Pulmonary Medicine

Pulmonary Medicine is the sub-specialty of internal medicine that deals with the causes, diagnosis, prevention, and treatment of diseases affecting the lungs and respiratory tract.

A pulmonologist evaluates patients with breathlessness, cough, wheezing, and chest tightness, as well as abnormalities found in chest x-rays, chest CT scans and other chest imaging studies.

An initial visit to the pulmonologist includes a review of the patient's medical history and pulmonary symptoms followed by a detailed physical examination.

After careful review of all available information, including prior laboratory or imaging studies, the pulmonologist renders a preliminary opinion as to what disease processes may be present. Further diagnostic testing may be ordered and treatment recommendations are made.

Usually follow-up visits are required to review the results of diagnostic testing and to assess the response to therapies. The pulmonologist works closely with the patient's primary care provider for optimal management of the patient's disease.

    Common Pulmonary Diseases

  • Asthma

    A chronic (long-term) lung disease that causes inflammation and narrowing of the airways (bronchi). These airways are tubes or passages that carry air into and out of the lungs. People with asthma have inflamed airways and excessive production of mucus which causes chest tightness, shortness of breath (dyspnea), and coughing.

    Certain substances and conditions, such as dust, pollen, animal dander, cold or humid air, upper respiratory infections, or stress may trigger an asthmatic attack. When the airways react the muscles around them tighten. This causes the airways to narrow and less air flows to the lungs.

    Asthma frequently develops in childhood and is the most common cause of chronic illness in children. In the United States more than 22 million people are known to have asthma with 6 million being children.

    Effective medications are available to help control and treat asthma. Patients who work closely with their physicians are able to manage the disease effectively and live relatively healthy and active lives.

  • Chronic Bronchitis

    A chronic (long-term) lung disease with inflammation of the airways (bronchi) which results in increased production of mucus. It is described as a persistent cough that produces phlegm and mucus for at least three months in two consecutive years. The main symptoms are cough with expectoration (spitting out of mucus), breathlessness, wheezing, chest tightness, and swelling of the lower extremities.

    Cigarette smoking is the most common cause of chronic bronchitis. Other contributors may be bacterial or viral infections, or environmental pollution.

    Management includes smoking cessation and regular use of bronchodilators and other pulmonary medications.

  • COPD-Chronic Obstructive Pulmonary Disease

    Persistent, progressive obstruction of the airways occurring with emphysema, chronic bronchitis or both. Airflow though the airways within the lungs is partially blocked, resulting in difficulty breathing. As the inflammation gets worse, the airways (bronchi) fill with mucus making it harder for air to flow. Symptoms develop slowly and often worsen over time. Symptoms include a cough that produces large amounts of mucus, wheezing, shortness of breath, chest tightness, along with other symptoms.

    COPD is the fourth leading cause of death in the United States and Canada. The leading risk factor for COPD is smoking. COPD can also cause high blood pressure in the lungs (pulmonary hypertension) which can lead to heart disease. There is no cure for COPD and the damage caused to the airways and lungs cannot be reversed. Treatments and lifestyle changes can help patients remain more active and slow the progress of the disease.

  • Emphysema

    A chronic (long-term) lung disease usually seen in patients with longstanding smoking histories. Lung inflammation destroys the walls of the air sacs which causes them to lose elasticity . Air becomes trapped in the air sacs and interferes with the patient's ability to exhale.

    The main symptoms are shortness of breath (dyspnea), breathing difficulty and reduced capacity for physical activity, cough, fatigue, loss of appetite and weight loss.

    Smoking accounts for 85% of people who die from emphysema. Quitting smoking can slow the disease down, however, a large part of the disease process is not reversible.

    Treatment generally consists of preventative measures such as smoking cessation and flu vaccinations in addition to bronchodilators and other pulmonary medications. Advanced emphysema may be treated with oxygen therapy.

  • Idiopathic Pulmonary Fibrosis

    This disorder is believed to be an autoimmune phenomenon of the body attacking the lung tissue which results in scarring of the lungs. Patients with this disease will have gradually progressive shortness of breath, cough, and abnormal breath sounds called "crackles." Patients may be thought to have congestive heart failure or pneumonia, however, they do not respond to treatments for those diseases.

    A CT scan may show the features of scarring. The diagnosis is confirmed by a lung biopsy generally performed by a thoracic surgeon. Treatment involves prednisone to suppress the autoimmune process. In patients who do not respond to prednisone additional chemotherapy or immunosuppressant agents may be used.

