Introduction

Pediatric respiratory illnesses are one of the common causes of morbidity and mortality in children. The proportion of children attending the outpatient department (OPD) or getting admitted due to respiratory diseases might be 30–50% in various healthcare facilities [1]. Therefore, postgraduates in Pediatrics spent a significant time of their training in management of respiratory disorders. The training includes skill development for identifying and appropriately treating respiratory infections, asthma, and chronic respiratory illnesses.

Pediatric super specialties have evolved over the past 6–7 decades [2, 3]. Till 3–4 decades ago, pediatrics was considered one of the super specialty branches in India. However, the development of subspecialties or super specialties in Pediatrics is a felt need because of the significant increase in knowledge that may not be possible for a single specialist to handle [4].

Respiratory illnesses are common and have increased significantly due to better survival of preterm infants, early diagnosis and management of chronic respiratory diseases, and availability of better diagnostic tools [5]. Diagnosing rare illnesses, better therapeutic interventions, and improving survival with some chronic morbidities are now possible. With ongoing research and advanced care in Pediatric Pulmonology, there is increased survival and improved quality of life in developed countries. Therapeutic interventions and supportive care require advanced training of pediatricians to care for these children with acute/ chronic respiratory problems.

Improved Survival of Preterms

The majority of preterm infants survive without major morbidities. However, a significant proportion may have morbidities, including bronchopulmonary dysplasia, problems secondary to interventions, including mechanical ventilation, airway problems, exposure to environmental hazards, aspirations, and increased infections [6]. Many of these children need respiratory support at home. Management of these morbidities requires specialized training to equip a pediatrician to improve the quality of life and reduce stress in caretakers.

Increased Diagnosis and Survival of Chronic Respiratory Illnesses

Some conditions were considered rare or non-existent, but now these are being increasingly diagnosed in India. With better diagnostic tools, including molecular diagnostics, imaging, bronchoscopies, and intervention bronchoscopies, we can diagnose rare illnesses. Many children with conditions like cystic fibrosis, primary ciliary dyskinesia, interstitial lung diseases, congenital airway and lung malformations that underwent surgery, etc., survive due to early diagnosis, intervention, and better supportive care [7, 8].

Impact of Information Technology

With improved communications, physicians' awareness about chronic respiratory illnesses has increased. The parents of children also get knowledge and have increased expectations from physicians caring for children with chronic respiratory diseases. Therefore, physicians must know the details of the advancement of management during their training. Therapeutic interventions are costly and challenging to implement in resource-limited settings [9]. This results in frustration among physicians as well as parents and grown-up children. There is a need to develop country-specific treatment protocols using available resources and innovations to overcome this complex situation (knowing the intervention but not being able to implement it because of non-availability and cost). Trained persons may discuss, decide on appropriate treatment, identify research priorities, and counsel the families. Hence, there is a need to develop Pediatric Pulmonology as a sub-specialty.

Pediatric Pulmonology as a Super Specialty

In the developed world, Pediatric Pulmonology is a separate specialty started by pediatricians interested in Pulmonology. In North America, the increasing need for Pediatric Pulmonology as a respective discipline was first recognized by Edwin Kendig in 1973 [3]. In early 1978, the section on chest diseases, American Academy of Pediatrics first published guidelines for training in Pediatric Pulmonology, emphasizing research and statistics in training [10]. The separate board of Pediatric Pulmonology was established in 1985 in America. The organization of Pediatric Pulmonology in Europe, the UK, and the Commonwealth countries was always much less formal than in the USA for many years [2]. It was during the early 1970s that the Pediatric Pulmonology sub-specialty began to emerge in the UK. However, the Pediatric Pulmonology sub-specialty began organizing in Europe in 1980.

In India, a separate society was made under the aegis of the Indian Academy of Pediatrics (IAP), initially named as IAP Respiratory Chapter in 1987 and currently registered as IAP National Respiratory Chapter (NRC). The IAP NRC has branches at the state level. The first conference of the IAP Respiratory chapter was organized in 1989 [11]. The primary function of the IAP NRC includes the organization of conferences, providing updates, and conducting courses. The IAP NRC took the initiative to develop India-specific guidelines to treat common respiratory problems, including asthma, acute respiratory infections, tuberculosis, etc. [12]. These module-based training programs have helped to improve the care of children with common respiratory problems.

