2024-2025 M3/M4 Course Syllabi
Pediatrics
COURSE NUMBER:
16 01 86
TITLE:
PEDIATRIC PULMONOLOGY -ICE
This clinical elective combines outpatient, inpatient and observation of procedures. Students will learn the diagnostic approach and current management of a wide range of pulmonary conditions and/or chronic respiratory symptoms including but not limited to: Asthma Cystic fibrosis Chronic cough and chest congestion Wheezing Dyspnea on Exertion Recurrent respiratory infections (e.g. pneumonias, bronchitis) Chronic aspiration into the airways Acute and chronic respiratory failure in children with neuromuscular diseases, restrictive lung disease, central alveolar hypoventilation, chronic lung disease of prematurity, mechanical ventilation in children with chronic respiratory failure and acute on chronic respiratory failure Airway abnormalities and Obstruction (e.g., obstructive sleep apnea, congenital anomalies, acquired subglottic stenosis, hypoplastic lungs, etc) Sleep disorders (e.g., obstructive and/or Central Sleep apnea, non-invasive positive pressure ventilation- CPAP, BIPAP)
PREREQUISITES:
26961373 (PEDIATRICS CORE CLKSP), 26961373 (PEDIATRICS CORE CLKSP)

Must have passed the Pediatric Core Clerkship
expand all

GENERAL INFORMATION

COURSE YEAR:
M4
CREDIT HOURS:
8
CREDIT WEEKS:
4
DOMESTIC VISITING:
YES
INTERNATIONAL VISITING:
YES
GRADED:
Honors/High Pass/Pass/Fail
COURSE QUALIFICATIONS:
ICE
STATUS:
Full-Time   
OFFERED AS FULL-TIME AND PART-TIME: NO
ALLOWS OVERLAP: NO
COURSE LENGTH:
2 or 4 weeks
DIRECTOR:
Cherie Torres-Silva, MD, MPH, MEd
Cherie.Torres-Silva@cchmc.org
(513) 636-6771
S Building, 9.548
ADMINISTRATIVE SUPPORT PERSON:
Mimi Pence
Mimi.Pence@cchmc.org
513-636-0339
Kasota Building, 7th Floor at CCHMC, BN7.722
SITE(S):
CCHMC - Burnet Campus
CCHMC - Liberty Campus
MAX ENROLL:
1 
ROTATIONS:
Rotation Dates Max
1 05/06/2024 - 05/17/2024 1
1 05/06/2024 - 05/31/2024 1
2 06/03/2024 - 06/14/2024 1
2 06/03/2024 - 06/28/2024 1
2 06/17/2024 - 06/28/2024 1
3 07/01/2024 - 07/12/2024 1
3 07/01/2024 - 07/26/2024 1
3 07/15/2024 - 07/26/2024 1
4 07/29/2024 - 08/09/2024 1
4 07/29/2024 - 08/23/2024 1
4 08/12/2024 - 08/23/2024 1
5 08/26/2024 - 09/06/2024 1
5 08/26/2024 - 09/20/2024 1
5 09/09/2024 - 09/20/2024 1
6 09/23/2024 - 10/04/2024 1
6 09/23/2024 - 10/18/2024 1
6 10/07/2024 - 10/18/2024 1
7 10/21/2024 - 11/01/2024 1
7 10/21/2024 - 11/15/2024 1
7 11/04/2024 - 11/15/2024 1
8 11/18/2024 - 12/13/2024 1
8 12/02/2024 - 12/13/2024 1
9 12/16/2024 - 01/10/2025 1
9 12/30/2024 - 01/10/2025 1
10 01/13/2025 - 02/07/2025 0
11 02/10/2025 - 02/21/2025 1
11 02/10/2025 - 03/07/2025 1
11 02/24/2025 - 03/07/2025 1
12 03/10/2025 - 03/21/2025 1
12 03/10/2025 - 04/04/2025 1
12 03/24/2025 - 04/04/2025 1
13 04/07/2025 - 04/18/2025 1
13 04/07/2025 - 05/02/2025 1
13 04/21/2025 - 05/02/2025 1

NOTE: If a rotation is offered in both 2 and 4 week slots, the max capacity is limited to the actual spots offered for the 4 weeks. (ie: the 2 week rotations listed share the max of the 4 week rotation)
WORKING HOURS:
8:00 a.m. - 5:00 p.m., Monday - Friday
REPORT 1ST DAY:
You will receive an email with detailed information prior to the elective from the department that will provide all the details regarding time and location to report for your elective. You may contact Ms. Tiffiney Wunsch, Tiffiney.Wunsch@cchmc.org, or Dr. Cherie Torres-Silva (Pulm Clerkship/Elective director) at cherie.torres-silva@cchmc.org if you have questions or specific requests regarding areas of interests and preferences to be assigned during your rotation.

