learning pack: paediatric respiratory medicine and ent · instructions for participants: read...
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Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 1
Learning Pack: Paediatric Respiratory Medicine and ENT
This learning pack is designed to be used to support local teaching and for individual reading and
reflection. Several activities have been designed and they have been mapped to the RCPCH Progress
Curriculum.
Feel free to use any or all of this pack in your department. If you wish, you can reflect on the learning
activity and upload to your e-portfolio linking to the relevant domains. Other learning packs are available
on https://londonpaediatrics.co.uk
Comments/feedback to [email protected] , [email protected] ,
Contents: Title Progress Domains Level Page
Activity 1: Simulation Acute Severe Asthma
Domain 4: Patient Management Domain 6: Leadership
1-3 2
Activity 2: Safe Prescribing IV Salbutamol
Domain 7: Patient Safety and Prescribing Domain 4: Patient Management
1-2 4
Activity 3: Part-Task Teaching inhaler technique
Domain 2: Communication 1-3 5
Activity 4: History Taking Asthma Clinic Consultation
Domain 2: Communication Domain 5: Health Promotion
1-2 6
Activity 5: Part Task Asthma Action Plan
Domain 10: Education and Training Domain 2: Communication
1-2 8
Activity 6: Simulation Emergency Tracheostomy Change
Domain 4: Patient Management Domain 6: Leadership
1-3 9
Activity 7: Case Based Discussion Cystic Fibrosis
Domain 1: Professional Values and Behaviours Domain 5: Health Promotion
1-3 11
Activity 8: Quick Teach CF Modulators
Domain 10: Education and Training Domain 11: Research
1-3 12
Activity 9: Case Based Discussion Recurrent LRTI
Domain 2: Communication Domain 4: Patient Management
1-3 13
Activity 10: Flipped Classroom Stridor
Domain 4: Patient Management Domain 7: Patient Safety and Prescribing
1-3 14
Activity 10: Flipped Classroom Bronchiolitis
Domain 4: Patient Management Domain 7: Patient Safety and Prescribing
1-3 15
Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 2
Asthma
Objectives Appropriately manage acute severe asthma in the ED
Practice safe prescribing of salbutamol IV and Aminophylline
Teach good inhaler technique
Understand step-up and step-down of asthma management in a clinic consultation
Practice completing and explaining an Asthma Allergy Plan for a child seen in clinic
Activity 1: Simulation Session: Child with severe wheeze
Facilitator: Consultant/Senior Trainee with debriefing skills
Participants: SHOs, SPRs, Nurses
Instructions for Facilitator: This is designed for low fidelity simulation (15 minutes) depending on
available resources. History should be provided only when asked for it. The child should deteriorate if
appropriate management is not implemented in a timely manner. Facilitate debrief session (30 minutes),
with technical skills and human factors.
Instructions for participants: You have been called to ER to see a 7 year old child with known asthma.
The nurse is just putting on monitoring as you arrive. The child is accompanied by their mother.
Set-up: ED in DGH with access to resus area, resus trolley, acute asthma pathway (if requested) and
telephone for escalation of care.
Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 3
Participants are expected to:
Assess systematically (A-E)
Implement appropriate management (consider IV treatment early)
Maintain effective communication with child and mother
Call for help early
Lead and work effectively in a team
Further Reading
https://dontforgetthebubbles.com/asthma-medical-management/
provides a comparison of IV treatments
https://www.rcemlearning.co.uk/foamed/w-is-for-winter-and-wheeze-paediatric-acute-asthma/
further analysis of acute asthma management
https://site.cats.nhs.uk/wp-content/uploads/guideline-asthma.pdf
CATS guideline
Case for Facilitator Only:
Bobby Nichols, NHS 700123456, DOB 15/07/2010, Weight unknown
Known asthmatic, had been feeling unwell this morning, but went to school, while walking to
school felt wheezy and short of breath. Took 10 puffs of his salbutamol and rang mum. No
improvement so called ambulance. Paramedics have given 2 salbutamol nebulisers
Observations, RR 20, Sats 93% (in 15L), HR 135, T 36.5 BP (not done)
Examination: Visible increased work of breathing, quiet bilateral wheeze, prolonged expiratory
phase, unable to complete sentances.
Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 4
Activity 2: Safe Prescription of IV Salbutamol
Equipment: Prescription Chart, Fluid Chart, Local protocol or guideline
IV salbutamol is a commonly used medication in acute asthma but does often pose issues when it is
prescribed due to the need for a loading dose and a weight limited IV infusion.
Tasks:
Child is 13 years old, 40kg and needs IV salbutamol
Prescribe the loading dose
Prescribe the infusion
Discuss when aminophylline would be used instead or first line
Salbutamol
Acute asthma
By intravenous injection
For Child 1–23 months
5 micrograms/kg for 1 dose, dose to be administered over 5 minutes, reserve intravenous beta2
agonists for those in whom inhaled therapy cannot be used reliably or there is no current effect.
For Child 2–17 years
15 micrograms/kg (max. per dose 250 micrograms) for 1 dose, dose to be administered over 5
minutes, reserve intravenous beta2 agonists for those in whom inhaled therapy cannot be used
reliably or there is no current effect.
By continuous intravenous infusion
For Child
1–2 micrograms/kg/minute, adjusted according to response and heart rate, increased if necessary up
to 5 micrograms/kg/minute, doses above 2 micrograms/kg/minute should be given in an intensive
care setting, reserve intravenous beta2 agonists for those in whom inhaled therapy cannot be used
reliably or there is no current effect.
Source: BNFc
Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 5
Activity 3: Teaching Inhaler Technique
Equipment: MDI Inhaler, Volumatic Spacer,
A large part of compliance and good management of asthma depends on good inhaler technique.
Tasks:
Explain and demonstrate appropriate inhaler technique and how this varies with age
Be able to explain the importance of spacers
The following resources demonstrate good technique
https://www.asthma.org.uk/advice/inhaler-videos/
https://www.asthma.org.uk/advice/inhalers-medicines-treatments/inhalers-and-spacers/spacers/
Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 6
Activity 4: History Taking Station – Asthma Clinic
Objectives
Communicate effectively with parents and child to address their concerns
Understand the concept of step-up and step down treatment for asthma
Understand the role of PEFR and Lung function testing
Consider how to approach poor compliance
Facilitator: Consultant
Participant: SHOs
Equipment: https://www.rcpch.ac.uk/resources/mrcpch-clinical-examination-candidate-guidance
Instructions for Facilitator: Set up a communication scenario following the structure and timing of the
MRCPCH clinical History station with candidate and parent. Support the two parts of the station and lead
on feedback and discussion following the discussion
Instructions for participants: Read through the case below and take a focussed history from the patient.
You will then be expected to go through your findings and management plan
Case:
Louise is a 13 year old girl attending the asthma clinic with her mother. She has been referred by her GP
due to multiple asthma exacerbations in the last month. She was diagnosed with asthma as a 5 year old
and is currently on two inhalers and a medicine that she takes in the morning. Her parents are increasingly
concerned by the repeated visits to A+E.
Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 7
Louise’s Parent
You are concerned that you keep having to take Louise to A+E with exacerbations of her asthma.
Louise
On questioning – you don’t like having to take your inhalers at school and if asked you will admit that you
only take your Seretide 50% of the time. You currently need your blue inhaler on a daily basis.
Role for Facilitator on questioning
- Has compliance been thought of, and how can it be addressed
- What step of the asthma ladder is the patient currently on
- What investigations would help support deciding whether to adjust medications
Further Reading:
Compliance
https://breathe.ersjournals.com/content/9/4/268
Diagnosis of asthma
https://www.guidelines.co.uk/respiratory/sign-and-bts-management-of-asthma-in-children-
guideline/454880.article
Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 8
Activity 5: Asthma Action Plan Explanation
Equipment: Printed Asthma Action Plan
Facilitator: Consultant, Registrar, Asthma specialist nurse
Participant: SHO or SPR
Instructions for Facilitator: Encourage participant to review and complete the asthma plan individually
and then explain it to the parent, explaining both chronic and acute management
Instructions for participants: Complete an asthma management plan and explain it to the parent/child
Asthma UK Asthma Action Plan
https://www.asthma.org.uk/advice/child/manage/action-plan/
Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 9
Management of a child with a tracheostomy
Objectives Appropriately management of a tracheostomy requiring an acute change
Practice emergency tracheostomy change
Identify the important equipment required for a child with a tracheostomy
Activity 6: Simulation Session: Child with Tracheostomy
Facilitator: Consultant/Senior Trainee with debriefing skills
Participants: SHOs, SPRs, Nurses
Equipment: Tracheostomy box and emergency sheet
Instructions for Facilitator: This is designed for low fidelity simulation (15 minutes) depending on
available resources. History should be provided only when asked for it. The child should deteriorate if
appropriate management is not implemented in a timely manner. Facilitate debrief session (30 minutes),
with technical skills and human factors.
