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everything okay and huh? Yeah, it sounds good. All the lovely lovely or I'll give you any problems. Hi, everyone. Welcome back from your break. Uh, and I have the pleasure this afternoon to introduce Doctor. She'll be seeing her, so she'll pee. Is a pediatric training ASDA currently working in L. R. I. A letter from my family. She has trained in work in East Midlands, but I don't. She has trained in the Midlands, but I have gained experience out of scenery in pediatrics to during her level three piece training. She has worked for 18 months into territory respiratory sensors while completing her spin special interest modules in pediatric allergy. So she's an allergist with extensive experience in pediatric respiratory mainly difficult asthma. And she is really looking forward to giving an insight in pediatric respiratory. Uh, thank you, Stephanie. That's brilliant. Hi, everyone. I can't see anyone at the moment, So, um, I'm going to start sharing my screen. Um, we did decide that we would probably have the QNASL as we go along. Um, unless you guys preparation any other way, I'm definitely free to use the jargon, so please do interrupt if there's anything I could expand on or explain. So I'm just going to share my screen, right? So I can everyone here me still and can see the slide. I want to Just one years with you and you and you're like, Yeah, brilliant. Thank you. So welcome to my chat. And thank you for inviting me. Stephanie, we are going to just have a very brief overview on what involves, um, what it involves to be a pediatric respiratory registrar. So just a little bit about me. Um, I am not born British. I am an international medical graduate. Um, as Stephanie introduced earlier, I joined East Midlands. Um, during my foundation training so very much have been in your shoes before. I then applied for pediatric run through training. There was an old school pediatric training, which could be you could choose to do what you want, But then, obviously it's become much more organized. And it's the longest training period of, uh, in in in its kind. So my pediatric training has gone between 2010 and 2022 which has seen me taking maternity break, a career break. And when I came back to do my level three training I chose to sub specialize in allergy. The spin word stands for special interest. So allergy usually goes hand in hand with either respiratory gastro immunology dermatology. So I chose to do respiratory, and hence I've done spin in both. So, um, before we go into that, I I would probably just quickly speak about why I ended up doing this. So between my level one and level to training, I took a career break, and that was purely because I wanted to stay at general pediatrician, But I had no idea what I wanted to subspecializes in. Plus, I had really young kids at the same time. So, um, during my one of the s t three sessions, I came back home after my night shift, and I found my son wheezing away. Um, he had never done this before. Now he's a child who has a bit of a topic. So he had neonatal eczema, um, egg allergy, and, um, I saw him wheezing. I thought he was happy Visa as we used to have the term back then. It's completely gone out of fashion now, but I gave him some inhalers, came back after a shower and found him to be wheezing to cut the long story. We ended up in hospital with shots of 84% and it just made me think that, you know, sometimes you rely a lot on your, um, intuition. You realize that the kids look well, and whereas they often not as well as they look and they have a capacity to keep up the facade for a very long time until they really go dramatically down and being a pediatric training, the pressure of trainee pressure is even more. You feel like you must know this, but you really don't. So, um, my reason to go into allergy was partly because I had to deal with the allergy and asthma and he's at home. So it's always useful as you decide your subspecialty to to find a personal motivation, find something which actually gets you relating to what the parent is going through and and when they actually deal with one problem and I say what goes together, stay together, as and literally you don't get one problem by itself, you really just get the whole panel. So in my case, I then decided to sub specialize in difficult asthma purely because I could see him breathing. And I knew I wanted to learn more about this And what what it has done over the last 10 years on Earth is that it's definitely not become a concern. It's It's not about what I'll end up becoming. Will I become a consultant, respiratory or consultant? Allergist or this? I know I'll become a general pediatrician with a very good insight into respiratory analogy. So, So So choose what you like, enjoy the journey. Learn as you go along. And it it does become more enjoyable in due course of time. Okay, so you probably heard this during the day and it may just be a reputation, but very quickly. Pediatric respiratory training programs. It follows the General Pediatric run through training, which at the moment goes from ST 12 s t eight. I know from next year it actually cuts short to ST seven ST. One is level one training where you mainly aimed to get your MRC PCH alongside You can develop your, um, your experience in general pediatrics. You do que i projects which are