INSTRUCTION

LEARNING ACTIVITIES:
  • Case-Based Instruction/Learning
  • Clinical Experience - Inpatient
  • Conference
  • Journal Club
  • Lecture
  • Patient Presentation--Faculty
  • Patient Presentation--Learner
  • Research
  • Self-Directed Learning (Learners take initiative for their own learning; diagnosing needs; formulating goals; identifying resources; implementing appropriate activities; and evaluating outcomes.)
  • Ward Rounds
LEARNING ENVIRONMENT POLICIES:
UCCOM strives to provide medical students with a learning environment that is conducive to their professional growth. All UCCOM and visiting medical students are encouraged to review the Student Handbook.

The Office of Student Affairs and Admissions is available to all UCCOM and visiting medical students to discuss any concerns/questions related to the learning environment. Please call 558-6796 to access faculty/staff that can assist you.
TEACHING:
50% Attending Physician
20% Senior Resident
5% Junior Resident
5% Respiratory Therapist
20% Fellow Physician
FEEDBACK:
ASSESSMENT:
 Participation in Clinical activities including contributions in rounds and patients presentations in the inpatient and outpatient setting

ASSESSMENT METHODS:
Clinical Performance Rating/Checklist
Oral Patient Presentation
Participation
FINAL GRADE:
GRADE ASSIGNED BY: Course director

OBJECTIVES

Curricular Resources :
PRIMARY TEXT: Disorders of the Respiratory Tract in Children.  Kendig 9th Edition

REVIEW QUESTIONS: Comprehensive portfolio of review questions given to cover Pediatric Respiratory Diseases

RESOURCES

Pulmonary Medicine CCHMC Team Home Web-page in CenterLink: http://centerlink.cchmc.org/department/residents/team-home-pages/pulmonary-team-home-page

Respiratory Guidelines per Cystic Fibrosis Foundation: https://www.cff.org/Care/Clinical-Care-Guidelines/Respiratory-Care-Guidelines/

American Thoracic Society: Pediatrics Lung Diseases and Development Guidelines: https://www.thoracic.org/statements/pediatric.php

Online Lectures in Respiratory Physiology by John B West MD, PhD. A complete course of respiratory physiology medical students, residents and Fellows: https://www.youtube.com/playlist?list=PLE69608EC343F5691

REFERENCE ARTICLES (Articles distributed upon request)

ASTHMA
A Practical Approach to Severe Asthma in Children. Barsky, E. E., Giancola, L. M., Baxi, S. N., & Gaffin, J. M. (2018).  Ann Am Thorac Soc, 15(4), 399-408. doi: 10.1513/AnnalsATS.201708-637FR

"Global strategy for asthma management and prevention: GINA executive summary." E.D. Bateman, S.S. Hurd, P.J. Barnes, J. Bousquet, J.M. Drazen, J.M. FitzGerald, P. Gibson, K. Ohta, P. O'Byrne, S.E. Pedersen, E. Pizzichini, S.D. Sullivan, S.E. Wenzel and H.J. Zar. Eur Respir J 2008; 31: 143-178. (2018). [Published Erratum]. Eur Respir J, 51(2). doi: 10.1183/13993003.51387-2007

Monitoring asthma in childhood: lung function, bronchial responsiveness and inflammation. Moeller, A., Carlsen, K. H., Sly, P. D., Baraldi, E., Piacentini, G., Pavord, I., . . . Saglani, S. (2015). [Review]. Eur Respir Rev, 24(136), 204-215. doi: 10.1183/16000617.00003914

Daily or intermittent budesonide in preschool children with recurrent wheezing. [Comparative Study Multicenter Study Randomized Controlled Trial Research Support, N.I.H., Extramural]. Zeiger, R. S., Mauger, D., Bacharier, L. B., Guilbert, T. W., Martinez, F. D., Lemanske, R. F., Jr., . . . Taussig, L. M. (2011). N Engl J Med, 365(21), 1990-2001. doi: 10.1056/NEJMoa1104647


AERODIGESTIVE DISORDERS/ AIRWAY
Structure and Functions of Pediatric Aerodigestive Programs: A Consensus Statement. Pediatrics. doi: 10.1542/peds.2017-1701. Boesch, R. P., Balakrishnan, K., Acra, S., Benscoter, D. T., Cofer, S. A., Collaco, J. M., . . . Wood, R. E. (2018).


Official American Thoracic Society technical standards: flexible airway endoscopy in children. Am J Respir Crit Care Med, 191(9), 1066-1080. doi: 10.1164/rccm.201503-0474ST.
Faro, A., Wood, R. E., Schechter, M. S., Leong, A. B., Wittkugel, E., Abode, K., . . . Michelson, P. H. (2015).

