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When do I need to see a pulmonologist, and what to expect?

The respiratory system includes the lungs, trachea, bronchi, pharynx and other organs, and they help facilitate breathing. Suppose you have been diagnosed with lung disease or have trouble breathing, like shortness of breath (dyspnoea); your general practitioner may refer you to a pulmonologist. But what is the role of a pulmonologist? A pulmonologist is a specialist who diagnoses and treats respiratory conditions. These specialists are equipped with the experience and expertise required to address any respiratory illness that you may have. If you have not consulted a pulmonologist before, we will walk you through what can be expected at the clinic and how you can prepare for your visit.

What conditions do pulmonologists treat?

Pulmonologists are trained to diagnose and manage various lung diseases. Some conditions treated or managed by pulmonologists include, but aren’t limited to:

Aspergillosis: This is a fungal infection caused by common mould (aspergillus) and causes breathing difficulties.
Asthma: Bronchial asthma is a long-term condition that causes breathing difficulties due to the narrowing of the airways.
Bronchiectasis: This condition occurs when the airways become widened, thickened, and permanently damaged, making the lungs vulnerable to infection.
Bronchitis: In bronchitis, the airways (bronchial tubes) leading to the lungs are inflamed and filled with mucus resulting in a nagging cough.
Chronic Obstructive Pulmonary Disease (COPD): COPD is a chronic inflammatory lung disease that causes airflow limitation and breathing difficulties.
Emphysema: This type of COPD develops over time and damages the lung tissue due to noxious elements like cigarette smoke.
Interstitial lung disease: Interstitial lung disease or diffuse parenchymal lung disease (DPLD) comprises a large group of diseases (over 200 conditions) that causes inflammation and scarring in the lungs.
Lung cancer: Lung cancer or carcinoma refers to cancer that forms in the tissues of the lungs; this may spread to lymph nodes and other organs and may even lead to severe consequences and death
Pneumonia: Pneumonia can be a viral, bacterial, or fungal infection that causes inflammation in one or both lungs. Symptoms include cough with phlegm or pus, fever, and difficulty in breathing.
Pulmonary fibrosis: In this condition, the lungs become thickened and scarred, resulting in breathing difficulties.
Pulmonary hypertension: This is a severe condition with abnormally high pressure in the blood vessels that supply blood to the lungs resulting in fatigue and shortness of breath.
Sarcoidosis: This rare condition is characterised by clusters of inflammatory cells known as ‘granulomas’; the cause is unknown, but most evidence suggests that it occurs due to an aberrant immune response.
Sleep apnea: If you snore loudly and still feel exhausted after a good night’s sleep, you may have sleep apnea; this potentially serious sleep disorder is characterised by frequent breathing ‘stops’ and ‘starts’.
Tuberculosis (TB): TB is a potentially serious bacterial infection that mainly affects the lungs but can also affect other parts of the body.

What symptoms and signs indicate you need to consult a pulmonologist?

There are a number of symptoms and signs that may suggest a visit to the clinic. Let’s take a look at a few symptoms:

Shortness of breath: If you have been experiencing breathing difficulties during physical activity or rest, this could indicate an underlying respiratory condition.
Fatigue: Feeling tired after an activity is normal, but if you feel worn out all the time, this could be a sign of a lung condition such as COPD.
Chronic cough: A severe cough or a lingering cough that has lasted for more than three weeks needs to be investigated.
Wheezing: This is a high-pitched whistling sound that may occur while breathing; this may be a symptom of conditions such as asthma, pneumonia, bronchitis, and more.
Recurrent colds or respiratory infections: Frequent infections need to be further investigated by a pulmonologist.
Abnormal imaging investigation findings: If you have any abnormalities on your chest X-ray or CT scan, you may need to get it evaluated by a pulmonologist.

What to expect at the clinic and how to be prepared?