  • Lung Cancer and Tumors

    Lung cancer is one of the most common cancers in both men and women, as is the leading cause of cancer deaths. As in other cancers, lung cancer occurs after repeated insults to the genetic material of the cell. The most common source of these insults is tobacco smoke, which is responsible for 85% of U.S. lung cancer deaths.

    Lung cancer commonly spreads (metastasizes) to the brain, bone, liver or bone marrow. Lung cancer that originates in the cells of the lungs is called primary lung cancer. However, cancer may spread to the lungs from other parts of the body.

    Lung cancer is most often first detected as a "spot" on the lung seen on a chest x-ray. Luckily most "spots" turn out to be benign (noncancerous). However, when a "spot" is discovered, it must be followed closely to determine if it is cancerous.

    Treatment depends upon the type of cancer. Generally lung cancers are divided into two types according to the type of cell present in the tumor. These types have different patterns of growth and spread. The type called small-cell cancer is generally treated with chemotherapy and/or radiation, but not with surgery. Non-small-cell cancers can sometimes be removed surgically.

    Lung cancer has no symptoms in the early stages. Once symptoms occur, the cancer has usually reached an advanced stage. People most at risk for lung cancer are those who are current or former smokers, people who have had prolonged exposure to asbestos and people with prolonged exposure to second-hand smoke.

  • Occupational Lung Disease

    Lung conditions can develop as a results of inhaling harmful substances at work. Occupational lung diseases are the most common work-related illness in the United States. Fortunately, many of these diseases are preventable or controllable with proper treatment.

    Inhaling certain substances can damage the airways and lungs and cause or worsen conditions such as asthma, asbestosis, lung cancer, emphysema, bronchitis, and others. Repeated and long-term exposure to certain irritants can lead to an array of lung diseases that may have lasting effects, even after exposure ceases.

  • Pneumonia

    An infection of the lungs caused by bacteria, viruses, or other organisms. Aspiration pneumonia is caused by breathing in vomit, fumes or other substances. This type of pneumonia cannot be spread to other people. Pneumonia can range from mild to severe, even fatal. The severity of the disease depends on the type of organism causing the infection, as well as the general health of the patient.

    The most common symptoms are shortness of breath (dyspnea), chest pain especially when breathing in, cough, shallow rapid breathing, fever and chills. Coughs usually bring up mucous (sputum). Pneumonia is usually treated with antibiotics.

  • Pulmonary Hypertension

    A rare lung disorder in which the blood pressure in the pulmonary arteries (the blood vessels that feed the lungs) rises far above normal levels. Over time, the increased pressure damages both the large and small pulmonary arteries. When the vessels are no longer able to transfer oxygen and carbon dioxide normally between the blood and the lungs the levels of oxygen in the blood may fall.

    Other disorders may cause pulmonary hypertension such as congestive heart failure, malfunction of the heart valves or congenital heart diseases (heart problems at birth). Lung disorders such as COPD or emphysema, fibrosis of the lung, pulmonary embolism (blood clots to the lung) and obstructive sleep apnea can cause pulmonary hypertension. Symptoms may include difficulty breathing with activity, chest pain, lightheadedness or fainting.

    Treatment involves treating the underlying cause, however, frequently this disease cannot be cured and may worsen.

  • Sarcoidosis

    This disease results from a specific type of inflammation of tissues in the body. It can appear in almost any body organ, but it starts most often in the lungs or lymph nodes. 90% of patients with sarcoidosis have lung involvement. The cause is unknown, although it is theorized that it may be an autoimmune disease.

    Shortness of breath (dyspnea) and chronic cough may be the first symptoms, but sarcoidosis can begin suddenly with the appearance of skin rashes or red bumps on the face, arms, or shins or inflammation of the eyes. It is not unusual for the patient to experience weight loss, fatigue, night sweats, and fever.

    Although sarcoidosis occurs in all races and both genders, the most susceptible populations seem to be of African-American, Scandinavian, German, Irish, or Puerto Rican origin. Some patients require prolonged treatment with prednisone.

    Common Pulmonary Tests

  • Arterial Blood Gas (ABG)

    Blood gas analysis is used to diagnose and evaluate respiratory diseases that influence how effectively the lungs deliver oxygen to and eliminate carbon dioxide from the blood.

