Pulmonary

Educational Plan: A competency based development of knowledge and skills in Pulmonology through clinical experience, bedside teaching, didactic conferences and readings to achieve competence, proficiency and the foundation for mastery. 

Educational Methods:

Clinical Information and Didactics

• Residents will function as integral members of the Pulmonary Consultation/Inpatient Service.
• Scheduling of rounds will be determined on a daily basis with the faculty member.  Residents will be permitted to leave at 6:00 pm, in the event that rounds run later into the evening.  Residents will not be required to work on weekends.

• Residents will be expected to attend all Pulmonary specific conferences scheduled above.
• NMH Pulmonary Consultation/In-patient Service Fellow Pager:  312-695-6448

1. Become familiar with the diagnosis and management of both common and unusual disorders affecting the chest. 
2. Learn basic pulmonary physiology related to pulmonary function testing and gain experience in interpretation. 
3. Learn about the role of flexible bronchoscopy in the evaluation of lung disease and observe bronchoscopic procedures.

PGY1

• Describe basic patterns of parenchymal infiltration on chest x-ray and chest CT scan, including alveolar, reticular-nodular and ground-glass opacification.
• Recognize the features of obstructive and restrictive ventilatory defects on pulmonary function testing, and become familiar with the American Thoracic Society criteria for diagnosis of each of these patterns.

PGY2,3

• Formulate a differential diagnosis of common presenting symptoms, signs and laboratory findings, such as cough, sputum production, dyspnea, wheezing, hemoptysis, chest pain, hypoxemia, polycythemia, and others.

Understand Definition, Pathophysiology, Epidemiology, Clinical History, Physical Exam, Laboratory and Imaging findings, Diagnostic criteria and Management of the following:

• Obstructive lung diseases, including asthma, bronchitis, emphysema, bronchiectasis and cystic fibrosis.
• Pulmonary malignancy, primary and metastatic.
• Pulmonary infections, including community-acquired bacterial and atypical pneumonias, hospital-acquired pneumonias, pyogenic lung abscess, tuberculosis, fungal disease, and infections in immunocompromised hosts (including patients receiving chemotherapy for cancer or immunosuppression following organ transplantation, and patients infected with HIV).
• Diffuse interstitial lung diseases.
• Pulmonary vascular disease, including pulmonary embolism, pulmonary hypertension, pulmonary vasculitis and alveolar hemorrhage syndromes.
• Occupational and environmental lung diseases.
• Radiation- and drug-induced lung disease.
• Pulmonary manifestations of systemic diseases, including collagen vascular diseases.
• Neuromuscular diseases.
• Disorders of the pleura and mediastinum.
• Sleep disorders.
• Describe the indications, contraindications, utility and limitations of flexible bronchoscopy in the evaluation of patients with known or suspected pulmonary disease.

­­­­­­­­­­­­­­References: Top References

• Laviolette M, Malmstrom K, Lu S, et al. Montelukast added to inhaled beclomethasone in treatment of asthma. AJRCCM 1999;160:1862-68.
  • This randomized, double-blinded study supports the addition of a leukotriene inhibitor for asthmatics with inadequate symptom control with inhaled corticosteroid alone.
• Lange P, Parner J, Vestbo J, Schnohr P, Jensen G. A 15-year follow-up study of ventilatory function in adults with asthma.NEJM 1998;339:1194-200.
  • Noteworthy for being one of the studies showing that a portion of patients with asthma go on to develop fixed airway obstruction.
• Niederman MS, Mandell LA, Anzueto A, et al. Guidelines for the management of adults with community-acquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy, and prevention. AJRCCM 2001;163:1730-54.
  • Latest recommendations from the ATS.
• ATS / ERS Task Force: Standards for the diagnosis and treatment of patients with COPD: A summary position of the ATS / ERS position paper. Eur Respir J 2004;23:932-46.
  • This is an abbreviated summary of a serially updated web document:
• American Thoracic Society/European Respiratory Society international multidisciplinary consensus classification of the idiopathic interstitial pneumonias.   AJRCCM 2002;165:277-304.
  • Written to standardize the diagnostic criteria and terminology for idiopathic interstitial pneumonias, this article nicely summarizes the clinical, radiologic, and histologic features of the ILD alphabet soup.
• Channick RN, Simonneau G, Sitbon O, et al. Effects of the dual endothelin-receptor antagonist bosentan in patients with pulmonary hypertension: a randomized placebo-controlled study.   Lancet 2001;358:1119-23 
  • First study of chronic bosentan in 32 patients with primary or scleroderma-related pulmonary hypertension.   Over the 12 weeks of the study, bosentan was well-tolerated and improved cardiac index and exercise capacity (70 meter gain in 6-minute walk). Similar results were obtained in a subsequent larger study of 213 patients (Rubin LJ et al. NEJM 2002; 346:896-903).
• Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of COPD. NEJM 1995;333:817-22.
  • Landmark prospective, randomized study found use of NIPPV in selected patients with COPD exacerbations resulted in fewer intubations, complications, days in hospital, and lower in-hospital mortality compared to standard treatment.
• Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med 2001;135:98-107.  
  • Large prospective cohort study using the SimpliRED d-dimer assay (which has sensitivity lower than, and specificity higher than, most other d-dimer tests) found the combination of a low clinical suspicion for PE and a negative d-dimer safely ruled out pulmonary embolism without additional testing.

Collection by Dr. Joseph Weber

For an extended list of references with direct article links, sign in to the Galter Health Library website at:

http://www.galter.northwestern.edu/guides/expand/resident-reading-lists

The ATS has also developed a excellent reference list that is posted online: www.thoracic.org/go/atsreadinglist