Update on treatment of childhood bronchiectasis unrelated to cystic-fibrosis. Redding, G. J. (2011).  Paediatr Respir Rev, 12(2), 119-123. doi: 10.1016/j.prrv.2010.10.012

Chronic Pulmonary Aspiration in Children: Diagnosis and Management. Torres-Silva, C. A. (2018). Curr Probl Pediatr Adolesc Health Care, 48(3), 74-81. doi: 10.1016/j.cppeds.2018.01.004


CARDIOVASCULAR DISEASE AND PULMONARY DISORDERS

Executive Summary of the American Heart Association and American Thoracic Society Joint Guidelines for Pediatric Pulmonary Hypertension. Am J Respir Crit Care Med, 194(7), 898-906. doi: 10.1164/rccm.201606-1183ST. Abman, S. H., Ivy, D. D., Archer, S. L., & Wilson, K. (2016).


CHRONIC LUNG DISEASE OF PREMATURITY
Airway Disease and Management in Bronchopulmonary Dysplasia. [Review]. Clin Perinatol, 42(4), 857-870. doi: 10.1016/j.clp.2015.08.011 Amin, R. S., & Rutter, M. J. (2015).

Official American Thoracic Society Clinical Practice Guidelines: Diagnostic Evaluation of Infants with Recurrent or Persistent Wheezing. [Practice Guideline]. Am J Respir Crit Care Med, 194(3), 356-373. doi: 10.1164/rccm.201604-0694ST. Ren, C. L., Esther, C. R., Jr., Debley, J. S., Sockrider, M., Yilmaz, O., Amin, N., . . . Wilson, K. C. (2016).


CHRONIC RESPIRATORY SYMPTOMS
An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. [Consensus Development Conference Practice Guideline]. Am J Respir Crit Care Med, 185(4), 435-452. doi: 10.1164/rccm.201111-2042ST. Parshall, M. B., Schwartzstein, R. M., Adams, L., Banzett, R. B., Manning, H. L., Bourbeau, J., . . . O'Donnell, D. E. (2012).

Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines. [Review]. Chest, 129(1 Suppl), 260S-283S. doi: 10.1378/chest.129.1_suppl.260S. Chang, A. B., & Glomb, W. B. (2006).


CYSTIC FIBROSIS
Guidelines for diagnosis of cystic fibrosis in newborns through older adults: Cystic Fibrosis Foundation consensus report. [Consensus Development Conference Practice Guideline Research Support, Non-U.S. Gov't]. J Pediatr, 153(2), S4-S14. doi: 10.1016/j.jpeds.2008.05.005+ Farrell, P. M., Rosenstein, B. J., White, T. B., Accurso, F. J., Castellani, C., Cutting, G. R., . . . Campbell, P. W., 3rd. (2008).

Cystic fibrosis pulmonary guidelines: treatment of pulmonary exacerbations. [Practice Guideline Research Support, Non-U.S. Gov't  Review]. Am J Respir Crit Care Med, 180(9), 802-808. doi: 10.1164/rccm.200812-1845PP. Flume, P. A., Mogayzel, P. J., Jr., Robinson, K. A., Goss, C. H., Rosenblatt, R. L., Kuhn, R. J., & Marshall, B. C. (2009).

Cystic fibrosis pulmonary guidelines: pulmonary complications: hemoptysis and pneumothorax. [Practice Guideline]. Am J Respir Crit Care Med, 182(3), 298-306. doi: 10.1164/rccm.201002-0157CI10.1164/rccm.201002-0157OC. Flume, P. A., Mogayzel, P. J., Jr., Robinson, K. A., Rosenblatt, R. L., Quittell, L., & Marshall, B. C. (2010).

Cystic fibrosis pulmonary guidelines: airway clearance therapies. [Practice Guideline Research Support, Non-U.S. Gov't]. Respir Care, 54(4), 522-537. Flume, P. A., Robinson, K. A., O'Sullivan, B. P., Finder, J. D., Vender, R. L., Willey-Courand, D. B., . . . Marshall, B. C. (2009).



INTERSTITIAL LUNG DISEASE
An official American Thoracic Society clinical practice guideline: classification, evaluation, and management of childhood interstitial lung disease in infancy. [Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't Review]. Am J Respir Crit Care Med, 188(3), 376-394. doi: 10.1164/rccm.201305-0923ST. Kurland, G., Deterding, R. R., Hagood, J. S., Young, L. R., Brody, A. S., Castile, R. G., Redding, G. J. (2013).