At first, the specialist will take a detailed medical and family history, followed by a physical examination. This is performed to determine the diagnosis and to commence the required management. Depending on your symptoms and medical history, they may also require a few investigations, such as a chest X-ray, spirometry, bronchoscopy, or a CT scan, to make the proper diagnosis.

Being prepared before your appointment will help you make the most out of your visit. Make sure that you bring any relevant past medical records and make a note of your past and current medications, including any over-the-counter (OTC) supplements or vitamins.

It is advisable to wear loose-fitting and comfortable clothing, as you may be required to undergo tests that require deep breathing or physical activity. If you have any questions or concerns, don’t forget to write them down so that you can get them clarified at the clinic. Lastly, it is recommended that you bring a family member to accompany you at the appointment. This will help you be at ease and free from anxiety or stress.

Smoking and lung cancer

Smoking is one of the most harmful habits a person can get into. It is a major contributor of several chronic illnesses and lung cancer, so it would be wise to think twice before lighting that cigarette. For many smokers, it is not too late for a lifestyle change and there are now proven ways that can help smokers kick the habit.

What is lung cancer?

Lung cancer is a type of cancer that begins in the lungs and may spread to other parts of the body, including the lymph nodes, liver, bones, and brain. The lungs may also get affected by cancer cells from other organs; this is referred to as metastasis.

The leading cause of lung cancer worldwide is cigarette smoking. This also includes the smoking of pipes as pipe tobacco contains many of the same type of carcinogens as cigarette tobacco.

Cancer risk increases with the time and number of cigarettes smoked. However, if a person quits smoking (even after smoking for many years), the chances of reducing the risk of developing lung cancer can be significant. Smoking cessation medications and counselling can be effective in helping you stay away from smoking in the long term.

Active smoking is not the only way an individual may get lung cancer. Inhaling secondhand smoke, also known as involuntary or passive smoking, can pose a considerable risk. Therefore, stopping smoking will not only reduce the risk of lung cancer and improve the health of the smoker but that of household members as well.

Other risk factors associated with lung cancer include:

Family history of lung cancer.
Occupational exposure to substances such as asbestos, arsenic, chromium, beryllium, nickel, or tar.
Exposure to radiation from radiation therapy, radon, or imaging investigations, such as CT scans.
Air pollution

Types of lung cancers in smokers

Smoking has the potential to cause two particular types of lung cancer. They are:

Small cell lung cancer (SCLC): This type of cancer is uncommon and is usually found in individuals with a long history of tobacco smoking; Early diagnosis and management has the potential to increase life expectancy.
Non-small cell lung cancer (NSCLC): This epithelial lung cancer accounts for more than 80% of lung cancers and can be classified into three subtypes – squamous cell carcinoma, adenocarcinoma, and large cell carcinoma. Squamous cell cancer is typically associated with long-term smoking.

What are the symptoms and signs of lung cancer?

The following symptoms and signs may be seen with lung cancer:

Headache
Chronic cough
Chest pain
Breathing difficulties
Hoarse voice
Blood in sputum (phlegm or mucus)
Loss of appetite
Unintended weight loss
Fatigue
Bone pain
Swelling of the face and neck veins

In the early stages of lung cancer, patients may be asymptomatic (no symptoms). Symptoms usually occur when the disease is advanced. As such, if you believe you are at risk or have symptoms that do not resolve on their own, it is advisable to see a lung specialist who will be able to conduct a thorough evaluation of your respiratory condition and advise on appropriate treatment if necessary.

How does smoking cause lung cancer?

The lung isn’t the only place affected by cigarette smoking. It can affect other parts of the body, such as the mouth, voice box, trachea, oesophagus, stomach, colon, rectum, liver, pancreas, and so on. It also significantly impacts an individual’s DNA or deoxyribonucleic acid (the hereditary component in humans). It can increase DNA methylation — a biological process that can change the activity of DNA segments and cause DNA damage. Smoking provides direct exposure of the epithelial tissue to at least 60-70 harmful carcinogens that may result in the damage of segments of DNA and thereby leading to lung cancer.

