Sir Ganga Ram Hospital, New Delhi, India

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Chest Medicine

Introduction

The speciality of Chest Medicine deals with a gamut of diseases that involve the lungs, airways, mediastinum, pleura, diaphragm and the chest wall. Not only thoracic, but disorders that affect the breathing indirectly like neuromuscular disorders, sleep disorders are also part of the speciality.

The burden of chest diseases is increasing with growing urbanization, pollution and due to harmful effects of smoking. The diseases that we encounter commonly in our population for which Chest Medicine services are required are Asthma, Bronchiectasis, Tuberculosis, Pneumonias, Chest traumas, Pneumothorax, Pleural effusions, Mediastinal lymph adenopathy, Lung cancer, Sleep disorders, Allergies, and Respiratory failure due to various causes.

The department of Chest Medicine has been functional at Sir Ganga Ram Hospital since 1993. It provides all that is necessary for high quality care of patients, viz. excellent manpower resources in its consultants and post graduate residents, state-of-the-art equipment required for diagnosis and treatment of respiratory diseases, a humane approach combined with total dedication and academic activities to always remain abreast with the latest developments in the field of respiratory medicine.Research in progress

Our department is well equipped to deal with preventive, diagnostic, therapeutic, emergency and rehabilitative aspects of Chest Medicine to provide quality and comprehensive care for our patients which is comparable to best in the world.

One of the major highlights is our foray in recent years into interventional pulmonology which is likely to become a super speciality in the coming future. We are proud of our setup of Endobronchial ultrasound (EBUS), which is the first of its kind in the country which offers both linear and radial EBUS facilities. We have performed more than 1200 EBUS procedures in the last 3 years, which is by far the highest by any centre in the country. Another highlight of the department is the dedicated Respiratory High Dependency Unit (HDU) fully equipped with invasive and non-invasive ventilators and hemodynamic monitoring.

ACADEMIC ACTIVITIES

Our department trains 4 DNB post graduates every year. It is a Post MD medicine 3 year course. The department has an organized academic program supervised by the consultants for both theoretical and practical training. There is a departmental seminar every alternate Tuesday. Bed side case presentations are done every alternate Friday. A case presentation is held every 4th Friday in Clinical Combined rounds with other medical and surgical specialities.

Recent Publications

  • Ruptured pulmonary hydatid disease mimicking a lung mass: diagnosed by flexible video bronchoscopy. Basu A, Dhamija A, Agarwal A, Jindal P. BMJ Case Rep. 2012 Oct 12;2012. doi:pii: bcr2012006977. 10.1136/bcr-2012-006977.
  • Hilar lymph node eroding into the pulmonary artery diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration. Dhamija A, Agarwal A, Basu A, Bakshi P. BMJ Case Rep. 2012 Nov 27;2012. doi:pii: bcr2012007438. 10.1136/bcr-2012-007438
  • Endobronchial Ultrasound. Bhalotra B, Jain N The Ganga Ram JournalVol. 2, No. 6, 2012. Human parvovirus infection and aplastic crisis in hereditary spherocytosis. A.Gogia, A.Kakkar, S.P.Byotra, U. Parakh. The Ganga Ram Journal
  • Pulmonary coccidiomycosis in New Delhi, India. Oberoi JK, Wattal C, Aggarwal PK, Khanna S, Basu AK, Verma K. >Infection. 2012 Dec;40(6):699-702. Inflammatory Myofibroblastic Tumor of Trachea. Jain, Sunila; Chopra, Prem; Agarwal, Alok; Gogia, Shweta; Basu, Arup. Journal of Bronchology & Interventional Pulmonology. 20(1):80-83, January 2013
  • Chapter:Management of Acute Asthma. Bobby Bhalotra.Residents Manual of Sir Ganga Ram Hospital
  • Chapter:Acute Exacerbation of COPD. Ujjwal Parakh. Residents Manual of Sir Ganga Ram Hospital

Research Work

Ongoing drug trials:

  • Nasal allergies
  • Bronchial asthma

Research recently approved by the National Board of Examinations

  • To study clinicopathological picture of mediastinal lymphadenopathy with special reference to EUS FNAC for histopathological diagnosis.
  • To evaluate the pulmonary function in treated cases of tuberculosis and correlate them with radiological findings
  • Study of etiology of pleural effusion in ICU

Research in progress

  • Resistance pattern and treatment out come in patients with multidrug resistant tuberculosis in a tertiary care hospital
  • Pulmonary infections in renal transplant patients
  • Role of EBUS TBNA in tuberculosis mediastinal lymphadenopathy
  • Role of TB, PCR in EBUS guided FNAC sample
  • Role of broncho alveolar lavage in diagnosis of sputum smear negative pulmonary tuberculosis
  • Role of endobronchail ultrasound guided trans-bronchial fine needle aspiration in diagnosing patients with mediastinal and hilar lymphadenopathy

SERVICES OFFERED

Outdoor and Indoor services

The department provides outdoor services daily (except Sunday). These services include both General and Private OPDs. General OPDs are run twice a week (Monday and Thursday) from 9:00 to 10:30 AM. All consultants run their private OPDs daily with at least one consultant available from 9AM to 8PM.

