The History of our Division
The illustrious history of the Pulmonary Division commenced before World War II, when the Pulmonary Division consisted of the tuberculosis ward on the 7th floor of the University Hospital (referred to as “Old Main”). Dr. John Blair Barnwell came to the University of Michigan from the University of Pennsylvania in 1928 to develop and preside over the tuberculosis unit. As many other physicians of that time, he himself had contracted TB and was “cured” at the Trudeau Sanatorium. Dr. Barnwell served in this role until 1946, when he was recruited to Washington to head the Veterans Administration-Armed Forces Chemotherapy of Tuberculosis Research Program.
The Division was referred to as the Medical Chest Section up until 1971, the Pulmonary Division from 1971-1974, and the Division of Pulmonary and Critical Care Medicine from 1974 to the present day.
In 1947, Winthrop Newbury Davey, MD, assumed leadership of the Division. In 1958, he was joined in practice by Nancy Furstenberg, MD, daughter of Dr. Albert Furstenberg, former Dean of the University of Michigan Medical School.
In 1958, Robert Green, MD, arrived and became section head of the the Veterans Affair Medical Center, Ann Arbor. He promptly broadened the teaching, consulting, and patient care activities. Most notable was his weekly chest conference, which was a highlight of the weekly educational activities.
In 1971, John G. Weg, MD, was recruited to the University of Michigan from Baylor University and served as Physician in Charge of the Division from 1971-1974, and then Chief of the Pulmonary Division from 1974-1985.
Joseph P. Lynch, III. MD was named Acting Chief in July 1985, and served in this role until Department Chair William Kelley recruited Galen B. Toews, MD in July 1987. Under his leadership, there was a considerable expansion of the clinical, research, and educational activities, and the Division grew from 13 to 46 faculty members. During this time, Marc Holman was brought in as the first full time administrator of the Division, a role he served in until 1987.
Theodore J. Standiford, MD served as acting chief of the Division since Dr. Toews passing, and was named permanent chief in June 2014. The Division continues to grow, with the current number of faculty nearing 50
He promptly broadened the teaching, consulting, and patient care activities. Most notable was his weekly chest conference, which was a highlight of the weekly educational activities. Dr. Green was succeeded by Jay Rowedder MD in 1972, followed by Dan Olsen, MD. For the past 24 years, the section has been led by Jeffery Curtis, MD. The VA section currently has eight research and clinical faculty.
In the early 80s, Marc Holman was brought in as the first full time administrator of the Division, a role he served in until 1987. He was succeeded by Jeff Holden, who helped the organization grow through the early years of Dr. Toews' tenure through 1994. Jeff was succeeded by Tatiana Bailey, Jeff Albers, Robert Keast, and Rod Hayhurst.
Mary Freer has been with the Division since 2004. She has administered the expansion of clinical services, NIH grants, and industry trials. Based on her many contributions, Mary was named Administrator of the Year by the Department in 2010.
Dr. Toews served as Chief of the Division until his untimely death in October 2011.
Our Clinical History
The Division of Pulmonary and Critical Care Medicine at Michigan has a rich tradition of delivering innovative clinical care to patients with pulmonary disease and critical illness. Tuberculosis represented the primary thrust of clinical care delivered during the early years of the Division. By the mid-fifties, clinical activities expanded to the care of patients with lung cancer, histoplasmosis, and sarcoidosis. Intensive care at the Old Main University Hospital was delivered in the ten-bed Medical Intensive Care Unit (MICU), which was staffed by the chief medical residents, and the six-bed Respiratory Intensive Care Unit (RICU), which was staffed by the pulmonary faculty. Both units were located on 10 East of Old Main. The units were merged in the summer of 1982.
A common cause of chronic respiratory failure in the 50’s and 60’s was polio, and as a consequence, iron lungs, cuirasses, and rocking beds were routinely in operation in the RICU and the respiratory ward on 11 East.
A hyperbaric oxygen chamber also existed at the main hospital, which was under the medical directorship of the Division. This chamber was primarily used to treat decompression sickness and gas gangrene. Treatment routinely lasted 3-5 hours, and usually required the pulmonary fellow to be inside the chamber with the patient during treatment. The hyperbaric chamber was decommissioned in the mid-eighties.