The formal post-MD training program, Doctorate in Medicine (DM), started in India in 2016 at the All India Institute of Medical Sciences (AIIMS), New Delhi. Over the past six years, four more centers (Post Graduate Institute of Medical Education and Research, Chandigarh; AIIMS, Jodhpur; AIIMS, Rishikesh, and AIIMS, Bhubaneswar) have started the program. Three centers (two in Bengaluru and one in Mumbai) started IAP NRC Fellowship in Pediatric Pulmonology last year. Going by the population of India, there is a need for a large number of trained workforce for pediatric respiratory illnesses. There is a need for other institutions to start the training program.

The training program in government institutions involves various steps, so it takes a long time. IAP NRC has taken the initiative to start a training program at multiple institutions. Many centers across India have shown interest in starting Fellowship programs in Pediatric Pulmonology. This training program aims to prepare human resources trained in pediatric respiratory diseases.

Though the fellowship program started by IAP NRC will create a pool of trained workforce, the training needs to be recognized by governmental agencies, including National Medical Council. Till then, there may not be positions for specialists. As a step toward getting recognition for super specialty, the IAP has initiated the Indian College of Pediatrics, which is responsible for uniform training and quality improvement of super specialty training [13].

Structure of the Training Program

There are ongoing training programs in the Americas and Europe [14]. These programs may be examined for developing training programs in India. Because of the different disease spectrum, available resources, and priorities, we must modify protocols/guidelines suitable for low-resource countries like India. There is a need to develop treatment protocols for uniformity of care for common illnesses. The nurses, physiotherapists, dieticians, etc., must be trained in chronic respiratory problems in children.

Clinical Training

The training program for India can be divided into clinical care, basic investigations, advanced investigations, and therapeutic interventions.

Developing special care for respiratory illnesses includes providing care for an acute problem and ensuring regular follow-up for supportive care. This can be achieved by developing the team (doctor, nurse, physiotherapist, dietician, social worker, etc.) and identifying the day, time, and place for OPD and inpatient services. The proforma for recording details of children specifically for chronic respiratory illnesses should be prepared. There should be a program for regular follow-up. At large, trainees are required to gain experience in asthma, bronchopulmonary dysplasia, cystic fibrosis, pulmonary infections, respiratory disorders in systemic diseases and immunocompromised hosts, neuromuscular diseases, disorders of ventilatory control, interstitial lung diseases, congenital malformations of the respiratory system, etc. It is also crucial for trainees to gain experience in the use of supplemental oxygen, home mechanical ventilation, non-invasive mask ventilation, and other technologies [15].

An essential component of Pediatric Pulmonology training is understanding respiratory physiology and the use of basic investigations to diagnose and manage common respiratory illnesses. Therefore, procuring equipment for basic investigations, including spirometry, Peak Expiratory Flow Rate (PEFR) meter, basic radiology including X-ray and CT scan, and microbiology, including investigations for tuberculosis, etc., should be done. The basic diagnostic bronchoscopic service must be separate for children. However, facilities for advanced investigations may be either at the individual site or shared among different sub-specialties, including endobronchial ultrasound, intervention bronchology services, sleep lab, sweat testing, molecular diagnostic, etc. A simulation-based training may be helpful in building confidence in the trainee for the procedure. Besides the knowledge of basic and advanced investigations, the trainee should know the skill of chest physiotherapy. The trainees are also expected to be experts in procedures essential for Pediatric Pulmonology, especially flexible bronchoscopy. The training should provide extensive exposure to the hands-on training on bronchoscopy, performance, and interpretation of routine pulmonary function tests, sweat tests, sleep studies, etc.

Additional clinical training opportunities at overseas centers or other centers in India, such as training in interventional bronchoscopy, specialized cystic fibrosis care, pediatric sleep lab, etc., should be offered to the trainees during the final year of training or after the completion of training.

