Pulmonology (Peds 406)
The Pulmonary Division of the Department of Pediatrics at the University of North Carolina School of Medicine provides evaluation and management services for children with chronic respiratory diseases. The faculty and fellows in the division have expertise in the diagnosis and treatment of these disorders, and are also active in clinical, translational, and basic science research.
The clinical activities of the division consist of the Inpatient and Consultation Service, Bronchoscopy Service, Outpatient Clinics and Pediatric Pulmonary Function Testing. Separate attending pulmonologists are assigned to cover each of these areas. Fellows may or may not be on the clinical service during your elective. Attending and Fellow schedules for the period of time of your elective are available in the division offices at 450 MacNider (966-1055).
For this elective, you already have a list of specific objectives and criteria for evaluation. A more detailed list for each of our services is attached. Your individual goals may vary depending on your current stage of training and future plans. However, during your month on elective, it is suggested that you try to accomplish the tasks listed on the attached pages, at a minimum.
Dr. W. Adam Gower (beeper 919-216-5218; email: firstname.lastname@example.org) coordinates the resident and medical student electives. You should meet with Dr. Gower at the start of your elective to define goals for the month, and again at the end of the month to determine whether they were met. Additionally, questions about the rotation which arise during the month can be addressed to Dr. Gower at any time.
Please page the fellow on service when you arrive. You can find the current fellow on Pulmonary here
Objectives and Criteria for Evaluation
Specific objectives and criteria for evaluation of medical students and residents
I. Overall Educational Goal
The medical student and/or resident is expected to participate in the clinical management of pediatric patients with pulmonary disease under the direct supervision of a pediatric pulmonary attending, and to gain evaluative skills necessary for general pediatric practice. The clinical settings include the inpatient ward service, pediatric intensive care unit, neonatal intensive care unit, the pediatric pulmonary outpatient clinics, pediatric pulmonary function testing and the pediatric bronchoscopy service.
II. Specific Objectives
- Develop and demonstrate competent skills in obtaining a history and performing a physical examination focused on the pulmonary system, including but not limited to evaluation of breath sounds, work of breathing, lung consolidation and pleural effusion.
- Develop and demonstrate ability to interpret chest radiographs, arterial blood gas, pulse oximetry, pulmonary function tests, and respiratory tract cultures in the context of the overall pulmonary evaluation.
- Understand the capabilities and limitations of specialized techniques (e.g., bronchoscopy, fluoroscopy, chest CT, chest MRI) to characterize airway, lung, pleural, and mediastinal disease.
- Develop and demonstrate an orderly approach to evaluate pediatric patients with pulmonary disorders such as stridor, wheezing, chronic cough, apnea, recurrent pneumonia, chest pain and hemoptysis.
- Understand the natural history and recognize exacerbations of chronic lung diseases such as cystic fibrosis, asthma, interstitial lung diseases and bronchopulmonary dysplasia.
- Understand the appropriate use, risks and benefits of commonly used therapeutic modalities such as supplemental oxygen, airway clearance techniques, bronchodilators, diuretics, systemic and inhaled corticosteroids, and antibiotics.
- Understand the indications for performing tracheostomies in children and the inpatient/outpatient management of these children.
- Recognize obstructive sleep apnea and understand the evaluation, management and adverse effects of this disorder.
III. Learning Activities of the Rotation
The principal learning activity of residents and medical students during the Pediatric Pulmonary rotation involves assessment of inpatients and outpatients with prompt review by a pediatric pulmonologist. Immediate feedback on the resident’s assessment and treatment plan is provided. Experience in the bronchoscopy laboratory is primarily observational, to expose the student or resident to the structural correlates of respiratory symptoms.
Medical students and residents attend the biweekly Chest Conference, a multidisciplinary conference attended regularly by students, residents, and numerous subspecialists, including pediatric pulmonologists, pediatric infectious disease specialists, and pediatric radiologists, with occasional attendance by pediatric cardiologists, pediatric surgeons, cardiothoracic surgeons, and pathologists. The resident or medical student on the Pulmonary rotation is expected to prepare a short presentation for one Chest Conference, reviewing a topic that is mutually agreeable to the resident/student and the attending, and preferably relates to a current pulmonary patient.
Other conferences attended by residents/students on the Pulmonary rotation are a weekly pulmonary division clinical conference (pediatric pulmonary faculty and fellows discuss interesting patients, outpatients, and bronchoscopies), a weekly pediatric pulmonary division conference (faculty and fellows discuss pulmonary topics in depth), and a weekly Children’s Airway Center conference (multidisciplinary review of patients with complex airway issues).