Dr. Josef Smith was hired in the early 60’s to develop the pulmonary function laboratory. The first “modern” pulmonary function lab was established in the early 80s, and considered state of the art at the time. This included a large water-filled tank which used an inverted cylinder to measure volumes quite accurately. Flow volume loops, expiratory time and volume were calculated by plotting on graph paper and then measured. The Division was proud of the fact that the pulmonary function lab could perform eight pulmonary function tests per day (only seven if one study was a methacholine challenge). Under the direction of Fernando Martinez and now Helena Schotland, the Division now operates PFT labs at four sites, including the University Hospital, the Taubman Clinic, Brighton, and Briarwood, and performs over 100 pulmonary function studies daily. The Northville lab opened in July 2014.
Division faculty also practiced at the Wayne County General Hospital in Nankin Twp, MI. This institution dates back to 1913, when this complex existed as the Eloise Mental Hospital, the Eloise Poorhouse, and the Eloise TB Sanitarium. The General Hospital was established in 1974, it was in this institution where faculty and fellows would care for primarily indigent patients with diseases such as tuberculosis, empyema, and advanced lung cancer. The Wayne County General Hospital closed in 1984.
The mid-eighties brought expansion of both clinical and research faculty within the Division. The new University Hospital was opened in 1986, which included a 20-bed Critical Care Medicine Unit (CCMU) and an inpatient pulmonary ward located on 6C. The new Ann Arbor VAMC was opened in 1998 and included seven medical ICU beds staffed by Division faculty. The addition of faculty and ICU beds at the University resulted in an explosion of critical care at the institution, including a major focus on sepsis, ARDS, acute respiratory failure, and acute liver failure. The CCMU has been directed by Dr. Robert Hyzy since his return back to Michigan in June 2007. A four-bed chronic ventilator unit was opened on 6C in 1996, which was followed by the creation of a ten-bed intermediate care unit on 8D for management of chronically-ventilated patients in December 2008, under the direction of Kristy Bauman, MD. Due largely to house staff work hour restrictions, the inpatient pulmonary house staff services were dissolved in June 2011. In their place was the creation of pulmonary services incorporating mid-level providers and primarily caring for patients with chronic respiratory failure, cystic fibrosis, and lung transplantation. The number of mid-level providers has now been increased to 10, and the services will be expanded to over twenty patients by fall 2014.
Over time, the Division developed key clinical programs to meet the needs of the local and state-wide community. Several programs are especially noteworthy.
Fiberoptic bronchoscopy was introduced at the University in the early 70’s, at which time the procedure was performed only in the inpatient setting. The first BAL was performed in a patient with sarcoidosis by Joseph P. Lynch, III in 1980. At that time, bronchoscopies were performed in the utility room on 11 East without nursing support. Under the direction of Douglas Arenberg, MD, advanced bronchoscopy was introduced in 2006, including endobronchial ultrasound and navigational bronchoscopy. This program has enjoyed continued growth, as 804 standard bronchoscopies, 340 endobronchial ultrasound bronchoscopies (EBUS), 80 superdimension navigational bronchoscopies were performed at the University and VAMC in 2013.
Interstitial Lung Disease
The Division has had a long standing presence in the care of patients with interstitial lung disease. The ILD program was started by Dr. Lynch in the early 80s, with an emphasis on sarcoidosis and IPF. The program continued to grow with addition of Dr. Martinez in 1991, and Kevin Flaherty, who trained at Michigan and came on faculty in 2000. The Dyspnea Program was introduced in 1994 to care for patients with end stage lung disease including interstitial lung disease (ILD) and COPD. The ILD program has participated in multiple NIH and industry sponsored trials, providing new therapeutic options to many patients with this devastating disease. Based on the clinical and research excellence of the program, the Michigan has recently been designated as one of only nine Pulmonary Fibrosis Foundation Care Center Network sites nationwide, with the Michigan site being directed by Kevin Flaherty, MD. A dedicated sarcoidosis clinic came to fruition in July 2011, headed up by Dr. Eric White. This clinic has grown to nearly 500 patients.
