Respiratory medicine is one of the largest medical specialties, covering a diverse range of acute and chronic diseases, all of which impact on breathing. These diseases variously affect the lung substance, the lower and upper airway, and the blood vessels of the lungs. They include at least 10 major conditions and a much larger number of rarer and ‘orphan’ diseases. The commoner diseases comprise: acute and chronic infections (pneumonia, tuberculosis); malignancy (lung cancer); chronic airway diseases (asthma, chronic obstructive pulmonary disease, cystic fibrosis); interstitial and occupational diseases; pulmonary vascular disease (pulmonary thromboembolism, pulmonary hypertension); and obstructive sleep apnoea syndrome. The symptom common to all of these, and which usually causes patients to seek medical attention, is difficulty breathing (dyspnoea); often this is accompanied by other symptoms, particularly coughing, with or without the production of sputum or, less commonly, blood. Respiratory disease is a major cause of morbidity and mortality and is responsible for a very large proportion of the overall health and socioeconomic burden of illness.
Respiratory medicine developed largely from the care of patients with TB, the great scourge of the 19th century. Although TB declined dramatically in the developed world in the 20th century, it remains a major problem in many countries and still presents new challenges in the 21st century. Other diseases have, however, come to dominate the practice of respiratory physicians, most notably asthma, COPD (also known as chronic bronchitis and emphysema) and lung cancer. The major cause of both COPD and lung cancer is tobacco smoking and the 20th century – and ongoing – epidemics of these diseases are closely related to the epidemic of smoking. There has been an encouraging decline in tobacco consumption in many developed countries over the past 30 years but, in others, smoking rates remain depressingly high. Where smoking has declined, the prevalence of COPD in men has started to level off, but this is not yet the case in women and lung cancer continues to increase in both sexes. Although a reduction in both conditions is anticipated eventually, the considerable time lag of 20–30 years between tobacco exposure and the development of disease implies that both will remain major challenges for several decades yet. Furthermore, in some countries, tobacco consumption has shown little decline and in many less developed countries it is still increasing.
Asthma also increased in prevalence in many countries in the late 20th century; the precise reason(s) remain to be clarified but are in some way related to the ‘western’ lifestyle and increasing urbanisation. Although the peak of this asthma ‘epidemic’ seems to be passing in western Europe, evidence suggests that in many eastern European countries the prevalence of asthma is ‘catching up’ as socioeconomic conditions improve and the lifestyle approaches that of western countries.
The prevalence of some other respiratory conditions is also increasing. The most noteworthy development is appreciation of OSAS as a major health and social problem. In retrospect, it is clear that the condition has been with us for centuries but it is only since the 1970s that it has been recognised as a major and common cause of morbidity. Although by no means restricted to the obese, it is closely related to weight and the increase is not just a matter of better recognition, but also represents a truly rising prevalence as obesity becomes more common. Another increasingly important influence on adult respiratory practice is disease in infancy and childhood. For example, the progressively improving survival of patients with CF means that it has become an important disease of adults; the recent increase in childhood asthma is likely to be followed by an increase in young (and subsequently older) adults with the disease; and the dramatically improved survival rate of very premature infants brings its own respiratory complications, which are now being seen in older children and young adults.
In contrast to specialties with a universally recognised name ( e.g . cardiology, neurology), respiratory medicine has several synonyms. Respiratory physicians are known variously as pneumologists, pulmonologists, respirologists, lung doctors, chest physicians or thoracic physicians; in some countries where practice is still dominated by TB, specialists are known as phthisiologists. This variation tends to blur the identity of the specialty and causes confusion among the public.
In recent years, respiratory physicians have followed the general trend to greater specialisation and several subspecialties of respiratory medicine have developed to varying degrees in different countries. Larger respiratory departments now commonly have several physicians, each with particular expertise in, for example, asthma, CF, lung cancer or sleep disordered breathing. Increasingly, evidence shows the benefits for patients of such highly specialised expertise and this pattern is likely to accelerate in the future. Similarly, increasing specialisation is seen in other health professions, with specialist respiratory nurses and physiotherapists playing increasingly important roles in the investigation and care of patients.
The practice of respiratory physicians overlaps with other specialists in several situations, for example with intensivists for management of the acutely ill, with oncologists for lung cancer, with clinical allergists (allergologists) for management of asthma and allergic disease, and with neurologists for sleep disorders. In practice, patterns of provision of care vary from country to country and from centre to centre, with the expertise of the physician (and, increasingly, also of the specialist team of nurses and allied health professionals) being more important than the official designation of the post.
The first European Respiratory Society ‘White Book’ was published in 2003, with the aim of highlighting the health and socioeconomic burden of respiratory disease across Europe. It was well received by both health professionals and those responsible for organising healthcare, and the information it contained has been widely used by policymakers. After 10 years, the ERS considers it timely to update the information in order to illustrate how the specialty is changing and how recent trends are influencing practice. We hope that this new White Book will help to inform decision making about the future provision of healthcare for patients with respiratory disease and to highlight the conditions for which more facilities and resources are likely to be required, as well as areas where further research is most needed. As in the previous edition, we have interpreted ‘Europe’ liberally, by following the World Health Organization definition of the European region, i.e. including not only the conventional geographic boundaries, but also all the countries of the former Soviet Union. At the same time, we have also focused on the impact of respiratory disease on the 28 countries of the European Union. Inevitably, due to the diversity of respiratory diseases, the lack of universal definitions and suboptimal reporting systems, data for many diseases and many countries are incomplete. Another aim of this publication is to highlight these deficiencies and the urgent need for them to be addressed.