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Pulmonology – The Specialty of the Lungs

Pulmonology in India

What is Pulmonology or Chest medicine?

The word pulmonology has its origin from greek words – pulmo and logia – which means lungs and study respectively. In essence, it refers to the specialty which deals with the study of the respiratory system, which includes the air passages and the lung parenchyma.

Why would you come to a pulmonology specialist?

It is important in identifying medical problems related to the lungs and the heart separately, because of the medical aid that is to be decided in treatment of the patient. It is relatively difficult in distinguishing the problems related to both the systems, because of the similarities in presentation. 

 

For example, breathlessness could be a presentation of a purely respiratory illness like asthma or lung disease, but may present similarly in a case of heart disease, when interventions need to be given immediately without delays to save lives.

 

On the contrary, chest pain may appear like a heart attack, but can be due to a chest wall cause or even pleuritic, which is absolutely respiratory in origin. Hence, it is necessary in identifying the right system before planning with a treatment strategy.

What are the signs and symptoms of respiratory disease?

The symptoms of respiratory disease include:

  • Cough: This is one among the earliest symptoms in respiratory disease and may be productive with phlegm or non-productive in nature. Medical texts describe cough by its nature into various categories:
  1. Loud or brassy cough: suggestive of a compression on the trachea as in case of any local tumour
  2. Hollow or bovine cough: The coarse texture of the cough is lost and is often seen in a recurrent laryngeal nerve palsy
  3. Barking cough: The quality of the cough appears more coarse than usual and is seen in croup or laryngo-tracheo-bronchitis, which is a viral infection
  4. Chronic cough: It can be infective as in tuberculosis or even pertussis (whooping cough) where there is an associated whoop. Asthma may present similarly as a cough variant and can be nocturnal. It may also be seen in acid reflux disease, where stomach acid may regurgitate with a bitter taste in the mouth with heart burns
  5. Haemoptysis: Blood in sputum or phlegm is referred to as haemoptysis. This is a red flag symptom and needs attention, as it can be a forerunner of an infection like tuberculosis or any malignancy like lung cancer. However, even trauma may result in haemoptysis.
  • Phlegm or sputum: In productive cough, the expectorated phlegm may suggest the nature of disease:
  1. Black or carbon specks: mostly in smoking
  2. Yellow or green phlegm: in infections like pneumonia, lung abscess and bronchiectasis
  3. Pink frothy phlegm: is commonly seen in pulmonary oedema and may be suggestive of heart failure
  • Dyspnoea or breathlessness: Dyspnoea or difficulty in breathing is a very common symptom where a complete assessment is required in order to distinguish between the systems involved with the disease process. It is commonly associated with the respiratory and cardiac systems and can be quite confusing in its presentations, where we may need a detailed history in assessing the degree of involvement of the body systems and carry out a systematic examination to draw clues as to what really causes the dyspnoea. Dyspnoea may be of three types based on its presentation:
  1. Acute onset: As seen in acute asthma, pulmonary embolus, pulmonary oedema, pneumothorax or foreign body aspiration
  2. Subacute onset: As seen in asthma, pleural effusion and alveolitis or pneumonia
  3. Chronic: COPD (chronic obstructive pulmonary disease) and lung parenchymal diseases and interstitial lung diseases
  • Hoarseness: This is more or less a symptom of laryngeal involvement and may be due to an inflammation of the larynx (laryngitis), vocal nodules (Singer’s nodules), and recurrent laryngeal nerve palsy or laryngeal tumours.
  • Wheeze (or rhonchi): This refers to a sharp, high pitched musical sound which is heard during exhalation and is very frequently seen in asthma.
  • Stridor: It is also a sharp high pitched sound heard due to partial closure of the upper airways during inhalation. It is mostly seen in emergency situations.This is seen due to an obstruction in the lumen, within the wall or external to the wall. Often seen in foreign body obstruction, tumours, bilateral vocal cord palsy, angioedema, laryngospasm, croup, acute epiglottitis, amyloidosis, goitre etc.
  • Chest pain: Pain in the chest may be seen in pneumonia, pulmonary embolism or costochondritis.
  • Constitutional symptoms like fever and night sweats: May be seen associated with infections like tuberculosis.