Some examples of such toxic carcinogens include:

Arsenic
Benzene
Cadmium
Formaldehyde
Nickel
Lead
Isoprene

How to diagnose and treat lung cancer?

The following investigations may be carried out to diagnose lung cancer:

Medical and family history.
Physical examination.
Imaging tests, such as chest X-ray or CT scan.
Lab investigations (including blood and sputum tests).
Lung biopsy.

Once the diagnosis is made, the specialist will classify the cancer according to the stages — this will offer integral information regarding the extent of cancer and the required response to the treatment. Screening for lung cancer is generally performed using a low-dose computerised tomography scan (LDCT). This scan doesn’t take up much time and isn’t painful.

How to prevent lung cancer?

Here are some strategies which can help prevent lung cancer:

Stop smoking.
Avoid secondhand smoke.
Reduce exposure to toxic chemicals such as asbestos, arsenic, radon, and lead.

Electronic cigarettes

While electronic cigarettes (e-cigarettes) appear less harmful than cigarettes, they are not safe. E-cigarettes (also known as vaping products) contain many harmful chemicals such as nicotine and heavy metals that can be inhaled deep into the lungs. The flavours in e-cigarettes are also known to be carcinogenic. Vaping comes with the risk of serious lung diseases like asthma, lung scarring, popcorn lung among others. It is generally believed that e-cigarettes don’t usually contain tobacco but this is not always the case; E-cigarettes often contain nicotine which comes from tobacco and is the key ingredient responsible for continued addiction. As such, e-cigarettes are classified as tobacco products by the Food & Drug Administration (FDA) in the U.S.

There are several harmful health effects linked with prolonged tobacco use. They include:

Heart disease
Stroke
Leukaemia
Type 2 Diabetes
Cataracts

Cigarette smoking is one of the major causes of illness and death in Singapore. According to statistics, over 90% of lung cancer cases are caused by smoking. Therefore, it is wise to consult a lung specialist if you need any assistance with quitting smoking.

Can you die from pneumonia?

Pneumonia is a common infection that can be contracted by anyone at any stage or age. In most cases, the patient recovers completely. Occasionally, especially in older patients, the condition stays undiagnosed and untreated until it becomes life-threatening. It is one of the leading causes of death in both children and adults and is among the top five causes of death in developed countries.

Pneumonia

Pneumonia is an infection that occurs when the alveoli (air sacs) of the lungs get inflamed. This inflammation is usually caused by a bacterial or viral infection. However, other organisms, such as fungi and parasites, may also cause pneumonia in some patients who have weak immunity. Some types of pneumonia can be contagious. Many viruses and bacteria that cause pneumonia are easily transmitted from one person to another, but some types aren’t usually infectious, such as fungal and aspiration pneumonia.

Pneumonia can vary in severity depending on the age and immunity of the individual. The most vulnerable patients are infants, young children, older patients (over the age of 65), and individuals who are immunocompromised (such as patients with AIDS, or those with cancer undergoing chemotherapy). Individuals who smoke are also at risk of being infected with pneumonia. But this does not mean that healthy individuals will not get infected as anyone can be at risk of pneumonia. Early medical treatment can, however, help in curing the infection and preventing possible complications.

What are the symptoms of pneumonia?

Although this condition may present itself like the common cold or flu, there are some common symptoms that are suggestive of pneumonia:

Fever with chills and sweating
A feeling of general malaise and fatigue
Cough with mucus (green, yellow, or with blood)
Headaches
Loss of appetite
Difficulty breathing
Chest pain
Joint aches
Confusion
Bluish lips and fingernails

If the symptoms mentioned above are noticed, or the condition starts worsening, your general practitioner may refer you to a lung specialist.

How is pneumonia classified?

This condition can be classified according to the type of pneumonia, how it is acquired, and the degree of severity.

