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CARDIORESPIRATORY: Respiratory System

Index

• General Outcomes for the Respiratory System
• Asthma (Priority 1*)
• Chronic Obstructive Pulmonary Disease (COPD) (Priority 1*)
• Respiratory Failure (Priority 1*)
• Pneumonia (Priority 1)
• Pulmonary Embolism (Priority 1*)
• Deep Vein Thrombosis (Priority 1)
• Carcinoma of the Bronchus (Priority 2)
• Pulmonary Tuberculosis (Priority 2)
• Pleural Effusion and Pleural Disease (Priority 2)
• Pneumothorax (Priority 2*)
• Chest Trauma and Haemothorax (Priority 3*)
• Bronchiectasis and Cystic Fibrosis (Priority 3)
• Sarcoidosis (Priority 3)
• Interstitial Lung Disease (Priority 3)
• Obstructive Sleep Apnoea (Priority 3)
• Pulmonary Hypertension (Priority 3)
• Occupational Lung Disease (Priority 3)

• General Outcomes for the Respiratory System
  • Medical knowledge: ANATOMY (TD 8.1)
    • General Anatomy of the Thorax
      1. Revise the bony thorax, the lungs, and the neuronal control of breathing.
      2. Identify, on an articulated skeleton, bones forming the thoracic cage, manubrium and body of the sternum, xiphisternum, costal cartilages and ribs and thoracic vertebrae.
      3. Revise the gross anatomy of the chest wall, the pleura, the lungs and bronchial tree (CR2)
      4. Describe the parts of a typical thoracic vertebra.
      5. Describe the attachments of the diaphragm. Identify the main structures passing through it and note their vertebral levels.
      6. Describe the attachments and neurovascular bundle of a typical intercostal space.
    • Pleural Cavity and Lungs
      1. Identify the components of the respiratory mucous membrane. (GEP/CO2)
      2. Learn the basic anatomy of the lungs (CR3)
      3. Describe the use of lung function in the diagnosis of respiratory diseases (CR3)
      4. Describe the surface anatomy of the lungs and relate this to auscultation and percussion (CR2)
      5. You should know the surface markings of the normal lungs. (CR2)
      6. Be able to interpret spirometry, lung volumes and gas transfer (CR3)
      7. Describe the positions of the lobes of the lungs.
      8. Explain the functional anatomy of the pleura
      9. Describe the structure and innervation of the lungs and bronchi
      10. Be able to differentiate obstructive and restrictive patterns (CR3)
      11. Learn about peak expiratory flow measurement and its usefulness (CR3)
      12. Describe the structure and function of the pleurae
      13. Describe the roles of peak flow and spirometry in the diagnosis and monitoring of respiratory diseases (CR3)
      14. Identify the lobes of each lung and describe the pattern of division of bronchi entering the lobes.
      15. Examine the extent of the pleural cavity differentiating between visceral and parietal pleura.
      16. Be able to explain to a patient how to perform spirometry and peak flow and, in the case of peak flow, record the results (CR3)
      17. Be able to interpret acid-base balance results (CR3)
    • Muscles of the Thoracic Wall and Respiration
      1. Describe the arrangement of an intercostal space
      2. Name the major and accessory muscles involved in inspiration
      3. Trace the flow of air from the nose to the alveoli
    • Larynx and Trachea
      1. Describe the structure and position of the trachea.
      2. Understand the cartilaginous and bony skeleton of the larynx.
      3. Identify some of the important membranes and intrinsic muscles of the larynx.
    • Nasal Cavity and Sinuses
      1. Identify the important structures within the nasal cavity.
  • Medical knowledge: PHYSIOLOGY (TD 8.2)
    • Carriage of Gases
      1. Describe the unique features of haemoglobin that make it able to transfer oxygen from lungs to tissues.
      2. By means of an annotated diagram, show how red blood cells are involved in the transport of carbon dioxide.
      3. Show, by means of graphs, the contributions of dissolved carbon dioxide, bicarbonate ion and carbamino-Hb to carbon dioxide transport in arterial and venous blood.
      4. Explain how the allosteric properties of haemoglobin may affect oxygen binding (the Bohr effect) and carbon dioxide transport (the Haldane effect).
    • Physiological Adaptation to Altitude
      1. Explain the changes in the atmospheric and alveolar partial pressures during accent to high altitude.
      2. Describe the chemical/physical changes to blood expected in high altitude acclimation.
      3. Explain the acid base disturbance common in rapid accent to high altitude.
      4. Outline the changes in the control of respiration at altitude.
      5. Outline the pharmacological approach to altitude sickness
    • Acid Base and the Control of Breathing
      1. Review the definition of gas partial pressure in a mixture of gases and gas partial pressure in a solution.
      2. State the normal pH of arterial plasma, define the terms acidosis, alkalosis, acidaemia and alkalaemia, and explain the effects on arterial pH of hyper- and hypo-ventilation
      3. State the normal pH of arterial plasma, define the terms acidosis, alkalosis, acidaemia and alkalaemia, and explain the effects on arterial pH of hyper- and hypo-ventilation.
      4. Briefly describe the brainstem structures involved in the production of breathing, and list the inputs to the brainstem which influence breathing. Describe the types of pathological respiratory patterns that can occur.
