General

By the end of training the resident should:

History

Understand the effect of pulmonary disease on normal growth and development

Understand the perinatal, genetic and environmental factors that pre-dispose to the development of respiratory problems

Understand normal fetal and perinatal development of the respiratory system

Understand normal respiratory physiology and pathophysiology

Know the epidemiology of local respiratory pathogens

Know that exercise intolerance may be a presenting symptom of chronic lung diseases (eg, asthma, interstitial lung disease) but may also have a range of non-respiratory causes

Know that upper respiratory tract infection and airway obstruction in young infants lead to respiratory distress

Be able to:

Identify symptoms suggestive of acute and chronic respiratory disease

Identify predisposing factors to the development of respiratory disease, biological (eg, neuromuscular and skeletal disorders and immunodeficiency) and environmental (eg, infections, smoking)

Identify features in the presentation which suggest serious or unusual pathology

Physical

Know the disorders associated with clubbing

Be able to:

Perform a complete examination of the upper airway and lungs

Recognize signs indicating upper and lower airway disease

Detect clubbing

Diagnosis

When evaluating lower airway disease, know when chest radiography is and is not indicated

Be able to:

              Perform and interpret basic lung function tests (eg, peak flow, spirometry)

Perform and interpret blood gas measurements

Perform and interpret chest radiography

Utilize more complex radiological investigations (eg, ventilation perfusion scans, CT scan, video-fluroscopy) consulting a specialist when necessary

Refer appropriately children needing bronchoscopy for diagnostic evaluation

Effectively use a range of diagnostic studies to evaluate a child with an undifferentiated respiratory ailment

Management

Be able to:

Assess and initiate management of patients presenting with respiratory problems in acute and outpatient settings

Undertake long term management of some chronic respiratory problems

Consult with specialists effectively

General signs and symptoms (including distress and severe respiratory distress)

By the end of training the resident should:

Stridor

History

Know the causes of acute and chronic stridor in children of different ages (eg, infection, laryngo-tracheo-bronchomalacia, subglottic stenosis, vocal cord paralysis, subglottic hemangiomata)

Know the importance of a history of previous endotracheal intubation

Understand the potentially life-threatening nature of acute stridor

Be able to:

Elicit factors in the history that may predispose to, or be the cause of, stridor

Identify children with existing chronic upper airway problems

Physical

Be able to:

Distinguish between upper and lower airway obstruction

Diagnosis

Be able to:

Formulate the differential diagnosis of congenital stridor, acute and chronic stridor

Appropriately utilize endoscopy as the diagnostic tool of choice for laryngeal and vocal cord disorders

Management

Be able to:

Identify those causes of stridor that require specialty referral

Plan the appropriate management for stridor of various etiologies

Respiratory failure

History

Know the parameters of respiratory failure

Physical

Be able to:

Recognize the manifestations of chronic hypoxemia: polycythemia, pulmonary hypertension, cor pulmonale

Recognize the clinical manifestations of acute hypercapnia: flushing, agitation, confusion, tachycardia, headache

Diagnosis

Be able to:

Recognize the combination of arterial blood gas values that indicate chronic carbon dioxide retention (eg, increased PCO2, normal pH, increased serum bicarbonate concentration, increased base excess)

Recognize the arterial blood gas values associated with acute respiratory failure in a normal child as well as one with chronic respiratory failure

Management

Know the potential risks and benefits of administering oxygen to children with chronic respiratory failure

Understand the indications for mechanical ventilation and non-invasive forms of assisted ventilation

Be able to:

Initiate treatment, including assisted ventilation, for a child with acute respiratory failure

Consult with other pediatricians, anesthetists, and intensivists when appropriate

Cough (acute and chronic)

History

Know that cough is a major, and at times the only, manifestation of asthma

Know which conditions impair the effectiveness of cough (eg, cerebral palsy, muscle weakness, vocal cord dysfunction, CNS disease, thoracic deformities, pain)

Be able to

Elicit features in the history that suggest that a cough may be psychogenic rather than indicative of respiratory pathology

Physical

Be able to

Elicit physical signs that may accompany cough (eg, wheeze, decreased breath sounds)

Diagnosis

Be able to:

Formulate the differential diagnosis of chronic cough in children of different ages

