Knowledge guides

LG16: Acute respiratory care

Key presentations and conditions

Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.

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Less common or more complex presentations and conditions

Advanced Trainees will understand these presentations and conditions.

Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.

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Epidemiology, pathophysiology, and clinical sciences

Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.

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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 and management and integrate these into care.

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Presentations
  • Abnormal chest radiology (including chest x-ray or CT scan)
  • Chest pain
  • Chest tightness
  • Cough
  • Dyspnoea
  • Fatigue
  • Fever
  • Haemoptysis
  • Hypercapnia
  • Night sweats
  • Orthopnoea
  • Respiratory failure, including hypoxaemia
  • Sleep disruption
  • Snoring
  • Somnolence
  • Sputum production
  • Stertor
  • Stridor
  • Symptoms related to occupational or environmental exposure
  • Tachypnoea
  • Weight loss
  • Wheeze
Conditions

Airways disorders

  • Acute exacerbation of obstructive airways disease, including:
    • allergic bronchopulmonary aspergillosis
    • asthma
    • bronchiectasis (cystic fibrosis and non-cystic fibrosis related), bronchiolitis
    • chronic obstructive pulmonary disease

Diffuse parenchymal lung disorders

  • Acute exacerbation of obstructive airways disease, including:
    • Acute eosinophilic pneumonia
    • Acute exacerbation of connective tissue disease-related and other interstitial lung disease
    • Acute exacerbation of idiopathic pulmonary fibrosis
    • Acute hypersensitivity pneumonitis
    • Acute interstitial pneumonia
    • Acute pulmonary oedema
    • Acute rejection post lung transplantation
    • Acute respiratory distress syndrome
    • Drug-induced pneumonitis
    • Organising pneumonia
    • Radiation pneumonitis

Large airways disorders

  • Acute / Subacute or critical upper airway obstruction, including:
    • foreign body aspiration
    • malignant central airway obstruction
    • subglottic stenosis
    • tracheal stenosis
    • tracheo- and broncho-oesophageal fistula

Pleural disorders

  • Chylothorax
  • Empyema
  • Haemothorax
  • Persistent air leak, including bronchopleural fistula formation
  • Pleural effusions
  • Pneumothorax

Pulmonary infections

  • Aspiration pneumonitis
  • Community or healthcare-acquired pneumonia
  • Fungal infections, including aspergillus, cryptococcus, and pneumocystis jirovecii
  • Infections in patients who are immunocompromised
  • Infections in patients with underlying structural lung disease and airways disease
  • Infections related to inserted devices
  • Non-tuberculous mycobacterial infections
  • Parapneumonic effusions, pleural infections, and empyema
  • Respiratory viral infections, including influenza and SARS-CoV-2
  • Tuberculosis with pulmonary and extrapulmonary manifestations

Pulmonary vascular disorders

  • Acute or massive haemoptysis
  • Acute right ventricular failure secondary to lung disease / pulmonary arterial hypertension
  • Diffuse alveolar haemorrhage
  • Pulmonary arterial hypertension
  • Pulmonary embolism
  • Pulmonary vasculitis

Respiratory failure

  • Acute and acute-on-chronic hypercapnic respiratory failure in chronic respiratory conditions, including:
    • airways diseases
    • kyphoscoliosis
    • neuromuscular diseases
    • obesity hypoventilation
  • Acute hypercapnic respiratory failure secondary to exacerbation of airways diseases, especially chronic obstructive pulmonary disease
  • Acute hypoxaemic respiratory failure
  • Acute pulmonary oedema
  • Drug-induced or over-sedation related respiratory failure
  • Post-extubation respiratory failure

Thoracic malignancy and mediastinal disorders

  • Complications relating to thoracic malignancies
  • Large airway obstruction or endobronchial disease with associated symptoms
  • Mediastinal mass effect
  • Superior vena cava obstruction

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • recognise the clinical presentation
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • take a comprehensive clinical history
  • conduct an appropriate examination
  • establish a differential diagnosis
  • plan and arrange appropriate investigations
  • consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
  • provide evidence-based management
  • prescribe therapies tailored to patients' needs and conditions
  • recognise potential complications of disease and its management, and initiate preventative strategies
  • involve multidisciplinary teams
Consider other factors
  • identify individual and social factors and the impact of these on diagnosis and management
Conditions

Diffuse parenchymal lung disorders

  • Alveolar proteinosis
  • Barotrauma
  • High altitude and diving-related lung injury, including drowning
  • Post-haematopoietic bone marrow transplant syndromes:
    • engraftment syndrome
    • graft versus host disease
  • Traumatic lung injury, including contusions
  • Vaping and inhalation-related acute lung injury

Pulmonary infections

  • Parasitic lung infections, including:
    • hydatid
    • strongyloides
  • Pulmonary infections endemic only to certain geographical locations in Australia, New Zealand, or globally:
    • burkholderia mellioid
    • histoplasmosis
    • strongyloidiasis
    • toxoplasmosis

Thoracic malignancy and mediastinal disorder

  • Extra-pulmonary complications of thoracic malignancy, including:
    • oesophageal obstruction
    • pericardial tamponade
    • spinal cord compression

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • recognise the clinical presentation
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • take a comprehensive clinical history
  • conduct an appropriate examination
  • establish a differential diagnosis
  • plan and arrange appropriate investigations
  • consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
  • provide evidence-based management
  • prescribe therapies tailored to patients' needs and conditions
  • recognise potential complications of disease and its management, and initiate preventative strategies
  • involve multidisciplinary teams
Consider other factors
  • identify individual and social factors and the impact of these on diagnosis and management