quality improvement audits. S t four and five is when you come back as a new Reg, and that's the time to grow confidence in becoming a Reg. But then also time to find out your subspecialty what you're interested in, what you're going to apply. Because, um, although there's no number of, uh, there's no number limit of number of application number of times, you can apply to a sub specialization. You do need one year, and considering ST 6 to 8 is your Level three training. You only get two chances in U. S. T. Six and 87 to apply for your sub specialization. So pediatric respiratory, um, in UK, as per the Royal College of Pediatrics and Child Health offers a grid and spin program. Now grid is obviously more intense. This is what leads to you to become a tertiary care pediatric respiratory consultant. Um, it's heavily research oriented, but at the same, that's what you do. That's what you end up doing more of. So in a way, the buck stops with you. You get the referral from secondary level primary level, and then, um, you probably end up looking after them with input from your colleagues from level, too. But pediatric spin which suits someone like me, and it's really what kind of person you are and what you end up becoming. Because if you're someone who is more academic, then maybe grade suits you more. But if you're someone who is more clinical and more holistic, then maybe spin suits you more. You're really free to decide, and you have a long time before you make that decision. But just to give you a taste of that. So spin aims at level, too, which is secondary care. So you know the whole tier system, level one being GP and community level to being district general hospitals and level three being tertiary care hospitals. But the good thing about skin is you are always you remain general pediatrician with special interest so you can get the combination. And that really helps you keep your skills of general pediatrician if you prefer. And yet, let's you practice what you what you like. Okay, so for this year, there you are. Royal College Pediatric application starts on Third of November, so good luck to all of you who are going to be applying this year. And that's for 2023 national recruitment. Cool So, um, the reason I put this slide up is is really not to see which color of phlegm are you. So it's really because, um, I looked back at last 11 years, and, um, if at the beginning of my ST one if anyone asked me if I was ever going to be a respiratory or allergist, I would have laughed. Um, I would have never imagined I will end up this. So, um, where I work, if we ever crossed through a respiratory world, we have the luxury of a pediatric respiratory ward. And I heard a wet cough. All I could actually visualize is the color of the phlegm, or all I could hear and smell was a monkey flame. But what I have evolved into with obviously due course of training and time is that if I now hear a sound of a cough, um, instead of the color of the phlegm that the anatomy of the lung, it comes in front of me, I'm trying to constantly figure out. Is it upper respiratory or lower respiratory? Is it actually more deeper? Is it more, um, throaty or it's Friday. Is it these? So don't worry, if you really don't know at this point. And really, this is not You don't have to have a burning passion for any sub specialization. It comes. It comes with time. It comes as you evolve and there's plenty of time to evolve. So, yeah, here I am. I know a little more about the nebulizer and windpipes now than I did ever before. Um, so, pediatric respiratory service, what actually does it mean now? I was actually hoping to ask, um, team at this point that what do they know of these respiratory service? I think from my previous memory when I presented and spoken to juniors, they often no asthma, difficult asthma, and they sometimes know cystic fibrosis because those two are the biggest umbrella terms that we actually work under. But then it's actually evolving, and actually it's developing more and more. So my car pediatric center, which is Lester Royal Infirmary, has started. They run a sleep service where they look at disordered sleep in Children, which is actually quite a big field in itself, because it's very contributory to developing, um, asthma or any other medical conditions like upper respiratory sounds, rhinitis. Everything contributes to a disturbed sleep. There is complex chest clinic which deals with Children with neuromuscular conditions where they actually have a weak muscle. So any decisions, anything you can think they are. They come under M S K, but they definitely have a respiratory insight into it. And then, um, ever evolving. The newest involving field is long term ventilation service. So that's, um, that essentially involves us giving artificial ventilation, which is noninvasive ventilation by way of CPAP or bipap to Children who they need it for temporary or long term purposes for a variety of reasons. For a child, a younger child with any syndrome. Trisomy 21 who has tracheobronchial Malaysia does have poor oximetry. Needs LTV for a couple of months, or at least a year, till he grows bigger and they can easily grow out of it. Or sometimes they can grow dependent on it for a while. But it does help them stay at home, stay with their loved ones and actually enjoy a longer life. Um, sorry, Lung defense