      5. Briefly describe the brainstem structures involved in the production of breathing, and list the inputs to the brainstem which influence breathing. Describe the types of pathological respiratory patterns that can occur.
      6. Briefly describe the brainstem structures involved in the production of breathing, and list the inputs to the brainstem which influence breathing. Describe the types of pathological respiratory patterns that can occur. (GEP/BB)
      7. State the normal pH of arterial plasma, define the terms acidosis, alkalosis, acidaemia and alkalaemia, and explain the effects on arterial pH of hyper- and hypo-ventilation.
    • The Lungs and Pulmonary Circulation
      1. Explain how the pulmonary and systemic circulations differ in terms of pressure and other factors
      2. Explain the changes that occur in the pulmonary circulation at birth
      3. Describe the theory of nitric oxide function in the pulmonary circulation (GEP/CO2)
      4. Describe the theory of nitric oxide function in the pulmonary circulation
    • General Outcomes for Respiratory Physiology
      1. List the functions of the respiratory system. (GEP/CO2)
      2. List the functions of the respiratory system. (CR1)
      3. Name the main structural features of the lungs. (CR1)
      4. Name the main structural features of the lungs (GEP/CO2)
      5. Distinguish between respiratory and non-respiratory components of the lungs and show how histological features are related to function. (CR1)
      6. Distinguish between respiratory and non-respiratory components of the lungs and show how histological features are related to function. (GEP/CO2)
      7. Describe the branching pattern of the respiratory tree, commenting on the significance of the cross-sectional area at different levels. (CR1)
      8. Describe the branching pattern of the respiratory tree, commenting on the significance of the cross-sectional area at different levels (GEP/CO2)
    • Lung Volumes and the Rates of Air Flow
      1. Describe and demonstrate the use of a spirometer, to measure tidal volume, respiratory rate, inspiratory reserve volume, expiratory reserve volume and vital capacity.
      2. Name those lung volumes which cannot be measured using a spirometer and describe one method for their measurement.
      3. Describe and demonstrate the use of the Vitalograph to measure the FVC and FEV1. Define the terms forced vital capacity (FVC), Forced Expiratory Volume 1 (FEV1) and the ratio FEV1/FVC expressed as a percentage (FEV1 %).
      4. Describe how the Vitalograph may be used to distinguish between restrictive and obstructive types of lung function disorders.
    • Ventilation and Perfusion
      1. Outline the responses of bronchiolar and arteriolar smooth muscle which maintain a balance between ventilation of the alveoli and blood flow (perfusion) to the alveoli in normal conditions.
      2. Define the term ventilation to perfusion ratio (Va/Q); give values for the whole lung, the base, and apex in a normal subject in the upright position, explaining why these differ.
      3. Illustrate, by means of diagrams, how the perfusion of the lung may be considered as a ‘three zone model’.
      4. Comment briefly on the effects, on blood passing through the lungs, of a high or a low Va/Q.
    • Lung Mechanics
      1. Outline the relationships between the lungs, pleura, chest wall and diaphragm.
      2. List the components of the total work of breathing
      3. Compare and contrast the structure of conducting components of the respiratory system and relate their structural differences to differing functions. (GEP/CO2)
      4. Explain why a negative pressure exists in the (potential) pleural space
      5. Define the term compliance, as applied to the lungs (or chest wall). Comment on the significance of surface tension forces and the role of pulmonary surfactant.
      6. Identify the respiratory components of the lung and understand their functions. (GEP/CO2)
      7. Explain the relationship between airflow, airway calibre and airway resistance at different levels in the respiratory tree and name two conditions which may significantly affect the work of breathing.
      8. Show, by means of graphs how the main components of the work of breathing contribute to the total work done in normal, tidal ventilation.
      9. Explain why alterations to lung recoil (in for example emphysema and pneumonia) may produce alterations to the shape of the chest.
      10. Show, by means of simple diagrams, how the ribs move during breathing.
      11. List the muscles active in a) quiet breathing; and b) vigorous breathing.
    • Gas Exchange and Lung Function Testing
      1. Draw a simple diagram of an alveolus (and its blood supply), annotated to show how the microscopic structure is suited to efficient gas exchange.
      2. Know what pulmonary surfactant is, where is it produced and why is it important.
      3. Be able to tabulate the normal partial pressures of oxygen and carbon dioxide in room air, alveolar air, pulmonary arterial (or ‘mixed venous’) blood, pulmonary venous (or systemic arterial) blood and expired air; comment on why these differ.
      4. Give an equation for Fick’s law of diffusion as applied to gas exchange in the lung the lung, identify the components of the equation, and name one pulmonary disorder affecting each component.
      5. Show, by means of simple graphs, how gas exchange comes to equilibrium along a pulmonary capillary; relate this information to physical exercise and progressive loss of lung function.
      6. Define, and give typical values for, commonly used terms in lung function testing and explain how clinically important measures of lung function are obtained.
    • Blood Gases, Control of Ventilation and Plasma pH
      1. State normal values of the partial pressures of oxygen and carbon dioxide in arterial blood (PaO2, PaCO2). How are these measured directly and estimated indirectly?
      2. Describe the location and properties of the peripheral and central chemoreceptors and show, by means of simple graphs, how alterations in PaO2 and PaCO2 alter ventilation.
