The Department of Respiratory Medicine at the Juntendo University Faculty of Medicine (Tokyo, Japan) was established in 1968 to provide specialized clinical services for patients with pulmonary disease, education for medical students and fellows, and to carry out research in pulmonary medicine. This department comprises 28 full-time staff members, 14 postgraduate students, and 20 staff members at affiliated hospitals. In addition, 5 staff members are currently studying abroad as postdoctoral fellows. The department takes care of about 915 inpatients and 37,210 outpatients per year (2010), and conducts bronchoscopic examinations, pulmonary function tests, chest ultrasonography, and other physiological and imaging examinations on these patients. Our eight clinical groups and the treatment modalities used are shown below.
Table 1. Clinical groups and treatment modalities (Department of Respiratory Medicine)
|Clinical group||Diseases treated or diagnostic modalities used||Treatments administered|
|Lung Cancer||Lung cancer, Mediastinal tumors, Mesothelioma etc.||Chemotherapy, Chemoradiotherapy, Radiotherapy, Molecular targeted agents|
|COPD||COPD||Inhaled LAMA, LABA, ICS/LABA, Pulmonary rehabilitation, (LVRS)|
|Pulmonary circulation||Pulmonary hypertension, PTE||Sildenafil, Bosentan, Beraprost, Warfarinization, Home oxygen therapy (HOT)|
|Bronchial asthma||Bronchial asthma, Eosinophilic pneumonia, Churg-Strauss Syndrome, Chronic cough etc.||Inhaled ICS, ICS/LABA, LTRA, Theophylline
|Diagnostic imaging||EBUS/GS, EBUS/TBNA, USAB|
|Interstitial pneumonia||IIPs, CVD-IP etc.||Pirfenidone, Corticosteroids, Immunosuppressants, Inhaled N-acetylcystine|
|Respiratory care||SAS, Acute/chronic respiratory failure||LTOT, NPPV(CPAP, BIPAP)|
|Lymphangioleiomyomatosis (LAM)||LAM (sporadic or TSC-associated), Birt-Hogg-Dubé syndrome (BHDS), and other cystic lung diseases; FLCN genetic testing||GnRH analogues, Sirolimus, Inhaled long-acting bronchodilators, Pulmonary rehabilitation|
The types of inpatients treated in the Department of Respiratory Medicine (January 1, 2011-December 31, 2011)
Lung cancer group. In collaboration with the diagnostic imaging group, an accurate diagnosis for clinical staging is easily and quickly made by EBUS-GS, EBUS-TBNA and USAB, mostly in the outpatient setting. We are also developing a new monitoring biomarker system for mesotheioma, which is also expected to provide an early diagnosis, in collaboration with the Department of Pathology and Oncology. After the determination of the accurate diagnosis, operable lung cancer and other neoplastic patients are referred to the Department of General Throracic Surgery, where they undergo surgery. The patients with locally advanced non-small cell lung cancer are immediately provided chemoradiotherapy, and those with stage IV disease are treated with chemotherapy and/or molecular targeted agents based on their genetic profile, such as their EGFR mutation status. Most of the patients are evaluated not only for efficacy and adverse effects, but also for quality of life (QoL) using several QoL questionnaires in order to ensure that they are provided the best medical care. We regularly discuss the treatment plan for the patients with pulmonary surgeons and radiologists. We belong to the Japan Clinical Oncology Group (JCOG) and other clinical trial groups, and participate in high quality clinical studies to establish novel evidence of the efficacy of new treatments for advanced lung cancer. We have also been developing new treatments for immunotherapy, including a combination treatment with an EGFR-TKI and adoptive cellular immunotherapy, and with cancer peptide vaccines.
COPD group. The COPD (chronic obstructive pulmonary disease) group utilizes a standard diagnostic and therapeutic strategy based on the GOLD (Global Initiative for Chronic Obstructive Pulmonary Disease) and JRS (Japanese Respiratory Society) guidelines. For patients with moderate-to-severe COPD, we also provide a pulmonary rehabilitation program, both in the 2-week inpatient or 12-week outpatient settings. In the last decade, the group has confirmed the effectiveness of the comprehensive rehabilitation program, which is conducted by an interdisciplinary team comprising a medical director (pulmonary physician), registered nurses, physical therapists, inhalation therapists, pharmacists, dietitians, medical social workers, medical engineers, and long-term oxygen therapy providers. Because of the complexity of introducing the program, they started utilizing a simplified rehabilitation program just for 12-weeks (12 visits) in the outpatient setting in 2007. Significant improvements in dyspnea, QOL (quality of life), and the 6MWD (6-minute walking distance), have been achieved in patients who completed the program.
Pulmonary circulation group. The patients with pulmonary hypertension are quickly diagnosed by echocardiaography in the outpatient setting. The final diagnosis of pulmonary hypertension is confirmed by right heart catheterization. The etiology is precisely examined and confirmed by several studies, including blood tests, blood gas analyses, pulmonary function tests, CT, and scintigraphy. We provide treatment with pulmonary vasodilators such as sildenafil, bosentan, beraprost, or combinations of these agents. When the patients are complicated with respiratory failure, oxygen therapy is provided. In addition, if the patients are suffering from an embolism, warfarinization is also performed. Our clinical research has been focused on examining the prevalence of pulmonary hypertension among patients with collagen vascular disease or chronic respiratory disease. We also provide treatment to the patients with secondary pulmonary hypertension from collagen vascular disease or chronic respiratory disease.
