What to know being a Pulmonologist

August 20, 2019AGNES JOSEPHStudy abroad

A pulmonologist is a physician who specializes in diseases of the respiratory tract. This includes the lungs, airways (mouth, nose, pharynx, larynx, and trachea), and respiratory muscles (including the diaphragmand intercostal muscles).

Pulmonology, known as chest medicine is some countries, is a subspecialty of internal medicine. Pulmonologists can treat a wide range of respiratory diseases and disorders, from asthma and bronchitis right through to lung cancer and COPD. A pulmonologist requires no less than 13 years of education and training, sometimes more for certain subspecialties.

According to 2016 study from the Centers for Disease Control and Prevention, between 12,000 and 12,500 pulmonologists are currently practicing in the United States, the majority of whom are clustered in urban centers.

Concentrations

Pulmonologists are trained to diagnose, treat, manage, and prevent respiratory diseases. Moreover, they have a broad understanding of the impact respiratory diseases have on other interconnected organ systems. Some of the respiratory diseases are primary (meaning that they originate in the respiratory tract), while others are secondary (meaning that they are the consequence of another condition).

A pulmonologist may serve as the sole specialist for certain conditions or work as part of a care team consisting of a primary care physician, oncologist, rheumatologist, thoracic surgeon, cardiologist, geneticist, allergist, respiratory therapist, and critical care specialist.

Here are some of the conditions a pulmonologist can diagnose and treat:

• Asthma, a chronic condition characterized by periodic wheezing, chest tightness, shortness of breath, and coughing
• Bronchiectasis, a condition that arises from the damage and dilation (widening) of the large bronchial airways
• Bronchitis, the acute or chronic inflammation of the airways, usually caused by an infection
• Chronic obstructive pulmonary disease (COPD), a group of inflammatory and restrictive lung diseases that include chronic bronchitis and emphysema 
• Cystic fibrosis, an inherited, life-threatening disorder characterized by the excessive production of mucus in the lungs and digestive tract
• Interstitial lung disease (ILD), an umbrella term for a group of disorders that cause scarring (fibrosis) of the lungs, usually as a result of toxic exposure or an autoimmune disease
• Lung cancer, comprised of non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC)
• Occupational lung diseases, such as asbestosis, silicosis, byssinosis (brown lung disease), and hypersensitive pneumonitis
• Pleural effusion, the build-up of fluid between membranes surrounding the lung (called the pleura), most often as a result of heart failure or lung inflammation
• Pneumonia, an infection that inflames the alveoli (air sacs) in one or both lungs, causing them to fill with fluid or pus
• Pneumothorax, a collapsed lung caused by many types of disease, including COPD, cystic fibrosis, and pneumonia
• Pulmonary embolism, a condition in which one or more arteries in the lungs become blocked by a blood clot
• Pulmonary hypertension, a serious type of high blood pressure caused by blocked or narrowed arteries in the lungs
• Rheumatoid lung disease, caused when rheumatoid arthritis targets tissues of the lungs, leading to inflammation (pleuritis), fibrosis, and pleural effusion
• Sarcoidosis, an inflammatory disease of unknown origin that is characterized by the formation of granulomas (tiny granules of immune cells) in the lungs and other organs
• Sleep apnea, a potentially serious sleep disorder in which breathing sporadically stops and starts
• Tension pneumothorax, the progressive and serious build-up of air within the chest cavity as a result of a cut or tear in the lung
• Tuberculosis (TB), an infectious lung disease caused by the bacterium Mycobacterium tuberculosis

Procedural Expertise

A pulmonologist will rely on an expansive range of tools and techniques to diagnose and treat respiratory diseases. Some can be used for both diagnostic and therapeutic purposes.

Diagnosis

Pulmonologists will diagnose respiratory illnesses with a combination of procedures which may include a physical exam, lab tests, respiratory tests, imaging studies, and even exploratory surgery. Among them:

• Pulmonary function tests are breathing tests that measure airflow, lung volume, gas exchange, and respiratory muscle function. These include spirometry (which measures lung capacity and respiratory function) and pulse oximetry (which measures oxygen saturation).
• Cardiopulmonary exercise testing provides a breath-by-breath analysis of respiratory gas exchange and heart function during a period of exercise
• Chest imaging tests include chest X-ray, computed tomography (CT), magnetic resonance imaging (MRI), chest fluoroscopy (using a continuous X-ray beam to image lung movement), and endobronchial ultrasonography (a type of ultrasound inserted into the lungs through the trachea).
• Nuclear scanning is a type of imaging study that uses radioactive tracers. It includes V/Q scanning which measures air and blood flow in the lungs and positron emission tomography (PET) which measures metabolic activity consistent with cancer.
• Bronchoscopy is a procedure in which a fiber optic scope, called a bronchoscope is inserted through the mouth and into the trachea to view the internal airways of the lungs
• Bronchoalveolar lavage, performed during a bronchoscopy, involves the injection of sterile water into the airways which is then suctioned out and sent to the lab for analysis.
• Transbronchial biopsy is performed during bronchoscopy to remove a sample of tissue in the larger airways.
• Pleural biopsy is a minimally invasive procedure in which a needle is inserted through the chest wall to obtain a small piece of pleural membrane.
• Thoracentesisinvolves the insertion of a needle through the chest wall to obtain fluid from the pleural space.
• Pleuroscopy is a procedure in which a fiber optic scope is inserted through an incision in the chest to view the pleural space.

