Pediatric Pulmonary and Sleep Medicine

During our three-year training program, time is distributed among both clinical and research opportunities to ensure that fellow’s develop expertise in the field of pediatric pulmonary. The program provides approximately 5 months in the first year and 3 months in each of the second and third years for clinical work. Approximately 17 months of protected time dedicated to hypothesis driven research. 

Program Goals

• To adequately educate and provide the necessary background for a trainee to diagnose and manage pediatric respiratory disorders.
• To prepare the trainee to conduct research in the area of pediatric respiratory diseases.
• To enable the trainee to become a competent teacher of pediatric pulmonary physiology and pediatric respiratory disease. 

1st year fellows

• Will learn the role of a consultant
• Will begin to staff patients with residents and students with direct faculty supervision
• Will be involved in telehealth with supervision in video visits and participate in sick and urgent phone call medicine and triage with faculty supervision.
• Introduction to bronchoscopy and assist and begin to perform bronchoscopies
• Identify a research topic and mentor

2nd and 3rd year fellows

• Will work in a consultative role with graduated independence
• Increased teaching opportunities with the medical team in addition to students and residents
• Expand their outpatient practice with graduated independence in fellows’ clinic and with sick/urgent telephone calls
• Increased comfort with telehealth with graduated independence
• Continue to perform bronchoscopies with increasing independence and exposure to more complicated cases
• Further development of research goals including local and national presentations and manuscript writing.
• Determine sub-specialty interests in pulmonary medicine and build an area of expertise

Clinical training in Pediatric Pulmonary Fellowship centers on a multidisciplinary approach to the care of patients with respiratory diseases at Children’s Hospital of Wisconsin. Children’s Hospital is an award-winning health care system dedicated solely to the health and well-being of children. Multidisciplinary teams of physicians, nurses, and many other health care professionals specializing in pediatrics are available to meet the full range of patient-care needs.

A variety of essential lectures and conferences are included in the fellows’ weekly schedule which include, but are not limited to: daily inpatient rounds with the attending, intensive care unit ward team and general ward team; weekly inpatient sign-out rounds with all members of the pulmonary section; fellows conference where a pulmonary topic is reviewed, and monthly radiology/pathology, journal club, and research conference. Additionally, all fellows are expected to attend the monthly Joint Fellowship Curriculum, which is overseen by the Department of Pediatrics, which reviews certain basic concepts, including development of research design, abstract and manuscript preparation, basic biostatistics, quality improvement, and professionalism and communication, among other topics. 

Subspecialty Clinics

The Pulmonology division is involved in various multidisciplinary clinics that provide care to patients with disorders requiring a multidisciplinary approach. The following clinics are currently active and will be included to enhance the fellows’ outpatient Pulmonology experience.

• Cystic Fibrosis
• Trach/Vent
• Positive Airway Pressure Program
• Muscular Dystrophy
• Asthma Plus
• Aerodigestive

Clinical Rotations

During the 3-year training program, time is distributed to ensure that fellows develop clinical expertise. Clinical time will be split between outpatient clinics, inpatient service, procedures, and the corresponding service related conferences. Fellows will hold a one-half day per week of continuity clinic for the duration of their training.

Year 1

The focus of the first year of the fellowship is to develop the clinical skills and abilities to provide optimal patient care for children with respiratory diseases. The program provides approximately 10 months of clinical experience, including both inpatient and outpatient care during the first year. During their inpatient rotation the fellow will be on first call from 7:30 am-4:30 pm and will also take two weekends per month and two nights per week on the assigned inpatient service. Continuity clinic will focus on pulmonary patients one-half day per week throughout the first year. During the first year, the fellow will devote his/her effort to the following rotations:

Pulmonary Service
The fellow will spend 5 months on the pulmonary service during the first year. At the end of the first year the fellow will have a diversity of experiences with children with respiratory diseases and develop the clinical skills needed to function as a clinician.

Responsibilities include:

• Graduated responsibility for the care of pulmonary inpatients with increasing responsibility as training progresses.
   
• Graduated responsibility completing pulmonary inpatient consultations on general floors and the PICU. The fellow will be responsible for the initial contact and evaluation, staffing with a faculty member, and appropriate documentation and communication with the primary team.
   