MECHANICAL VENTILATION in the ICUs
 An Official American Thoracic Society/European Respiratory Society Workshop Report: Evaluation of Respiratory Mechanics and Function in the Pediatric and Neonatal Intensive Care Units. [Review]. Ann Am Thorac Soc, 13(2), S1-11. doi: 10.1513/AnnalsATS.201511-730ST. Peterson-Carmichael, S., Seddon, P. C., Cheifetz, I. M., Frerichs, I., Hall, G. L., Hammer, J., . . . Ranganathan, S. C. (2016).


NEUROMUSCULAR DISEASES

Sleep-Disordered Breathing in Neuromuscular Disease: Diagnostic and Therapeutic Challenges. [Review]. Chest, 152(4), 880-892. doi: 10.1016/j.chest.2017.03.023. Aboussouan, L. S., & Mireles-Cabodevila, E. (2017).



PULMONARY FUNCTION TESTING

Pulmonary Function Testing in Neuromuscular and Chest Wall Disorders. [Review]. Clin Chest Med, 39(2), 325-334. doi: 10.1016/j.ccm.2018.01.005. Gartman, E. J. (2018).

An official American Thoracic Society workshop report: optimal lung function tests for monitoring cystic fibrosis, bronchopulmonary dysplasia, and recurrent wheezing in children less than 6 years of age. [Review]. Ann Am Thorac Soc, 10(2), S1-S11. doi: 10.1513/AnnalsATS.201301-017ST. Rosenfeld, M., Allen, J., Arets, B. H., Aurora, P., Beydon, N., Calogero, C., . . . Vilozni, D. (2013).

Pulmonary function testing in neuromuscular disorders. Pediatrics, 123 Suppl 4, S219-221. doi: 10.1542/peds.2008-2952D. Sharma, G. D. (2009).



SLEEP DISORDERS
ERS statement on obstructive sleep disordered breathing in 1- to 23-month-old children. [Review]. Eur Respir J, 50(6). doi: 10.1183/13993003.00985-2017.
Kaditis, A. G., Alonso Alvarez, M. L., Boudewyns, A., Abel, F., Alexopoulos, E. I., Ersu, R., . . . Verhulst, S. (2017).

Non-respiratory indications for polysomnography and related procedures in children: an evidence-based review. [Review]. Sleep, 35(11), 1451-1466. doi: 10.5665/sleep.2188. Kotagal, S., Nichols, C. D., Grigg-Damberger, M. M., Marcus, C. L., Witmans, M. B., Kirk, V. G., . . . Hoban, T. F. (2012).

Diagnosis and management of childhood obstructive sleep apnea syndrome. [Review Technical Report]. Pediatrics, 130(3), e714-755. doi: 10.1542/peds.2012-1672. Marcus, C. L., Brooks, L. J., Draper, K. A., Gozal, D., Halbower, A. C., Jones, J., . . . Spruyt, K. (2012).

Executive summary of respiratory indications for polysomnography in children: an evidence-based review. [Review]. Sleep, 34(3), 389-398AW. Wise, M. S., Nichols, C. D., Grigg-Damberger, M. M., Marcus, C. L., Witmans, M. B., Kirk, V. G., . . . Hoban, T. F. (2011).
Instructional Methods:
Instructional Methods will include clinical teaching at the bedside, in the outpatient clinics, and the operating room, plus didactive activities e.g., conferences.

Medical Students will learn through participating in a combination of Inpatient and Outpatient Activities, and engage in direct patient Care

Students are expected to join the inpatient team doing patient evaluation(s) and participate in Rounding, as well as attend outpatient clinics. 

In the Inpatient settings either TCC Transitional Care Center (Tracheostomy Unit), Main Pulmonary Service or Pulmonary Medicine Consultation Service: 
-          Student will be assigned 1 or 2 patients (by the Ped Resident or Pulm Fellow) to evaluate, follow and present in rounds  in the Inpatient service
-          Student will examine only the patient(s) assigned to him/her and get ready to present the patient(s) in the rounds (or virtual rounds)
-          Student will participate/attend the Main Pulmonary Rounds (please ask the residents or the Pulm Fellow to provide you access to the virtual meetings, as applicable, on your first day of rotation)
-          After multidisciplinary rounds (or Virtual rounds) the student will join the Pulmonary Attending and Fellow in Bedside rounding and Teaching.
-          After completing rounds or consults for the day, the Student will engage in other clinical activities per discretion of the Pulm Attending and/or pulmonary fellow— alternatively (per discretion of the Pulm attending and/or Pulm Fellow) the student may be allowed to leave the clinical setting for the rest of the day and attend academic activities (or virtual activities) from his/her home or other location.