Types of pneumonia:

Viral
Bacterial
Mycoplasma pneumonia (walking pneumonia)
Fungal pneumonia

How it is contracted:

Community-acquired pneumonia
Hospital-acquired pneumonia
Ventilator-acquired pneumonia

Degree of severity:

Mild
Moderate
Severe

How does pneumonia lead to death?

When an individual gets infected with pneumonia, the alveoli begin to fill with fluid or pus, which may result in fever, chills, and difficulty breathing and ultimately lead to asphyxiation. Without prompt treatment, there is a risk of severe consequences and even death. Pneumonia can also result in a number of complications, such as:

ARDS (acute respiratory distress syndrome): This type of lung injury causes respiratory failure due to the fluid build-up in the lungs.
Pleurisy: This condition occurs when the pleura (lining of the lungs) becomes inflamed and causes sharp chest pains.
Lung abscess: This lung infection is characterised by a cavity filled with pus; it is usually caused by bacteria in the oral cavity.
Respiratory failure: This condition occurs when the respiratory system fails to adequately carry out the gas exchange leading to low oxygen or excess carbon dioxide in the blood.
Sepsis: In this condition, the immune system overreacts to an infection and can lead to organ failure and death.

How is pneumonia diagnosed and treated?

Before making a diagnosis, the lung specialist will take a complete medical history and conduct a thorough physical examination. Further testing may also be required for diagnosis. Investigations may include:

Blood tests
Chest X-ray
Sputum culture
Pulse oximetry
Chest CT scan
Pleural fluid culture
Bronchoscopy

In some cases, the patients may be treated at home while for severe cases, patients may need to be treated hospitalised. Mild pneumonia can be treated with antibiotics (if the pathogen is bacterial), accompanied by plenty of rest and a high fluid intake. Cough suppressants, pain relievers, and oxygen therapy may be required, especially if the condition is severe. Most cases of viral pneumonia do not require any treatment and may resolve on their own.

Immunisation can help with the prevention of pneumonia. As the flu is one of the most common causes of pneumonia, a yearly flu vaccine is highly recommended. In addition, a pneumococcal vaccine can protect patients from bacterial pneumonia. It is recommended that infants, those older than 65 years, and those with a weak immune system be vaccinated.

In addition to these vaccinations, there are other ways in which this disease can be prevented:

Cover your mouth and nose when you cough or sneeze.
Wash your hands regularly.
Practise good hygiene
Stop smoking.
Avoid excessive alcohol consumption.
Avoid crowded places
Follow a healthy lifestyle that includes adequate rest, exercise, as well as a healthy and balanced diet
Keep a distance from those who may be suffering from infectious diseases.
Ensure existing chronic conditions are well-controlled, such as asthma, chronic cough, COPD, heart disease, and diabetes.

Getting infected with pneumonia can be serious. It is therefore important that you be aware of your general health and not wait to seek medical help when you feel unwell, especially when you have a respiratory infection.

Should I be concerned about a persistent cough?

Most coughs aren’t usually serious and go away within a few days. They are the body’s natural way of responding to something that irritates the airways. It helps to clear mucus and foreign particles from the airways, thereby preventing infection and inflammation of the lungs. This process is initiated by stimulating the larynx (voice box) and the nerves of the respiratory tract.

But what if you have a cough that won’t seem to go away? While many individuals may not usually worry about a cough arising from a cold or the flu, it is advisable to seek medical attention if your cough lingers on for more than three weeks. It is particularly important to see your doctor when the coughing is prolonged or severe, accompanied by thick, greenish yellow phlegm or blood, or if you have breathing difficulties, fever and/or chest pain. Cough can be a symptom of a more serious underlying condition and as such, a lingering cough should never be ignored. Early detection and intervention can certainly help better manage the symptoms with improved quality of life and a better medical outcome.

Depending on the severity, your general practitioner (GP) may refer you to a respiratory specialist.