      3. Name the FOUR simple classes of acid-base disturbance, stating the primary disturbance and the form of compensation for each class. Comment on the time scale for renal as compared with respiratory compensation and give ONE clinical cause for each class.
    • Renal Function
      1. Outline the role of hydrogen carbonate, phosphate and ammonium ions in the renal excretion of acid, noting the relationship between tubular pCO2, hydrogen carbonate reabsorption and proton excretion
      2. Name the FOUR simple classes of acid-base disturbance, stating the primary disturbance and the form of compensation for each class. Comment on the time scale for renal as compared with respiratory compensation and give ONE clinical cause for each class.
  • Medical knowledge: BIOCHEMISTRY (inc. Metabolism) (TD 8.3)
    • Acid-Base Balance
      1. Define 'pH' and state the normal range for arterial pH and the range compatible with life. Comment on the differences between normal arterial and mixed venous pH values.
      2. Outline the role of hydrogen carbonate, phosphate and ammonium ions in the renal excretion of acid, noting the relationship between tubular pCO2, hydrogen carbonate reabsorption and proton excretion
      3. Name the FOUR simple classes of acid-base disturbance, stating the primary disturbance and the form of compensation for each class. Comment on the time scale for renal as compared with respiratory compensation and give ONE clinical cause for each class.
  • Medical knowledge: PATHOLOGY (TD 8.7)
    • General Outcomes for Respiratory Disorders
      1. Describe the neurological pathways involved in the sensation of breathlessness (CR2)
      2. Recognise and describe specific disease processes that affect the lung, relating pathological features to radiological changes. (CR2)
      3. Discuss the differentiation between obstructive and restrictive lung disease.
      4. Explain the basic anatomical changes in some common lung pathologies and how they are identified in a chest X-ray.
      5. Discuss the natural history and prognosis of obstructive and restrictive lung conditions
  • Medical knowledge: PHARMACOLOGY (TD 8.10)
    • General Outcomes for Respiratory Pharmacology
      1. List and describe the actions of the autonomic nervous system on bronchial smooth muscle and secretory mucosa, relating these actions to the microscopic structure of the airway.
      2. List and give mode of action of agents which induce bronchoconstriction and bronchosecretion.
      3. Outline the consequences of antigen interaction with fixed mast cell antibody and the actions of mediators released from mast cells. (CR1, GEP/CO2)
  • Medical knowledge: CLINICAL FEATURES of DISEASE (TD 8 b)
    • General Outcomes for Respiratory Disorders
      1. Describe examples and causes of the common obstructive and restrictive lung diseases
      2. Describe clinical symptoms and signs that are associated with the obstructive and restrictive lung diseases
  • Medical knowledge: EPIDEMIOLOGY
    • Respiratory Disease (inc. Tuberculosis)
      1. Outline the causes and social impact (in terms of mortality and morbidity) of a) airways disease; and b) respiratory infection (CR1)
      2. Outline the causes and social impact (in terms of mortality and morbidity) of a) airways disease; and b) respiratory infection (GEP/CO2)
      3. Comment on the major social, environmental and occupational factors associated with pulmonary disease. (GEP/CO2)
      4. Comment on the major social, environmental and occupational factors associated with pulmonary disease. (CR1)
  • Clinical skills: HISTORY (TD 13 a-b)
    • Examination of the Respiratory System
      1. You should be able to auscultate the lungs and recognise normal breath sounds. (CR2)
      2. You should be putting together examination of the hands, pulse, JVP and lungs to conduct a systematic examination of the normal respiratory system. (CR2)
  • Clinical skills: PLANNING AND INTERPRETING INVESTIGATIONS (TD 14 c-d)
    • Lung Function Testing
      1. Discuss the limitations of current tests and how the technique of performing the tests may affect the results, with understanding of how individuals are compared to equivalent populations.
      2. Explain the importance of lung function testing, especially spirometry, in the diagnosis of lung disease.
      3. Discuss the abnormalities seen in asthma and COPD where there is an obstructive defect, and the patterns of obstruction and restriction and their causes.
      4. Discuss other tests of respiratory function, including exercise testing and their use in assessing operative risk.
    • Respiratory Imaging
      1. Describe the basic features of a normal chest X-ray.
      2. Explain the basic anatomical changes in some common lung pathologies and how they are identified in a chest X-ray.
      3. Describe a normal chest x-ray, and compare this with chest x-rays from patients with lung cancer, tuberculosis, Chronic Obstructive Pulmonary Disease and pneumothorax (CR2)
  • Clinical skills: MAKING A DIAGNOSIS and CLINICAL JUDGEMENT (TD 14 e-f)
    • General Outcomes for Respiratory Diagnosis
      1. Identify the anatomical features of COPD, pneumonia, carcinoma and tuberculosis on pathological specimens and on radiographs (CR2)
  • Clinical skills: DIAGNOSTIC PROCEDURES (TD 18 a)
    • Respiratory Function Tests
      1. Describe and demonstrate the use of a spirometer, to measure tidal volume, respiratory rate, inspiratory reserve volume, expiratory reserve volume and vital capacity.