clinics. Um, that's not something we run in Leicester Oil, But I know Cambridge has a center and and that's for Children who have who have a risk of greater, greater risk of developing recurrent chest infections. Um, Children with primary biliary diskinesia Children with Kartagener's syndrome, where they have difficulty clearing up mucus so they end up harboring infection, keeping it longer in the airways. And they that involves a bit of immunology, um, pragmatic use of sputum culture and antibiotic use, but also chest physio. And there are different devices. So it's it's such a vast field. So from where we started this, actually, there's plenty of room for everyone to grow in because a typical pediatric tertiary care team will definitely have one or two pediatricians or respiratory physicians who would want to do difficult asthma. Only um, that's one of me who's evolving in to a general pediatric with interest in difficult asthma. So that would be my future. Um, asthma clinic. There are cystic fibrosis, um, leads. And East Midlands definitely has some world level lead, um, in Nottingham, where they actually it's a very evolving research field, Um, and then, um, sleep study, which is partly shared with Allergist and e n. T. Team. So there's lots of room for you to grow in. Okay, so I was asked to talk about a typical day in in, uh, in pediatric respiratory. And I really have to say there is no typical day. There is a typical week. There is definitely a pattern which actually goes on the whole week. And I won't bore you with a lot of details. But essentially, what I wanted to focus on is that a typical week, we'll see you doing the same things every morning. Which would be you have to go for general pediatric handovers where you, um, work with, Because remember, you're one of the subspecialties working with a much bigger team. Um, a bigger team which involves General Pediatrician's, which involves, um, a gastroenterologist. So general pediatric handovers are a good place where you catch up with everyone. We then come back and we have a little huddle and cuddle with our own respiratory nurse is where we go through what's going on overnight, how the baby's and kids have behaved. And then there's a war drowned, then lunch break. Now, the second half I really want you to focus on is, um, Monday. We have a difficult asthma clinic. Tuesday, there's a CF clinic. Wednesday, there's a bronchoscopy list And then Thursday is the respiratory grand round, and there's almost teaching on every day. So we have, um, s h o teaching essentially lead teaching on Tuesday. There is a red lead teaching with General Club on Wednesday and radiology teaching, which we do it with the radiographers. Um, so it's it's a field where they're constantly teaching us. They're constantly helping us understand what's going on in the physiology. Um, what's going on on the anatomy? Or if you actually were to cut through the lung, what would you actually see? And some of the latest development in radiology is so amazing that you are actually get a beautiful three d image. And, um, a lot of job is done for you. So you're never alone. You always have a whole a big group of people actually working with you, helping you, guiding you along the way. And it actually does make the training quite fun. I personally have enjoyed my last two years in respiratory team, absolutely every single day. So, um, as I said before a day for me, I would start with attending general pediatric handover. I would then come back and have our respiratory hand over the war drowned. Now we have the luxury of respiratory ward, but often it's not the case in in in every other hospital. Sometimes you just have had lots of outliers, which means that our respiratory patients who are either shared care, um or they have any other medical they presented with another medical problem. But respiratory is part of the so we get involved. So we see outlier patients, and then we also have referrals, and a lot of my day goes into seeing general referral and then their their efforts from all over so that this could come from General Pediatrician's who have seen a child with difficult asthma for a couple of days have difficulty stretching him so they want peace Referral Review. There is Children's E D department, where they have a tracking ventilated child who has come in, and they would ask us to get involved because we can help them plan care daycare patients where they have come in for something and then found to have really wet cough. And they want they think this child needs antibiotics. The nurses will call you and then obviously clinics, and it's amazing how so many, um, clinic patients who you would assume because they're coming to our patients are well in themselves. Actually, patients patients actually postpone coming to hospital thinking they have a clinic appointment, and they presented the clinic acutely and well. Often, Um, it doesn't always happen in general pediatric, but routinely happens in sub specialty. So my plan is to actually see them and then keep them safe. Make a plan. Remember not having a plan does skills. So it's easy, too much easier to involve the team. Make a plan, admit them. So it's a busy job. It's really exciting. It's also a job where you can make a plan. And once you've implemented your plan, when you have finished your work, you have handed over and