Pulmonary and critical care medicine: a peculiarly American hybrid?

Abstract

The physiological consequences of altered airways structure on the function of asthmatic airways has been of interest to clinicians and physiologists since the classic study of Huber and Koessler in 1922. 1 These authors provided the first measurements of airway wall thickness in relation to their size and reported that the airway wall of patients who died of asthma was thicker than that of controls. Many have subsequently commented on this finding, 2-7 and Freedman provided an excellent review of its functional significance in 1972.8 A systematic analysis of the eVect of wall thickening on airway function by Moreno and colleagues showed that a thickening of the inner aspect of the airway wall that had little or no eVect on baseline airways resistance was capable of amplifying the eVect of smooth muscle shortening on airway calibre to account for the airways hyperresponsiveness of asthmatic subjects.9 A series of studies followed that further explored this problem using both quantitative histology and computer based models of the airways. [10][11][12][13][14][15] Wiggs et al 15 used a computer model to argue that the greatest eVect of the combination of smooth muscle shortening and wall thickening on the reduction of airway calibre is in the peripheral airways because these structures are encircled by airway smooth muscle. Yanai et al 16 subsequently investigated the site of increased resistance in human airways using direct measurements of pressure and flow to establish that the peripheral airways were the major site of lower airway obstruction in asthma.In this issue of Thorax Orsida and colleagues 17 provide information on the nature of the vascular changes in bronchial biopsy specimens, arguing that the observations made in the bronchi reflect those in the smaller airways. They compare biopsy tissue from a control group with that from two groups of asthmatic patients-one treated and the other not treated with inhaled steroids-and show an increase in the number of vessels and total area of submucosa occupied by vessels in the biopsy specimens from patients with asthma. They also found that inhaled steroids reduced the area of the submucosa occupied by vessels in the asthmatic patients without influencing the number of vessels observed.This study extends the available data on airway vasculature in asthma [18][19][20][21] and is consistent with the concept that the inflammatory response that underlies asthma increases the submucosal vascular compartment, possibly by inducing the growth of new vessels. The authors argue that these vascular changes alter airways function because they found that the change in number of vessels/mm 2 of lamina propria induced by steroids correlated with the percentage change in forced expiratory volume in one second (FEV 1 ) after bronchodilator and the airways response to inhaled methacholine. They suggest that a positive eVect of inhaled steroids may be in reducing the size of this vascular compartment, but recognise that this finding will need to be confirmed by future longi...

Critical care workforce*

“…This is, indeed, as Tobin and Hines (3) pointed out in 1999, "a peculiarly American hybrid" resulting from the vacuum left in 1983 when the American Board of Medical Specialties acknowledged the impasse of the individual specialty boards and dissolved their multispecialty committee, which had been charged with developing a joint critical care fellowship, allowing each specialty to develop an individual certification process.…”

Respiratory intermediate care units: a European survey: European Respiratory Society Task Force on epidemiology of respiratory intermediate care in Europe

“…In some cases (three of 12), these respiratory ICUs, directed by pneumologists, performed general ICU functions in their hospital. It is evident that, before European pneumologists can have a more comprehensive role in the conduction of the medical general ICU, alongside the currently prevailing professional positions (intensivists, anaesthesiologists), it will be necessary to change the process of education and training of the pneumologist in Europe to also include critical medicine, in line with the American system [39]. The European Respiratory Society and the European School of Respiratory Medicine should have a key role in the promotion and further enhancement of the training of the pneumologist.…”

Critical Care Medicine and Infectious Diseases: An Emerging Combined Subspecialty in the United States: Figure 1.

“…Within the American Board of Medical Specialties, 4 member boards (Internal Medicine, General Surgery, Pediatrics, and Anesthesiology) offer CCM certification. The American Board of Internal Medicine offered its first subspecialty exam for CCM in 1987 [6]. There is now a strong body of evidence to support the benefit of trained intensivists in caring for ICU patients, both in terms of improved patient outcomes and cost-effectiveness [7][8][9].…”