Definition and Scope of Pulmonology
Pulmonology (pulmonary or respiratory medicine) is a subspecialty of internal medicine that deals with the diagnosis and treatment of diseases of the respiratory system. The respiratory system consists of the upper airways (pharynx, larynx, trachea), the lungs and the bronchi and bronchioles inside the lungs, the thoracic cavity, and the chest wall.
A specialist in pulmonary medicine is known as a pulmonologist. A pulmonologist may practice general pulmonology or sub specialize in pulmonary/critical care medicine or sleep medicine.
Because critically ill adults tend to have serious/life-threatening pulmonary diagnoses, there is significant crossover in training and practice between pulmonology and critical care medicine. Pulmonologists are trained in complex techniques such as mechanical ventilation and management of respiratory failure, and so their work overlaps often with critical care physicians, otherwise known as intensivists, in the intensive care unit (ICU). Sometimes, pulmonologists pursue further training in critical care medicine and work exclusively in the ICU.
Pulmonology-Related Medical Specialities
Medical specialities related to pulmonology include:
Thoracic Surgery
Critical Care Medicine
Hospitalist Medicine
Infectious Diseases
Sleep Medicine
Family Medicine
Geriatrics
Common Diseases and Medical Procedures
Pulmonary diseases frequently seen in clinical practice:
Asthma: A common lung disease in which airways are inflamed or swollen causing problems with the flow of air. Asthma is a chronic condition with no cure. People with asthma are prone to “allergens” or “trigger factors” that can exacerbate symptoms. These factors can be anything from seasonal changes to environmental agents such as dust or dander.
Chronic Obstructive Pulmonary Disease (COPD): COPD is a common, progressive lung disease in which less air flows in and out of the lungs. COPD includes two main conditions–chronic bronchitis and emphysema. In chronic bronchitis, the lining of the airways within the lungs is inflamed and irritated. In emphysema, the air sacs inside the lungs become loose and floppy. People with COPD experience shortness of breath, wheezing, chest tightness, and chronic cough with mucus.
Lung cancer: Cancer originating in the lung tissue is known as primary lung cancer. In secondary lung cancer, cancerous cells from other organs spread (metastasize) to the lungs. There are two main types of lung cancer—small cell lung cancer and non-small cell lung cancer.
Pneumonia: Infection of the lungs (one or both lungs) caused by bacteria, virus, or fungi. Most cases of pneumonia are caused by microbes, such as bacteria.
Tuberculosis (TB): TB is an infectious disease caused by the bacteria Mycobacterium tuberculosis. Most times, TB occurs in the lungs. Bacteria can also invade the intestines, the kidneys, brain, and spine.
Interstitial Lung Disease (ILD): Multiple diseases that causes scarring of the lung tissue. The scarring results in stiffness of the lung tissue leading to breathing problems. The lung damage in ILD is permanent, and the condition is progressive.
Pleural effusion: The pleura are thin membranes that line the lungs and the inside of the chest cavity. Build-up of excess fluid between layers of pleura is known as pleural effusion.
Medical procedures in pulmonology are typically interventional. The common interventional procedures are as follows:
Bronchoscopy: An endoscopic technique used in the diagnosis of lung diseases. The technique involves a bronchoscope, a thin tube-like device which is passed through the nose or the mouth, down the throat, into the lungs. The bronchoscope is fitted with light source and a camera which allows visualization of the lung airways. When used for diagnostic purposes, bronchoscopy can help detect tumors, inflammation, bleeding, and obstruction in the lung airways. Moreover, it can also help collect tissue or fluid samples for laboratory testing.
Airway ablation: An interventional procedure used to open airways that are blocked.
Balloon dilation: In this procedure, narrowed airways are opened by introducing balloons into the airways. The procedure is performed via a bronchoscope.
Bronchial Thermoplasty (BT): This procedure is used with asthma patients. The airways in severe asthma are narrowed by smooth muscle. With this technique, controlled thermal energy is delivered through a bronchoscope to the airways to reduce the amount of smooth muscle.
Stent placement: Silicone or metal stents are placed via bronchoscope within airways to keep them open.
Pleuroscopy: A minimally invasive procedure, also known as thoracoscopy, which allows doctors to visualize the pleura and the lung surface.
Medical-Legal Cases Involving Pulmonology
Mild respiratory conditions are ordinarily treated by primary care physicians who may then refer a patient to a pulmonologist if further investigation is needed or if the patient is suspected of having a serious pulmonary disease. The failure to diagnose by a primary care physician usually presents causation/damages issues that require the opinion of a pulmonologist.
Pulmonologists may have to work with cardiothoracic surgeons in lung, chest, and mediastinal surgeries. Atelectasis and pneumothorax may require surgical intervention. As well, pulmonary cancers, particularly those involving a pulmonary tree, necessitate co treatment by pulmonologists and thoracic surgeons. Lung transplant patients also require treatment by a pulmonologist as well as a lung transplant (thoracic surgeon).
Common malpractice issues in pulmonology include:
Delay in the diagnosis of a lung disease
Misdiagnosis of a lung disease
Negligence in monitoring asthma and asthmatic exacerbations
Negligence in ordering appropriate tests for infectious lung diseases such as pneumonia
Many medical malpractice claims in pulmonology relate to complications during bronchoscopy or interventional procedures, such as:
Bronchoscopic injury to a structure
Nasopharyngeal (the nose and the pharynx)
Glottis (and related structures)
Vocal cords, which may be permanent or temporary
Airway, including bronchi
Bronchoscopic trauma:
Hemorrhage
Bronchospasm
Laryngospasm
Elevated airway pressure
Mediastinal bleed
Bronchoscopy sequellae:
Aspiration