Although close collaboration with a variety of specialists outside of rheumatology is important, you could make the case for rheumatologists and pulmonologists having to work together even more closely. If lung symptoms are severe and not under control, the results could be fatal.
However, the question sometimes is when to refer—even when there are not any evident lung symptoms and the patient’s rheumatic disease is well controlled with therapy.
Rheumatologists and pulmonologists have a great deal of clinical crossover for conditions like interstitial lung disease, pulmonary arterial hypertension in scleroderma and vasculitides (see sidebar, below).
In some circumstances, the rheumatologist receives a referral from the pulmonologist. “When lung symptoms with lung radiographic findings are the presenting symptom, patients usually see the pulmonologist first,” says Petros Efthimiou, MD, FACR, associate chief of rheumatology, New York Methodist Hospital, and associate professor of clinical medicine and rheumatology, Weill Medical College of Cornell University, N.Y. “If it is more subtle or chronic, then it may be the rheumatologist who determines that the lungs are involved and refer to the pulmonologist for evaluation.”
For example, patients may mention feeling shortness of breath when climbing stairs, and that could lead to a pulmonologist referral, says rheumatologist Stanley Cohen, MD, Irving, Texas.
Stuart D. Kaplan, MD, chief of rheumatology at South Nassau Communities Hospital in Oceanside, N.Y., refers patients to a pulmonologist when they experience shortness of breath or if he suspects lung involvement, even if there are no obvious symptoms.
Although there are varying accounts regarding how often lung disease is present in patients with such conditions as rheumatoid arthritis (RA), the key point is that lung involvement can be serious. “On CT scans or tests, two-thirds of patients may have some lung involvement, and 10–20% may have lung disease that is symptomatic. That’s a small percent, but it’s debilitating,” Dr. Cohen says.
When pulmonologists evaluate patients with an underlying rheumatic disease for lung involvement, they typically perform a pulmonary function test and a chest X-ray. The use of a high-resolution CT scan provides more definitive information regarding lung involvement, says pulmonologist Gregory P. Cosgrove, MD, chief medical officer, Pulmonary Fibrosis Foundation, and associate professor of medicine, National Jewish Health and University of Colorado–Denver. “In specific instances, a surgical lung biopsy can be utilized to better understand how the lung is affected,” he says.
The Big Question
Specialists from both sides of the diagnostic and treatment fence would like to have a better understanding of the significance of lung abnormalities, says Dr. Cosgrove.