Residents are expected to review a syllabus of reading material that has been compiled for their use and is available on the website, as well as perform literature searches on topics pertaining to the patients they encounter in the inpatient and outpatient setting.
Most of time spent in clinic, consults, bronchoscopy, educational conferences
Residents/Students are asked to tailor their elective to their wishes and needs based on career plans. For example, primary care-bound residents should spend more time in clinic, those planning PICU fellowship should focus on consults (Especially in PICU) and bronchoscopy.
Raleigh Pulmonary Clinic is recommended to all residents/students and takes place on most Tuesdays and Thursdays. Schedule there varies so much of it must be arranged with faculty leader. A fellow or attending can provide transportation to students who need it in order to attend the Raleigh clinic.
Faculty leader can assist with arrangement of additional experiences (observing sweat chloride testing, cardiopulmonary exercise challenge, infant pulmonary function testing, ENT clinic and OR for airway cases, etc.)
If rotation is overscheduled with learners, faculty leader will draft schedule for the month with input from learners and then allow residents and students to make trades depending on level of interest and any changes in their availability that may arise (interviews, back-up, etc.).
Inpatient and Consultation Service
The Attending on the inpatient service (and Fellow, if there is one on service) will be one of your supervisors for the elective, and will help fill out your evaluation at the end of the month. Input will also be obtained from other faculty members.
Suggested activities include:
- Do literature searches on patient related problems or topics of interest, synthesize a summary of your findings, and report back to the team. A website has been established for the Pediatric Pulmonology Division that includes a list of review articles. This is usually a good starting place for your reading, but you will often need to supplement this reading with more current articles from your literature searches.
- Participate in conferences relevant to the service (see attached schedule template)
- Learn history taking elements relevant to respiratory disease
- Learn chest physical examination skills and correlate with lung anatomy
- Learn basic interpretation of lung function studies including spirometry, blood gases, and pulse oximetry
- For most non-emergent inpatient consultations, do the initial history taking, physical examination, and gathering of data, and then present the case to the attending and fellow
- Participate in inpatient evaluation and management of cystic fibrosis (CF), asthma, apparent life-threatening event (ALTE), chronic lung disease of prematurity, gastroesophageal reflux-associated respiratory symptoms (apnea, recurrent pneumonia, wheezing), complicated pneumonia, hemoptysis, interstitial lung disease, immunocompromised children with pneumonia, tracheostomy dependent children, patients with upper airway obstruction/obstructive sleep apnea and suspected tuberculosis.
- Prepare and give a 10 minute presentation on a topic related to a patient of interest at Chest Conference. The Attending and/or Fellow will assist you with choice of patient and topic, and give you guidance as to the expected format of the talk.
You may also participate in Pulmonary team inpatient work rounds, which are held with the Blue Team. However, this is optional if you have already had rotations on the Blue team.
Elective bronchoscopies are scheduled on Tuesdays and Fridays in the Bronchoscopy Suite, intensive care units, and operating rooms. In general, you can ask the inpatient attending which procedures you should observe. Suggested activities include:
- Observe bronchoscopy for evaluation of atelectasis or to obtain cultures in CF; look at a cytospin slide from a CF patient’s bronchoalveolar lavage fluid
- Observe bronchoscopic evaluation for stridor or other upper airway obstruction
- Observe bronchoscopic evaluation for chronic wheezing
- Observe tracheostomy evaluation
- Observe fiberoptic intubation in children with critical airways
Attend meetings of the multidisciplinary Children’s Airway Center (Tuesday mornings at 7:30 am in the 6-Children’s conference room), where providers from the Pulmonary, ENT, GI, and Speech Therapy services review complex airway cases.
You should plan to spend some Tuesdays, Wednesdays, and Fridays in the Outpatient Pulmonary Clinic (main floor of Children’s Hospital, Clinic II). When you come to the clinic, you should ask an Attending to orient you and to help you decide which patients are best for you to see that day.