The additional elements of significance while considering a respiratory history from a patient include:

  1. Any past medical history of any respiratory disease or allergy or asthma or any lung surgeries, including the medications used
  2. Some airway diseases like asthma may run in families 
  3. Smoking history is extremely important and adds to the bulk of population presenting with respiratory ailments
  4. Occupational exposure to farming, mining, or shipyard works, may cause diseases like bagassosis, byssinosis, asbestosis and silicosis

The signs which we will be able to find on an individual suffering from respiratory illnesses are:

  • Cyanosis: inadequate oxygenation may lead to cyanosis of the tissues which is evident as a bluish discolouration of the lips, tip of the tongue, nose and ear lobes
  • Clubbing of the fingers: may be seen in suppurative lung diseases like bronchiectasis and lung abscess, but can be nonspecific
  • Lymphadenopathy: especially in infections and malignancies, may present with supraclavicular lymphadenopathy, and involvement of other groups like cervical and axillary nodes
  • Asymmetry of the chest wall: This maybe evident as a barrel shaped chest where the normal symmetry with the anteroposterior diameter being smaller than the transverse diameter, is lost.
  • Asymmetry of chest wall movements: The chest wall movements in a normal individual are usually bilaterally symmetrical. This can be lost in an individual, with lung disease
  • Deviation of the trachea: The trachea is usually in the midline. There can be a push to the trachea  to the opposite side in an effusion; and a pull to the same side in a collapse or fibrosis
  • Vocal resonance: The resonance of breath sounds is usually the same when auscultating in corresponding areas of both lung fields one after the other. However, this may be different in cases of consolidation or effusions.
  • Added sounds: On auscultation, there can be added sounds in the lung fields like wheeze (rhonchi) or crackles (crepitations). Other sounds can be a pleural rub in pleuritis.

The broad range of symptoms and signs suggest respiratory medicine as a separate entity on its own. It is very important to know about respiratory disorders to treat them and pulmonogists are the specialists in the area.

What are the common diseases handled by pulmonology specialists?

The specialty as such handles a broad range of ailments pertaining to the respiratory system. The cases that are commonly encountered in a setting are:

  • Acute respiratory distress syndrome (ARDS) or acute lung injury and pulmonary oedema: It can be fatal and may be due to direct injury to the lungs or secondary to inflammatory damage of the lungs.
  • Respiratory failure: Gaseous exchange becomes inadequate in this condition leading to hypoxia and maybe of two types based on blood levels of oxygen and carbon dioxide.
  • Pulmonary Infections: Infections of the lung are very common problems encountered on a daily basis. Treatment of infections is best possible in India, where hands on training has been obtained by all practitioners because of the huge load of cases presenting at the OPD on a regular basis.They may be:
  1. Pneumonia : Infection of the lung parenchyma
  2. Lung abscess: Focus of pus collection in the lung
  3. Aspergillosis: A fungal infection of the lung which has various presentations from an allergic response to even an invasive presentation.
  • Obstructive lung diseases: These are airway disorders which decrease the efficiency of the respiratory process. They include:
  1. Asthma: It is often associated with a wheeze and also has an allergic aetiology mediated by hypersensitivity reactions or atopy.
  2. COPD or Chronic Obstructive Pulmonary Disease: is an umbrella term for two distinct diseases, namely chronic bronchitis and emphysema
  3. Bronchiectasis: It is a suppurative lung disease with broadening of the airways resulting from chronic infections and produces foul smelling expectoration. It is often associated with genetic diseases like cystic fibrosis.
  • Interstitial Lung diseases: This is a broad term referring to diseases affecting the lung parenchyma diffusely. They may be:
  1. Idiopathic pulmonary fibrosis: the most common cause for interstitial lung disease. Treatment is only supportive, and there is no known cause and hence called idiopathic.
  2. Sarcoidosis: It is a granulomatous disease of the lung with systemic manifestations and requires long term therapy
  3. Caused by drugs: nitrofurantoin, bleomycin, sulfasalazine etc.
  4. Caused by infections: Tuberculosis and other infections like aspergillosis causing extrinsic allergic alveolitis and hypersensitivity
  5. Associated with occupational exposure: silicosis, berylliosis, asbestosis and byssinosis
  6. Caused by systemic diseases: Rheumatoid arthritis, Systemic lupus erythematosus (SLE) , systemic sclerosis or Sjogren’s syndrome
  • Diseases of vascular origin:These are diseases of the pulmonary vasculature or blood supply:
  1. Pulmonary embolism: Very common among frequent flight travellers and oral contraceptive pill (OCP) users. Development of deep vein thrombosis in the legs, which when dislodged, will go to the heart and then to the pulmonary arteries resulting in diminished blood supply to the lungs. It is often an acute presentation.
  2. Pulmonary hypertension: Increase in pressure levels of the pulmonary vasculature and is often treated with medicines, and can lead to right sided heart failure.
  • Lung tumours and solitary pulmonary nodules: Tumours of the lung are assessed based on the size and associated symptoms like haemoptysis, weight loss and loss of appetite, alongside breathlessness, anaemia and fatigue. However, most of the times incidental nodules are seen on radiographs or scans and referred to as solitary pulmonary nodules which are less than 3cm in size. They require regular follow ups or maybe interventions in case it is suspicious. Lung cancers on the other hand require early detection and referral for management by a multidisciplinary team based on the stage and type of the cancer.
  • Diseases of the pleura:
  1. Pneumothorax: Presence of air in the pleural space, and it is an acute emergency
  2. Pleural effusion: The presence of fluid within the pleural cavity will cause difficulty in breathing and needs to be tapped
  3. Empyema: This is the presence of pus in the pleural cavity due to an infection and needs to be drained, and treated with antibiotics
  4. Mesothelioma: It is a type of lung cancer seen in patients often exposed to asbestos like shipyard workers and plumbers. It is often associated with a poor prognosis.
  • Obstructive Sleep Apnoea: This is a disorder causing snoring and collapse of the air passage intermittently resulting in apnoeic episodes waking up a patient at night. It needs lifestyle modifications and sometimes positive pressure ventilation devices to help with the breathing while at sleep.
  • Corpulmonale: This refers to right heart failure from longstanding pulmonary artery hypertension. This maybe often associated with pulmonary vascular disorders or chronic lung diseases.