In the Outpatient settings Pulmonary clinics (e.g., General Pulm clinic or Pulm Subspecialty clinics like Aerodigestive, Sleep, Asthma, CF, etc): 
- Pulmonary clinics take place in Main campus CCHMC C-building, 5th floor
- Some clinics take place in Liberty campus
- Morning clinics start at 8 AM, end at 12 noon, Afternoon clinics start at 1PM, end at 5 pm. 
- Students are expected to be in clinic on time. If unable to get to clinic on time the student should call the clinic and ask for the pulm attending or his/her nurse to excuse themselves. Alternatively the student may contact Ms. Tiffiney Wunsch- Admin assistant for Dr. Cherie Torres-Silva at 513 636-6771. 

-      Student will be assigned 1 or 2 patients (by the Pulm attending) to obtain a clinical history, evaluate, and present to the attending for every 1/2 day of clinic
-      Student will observer clinical encounter for other patients attending the clinic that afternoon and is expected to actively participate in discussions about the patients, their diagnosis and management with attending physician seeing the patients in clinic 
-      Student are expected to review and become familiar with available information on the patients to be seeing in the designated clinic in order for them to contribute to the patient's discussion, evaluation and management.
Knowledge/Skills:
ASTHMA

Demonstrate* knowledge/understanding of:

Demonstrate these skills/abilities:

History

·    Assessment of asthma severity, asthma control and patient’s wheezing triggers

·    Appropriateness of current home asthma regimen in relation to asthma control

·    Comorbidities that may influence asthma control  and asthma exacerbation frequency

·    Perform a focused asthma history
     
     Obtain a CHILD ASTHMA RISK ASSESSMENT TOOL (CARAT) for all patients admitted for asthma exacerbation”

Physical Exam

·    Pulmonary findings that define chronic stable asthma and an asthma exacerbation

·    Pertinent positives and negatives on non-pulmonary exam in patient with asthma

·    Perform a focused asthma physical exam

Differential diagnosis

·    Know additional causes of wheezing in the pediatric patient (infant, toddler, school age)

·    Know additional causes of respiratory distress in the pediatric patient (infant, toddler, school age)

·    Develop a diagnostic plan to evaluate a pediatric patient with new-onset wheezing

Diagnostic approach

·    Indications for chest radiograph in asthma

·    Indications for Pulmonary Function Testing in asthma

·    Indications for Bronchoscopy in asthma

·    Existence of other biomarkers for asthma diagnosis and management

·    Identify chest radiograph findings consistent with asthma

·    Distinguish normal and obstructive ventilatory patterns on spirometry

Therapeutics

·    Pharmacotherapy of asthma (beta-agonists, ipratropium, inhaled and oral corticosteroids, leukotriene modifiers)

·    Potential changes in outpatient regimen to improve asthma control

Disposition

·    Indications for changing outpatient asthma regimen

·    Frequency of follow-up required based on patient’s level of asthma severity and control

·    Design an asthma action plan

Prevention

·    Preventive home therapies

·    Potentially modifiable environmental triggers

·    Resources available to families for asthma education



CHRONIC RESPIRATORY FAILURE

Demonstrate* knowledge/understanding of:

Demonstrate these skills/abilities:

History

·    Assessment of respiratory failure

·    Appropriateness of current home chronic respiratory support

·    Pathophysiology that mandates chronic respiratory support in each patient

·    Comorbidities that may impair ventilation

·    Risk factors for increased susceptibility to respiratory infections in patients with chronic respiratory support

·    Perform a focused history in a patient requiring chronic respiratory support

Physical Exam

·    Important pulmonary findings in a patient  requiring chronic respiratory support

·    Pertinent positives and negatives on non-pulmonary exam

·    Anatomic and physiologic limitations that contribute to respiratory failure

·    Perform a focused physical exam in a patient requiring chronic respiratory support

·    Recognize the presentation of acute on chronic respiratory failure

Differential diagnosis

·    Know causes of respiratory  failure in the pediatric patient

·    Know causes of respiratory distress in the pediatric patient

·    Develop a diagnostic plan to evaluate a pediatric patient with chronic respiratory failure in respiratory distress

Diagnostic approach

·    Indications for a blood gas in a patient with  chronic respiratory failure

·    Indications for chest radiograph in a patient with  chronic respiratory failure

·    Indications for Bronchoscopy in a patient with  chronic respiratory failure

·    Interpret a blood gas in a patient with  chronic respiratory  failure

·    Interpret a blood gas in a patient with  acute respiratory  failure

·    Interpret chest radiograph findings in a patient with respiratory  failure

Therapeutics

·    Pharmacotherapy of pneumonia in a hospitalized pediatric patient with chronic respiratory failure