Coughs can be categorised according to the duration — acute, sub-acute, and chronic. An acute cough is a cough that lasts less than three weeks; a subacute cough, on the other hand, lasts between three to eight weeks. A cough is referred to as chronic if it lasts more than eight weeks. This classification is important — the duration of the cough at the time of presentation can help determine the likely causes.

What are the main causes of a chronic cough?

A persistent cough can occur due to a range of reasons. Some of the most common causes of chronic cough include:

Asthma: This is a common lung condition that causes the airway to narrow, which makes it difficult for the patient to breathe.
Chronic Obstructive Pulmonary Disease: COPD refers to a group of lung diseases that cause breathing difficulties.
COVID-19: This contagious disease is caused by the SARS-CoV-2 virus.
Gastroesophageal disease (GERD): This condition occurs when stomach acid and contents are regurgitated into the throat and mouth; this is also commonly known as chronic acid reflux.
Infections: Cough may present as a symptom of some respiratory infections such as pneumonia or whooping cough.
Lung cancer: A worsening or prolonged cough may present in patients with lung cancer. It may start as a dry cough and progress to shortness of breath and coughing blood.
Medications: Certain drugs, such as angiotensin-converting enzyme inhibitors (ACEIs) have been known to cause chronic coughs.
Postnasal drip: This condition may lead to the constant sensation of wanting to clear your throat, with time this may lead to a chronic cough.
Smoking: Smoke from cigarettes contains toxins that damage the airways and cause chronic coughing.

When do you need to see a doctor?

Although many cases of chronic cough may not be serious, some may warrant immediate medical attention. The warning signs and symptoms include:

High fever
Shortness of breath
Chest pain
Wheezing
Copious sputum production
Fatigue
Night sweats
Loss of appetite
Coughing up blood
Unintended weight loss

How is chronic cough treated?

First, your doctor will take your medical history and perform a physical examination. Investigations, may include:

Laboratory tests (a sample of blood or phlegm will be tested for the presence of bacteria)
Lung function tests (such as spirometry or cardiopulmonary exercise test)
Imaging tests (may include chest X-rays, Ultrasound testing, CT, and MRI scans)

A high-quality digital chest X-ray (done in posterior anterior and left lateral position) can usually suggest conditions like:

Lung cancer
Metastatic cancer (cancer from elsewhere spreading to the lung)
Bronchiectasis
Active pulmonary tuberculosis
Idiopathic pulmonary fibrosis
Chronic obstructive pulmonary disease (COPD)

Sometimes, a CT scan of the thorax is done to clarify the chest X-ray abnormality.

In some cases, the doctor may recommend scope tests such as Bronchoscopy and Rhinoscopy. If needed, the doctor may also perform a biopsy to look for any abnormalities in the airway.

If the Chest X-ray is normal, the usual causes of chronic cough are:

Cigarette smoking
Post nasal drip due to allergic rhinitis
Asthma
Gastroesophageal reflux
Drugs e.g., ACE inhibitors prescribed for hypertension

Treatment will depend on the findings of the investigations and may, for most cases, include:

Decongestants, antihistamines, and corticosteroids — the standard treatment for a runny nose and allergy symptoms.
Cough suppressants — to get relief from the cough
Nasal sprays — for allergies and sneezing
Antibiotics — for infections such as sinusitis or bacterial pneumonia
Acid blockers — this medication may be given to patients with acid reflux

To quicken the recovery process, your doctor may also suggest the following advice:

Drink plenty of water (at least eight glasses per day)
Avoid certain foods and prop up your head during sleep (to reduce acid reflux)
Avoid environments with dust and toxic fumes
Avoid tobacco smoke

What are the complications and risk factors of chronic cough?

Smoking is one of the main risk factors for chronic cough. Other common risk factors include allergies, air pollution, and infections. Frequent exposure to these factors can result in severe consequences such as lung damage.