The disorders in respiratory system to enlist are still many. The commonest have been enlisted above for an overview. Your pulmonologist can help you in a lot many ways. 

What are the treatment modalities offered in pulmonology?

There are a broad range of medicines which can help in treatment of longstanding illnesses like asthma and chronic obstructive pulmonary diseases. Moreover, management on a pulmonology setup is purely medical, with few interventional procedures. The methodologies offered by the specialist are as follows:

  1. Inhalers, nebulisers and medical therapy: These are the most important route of administration of drugs and needs dose adjustments, regular follow ups and recordings to track a progress
  2. Non- invasive ventilation and oxygen therapy: Non invasive ventilation as positive or negative pressure ventilations may help in managing acute exacerbations and obstructive sleep apnoea. It may also include LTOT (long term oxygen therapy) in cases of chronic hypoxia in COPD which can be given as a home therapy
  3. Palliative care and pulmonary rehabilitation: We can also offer palliative treatment and pulmonary rehabilitation by our focussed clinical setups, dedicated to management of cases of lung cancer
  4. Smoking cessation clinics: These are widely available and we would always recommend it in case you smoke. This ensures a disease free life. We make use of all the latest management principles in handling cases of smoking.
  5. Bronchoscopy: It is a procedure by which a telescope or camera is introduced into the respiratory system to see any abnormalities in architecture. It may also aid in taking tissue biopsies for early diagnosis and management of diseases like cancer. It can also help in foreign body removal or sampling techniques like brushings or washings, broncho alveolar lavage (BAL) and even interventional procedures like Transbronchial needle aspiration (TBNA) or Endobronchial ultrasound (EBUS) and autofluoresent bronchoscopy (AFB)
  6. Airway management, cricothyroidotomy and tracheostomy: It includes simple airway adjuncts to intubation and other measures like cricothyroidotomy or tracheostomy to maintain airway patency.
  7. Pleural biopsy: To diagnose diseases of the pleura
  8. Pneumothorax aspiration and chest drain insertions: To remove the air from the pleura and manage cases of tension pneumothorax
  9. Pleurodesis: In cases of recurrent pleural effusions and pneumothoraces, we may use sclerosants to manage the problem and talc is commonly used for this purpose
  10. Thoracentesis: A pleural tap is required for fluid aspiration and can act as therapeutic and diagnostic in its purpose
  11. Thoracic imaging: Helps in understanding the anatomy and all modalities like Xrays, CT scans, MRI scans and Ultrasound has specific indications in different lung diseases
  12. Other tests include spirometry for asthma and allergy testing which includes skin prick tests and radio-allergo sorbent tests (RAST) and bronchoprovocation tests. Sputum sampling may sometimes need induction of sputum as well. Moreover, the common blood tests will also help to some extent in identifying specific diseases.

Every treatment plan is decided on an individual basis and needs a consultation with one of our doctors. Leave us a message now and we will get back to you at the earliest.

Are you the right person for a pulmonology consultation?

Whenever, our specialists suspect any disorder, they will discuss the pros and cons of the problem with you and engage in a two way discussion to make a holistic plan to your problem. If in case you have got any of the problems with breathing elaborated in the discussions above, kindly leave us a message and we will be more than happy to see you breathe easy. Your health is our priority.

Why choose our pulmonology specialists at MedcureIndia?

We have specific clinics that deal with each sub-specialties in pulmonology and we can direct you to the right place, to ensure your treatment happens in the best way possible.

 

We have a competent team of pulmonologists and medical personnel who can help you with making a right decision on your health. 

 

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