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Pulmonology (Peds 406)

Introduction

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 routinely cover the Inpatient and Consult services, as well as the Bronchoscopy service on certain days. Attending and Fellow schedules for the period of time of your elective are available in the divison offices on Amion (access code: UNCPedsPulm!)

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. William Stoudemire; (email: william_stoudemire@med.unc.edu) coordinates the resident and medical student electives. You should meet (in persor or virtually) with Dr. Stoudemire 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. Stoudemire at any time.

First Day

Please page the fellow on service when you arrive. You can find the current fellow on the hospital directory.

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

  1. 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.
  2. 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.
  3. Understand the capabilities and limitations of specialized techniques (e.g., bronchoscopy, fluoroscopy, chest CT, lung ultrasound, chest MRI) to characterize airway, lung, pleural, and mediastinal disease.
  4. 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.
  5. Understand the natural history and recognize exacerbations of chronic lung diseases such as cystic fibrosis, asthma, interstitial lung diseases and bronchopulmonary dysplasia.
  6. 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.
  7. Understand the indications for performing tracheostomies in children and the inpatient/outpatient management of these children.
  8. 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 learner’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. Please discuss the topic of your presentation with the on-service fellow, attending or Dr. Stoudemire.

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), weekly BPD Huddles (with Neonatology) and a weekly Children’s Airway Center conference (multidisciplinary review of patients with complex airway issues).

Residents are expected to perform literature searches on topics pertaining to the patients they encounter in the inpatient and outpatient setting and review articles suggested to them by fellows/attendings.

Schedule

Most of the learner’s time will be 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 (Blue Ridge) Pulmonary Clinic is recommended to all residents/students. Schedule there varies so much of it must be arranged with faculty leader.

Faculty leader can assist with arrangement of additional experiences (observing sweat chloride testing, cardiopulmonary exercise challenge, home ventilator team, 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 or Fellow 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 or article 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. Please make sure to discuss your presentation with them and/or Dr. Stoudemire ahead of time.

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.

Bronchoscopy Service

Elective bronchoscopies are scheduled throughout the week 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
  • 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 via Zoom), where providers from the Pulmonary, ENT, GI, and Speech Therapy services review complex airway cases.

Outpatient Clinics

You should plan to spend some Tuesdays, Wednesdays, and Fridays in the Outpatient Pulmonary Clinic (main floor of Children’s Hospital, rooms 3-14). 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