• Graduated responsibility for resident education on the pulmonary inpatient team for residents and medical students.
   
• Graduated responsibility in the care of inpatients with tracheostomies and home ventilators. 

Cystic Fibrosis (CF)
The fellow will spend 1 month observing pediatric and adult Cystic Fibrosis clinics.

Responsibilities include:

• Attend weekly CF team meetings.
   
• Participating in CF multidisciplinary clinics.
   
• Independent study to gain familiarity with landmark CF research trials and scientific rationale behind current CF therapies.

Objectives include:

• Gain a thorough understanding of current CF practice guidelines.
   
• Gain an appreciation of the team approach to CF care, and available team members and tools such as Port CF.
   
• Gain an appreciation of the role of multi-center trials in CF research and advancement of care.
   
• Develop knowledge to identify and manage CF nutritional needs.
   
• Gain familiarity with standard medications and airway clearance techniques used in CF care.
   
• Master the criteria for CF admission for pulmonary exacerbation.

Research
The fellow will take one month during the first year to identify a research mentor and project with the guidance of the Scholarship Oversight Committee. This month will also give exposure to various potential basic and clinical research projects that are available within the Pulmonary Section, the Department of Pediatrics, and throughout the Medical College of Wisconsin.

Objective:

• Identify a research interest area and select a mentor.
   
• Develop a research question and build a research plan.
   
• Present a poster at the MCW Pediatric Fellows’ poster session in April with an overview of research plan.

Years 2 and 3

The second and third years of the fellowship training provides ample protected time to pursue research endeavors while fostering improved clinical, administrative, and teaching skills.

Research
The fellow will spend 7-8 months during the second and third year implementing their research project. This will involve building new skill sets within the scope of their project, including specific knowledge within the field of study and more general skills such as IRB submission, grant writing, abstract writing and manuscript preparation.

Objectives:

• Present at local, regional, and national meetings beginning in the second year.
   
• A peer-review publication, an in-depth manuscript, a thesis or dissertation written in connection with the pursuit of an advanced degree, an extramural grant application that has either been accepted or favorably reviewed.
   
• Building a skill set and academic focus/research area that can be maintained throughout the fellow’s career.

Sleep Medicine
The fellow will spend 1 month attending sleep clinics during the second year.

During this rotation the fellow will:

• Attend all sleep clinics.
   
• Attend all Positive Airway Pressure clinics.
   
• Attend the Sleep Conference every Friday.
   
• Begin to learn to score and read sleep studies, gaining an appreciation for the information they contain.
   
• Learn the indications for sleep studies and additional sleep related testing.

Procedural Skills and Diagnostic Studies

Fellows in the program are expected to develop procedural skills which include but are not limited to, flexible bronchoscopy and bronchoalveolar lavage, transbronchial biopsies, intubation and airway management techniques. Each fellow will participate in a minimum of 100 flexible bronchoscopies his/her fellowship.

Fellows will become proficient in the interpretation of pulmonary function tests (PFTs), including methacholine challenges, cardiopulmonary exercise testing and infant PFTs. In addition, they will interpret overnight pulse oximetry studies and learn their indications and limitations. The fellowship also allows the fellows to become familiar with interpreting overnight polysomnographic studies.

 

In addition to clinical and research rotations, there are a variety of conferences to enhance the fellows’ learning opportunity including daily inpatient rounds with the attending, intensive care unit ward team and general ward team; weekly inpatient sign-out rounds with all members of the pulmonary section; fellows conference where a pulmonary topic is reviewed, and monthly radiology/pathology, journal club, and research conference. Additionally, all fellows are expected to attend the monthly Joint Fellowship Curriculum, which is overseen by the Department of Pediatrics. Fellows are strongly encouraged to attend Pediatric Grand Rounds and Professors rounds and any other presentations or conferences they feel would benefit their education during the fellowship.

• Journal Club – fellows present a variety of journal articles on interesting Pulmonary related publications. Faculty and staff from the section attend.
   
• Radiology/Pathology Conference – a monthly conference to discuss interesting cases/films with the Radiology/Pathology department.
   