Chronic Obstructive Pulmonary Disease (OCPD)
COPD was not a major clinical focus of the Division during the early years. However, clinical programs focused on this disease were developed by Fernando Martinez and Galen Toews in the early 90’s as a component of the dyspnea program. In addition to providing state-of-the-art clinical care, the COPD clinical program has been closely integrated into the lung transplantation and pulmonary rehabilitation programs. In addition, the COPD initiative has driven past and ongoing investigative programs, including surgical and bronchoscopic volume reduction trials, as well as the genetic, immunologic, and radiographic phenotyping of patients with COPD. Drs. MeiLan Han, Jeffery Curtis, and Steven Gay are major contributors to ongoing clinical and translation research programs.
Advances in the diagnoses and treatment of cystic fibrosis resulted in extended life expectancy of these patients beyond childhood and teens. As a consequence, the Division, led by Cyril Grum, MD, developed the adult cystic fibrosis program at Michigan starting in 1986. Richard Simon, MD, was named director of the center in 1994, a position he holds to this day. The adult CF program has enjoyed tremendous growth in recent years, now caring for over 250 patients and has emerged as one of the top CF centers regionally and nationally. Dr. Simon also serves on the CF Foundation Advisory Board and leads the Foundation Drug Safety Monitoring Board overseeing clinical trials in cystic fibrosis.
Lung Transplantation Program
The first successful experimental lung transplantation at Michigan was performed on a flop-eared hound dog by Donald H. Kahn, MD, on May 26, 1961. The first human lung transplantation was performed at the University of Michigan by Dr. Kahn on September 2, 1969. This was single left lung transplantation in a patient from Bloomfield Hills, Michigan for terminal emphysema, with the patient surviving for only three days post transplant. Dr. William Hubbard, Dean of the Medical School at the time, stated that ‘I do not think lung transplants are likely to become commonplace anywhere”. Despite this proclamation, the modern transplantation program was introduced in the late 1980s, beginning with the performance of a heart-lung transplant on December 17, 1988 by Dr. Michael Deeb. Drs. Deeb and Joseph Lynch, III, MD, were the first directors of the lung transplant program. With Dr. Lynch’s departure to UCLA, Kevin Chan, MD, was recruited to the University and assumed leadership of the program in 2005. There has been steady growth of the program at Michigan, with 837 transplants being performed in 580 patients from the period between 1990 through December 31, 2013. In fact, the 44 transplants done in 2013 represented the highest number performed on an annual basis and places the University of Michigan in the top fifteen of lung transplant centers nationally.
Assisted Ventilation Program
The introduction of new modes of long-term positive pressure ventilation, including BiPAP, spurred the creation of the Assisted Ventilation Program in July 2009. This multidisciplinary clinic involving Respiratory Therapy, Physical Medicine and Rehabilitation, Neurology, and Pulmonary Medicine was created and directed by Robert Sitrin, MD. The program has grown exponentially and now cares for nearly 500 patients with various forms of chronic respiratory failure. An adult Duchenne Muscular Dystrophy clinic has just recently been opened.
Lung Cancer Program
A comprehensive lung cancer program was initiated in 2006, under the leadership of Douglas Arenberg, MD. The centerpiece of the program is a multidisciplinary Thoracic Oncology conference involving clinical experts from oncology, thoracic surgery, radiology, radiation oncology, pathology, and pulmonary medicine. Dr. Arenberg developed a lung cancer screening clinic that is now located at the new Northville Health Center.
Sleep Medicine Program
The Sleep Program at Michigan has historically been directed and staffed by sleep-trained neurologists. Helena Schotland, MD, was recruited to the PCCM Division in July 2011 to become the first sleep-trained pulmonologist to join the sleep program. Dr. Schotland’s considerable success within the program resulted in the addition of Hillary Loomis-King, MD, in July 2013.
The care of patients with TB represents a fundamental thrust of the Division since its inception. This commitment continues today. Robert Green, MD, whose primary passion was the fight against tuberculosis, served on the Washtenaw County Health Department TB Advisory Board from 1963-1972, and was the physician in charge of the Washtenaw County TB clinic for twenty years. He was succeeded by Paul Christensen, who served in this role from 2005 through July 2012. Theodore Standiford currently serves as the TB consultant for Washtenaw County. Dana Kissner, MD, a renowned TB physician and former faculty member, will be re-appointed to the Division and will assume leadership of the TB clinic in early 2015.
