Allergy and Pulmonary: Clinical Conflict

Since some of the patients seen by allergy-immunology and pulmonary medicine physicians have the same clinical problems, it is not surprising that conflicts arise between these subspecialties. However, if there are clinical conflicts, there should be an open discussion and attempts to resolve these conflicts in the best interest of patient care, education, and the use of declining medical economic resources. The management of pulmonary disease will depend on the training and experience of the individual clinician specialist. The major overlap and the area of conflict lie in the common clinical problem of asthma.

Reasons for current conflict include the view of some pulmonary physicians that allergen immunotherapy (IT) may be (1) overused and abused by allergists in the management of asthma, and (2) that this therapy is unproven at best or ineffective at worst. Dealing with the first question, there are physicians who overuse and abuse allergen IT not only in the community of allergists but also among otorhinolaryngologists and other physicians. This is a bad practice and should not be condoned. In regard to the second question the of effectiveness of IT in asthma, this is an area that deserves further study. Clearly effective in allergic rhinitis, there is some evidence of effectiveness in asthma. The effectiveness of IT in reducing symptoms due to inhaled allergens in allergic rhinitis should apply theoretically the to reduction of symptoms in allergic asthma because the latter logically is activated by the IgE antibody—mast cell system.

The difference in apparent efficacy of IT in rhinitis as compared with allergic asthma may be that the basic abnormality of asthma is the hyperreactive airway and not the contributing allergic factors. Thus, any reduction in symptoms of asthmatic patients with IgE antibody triggered asthma is the only reduction of symptoms occurring in response to allergen inhalation but not any alteration of the basic mechanism of the hyperreactive airway. The result would be a reduction in symptoms but continuation of chronic asthma in many patients. Further studies of IT as a means of immunomodulation of allergen-induced responses are indicated in asthma.

From another point of view, some allergists may feel that pulmonary physicians do not exclude immunologic factors in asthma citing some cases of cat or dog asthma as examples of asthma that may be almost entirely due to animal dander and where a complete or nearly complete cure may be obtained by animal avoidance. The answer to these two conflicts seems obvious to the authors. In the evaluation of the patient with asthma, allergic factors of importance should be excluded and unnecessary IT should be excluded as the bad practice of medicine. Other than that, pharmacologic management of asthma is appropriate by either subspecialty. In our rapidly changing medical economic environment, however, the competition between our two subspecialties may be moot. Asthma of mild to moderate severity will most likely be managed by primary care health maintenance physicians and referrals to subspecialists in either allergy-immunology or pulmonary medicine made only for complex diagnostic or management problems.

Final Comments

By developing special expertise, experience, and training, certain diagnostic and management programs evolve. Examples of these in the pulmonary medicine and allergy-immunology sections of the Department of Medicine of Northwestern University are shown in Tables 1 and 2. Our programs are not competitive but cooperative, and in many complex diagnostic and management cases, this cooperative approach is more than additive, it is synergistic. Thus, we are not at odds but should continue to work in concert in practice and research.

There are broad health issues where both specialties must cooperate. We must (1) educate physicians and the lay public about proper diagnosis and management of pulmonary disease; (2) combat improper and unproven techniques and quackery which are cost ineffective, possibly dangerous, and at the least, delay appropriate diagnosis and management; and (3) encourage national health policy formulators, Deans and Chairmen of departments of pediatrics and medicine to develop and strengthen both subspecialties.

Additional important broad areas of cooperation in research can be cited. Historically, pulmonary medicine was involved in the clinical and epidemiologic evaluation of environmental dust exposures such as coal, silica, asbestos, and berrylium. Allergists were involved with the immediate-type reactions to soluble or microscopic antigens such as animal danders and mold spores. Newer information about the role of immunopathologic mechanisms in environmental exposures in the industry will require the expertise of both specialties to develop better prevention and treatment strategies.

Table 1—Special Diagnostic Techniques as Used by AUergy-immunology and Pulmonary Medicine Sections

Table 2—Examples of Management Programs in the Pulmonary and Allergy-immunology Sections of the Department of Medicine of Northwestern University