Airways disorders

  • Apply knowledge of epidemiology and pathophysiology of airways disease in the appropriate diagnosis and personalised management for patients

Diffuse parenchymal lung disorders

  • Apply knowledge of epidemiological factors, diagnostic sensitivity / specificity of investigations (serology, bronchoscopic, and surgical specimens), and pathophysiology of autoantibody syndromes (e.g., MDA-5, Jo-1), in determining appropriate diagnosis and treatment options for undifferentiated or new presentations of acute interstitial pneumonia

Pleural disorders

  • Apply epidemiology and pathophysiology in determining appropriate diagnosis, requirement for intervention, and management options for undifferentiated unilateral and bilateral pleural effusion

Pulmonary infections

  • Apply local epidemiology of prevalence of microbes and drug susceptibility patterns in aiding appropriate diagnosis and management avenues
    • apply local epidemiology and risk factors for diagnosis of legionella infections
    • empirical antimicrobial choice in treatment of latent tuberculous infection or culture-negative tuberculosis
  • Apply knowledge of timings of opportunistic infections and radiological patterns in guiding appropriate diagnosis and management, especially if empiric therapy is utilised
    • empirical antimicrobial choice in treatment of suspected fungal disease in post-HSCT lung infections

Respiratory failure

  • Apply knowledge of epidemiology and various pathophysiological mechanisms contributing towards respiratory failure in determining appropriate positive airway pressures, additional non-invasive ventilation settings, and adjunct treatment modalities (e.g., cough assist device)

Thoracic malignancy and mediastinal disorders

  • Apply epidemiological risk factors in determining asymptomatic individuals suitable for lung cancer screening with low dose chest CT scan
  • Apply epidemiological risk factors in determining individuals at high risk of harbouring driver or targetable mutations, and therefore most suitable for advanced testing, including molecular analysis, next generation sequencing and/or liquid biopsy
Investigations
  • Blood gas analysis, including interpretation of arterial, venous, capillary, exhaled, and transcutaneous samples
  • Capnography
  • Lung function tests:
    • calculation of shunt fraction
    • cough peak flow and sniff nasal inspiratory pressures
    • gas transfer assessment
    • peak flow monitoring and assessment
    • plethysmography
    • spirometry, including pre- and post-bronchodilator, and in erect and supine positions
  • Oximetry, including continuous / overnight studies
  • Positive airway pressure device downloads
  • Radiological investigations:
    • chest x-ray
    • CT, including pulmonary angiogram and high-resolution protocols
    • right heart catheterisation and haemodynamic measurements (basic knowledge and interpretation)
    • scintigraphy / nuclear medicine tests (e.g., PET and ventilation / perfusion scans)
    • ultrasonography
      • doppler ultrasound imaging and flow studies
      • thoracic and pleural ultrasound
      • trans-thoracic echocardiography
  • Serological, cytological, and histological biomarkers (e.g., utility of serology, cultures, PCR techniques, and histology for diagnosis of pulmonary infections)
Procedures
  • Bronchoscopy, including endobronchial ultrasound (linear and radial modalities), flexible bronchoscopy (including single use), and rigid bronchoscopy:
    • advanced therapeutic modalities, such as APC, cryotherapy, endoscopic lung volume reduction, and Nd-YAG laser
    • bronchial brushings
    • bronchoscopic drug delivery
    • collateral ventilation assessment
    • cryobiopsy
    • cytology and microbiology from washings / bronchoalveolar lavage fluid
    • differential cell counts from bronchoalveolar lavage fluid
    • fine needle aspiration
    • forceps endobronchial and transbronchial biopsy
    • foreign body removal
    • large airway debulking or stent placement
    • management of persistent air leak
  • Pleural procedures:
    • Procedure techniques:
      • ambulatory and underwater seal drainage
      • indwelling tunnelled pleural catheter
      • large bore drain insertion
      • needle thoracentesis
      • pleural ultrasound
      • small bore intercostal catheter insertion
      • thoracoscopy
    • Therapeutic interventions:
      • advanced management of persistent air leak, including blood patch pleurodesis, endobronchial interventions, talc insufflation, and basic knowledge of surgical options
      • intrapleural fibrinolysis and irrigation
      • pleural fluid drainage
      • pleurodesis
      • pneumothorax management
  • Appreciation for multidisciplinary team management (including allied health, medical, surgical, and critical care specialties) of severe or life-threatening presentations, particularly with:
    • acute interstitial pneumonias
    • decompensated respiratory failure
    • haemoptysis
    • large airway compromise
    • pneumothorax
    • pulmonary emboli
    • respiratory tract infections
    • severe asthma
  • Investigation and management of undifferentiated hypercapnia with understanding of pathophysiological mechanisms, various modalities of management and positive airway pressure delivery, and subsequent monitoring methods
  • Investigation and management of undifferentiated hypoxaemia, with understanding of utility of various diagnostic modalities, different oxygen delivery modalities, and use of controlled oxygen therapy
  • Knowledge of appropriate timings and methods for investigations, as well as their diagnostic yield, in management of patients with pulmonary infections, especially those that are severe or associated with underlying lung disease or concurrent immunocompromise
  • Principles of mandatory reporting, contact tracing, treatment observation, and other public measures in management of communicable diseases, particularly tuberculosis
  • Understanding of the interplay between various acute concurrent pathologies and comorbidities in contributing towards a patient’s clinical presentation, as well as treatment implications