a stethoscope) of the lung fields for diminished or unusual breath sounds.
  • Rales or Rhonchi heard over lung fields with a stethoscope.

As many heart diseases can give pulmonary signs, a thorough cardiac investigation is usually included.

Other tools include:

• Laboratory investigation of blood (blood tests). Sometimes arterial blood gas measurements are also required.
• Spirometry (the determination of lung volumes in time by breathing into a dedicated machine; response to bronchodilatators and diffusion of carbon monoxide)
• Bronchoscopy with bronchoalveolar lavage (BAL), endobronchial and transbronchial biopsy and epithelial brushing
• Chest X-rays
• CT scanning (MRI scanning is rarely used)
• Scintigraphy and other methods of nuclear medicine
• Positron emission tomography (especially in lung cancer)
• Polysomnography (sleep studies) commonly used for the diagnosis of Sleep apnea

Treatment

See also: Cardiothoracic surgery and Pulmonary rehabilitation

Surgical treatment is generally performed by the (cardio)thoracic surgeon, generally after primary evaluation by a pulmonologist. Medication is the most important treatment of most diseases of pulmonology, either by inhalation (bronchodilators and steroids) or in oral form (antibiotics, leukotriene antagonists). A common example being the usage of inhalers in the treatment of inflammatory lung conditions such as Asthma or Chronic obstructive pulmonary disease. Oxygen therapy is often necessary in severe respiratory disease (emphysema and pulmonary fibrosis). When this is insufficient, the patient might require mechanical ventilation.

Pulmonary rehabilitation or respiratory therapy may be initiated as a treatment after all or most other treatments do little to help the patient. Pulmonary rehabilitation is for patients whose respiratory function has decreased or improved very little, even with extensive medical treatment. Pulmonary rehabilitation is intended to educate the patient, the family, and improve the overall quality of life and prognosis for the patient. Although a pulmonologist may refer a patient to therapy, the therapy is generally practiced by respiratory therapists.

Pulmonology as a career

In the United States, pulmonologists are physicians who, after receiving a medical degree (MD or DO), complete residency training in internal medicine (3 years), followed by at least 2 additional years of subspeciality fellowship training in pulmonology. After satisfactorily completing a fellowship in pulmonary medicine, he or she is permitted to take the board certification examination in pulmonary medicine. After passing this exam, he or she is now board certified. Most pulmonologists complete 3 years of combined subspecialty fellowship training in pulmonary medicine and critical care medicine.

In the United States, pediatric pulmonologists are physicians who, after receiving a medical degree (MD or DO), complete residency training in pediatrics (3 years), followed by at least 3 additional years of subspeciality fellowship training in pulmonology.

Usually, respiratory problems can be managed by a specialist in internal medicine; however, some cases require the attention of a pulmonologist.^[1] Usually, a pulmonologist will be required in advanced cases of many respiratory diseases.

Scientific research

Pulmonologists are involved in both clinical and basic research of the respiratory system, ranging from the anatomy of the respiratory epithelium to the most effective treatment of pulmonary hypertension (a disease notoriously resistant to therapy). Scientific research also takes place to look for causes and possible treatment in diseases such as pulmonary tuberculosis and lung cancer. Several societies are dedicated to expanding the field of pulmonary medicine, some of which are listed below:

• American College of Chest Physicians
• American Lung Association
• American Thoracic Society
• British Thoracic Society
• European Respiratory Society

References

1. ^ ^{a b} ACP: Pulmonology: Internal Medicine Subspecialty. Acponline.org. Retrieved on 2011-09-30.
2. ^ Luis M. Seijo and Daniel H. Sterman (2001). "Interventional Pulmonology". N. Engl. J. Med. 344 (10): 740–49. doi:10.1056/NEJM200103083441007. PMID 11236779. 
3. ^ Sharif Kaf A-Ghazal (2002). "The discovery of the pulmonary circulation – who should get the credit: ibn Al-Nafis or William Harvey". JISHIM 2: 46. http://www.ishim.net/ishimj/2/09.pdf. 
4. ^ History of the Division. Hopkinsmedicine.org. Retrieved on 2011-09-30.

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