finished. It's a good work. Life balance. I wouldn't say that this is something like, It's not. I wouldn't I wouldn't want to assume cardiology does it all the time, but I know some some fields where they have to be on phone. I'm definitely not somebody who needs to be available at the end of phone at all times, so I have. I've managed to do my if I make a contingency plan. Then it's easier for me to step back. Is that clear? So far, can everyone is everyone still with me or going to sleep? Definitely. Think you should be super. Okay, So, um, going forward, I wanted to have spoken about a typical day and a typical week. I wanted to give you a little bit of understanding. Um uh, what the main conditions we deal with, and and there's a reason why I'm doing that. So bear with me. So in terms of asthma, we run three clinics per week, and we definitely do General pediatric clinic with recurrent visa. Remember these and viral upper respiratory infection is bread and butter of pediatrics. So we get multiple kids who may not be asthmatic in the long run, but definitely wheeze. Um, what I wanted to highlight to that is that some of them will end up becoming difficult asthmatics or asthmatics, where we have a very nice, um, multidisciplinary team approach. And we actually have a clinic together with asthma nurses. Just physiologists. Psychologist. Just because of chronic illness. Um, but I wanted to bring your attention to the NRA D, which is national review of asthma debt. Now, this is, um, annual review. The last report we had was in 2021. It takes your asthma, asthma, death review for adults and pediatrics and, uh, not just UK, but all over Europe. Um, it was actually quite, uh, and disturbing figure because since 2014, um, UK has one of the highest rates of asthma. Death amongst 10 to 24 year old now 50% of asthma deaths is pediatric. And imagine in that 50% 46% is preventable. So there's a big chunk which is preventable, and the fact that we are in the bottom too. And I think the only country below was probably last week. Uh, but we we really are quite at the bottom of the whole list, and it it tells me that we're not doing something right, but we're definitely doing something wrong again and again. Something which is wrong, which we are continuing to do, is also contributing that we're really not improving. And I think part of the NRA d was, um that we're using. Um Salbutamol inhaler is a lot. Now. The aim of this was not to not to go into details of this, But it was actually to highlight to you that there is a bigger need for chest physiologist. There is a There is a very robust training program which has which has it sees you through learning through latest evidence, very experienced team. But then there is a clinical need for it because they're actually debts which are preventable. Okay. And from a very depressing NORAD review, I want to talk about CF next. Now, I talked quite happily about CF. Um, I think I'm sure you all know what CF is. You know, it's the Communist inherited congenital condition. It affects CFTR. But the reason I I talk happy about it is because it's a very exciting time for CF world. Um, we have recently discovered what we call CFTR modulators. When I say recently, it's been good 57 years 2015 2017 on words. But for me to go into that, I'll just give you a very brief flavor of it that we know that cystic fibrosis, um, CFTR gene is what actually gets, uh it makes the protein which opens up the chloride channel, and then it actually leads to, um when the chloride comes out, brings along with the sodium water and makes the mucous quite wet. Easy for the ciliary body to clear it. When you can't do that, um, you get you get what we call CF, which is not just the lung but also a multi system disease. But respiratory system is definitely the most affected by it now. Old school, or also, when I sold schools, they're not old school. It's actually the easiest way for us. Was the symptom manage where we would give loads of antibiotics? Just physio. But, um so this slide, um, does look very busy, but it's actually not very busy. It's it's very, uh, it's quite easy, So just just stay with me on this. So if you just focus on the first cell where they talk about the CFTR gene and then you can see that it actually comes out in a three d protein structure, I believe everything worked. Then, um, the CF tr will actually lead to the mucus being soft, but then the if you follow it along, come to the 3rd, 4th and 5th slide you can see on top. There is, um, the CFTR gene is not actually leading to a functional protein. That protein is completely convoluted. It's really not helping the chloride come out. It's not helping the mucus breakdown. So what actually happens is a buildup of mucous on top of the cell membrane that makes a biofilm, which then catch is secondary infection. That infection, and that bug, which is actually caught in that thick mucus, finds it's extremely difficult to wriggle out. So it continues, and a very inflammatory changes there, which ultimately leads to the fibrosis and loss of lung function. Now CFTR modulators are drugs, which can alter the CF, the gene protein so they actually work on the genetic level to help the CFTR gene. Um, it works in three different ways. Um, Ivacaftor is recently, actually, it's been used for a while. Um, it's a It's a protein, which is