Plan the initial screening evaluation of a chronic cough

Management

Understand the limited indications for cough suppressants

Be able to:

Refer to a specialist a child who has a persistent cough unresponsive to treatment

Apnea (for Neonatal Apnea see Critical Care of the Newborn: Apnea, for Sleep apnea see Rehabilitation: Sleep Related Disorders)

Wheezing (see also Asthma)

History

Know the causes of wheezing (eg asthma, respiratory infection, vocal cord dysfunction, tracheomalacia, respiratory tract obstruction due to external compression, foreign body)

Be able to:

Elicit an accurate history of the onset, timing, duration and precipitating factors associated with wheezing

Physical

Be aware that the absence of wheezing does not preclude lower airway obstruction

Know that the expiratory phase of respiration is often prolonged in lower airway obstruction

Be able to:

Identify true wheezing on physical examination

Diagnosis

Know that persistent wheezing unresponsive to bronchodilators or unilateral wheezing is an important indication for bronchoscopy

Be able to:

Develop a differential diagnosis of recurrent or persistent wheezing

Plan the appropriate clinical and diagnostic evaluation of wheezing of various etiologies

Management

Be able to:

              Plan the appropriate management for wheezing of various etiologies

Tachypnea

History

Know the normal respiratory rates for age and the variations that occur with sleep, eating, and activity in normal children

Know the non-pulmonary causes of tachypnea

Physical

Be able to

Identify abnormal respiratory rates in children of varying ages

Identify any associated respiratory signs eg recession, wheeze

Diagnosis

Be able to:

Formulate a differential diagnosis in a child with a raised respiratory rate

Plan the appropriate diagnostic evaluation of a child with tachypnea of various etiologies

Management

Be able to:

Plan the management of tachypnea according to the cause

Hemoptysis

History

Know that hemoptysis is unusual in children

Know that hemosiderosis is associated with hemoptysis

Be able to:

Assess severity of hemoptysis based on history

Physical

Be able to:

Evaluate the upper airway including mouth and nose for bleeding sources

Diagnosis

Know the indications for bronchoscopy

Be able to:

Formulate the differential diagnosis of hemoptysis in children of varying ages

Management

Be able to:

Plan the initial management of hemoptysis in children and adolescents

Cyanosis (for non-respiratory cyanosis see Critical Care of in Neonates and Cardiology)

History

Know that cyanosis is not a sensitive indicator of oxyhemoglobin desaturation

Know the common extrapulmonary causes of cyanosis: right-to-left shunt, methemoglobinemia, acrocyanosis

Physical

Know that different skin colors and races affect appearance of cyanosis

Be able to:

Identify features that differentiate between central and peripheral cyanosis

Diagnosis

Be able to:

Measure and interpret peripheral oxygen saturation

Interpret blood gas analysis

Management

Know when oxygen therapy is appropriate

Be able to:

Initiate supportive treatment

Formulate a treatment plan according to the causes of cyanosis

Initiate appropriate consultations

Snoring or features of sleep obstruction

History

Know the causes of snoring

Physical

Be able to:

Recognize this condition and its complications

Diagnosis

Be able to:

Initiate sleep studies appropriately when indicated

Management

Be able to:

Refer appropriately to an ENT surgeon

Upper airway

Croup (see Otolaryngology)

Epiglottitis (see Otolaryngology)

Foreign body (see also Otolarngology)

History

Know the risk factors and age groups at risk for foreign body aspiration

Understand that foreign body aspiration may present with a variety of symptoms depending on the level of obstruction (eg, stridor, wheezing, chronic pneumonia)

Be able to:

Elicit a history suggestive of inhalation of a foreign body (eg, initial choking or coughing after foreign body ingestion is often followed by an asymptomatic period)

Physical

Be able to:

Perform an appropriate physical examination including lung auscultation

Diagnosis

Be able to:

Utilize, and understand the shortcomings of, radiographic techniques to diagnose an aspirated foreign body

Management

Know the utility of fiber-optic and rigid bronchoscopy in the diagnosis and management of foreign body aspiration

Be able to:

Perform emergency airway clearance maneuvers

Refer appropriately to a specialist

Tracheomalacia (see also Otolaryngology: Laryngomalacia)

History

Know that tracheomalacia can occur as a complication of chronic mechanical ventilation in children

