Episodic shortness of breath, dyspnea on exertion. Sleep interrupted by shortness of breath, cough, or breathing movements Tobacco addiction, Smoking

Transcription

1 Pulmonary Curriculum The Educational Purpose This curriculum promotes respiratory health and addresses disorders of the nasopharynx, tracheobronchial tree, pulmonary and bronchial vasculature, alveolar capillary bed, interstitium, pleura, mediastinum, and chest wall. The general internist is expected to understand the environmental, immunologic, inflammatory, and genetic mechanisms that usually maintain gas exchange but can sometimes lead to disordered function. He or she is expected to apply this understanding to obtain the history, examine and counsel the patient. The general internist is also expected to understand the indications and contraindications of diagnostic tests or interventions, to assess validity of tests before interpreting them, and to know how to optimize consultation with specialists in the care of one's patients. Patient Care Goal #1: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Objective #1: Residents must be able to gather essential and accurate patient information to assess patient concerns, with special attention to the following presentations: Emphasize in history taking the family, occupational and environmental history Episodic shortness of breath, dyspnea on exertion Emphasize in the physical exam nose, mouth, dentition, pharynx (eg Mallampati score), chest and extremities Wheeze Cough Sleep interrupted by shortness of breath, cough, or breathing movements Tobacco addiction, Smoking Bronchitis/bronchiectasis Acute pulmonary embolus Acute and unremitting shortness of breath Recurrent lung or airway infection Hemoptysis Pleural effusion Primary pulmonary hypertension Lung cancer Pulmonary mycoses Massive hemoptysis Lymphangioleiomyomatosis Environmental lung disease Genetic and congenital lung disease Chest Pain Abnormal chest x-ray Pneumonia Obstructive sleep apnea Chronic thromboembolism Chronic progressive shortness of breath Weight loss Pneumothorax Interstitial lung disease Pulmonary vasculitis Atypical mycobacteria Pulmonary disease in pregnancy Occupational lung disease Central sleep apnea 1

2 Objective #2: Residents will be able to develop and carry out patient management plans by making informed decisions on diagnostic and therapeutic interventions, counseling and educating patients and their families, and preventing health problems or maintaining health based on patient information and preferences, up-to-date scientific evidence, and clinical judgment with special attention to the following illnesses or conditions: Smoking cessation: 5A's, setting a quit date Obstructive sleep apnea Bronchitis/bronchiectasis Acute pulmonary embolus Pulmonary problems or changes during pregnancy Occupational lung disease Hypersensitivity pneumonitis Lung cancer Primary pulmonary hypertension Systemic disease manifestations in the lungs Pneumonia Abnormal Chest Xray Chronic pulmonary thromboembolism Central sleep apnea Drug-induced lung disease Interstitial pulmonary fibrosis Genetic Pulmonary Disorders Neuromuscular disease that affects respiration Objective #3: Residents must competently perform, assess the technical validity, and interpret the results of all diagnostic and therapeutic medical and invasive procedures considered essential after obtaining informed consent, with minimal discomfort to patients: Chest x-rays Spirometry, Flow-volume loops Peak flow rate Arterial blood gases 6-min walk test Oxygen supplmentation (ambulatory) Electrolytes (anion gap) Thoracic CT scans (including thin-section and helical) Skin test for anergy and PPD reaction Rational low-flow or high-flow oxygen supplementation Thoracentesis (diagnostic and therapeutic) Intubation and extubation Diagnostic and therapeutic polysomnography, Ventilator management (see Critical Care) CPAP, BiPAP Understand indications, contraindications, and limitations of: Chamberlain procedure Mediastinoscopy Percutaneous lung biopsy Bronchoscopy (including bronchoalveolar lavage, brush, endo- vs transbronchial biopsy) Percutaneous lung needle biopsy Wedge resection Bronchoalveolar lavage Video-assisted thoracoscopy Open lung biopsy Mediastinoscopy Pulmonary artery catheterization Objective #4: Residents must communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families. Motivational interviewing for smoking cessation: 5A's, set a quit date. Control Test score, Assessment Score, Epworth Score, management plan Explaining and preparing for oxygen therapy Giving bad news regarding terminal illness (e.g. end-stage, IPF, lung cancer) 2

3 Objective #5: Residents must work effectively with other health care professionals including those from other disciplines, to provide patient-focused care. Radiologists, allergists, ENT Cardiology (distinguish pulmonary vs. cardiac causes of symptoms) Gastroenterology for reflux, swallowing, aspiration issues. Psychiatry-depression in or cancer. Medical Knowledge Goal #2: Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Objective #1 Residents must demonstrate investigatory and analytical thinking approach to clinical situations. Airway disease: upper airway, laryngospasm, obstructive sleep apnea, Pleural disease: transudative vs. exudative effusions Infection: (infection, active disease) Infection: Pneumonia (community-acquired, nosocomial) Prevention: vaccination Prevention: anticoagulation Progressive dyspnea Vascular disease: secondary pulmonary hypertension, cor pulmonale Pleural: pneumothorax (spontaneous, barotrauma, tension) Interstitial pneumonitis: "usual" (idiopathic pumonary fibrosis), "desquamative," "non-specific" Interstitial pneumonitis: drug-induced, eosinophilic, hypersensitivity Vascular disease: vasculitis Neoplasia: metastatic cancer Infection: atypical mycobacteria Airway disease: asthma, reactive airways dysfunction, Vascular disease: acute and chronic venous thromboembolism Infection: Aspiration pneumonia, abscess, empyema Prevention: smoking cessation, diet, exercise, weight management Prevention: allergen avoidance Vascular disease: primary pulmonary hypertension (include HIV, HHV8,anorixogenic) Pleural: malignant effusions, parapneumonic effusion, empyema Interstitial pneumonitis: collagen vascular Interstitial disease: histiocytosis, sarcoid Neoplasia: bronchogenic lung cancer (small cell, nonsmall cell Vascular and interstitial: ARDS (see Critical Care and Inpatient Medicine curriculum) Infection: pulmonary mycoses (histoplasmosis, blastomycosis, aspergillus lung disease) 3