In addition to dedicated care of patients with tuberculosis, Division members have served in a consultant role for non-human clients. In particular, Richard Simon, MD, assisted in the performance of several surveillance bronchoscopies for Rudi, a 42 year African Rhino at the Detroit Zoo, who was exposed to another animal with tuberculosis. Fortunately for Rudi, he never developed clinically active disease.
Our Research History
The Division is perhaps best recognized nationally for their sustained and impactful contributions to pulmonary research.
The early thrust of research in the Division centered on the diagnosis and treatment of tuberculosis. Dr. Green’s research at the VA included participation in VA cooperative studies in TB and lung cancer. An additional investigative focus was non-tuberculous mycobacterium. The 70’s and early 80’s were characterized by cutting-edge pulmonary physiology research centered on gas exchange and thromboembolic disease. Much of this work was performed in the dog lab located in the old Kresge building. Division faculty made seminal observations of gas exchange abnormalities and oxygen uptake in obliterative pulmonary vascular disease and in patients with ARDS. Jack Weg and others were major leaders of PIOPED studies identifying the accuracy of diagnostic modalities in pulmonary thromboembolic disease.
Recruitment of key faculty in the early to mid-80’s resulted in a shift in research focus toward cellular and molecular biology. This effort was greatly facilitated by the arrival of Dr. Toews, a skilled and passionate lung immunologist. Under Dr. Toews leadership, the NIH grant funding increased from $600,000 annually in 1987 to over 13 million dollars today. Dr. Toews recruited and nurtured a group of outstanding faculty members with expertise in cell and molecular biology, and forged strong collaborative ties with investigators in the Department of Pathology. Particular areas of expertise included lung innate and acquired immunity, acute lung injury, and pulmonary fibrosis. Expansion of basic research in the Division was greatly enhanced by the recruitment of talented PhD investigators. Landmark observations made by this highly collaborative group included: describing fundamental biology of alveolar macrophages, dendritic cells, lung fibroblasts and alveolar epithelial cells; and defining the contributions of cytokines, chemokines, and eicosanoids to antibacterial and antifungal host defense, lung injury responses, and lung fibroproliferation. A particularly impactful and high visibility study performed by Drs. Michael Iannuzzi, Francis Collins and colleagues was the identification of the human cystic fibrosis gene, published in the journal Science.
This period was also marked by the expansion of existing laboratory space. In 1998, the Division moved into 13,000 square feet of newly constructed contiguous research space in Medical Sciences Research Building III.
The pulmonary rehabilitation program was launched in 1998 at Domino's Farms as a necessary component of the NETT trial. The first NETT patient was enrolled on April 13, 1998, and she went on to survive for an additional 15 years. The program is now located at Briarwood and has grown to approximately 100 referrals and 25 maintenance patients annually. The program received AACVPR accreditation in 2012. The clinic also serves as the site for the monthly IPF support group supported by the Martin E. Galvin Fund for Pulmonary Fibrosis Research.
The investigators at the VA Ann Arbor Healthcare System (VAAAHS) occupied 5,000 square feet of research space in a newly constructed research facility.
Several pulmonary investigators moved into laboratory space contiguous to pathology colleagues within the Immunology Center in the Biomedical Science Research Building in February 2006.
The last five-years have been characterized by new major areas of modern biology, including genetics/genomics, metagenomics, proteomics, metabolomics, stem cell biology, computational biology, and the microbiome. Most notable is the nationally and internationally recognized Microbiome program, which was initially created by Gary Huffnagle, PhD, and now involves multiple pulmonary faculty at both the University and the VAAAHS. Emerging fields of patient-oriented research have been added or expanded, including health services research and sleep.
Disease-Specific Translational Research Programs
The early to mid-90’s was a period that was marked by the development of cutting-edge disease-focused translational research programs in interstitial lung disease, COPD, acute lung injury and lung transplantation. A central tenant of the clinical research programs was a rigorous Master's Degree training program in Clinical Research Design and Statistical Analysis within the University of Michigan School of Public Health (referred to as On Job/On Campus or OJ/OC). A number of faculty and trainees completed this program, which provided the fundamentals of clinical research and introduction to advanced statistical methodology. The translational research programs in ILD and COPD where greatly enhanced by the recruitment of Fernando Martinez, MD, MS, in 1991, who was the first pulmonary faculty member to complete the OJ/OC program. Health services research blossomed in 2008 with the addition of Theodore (Jack) Iwashyna, MD, PhD. Dr. Iwashyna assembled a vibrant research group investigating short and long term outcomes in critically ill patients and health services utilization in the intensive care unit. He is the Associate Director of the Roberts Woods Johnson Clinical Scholars program, a program that now serves as the backbone for health services research training within the Division.