·    Indications for changing a tracheostomy tube

·    Indications for initiating non-invasive respiratory support

·    Indications for initiating or adjusting mechanical ventilation settings

·    Indications for transfer to PICU

·    Select antibiotic regimen for a patient with pneumonia and chronic respiratory failure

·    Perform a tracheostomy tube change

·    Adjust ventilator settings based on patient comfort, oxygenation and ventilation status

Disposition

·    Indications for admitting a patient with chronic respiratory failure

·    Discharge criteria for a  patient with chronic respiratory failure

·    Work with a multidisciplinary team to arrange for the safe discharge of the patient with chronic care needs to the home environment

Prevention

·    Preventive home regimen

·    Resources available to families for children with chronic care needs

·    Understand basic self-management principles for chronic disease


CYSTIC FIBROSIS

Demonstrate* knowledge/understanding of:

Demonstrate these skills/abilities:

History

·    Assessment of severity of CF lung disease

·    Triggers for a CF pulmonary exacerbation

·    Comorbidities that may increase CF pulmonary exacerbation frequency

·    Perform a focused CF history

Physical Exam

·    Pulmonary findings in a patient with a CF pulmonary exacerbation

·    Abdominal findings in a patient with Distal Intestinal Obstruction Syndrome

·    Pertinent positives and negatives of non-pulmonary exam in patient with CF

·    Signs of respiratory failure in CF

·    Perform a focused CF physical exam

·    Recognize severity of presentation of pulmonary exacerbation of CF in relation to vital signs and patient appearance

Differential diagnosis

·    Know causes of crackles and tachypnea in the pediatric patient

·    Know causes of respiratory distress in the pediatric patient

·    Understand causes of abdominal pain in a patient with CF

Diagnostic approach

·    Indications for a blood gas

·    Indications for a chest radiograph

·    Indications for a KUB

·    Indications for Pulmonary Function Testing

·    Indications for Bronchoscopy

·    Interpret a blood gas in patient with CF

·    Demonstrate chest radiograph findings consistent with CF

·    Differentiate obstructive from non-obstructive KUB findings

·    Interpret a Pulmonary Function Test

Therapeutics

·    Acute therapy of a CF pulmonary exacerbation

·    Acute therapy of Distal Intestinal Obstruction Syndrome

·    Indications for BiPAP support in CF

·    Indications for intubation and ventilation in CF

Disposition

·    Indications for admitting a patient with a CF pulmonary exacerbation

·    Indications for admitting a patient with Distal Intestinal Obstruction Syndrome

·    Indications for discharge in a patient with a CF pulmonary exacerbation

·    Indications for discharge in a patient with a Distal Intestinal Obstruction Syndrome

Prevention

·    Understand rigor and details of preventive home airway clearance regimen

·    Understand basic self-management principles for chronic disease


NEUROMUSCULAR DISEASE

Demonstrate* knowledge/understanding of:

Demonstrate these skills/abilities:

History

·    Assessment of respiratory status

·    Triggers for acute respiratory failure in a patient with neuromuscular  weakness

·    Comorbidities that may increase pneumonia risk

·    Perform a focused history in a patient with neuromuscular  weakness

Physical Exam

·    Pulmonary findings in a patient with  neuromuscular  weakness

·    Pertinent positives and negatives of non-pulmonary exam in patient neuromuscular  weakness

·    Signs of respiratory failure in a patient with neuromuscular  weakness

·    Perform a focused physical exam  in a patient with neuromuscular  weakness

·    Recognize severity of presentation of acute respiratory decompensation in a patient with neuromuscular weakness

Differential diagnosis

·    Know additional causes a weakened cough in the pediatric patient

·    Know additional causes recurrent pneumonia in the pediatric patient

·    Know additional causes of respiratory distress in the pediatric patient

·    Develop a plan to distinguish between pulmonary and non-pulmonary causes of respiratory distress in a patient with neuromuscular weakness

Diagnostic approach

·    Indications for a blood gas  in a patient with  neuromuscular  weakness

·    Indications for a chest radiograph  in a patient with  neuromuscular  weakness

·    Indications for Pulmonary Function Testing  in a patient with  neuromuscular  weakness

·    Interpret a blood gas in a patient with neuromuscular weakness

·    Demonstrate common chest radiograph findings in a patient with neuromuscular  weakness 

·    Interpret a Pulmonary Function Test in a patient with neuromuscular weakness

     Recognition of clinical signs suggestive of clinical deterioration in a patient with hypotonia- including lower saturations, tachypnea, lethargy, absence of increase work of breathing due to muscle weakness
 

Therapeutics

·    Empiric therapy of recurrent pneumonia in a patient with neuromuscular  weakness