Instructions for participants: You have been called to the ward to see an ex premature infant with a
tracheostomy who is desaturating.
Set-up: Ward bed, middle of the night, tracheostomy box and emergency sheet clear at the bedside
Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 10
Participants are expected to:
Assess systematically (A-E)
Implement appropriate management (Oxygen, Emergency tracheostomy change)
Maintain effective communication with child and mother
Call for help early, including acknowledging the need for anaesthetics and ENT
Lead and work effectively in a team
Further Reading
Algorithm and Bedside Poster
http://www.tracheostomy.org.uk/storage/files/Paeds%20Bedhead%20Algorithm%20Combo.pdf
National Tracheostomy Safety Project teaching slides
https://kids.bwc.nhs.uk/wp-content/uploads/2014/11/NTSP-teaching-slides-20141127.pdf
Emergency Tracheostomy Change Video
http://www.tracheostomy.org.uk/healthcare-staff/emergency-care-child/emergency-paediatric-
tracheostomy-care
5 Rs
http://www.tracheostomy.org.uk/storage/files/RMCH%205%20R_s%20of%20tracheostomy%20care.pdf
Case for Facilitator Only:
Jimmy Nichols, NHS 700123456, DOB 15/12/2018, Weight unknown
Admitted with LRTI yesterday, has tracheostomy due to CLD and need initially for continuous
ventilation via tracheostomy, now only required NIV when asleep.
Suddenly desaturated down to the 80s with significant work of breathing, nurse has tried to
suction
Examination: Visible increased work of breathing, saturations 80s, HR 150, RR 36, T 37.0
Tube is blocked and suction is not possible
Can be ventilated by mouth if required (but intubation would be difficult)
Will need emergency tracheostomy change – will only be successful with smaller tube (should be
in box)
Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 11
Cystic Fibrosis
Objectives - Identify current issues for this child with Cystic Fibrosis
- Consider changes in current management
- Consider emergency situations and when a child with CF should be admitted to the hospital
- Review current CF modulators and their current role in CF management
Activity 7: Case Based Discussion – Child with CF Case Based Discussion: Group Discussion or individual reflection
Facilitator: Consultant or senior trainee with respiratory interest
Participants: SHOs, SPRs
Instructions for Facilitator: Support and chair discussion of case
Instructions for participants: Read through the case below and discuss each clinical question
Case:
Olivia Jenkins, DOB 12/07/2015, Weight 16kg
- Locations: CF MDT Clinic
- 5 year old Olivia is being seen for her routine clinic consultation by the CF MDT
Clinical Questions:
1. What specific questions would you like to ask
a. Respiratory Symptoms
Olivia is generally well but has had an increasing cough over the last 2 weeks, it is productive
but she swallows her secretions rather than spitting them out. She is doing her physio twice
a day and is productive with each session
b. Gastro symptoms
She is not gaining weight as well as previously and at times her stools are fatty. Over the last
48 hours she has not passed stool, she is not complaining of any abdominal pain
c. Medications
There have been no changes to her medications recently
2. Based on the short history above – what are you concerned about at present
3. What (if any) investigations would you like to organise
4. Who else would you like at your MDT clinic with you
5. Does Olivia need to be admitted to hospital – if so what acute treatments would you organise
Further Reading
https://www.cysticfibrosis.org.uk/the-work-we-do/resources-for-cf-professionals/consensus-documents
https://www.paediatricfoam.com/2017/09/cystic-fibrosis-part-1/
https://www.paediatricfoam.com/2017/08/cystic-fibrosis-in-paediatric-ed/
Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 12
Activity 8: Quick Teach – CF Modulators
Objectives - Update on CF modulators
o What they are
o What they do
o Who are they for
- Deliver and evidence-based teaching session
- Reflect of teaching practice based on feedback from the audience
Group Teaching:
Group Discussion
Participants: SPRs
Attendees: Consultants, SHOs, SPRs, Nurses, AHPs
Instructions for attendees: Participate in teaching and discussion, taking note of teaching style. Provide
constructive written feedback on teaching skills
Instructions for participant: Prepare a 15 minute teaching session using the reading list below. Facilitate
a further 10 minute discussion and address any questions from the audience. Reflect on teaching
experience on e-portfolio.
