The Evolution of Pediatric Pulmonology as I Have Seen It

To talk about the field of pediatric pulmonology I need to start with my fellowship at the National Jewish Hospital from 1969 to 1971. That institution had, since 1899, dealt with difficult pulmonary diseases. At the beginning, that was “consumption,” tuberculosis, the major chronic respiratory disorder. As tuberculosis became more manageable because of effective antibiotics, the patient population eventually evolved to asthma. Close ties developed with the University of Colorado. For the pediatric program at National Jewish, that relationship with the university brought Ernie Cotton, MD, recognized as a leading pediatric pulmonologist of the day. That brought cystic fibrosis and other chronic respiratory disorders into the patient population. The other program directors at that time included David Perlman at the University of Colorado and Elliot Ellis (1929–2014), the pediatric program director at National Jewish.¹

Since it is a truism that we stand on the shoulders of those who preceded us, we need to review the developments that preceded my introduction to pediatric pulmonology. The development of pediatric pulmonology in North America was reviewed by Dr. Victor Chernick, a Canadian, and Dr. Robert Mellins, a New Yorker (1928–2014), two leaders in formalizing the subspecialty.² Other prominent leaders of the time, Dr. Simon Godfrey, an Israeli from England, and Dr. Louis Landau, an Australian, reviewed the development in the United Kingdom, Europe, and Australasia.³ The description in a less developed country, India, provides additional insight into the development of pediatric pulmonology.⁴

I and a few others developed divisions at our institutions of allergy and pulmonology within the pediatric department. The rationale for that combination was that asthma made up the most common disorder for both areas. I was board certified in pediatrics in 1970 and in the sub-board of pediatric allergy and clinical immunology in 1972. Divisions of pediatric pulmonology developed from other specialties elsewhere. At some, major care programs for cystic fibrosis were a natural for expansion into general pediatric pulmonology. At the University of Iowa, the cystic fibrosis center became part of the allergy and pulmonary division with me as Cystic Fibrosis Center Director. Other institutions saw pulmonary divisions grow out of neonatology. Meanwhile, the number of physicians with training specifically in pediatric pulmonology was increasing. A movement toward the formation of a separate pediatric pulmonology sub-board was growing. The sub-board was successfully formed in 1985, 10 years after I started a division of allergy and pulmonary in the pediatric department of the University of Iowa. I took the first examination developed by the new sub-board, passed it in 1986, number 146 of the 158 certified at that first examination. Since maintenance of certification had come into play, I took examinations for recertification in 1995, 2001, and 2013.

Meanwhile, the practice of pediatric pulmonology was evolving. Although asthma and cystic fibrosis dominated by numbers and intensity, the pediatric pulmonology content outline published by the American Board of Pediatrics in 2018 included, in addition to asthma and cystic fibrosis, respiratory distress in the newborn infant, pulmonary complications related to prematurity, congenital malformation so the airways and lungs, respiratory infections, bronchiectasis, restrictive lung disease, lung transplantation, interstitial lung disease, pulmonary vascular and lymphatic diseases, and environmental injuries and exposures. Sleep disorder was added resulting in the section of pulmonology of the American Academy of Pediatrics becoming the section of pulmonology and sleep. Knowledge of sleep was added to the certification examinations.

Some activities of pulmonologists such as interpreting pneumograms to predict those at risk of sudden infant death syndrome became passé because studies did not support the practice.^5,6

Another change that influenced pediatric pulmonary practice was the evolution of bronchopulmonary dysplasia (BPD). First described by Northway in 1967,⁷ the volume created by neonatology keeping infants alive with respirators was sufficient for our division at the University of Iowa to maintain a 6-bed BPD unit. But neonatologists learned to prevent this classic BPD thereby decreasing that aspect of our pulmonary service. Neonatal care practices and outcomes have changed with the use of antenatal corticosteroids, surfactant, and improved ventilation equipment. Now many infants whose birthweights are <1 kg and gestational ages are <28 weeks survive resulting in what has been called a new BPD. Those are likely to remain on the neonatology service.⁸ Meanwhile, pulmonary services are caring for more technically dependent infants with tracheostomies and ventilator dependency in and out of the hospital. These are very time-consuming long-term problems requiring adjustments of the clinical service of pediatric pulmonology.

Clinical problems in ambulatory patients that have utilized the skills of pediatric pulmonologists have included evaluation of exertional dyspnea among teenage athletes and wannabee athletes. This utilized their knowledge of exercise physiology. The studies have added to our knowledge of dyspnea.^9,10 The development of pediatric bronchoscopes and their use evolved in the early 1980s, thanks to the work of Bob Wood.¹¹ This practice was rapidly adopted by pediatric pulmonologists, many of us under the tutelage of Bob, and provided a powerful tool that enabled the identification of new clinical disorders such as protracted bacterial bronchitis.¹²

An understanding of chronic cough in children evolved from the studies of Anne Chang and her colleagues in Brisbane Australia.¹³ Increased understanding of functional respiratory disease in children was an important addition to pediatric pulmonology.^14,15 There is potential for iatrogenic morbidity if those disorders without apparent medical explanation are not appropriately identified and treated. Pediatric pulmonologists, because of their extensive experience are more likely to recognize functional respiratory disorders such as habit cough,¹⁶ vocal cord dysfunction,¹⁷ exercise induced laryngomalacia, and habit sighing.¹⁵

A growing concern is the workforce of our specialty. Too many positions are unfilled, and an aging population of current pediatric pulmonologists is in danger of not being adequately replaced. During the 2020 match, there were only 52 applicants for 74 pediatric pulmonary positions offered by 46 programs. Forty-six percent of programs did not fill available fellowship positions.¹⁸ Nonetheless, pediatric pulmonology has had sufficient fascination for me that I remain optimistic for its future. Exposure as early as possible to medical students and residents is essential, and they need to see more than the technically dependent children and cystic fibrosis patients receiving prolonged treatment. The combination of physiology, diagnostic challenges, procedures, sustained patient contact, and the availability of future positions could continue to attract trainees. Working with fellows and residents during the 40 years I spent with the division I started in 1975 was gratifying both for me and, I hope, those who are now colleagues utilizing the skills and experiences that they acquired from our relationship.

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No competing financial interests exist.

Funding Information

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