Curriculum standards: LG15: Scientific foundations of respiratory medicine

Knowledge guides

LG15: Scientific foundations of respiratory medicine

Epidemiology, Pathophysiology, and Clinical sciences

Advanced Trainees will have in-depth knowledge of the topics listed under each clinical sciences heading.

For the statistical and epidemiological concepts listed, trainees should be able to describe the underlying rationale, the indications for using one test or method over another, and the calculations required to generate descriptive statistics.

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Investigations, procedures, and clinical assessment tools

Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.

Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.

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Important specific issues

Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis, management, and outcomes.

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Environmental factors:
- air pollution
- effect of altitude and diving on lung disease
- occupational and environmental toxins, including silica dust and asbestos:
  - medicolegal implications of occupational dust exposure
  - methods for screening for occupational dust exposure and related disease
- smoking (tobacco and marijuana) and vaping:
  - the adverse effects on health
  - the specific effects on respiratory health
  - methods for screening for exposure to environmental tobacco smoke, including urinary / salivary cotinine
Pharmacology:
- aerosol drug delivery:
  - aerosol delivery through different interfaces, such as spacers, facemasks, high flow circuits, invasive and non-invasive positive pressure ventilation
  - mechanisms and adverse effects of aerosol treatments
  - principles of aerosol delivery to the lungs
  - principles of infection control in aerosol therapy
  - principles of pressurised metered dose inhalers, dry powder inhalers, and nebulisers
- biologics in respiratory disease
- dosing and side effects
- drug interactions and contraindications of medications
- effects of non-respiratory medications on the respiratory system
- formulations of medications
- mechanism of action
- monitoring of drug levels
- pharmacodynamics
- screening for adverse effects
Principles of statistics and epidemiology:
- basic statistics
- critical appraisal of published research and appropriate application towards clinical care
- levels of evidence and classes of recommendations
- population risk determinants of respiratory disease
Structure and function of the respiratory system:
- immunology and host defence mechanisms:
  - acquired immunity
  - antibody classes and function
  - atopy and hypersensitivity reactions
  - autoimmunity
  - cell mediated immunity
  - effects of systemic and localised immunodeficiency (e.g., GM-CSF antibody syndrome) on lung health
  - humoral immunity
  - innate immunity
  - lung microbiomeo
  - pulmonary defence mechanisms, particularly the role, makeup, and function of mucus, cilia, and cough
  - transplant immunology
  - vaccines and vaccine responses
- lung development:
  - normal development
  - surfactant physiology
  - the effects of early life lung disease on long-term health
- pulmonary physiology:
  - acid-base balance
  - alveolar gas equation
  - control of ventilatory drive
  - diffusion
  - mechanics of breathing
  - metabolic functions of the lung
  - peripheral blood flow, gas transport, and oxygen-haemoglobin dissociation
  - physiological changes and compensations under altered states
  - pulmonary blood flow, vascular resistance, and heart-lung circulatory relationships
  - ventilation and gas exchange, including ventilation perfusion relationships:
    - ageing
    - diving physiology
    - exercise
    - high altitude physiology
    - pregnancy
- the normal and abnormal structural components of the respiratory system:
  - alveoli (including type 2, Clara, and goblet cells)
  - chemoreceptors
  - chest wall
  - interstitium
  - lower airway segments (1-19)
  - mediastinal lymph node stations
  - pulmonary vasculature
  - respiratory control centres
  - respiratory muscles
  - smooth muscle and receptors
  - upper airway anatomy

Investigations

Blood gas analysis, including interpretation of arterial, venous, and capillary samples
Capnography, including exhaled and transcutaneous samples
Lung function tests:
- bronchial provocation testing, including direct and indirect methods
- bronchodilator response
- calculations of shunt fraction
- cardiopulmonary exercise testing
- diffusion assessment
- forced oscillometry testing
- fraction of exhaled nitric oxide
- high altitude simulation tests
- lung volume assessment techniques
- respiratory muscle testing, including maximal inspiratory and expiratory pressures, sniff nasal inspiratory pressures, supine spirometry, and cough peak flow
- six-minute walk test
- spirometry, including office / bedside testing
Oximetry, including continuous / overnight studies
Oesophageal manometry and pH monitoring
Positive airway pressure device downloads
Polysomnography:
- address the benefits and limitations of different levels of polysomnography testing
Radiological investigations:
- chest x-ray
- contrast swallow tests
- CT scan of the chest
- fluoroscopy
- magnetic resonance imaging of the chest
- scintigraphy / nuclear medicine tests:
  - PET with / without integrated CT
  - ventilation / perfusion scans
- ultrasonography:
  - doppler ultrasound imaging and flow studies
  - thoracic and pleural ultrasound
  - trans-thoracic echocardiography
Radiological, serological, cytological, histological, and ancillary testing for primary lung disease and systemic disorders with pulmonary overlap:
- allergy and delayed hypersensitivity tests
- cilia studies:
  - cilial function testing
  - electron microscopy for cilial ultrastructure
  - nasal nitric oxide testing
- sweat test and genotyping for cystic fibrosis
Technical aspects of lung function testing:
- clinical interpretation of test results, and appreciation of clinically meaningful change
- clinical versus research role of the above investigations
- margins of error, and operator-dependant and patient-related factors and their implications
- methods of performing tests
- reference values and their limitations