·    Indications for BiPAP support in a patient with  neuromuscular  weakness

·    Indications for intubation and ventilation

·    Evaluate the effectiveness of non-invasive ventilation and cough assist support in a patient with neuromuscular weakness

Disposition

·    Indications for admitting a patient with neuromuscular weakness and respiratory illness

·    Indications for discharge in a patient with neuromuscular weakness and respiratory illness

Prevention

·    Preventative home cough assist regimen

·    Resources available to families for children with chronic care needs

·    Understand basic self-management principles for chronic disease


Obstructive Sleep Apnea and other Sleep Related Disorders

Demonstrate* knowledge/understanding of:

Demonstrate these skills/abilities:

History

·  Assessment of sleep symptoms, severity and triggers, sleep habits

·  Appropriateness of current home treatment or management

·  Comorbidities that may influence sleep symptoms or sleep disorders

·  Perform a focused Sleep history
Indications for Airway clearance and cough assist in a patient with neuromuscular weakness, including indications for extrapulmonary percussive therapy (e.g., VEST), intrapulmonary percussive therapy (e.g., IPV), and use of nebulization to clear lower respiratory tract secretions.

   Appropriateness and adherence of current home treatment or management


Physical Exam

·  Physical findings that may suggest or be associated to obstructive or central sleep apnea, hypoventilation, or insomnia.

·  Pertinent positives and negatives on non-pulmonary exam in patient with sleep disorders.

·  Perform a focused sleep physical exam

Differential diagnosis

·  Know additional causes of sleep maintenance difficulty, or noisy breathing in the pediatric patient (infant, toddler, school age)

·  Know additional causes of  or excessive daytime sleepiness, excessive fatigue, morning headaches or other morning symptoms in the pediatric patient (infant, toddler, school age)

·  Develop a diagnostic plan to evaluate a pediatric patient with sleep disorders, e.g., obstructive sleep apnea and restless leg syndrome

·    Develop differential diagnosis for sleep related symptoms and a plan for further evaluation

Diagnostic approach

·  Indications for polysomnography (PSG)

·   Indications for titration PSG

·  Indications for overnight saturation study

·  Indications for Airway evaluation in patients with OSA

·  Identify polysomnography findings consistent with sleep apnea

·  Distinguish normal and abnormal findings on a sleep study

Therapeutics

·  Pharmacotherapy of sleep disorders and medications to avoid

·  Potential changes in outpatient regimen to improve sleep

·  Indication and criteria for referrals to other subspecialties (sleep psychology, neurology) to address comorbid conditions that impact sleep.

Disposition

·  Follow-up on patient with sleep disorders

Prevention

·  Preventive home management and safety measures

·  Potentially modifiable environmental triggers

·  Disorders caused by untreated sleep apnea
Main Course Topics :
                                   
Pulmonary Disorders and Symptoms:

Asthma
Airway Obstruction
Chronic cough
Cystic Fibrosis
Neuromuscular Disease
Obstructive Sleep Apnea and Other Sleep disorders
Pulmonary Physiology And Pathophysiology
Pneumonia
Respiratory Failure (Acute versus Chronic)
            -Invasive Positive Pressure Ventilation (Trach and Vent)
            -Non-Invasive Positive Pressure Ventilation (CPAP and BIPAP)
 

Diagnostic Studies and Procedures:
Blood gas
Bronchoscopy
Chest X-ray
Chest Tomography (CT scan)
Polysomnogram- Sleep Study
Pulmonary Function Testing
Swallow Studies
-Video fluoroscopic Swallow Study (VSS)
-Fiberoptic Endoscopic Evaluation of Swallow (FEES)
-Dye testing in patients with Tracheostomy
Tracheostomy Care and Emergency Management (e.g., Decannulation and mucus plugging)
Ventilator Management-
-Understanding Ventilator settings
-Understanding the differences between Home (e.g., Trilogy) vs. Hospital ventilators (e.g., Servo)
Procedures:
 No procedures are required as part of this elective rotation, however the student will have the opportunity to learn and practice how to change a tracheostomy tube and directly perform a tracheostomy change as part of their rotation in the TCC (Transition Care Canter= Tracheostomy Unit).

 In addition the student will become familiar with the interpretation of studies, such as: 
  • pulmonary function tests

  • chest radiographs

  • chest CT scan

  • blood gases/ renal Profile

  • sleep studies

  • Airway evaluation by flexible bronchoscopy - the student will have exposure to flexible bronchoscopies in the OR setting.
Remediation Plan:
Elective Director's discretion.

Students are expected per GME guidanceto complete a minimum of 16 out of 20 half days per 2 weeks rotations, with allowed half days off for continuity clinics, standardized exams, formal Holidays or personal illness. 
 The student should expect to have to do remediation time for time lost over 16 half days for every 2 weeks rotation period- for example- this could be accomplished by attending weekend rounds.