      2. Name those lung volumes which cannot be measured using a spirometer and describe one method for their measurement.
      3. Describe and demonstrate the use of the Vitalograph to measure the FVC and FEV1. Define the terms forced vital capacity (FVC), Forced Expiratory Volume 1 (FEV1) and the ratio FEV1/FVC expressed as a percentage (FEV1 %).
      4. Describe how the Vitalograph may be used to distinguish between restrictive and obstructive types of lung function disorders.
  • Clinical skills: FORMULATING A TREATMENT PLAN (TD 14 g)
    • General Outcomes for Respiratory Disorders
      1. Discuss how variable the symptom of breathlessness may be, and how it may or may not correlate with other tests of lung function. (CR2)
      2. Describe the effects of airway resistance, chest wall loading and chest wall stiffness on breathlessness; describe the ways in which we may treat this sensation (CR2)
• Asthma (Priority 1*)
  • General Outcomes for Asthma
    1. Learn the basic anatomy of the larger and smaller airways (CR3)
    2. List the clinical features of bronchial asthma (CSP3)
    3. List the types and triggers of bronchial asthma (CSP3)
    4. Describe the aetiology and pathophysiology of asthma (CR3)
    5. Explain the two phases of asthma and how bronchial hyper-responsiveness is documented (CSP3)
    6. Give a differential diagnosis for a wheeze (CR3)
    7. Explain the role of mast cells, eosinophils, dendritic cells, B lymphocytes and CD4 Th1 and CD4 Th2 T-lymphocytes in asthma (CSP3)
    8. Describe investigations that can be used to confirm the diagnosis of asthma including the diagnosis of atopy (CR3)
    9. Describe the mechanism of action, place in therapy and major side effects of asthma treatments including short and long acting beta2 agonists, corticosteroids, leukotriene antagonists and anti-IgE. (CR3)
    10. Explain the role of IgE, Fcel1, FceRII, IL2, IL3, IL4, IL5, IL13, GMCSF gamma interferon, histamine, leukotrienes, cytokines, adhesion molecules and the Th1/Th2 paradigm (CSP3)
    11. Explain the rationale behind the stepwise approach used in asthma management and demonstrate use of the British Thoracic Society (BTS) and Scottish Intercollegiate Network (SIGN) guidelines to choose treatments for asthma (CR3)
    12. List environmental and genetic factors predisposing to or protecting from asthma (CSP3)
    13. Explain the role of specialist nurse practitioners and self management plans in the management of asthma (CR3)
    14. Explain to a patient the difference between a reliever and preventer inhaler and the use of each in asthma management (CR3)
    15. Demonstrate the use of a metered dose inhaler with and without a spacer to a patient (CR3)
    16. Be able to recognise differences and similarities in the management of asthma and COPD (CR3)
  • Acute Asthma Exacerbation
    1. Learn the precipitating factors for an asthma attack (CR3)
    2. Describe symptoms and signs of different severities of asthma exacerbations (as per the BTS guideline) (CR3)
    3. Describe the emergency management of asthma in a person presenting to Emergency Department and indications for admission (CR3)
    4. Discuss the role of intensive care in managing an acute asthma attack (CR3)
    5. Describe how a patient with acute asthma should be monitored following admission to hospital (CR3)
    6. Describe measures that should be taken prior to hospital discharge to prevent asthma recurrence (CR3)
    7. Discuss the role of pharmacological and non-pharmacological interventions in preventing asthma exacerbations (CR3)
• Chronic Obstructive Pulmonary Disease (COPD) (Priority 1*)
  • General Outcomes for COPD
    1. Describe symptoms and signs in patients with COPD (CR3)
    2. Give a differential diagnosis for exertional breathlessness and cough (CR3)
    3. Describe the pathology and causes of COPD (CR3)
    4. Describe how a patient's 'pack years' are calculated (CR3)
    5. Describe the role of spirometry in diagnosing and measuring the severity of COPD (CR3)
    6. Describe the purpose and potential abnormal findings of other investigations including chest X-Ray, full blood count and arterial blood gases in a patient with COPD (CR3)
    7. Explain the rationale behind the stepwise approach to COPD management and demonstrate use of the British Thoracic Society and NICE guidelines on COPD to choose drugs for COPD (CR3)
    8. Learn the drugs that can be used to aid smoking cessation and give evidence for their effectiveness and be aware of their contraindications (CR3)
    9. Give smoking cessation advice to a patient (CR3)
    10. Explain the mechanism of action and major side effects of bronchodilators, corticosteroids and theophylline in the management of COPD. (CR3)
    11. Describe the roles of specialist nursing, physiotherapy and pulmonary rehabilitation in the management of COPD (CR3)
    12. Learn the role of community services in the management of COPD (CR3)
    13. Learn complications of COPD and describe their investigation and management (CR3)
  • Acute Exacerbations of COPD
    1. Understand the indications and rationale for long term oxygen therapy (LTOT)
    2. Describe the clinical features (symptoms and signs) of an acute exacerbation of COPD (CR3)
    3. Give a differential diagnosis for increased breathlessness in a patient with COPD (CR3)
    4. Describe the investigation of a patient presenting with an acute exacerbation of COPD (CR3)
    5. Describe the emergency management of a patient with an acute exacerbation of COPD (CR3)
    6. List organisms that may cause pulmonary infection in patients with COPD (CR3)
    7. Discuss the role and choice of antibiotics for treatment of an acute exacerbation of COPD (CR3)
    8. Discuss the role of pharmacological and non-pharmacological interventions in preventing COPD exacerbations (CR3)
    9. Learn the role of community services in the management of COPD exacerbation (CR3)
• Respiratory Failure (Priority 1*)
  • General Outcomes for Respiratory Failure
    1. Learn the oxygen dissociation curve and its importance in oxygen delivery (CR3)
    2. Describe the pathological consequences of hypoxia and hypercapnoea (CR3)
    3. Define type 1 and type 2 respiratory failures and interpretation of arterial blood gas results in these conditions and be able to differentiate these from other (metabolic) blood gas derangements (CR3)
    4. Explain the importance of correcting hypoxia in respiratory failure (CR3)
    5. Explain why oxygen replacement can cause deterioration as well as improvement in a patient with respiratory failure (CR3)
    6. Be aware of the treatment options for patients with ventilatory failure including: (a) non-invasive ventilation (NIV or BIPAP) & (b) continuous positive airways pressure (CPAP) (CR3)
    7. Discuss situations in which treatment may not be appropriate for ventilatory failure and describe palliative measures that could be used to relieve symptoms in these patients (CR3)
    8. Be able to interpret arterial blood gases and pH in order to assist making a diagnosis (CR3)
    9. Discuss the benefits of supplemental oxygen therapy in patients with acute and acute on chronic respiratory failure, and describe any precautions necessary in administering therapy.
