Pulmonology | Jaslok Hospital

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Pulmonology - About the Department

The Department of Respiratory Medicine caters to diagnosis and treatment of all respiratory disorders. The department runs a daily outpatient clinic and inpatient services, which include intensive care management of patients on ventilators and in wards. The department has many achievements to its credit, among them are studies conducted to establish normal parameters for lung function, etiology of interstitial lung disease, and estimation of serum angiotensin converting enzyme (ACE) in Indian patients. The department was amongst the first to start ACE level estimation in Western India.

The department, over the period of 10 to 14 years, was involved in International Studies for Asthma and Allergies in Childhood (ISAAC), wherein it was the Regional Coordinator for Southeast Asia. Numerous papers have been published in international journals regarding prevalence of rhinitis, eczema and asthma in children, based on ISAAC study. Our Pulmonary Function Lab is fully equipped with state-of-the-art technology for all lung function tests, exercise testing and sleep studies.

Bronchology section has fibreoptic videobronchoscope for routine and ICU bronchoscopies. Interventional bronchoscopes for transbronchial lung biopsies and endobronchial ultrasound (EBUS) for mediastinal node sampling are also available. Bronchoscopy has become the most commonly performed invasive procedure by chest physicians. EBUS is a technique that uses ultrasound along with bronchoscope to visualize airway wall and the structures adjacent to it.

Types of EBUS

Radial Probe EBUS
The system has an ultrasound processor and a balloon catheter that are attached to the probe. The balloon is fixed at the tip of the probe. The 20 MHz miniature radial probe is the standard probe.

Convex Probe EBUS
Currently available CP-EBUS bronchoscope has a linear curved array ultrasonic transducer of 7.5 MHz at the distal tip, which has the capability of displaying B-mode and color Doppler mode.

Interventional Pulmonology
It is a specialised subspecialty of pulmonary medicine, which deals with advanced diagnostic and therapeutic manoeuvre for the management of various lung disorders. The main application of interventional pulmonology is in the diagnosis, staging and palliative treatment of patients with lung cancer. In addition, dilation of benign tracheobronchial strictures, management of unclassified pleural disorders and temporary percutaneous tracheostomies for chronic airway management also fall under the realm of this subspecialty of pulmonary medicine.

Procedures

Flexible bronchoscopy - Bronchoscopy is the most common interventional pulmonology procedure. During bronchoscopy, the doctor advances a flexible endoscope (bronchoscope) through a person's mouth or nose into the windpipe and the airways in each lung, checking for problems. Images from inside the lung are displayed on a video screen.

The bronchoscope has a channel at its tip, through which the doctor can pass small tools and perform several other procedures.

Bronchoalveolar lavage - This procedure is performed during bronchoscopy. Sterile water is injected through the bronchoscope into a segment of the lungs. The fluid is then suctioned back and sent for tests. Bronchoalveolar lavage can help diagnose infection, cancer, bleeding and other conditions.

Biopsy of lung or lymph node - During bronchoscopy, the doctor may collect a small piece of tissue from either the lungs or a nearby lymph node. The interventional pulmonologist advance a needle or forceps through the bronchoscope to get a sample of the tissue. Biopsies can detect cancer, infection, sarcoidosis and other conditions.

For people with lung cancer or other cancers, interventional pulmonology biopsies can often accurately identify spread of cancer into lymph nodes. This can prevent unnecessary surgery or help determine the best choice for treatment.

Airway stent (bronchial stent) - Advanced cancer or certain other conditions can constrict or compress the airway tube (bronchus). If the bronchus becomes blocked, difficulty breathing, cough, and pneumonia can result.

Using a bronchoscope, the doctor can advance a wire mesh stent into the narrowed airway. Expanding the stent can open the bronchus and relieve symptoms caused by the constriction.

Balloon bronchoplasty - The doctor advances a deflated balloon into a section of abnormally narrowed airway. By inflating the balloon with water, the airway is expanded, potentially relieving symptoms. Balloon bronchoplasty may be performed prior to airway stent placement to help expand a bronchus.