All expected days or half days off should be reported in advance to the Pulmonary Clerkship administrative coordinator (Tiffiney Wunsch) and clerkship director (Cherie Torres-Silva, MD)- to be taken into account when planing for rotation assigned clinical experiences/clinics.


The student should communicate of any unexpected absence (e.g., due to illness or personal reasons) as soon as possible by calling or emailing the Pulm Clerkship coordinator tiffiney.wunsch@cchmc.org or call 513 636 6771.


SAMPLE WEEK

Monday:
8:00AM 12:00PM Pulmonary Clinic
12:00PM 1:00PM Pulmonary Lecture Series
1:00PM 5:00PM Pulmonary Clinic
Tuesday:
8:00AM 12:00PM Pulmonary Clinic
12:00PM 1:00PM Pediatric Resident Conference
1:00PM 5:00PM Aerodigestive Clinic
Wednesday:
8:00AM 12:00PM Pulmonary Clinic or Bronchoscopy
12:00PM 1:00PM Pulmonary Lecture Series
1:00PM 5:00PM Pulmonary Clinic or Bronchoscopy
Thursday:
8:00AM 12:00PM Inpatient Rounds or Consults
12:00PM 1:00PM Pediatric Resident Conference
1:00PM 5:00PM Pulmonary Clinic or Consults
Friday:
8:00AM 12:00PM Inpatient Rounds, Consults or Bronchoscopy
12:00PM 1:00PM Pulmonary Lecture Series
1:00PM 5:00PM Consults or Bronchoscopy
SCHEDULE NOTE:

ATTENDANCE AND ABSENCE POLICY

 

Session Attendance for M4 Students

  • Students may miss no more than two days of planned excused absences on a four week rotation without being required to make-up the work, at the discretion of the clerkship/elective/course director or his/her designee.
  • Non-AI Rotations - Per the Student Duty Hours Policy, an average of one day (24 hours) in every seven must be free of clinical responsibilities (including seminars, clinic, rounds, lectures) averaged over a four week period. These days off are assigned by the clerkship director to best align with the site schedule. Students may request to schedule 1 or more of these 4 days for planned absences that fall under 1 of the categories listed below for excused absences during non-AI rotations, in consultation with the course/elective director, who may or may not approve such planned absences.
  • AI Rotations - Per the Student Duty Hours Policy, an average of one day (24 hours) in every seven must be free of clinical responsibilities (including seminars, clinic, rounds, lectures) averaged over a four week period. These days off are assigned by the course director to best align with the site schedule. Students may request to schedule 1 or 2 of these days for planned absences that fall under 1 of the categories listed below for excused absences during AI rotations, in consultation with the course director, who may or may not approve such planned absences. Students must avoid scheduling Step 2 examinations during an Acting Internship.
  • Excused Absences - The following will be considered excused absences:
    • Diagnostic, preventative, and therapeutic health services (e.g. doctor appointments, physical therapy, counselling, etc).
    • Personal illness, accident or a major catastrophic event
    • Death or serious illness of immediate family members. Immediate family members, as defined by UC, are Grandparents, Brother, Sister, Brother-in law, Sister-in-law, Daughter-in-law, Son-in-law, Father, Mother, Mother-in-law, Father-in-law, Step-sister, Step-brother, Step-mother, Step-father, Spouse or domestic partner, Child, Grandchild, legal Guardian or other person who stands in place of parent (in Loco Parentis)
  • Whenever possible, planned absences should be requested a minimum of six weeks in advance of the start of the clerkship/elective/course in which the absence will occur; this enables the clerkship/course/elective to help plan for educational event scheduling (e.g. a known appointment could be scheduled around with enough notice and the student might not have any required coursework to make up). Absences requested less than 1 week prior to the planned absence may not be considered for a possible excused absence unless extenuating circumstances prevented the student from providing timely notification per the policy. Students should first submit their request for a planned absence to the clerkship/elective/course director using the online MSSF. All planned/excused absences for any reason should be documented on the MSSF.
  • The COM abides by the UC Religious Observance Policy that respects the religious diversity of its students by providing opportunities, where possible, for accommodation in cases where conflicts exist between students’ religious beliefs/practices and educational activities. In clinical settings, such accommodations must honor the primacy of a commitment to patient care and avoid unduly burdening faculty, staff and the general student population involved in the affected educational and/or patient care activity.
  • The following items are explained in detail in the Medical Student Handbook:
    • Excused/unexcused/unplanned absence, religious holidays, jury duty, and make-up work

See Attendance and Absences Policy, Religious Observance Policy, Medical Student Handbook.




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