PCCM investigators are at the forefront of several nationally recognized areas of patient-oriented research. In 2009, the University of Michigan purchased the 2.1 million square ft. North Campus Research Complex (NCRC). This allowed for co-localization of investigators and expansion of health services research, and led to the establishment of the Center for Healthcare Outcomes & Policy (CHOP), of which several Division members, including Jack Iwashyna and Colin Cooke, are active participants.
Interstitial Lung Disease (ILD)
A major emphasis of basic and clinical research in the Division over the past 25 years has been directed at the pathogenesis, diagnosis, and treatment of ILD, most notably IPF. Division investigators have held many large NIH-funded contracts or multi-investigator awards to study patients with this disease. The first major award was the Specialized Center of Research (SCOR) in Fibrotic Lung Diseases, awarded in December 1996 and competitively renewed in 2001, both SCORs directed by Galen Toews. This program established the framework for collaborative research between clinical scientists and basic scientists. Subsequent programs included the Lung Tissue Research Consortium (LTRC), the IPF Clinical Research Network; and CADET. Landmark studies published by UM investigators include the identification of prognostic indicators in IPF, characterization of cells, cytokines, and pathogen recognition receptors involved in the pathogenesis of IPF and sarcoidosis, description of clinical features in acute exacerbations of IPF, and testing of new therapies in patients with interstitial lung disease. Ongoing research in the White laboratory has employed a human de-cellularized or “bioengineered” lung model to study how matrix components within the interstitium influence the behavior of lung cells.
Chronic Obstructive Pulmonary Disease (COPD)
Multidisciplinary research in COPD has been a mainstay of translational patient-oriented research in the Division at both the University and the VA. Shortly after his arrival, Dr. Martinez was awarded a Clinical Center for the NIH National Emphysema Treatment Trial Network (NETT). This network performed the definitive multicenter trial identifying predictors of outcome in patients undergoing lung volume reduction surgery. UM investigators were also instrumental in identifying the impact of macrolides on COPD exacerbation rates. Current multicenter clinical trials include the COPD Clinical Research Network, Long Term Oxygen Therapy (LOTT), SPIROMICS, STAT-COPE and COPD Gene. These trials have discovered the important of CD8 T cells in COPD disease severity, defined molecular phenotypes of disease expression, and have characterized the microbiome in COPD, including the influence of various therapies on the microbiome in these patients.
The division has a rich tradition of research involving critically ill patients, most notably Acute Respiratory Distress Syndrome (ARDS). Research involving ARDS patients at Michigan dates back to the late 70’s and early 80’s, when UM investigators described delivery-dependent uptake of oxygen in ARDS. This observation resulted in fundamental change in the therapeutic strategies employed in these patients. Led by Robert Strieter, M.D. and Steven Kunkel, PhD, ARDS research at Michigan evolved to defining cellular and molecular processes responsible for the pathogenesis of acute lung injury. This work culminated in Michigan receiving an NIH/NHLBI SCOR in Acute Lung Injury in 1997, and was followed in 2003 by a Specialized Center of Clinically-Oriented Research (SCCOR) in Acute Lung Injury, directed by Theodore Standiford, MD. The centerpiece of this SCCOR was a randomized multi-center therapeutic trial to evaluate the role of GM-CSF on outcome in patients with ALI. This trial recruited 130 ALI patients and generated considerable clinical and biological data which continues to be interrogated. University of Michigan investigators were also active participants in the ARDS Network, a multi-institutional network performing clinical trials in patients with ARDS. Division ARDS Net investigators were instrumental in establishing the benefit of low tidal volume ventilation in ARDS (VALI trial), conservative fluid management (FACTT trial), and assessing the impact of corticosteroid on outcome (LASRS trial) in ARDS patients. Michigan has been named one of 12 sites nationally for the new Prevention and Early Treatment in Acute Lung Injury (PETAL) Network, an extension of the ARDS Network, led by Robert Hyzy and Theodore Standiford. Health services research is a rapidly evolving critical care research initiative. Dr. Iwashyna has published seminal papers describing cognitive and functional impairment in sepsis survivors. Additional health services research initiatives have included influence of sedation protocols on outcomes, regional variation in health care utilization, and end-of-life medical expenditures.