Bronchial asthma group. While asthma cannot be completely cured, it can be controlled. Asthma is a serious public health problem throughout the world. Asthma is a chronic eosinophilic inflammatory airway disorder associated with airway hyperresponsiveness with recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with airflow limitation of the airway that is often reversible either spontaneously or with treatment. A clinical diagnosis of asthma is diagnosed by symptoms such as temporary wheezing, breathlessness and cough. In addition to these symptoms, pulmonary lung function tests are helpful to diagnose asthma, and include examinations of spirometry or the peak expiratory flow to assess the severity of the airflow limitation. Airway hyperresponsiveness is also a good marker to evaluate eosinophilic airway inflammation and diagnose the severity of airway hyperresponsiveness. Fractional exhaled nitric oxide (FeNO) is a noninvasive marker of eosinophilic airway inflammation, and FeNO measurement is easily done, and the results are immediately available.
We evaluate the severity of a patientfs asthma using these markers. Measurements of allergic status also help to identify risk factors that cause asthma symptoms in individual patients, such as an occupational asthma, allergic asthma, food allergies, etc. Medications for asthma include controllers or relievers. Controllers are medications taken daily on a long-term basis to keep asthma symptoms at a minimum through their anti-inflammatory effects. Relievers are medications used on demand to recover from acute asthma exacerbation. We use an inhaled glucocorticosteroid as the main controller to relieve the airway inflammation. In addition to this drug, we use long-acting inhaled β2-agonists, cysteinyl-leukotriene 1 (CysLT1) receptor antagonists, theophylline, sodium cromoglycate, anti-IgE (omalizumab), and anticholinergic agents. Our goal of asthma treatment, to achieve and maintain clinical control, can be reached in the majority of patients with a pharmacologic intervention strategy developed by the partnership between the patient/family and the doctor.
Interstitial pneumonia group. The patients are required to visit the outpatient clinic to determine whether or not therapy should be introduced by monitoring of CT findings, pulmonary function tests, and respiratory symptoms. The patients are differentially diagnosed with idiopathic interstitial pneumonia based on their clinical course or serology. Lung biopsy by transbronchial lung biopsy (TBLB) or by video-associated thoracic surgery (VATS) is performed for the differential and pathological diagnosis of lung disease. We provide treatment with pirfenidone, an anti-fibrotic drug, N-acetylcystine, an anti-oxidant drug, or both for the patients with idiopathic pulmonary fibrosis with a slow progressive clinical course. We also provide treatment with combinations of steroids and immunosuppressants for the patients with interstitial pneumonia exhibiting a subacute to acute course. In addition, when the patients are complicated with respiratory failure, oxygen therapy is provided. The patients are referred to our department by other departments of internal medicine, especially by the Department of Internal Medicine and Rheumatology. Our clinical research includes evaluating the efficacy of pulmonary vasodilators for secondary pulmonary hypertension complicated with interstitial pneumonia.
Respiratory care group. We provide treatment to patients with breathing problems in our hospital in a variety of areas, such as in our intensive care units and emergency departments, and in our outpatient clinics. We also provide home oxygen therapy, non-invasive/invasive mechanical ventilation and other breathing assistance for patients with chronic/acute respiratory failure. Once a week, we conduct respiratory care rounds which are made by doctors, nurse physiological therapists and clinical engineers for consulting patients. For patients with sleep apnea, our special outpatient clinic is open once a week. We are available to provide screening for sleep disorders for outpatients and polysomnography (which requires hospitalization) as a definitive diagnosis of sleep apnea. Treatment with oral appliances and continuous positive airway pressure are also provided.
Diagnostic imaging group. Both EBUS-GS (endobronchial ultrasonography with a guide sheath) for peripheral pulmonary lesions, and EBUS-TBNA (endobronchial ultrasound guided transbronchial needle aspiration) for mediastinal tumors and lymphadenopathy, are routinely performed in our department. EBUS-GS allows us to obtain precise biopsy samples from peripheral pulmonary lesions, which are often difficult to detect on chest radiographs. EBUS-TBNA is capable of easily and non-invasively providing diagnoses of lymph node metastasis, sarcoidosis, and mediastinal tumors. Since 1985, ultrasonographic examinations have been routinely used for more than 6500 patients with various respiratory diseases, including lung cancer, pleural mesothelioma, pleurisy, mediastinal tumors, infectious diseases, and so on. Ultrasonically-guided needle aspiration (USGNA) and biopsy (USGNB) are also performed. This classical diagnostic technique is very safe and can be useful even if the patients have severe chronic respiratory disease, such as COPD (chronic obstructive pulmonary disease) and IP (interstitial pneumonia). In patients with pulmonary neoplasms and infectious diseases, the diagnostic accuracy is 83% and 77%, respectively.
Lymphangioleiomyomatosis (LAM) group. This group takes care of patients with lymphangioleiomyomatosis (LAM) (both sporadic and TSC-associated) and other cystic lung diseases including Birt-Hogg-Dubé syndrome (BHDS), Langerhans cell histiocytosis (LCH), etc. Our clinic is the largest LAM center in Japan, and more than 30 newly-diagnosed LAM patients are referred to the group annually. Under intimate cooperation with interventional radiologists at our hospital, patients with renal angiomyolipomas are treated with TAE (transcatheter arterial embolization) every month. Patients with suspected cystic lung disease with or without pneumothorax are referred to our clinic (approximately 20-30 patients per year) to establish the diagnosis of BHDS by FLCN genetic testing. This group is also dedicated to the basic research on these rare but devastating diseases.