Academic Training

Academic training should aim to produce a visionary figureheads in Pediatric Pulmonology. The trainees should also be involved in basic and clinical research. They might understand biostatistics, research design, and the ethics of research. Preparing a teaching schedule is one of the mainstays of the training program. Each site should develop teaching sessions at least twice a week. It should include case discussions, journal clubs, seminars, etc. A combined program of some institutions using teleconferencing may add to ancillary learning that may enhance interaction. It should involve periodic assessments of students enrolled for training.

Interdisciplinary Training

Pediatric Pulmonology heavily depends on radiological imaging, microbiology, pathology, nuclear medicine, etc. Therefore, specialists must interact with radiologists. Necessary radiological investigations include CT and MRI imaging of the chest, USG-guided sampling, study of swallowing, etc. Interpretation of imaging findings may play an essential role in diagnosing and monitoring respiratory problems [16].

Respiratory infections are one of the most common morbidities. Therefore close interaction with the microbiology department is essential. This will help in the identification of etiological agents by smear, cultures, molecular testing, and serology.

Pathology plays an essential role in the precise diagnosis of lung diseases. Bronchoalveolar lavage, considered a liquid biopsy of lungs, needs specialized training for the pathologists and an appropriate interpretation for the clinicians. Specialized training for interpreting findings on small tissue samples is of paramount importance. Equally important is the interaction between the pathologists and the clinicians, which will undoubtedly enhance diagnostic accuracy in challenging cases.

Children with neuromuscular problems and developmental delay have significant respiratory morbidities [17]. These children may need pulmonary rehabilitation with other supportive care, and pulmonologists should support these patients. Another important evolving specialty is sleep medicine. Therefore, pulmonologists need to interact regularly with neurologists and adult pulmonologists.

Children with immunocompromised status are at a risk for opportunistic infections. Pediatric Pulmonologists play a vital role in diagnosing and managing such patients.

Airway malformations, including tumors, malacias, etc., may need surgical interventions and close interaction with Pediatric Surgeons and Otolaryngologists.

Way forward for the Development of Pediatric Pulmonologists

From the above description, it is clear that there is a need to develop Pediatric Pulmonologist services and research in India. At present, there are fewer qualified specialists. Most are self-styled specialists, as happened 5–6 decades ago in Europe.

We need to develop trained Pediatric Pulmonologists to foster the field's growth. The institutions running the DM program have few seats reserved for pediatricians working in government institutions. Pediatricians interested in Pediatric Pulmonology and working in government institutions should undergo long-term training and develop Pediatric Pulmonology services and training programs at their respective centers. Pediatricians working in the private sector and interested in Pediatric Pulmonology may have training opportunities through the IAP NRC fellowship program in Pediatric Pulmonology. The faculties working at institutions where training is already being done should play a mentorship role to guide freshly trained Pediatric Pulmonologists in their career development. They should also help to develop Pediatric Pulmonology services at other centers. Faculty mentors must provide educational and research opportunities to budding Pediatric Pulmonologists.

Scope of Pediatric Pulmonology Training

Initial concerns of overshadowing Pediatric Pulmonology by other specialties like allergy or infectious disease are not considered a challenge now. Specialized skills in Pediatric Pulmonology training can not be acquired by other specialists [18]. Moreover, trained Pediatric Pulmonologists will improve the care of children with infectious diseases, immunocompromised, neuromuscular disorders, etc. Another issue is the need for a significant investment in developing Pediatric Pulmonology services. This can be overcome by developing basic services and sharing some services. The scope of Pediatric Pulmonology will increase with improved survival of preterm newborns, more prolonged survival of chronic respiratory problems, neuromuscular problems, and an ever-increasing number of immunocompromised hosts [19]. A pandemic like COVID-19 and other respiratory viruses will further increase the demand for trained Pediatric Pulmonologists all over the globe, as these disorders may have a long-term effect on lung health [20].

Pediatric Pulmonology is a vibrant field since it combines acute and chronic patient care with continuity of care and long-term relationships with families. Because there is a need for trained Pediatric Pulmonologists, we need to increase the number of facilities with good training to meet the requirement.