Conditions of the Respiratory System
General competencies
1. Understand basic and clinical knowledge of respiratory anatomy and
pathophysiology of common respiratory diseases
2. Relevant history and physical examination, documentation of findings,
differential diagnosis generation and plan for further evaluation and
management
3. Use evidence based approach to primary and secondary prevention of
respiratory diseases
4. Knowledge of current practices regarding the care of patients with respiratory
diseases and develop plans to improve care.
5. Work with physicians, nurses, pharmacists, dieticians and other health care
professionals to improve patient care
Topic Areas
1. Asthma
a. Severity
b. Complications
c. Need for hospitalization
2. Acute respiratory distress
a. In children
i) Asthma
ii) Bronchiolitis
iii) Foreign body aspiration
iv) Croup
3. Acute cough
a. Pneumothorax
b. Pulmonary embolism (PE)
c. Viral respiratory infections
d. Bacterial respiratory infections
4. Chronic cough
a. GERD
b. Congestive heart failure
c. Rhinitis
d. Cancer
e. PE
f. Medication induced
g. COPD
5.
6.
7.
h. Pertussis
i. Foreign body
Causes of stridor
a. Croup
b. Anaphylaxis
c. Foreign body (airway or esophagus)
d. Retropharyngeal Abscess
e. Epiglottitis
Pneumonia
a. Types: Bacterial, viral, atypical pathogens
Upper respiratory tract infection (URTI)
a. Viral vs bacterial causes
b. Epiglotitis
c. Retropharyngeal abscess
d. Bacterial sinusitis
e. Otitis externa/media, mastoiditis
f. Pharyngitis
For each topic area
1. Epidemiology
2. Anatomy
3. Pathophysiology/Etiology
4. Risk factors
5. History and physical exam
6. Diagnostic Tests
7. Differential diagnosis
8. Management
9. Psychosocial implications
Highlighted teaching points
1. Risk Factors
a. For complicated course of pneumonia and hospitalization
2. History and physical exam
a. Upper vs. lower respiratory symptoms
b. In patients with a diagnosis of pneumonia
i. Assess the risks for unusual pathogens (e.g., a history of
tuberculosis, exposure to birds, travel, HIV infection, aspiration)
ii. If demonstrate early signs of respiratory distress; assess, and
reassess periodically, the need for respiratory support
c. In a patient with upper respiratory symptoms:
3.
4.
5.
i. Differentiate viral from bacterial infection
d. Given a history compatible with otitis media, differentiate it from otitis
externa and mastoiditis
Diagnostic tests
a. In patients of all ages with respiratory symptoms (acute, chronic,
recurrent)
i. Confirm the diagnosis and determine severity of asthma by
appropriate use of history, physical examination, spirometry.
ii. Distinguish asthma or bronchiolitis from croup and foreign body
aspiration
b. In a child presenting with a clear history and physical examination
compatible with mild to moderate croup, make the clinical diagnosis
without further testing
c. In a patient with signs and symptoms of pneumonia, do not rule out the
diagnosis on the basis of a normal chest X-ray film
Differential Diagnosis
a. In patients presenting with an acute cough
i. Include serious causes (e.g., pneumothorax, pulmonary embolism)
in the differential diagnosis.
b. In a child with acute respiratory distress
i. Distinguish asthma or bronchiolitis from croup and foreign body
aspiration through history and physical examination.
c. Generate a differential diagnosis
i. Acute cough
ii. Persistent/recurrent cough
iii. Stridor
iv. Wheezing
d. Pneumonia
i. Include in differential of non-specific symptoms (e.g., deterioration,
delirium, abdominal pain), include pneumonia in the differential
diagnosis.
ii. Generate a differential diagnosis of lower respiratory tract
infections and subtypes
Management
a. Acute asthma exacerbation:
i. Treat the acute episode (e.g., use beta-agonists repeatedly and
early steroids, and avoid under-treatment)
ii. Rule out co-morbid disease (e.g., complications, congestive heart
failure, chronic obstructive pulmonary disease).
b.
c.
d.
e.
iii. Determine the need for hospitalization or discharge (based on risk
of recurrence or complications, patient expectations and
resources).
For the ongoing (chronic) treatment of an asthmatic patients:
i. Management plan including:
1. Self‐monitoring
2. Self‐adjustment of medication
3. When to consult
For a known asthmatic patient with ongoing or recurrent symptoms:
i. Assess severity
ii. Assess compliance with medications
iii. Recommend lifestyle adjustments (e.g., avoiding irritants, triggers)
to improve control
In patients with croup:
i. Identify the need for, and provide, respiratory assistance (e.g.,
assess ABCs, fatigue, somnolence, paradoxical breathing, in
drawing)
ii. Use of steroids
iii. Plan for and anticipate recurrence of the symptoms
Confirmed diagnosis of pneumonia:
i. New diagnosis: in patients with pre-‐‐existing medical problems
(e.g., asthma, diabetes, congestive heart failure
1. Treat both problems concurrently (e.g., with prednisone plus
antibiotics).
2. Adjust the treatment plan for pneumonia, taking into account
the concomitant medical problems (e.g., be aware of any drug
interactions, such as that between warfarin [Coumadin] and
antibiotics).
ii. Make rational antibiotic choices
iii. Ensure appropriate follow-up care
iv. Arrange contact tracing when appropriate
v. For patients not responsive to treatment:
1. Revise the diagnosis (e.g., identify other or contributing
causes, such as cancer, chronic obstructive pulmonary
disease, or bronchospasm)
2. Consider atypical pathogens (e.g., Pneumocystis carinii,TB)
3. Diagnose complications (e.g., empyema, pneumothorax).
4. Modify the therapy appropriately (e.g., change antibiotics).
vi. Prevention:
1.
f.
Identify patients who would benefit from immunization or
other treatments (e.g., flu vaccine, Pneumovax, ribavarine) to
reduce the incidence of pneumonia.
In patients with URTI:
i. High-risk patients (e.g. HIV/COPD/cancer) with upper respiratory
infections:
1. Aggressively search for complications
2. Follow up more closely
3. Take preventive measures (e.g., use flu and pneumococcal
vaccines)
ii. Treat early to decrease individual and population impact (e.g., with
oseltamivir phosphate [Tamiflu], amantadine).
References:
1. College of Family Physicians of Canada. (2010). Defining Competence for the
purposes of certification by the College of Family Physicians of Canada: The
evaluation objectives in family medicine. Mississauga, ON.