The Unified Airway and Medical Divisions of Labor

Last week, I attended a lecture by a physician for ENT (ear, nose, and throat) doctors and medical residents about the “unified airway.” Basically, this is the idea that the upper airway (sinuses and nasal passages) and the lower airway (the pharynx and lungs) are biologically connected. I learned that a number of processes, including the obvious physical connections, neurological signaling, and immune system signaling via immune system cells, chemical signals, and the bone marrow, connect the upper and lower airways. Inflammatory processes mediated by all these mechanisms seem to affect the airway as a whole. This, of course, will come as no surprise to the many people who suffer from a combination of food allergies and asthma.

As I’ve learned in my research, medical specialties divvy up responsibility for the body based on both function and proximity. For example, a general allergist is interested in allergic processes that go on throughout the body. But allergists are mainly interested in IgE-mediated allergies; for other kinds of sensitivities, a patient might be referred to a dermatologist or GI doctor. Or, if allergy may be playing a role in a complex disease, the allergist might treat the allergic components but send the patient to a doctor specializing in a particular body system (I’ve witnessed this particularly in the case of asthma).

Yet even when it comes to treating allergy, doctors from other specialties can give specialized advice based on the part of the body where an individual experiences allergy symptoms. Otolaryngologists (ENT doctors) have expertise with the upper airway. Lots of people see an ENT for a stuffy nose and later find out, through the allergy testing which some ENTs are trained to do, that they have environmental allergies. An asthma patient might find out from their pulmonologist that allergies are exacerbating asthma symptoms and get referred for allergy testing. A gastroenterologist might suspect that food allergies are contributing to stomach problems and help a patient identify the allergen through a combination of testing and elimination diets. A dermatologist can do patch testing to identify skin irritants and allergens.

Thinking about the airways as unified – neurologically, physically, and chemically – gives some doctors who treat allergy a way to think about more parts and functions of the body than they might have learned to think about in their initial training. In the lecture for ENTs that I attended, the speaker cited scientific evidence that suggested how allergic reactivity in one part of the airways seemed connected to reactivity in another part of the airways. There are lots of scientific articles out there with the details that are easy to find by searching for “unified airway”, but most are behind paywalls. Here is a summary with some key references which seems to be easier to access.

In addition to finding the scientific content very informative, I was struck by how enthusiastic the residents were to learn about this concept. In the Q&A, several shared stories about recent clinic cases that they couldn’t make sense of at the time. With this new concept at their disposal, though, what they had seen could make sense. They also asked questions about what medications to use to treat unified airway issues, what doses to prescribe, and how to combine them. These seem to be typical questions for medical residents to ask more experienced physicians. Still, it was amazing to me to see how quickly they could learn about new ideas, use them to analyze their medical practice, and come up with ways to integrate this knowledge into future clinical cases.

As I conduct more research on allergy, I’m always on the look out for these kinds of game-changing concepts. How do big, new ideas change how individual doctors practice medicine? How do these ideas get shared among professionals who are often very busy and (in the case of residents) learning lots of new information all the time? How do they reinforce or rework traditional divisions of labor within the medical profession? This is a great example of a big idea that has the potentially to create big changes in medical practice, and one that I will continue to follow as I continue my research.

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