Know that tracheoesophageal fistula may result in tracheomalacia

Know that severe malacia may present as ventilator dependency in the neonatal period

Know that those with milder involvement present with more non specific symptoms (eg, cough, recurrent infections, shortness of breath, wheeze, stridor)

Physical

Be able to:

Recognize the clinical signs of tracheomalacia

Diagnosis

Be able to:

Distinguish between tracheomalacia and other causes of respiratory symptoms

Rule out more serious diagnoses, such as vascular ring or tumors

Management

Be able to:

Initiate appropriate management of tracheomalacia

Refer to specialists as appropriate

Trache-esophageal fistula (see Critical Care in Neonates)

Bacterial tracheitis

History

Know the typical clinical course of bacterial tracheitis, including biphasic illness, precipitous worsening, requirement for intubation, and relatively prolonged intubation

Know the microbiology of bacterial tracheitis

Be able to:

Elicit the symptoms of bacterial tracheitis

Physical

Be able to:

Recognize the signs of bacterial tracheitis

Diagnosis

Know that definitive diagnosis is usually made at laryngoscopy

Be able to:

Formulate the differential diagnosis for tracheitis

Management

Be able to:

Initiate the treatment of bacterial tracheitis

Provide supportive airway management

Consult with specialists as necessary

Lower airway

Vascular abnormalities

History

Be able to:

Elicit the presenting symptoms of vascular airway anomalies (eg, stridor, wheezing, cugh, recurrent infections)

Physical

Know that there are usually no diagnostic physical findings

Diagnosis

Be able to:

Use the diagnostic modalities that facilitate identification of vascular anomalies obstructing the airway (eg, barium swallow, echocardiography, MRI, CT scan)

Management

Be able to:

Consult with specialists appropriately for indications and timing of surgery

Congenital malformations

History

Be aware of the congenital malformations of the lung (eg, absence of lobe or lung, small lungs, cystic lungs)

Know the symptoms that may be caused by congenital malformations of the lung

Physical

Diagnosis

Be familiar with the radiographic appearance of various congenital malformations of the lung

Management

Be able to:

Appropriately refer children with congenital malformations of the lung for surgical intervention

Bronchiolitis (see also Infectious Diseases)

History

Know that although the majority are associated with respiratory syncitial virus a wide range of other viruses cause a similar clinical picture

Know factors that predispose to severe symptoms (eg, prematurity, cardiovascular disease, chronic respiratory disease, immunosuppression)

Be able to:

Elicit symptoms associated with bronchiolitis

Identify factors that may predispose to severe disease

Physical

Be able to:

Identify the clinical manifestations of bronchiolitis (eg, tachypnea, recession,  crackles and wheeze)

Identify signs of severe illness (eg, apnea, listlessness, cyanosis, decreased level of consciousness)

Diagnosis

Know the uses and limitations of rapid antigen testing for viral pathogens

Know that chest Xray is rarely helpful

Be able to:

Make a diagnosis of bronchiolitis based on history and physical

Management

Know that bronchiolitis is associated with increased morbidity in the early years of life due to the development of chronic symptoms

Be aware of immunoprophylaxis against Respiratory Syncitial Virus

Be able to:

Appropriately admit a child with bronchiolitis to the hospital

Initiate the appropriate supportive management of a child with bronchiolitis

Aspiration syndromes ( See also Upper Airway: Foreign Body)

History

Know the long-term complications of foreign body aspiration

Know that there is often no history of foreign body aspiration

Know the pulmonary complications of gastroesophageal reflux

Know that recurrent aspiration can recur with swallowing disorders independent of gastroesophageal reflux

Understand that hydrocarbon pneumonitis may cause acute and chronic lung disease

Know that aspiration can occur despite the presence of a tracheostomy

Be able to:

Elicit a history suggestive of aspiration

Physical

Understand that foreign body aspiration may present with a variety of physical signs

Diagnosis

Be able to:

Evaluate for suspected aspiration

Recognize on x-ray the possible radiographic manifestations of foreign body aspiration

Management

Be able to:

Plan the management of a patient with aspiration of a foreign body

Plan the management of hydrocarbon pneumonitis

Bronchiectasis

History

Know the conditions which may predispose to the development of bronchiectasis (eg, infection: measles, pertussis, TB; cystic fibrosis, foreign body, gastro-esephageal reflux, immunodeficiency, primary ciliary dyskinesia)