  • Type 1 Respiratory Failure
    1. Explain how matching of ventilation and perfusion is achieved in the normal lung (CR3)
    2. Describe the pathogenesis of Type 1 respiratory failure (CR3)
    3. Learn causes of Type 1 respiratory failure (CR3)
    4. Describe symptoms and signs of Type 1 respiratory failure (CR3)
  • Type 2 Respiratory Failure
    1. Describe the normal mechanical process of ventilation (CR3)
    2. Describe the normal process of control of breathing (CR3)
    3. Describe the pathogenesis of Type 2 respiratory failure (CR3)
    4. Learn causes of Type 2 respiratory failure (CR3)
    5. Describe symptoms and signs of Type 2 respiratory failure (CR3)
• Pneumonia (Priority 1)
  • General Outcomes for Respiratory Tract Infections
    1. Describe the nature of viruses and the main therapeutic interventions against viral disease.
    2. Describe the main causes of lower respiratory tract infections.
    3. Discuss the effect of viruses on pre-existing respiratory conditions.
    4. Explain how to diagnose and treat lower respiratory tract infections.
    5. Explain why emerging viruses are such a threat.
    6. Discuss the importance of lower respiratory tract infections as a cause of morbidity and mortality, both in the hospital and community setting.
  • Pneumonia - General
    1. Describe symptoms and signs of pneumonia (CR3)
    2. Describe the physiological processes important for normal lung defence from infection (CR3)
    3. Learn pulmonary, immunological or other conditions which predispose patients to pulmonary infection (CR3)
    4. Learn about the principal organisms that cause pneumonia in those patients who are (a) immuno-competent, (b) immuno-compromised and (c) in hospitals/institutions (CR3)
    5. Learn about the “atypical pathogens” and the clinical, pathological and microbiological features that differentiate them from ‘typical’ pathogens. (CR3)
    6. Describe the relevant investigations of a patient with pneumonia (CR3)
    7. Explain how organisms causing lower respiratory tract infections are differentiated and identified by microbiological investigations (CR3)
    8. Name antibiotics likely to be effective against each of the major respiratory pathogens (CR3)
    9. Explain how the correct drug is chosen for lower respiratory tract infections (CR3)
    10. Describe routes of administration by which antibiotics can be given and state when each route should be used (CR3)
    11. Describe the major adverse consequences of antibiotics used in the treatment of LRTI a) for the individual, and b) for society (CR3)
    12. Know the indications for vaccination against the following: a) influenza b) pneumococcus (CR3)
    13. Recognise chest radiograph changes consistent with pneumonia (consolidation, lobar collapse and pleural effusion). (CR3)
    14. Identify and describe the histopathological changes in the lung in a patient with pneumonia (CR3)
    15. Describe the typical X-ray features of lobar pneumonia, bronchopneumonia and atypical pneumonia
    16. Compare and contrast lobar pneumonia and bronchopneumonia with particular reference to clinical features, pathogenesis, macroscopic appearance and complications
    17. Pneumonia: severity (CURB-65 score), guidelines, choice of antimicrobials (CSP3)
    18. Name the principal organisms that cause pneumonia in a) immuno-competent people b) immuno-compromised people, and c) people in hospitals and institutions
  • Pneumonia - Emergency Management
    1. Describe clinical features that differentiate mild, moderate and severe pneumonia; know about the use of CURB 65 (CR3)
    2. Identify patients who are likely to have poor outcomes with community acquired pneumonia (CR3)
    3. Explain how and why management differs in those with mild, moderate and severe pneumonia (CR3)
    4. Give reasons for hospital admission with pneumonia (CR3)
• Pulmonary Embolism (Priority 1*)
  • General Outcomes for Pulmonary Embolism
    1. Learn pathophysiology of venous thrombo-embolism. (CR3)
    2. Describe symptoms and signs of pulmonary embolism (CR3)
    3. Give a differential diagnosis for pleuritic chest pain (CR3)
    4. Explain how clinical history and examination can be used to distinguish between causes of pleuritic chest pain (CR3)
    5. Describe the role of D-Dimer, CXR, ECG, V/Q scanning, Spiral CT scanning and pulmonary angiogram in the diagnosis of pulmonary embolus (CR3)
    6. Learn about the usefulness of Well’s and other PE probability scoring systems (CR3)
    7. Describe the mechanism of action, place in therapy and major side effects of heparin and warfarin in the treatment of DVT and pulmonary embolus (CR3)