Procedures

Bronchoscopy:
- anatomy:
  - airway anatomy
  - normal anatomical variants of airways
  - visual appearance of upper and lower airway pathology (e.g., subglottic lesions, tumours)
- applications and use of single-use / disposable bronchoscopes
- investigations:
  - assessment and quantification of dynamic airway collapse
  - collateral ventilation assessment
  - cytology and/or microbiology from brushings
  - cytology and/or microbiology from fine needle aspiration and transbronchial core needle biopsies
  - cytology and/or microbiology from washings / bronchoalveolar lavage fluid
  - histology and/or microbiology from cryobiopsy
  - histology and/or microbiology from forceps bronchial and transbronchial biopsies
- management of intra- and postoperative complications
- techniques:
  - anaesthesia, airway protection, and ventilation strategies for bronchoscopic procedures
  - methods of introduction of bronchoscopes, including nasal intubation, oral intubation with mouth / bite guard, laryngeal mask airway (LMA), endotracheal tube (ETT), and direct tracheostomy approaches
  - navigational techniques, such as bronchial branch tracing (Kurimoto technique), electromagnetic navigation, robotic navigation, navigational software, fluoroscopy, cone beam CT
  - rigid and flexible bronchoscopy, including single-use instrumentation, and linear and radial endobronchial ultrasound
- the processes for sterilisation and maintenance of bronchoscopic equipment
- therapeutic techniques:
  - advanced therapeutic modalities, such as APC, cryotherapy, and Nd-YAG laser
  - bronchoscopic drug delivery
  - endobronchial lung volume reduction
  - foreign body removal
  - large airway debulking or stent placement
  - management of persistent air leak
  - therapeutics under investigation, including thermal vapour and microwave ablation
Pleural:
- diagnostic and therapeutic indications for pleural procedures
- normal and abnormal anatomy of the pleura
- physiology and biochemistry of pleural fluid
- procedure techniques:
  - anaesthesia (local, regional, and general approaches)
  - closed pleural biopsy (Abrams and image-guided techniques)
  - indwelling tunnelled pleural catheter insertion and removal
  - large bore intercostal catheter insertion
  - needle thoracentesis
  - small bore intercostal catheter insertion
  - thoracoscopy
  - underwater seal drainage systems, including digital ambulatory systems
- risks and benefits of each of the diagnostic / therapeutic interventions
- sedation, topical anaesthesia, and analgesia
- selection and assessment of patients for procedural intervention
- therapeutic interventions:
  - pleural fluid drainage
  - pleural infection management using intrapleural fibrinolytic, plus mucolytic therapy, saline irrigation, and basic knowledge of surgical options
  - pleurodesis (slurry and poudrage)
  - pneumothorax management
  - advanced management of persistent air leak, including talc insufflation, blood patch pleurodesis, endobronchial interventions, and basic knowledge of surgical options
- utility of ultrasonography in assessment and management of pleural disorders

The following issues apply to all knowledge guides

Advanced certification or training (generally beyond scope of advanced training) for advanced procedural interventions, including:
- advanced bronchoscopic therapeutic interventions
- endobronchial lung volume reduction
- indwelling tunnelled pleural catheter insertion and removal
- large airway management
- navigational techniques
- radial endobronchial ultrasound
Engage in preventive and adjunctive care for patients with respiratory disease, including a focus on smoking cessation, vaccinations, and pulmonary rehabilitation
Incorporate principles of entrustable professional activities into clinical management of respiratory disease
Patient care considerations for specific patient groups and those with culturally diverse backgrounds, including:
- Aboriginal and Torres Strait Islander background, ethnic minorities, religious ideologies (e.g., Jehovah’s Witness), refugees, overseas travellers, low socioeconomic background, non-English speaking background
- adolescent, elderly, pregnant, and peripartum states
Procedural competence for respiratory interventions:
- flexible bronchoscopy
- intercostal catheter insertion
- linear endobronchial ultrasound
- thoracic and pleural ultrasound
Recognise the inter-relationship and impact of comorbidities and respiratory conditions on each other, with respect to clinical presentation, diagnostics, management, prognostics and impact of illness