Be able to:

Elicit symptoms suggestive of bronchiectasis (eg, chronic cough, purulent sputum, recurrent chest infections)

Physical

Be able to:

Detect the physical findings associated with bronchiectasis

Diagnosis

Be able to:

Formulate the differential diagnosis of bronchiectasis

Utilize investigations to elicit the underlying cause (eg, sweat test, pH studies, immune function, ciliary function tests)

Use appropriate radiological imaging studies of the chest to arrive at the diagnosis of bronchiectasis in a child

Management

Be able to:

Treat acute exacerbations of infections guided by microbiological analysis

Work collaboratively with physical therapists to provide physiotherapy

Refer to specialists as necessary

Pneumonia (see also Critical Care in Children: Pneumonia, bronchiolitis; Critical Care in Neonates: Congenital Pneumonia; for specific organism see Infectious Diseases)

History

Know the definitions of community-acquired, nosocomial, pneumonia and slowly resolving pneumonia

Know the etiologies (bacterial/viral/ fungal/mycobacterial/parasitic ) of pneumonia in children of different ages and in those that are immunosuppressed

Know the major acute and chronic complications of pneumonia, (eg, empyema, sepsis, pneumothorax, bronchopleural fistula, and pneumatoceles)

Know which organisms are likely to cause the pleural and parenchymal complications

Know which congenital lesions of the lung may mimic pneumonia

Understand the significance of pneumonia in a child with neuromuscular disease

Understand the importance of immunization status of a child with pneumonia

Understand the contribution of pneumonia to global under-5 mortality and the patterns of infection in developed and developing countries

Understand the factors responsible for the changing incidence in pneumonia in different countries

Understand the significance of symptoms such as tachypnea and chest pain

Be able to:

Elicit symptoms that are suggestive of the development of pneumonia

Identify factors that may predispose to the development and transmission of pneumonia

Understand the pathogenesis of pneumonia including the role of normal protective mechanisms

Physical

Know the differences in clinical presentation of different types of pneumonia and in children of different ages

Be able to:

Detect the range of findings that may be found in pneumonia (eg, dullness on percussion, abnormal tactile or vocal fremitus, reduced breath sounds, crackles, bronchial breathing, and a friction rub)

Diagnosis

Know the Integrated Management of Children Illness (IMCI) guidance on the differential diagnosis of cough and difficulty in breathing in children and the classification of pneumonia

Understand the diagnostic value and limitations of laboratory and radiological investigations

Know the indications for the use of sonography, CT scan, bronchoscopy, pleural tap, and open lung biopsy

Be able to:

Interpret the significance of tachypnea, chest in-drawing, and cyanosis in a child with respiratory distress

Interpret physical signs to identify the site of consolidation and clinical complications such as empyema or pleural effusion or pneumothorax

Interpret appropriate laboratory investigations

Identify the usual radiological features of bacterial and viral pneumonia and the distinguishing radiological features of staphylococcus, pneumococcus, tuberculosis, mycoplasma, and chlamydia pneumonia

Refer for invasive studies (eg, bronchoscopy) when indicated in the evaluation of pneumonia

Arrive at the differential diagnosis of recurrent pneumonia

Perform a diagnostic pleural tap if indicated

Management

Be aware of local, national, and international guidelines on the management of pneumonia

Know the factors which determine the selection of appropriate antibiotics and duration of treatment for a child with pneumonia

Understand the role of empiric therapy

Understand the expected clinical course of a child who is treated appropriately and the factors that should be considered in a child with slowly resolving pneumonia

Understand the factors involved in global programs for the prevention and/or control of pneumonia

Be able to:

Identify when a child requires hospitalization

Interpret and act upon oximeter monitoring

Apply the IMCI guidance on the management of pneumonia including appropriate antimicrobial therapy, oxygen, and supportive care appropriate to the severity of pneumonia

Take into consideration any underlying conditions such as immunosuppression or neuromuscular disease

Work collaboratively with other health professionals including nurses, physiotherapists and community health workers

Manage complications such as pleural effusions and empyema, referring to other specialists as appropriate

Explain clinical course and prognosis to the child and care givers, including when the child can be safely discharged