• Fellows Conference – a weekly case conference 
  
  
• Joint Fellowship Curriculum – a monthly conference designed to address both the academic requirements mandated by the ACGME and the career and personal development of fellows within the Department of Pediatrics.

The Joint Fellowship Curriculum is overseen by the Department of Pediatrics and reviews certain basic concepts, including development of research design, abstract and manuscript preparation, basic biostatistics, quality improvement, professionalism, communication, teaching, administration and leadership, and career counseling, including the balance of work and family life. This core curriculum is designed to address both the academic requirements mandated by the American Council for Graduate Medical Education(ACGME) and the career and personal development goals expressed by our fellows.

The goal of the JFC is to provide an excellent educational experience to all fellows in the Department of Pediatrics through case-based, hands-on curriculum modules based on the needs of each year of fellowship (F1, F2, and F3)

Teaching Opportunities

As junior faculty members fellows are expected to supervise and teach pediatric residents and medical students in the case of hospitalized pediatric pulmonary patients. Several teaching and speaking opportunities are available to create a well rounded learning portfolio. As part of their fellowship training, fellows will be provided with instruction in clinical teaching skills. Fellows will supervise 2-4 residents each month and a variable number of medical students assigning tasks and reviewing consultation notes before presenting to the attending faculty. In the second and third years of the fellowship, fellows will present monthly on a variety of core lecture topics to rotating residents. They will develop necessary communication and teaching skills.

Yearly Lecture Topics

July and August Topics (practical)

1. PFTs
2. Chest physiotherapy devices
3. Tracheostomy
4. Polysomnography
5. Home ventilation and non-invasive ventilation
6. Inhaler devices and spacers

Physiology Topics

1. Exercise physiology and how to read cardiopulmonary physiology testing
2. Respiratory mechanics: compliance (lung and chest wall), airway resistance
3. Lung function test and correlation with physiology (what do they mean)
   1. Ventilation: Forced expiratory volumes, flow-volume, closing volume, measurement of alveolar ventilation (test of uneven ventilation)
   2. Gas Exchange:
      1. Hypoxia
      2. Hypoventilation
      3. Acid – base balance
      4. Diffusion capacity
   3. Other tests:
      1. Lung volumes
      2. Lung elasticity
      3. Airway resistance
      4. Control of breathing
      5. Topographic differences of lung functions
4. Blood flow to the lung (including PVR) and pulmonary hypertension

Anatomy and correlation with CXR, CT, and Bronchoscopy

Every 2-3 Year Lecture Topics

Upper Airway Disease

1. Congenital malformation: choanal atresia; micrognathia; laryngeal (malacia, web, atresia, cyst); laryngotracheoesophageal cleft; vocal cord paralysis, subglottic pathology (stenosis, hemangioma)
2. Infectious causes of stridor: croup and tracheitis

Lower Airway Disease

1. Congenital malformation: CDH, sequestration, TEF, bronchogenic cysts, lobar emphysema, agenesis
2. Malacia: trachea, bronchi with relation to vascular rings
3. Bronchiolitis: clinical picture, epidemiology, causes, treatment (role of steroid and bronchodilators), prognosis and long term consequences
4. Chronic cough: evaluation and management
5. Asthma:
   1. Mechanism of disease (including inflammatory cells and cytokines)
   2. Acute and chronic management (including detailed ICS differences)

Parenchymal Disease

1. Cystic Fibrosis:
   1. Genetics and disease mechanism (CFTR)
   2. Clinical manifestation, diagnosis (newborn screening) and prognosis

1. Recurrent pneumonia: evaluation and management
2. Chronic lung disease associated with prematurity: evaluation, management and long term outcome
3. GERD and Aspiration syndrome: respiratory complications
4. Pulmonary hemorrhage and hemoptysis
5. Lung abscess: evaluation and management
6. Cancer-related lung disease(opportunistic infections and post bone marrow transplant)
7. Sickle cell patients: acute chest syndrome
8. ARDS causes and management
9. Hypersensitivity pneumonitis
10. Alpha-1 antitrypsin deficiency and primary ciliary dyskinesia
11. Sarcoidosis, sickle cell disease, chronic granulomatous disease
12. SIDS
13. Respiratory disease and infections:
    1. Mycobacterial infections
    2. HIV
    3. Mycoses