    Because high concentrations of inhaled oxygen can be toxic and can damage the lungs and eyes, repeated blood gas analysis is especially useful for monitoring patients on oxygen. This is used to determine the lowest possible inhaled oxygen concentration needed to maintain the blood oxygen pressure at a level that supports the patient.

    Arterial blood for the analysis is usually extracted by a phlebotomist, nurse, or respiratory therapist. Blood is most commonly drawn from the radial artery in the wrist area, using a thin needle and syringe.

    The machine used for analysis aspirates the blood from the syringe and measures the pH and the partial pressures of oxygen and carbon dioxide.

  • Chest Radiography (X-rays)

    A chest x-ray is a painless, noninvasive test that creates pictures of the structures inside the chest, such as the heart and lungs. "Noninvasive" means that no surgery is done and no instruments are inserted into the body.

    X-rays are electromagnetic waves that use ionizing radiation to create pictures of the inside of the body. Chest x-ray is the most common x-ray test used to diagnose health problems.

    This test is done to find the cause of symptoms such as shortness of breath, chest pain, chronic cough and fever. The test is used to look for and track conditions of the heart, lungs and chest cavity such as pneumonia, lung tissue scarring, or sarcoidosis.

    There are few risks with chest x-rays and the patient does not need to do anything special to prepare for the test. A chest x-ray usually takes about 15 minutes and patients usually return to their regular routine after the test.

    Chest x-rays have limits because they only show conditions that change the size of a tissue or how radiation is absorbed. Also, they create two-dimensional pictures which means that denser structures, such as the heart or bone, may hide some signs of disease. For this reason, other tests may be needed to confirm a diagnosis.

  • Computerized Tomography

    Computerized tomography (often called CT scan or CAT scan), is a noninvasive medical test that helps physicians diagnose and treat medical conditions. This is a commonly used diagnostic test in both pulmonary and critical care medicine.

    CT imaging combines special x-ray equipment with sophisticated computers to produce multiple images or pictures of the inside of the body. It creates cross-sectional images one "slice" at a time. These images provide far more detail than simple x-rays and are useful in clarifying abnormalities.

    CT imaging is sometimes compared to looking into a loaf of bread by cutting the loaf into thin slices. The result is a very detailed multidimensional view of the body's interior. Modern CT scanners are so fast that they can scan through large sections of the body in just a few seconds.

    CT scanning is painless, noninvasive and accurate. After a CT scan the patient can return to normal activities. No radiation remains in a patient's body after a CT exam and there should be no side effects from the test.

  • Lung Scan

    A lung scan is a nuclear scanning test that is most commonly performed in order to detect a blood clot that is preventing normal blood flow to part of the lung (pulmonary embolism).

    There are two types of lung scans which are usually done together. During the ventilation scan

    A radioactive gas is inhaled into the lungs. Pictures from this scan can show areas of the lungs that are not receiving enough air or that retain too much air. The Perfusion scan requires a radioactive tracer substance to be injected into a vein in the arm. It travels though the bloodstream and into the lungs. Pictures from this scan can show areas of the lungs that are not receiving enough blood.

  • Oximetry

    Also known as pulse oximetry, this is a simple noninvasive method of determining the blood oxygen saturation without utilizing the arterial puncture required for arterial blood gas analysis. The test is performed by placing a sensor on the finger or earlobe that detects the pulsatile arterial blood flow.

    The pulse oximeter can distinguish oxygenated blood from non-oxygenated blood. However, it measures solely oxygenation, not ventilation, and is not a substitute for blood gases checked in a laboratory.

  • Pulmonary Function Tests (PFT's)

    Also called lung function tests, pulmonary function tests (PFT's) evaluate how well the lungs work. Consisting of several tests, PFT's determine how much air the lungs can hold, how quickly the air moves in and out of the lungs, and how well the lungs put oxygen into the blood and remove carbon dioxide from the blood.

    These tests identify patients who might have obstructive or restrictive lung disease. They also help determine the severity of the diseases and provide a baseline for future comparison if the patient shows improvement or deterioration.

    The basic pulmonary function test is the spirometry. It measures how much and how quickly air moves out of the lungs. For this test the patient breathes into a mouthpiece attached to a recording device called a spirometer.

    The exact procedure is different for each type of test. A body plethysmography requires the patient to sit inside a small enclosure similar to a telephone booth, with windows that allow the patient to see out. The booth measures small changes in pressure that occur as the patient breathes.

    PFT's are usually done in special exam rooms that have all the lung function measuring devices and equipment. The tests are done by a specially trained respiratory therapist or technician.