Patients with persistent coughs have a higher risk of developing several complications like headaches, sleep disruption, dizziness, fainting, and urinary incontinence (loss of bladder control). In addition, coughing may occasionally lead to fractured ribs in some cases.

How to avoid chronic cough?

First of all, it isn’t necessarily possible to avoid a cough since it is a symptom of several conditions, and coughs are the body’s reflex action. However, there are a few things that you can do to reduce the risk:

Smoking cessation (smoking is the most common cause of chronic cough)
Avoid secondhand smoke
Avoid toxic fumes or pollutants
Eat plenty of fruit and fibre-rich food and stay hydrated
Avoid contact with anyone with a respiratory infection such as pneumonia or bronchitis

How can chronic cough impact your life?

It is well known that a persistent cough can negatively affect one’s health and well-being. With early intervention and following a consistent treatment plan, patients can avoid progression of illness, find relief from their symptoms, and enjoy better health and quality of life.

Chronic Obstructive Pulmonary Disease: Symptoms, causes, diagnosis, and treatment

Chronic obstructive pulmonary disease

COPD is a chronic inflammatory lung disease that commonly affects both men and women worldwide. In patients with COPD, the airways may narrow due to a number of factors and processes, including abnormalities in the airways. There are two types of COPD — emphysema and chronic bronchitis. Emphysema affects the lungs’ alveoli (air sacs) and the walls between them; the air sacs get damaged and lose their elasticity. In chronic bronchitis, the lining of the airways is constantly inflamed — which causes it to swell and produce excess mucus.

Let’s take a look at some of the factors that can cause COPD:

Smoking (Major cause)
Exposure to certain dust and chemicals
Exposure to fumes from burning fuels
Genetics (individuals with alpha-1-antitrypsin deficiency are more at risk of developing COPD)

What are the common symptoms and signs of COPD?

In the early stage, patients may be asymptomatic (no symptoms) or present with mild symptoms. However, with the progression of the disease, the symptoms become severe. Some of the common symptoms include:

Persistent cough with phlegm
Frequent lung infections
Shortness of breath
Wheezing
Chest tightness
Fatigue

What to expect when you see a pulmonologist for COPD: Diagnosis and treatment of COPD

There are several tools that may be used to diagnose the condition:

Detailed medical and family history
Investigations such as spirometry (breathing test), blood investigations and imaging.

Based on the results of these investigations, the doctor will diagnose the condition and start the appropriate COPD treatment.

COPD is typically managed according to the Global Initiative for Obstructive Lung Disease (GOLD) guidelines. The GOLD guidelines are used to classify COPD severity and provide recommendations for first-line treatment. Medications such as bronchodilators, oral steroids, inhaled steroids, combination inhalers, and antibiotics may be prescribed. The doctor may advise on steps such as smoking cessation and vaccination. Treatment may vary depending on the patient, symptoms, stage (early or advanced), severity, and compliance.

COPD exacerbation

If a patient progresses rapidly from a stable condition to a severe one, it is referred to as a COPD exacerbation or flare-up. Exacerbations can last for days or even weeks. The two most common triggers for an exacerbation are respiratory tract infections, such as pneumonia and air pollution. There are some warning signs that may indicate a flare-up: more coughing, changes in the mucus (colour, thickness, and amount), and breathing difficulties.

Patients must seek immediate medical attention if the following occurs:

Severe shortness of breath
Chest pain
Bluish discolouration of lips or fingers
Confusion or difficulty in speaking a complete sentence

What happens at the clinic?

Patients may be referred to a pulmonologist for a severe and persistent cough lasting more than three weeks and/or any of the following symptoms:

Chest tightness or pain
Wheezing
Fatigue
Breathing difficulties
Dizziness or lightheadedness

The pulmonologist will take a detailed medical history and physical examination at the first visit and may order investigations to diagnose and manage the condition. The patient should bring any records of blood work and imaging to be assessed by the pulmonologist. In addition, it is wise to be prepared with any questions or doubts so that these can be clarified at the clinic.