    8. Be aware of the new classes of anticoagulation treatments and the indications for choosing between them. (CR3)
    9. Learn about prevention of venous thrombo-embolism. (CR3)
    10. Describe the relationship between DVT and pulmonary embolism.
    11. Discuss the causes and predisposing factors of DVT and pulmonary embolism.
  • Acute Emergency
    1. Describe the clinical features of massive pulmonary embolism (CR3)
    2. Describe the investigation of a patient with suspected massive pulmonary embolism (CR3)
    3. Outline the management of a patient with a suspected massive pulmonary embolism (CR3)
    4. Be aware of the indications for thrombolysis in massive PE (CR3)
    5. Discuss the advantages and disadvantages of thrombolysis and surgery in a patient with a massive pulmonary embolus (CR3)
• Deep Vein Thrombosis (Priority 1)
  • General Outcomes for Deep Vein Thrombosis
    1. Describe the anatomy of the lower limb venous system (CR3)
    2. Describe the symptoms and signs of deep venous thrombosis (DVT) (CR3)
    3. Give the differential diagnosis for calf swelling / tenderness (CR3)
    4. Learn the risk factors for deep venous thrombosis and pulmonary embolism (CR3)
    5. Describe how investigations are used to confirm or refute the diagnosis of a deep vein thrombosis (CR3)
    6. Describe the mechanism of action, place in therapy and major side effects of heparin and warfarin in the treatment of DVT and pulmonary embolus (CR3)
    7. Counsel a patient regarding avoidance of drugs, foods and alcohol whilst taking Warfarin (CR3)
    8. Describe the physiological and pathological processes that occur in a post-thrombotic limb; explain how these may lead to venous insufficiency and ulceration (CR3)
    9. Describe the management of a post-thrombotic limb and of venous ulceration (CR3)
    10. Learn about the indications for thrombo-prophylaxis for hospital in-patients and describe how this is done (CR3)
    11. Advise a patient on DVT / PE prophylaxis during travel e.g. a long haul flight (CR3)
    12. Be aware of the new classes of anticoagulation treatments and the indications for choosing between them. (CR3)
    13. Describe the relationship between DVT and pulmonary embolism.
    14. Describe the pathological and physiological mechanisms leading to DVT and pulmonary embolism.
• Carcinoma of the Bronchus (Priority 2)
  • General Outcome for Lung Cancer
    1. Learn about the risk factors for lung cancer and the usefulness of screening program (CR3)
    2. Learn about and be able to apply the histological classification and staging of lung cancer (CR3)
    3. Explain why it is important to differentiate between small cell and non-small cell forms of lung cancer (CR3)
    4. Describe clinical (including metastatic) manifestations of lung cancer (CR3)
    5. Describe investigations used in the diagnosis of lung cancer (CR3)
    6. Learn about bronchoscopy in general and its usefulness in the diagnosis of lung cancer and other conditions (CR3)
    7. Be able to break the news that the patient has lung cancer (CR3)
    8. Discuss the role of the multi-disciplinary team in the diagnosis, treatment and support of a patient diagnosed with lung cancer (CR3)
    9. Be aware of the potential paraneoplastic presentations of lung cancer and their pathogenesis, where known. (CR3)
    10. Understand the role of surgery, chemotherapy, radiotherapy and palliative care in the management of bronchial carcinoma (CR3)
  • Carcinoma of the Bronchus
  • Non-small Cell Lung Cancer
    1. Describe specific clinical features and likelihood and common sites of metastasis of non-small cell cancer (CR3)
    2. Describe the clinical course and prognosis of patients with non-small cell lung cancer (CR3)
    3. Describe the management of non-small cell lung cancer based on the TNM classification (CR3)
    4. Discuss the side effects and expected benefits of each treatment for non-small cell cancer (CR3)
  • Small Cell Lung Cancer
    1. Describe specific clinical features and likelihood and common sites of metastasis of small cell lung cancer
    2. Describe the clinical course and prognosis of patients with small cell lung cancer
    3. Describe the management of small cell lung cancer if (a) locally advanced and (b) metastatic (CR3)
    4. Discuss the side effects and expected benefits of the treatment for small cell cancer (CR3)
  • Palliative
    1. Explain how treatment may result in either improvement or deterioration in quality of life and discuss how treatment decisions are made (CR3)
    2. Learn symptoms experienced by patients dying of lung cancer and describe palliative measures which may be used to relieve each one (CR3)
    3. Describe the role of the palliative care home team in supporting patients dying at home and their families (CR3)
    4. Describe the role of primary care team in the palliative care of terminal respiratory disease (CR3)
    5. Explain the role of the hospice in providing care for patients with lung cancer (CR3)
    6. Explain the role of care of the dying pathways in the management of the dying patient (CR3)
• Pulmonary Tuberculosis (Priority 2)