Rigid bronchoscopy - In rigid bronchoscopy, a long metal tube (rigid bronchoscope) is advanced into a person’s windpipe and main airways. The rigid bronchoscope’s large diameter allows the doctor to use more sophisticated surgical tools and techniques. Rigid bronchoscopy requires general anaesthesia (unconsciousness with assisted breathing), similar to a surgical procedure.

Foreign body removal/Control of bleeding - Bronchoscopy is the preferred interventional pulmonology procedure to remove inhaled foreign objects that are lodged in the airway. The doctor may be able to remove the object using flexible bronchoscopy, or else, rigid bronchoscopy may be required. Also, bleeding from the lungs can be controlled by using various techniques under vision.

Medical thoracoscopy/pleuroscopy - It is a minimally invasive procedure that allows access to the pleural space using a combination of viewing and working instruments. It allows for basic diagnostic (undiagnosed pleural fluid or pleural thickening) and therapeutic procedures (pleurodesis) to be performed safely.

Ablation of endobronchial tumours - It allows for removal or debulking of tumours which are blocking the main airways and causing symptoms like bleeding or difficulty in breathing.

These technologies include:

o Endobronchial ultrasound
o Autofluorescence and narrow-band imaging
o Thermal techniques including argon plasma coagulation (APC), electrocautery, laser and cryotherapy
o Photodynamic therapy
o Electromagnetic navigational bronchoscopy
o Endobronchial brachytherapy
o Silicone, metallic, and hybrid airway stents
o Flex-rigid pleuroscope

It is a relatively new subspecialty, which has opened new horizons in the field of pulmonary medicine and eliminates the need for surgical treatment in the subgroup of relatively ill patients with significant co-morbidities.

PFT Lab Tests

o Standard lung function tests (spirometry pre- and post-bronchodilator, static lung volumes, diffusion capacity and blood gases)
o Pulmonary stress test
o Alveolar-arterial oxygen gradient (pre-/post-exercise and 100% oxygen)
o Therapeutic nebulization
o Test for exercise-induced asthma
o Oxygen saturation before and after exercise
o Dermal allergen tests
o Estimation of serum angiotensin converting enzyme
o Sleep study for diagnosis and treatment of sleep-disordered breathing, including obstructive sleep apnoea
o Exercise tests

Maximal aerobic capacity determination is very useful for evaluation of physical fitness, especially in sportspersons and athletes, and also for pre-operative evaluation in cardiac transplantation

Outpatient and Inpatient Services

Daily outpatient and round-the-clock inpatient services are available. Respiratory diseases such as obstructive airway disease (bronchial asthma, COPD, bronchiectasis), interstitial lung disease, pulmonary vasculitis (Wegener’s granulomatosis and systemic lupus erythemetosus), eosinophilic lung disease (tropical eosinophilia, eosinophilic pneumonia), lung infections (bronchitis, pneumonia, tuberculosis), lung cancers, pleural diseases (pleural effusion, empyemas, mesotheliomas) and chest wall diseases (kyphoscoliosis) are some examples of diseases treated.

Emergency and Intensive Care Services for Respiratory Failure

Round-the-clock emergency and intensive care services are available for respiratory failure due to acute asthma, COPD exacerbation, pneumothorax, massive haemoptysis, chest wall trauma, severe pneumonia, acute respiratory distress syndrome (ARDS) etc. Our team of trained staff, including respiratory physicians and intensivists, perform intubations, line insertions, chest tube insertions, and mechanical ventilation when necessary. Emergency bronchoscopies for diagnostic (lavage, biopsies) and therapeutic purposes are routinely carried out in ICU via endotracheal or tracheostomy tubes.

Non-invasive Ventilation (NIV) Support

NIV using CPAP and bi-level devices for COPD, neuromuscular disease with respiratory failure, and sleep apnoea is offered by the department as part of inpatient and outpatient services. NIV for respiratory failure is given in the high dependency unit or ICU as a part of treatment and for early weaning from ventilator.

Bronchoscopy Section

Fibreoptic videobronchoscopies using state-of-the-art Olympus equipment are routinely carried out, both for diagnostic and therapeutic purposes, in the Endoscopy Room located on the 17th floor of the hospital. Endobronchial and transbronchial biopsies, bronchoalveolar lavage and brush cytology are some of the procedures carried out with the bronchoscope. Instillation of cold saline, dilute adrenaline solutions and use of thrombin are useful for control of haemoptysis. Bronchoscopies via endotracheal and tracheostomy tubes on ventilated patients for both diagnostic and therapeutic purposes are routinely carried out in ICU setting.