Specific Topic to Explore:
- Update on CF modulators
o What they are
o What they do
o Who are they for
Reading List
https://www.cff.org/Life-With-CF/Treatments-and-Therapies/Medications/CFTR-Modulator-Therapies/
https://www.frontiersin.org/articles/10.3389/fphar.2016.00275/full
https://www.sciencedirect.com/science/article/pii/S156919931830585X
Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 13
Recurrent LRTI
Activity 9: Case Based Discussion – Child with recurrent LRTI
Case Based Discussion: Group Discussion or individual reflection
Facilitator: Consultant or senior trainee with respiratory interest
Participants: SHOs, SPRs
Instructions for Facilitator: Support and chair discussion of case
Instructions for participants: Read through the case below and discuss each clinical question
Case:
Jessica Stevens, DOB 12/07/2013, Weight 12kg
- Locations: General Paediatric Clinic, DGH
- 3 year old Jessica has been referred due to repeated need for antibiotics in the last 6 months
Clinical Questions:
- What specific questions would you like to ask
- Jessica is fully immunised
- She has had 6 courses of oral antibiotics in the last 6 months and 2 short admissions to
hospital with respiratory symptoms
- She does get well in between episodes, but has a cough most nights even when well
- She is a picky eater but never vomits
- As a baby she vomited after most feeds but as she grew well and it settled down she
didn’t need any intervention
- Jessica’s parents are concerned that she isn’t really growing or putting on weight as
expected
- She had a chest x-ray on the last admission and some blood tests – both showed “an
infection”
- No one else has any respiratory problems at home
- Based on the short history above – what are you concerned about at present?
- What (if any) investigations would you like to organise?
- What management would you consider starting?
- When would you consider referral to a respiratory paediatrician?
Further Reading:
https://www.bmj.com/content/362/bmj.k2698
https://www.uptodate.com/contents/approach-to-the-child-with-recurrent-infections
https://patient.info/doctor/lower-respiratory-tract-infection-in-children
Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 14
Stridor
Activity 10: Flipped Classroom Discussion – Stridor
Facilitator: Consultant or SPR
Participants: SHOs, SPRs, AHPs, Medical students
Instructions for Facilitator: Lead a 20 minutes group discussion on Stridor. Ensure the group has had a
chance to read the recommended reading.
Facilitator to take the group through the following questions;
- What are the different presentations of a child or baby with stridor?
- What are the differential diagnosis?
- What is the acute management of a child or baby with stridor?
- What investigations are needed in the case of chronic stridor?
Recommended Reading:
https://em3.org.uk/curriculum/pmp2
https://www.rcemlearning.co.uk/foamed/coughing-wheezy-and-stridulous-children/
https://litfl.com/croup/
https://teachmesurgery.com/ent/presentations/stridor/
https://bestpractice.bmj.com/topics/en-gb/754
Paediatric Respiratory and ENT Learning Pack, Abigail Whitehouse, August 2020 15
Bronchiolitis
Activity 11: Flipped Classroom
Facilitator: Consultant or SPR
Participants: SHOs, SPRs, AHPs, Medical students
Instructions for Facilitator: Lead a 20 minutes group discussion on Bronchiolitis. Ensure the group has
had a chance to read the recommended reading.
Facilitator to take the group through the following questions;
- What treatments are recommended in Bronchiolitis?
- Who needs admission to hospital?
- What are appropriate discharge criteria?
- When would care need to be escalated?
- Role of NIV
Recommended Reading:
https://dontforgetthebubbles.com/bronchiolitis/
https://onlinelibrary.wiley.com/doi/full/10.1111/jpc.14104
https://dontforgetthebubbles.com/evidence-high-flow-bronchiolitis/
https://www.nice.org.uk/guidance/ng9