Lung Transplant Translational Biology
An expanding arena of translational research in the Division over the past decade has focused on the biology of lung transplantation, including acute and chronic allograft rejection. Division researchers, led by Vibha Lama, MBBS, MS, have developed animal models of lung allograft rejection to identify the presence and functional significance of locally-derived mesenchymal progenitor cells that promote obliterative bronchiolitis. This group has gone on to describe the function and prognostic significance of mesenchymal stem cells within the airspace of lung transplant recipients, observations that may lead to new therapies for lung transplant patients with acute and chronic rejection.
Our Education History
The Division has a distinguished history of medical education at the medical student, resident, fellow, and practicing physician level. Pulmonary faculty have provided didactic medical student teaching during the respiratory sequence, led small group session during M1 and M2 year, and experiential teaching during years three and four. Pulmonary faculty have also played a major role overseeing house staff on the CCMU service, the pulmonary consult service, the VA ICU and consultative service, the general medicine service, and up until July 2011, on the inpatient pulmonary services. PhD faculty within the division were the first department faculty to teach accredited undergraduate and graduate level courses within several basic science departments. This major teaching initiative has been led by Drs. Gary Huffnagle, Tom Moore, and Bethany Moore. Dr. Bethany Moore is also the first faculty member to serve as the Director of the Immunology Graduate Program.
Fellow training in Pulmonary and Critical Care Medicine has been a vital mission of the Division since its inception. Informal fellowship training began in the early-60’s, at which time the fellowship consisted of one year of clinical training. Drs. Davey and Green established the formal two-year fellowship in 1967, with the second optional year dedicated to research. Fellows rotated through the Old Main, the VA, and Wayne County Hospital. Tom Johnson, MD, a member of the first fellowship class, was the longest serving Dean at the University of North Dakota School of Medicine (from 1977-1988). With the incorporation of critical care and a greater emphasis on research training, the program transitioned to a three-year fellowship in the late 70’s. The program received full ACGME accreditation in July 1994. Dr. Toews served as Fellowship Program Director from 1987-1996, followed by Marc Peters-Golden from 1996-2011. Kevin Chan has been the Program Director since November 2011. The program has gradually expanded to its current number of five fellows per year in 2012. In the last several years, additional subspecialty rotations were added, including the surgical, cardiovascular, and trauma/burn ICUs. New outpatient electives included sleep, pulmonary hypertension, thoracic oncology, cystic fibrosis, and the lung transplantation. A very popular night float call system was initiated on July 1, 2011 to address duty hour restrictions.
Research training has been a major divisional focus since the early 80’s. The training environment was greatly enhanced by the acquisition of a NIH-sponsored training grant. The NIH/NHLBI T32 Multidisciplinary Training Program in Lung Disease has served as an ideal vehicle to train several generations of MD and PhD scientists, and has grown to be one of the largest and most successful post-graduate training grants focused on lung disease. Dr. Toews successfully acquired the first T32 training grant (originally titled Pulmonary Cellular and Molecular Biology Training Program) in July 1993, which initially funded four fellow slots. The number of slots funded increased to 12 in 2003, which is the current number of slots today. The program has been continuously funded for over 22 years, and has supported the early careers of nearly 100 scientists. Dr. Standiford was named Program Director in 2011, and the program was successfully competitively renewed in 2012. The competitive renewal incorporated new major areas of modern biology, including genetics/genomics, metagenomics, proteomics, metabolomics, stem cell biology, computational biology, and the microbiome. Emerging fields of patient-oriented research have been added or expanded, including health services research and sleep. The foundation of clinical research training including the Master's Degree training program in Clinical Research Design and Statistical Analysis within the University of Michigan School of Public Health and the Robert Woods Johnson Clinic Scholars Programs. The training program is truly multidisciplinary, as there are over 50 participating faculty drawn from six different Divisions and Departments.