  • Notification and contact tracing
  • General Outcomes for Pulmonary Tuberculosis
    1. Define tuberculosis (CR3)
    2. Describe the epidemiology of tuberculosis; global, UK and risk factors (CR3)
    3. Be aware of the DOTS strategy (CR3)
    4. Review the symptoms of tuberculosis (see lung cancer for differential diagnosis of haemoptysis) (CR3)
    5. Differentiate between primary and post-primary tuberculosis (CR3)
    6. List the investigations for active tuberculosis (CR3)
    7. Understand the role of BCG vaccination. (CR3)
    8. Understand the standard treatment of tuberculosis (CR3)
    9. Explain why contact tracing is important (CR3)
    10. List the people in contact with a person with TB who should be traced
    11. Describe the importance of tracing and investigating contacts in the control of TB and explain how this is done
    12. List the indications for immunisation against TB and describe the vaccine used and its effectiveness
    13. Describe the symptoms of pulmonary tuberculosis
    14. Describe the nature of Mycobacterium tuberculosis and of other types of atypical mycobacterium.
    15. Describe how tuberculosis affecting organs other than the lung may present
    16. Discuss epidemiological factors associated with tuberculosis, and differentiate between primary and post-primary disease.
    17. Describe the presentation of tuberculosis, especially potential difficulties in diagnosis.
    18. Describe the tests required for a diagnosis of tuberculosis.
    19. Discuss the management of tuberculosis, to include chemotherapy, contact tracing and BCG vaccination.
    20. State features of diagnosis and treatment of infections with other mycobacteria.
    21. State features of diagnosis and treatment of infections with mycobacteria other than mycobacterium tuberculosis.
• Pleural Effusion and Pleural Disease (Priority 2)
  • General
    1. Learn the physiological mechanisms of pleural effusion (CR3)
    2. Describe symptoms and signs of a pleural effusion (CR3)
    3. Differentiate clinical signs of a pleural effusion from those of pulmonary consolidation, collapse, pneumothorax and lung fibrosis (CR3)
    4. Describe how pleural aspiration is performed and list analyses that should be performed on fluid obtained (CR3)
    5. Describe how these tests distinguish between an exudate and a transudate and explain why this is important (learn Light's criteria (CR3)
    6. List causes of an exudate and a transudate (CR3)
    7. Describe how investigations including chest X-ray, pleural aspiration, pleural biopsy, thoracic ultrasound and CT chest can help to differentiate between causes of effusion and the indications for each investigation. (CR3)
    8. Describe (in general) how pleural effusions are managed medically and surgically (CR3)
    9. Learn about chest drain insertion (CR3)
    10. Learn about VATS (video assisted thoracoscopic biopsy) (CR3)
• Pneumothorax (Priority 2*)
  • General
    1. Describe symptoms and signs of pneumothorax (CR3)
    2. Learn the risk factors and describe the pathogenesis of pneumothorax (CR3)
    3. Describe investigations used to confirm the diagnosis of pneumotharax (CR3)
    4. Describe conservative, medical and surgical management of pneumothorax and when each should be considered (CR3)
    5. Describe how an underwater chest drain is managed on a day to day basis on the ward (CR3)
    6. Describe the criteria used in order to remove a chest drain in a patient (CR3)
    7. Explain the chances of pneumothorax recurrence and activities to avoid to a young patient with a simple pneumothorax (CR3)
    8. Describe the role of smoking cessation in patients with pneumothorax (CR3)
    9. Define the terms, pneumothorax, spontaneous pneumothorax and tension pneumothorax and comment briefly on the management of these conditions.