Treatment

The range of treatments used in pulmonology is as vast and varied as the types of diseases diagnosed. Among some of the more common treatments, both pharmaceutical and mechanical:

• Antibiotics are taken orally or intravenously (through a vein) to treat infections ranging from bronchitis to TB.
• Bronchodilators such as albuterol, salmeterol, and formoterol are inhaled to open airways in people with asthma or COPD.
• Corticosteroids can be inhaled or taken orally to reduce systemic inflammation.
• Vasodilators are a type of drug taken by mouth, inhalation, or intravenously to open narrowed blood vessels in the lungs.
• Chest physiotherapy involves different mechanical techniques (such as chest percussion and postural drainage) to loosen mucus and clear airways in people with COPD, cystic fibrosis, and neuromuscular lung disorders
• Continuous positive airway pressure device (CPAP) is a wearable device used to treat sleep apnea by forcing air into the airways to keep them open.
• Oxygen therapy provides supplemental oxygen to people with breathing problems. The device can deliver oxygen through a face mask, nasal prongs, or a tracheostomy (an opening in the windpipe).
• Thoracostomy is the insertion of a needle or tube into the pleural space to drain fluid or allow air to escape (most commonly to treat tension pneumothorax).
• Balloon bronchoscopy is a technique used to dilate narrowed airways by inflating a balloon in the air passages.
• Airway stent placement involves the insertion of tiny tubes, called stents, in blocked or narrowed airway passages.
• Pleurodesis is a procedure in which chemicals are injected to the pleural space to fuse the two membranes of the pleura together. It is sometimes used for people with recurrent pleural infusions, such as those who have had lung cancer.
• Airway ablation is a technique performed with lasers, surgery, or thermal agents that can improve breathing in people with COPD and asthma by removing (ablating) the muscles associated with breathing constriction.

Lobectomies and lung transplants may be directed by a pulmonologist but would be performed by a thoracic surgeon.

Subspecialties

While many pulmonologists will maintain a general practice in a hospital, medical office, or outpatient clinic, others will pursue subspecialties that require additional training. Some of the more common include:

• Interstitial lung disease (diseases characterized by inflammation and scarring)
• Interventional pulmonology (involving airway disorders, lung cancer, and pleural diseases)
• Lung transplantation medicine
• Neuromuscular disease (diseases resulting from respiratory muscle failure)
• Obstructive lung disease (diseases caused by the narrowing or obstruction of airways)
• Pulmonology critical care medicine
• Sleep-disordered breathing (from loud snoring to obstructive sleep apnea)

Pediatric pulmonology is a subspecialty of pediatrics, not internal medicine. For this, you must first be board certified in pediatrics before embarking on a fellowship in pulmonology.

Training and Certification

Completing an undergraduate degree is the first step toward a career in pulmonology. For colleges that don’t offer a specific premedical program, you would need to take a number of prerequisite courses, including advanced math, physics, chemistry, and biology. Most medical schools today require you to pass the Medical Competency Aptitude Test (MCAT).

After graduation, the next four years would be spent at a medical or osteopathic college to obtain a degree as either a doctor of medicine (MD) or doctor of osteopathic medicine (DO). The first two years would be devoted to classroom studies and the second two would provide you hands-on experience in different fields of medicine at various medical facilities.

Upon graduating from medical school, you would need to obtain a medical license in the state in which you intend to practice. This typically involves passing a national board exam and, in some states, a state board exam.

Graduates with an MD degree would need to take the United States Medical Licensing Exam (USMLE), while those with a DO degree would take the Comprehensive Osteopathic Medical Licensing Examination (COMLEX).

Pulmonology is a subspecialty of internal medicine, so you would need to enter a three-year internal medicine residency after medical school. Upon completing the residency, you can obtain board certification by passing an exam administered by the American Board of Internal Medicine (ABIM).

The final step in your training would involve a two-year fellowship in pulmonology under the tutelage of experts in the field. At the end of the fellowship, you must pass a second set of board exams, called the Pulmonary Disease Certification Exam (PDCE).

ABIM certification lasts for 10 years. To be eligible for recertified, you must maintain a specific number of study hours every two years by taking ABIM-accredited continuing medical education (CME) programs.

Jobs prospects for newly certified pulmonologists remain robust. According to the annual Medscape Pulmonologist Compensation Report.