Responsibilites of the paediatric respiratory SpR and SHO
• Day to day care of children under the respiratory team
• Manage new patient referrals 
• Organise investigations for children with respiratory complaints
• Attend respiratory outpatient clinic and CF clinic when possible
• Attend or perform bronchoscopy
• Prepare an article each week for Thursday journal club

New referrals
For in-patient referrals, the juniors will usually need to see the patient before discussing them with the consultant on for the week. You will need to discuss outside referrals with the consultant on for the week to decide if transfer to the Children’s Hospital is required. You will be responsible for organising the bed and assessing the child.

In-patient management
Iolo Doull, Julian Forton and Lena Thia work as a team. Patients under each consultant are cared for by the respiratory team and responsibility is shared by the consultants. Each patient does have a named consultant and this consultant will make the major management decisions. The consultants are on clinical call in weekly cycles, starting on Monday mornings. New referrals should be discussed with the consultant on for the week. Problems relating to other patients already under a named consultant should be referred to that consultant where possible. In any case, any problems can be discussed with either consultant. We like to be kept up to date with our patients and appreciate it if you touch base with us at the end of the day.

All patients except the sleep study patients should be fully clerked in without using a proforma.

Cystic Fibrosis patients are frequently admitted for chest exacerbations. There is a specific CF admission sheet which is to be updated through the admission with sequential weight, lung function and tobramycin level measurements etc.. There is also guidance on what to do for these admissions and some problem solving on the back side of the admission sheet. Admission sheets are kept on Land ward in the drawers opposite the nursing station.
Sleep study patients. Children usually arrive in the evening (usually Mondays or Thursdays) after the day staff have has gone home for the day. They are clerked by the on-call team using a generic proforma which is provided by Nicola. You should try to get up to date with these patients the next morning before the consultant ward round. Janet James and Sarah Byrne  know the patients very well. Most of these patients will go home after they have been seen on the ward round. The sleep sudies are reported by Nicola Stonely. Every Thursday there is a sleep meeting to discuss these patients, which you will need to attend.
Difficult asthma. Children are often admitted for investigations as part of the difficult asthma protocol. The skeleton to these investigations are a CT, bronchoscopy and exercise test, which need to be organised and coordinated in advance – you will need to liaise with the respiratory secretaries, Nicola Stonely and the radiologists.
Empyema. We provide a regional service for the management of empyema. It is important to take a detailed history when you are referred a patient with a complicated pneumonia and its worth discussing it with the consultant on-call. Most patients will need to come to UHW for assessment even if they don’t have a drain inserted in the end. On the phone you need to identify how long the illness has been going on for, what treatment has been given, how high the fevers are spiking, what radiology they have had, how deep the empyema is on ultrasound (and also how extensive it is), whether the child is in oxygen, or whether the child is well enough to come over in the car with their parents. You need to ask the patient to be put nil by mouth, ensure the referring hospital  transfers radiology images electronically, and organise the bed. The radiologists insert the pigtail catheters. They need to know if an empyema is coming and every effort should be made to get the patient here before 5pm, so that they can have an ultrasound and preparation made for drain insertion the next morning. It is unusual for a child to need chest drain insertion on arrival. Many children can have the drain inserted under sedation – the consultant on-call will often attend for this procedure. Younger children will need a GA.

Organising investigations for children with respiratory complaints
These children may have been seen in the clinic or may have been referred from elsewhere. Organising investigations may require elective admission or may involve organising day care attendance to the ward, CIU or the outpatient investigation clinic run sporadically by the respiratory nurses. For many of these patients you will need to liaise very closely with the consultant secretaries (Leila and Lisa, who organise bronchoscopy and keep a close eye on everything), the respiratory nurses Janet and Sarah who organise the investigation clinic (nasal NO, blood tests and sweat tests – Thursdays), and Nicola who organises exercise tests and sleep studies.

Assessments include:
Clinical review (history and examination)
Chest radiographs
CT scans
Lung function tests
Exercise tests
Blood tests (usually for FBC, total Igs, functional anitbodies, IgE)
Nasal NO
Sweat test (carried out by Heather in biochemistry; ext 43650)
Bronchoscopy (see below)

Patients following the difficult asthma  protocol are admitted for investigations as per the protocol. For other patients you will receive a letter requesting the appropriate investigations. Exercise tests are generally done on a Wednesday, CTs on a Thursday and bronchscopy on a Friday. There is a nurse-led investigation clinic on some Thursdays.
Please inform Lisa and Leila of any admissions for investigations that you are planning – they look after bronchoscopy and can help you out with most things. Janet, Sarah and Clare run the investigation clinic and can provide nasal NO and blood tests . Heather Wheatley (43560) in Biochemistry performs sweat tests on Thursday lunchtimes and you will need to contact her directly. She is extremely obliging.

Bronchoscopy
Bronchoscopy is performed in theatre under GA on Friday mornings. Lisa and Leila organise bronchscopy so let them know. Children age < 1 year and < 10 kg will need a consultant anaesthetist so please highlight this to the secretaries. We have quite a number of semi-urgent bronchsocpies and these generally have to be negotiated onto the CEPOD list. If there are patients of interest to both our service and ENT, we often organise a combined procedure with Gareth Williams or Graham Roblin on the ENT surgical list. All children attending for bronchscopy need to be fully clerked. They need to be nil by mouth overnight. The consultant undertaking the procedure will take consent.
Please check that the scope is ready for use on the morning of the procedure. Endoscopy will automatically prepare the stack and scopes for Friday GA list patients but must be contacted directly on the day before, for ad-hoc scopes on the CEPOD list. You will need to tell them which scopes we will be using. For babies less than 6 weeks this will be the 8V scope (2.8mm). For all others it will be the 1170 scope (3.6mm).
Nasal NO
This is a screening test for Primary Ciliary Dyskinesia and is performed by the respiratory nurses in the investigation clinic, but also sporadically as requested.
Lung function tests
Simple spirometry is carried out either in the clinic or on the ward when patients come for assessment. We have  portable machines. This is usually performed by the physiotherapists but you must learn how to use the machines and understand lung function while you are here. It is important to remember that lung function requires maximal effort. This means that loads of encouragement is needed to get the children to produce reliable results.
If lung volumes or measures of airway resistance are needed, these are measured using body plethysmography. These tests are carried out at Llandough Hospital by Nicola Stonely on Wednesdays at our request.
Exercise test
These are usually used for bronchial challenge. Occasionally they are used as assessment of fitness or as proxy measures of diffusion defects. We do not have a treadmill on site. Tests are perfomed by Nicola Stonely on Wednesdays at Llandough hiospital and you will need to book one with her. Ask Nicola for the protocol so that you understand the test.
Sweat test
These are carried out by Heather Wheatley (43560), who usually does them on a Thursday lunchtime.

Out-patients
The respiratory clinics are on Monday afternoon and the CF clinic is on Tuesday morning. You should try and attend if possible. At the end of each clinic we all meet and discuss all the patients that have attended that day. Any outstanding ward problems can also be discussed.

Discharge summaries and letters
It is essential that letters are dictated as soon as possible because a lot of our patients are seen frequently or soon after admission. It is the combined responsibility of SPR and SHO to dictate discharge summaries. Please keep a book of all admissions that you can share so that patients are dictated and ticked off in order. This way you know what the other doctor has done. Sometimes the consultant will choose to dictate the discharge summary, and they will let you know. You do not have to dictate any sleep discharge letters as these are always dictated by the consultant on-service.