Discuss with families and other health care workers the role of immunization and antimicrobial prophylaxis in preventing pneumonia, including the relative effectiveness of these measures

Lung abscess

History

Know the pattern of illness in children who develop lung abscess following uncomplicated pneumonia

Understand the epidemiology and organisms associated with development of lung abscess

Physical

Recognize that the physical exam in patients with lung abscess is most often non-specific and consistent with that of simple pneumonia

Diagnosis

Be able to:

Use chest radiography and CT to identify lung abscess

Management

Understand that, depending on etiology, surgical intervention is often not necessary

Be able to:

Appropriately plan and manage the medical therapy for lung abscess

Refer to specialists appropriately

Pulmonary eosinophilia

History

Know the potential causes of pulmonary eosinophilia (eg, Infection: Ascaris Toxocara, Strongyloides infections Drugs: aspirin, penicillins, sulphonamides)

Know symptoms include cough, wheezing, shortness of breath, hemoptysis, weight loss)

Physical

Know that physical examination findings are not specific

Diagnosis

Know the differential diagnosis of pulmonary eosinophilia

Be able to:

Utilize blood and radiological investigations to help make diagnosis

Management

Plan management based on likely etiology

Asthma

By the end of training, the resident should:

History

Know that asthmatic patients may have bronchial hyper-responsiveness to exercise, viral URI, allergen exposure, weather changes, smoke pollutants and other irritants, aspirin, and beta adrenergic blocking drugs

Know that children with early-onset asthma (< 3 years of age) who have a parental history of asthma, a confirmed diagnosis of atopic dermatitis, or sensitization to aeroallergens are least likely to outgrow asthma

Understand the pathophysiology of asthma and its treatment

Know about the patterns of asthma and contributing factors

Be able to:

Identify the presence of atopic dermatitis (eczema) as an indicator of potentially more severe and persistent asthma

Elicit a history of non-specific symptoms that may be indicative of asthma such as nighttime cough

Identify the symptoms associated with exercise induced asthma

Physical

Be able to:

Assess the severity of an asthma attack         

Identify the development of atelectasis during an acute asthma exacerbation

Identify the signs of poorly controlled asthma

Identify other signs of atopy

Identify the presence of wheezing on lung examination

Assess reversibility

Diagnosis

Know the indications for chest radiography in an acute wheezing episode

Be able to:

Classify asthma based on frequency and severity of symptoms

Interpret pulmonary function tests in a patient with asthma

Identify the characteristics of exercise-induced asthma (eg, coughing and wheezing 5 to 6 minutes after exercise with gradual improvement after 20 to 30 minutes of rest)

Management

Know that exercised-induced asthma may be a sign of poorly controlled asthma

Know that corticosteroids in an acute exacerbation of asthma can increase adrenergic response, improve FEV1, and improve oxygenation

Understand the risks and benefits of inhaled corticosteroids

Know the kinetics of short- and long-acting inhaled beta-adrenergic agonists

Know that excessive daily use of beta adrenergic agonists has been associated with increased mortality and with diminished symptom control in asthma

Know that corticosteroids interfere with the late-phase but not the immediate response to allergen exposure

Know that long-term treatment with inhaled corticosteroids decreases bronchial inflammation and bronchial hyperresponsiveness

Know the role of leukotriene antagonists in the management of asthma

Know the importance of self-assessment in a patient with asthma

Know the importance of patient education in asthma management

Know about the complications of long-term use of medications for asthma

Be able to:

Develop a discharge plan for a hospitalized asthmatic child that includes assessment of potential asthma triggers in the home, school, and neighborhood

Plan the most appropriate treatment for a patient with an acute exacerbation of asthma

Recognize the clinical manifestations of toxicity to adrenergic agonists (eg, muscular tremor, tachycardia, hypokalemia)

Recognize the characteristics of a child at increased risk of ICU hospitalization because of asthma (eg, one or more life-threatening episodes, severe asthma requiring chronic steroids, poor control of daily symptoms, abnormal FEV1, poor adherence, depression/stress)

Plan appropriate outpatient treatment of mild, moderate, or severe persistent asthma to include daily anti-inflammatory drugs

Institute appropriate emergency treatment 

Recognize when help of other colleagues is needed             

Lead treatment of severe asthma and review ongoing treatment     

Institute age-appropriate individualized management plan for asthma

Teach children how to use a peak flow meter, journal, and to assess inhaler technique

