Continuous professional development: elevating sleep and breathing disorder education in Europe

Sleep and breathing disorders are highly prevalent, representing a growing subspecialty of respiratory medicine. The term sleep disordered breathing (SDB) encompasses a range of conditions characterised by abnormal breathing during sleep, from chronic or habitual snoring, to frank obstructive sleep apnoea (OSA) or, in some cases, central sleep apnoea (CSA) and hypoventilation syndromes. OSA is the commonest form of SDB, leading to many potential consequences and adverse clinical outcomes, including excessive daytime sleepiness, impaired daytime function, metabolic dysfunction, and an increased risk of cardiovascular disease and mortality [1]. The estimated reported prevalence of moderate-to-severe SDB (≥15 events·h⁻¹) was 23.4% in women and 49.7% in men, and the prevalence of symptomatic OSA was 9% and 13%, respectively [2]. However, in some populations, the prevalence of OSA is substantially higher, such as in patients been evaluated for bariatric surgery (estimated range 70–80%), in patients who have had a transient ischaemic attack or stroke (estimated range 60–70%) and in patients with cardiometabolic disease [3–6]. Limited data have been reported on CSA and non-obstructive sleep-related hypoventilation, which have received considerable interest in the sleep field within the past 10 years. Even if their prevalence was noted to be quite low relative to the prevalence of OSA [7], they are quite common in specific subpopulations [8–10].

Unquestionably, considerable progress has been made in past decades regarding basic science, and technical, clinical and therapeutic aspects of SDB. Furthermore, as sleep is essential for general health, SDB is important for general health as well. The field is still evolving and additional research to improve the diagnostic accuracy of simplified screening tools is needed to ensure that patients with SDB are accurately identified. However, the task of routine screening, assessment and management of SDB is particularly challenging. Inconsistencies in the diagnosis and management of SDB emphasise the need for standards in practice with special knowledge and expertise for medical practitioners managing respiratory sleep patients [11]. Moreover, in an era of evolving precision medicine, personalising therapeutic applications should be established on patient individualisation, correctly identifying their clinical profile and needs.

The respiratory sleep medicine project

Assembly 4 of the European Respiratory Society (ERS) is in the unique position of designing and delivering educational activities, such as successful symposia at the annual International ERS Congress, including Meet the Expert and Postgraduate Courses, research and education projects, Task Forces, Statements, Guidelines, research seminars and awards, which raise the standards of training for our respiratory health practitioners. Group 4.02, the largest in Assembly 4, provides a forum where scientists and clinicians interested in the causes and consequences of SDB can meet and share their ideas. By organising a specific Task Force, the Group has focused its activities on raising the awareness of sleep and breathing problems at the level of the European Commission and promoted identification of sleep-related disorders as a major priority in European Union health policies. Specifically, the Task Force produced Guidelines on non-continuous positive airway pressure (CPAP) therapies for obstructive sleep apnoea and Statements on the definition, discrimination, diagnosis and treatment of central breathing disturbances during sleep [12, 13]. Furthermore, upcoming statements are on the effectiveness of CPAP treatment on OSA in commercial and non-commercial motor vehicle drivers and new diagnostic techniques. Once published, the documents will provide clarity and direction for a number of topics in respiratory medicine with the aim of improving clinical practice. Moreover, the continuing educational interest of the ERS is shown by the number of issues of the ERS Monograph published in the past 20 years. The ERS Monograph is a quarterly book series covering a specific area of respiratory medicine and providing up-to-date and in-depth reviews that give clinicians a concise, comprehensive guide to symptoms, diagnosis and treatment. Group 4.02 also carries out educational and scientific activities in collaboration with the European Sleep Research Society (ESRS). In this direction, a collaborative European network project, the European Sleep Apnoea Database cohort, was established in 2007 with the objective to recruit a large prospective international cohort of patients with OSA for cross-sectional and outcome research and to serve as a bridge for education and knowledge transfer between the various participating centres [14].

The ERS, in collaboration with the ESRS, established the biannual Sleep and Breathing Conference. The ESRS initiated an examination in sleep medicine at the 2012 ESRS Congress in Paris, France, leading to “somnologist” certification, followed by a second examination held during the 2013 Sleep and Breathing Conference in Berlin, Germany. So far, over 600 physicians, psychologists and sleep scientists across Europe have obtained this certificate. The certification confirms successful education and training in sleep medicine, including clinical scientific knowledge and technical skills and, therefore, proof of competence in the field of sleep medicine. Although National Sleep Societies (NSSs) have not adopted this qualification, many provide a certificate in sleep medicine in accordance with local customs or regulations. However, the Assembly of NSS and the ESRS Sleep Medicine Committee are in the process of identifying strategies to endorse this qualification, in order to achieve a homogenous standard of practice across Europe. The ESRS has also produced a catalogue of knowledge and skills as a basis for sleep medicine education and a multi-author textbook on sleep medicine, based on this catalogue, which was finalised in 2014. The ESRS is in the progress of updating this edition. Together the ERS and ESRS could significantly enhance the quality of each project with the objective to improve the quality of care for patients throughout Europe who suffer from these disorders.

Periodical revisiting of the ERS curriculum development: future directions

As no harmonised standards of training exist across Europe for respiratory sleep medicine, the ERS supported an application for a Sleep Harmonised Education in Respiratory Medicine for European Specialists (HERMES) Task Force project [15]. The HERMES Sleep Task Force and project were officially launched during the 2009 ERS International Congress in Vienna (Austria). The European core syllabus in respiratory disorders during sleep was published in 2011, followed by the production of educational materials including the ERS Handbook of Respiratory Sleep Medicine [16] and the respiratory sleep medicine curriculum in 2015. The ERS curriculum (formerly known as HERMES) was developed to present a common curriculum for medical and allied-health professionals, as well as to support teaching and certification in respiratory sleep medicine. The first course of the respiratory sleep certified training programme, initiated by the ERS Sleep Training Committee, took place during the 2017 Sleep and Breathing Conference(Marseille, France), followed by a second course held during the 2019 Sleep and Breathing Conference (Marseille), which was well attended. The aim of this course was to train respiratory professionals at a post specialty or postgraduate level in respiratory sleep medicine. The programme includes two parts with five independent modules and, following successful completion, a respiratory sleep certified training programme certificate is obtained. The programme overview can be viewed on the ERS website(www.ersnet.org/professional-development/respiratory-sleep-certified-training-programme).

Over the years, the process of curriculum design has been improved within the ERS and it will continue to evolve, including more e-learning videos and CME online modules. There is also an updated edition of the ERS Handbook of Respiratory Sleep Medicine in planning. The sleep and breathing continuous professional development catalogue will be used as the contextual basis of our educational programme. This recently developed catalogue covers the SDB trajectory in 23 modules, as shown in table 1. Each module will be maintained and regularly updated according to future developments by a faculty composed not only of senior scientific specialists in SDB, but also of committed Early Career Members since they represent our future. Digital and social media might be used to deliver the message and the education itself, utilising the already available ERS communication channels.