Centre for Sleep Disorders

For snorers with excessive daytime sleepiness, especially those with a background of diabetes and hypertension, overnight polysomnography is carried out using 32-channel, state-of-the-art compumedics system that defines sleep-related breathing disorders, sleep apnoea and obesity hypoventilation syndrome. Overnight auto CPAP and auto bi-level titration with polysomnography is also done to determine optimum pressure settings to be used by patients on these machines as part of treatment. Sleep studies are useful in congestive heart failure, cerebrovascular disease, and resistant epilepsy, where concomitant obstructive or central sleep apnoeas are contributing to the disease.

Area of expertise

Bronchial Asthma, Pulmonary Tuberculosis

Area of expertise

Postgraduate studies in Internal Medicine folowing which persued studies in Chest Medicine in UK. On return, joined JHRC in 1979 as consultant in chest Medicine, Have beeb with the dept. of Chest Diseases, JHRC for 37years, dealing with Clinical Pulmonology, Respiratory Physiology, Fibre-opticBronchoscopy, sleep study

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Area of expertise

* Asthma

* Allergy & Immunology

* Pulmonary (lungs) Fuction test

* Sleep Studies

* Bronchoscopy

* Critical care

Area of expertise

Dr. Suresh Rang has done "Advanced Interventional Bronchoscopy" at the Royal Brompton Hospital Imperial College, London

Have gained experience in the following procedures:

- Endobronchail non surgical

- Cryotherapy- for removal of foreign bodies, also in management of cancers, etc.

- Cryoextraction

- Diathermy - tumor ablation

- Tumour ablation by laser, PDT & other modalities

- Bronchial Thermoplasty in the management of Bronchial Asthma

- Inteventional airwaymanagemnet in Airways Haemorrage

- Endobronchial (LVR) lung volume reduction treatment for Emphysema

- EBUS - Endobronchial ultrasonography for mediastinal & other lung biopsies

- Super Dimension Navigation bronchoscopy - for peripheral lesions diagnosis without external surgery in Cancers, etc.

Awards/Fellowship

* Elected vice president of the prestigious Indian Chest Society for two consecutive years

* Elected President for the year 1998/1999

* Organising secretary of the First Ntioanl Congress on respiratory disease, held in Mumbai

* Was on the committee of the board of Journal Lung India

* Presented papers at various conferences. Lectured in various CMEs. Lectured at various conferences of chest & allergy

* Post graduate teacher & guide for DNB exams, held by teh national board - India

* Trained in interventional Bronchoscopy at Royal Broumptom Hospital, London

* Guest Speaker - Indo - American society

* Has been speaker of API onMDR tuberculosis

* Research work started & continuing in teh following area:

6 minutes walk test - a valuable simple test to grade respiratory disability

Study normal values in Indian population from ages 5-40years & 40-80 years

Role of pleural fluid 'C' reactive protein in pleural effusion

Uptake pattern of 18 F- FLT-PET in tuberculosis lesions & its comparison with 18 F- FDG-PET

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Area of expertise

Interventional pulmonology, Electro-cantric ablation of endobronchial tumour, airwaystenting & dilation, Percutaneous tracheostomy, endobronchial USG, etc

Area of expertise

CRITICAL CARE & INTERVENTIONAL PULMONOLOGY (IP): Trained in IP in the department of Pulmonary, Allergy and Critical Care at University of Pennsylvania Medical Centre, Philadelphia under Dr Daniel H Sterman MD, FCCP (one of the pioneers of IP).

Well versed with CP-EBUS and Peripheral EBUS for diagnosis and staging of lung cancer; Laser, Electrocautery and APC treatment of obstructing endobronchial lesions;Stenting of benign and malignant stenosis of trancheo-bronchial tree; Rigid broncoscopy and its attendant procedures; placement of ICD tubes and subcutaneous tunneled catheters for drainage of pleural effusions; percutaneous dilational tracheostomy.

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