    PTF's present little or no risk to a healthy person. Some of the tests may be tiring for people with lung disease. The patient may cough or feel lightheaded from rapidly breathing in and out during a test, but patients are given time to rest between tests.

    Common Pulmonary Procedures

  • Bronchoscopy

    Bronchoscopy is a procedure that allows the physician to look at the patient's airway through a thin viewing instrument called a bronchoscope. The scope is usually a flexible rubber tube with a bright fiberoptic light and a miniature electronic camera.

    Bronchoscopy may be done to diagnose problems with the airway such as bleeding, difficulty breathing, or chronic cough or to treat problems such as an object or growth in the airway. It may be needed to take tissue samples or biopsies in order to diagnose lung diseases such as cancer.

  • Interventional Pulmonology

  • Thoracentesis

    Thoracentesis is a procedure to remove fluid from the space between the lungs and the chest wall. It is done with a needle inserted through the chest wall.

    Thoracentesis is done due to the accumulation of excess pleural fluid (pleural effusion) which can be caused by conditions such as infection, inflammation, heart failure, or cancer. If a large amount of fluid is present, it may be difficult to breathe.

    A small amount of the fluid will be sent to the lab for tests to help determine the cause of the pleural effusion. The removal of a larger amount of fluid provides symptom relief.

  • Thoracic Needle Biopsy

    Used to biopsy lung nodules and masses, a fine needle is inserted through the skin and the soft tissue between the ribs. The needle is guided by fluoroscopy, ultrasound or CT scan monitoring.

    This procedure may be performed under local anesthesia.

    Pulmonary Medications

  • Corticosteroid Inhalers

    AeroBid/Azmacort/Beclovent/Flovent/Pulmicort/Vanceril

    When used regularly suppress and control the underlying inflammation that causes persistent asthma. These medications are preventative and should, therefore, be taken as instructed and not miss doses even when the patient feels well.

  • Leukotriene Modifiers Tablets

    Singulair/Accolate/Zyflo

    Help prevent asthma or allergy symptoms by blocking the action of leukotrienes (substances found in humans that may help cause asthma and other allergy-related disorders). These medications are considered "controller" agents and are frequently used along with inhaled corticosteroids.

  • Long-Acting Bronchodilators Inhaler (beta-agonist type)

    Foradil/Serevent

    Improve symptoms of bronchospasm (wheezing, shortness of breath, chest tightness, or cough) within 15 to 30 minutes of use and should help control symptoms for approximately 12 hours.

  • Non-steroidal Inhalers

    Intal/Tilade

    Help with long-term control of symptoms of bronchospasm (wheezing, shortness of breath, chest tightness, or cough). These medications are not bronchodilators. They are sometimes used 15 to 30 minutes before exercise or allergy exposure to prevent bronchospasm. Patients must take these medications regularly in order for them to be effective.

  • Oral Anticoagulants

    Coumadin

    Used to treat disorders of excessive blood clotting or to prevent abnormal blood clots from forming. The dosage needs to be closely watched and adjusted based upon the results of a blood test called the prothrombin time.

  • Oral Corticosteroid Tablets

    Prednisone/Medrol

    Oral Corticosteroid Tablets Anti-inflammatory agents used in the acute setting for moderate to severe flare-ups of obstructive lung disease that are poorly responsive or controlled by the typical regimens.

  • Short-Acting Bronchodilator Inhaler (anti-cholinergic type)

    Atrovent

    Oral Corticosteroid Tablets

    Anti-inflammatory agents used in the acute setting for moderate to severe flare-ups of obstructive lung disease that are poorly responsive or controlled by the typical regimens.

  • Short-Acting Bronchodilator Inhaler (beta-agonist type)

    Alpuent/Brethaire/Maxair/Metaprel/Proventil/Tornalate/Ventolin/Xopenex

    Short-Acting Bronchodilator Inhalers (beta-agonist type)

    Effective medications to help improve symptoms of bronchospasm (wheezing, shortness of breath, chest tightness or cough) within 5 to 15 minutes and help control symptoms for 4 to 6 hours. These medications are usually prescribed on an "as needed" basis to be used every four hours, however, your physician may allow more frequent use during asthma flares.

  • Theophylline Oral Tablets

    Many trade names

    Theophylline Oral Tablets/Capsules

    Taken regularly as bronchodilators. They are slow to act and are only useful when taken regularly.

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