Interstitial Lung Disease: When to suspect and how to diagnose

Pleural Diseases

1. Air and fluid in the chest: how to evaluate and manage (chest tube, VATS)

Chest Wall/Diaphragm

1. Jeune Syndrome (asphyxiating thoracic dystrophy)
2. CDH, eventration
3. Scoliosis
4. Neuromuscular disease

Others

1. Pediatric Lung Transplant
2. Bronchiolitis obliterans
3. Immunosuppressive therapy in transplant patients (choices and how does it work)
4. Sleep
   1. Sleep disordered-breathing
   2. Excessive daytime sleepiness, “evaluation of sleepy teenager”
   3. Nightmares, night terrors, sleepwalking

3/4 Meeting/Year Lecture Topics

Pathology

The goal is to discuss cases and identify both normal and abnormal pathology involving the respiratory system

1. Upper airway
2. Lower airway
3. Lung
4. Interstitial and pulmonary vasculature

Radiology (review these topics in part of radiology conference)

1. Congenital malformation:
   1. CPAM
   2. Congenital lobar emphysema
   3. Bronchogenic cyst
   4. Pulmonary sequestration
   5. Eventration and congenital diaphragmatic hernia
   6. Lung hypoplasia
   7. TEF

1. BPD
2. Vascular rings and slings
3. CF
4. Asthma
5. Bronchiolitis
6. Swyer-James
7. ILD
8. Infections:
   1. Fungal
   2. TB
   3. Other atypical infections

Day in life of a fellow:

Fellows are provided a semi-private workspace within the Pediatric Pulmonary Division. The pulmonary office located in the clinics building and is directly connected to the hospital and pulmonary clinic via a skywalk. Free underground parking is available adjacent to the clinics building and connected by a skywalk. Several cafeterias, coffee carts and other food services are available throughout the medical complex.

Scholarly Activities:

When on research months the day usually starts around 8:30 a.m. and finishes around 4 p.m. Fellows are expected to complete a research project and a quality improvement initiative. Fellows will meet with the program direction during the first year of fellowship to help determine a research project. They are encouraged to attend and/or present at local and national conferences such as the American Thoracic Society, CHEST and North American Cystic Fibrosis Conference. There is also a Medical College of Wisconsin research day yearly that gives fellows a chance to present their work.

Along with research projects, fellows will also take part in the Pulmonary Sign-out rounds and Noon Conference that occur every Monday. This might include presenting an interesting case or bronchoscopy.

Clinical Duties

Outpatient:
While rotating in outpatient clinic the days are usually 8 a.m.-4 p.m., depending on the clinic. Also, each follow will have one half day clinic every week in which they see their own patients. This clinic is staffed by a different attending each week. Each fellow will also follow a cystic fibrosis patient. This patient is assigned in the first year and ideally a newly diagnosed infant so the fellow can follow that patient the entire three years. This patient is seen during the Multidisciplinary Cystic Fibrosis Clinic. The fellow can also be assigned a trach/vent patient to follow and see in Multidisciplinary Trach/Vent Clinic.

Inpatient:
The day usually will start around 7:30 a.m. and ends around 4:30 p.m. depending on the number of consults that day. The inpatient service is divided into two teams. Team A covers PICU consults. Team B covers the pulmonary service, acute care and NICU consults. There are usually about 2-4 patients on the pulmonary service. Each team averages about 15 patients on the list and about 1 consult per day.

Taking Call

The fellow will be first call one to two nights per week. Night call is from 4-8 a.m. Fellows will receive calls from the patient’s families, ED, inpatient teams and the PICU. The amount of calls varies, with the winter months usually receiving the most amount of calls. Most calls can be handled from home. On a rare occasion the fellow may have to come back into the hospital to perform an emergent flexible bronchoscopy.