Suggested clinic activities include:
- Observe and discuss new patient with chronic cough
- Observe and discuss new patient with chronic wheezing
- Observe and discuss new patient with recurrent croup
- Observe and discuss return CF patient
- Observe and discuss return asthma patient
- Auscultate crackles and wheezes in young children
- Learn chest x-ray abnormalities associated with CF
- Observe spirometry and discuss interpretation with preceptor
- Perform forced expiratory maneuver/generate your own flow-volume curve
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Bronchopulmonary dysplasia/chronic lung disease
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Euler AR. Upper respiratory tract complications of gastroesophageal reflux in adult and pediatric-age patients. Dig Dis 1998;16(2):111-7.
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Interstitial lung disease
Das S, Langston C, Fan LL. Interstitial lung disease in children. Curr Opin Pediatr 2011; 23(3):325-31
Esther CR, Barker PM. Pulmonary lymphangiectasia: Diagnosis and clinical course. Pediatric Pulmonology 2004; 38:308-13.
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Finder JD, Birnkrant D, Carl J, et al, for the American Thoracic Society: Respiratory care of the patient with Duchenne muscular dystrophy. ATS Consensus Statement. Am J Respir Crit Care Med 2004;170:456-465
Katz SL. Assessement of sleep-disordered breathing in pediatric neuromuscular diseases. Pediatrics 2009; 123:S222-25
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Sharma GD. Pulmonary function testing in neuromuscular disorders. Pediatrics 2009;123:219-21
Schroth MK. Special considerations in respiratory management of SMA. Pediatrics 2009; 123:S245-9
Pneumonia and pleural diseases
Balfour-Lynn IM, Abrahamson E, Cohen J, et al. BTS guidelines for the management of pleural infection in children. Thorax 2005;60(suppl I):i1-i21
Boesch RP, Daines C, Willging JP, Kaul A, Cohen AP, Wood RE, Amin RS. Advances in the diagnosis and management of chronic pulmonary aspiration in children. Eur Respir J. 2006; 28(4):847-61
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Durbin WJ, Stille C. Pneumonia. Pediatr Rev. 2008;29(5):147-58
Eastham KM, Hammal DM, Parker L, Spencer DA. A follow-up study of children hospitalised with community-acquired pneumonia. Arch Dis Child. 2008;93(9):755-9
Fuller MK, Helmrath MA. Thoracic empyema, application of video-assisted thoracic surgery and its current management. Curr Opin Pediatr. 2007; 19(3):328-32.
Jaffe A, Calder AD, Owens CM, Stanojevic S, Sonnappa S. Role of routine computed tomography in paediatric pleural empyema. Thorax. 2008;63(10):897-902.
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McIntosh K. Community-acquired pneumonia in children. N Engl J Med. 2002;7;346(6):429-37.
Nissen MD. Congenital and neonatal pneumonia. Paediatr Respir Rev. 2007 Sep; 8(3):195-203.
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Pulmonary function testing
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AAP Task Force on Sudden Infant Death Syndrome: The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics 2005;116:1245-1255.
Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002;109(4):704-12.
Capdevila OS, Kheirandish-Gozal L, Dayyat E, Gozal D. Pediatric obstructive sleep apnea: complications, management, and long-term outcomes. Proc Am Thorac Soc. 2008 15;5(2):274-82.
Gozal D, Kheirandish-Gozal L. Sleep apnea in children–treatment considerations. Paediatr Respir Rev. 2006; 7 Suppl 1:S58-61.
Halbower AC, Ishman SL, McGinley BM. Childhood obstructive sleep-disordered breathing: a clinical update and discussion of technological innovations and challenges. Chest 2007; 132(6):2030-41
Katz ES, D’Ambrosio CM. Pathophysiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008 Feb 15;5(2):253-62.
Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008 Feb 15;5(2):242-52.
Moore M, Allison D, Rosen CL. A review of pediatric nonrespiratory sleep disorders. Chest 2006; 130(4):1252-62.
Shine NP, Lannigan FJ, Coates HL, Wilson A. Adenotonsillectomy for obstructive sleep apnea in obese children: effects on respiratory parameters and clinical outcome. Arch Otolaryngol Head Neck Surg 2006;132(10):1123-7.
Tamay Z, Akcay A, Kilic G, Suleyman A, Ones U, Guler N. Are physicians aware of obstructive sleep apnea in children? Sleep Med 2006;7(7):580-4.
Tarasiuk A, Greenberg-Dotan S, Simon-Tuval T, et al. Elevated morbidity and health care use in children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2007;175(1):55-61.
Tauman R, Gozal D. Obesity and obstructive sleep apnea in children. Paediatr Respir Rev 2006; 7(4):247-59.
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