4 Pulmonary disease in pregnancy (pulmonary hypertension, asthma) Occupational lung disease, asbestos-related: pneumoconiosis, pleural manifestations, Occupational/environmental lung disease: environmental tobacco smoke, carbon monoxide Occupational/environmental lung disease: Altitude sickness Congenital: dysmotile cilia, cystic fibrosis Airway disease: lymphangioleiomyomatosis Occupational lung disease: hypersensitivity pneumonitis Occupational/environmental lung disease: Hydrogen sulfide, hydrogen cyanide Differential for restrictive lung disease: neuromuscular, skeletal, interstitial, pleural, vascular Congenital: alpha1 antitrypsin deficiency Control of breathing: central sleep apnea, narcolepsy Objective #2: Residents must know and apply the basic and clinical supportive sciences applicable to Pulmonary with special attention to: Innate and acquired immunity, Th1 vs. Th2 pathways Psychology/social: addiction, readiness to change (smoking) Pharmacology: anti-inflammatory medications (inhaled corticosteroids, cromolyn, nedocromil; prednisone) Pharmacology: leukotriene modifiers Biology, physics: oxygen supplementation, principles of low-flow and high flow oxygen delivery Depression and addiction, readiness to change Pharmacology: proteases and antiproteases (, smoking) Pharmacology: prostacylin, endothelin, angiotensin, and nitric oxide in pulmonary hypertension Genetics: DNA repair (lung cancer, smoking) Pharmacology: bronchodilators (short and long-acting beta agonists, muscarinic receptor antagonists, phosphodiesterase inhibitors) Immunology: Innate vs. acquired immunity (e.g: vs. infections) Pharmacology: oxidant stress and antioxidants (, smoking) Genetics: coagulation and fibrinolytic defects (VTE) Epigenetics: histones and chromatin (refractoriness to glucorticosteroids), other modifications. Early and fetal origins of chronic lung disease. Interpersonal and Communication Skills Goal # 4: Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Objective #1: Residents must use effective listening, nonverbal, questioning, and narrative skills to communicate with patients and families. Giving bad news, end of life care, advanced directives, cultural responses regarding weight and smoking The Teaching Methods Pulmonary Elective Pulmonary clinics at Queen Emma Clinics and the VA Program Conferences, Academic Half Day sessions - Pulmonary Case Conference, Grand Rounds 4

5 Pulmonary Reading List 1) Budinger GRet al. Update in environmental and occupational medicine Am J Respir Crit Care Med Jun 15;183(12): ) Ho SM. Environmental epigenetics of asthma: an update. J Allergy Clin Immunol Sep;126(3): ) Kazani Set al. Update in asthma Am J Respir Crit Care Med Aug 1;184(3): ) Laumbach RJet al. Respiratory health effects of air pollution: update on biomass smoke and traffic pollution. J Allergy Clin Immunol Jan;129(1):3-11; quiz ) Criner GJet al. The National Emphysema Treatment Trial (NETT): Part I: Lessons learned about emphysema. Am J Respir Crit Care Med Oct 1;184(7): ) Han MK. Update in chronic obstructive pulmonary disease in Am J Respir Crit Care Med May 15;183(10): ) Qaseem Aet al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med Aug 2;155(3): ) Stoloff SW. Chronic obstructive pulmonary disease megatrials: taking the results into office practice. Am J Med Sci Aug;342(2): ) Young RPet al. A clinical practice guideline update on the diagnosis and management of stable chronic obstructive pulmonary disease. Ann Intern Med Jan 3;156(1 Pt 1):68-9; author reply 9. Interstitial Lung Disease 10) Markart Pet al. Update in diffuse parenchymal lung disease Am J Respir Crit Care Med May 15;183(10): ) Peikert Tet al. Assessment of current practice in the diagnosis and therapy of idiopathic pulmonary fibrosis. Respir Med Sep;102(9): ) Chan ALet al. Therapeutic Update in Idiopathic Pulmonary Fibrosis. Clin Rev Allergy Immunol Jan 11. Pulmonary Vascular Disease 13) Dweik RAet al. Update on pulmonary vascular diseases Am J Respir Crit Care Med Jul 1;184(1): ) Gladwin MTet al. Update on pulmonary hypertension Am J Respir Crit Care Med May 15;181(10): ) Anderson JRet al. Pharmacotherapeutic management of pulmonary arterial hypertension. Cardiol Rev May- Jun;18(3): Obstructive Sleep Apnea 16) Mokhlesi Bet al. Update in sleep medicine Am J Respir Crit Care Med Jun 1;183(11): ) Yew WWet al. Update in tuberculosis and nontuberculous mycobacterial disease Am J Respir Crit Care Med Jul 15;184(2): ) Yew WWet al. Treatment of tuberculosis: update Eur Respir J Feb;37(2): ) Falzon Det al. WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update. Eur Respir J Sep;38(3): Revised by Elizabeth K. Tam, M.D. April 2012 Revised by the Curriculum Task Force July 27, 2012 Approved by Curriculum Committee August 6,