Respiratory High Dependency Unit (RHDU)

The department has its own high dependency unit (HDU), which provides closer observation and monitoring apart from both invasive and non-invasive ventilation as required by a team of dedicated nursing staff and a doctor on duty round the clock. The department caters to emergencies in the casualty by attending to patients presenting with various conditions like severe breathlessness, asthma attack, blood in sputum, pneumothorax, foreign body, chest trauma, pneumonia, etc. There is round the clock availability of a resident doctor and consultants on call.

Non Invasive Ventilation

The purpose of ventilation is supporting the respiration. This can be achieved by an invasively by a ventilator connected to an endotracheal tube, going to the central airways from the mouth. Or this can be achieved non-invasively with positive pressure devices like the BiPAP, which are machines with motors generating airflow at high pressure delivered to the patients through a face mask. This is very useful for patients who are sufficiently initiating their breathing and need support. It can be very useful for certain patients for symptomatic relief and even avoiding a ventilator. Our HDU is equipped with 7 latest BiPAP machines with humidifiers for maximal patient comfort. Same machines can also be used for treatment of obstructive sleep apneas.

 Figure: BiPAP Machine and a mannequin with a face mask
 

 Figure: Respiratory HDU

 

DIAGNOSTIC & THERAPEUTIC PROCEDURES OFFERED BY THE DEPARTMENT:

Pulmonary function testing

(Spirometry with diffusion and lung volume studies)

Pulmonary function tests are a group of tests that assess the functional status of the lungs and give us information about the likely cause of breathlessness. It measures how well we can inhale and exhale air and how well the gases such as oxygen move from the atmosphere into the body's circulation. PFT's are performed by our trained technician in the PFT lab.

Pulmonary function tests are done to:

  • Diagnose diseases such as asthma, bronchitis, ILD and COPD
  • Find the cause of shortness of breath
  • Check lung function before surgery
  • Measure progress in disease treatment
  • Assess the effect of medication
  • Measure whether exposure to chemicals at work affects lung function
     

 Figure: PFT machine

 

BRONCHOSCOPY & RELATED PROCEDURES:

Bronchoscopy is a technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. The bronchoscopeis inserted into the windpipe, usually through the nose or mouth, or occasionally through an endotracheal tube or tracheostomy. This allows the doctor to examine the patient's airways for abnormalities such as foreign bodies, bleeding, tumors, secretions, or inflammation as well as provides an opportunity to take diagnostic samples in the form of washings and lavage from the lung and biopsies of lung tissue for diagnosis of certain diseases. In cases of lung collapse due to secretions, it is therapeutic. The procedure is non-surgical, minimally invasive and routinely done on out-patient basis. The upcoming field of interventional pulmonology also opens up horizons for therapeutic interventions for treatment of disorders with relatively non invasive techniques, thus avoiding expensive, cumbersome and more invasive surgical procedures, at the same time being equally effective.  With the early diagnosis and rise in the prevalence of cancers, this is the need of the hour, giving patients instant relief and good quality of life despite a terminal illness.

Our Bronchoscopy Suite is equipped with state of the art technology inclusive of 2 ultra-modern video bronchoscopes, both Radial and Linear endobronchial ultrasound probe scopes, and facility for Endobronchial Stent placement, Electrocautery / Argon Plasma Coagulation with related tools for tumor removal, foreign body removal tools, fluoroscopy guidance, endobronchial glue insertion and hot biopsy forceps.

Figure: Bronchoscopy Suite

Endobronchial Ultrasound (EBUS)

Linear EBUS

Endo-Bronchial Ultrasound (EBUS) is one of the latest diagnostic tools in evaluating undiagnosed lung or mediastinal (the space between the two lungs where the heart and great vessels lie) masses and lymph nodes. The instrument comprises of a special flexible fibre-optic bronchoscope fitted with an ultrasound probe, which shows in great clarity hitherto unvisualised structures in the windpipe walls, in the mediastinum and surrounding lung, even differentiating blood vessels from masses, so that safe needle aspiration biopsies can be done. The procedure, much like bronchoscopy, takes 30 – 45 minutes, involves neither general anaesthesia nor hospitalisation, is minimally-invasive and safe. Besides giving faster results (mostly within 24 – 36 hours), it avoids major disabling diagnostic surgery, cuts down greatly on costs and allows rapid initiation of treatment. Besides being an invaluable tool in diagnosing and staging chest/lung cancers, more relevantly, for a country like India, it is of immense help in the diagnosis of lymph gland TB in the chest and differentiating it from its close mimic sarcoidosis (a disease earlier considered to occur exclusively in western countries, but now being detected very frequently in the east including India) and Lymphoma.