shaped like a tunnel, which, um, the potentiator helps the chloride move through the CFTR gene. So can you imagine the gait, which was an opening before because of systemic before? Because of the genetic mutation there are potentiator is we can actually lead to, even if it's a slightly abnormal protein, but protein leak, which improves the symptom multifold. But then there are characters who actually improve the protein structure as well. And if you use it together with the potentiator, the results are amazing. So when we now counsel a newborn who has been born out of meconium ileus and we have confirmed the diagnosis of CF, it's not all doom and gloom. There's actually the note is quite positive to say that there's plenty we can do for the child, and the earlier we know, the better it is, and we can actually help parents. So the difference is that there is asthma, which is still killing, um, potentially much common thing, which we all know about. But it's just surprising and shocking that it gives so strongly that as cystic fibrosis, which you would think should be a much more, um, worse condition itself actually is improving. So that's just the best thing about the training world. So apart from those two, the other specialist respiratory services which we are doing more and more as long term ventilation as I said before. Now, with the improvement in the neonatal unit with more kids with with surviving if there is a need for positive support, lt we can provide that either temporary or as long as they needed to be honest. And it really has helped Children sleep service and then long defense clinic. I think I've spoken about that before. So essentially plenty. Plenty of room to, um, to for you to join in and then, um, expand into anything that you want. Um, So what is a typical respiratory review mean? Where do you come in? And all these very complex talk essentially sounds very, um it sounds like it's extremely complex, but you're still the first line patient contact. You know, I'm the first person who possibly sees them and, um, again, just do the basics, right? Stick to the simple things done right, which is take a good history that always helps. You really need to go into as much detail as possible, which is the same format as you would do for anything else. You would go for the presenting complaint, and then you would go back as as long as it takes to say, When did it actually develop history of presenting complaint? And it can. It should always include a birth history. Um, I have put a crown on there, called Qatar. Qatar is a scoring system, which is a diagnostic of primary biliary diskinesia. So if it essentially involves that if the child was born and needed respiratory support in the 1st 24 hours and then needed help for some more time, um, it goes through a number of question. But then that's where the birth history comes in. Because I used to be in in, uh, respiratory clinics. We'll have 89 year old kids who is presented with chronic cough, and often the consultants would go back into birth history. And you're thinking, Well, why are we you know that the child looks well grown, but those things to help a detailed drug history. Anything over the counter? Um, any Britain is ever summer multicultural at the moment, if there's any over the shelf medicine but also some cultural herbs, anything they're taking is really important in your respiratory thing because obviously, if it's inhaled or if it's something applied on the skin, it does get absorbed. Your immunization schedule that if this is a recurrent chest infection and the child has it been immunized, you would really want to make sure that they actually get immunized, plus the amount of response to that trigger. So triggers are mainly important in asthma. Um, it could be multi trigger, or it could just be a single thing. It could be viral infections. Or it could be black mold in the toilet. Which then, you know, this is where the detailed history of housing You wouldn't think you would have to take that history. But it's actually asking, What kind of house do you live in? Is it at actually damp? Do you have black mold in the in the in the toilet or in the house? Is it always leaking in the winter? Those kind of things do make a difference in the que you provide. And actually, that's when you really understand how much How many people are teams will you need to involve for this child, um, family history, including can Sanguinetti, But family history mainly of any it okay, if they have any hyperreactivity history and then this cough and things like that. So that brings you to the examination. And I would just say Just stand at the end of the bed and look at the child and listen to the cough. There is no reason to actually jump in and go to go next to the child right away. It's quite important to just hear the cough and understand, Are you trying to try to differentiate? Is it upper respiratory lower respiratory or you just sound wet and you can't completely tell or it's a combination of sounds. So it's important to hear the cough. Um, Jackal. I'm sure everyone already knows. But, uh, any signs of chronic city or any signs of, uh, chronic illness could be expressed by way of John this anemia, clubbing cyanosis or edema and lymphadenopathy. And again, it's good to generally comment on the child's, um, body weight and height. Is it a