The fellow will also work 1-2 weekends per month. The weekend calls will start at 4 p.m. on Friday and go to Monday morning at 8 a.m., this is completed from home. Calls per night vary, most commonly ranging from 1-6. Situations requiring return to the hospital approximately once per year. For weekend calls, the fellow will usually come into the hospital around 7:30 a.m. on Saturday and Sunday. At that time the fellow will round on any pulmonary service patients and handle any consults and/or consult follow ups. Usually the fellow will be able to leave the hospital around 1 p.m. depending on the amount of the work for that day and the rest of the day can be managed from home.

Fellows are expected to work at least one major (Christmas, Thanksgiving and New Year’s) and one minor (4^th of July, Labor Day and Memorial Day) holiday each academic year.

Juan Ruiz, MD

• 2009 American Thoracic Society Internal Conference, Travel Scholarship Recipient
• 2009 Children’s Hospital of Wisconsin, Outstanding Teacher Among the Pediatric Fellows

Louella Amos, MD

• 2010 MCWAH Research & Quality Awards, “Treatment and Outcomes of Pediatric Restless Leg Syndrome (RLS)”

Julie Baughn, MD

• 2010 Medical College of Wisconsin, 4^th Annual Fellows’ Research Poster Session, Honorable Mention Award Recipient, “Genetic Variation in the CFTR Gene in Children with Community-Acquired Pneumonia”
• 2011 Abstract Excellence Award – American Thoracic Society, Respiratory Structure and Function Assembly “Genetic Variation in The Cystic Fibrosis Transmembrane Conductance Regulator Gene (CFTR) is Associated with the Need for Mechanical Ventilation in Pediatric Patients with Community Acquired Pneumonia”

Nisreen Rumman, MD

• 2010 Best Abstract by a Trainee at the 34^th Annual Midwest Pediatric Cardiology Society Scientific Session

Lauren Camarda, MD

• 2012 Fellow in Training Abstract Award, American Academy of Allergy Asthma and Immunology, “Impact of the Intestinal Microbiome on Severe Paramyxoviral Respiratory Infection”

Nick Antos, MD

• 2013 Medical College of Wisconsin Fellow Research Day, “Drawing a Cystic fibrosis (CF) Road Map: Improving CF Inpatient Care with an Admission Plan”

Ahsan Bashir, MD

• 2018 MCWAH Research & Quality Awards, "Polysomnography Provides Useful Clinical Information in the Liberation from Respiratory Technology"

Santiago Encalada, MD

• 2015 American Thoracic Society (ATS), Minority Trainee Development Scholarship (MTDS)

Brian Carroll, MD

• 2018 NACFC Pediatric Fellows Session
• 2019 MCW DOP Fellow Research Day Finalist
• 2020 MCWAH Research and Quality Award
  “Impaired Lung Function Following E-Cigarette or Vaping Product Use Associated Lung Injury (EVALI) in the First Cohort of Hospitalized Adolescents”

Sara Dawson, MD

• 2019 American Thoracic Abstract Scholarship
                “High pCO2 Levels at 36 Weeks is Associated with Longer Duration of Home Oxygen in Infants with BPD”
• 2019 MCWAH Research and Quality Award
                “High pCO2 Levels at 36 Weeks is Associated with Longer Duration of Home Oxygen in Infants with BPD”
• 2019 NACFC Pediatric Fellows Session
• 2020 American Thoracic Society Abstract Scholarship
                “Active Weaning of Diuretics in Preterm Infants with BPD does not Increase Duration of Supplemental Oxygen”
  
   

The Pulmonary (& Sleep Medicine) Division is comprised of nine clinical faculty members and six advanced practice nurses who provide treatment for infants, children, teens, and young adults with respiratory diseases. Our fellowship program offers innumerable clinical opportunities in collaboration with Children’s Wisconsin’s state of the art health care facilities and numerous sub-specialty focused clinics.

Our experienced, engaging faculty members are eager to help and support you throughout your time in our fellowship program.

Meet our Faculty

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Each fellow should develop and continually update a personal portfolio and a CV. The portfolio would include information not typically found in a CV including meetings attended, summaries and evaluations of talks given, lists of patients evaluated and procedures completed, and other information that demonstrates continued academic involvement and success. These materials will also be reviewed during the fellow’s semi-annual review with the fellowship program director and on an ongoing basis with each fellow’s clinical mentor.