  • Acute Tension Pneumothorax
    1. Describe the clinical features of a tension pneumotherax (CR3)
    2. Explain why a tension pneumothorax is life threatening (CR3)
    3. Describe the emergency management of a tension pneumothorax (CR3)
• Chest Trauma and Haemothorax (Priority 3*)
  • General
    1. Learn pulmonary and pleural complications of blunt, sharp and explosion related chest trauma (CR3)
    2. Describe how chest trauma is assessed as part of the Advanced Trauma Life Support (ATLS) protocol
    3. Understand the extent of the pleural cavity and the consequences of pleural injuries (CR2)
    4. Describe the diagnosis and management of haemothorax
• Bronchiectasis and Cystic Fibrosis (Priority 3)
  • General
    1. Give a differential diagnosis for cough with productive of sputum (CR3)
    2. Describe the pathology of bronchiectasis (CR3)
    3. Learn the common causes of bronchiectasis (CR3)
    4. Describe the symptoms and signs of bronchiectasis and Cystic fibrosis (CR3)
    5. Describe the genetic mutation of cystic fibrosis and explain current theories as to how this leads to lung disease (CR3)
    6. Describe the pathological effect and clinical consequences of cystic fibrosis in non-pulmonary organs (CR3)
    7. Describe the investigations that can be used to confirm diagnosis of bronchiectasis and cystic fibrosis (CR3)
    8. Learn the role of lung function and understand that bronchiectasis is one of the causes of COPD. (CR3)
    9. Learn about the organisms that exacerbate bronchiectasis and cystic fibrosis and explain how you would choose an antibiotic for patients with exacerbations (CR3)
    10. Discuss the significance of isolation of bacterial organisms like pseudomonas in sputum of those patients with bronchiectasis (CR3)
    11. Learn about the role of antibiotic prophylaxis in bronchiectasis (CR3)
    12. Describe the role of chest physiotherapy in the management of bronchiectasis (CR3)
    13. Describe nutritional problems and their management in cystic fibrosis (CR3)
    14. Describe the potential impact of chronic disease, such as cystic fibrosis, on the lives of young people (CR3)
    15. Cystic Fibrosis, Pseudomonas Aeruginosa, Staphylococcus Aureus, Physiotherapy, Ciproflaxacin, Flucloxacilin, DNAase, CFTR
    16. List the signs and symptoms of cystic fibrosis
    17. Describe the role of physiotherapy in the management of cystic fibrosis
    18. Describe the impact of cystic fibrosis on the education of young people
• Sarcoidosis (Priority 3)
  • General
    1. Describe symptoms and signs of sarcoidosis (CR3)
    2. Describe the pathological features of sarcoidosis (CR3)
    3. Describe how sarcoidosis affects a) the lungs and b) other tissues and organs (CR3)
    4. Describe clinical conditions which closely resemble sarcoidosis (CR3)
    5. Describe investigations that can be used to confirm the diagnosis of a) pulmonary and b) extra-pulmonary sarcoidosis (CR3)
    6. Describe the treatment options for patients with sarcoidosis and the indications for commencing treatment (CR3)
    7. Learn about the prognosis for patients with different presentations of sarcoidosis (CR3)
• Interstitial Lung Disease (Priority 3)
  • General
    1. Describe the symptoms and signs of interstitial lung disease
    2. Give a differential diagnosis for finger clubbing
    3. Describe the tests for gas transfer and their limitations and value, especially in interstitial lung disease.
    4. Describe investigations that can be used to confirm the diagnosis of interstitial lung disease
    5. Summarise the other causes of lung fibrosis including occupational dusts, sarcoidosis, extrinsic alveolitis, TB, connective tissue diseases and drugs
    6. Describe which patients with interstitial lung disease should be referred for specialist management
    7. Describe the role of steroids and immune-modulating drugs in the therapy of interstitial lung disease
    8. Describe the symptoms and signs characteristic of a restrictive lung defect including the changes in lung function
    9. Discuss the indications for a single lung or heart-lung transplant
    10. Describe the linkages between medication and interstitial lung disease
• Obstructive Sleep Apnoea (Priority 3)
  • General
    1. Describe the clinical features of sleep apnoea in a child (CR3)
    2. Identify patients who may be suitable for referral to a sleep service (CR3)
    3. Discuss the difference between obstructive and central sleep apnoea (CR3)
    4. Learn the basic components of a sleep study and changes in sleep apnoea (CR3)
    5. Explain to a patient what they can expect when undergoing a sleep study (CR3)
    6. Describe the treatments available for obstructive sleep apnoea including conservative measures, Continuous Positive Airways Pressure (CPAP) therapy and surgery and when they are indicated (CR3)
    7. Discuss the complications of untreated sleep apnoea and describe the implications of driving with this condition (CR3)
    8. Outline the causes of sleep apnoea in children and adults (CR3)
• Pulmonary Hypertension (Priority 3)
  • General
    1. Describe the differences, including pressure differences, between the systemic and pulmonary circulation, and left and right sides of the heart (CR3)
    2. Learn about the common causes of pulmonary hypertension, particularly other systemic conditions (CR3)
    3. Outline investigations that can be used to confirm the diagnosis of pulmonary hypertension (CR3)
    4. Describe which patients with pulmonary hypertension should be referred for specialist management (CR3)
    5. Learn the outcomes of those patients having pulmonary hypertension secondary to underlying lung diseases (CR3)
• Occupational Lung Disease (Priority 3)
  • General Outcomes for Occupational Lung Disease
    1. Give examples of occupational exposures that predispose to a) asthma, b) extrinsic allergic alveolitis, c) lung fibrosis, and d) pulmonary malignancy (CR3)
    2. Describe measures that can be taken to prevent occupational lung disease (CR3)
  • Asbestos Related Lung Disease
    1. Learn about those occupations that have a high chance of asbestos exposure (CR3)
    2. Describe the pulmonary consequences of asbestos exposure (CR3)
    3. Describe investigations that can be used to confirm the diagnosis of asbestos-related lung disease (CR3)
    4. Learn about the patient categories with asbestos-related lung disease who are entitled to compensation (CR3)
  • Mesothelioma
    1. Learn about the clinical symptoms and signs of mesothelioma (CR3)
    2. Describe the role of the primary care team in the palliative care of terminal respiratory disease
    3. Learn about how mesothelioma is diagnosed (CR3)
    4. Understand the role of the MDT in the diagnosis and management of mesothelioma (CR3)
    5. Understand the role of surgery, chemotherapy and radiotherapy in the management of mesothelioma (CR3)

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