Indications

  • Mediastinal lymph nodes – Tuberculosis, Sarcoidosis
  • Lung cancer
    • Mediastinal staging of lung cancer
    • Restaging after induction chemotherapy
    • Diagnosis of primary lung tumors
    • Assess the extent of airway invasion
  • Peripheral intrapulmonary mass lesions
  • Suspected mediastinal cyst
  • To aid in certain therapeutic procedures

Figure: EBUS Scope and needle sampling the node with adjacent blood vessel

 

Radial EBUS

Till date we are the only centre in the country with facilities for radial endobronchial ultrasound.Just as linear EBUS helps us to sample lesions which are juxta-bronchial, Radial EBUS aids in diagnosing diseased areas within the lung tissue which were traditionally accessible only surgically. This procedure thus has greatly reduced the cost and morbidity in diagnosis of these lesions which can range from benign lung tumors to lung cancers and infections like Tuberculosis and fungal.

Figure: Picture showing actual procedure of Radial EBUS and the kind of lesions now accessible

Endobronchial Tumour removal and airway stenting

Recent technological refinements of the electrodes and the use of high frequency current have made possible safe use of electrocautery through the bronchoscope. Various instruments like Hot Forceps, Snare, Knife powered by cautery can be used for diagnosing and treating endobronchial obstructive lesions like lung cancers, benign tumors, tracheo-bronchial stenosis, sub-glottic stenosis, relapsing polychondritis, amyloidosis, tracheobronchial papillomatosis and Wegener’s granulomatosis. Cautery coagulates the vessels thus reducing bleeding and making removal of vascular lesions possible. The procedure can even be done with a flexible therapeutic bronchoscope thus avoiding need for general anaeshesia or a more invasive surgical procedure. These procedures give patients an instant relief.

Argon Plasma Coagulation is the application of heat produced by an electric current to nearby tissue without touching it. This heat will coagulate the tissue and stop bleeding. APC can be used with a flexible bronchoscope for control of bleeding in refractory cases.

In many cases of central airway obstruction caused by cancers or benign diseases like tracheal, sub-glottic stenosis and trachea-oesophageal fistula(communication between wind pipe and food pipe), a stent can be placed inside the airway to keep the airway open. This can be done through the bronchoscope using various temporary or permanent stents. Stenting provides a consideable improvement in quality of life of non-surgical patients. This can also be placed after resecting the tumor using electrocautery. We commonly place these stents in our Bronchscopy Suite under fluoroscopy guidance.

Indications:

  • Lung cancer
  • Benign tumors
  • Oesophageal cancer
  • Thyroid cancer
  • Head and Neck tumours
  • Benign tracheal stenosis (Postintubation, Wegener’s ganulomatosis, Relapsing Polychondritis)
  • Tracheobronchial malacia
  • Vascular compression

Figure: Tumor being removed and image of patent airway after putting airway stent

Medical Thoracoscopy/ Pleuroscopy

Medical Thoracoscopy is a procedure to examine the chest wall from the inside using an endoscope like device, called a thorascope, through a little hole (about 1-2 cm) in the chest. This also allows examiner to examine around the outside of the lungs apart from inside of the chest wall. During the procedure, samples are taken for establishing diagnosis of pleural disorders in the form of biopsies from the pleura (the covering of lungs and chest wall) and fluid. The procedure is done in our bronchoscopy suite under mild sedation (not general anaesthesia) and local anaesthesia. The total duration of the procedure is around 30-45min. The same sitting can also be used therapeutically for pleurodesis.

Indications:

  • Undiagnosed pleural effusion
  • To inspect the lung and chest wall pleura(covering of the lungs) and take biopsies for diagnosis
  • To instill substances like talc to seal the pleural space and prevent recollection of fluid or air

 


Figure: Thoracoscopy being done and thoracoscopic view from inside the pleural cavity

Foreign Body Removal

We are equipped with all the necessary tools needed to remove any sort of foreign bodies accidentally finding their way into the respiratory tract and have removed foreign bodies including bone, dental file, needles, etc. from the airways.

Figure: Various types of foreign bodies removed

Pleural Aspiration

This is a procedure wherein fluid accumulated outside the lungs in the chest cavity is taken out using a plastic cannula/needle for diagnosis of pleural diseases as well as therapeutic benefit when a large amount of fluid is causing respiratory embarrassment. This is an outpatient procedure requiring 15-20 minutes.

Various indications are:

  • Tuberculosis
  • Cancer
  • Pneumonia
  • Congestive Heart Failure / Renal failure / Liver failure
  • Recent Surgery

Figure: The basis of Pleural aspiration and how it is done

 

Chest Tube/ Intercostal Drain

Various diseases involving the pleura (covering of lungs) cause accumulation of fluid/ pus/ air in the chest cavity. This compresses the lungs and has to be drained. A thin tube needs to be put in the chest cavity to drain this collection. We perform this procedure under ultrasound guidance, to ensure safety on a routine basis. Also the cavity can be sealed after the collection is drained to prevent re-accumulation in case of air of rapidly collecting fluid in cases like malignancy, liver and kidney diseases.

Indications:

  • Pneumothorax (air)
  • Pleural effusion
  • Chest-Medicine

Figure: Intercostal drain/chest tube inside the pleural cavity to drain air or fluid

Allergy testing

Allergy skin tests are tests used to find out which substances cause a person to have an allergic reaction in the form of asthma or allergic rhinitis. The skin prick test is routinely done by our department to find out the cause of allergic symptoms patients have and subsequent advice regarding avoiding some agents or specific therapy.