well built child? It's a child who looks very small for the age. Um, I was told that it's a sign of a mature pediatrician who can who can look at chess shape? Um, I learned that slowly and steadily just to show myself being mature, but essentially, you know that if someone is asthmatic and they're constantly struggling, they will, in due course of time developed, Harrison sulk, I so if they are then presented, I mean it could well be. You know, we've recently seen a child with clubbing at 11 years of age who's an immigrant, unfortunately, and, uh, then just not had a chance to receive the right care. So you can't assume that every child has had a normal background. You really just have to go back and examine and look at and then you could You just don't know what you'll find. Um, breathing pattern. Is it a disorder? Breathing? Are they? Are the breathing weird or funny? Do they have a regular respiratory drive? Are they having apnea or pauses? Um, chest signs. Actually, what you hear in the chest is quite important. And then you can combine what you find with a whole lot of investigations you could only choose to do chest X ray. You can do spyrometry. And then if you think there is asthma or some kind of a topic, you could definitely do a blood panel, too. Give you a sign. That is it, actually, um, allergy, mediated or not. So again, do the basics right. If you just stick to the basic thing, a lot of complex things will become very easy if you stick to a certain pattern of your your develop, your own pattern of history, examination, investigation and things do get easier. Okay, so, um, that brings me to the end. I'm not sure how much time I have, but I personally have grown into this field, and I think I have never I think it's an amazing subspecialty because you really can make a difference. Um, I have chosen to do spin. You could do either spin or grid, but and even as a grid, you can always do General Peds Clinic because the bread and butter the vast majority of general peds patients who are coming busy they would still want to come to see a specialist. Um, the whole NHS system is moving towards consultant lead care. So as you evolve into that, you then can specialize into whatever you want. Um, in terms of asthma, there's definitely potential to change and save lives. But then, if you go into things like sleep, um, services or cystic fibrosis, um, it's it's still quite evolving and research oriented, and I think you can always do loads, and you're never alone. It's always always a big team, so you always have a huge um experience holding respiratory nurse is they've been there much longer than any of us, and they really do know the family background. So these nurses work across community respiratory nurses in community really do home visits, and they understand What's the home the home situation like or who's actually the main care provider in hospital. You then have your chest Physiologists will do your spyrometry. You would understand what's the breathing pattern? You then have chest physio and the chest physio to him and then psychologist. So you really never sat in the room alone making a decision. So I'm thinking, What am I going to do with this child? You will always have. As soon as you asked that question even before you asked that question, there were so many people who have actually told you. I think this is what's wrong with him, and I think you need to do this. I mean, that's what got me through initially, as I have to admit it, but it's it's better now. So on that note, guys, I will stop sharing and feel free to shoot away. If there's any questions I can answer for the team, please Thanks. So much for your wonderful talk. That was really good insight into you do pee. It's respiratory. Think, unfortunately, have run out of time for questions. I know it's probably because we started a little bit late, but there are some questions on the chat box. Would you mind if that's okay? We will absolutely hang around just for a bit. If anyone wants to drop any questions, feel free to drop in the question box and she will be kind enough to answer for a few minutes. Um, do you have time to answer, or do you want me to type it out? Do we not have time? Do they need to go join some of the session? I think unfortunately, we need to go to the main for the main page to go for the next talk. But if it's okay with you, would you mind just answering the questions so that they can come back and have a look at the answers? And that's not a problem. I'll do that. Thank you, Stephanie. And sorry, overrunning. Thanks, guys. Enjoy your day. So but thank you again. Honestly, on Saturday for giving this talk. Uh, pleasure. Thank you for the rest of us. Um, if it's okay to just join the main page again for the following talk and talk about if three. Thanks again for you. Okay, guys. Thank you. Bye. Stephanie. I'll answer the questions there. I hope so. I'm sorry I'm not able to write because my account isn't verified. But to be honest, um, direction, I would say, is, uh, um, cf kids transition when they are 18. Uh, and in terms of peace, respiratory? No, not really. When you start your level to training, speak to your team and see if they can help you with your application. All right, guys, I'll let you go. Thank you so much. Bye bye. You could just go back to the main stage, please. On the left hand side.