Modify an asthma management plan appropriately

Ensure the child has access to emergency treatment at school and other settings

Identify impending respiratory failure during an acute asthma exacerbation

Cystic fibrosis

By the end of training, the residents should:

History

Understand the pathogenesis, genetics and natural history of cystic fibrosis

Know the common microbial pathogens involved in the pulmonary complications of cystic fibrosis

Understand the inheritance issues related to cystic fibrosis

Know the association of rectal prolapse and cystic fibrosis

Know that hemoptysis and pneumothorax can be potentially life-threatening complications of cystic fibrosis

Know that children with cystic fibrosis may present with failure to thrive and/or recurrent respiratory infections.

Be able to:

Identify respiratory symptoms suggestive of cystic fibrosis

Identify the non-pulmonary manifestations of cystic fibrosis in the neonatal period (eg, meconium ileus, meconium peritonitis, and prolonged jaundice)

Identify gastrointestinal symptoms suggestive of cystic fibrosis (eg, steatorrhea, failure to thrive, intestinal obstruction)

Identify the common extrapulmonary complications of cystic fibrosis (eg, liver disease, diabetes, salt depletion, low bone mineral density)

Physical

Be able to:

Identify clubbing and any chest signs

Assess nutritional status

Identify signs of complications (eg, edema secondary to hypoproteinemia, hepatomegaly)

Diagnosis

Be aware of the uses and shortcomings of various testing modalities for cystic fibrosis, including antenatal and neonatal screening

Be able to:

Plan the appropriate diagnostic evaluation of a child suspected of having cystic fibrosis

Recognize and diagnose exocrine pancreatic insufficiency in infants

Utilize investigations to diagnose complications of cystic fibrosis

Management

Know the indications for aggressive management with antimicrobial therapy for cystic fibrosis

Understand the need for supplemental calories, pancreatic enzymes, and fat-soluble vitamins in patients with cystic fibrosis

Understand the management of pulmonary disease (eg, inhaled antibiotics, DNase) in patients with cystic fibrosis

Be able to:

Manage a child with cystic fibrosis in partnership with a specialist

Work with a multi-disciplinary team, particularly physiotherapy and dieticians

Recognize the importance of planning for survival into adulthood for patients with cystic fibrosis

Plan appropriate management of a patient with extra-pulmonary complications of cystic fibrosis

Primary ciliary dyskinesia (dysmotile cilia syndrome)

By the end of training, the resident should:

History

Know that otitis media, recurrent sinusitis, dextrocardia, and/or bronchiectasis may be due to primary ciliary dyskinesia

Physical

Be able to:

Diagnose situs inversus on physical exam

Diagnosis

Be able to:

Plan the appropriate diagnostic evaluation of a patient suspected of having primary ciliary dyskinesia, including exclusion of other diagnosis

Management

Consult appropriately with specialists in the ongoing management of patients with primary ciliary dyskinesia

Extrapulmonary

By the end of training, the resident should:

Pleural fluid/empyma

History

Understand the etiologies of pleural fluid accumulations (eg, transudate, exudates, empyema, chylothorax)

Physical

Be able to:

Detect the physical findings associated with accumulation of pleural fluid

Diagnosis

Be able to:

Diagnose the presence of pleural fluid with an imaging study of the chest

Management

Be able to:

Manage accumulation of chest fluid according to the cause and in association with specialist as necessary

Pneumothorax, pneumomediastinum

History

Know that spontaneous pneumothoraces occur and may recur in young asthenic boys

Know the natural history of spontaneous pneumothorax

Know that asthma may be associated with pneumothorax and/or pneumomediastinum

Know that pneumothorax may be a complication of resuscitation and mechanical ventilation

Physical

Be able to:

              Identify the signs and symptoms of pneumothorax

              Identify tension pneumothorax

              Identify subcutaneous emphysema

Diagnosis

Be able to:

              Formulate a differential diagnosis

              Identify pneumothorax and/or pneumomediastinum on chest radiograph

Management

Understand that pneumomediastinum usually requires no intervention

Be able to:

Plan and initiate the appropriate therapy for a child with pneumothorax

Thoracic deformities (see also Musculoskeletal Disorders: Kyphosis and Scoliosis)

History

Know the association between scoliosis and restrictive pulmonary disease

Know that severe progressive neuromuscular disease of any etiology can produce serious restrictive pulmonary disease

Know that pectus excavatum is not usually associated with pulmonary disease or exercise limitation

Physical

Be able to:

Identify thoracic deformities

Diagnosis

Know that pulmonary function has to be evaluated in patients with rigid  kyphosis

Management

Be able to:

Refer to specialist as appropriate

Mediastinal masses including lymph nodes

History

Know the symptoms associated with a mediastinal mass

Physical

Be able to:

Identify jugular venous distention, persistent/irreversible wheezing, hoarseness, and arrhythmia as signs of mediastinal mass and compression

Diagnosis

Be able to:

Utilize chest radiography and computerized tomography to assist in the diagnosis of a mediastinal mass

Management

Understand the risks of sedation in a patient with a mediastinal mass

Be able to:

Refer to appropriate specialist

Pulmonary hypertension and cor pulmonale

By the end of training, the resident should:

History

Know that oxygenation may decrease during abnormal sleep, which may cause pulmonary hypertension or exacerbate existing cor pulmonale

Know that pulmonary hypertension is potentially reversible

Know the situations in which pulmonary hypertension and cor pulmonale may occur

Physical

Know that there are no specific physical findings associated with pulmonary hypertension until it becomes very severe

Diagnosis

Understand the echocardiographic findings that are associated with pulmonary hypertension

Management

Know that certain medications may be useful in the management of pulmonary hypertension

Respiratory sleep disorders (see also Rehabilitation: Sleep related disorders)

By the end of training, the resident should:

History

Know the respiratory and non-respiratory conditions that may cause sleep disorders

Know that children with severe obstructive apnea due to upper airway obstruction are at significant risk for respiratory distress postoperatively (eg, due to postoperative airway swelling, postoperative obstructive pulmonary edema)

Know common causes of somnolence in adolescents

Know that narcolepsy can be present in adolescents

Know that prescribed and over-the-counter medications may affect sleep

Be able to:

Take an accurate history to elicit symptoms suggestive of disordered sleep (eg, snoring, apnea, cor pulmonale, growth failure, daytime somnulence)

Physical

Be able to:

Identify physical signs suggestive of chronic hypoxemia

Diagnosis

Understand the role of sleep physiology studies (eg, polysomnography, pneumotachograph, respiratory inductance plethysmography,) together with pulse oximetry and blood gas analysis in making a diagnosis of a sleep disorder

Be able to:

Formulate the differential diagnosis of obstructive sleep apnea in children

Management

Know the indications for surgery in adenoid/tonsillar hypertrophy causing obstructive sleep apnea

Know which respiratory conditions may be managed by home ventilation support (eg, obstructive airways disease, parenchymal lung diseases; cystic fibrosis and bronchopulmonary dysplasia and disorders control of ventilation)

Know the advantages and disadvantages of home mechanical ventilation

Understand the ethical issues surrounding long-term ventilation support

Be able to:

Consult with physiotherapists to provide chest physiotherapy to prevent complications of chronic lung disease and ventilation difficulties

Refer to specialists for the provision of home ventilation if this is available in your locality

Sudden infant death syndrome/ acute life threatening events

By the end of training, the resident should:

History

Know the risk factors for sudden infant death syndrome (unexpected infant deaths)

Be able to

Collect, with sensitivity, as much information as possible about factors that may have contributed to an infant’s unexpected death.

Physical

Be able to:

Recognize a child with an apparent life-threatening event (ALTE)

Diagnosis

Be able to:

Exclude identifiable causes of apparent life-threatening events (ALTE) in infancy(eg,  infection, metabolic abnormality, gastroesophageal reflux, aspiration, cardiac dysrhythmia, seizures, non-accidental trauma, apnea of infancy)

Recognize the limitations of cardiorespiratory ("apnea") monitors in following infants with apparent life-threatening events (ALTE)

Management

Be able to:

Provide initial resuscitation as appropriate in a child with and an apparent life-threatening event (ALTE)

Counsel families who have had a child who has had an acute life threatening event or and unexplained death about avoidance of risk factors

Work collaboratively with other professionals in investigating and supporting families of a child who has had an acute life threatening event or unexplained death