Tables
- Table 1
Module-based continuous professional development training
Module 1: Neuroanatomy and neurobiology of sleep Regulation of sleep–wake cycle Recognise basic neural processes and transmitters controlling wakefulness, non-rapid eye movement and rapid eye movement sleep states Describe sleep architecture in a normal adult Understand how the ageing process from fetal life to old age affects the sleep cycle Sleep as a biologic process essential for life and optimal health Module 2: Physiology of sleep and breathing Control of breathing: explain factors that control breathing during sleep and wakefulness
Understand ventilatory response to hypercapnia, and hypoxaemia (including loop gain), arousal and apnoea threshold
Describe the functional anatomy of the upper airway
Discuss the factors that cause upper airway collapse during sleep
Relate control of breathing and upper airway function to the pathophysiology of obstructive sleep apnoea and central sleep apnoea
State how respiratory mechanics and ventilation are influenced by pathology
Explain sleep-related changes in respiratory mechanics in the aetiology of nocturnal hypoventilation Module 3: Cardiovascular and homeostatic mechanisms and sleep Understand how cardiovascular function, e.g. blood pressure and heart rate is affected during sleep and arousal from sleep
Appreciate impact of sleep on autonomic regulation and the consequences of sleep pathology. e.g. in OSA and CSA Module 4: Physiology of arterial blood gas and acid-base status The utility of arterial blood gas, capillary blood gas and venous blood gas
Diagnosis of A-B disorders: Henderson–Hasselbach equation, the relationship of oxygen tension, carbon dioxide tension and pH
A-B disorders: the importance D(A-a) difference, inspiratory oxygen fraction, alveolar gas equation and measuring oxygen shunts Module 5: Define SDB OSAHS, CSA, periodic breathing, Cheyne–Stokes respiration, obesity hypoventilation syndrome, nocturnal hypoventilation, upper airways resistance syndrome
Describe the epidemiology of OSAHS and CSA
Describe the different clinical phenotypes of OSA and their relationship to underlying pathophysiology Module 6: Assessment of the patient Sleep history to include:
Sleepiness and fatigue
Insomnia
Poor sleep quality
Nocturnal choking and gasping
Snoring
Morning headaches
Impotence
Low mood or labile mood
Cognitive impairment Signs: Clinical examination of upper airway, nasal obstruction, tonsils and adenoids
Craniofacial disorders
Hypothyroidism
Obesity Assess for comorbidities, e.g. COPD, chest wall disease, neuromuscular or neurological disorder, cardiovascular disease, endocrine or metabolic disorder Module 7: Evaluate impact of symptoms and establish pre-test probability of SDB Use of questionnaires: Epworth Sleepiness Scale, STOP-BANG score, Berlin questionnaire, 36-Item Short Form Health Survey, insomnia evaluation
Identify high-risk patients, e.g. severe sleepiness, unstable cardiac disease, nocturnal arrhythmia, baseline hypoxaemia, driving or other occupational risk Module 8: Diagnosis of respiratory sleep disorder Recognise the methodology of the different sleep tests (oximetry, respiratory polygraphy, full polysomnography)
Understand limitations of overnight oximetry, respiratory polygraphy and polysomnography, and home versus hospital-based sleep studies
Appreciate which patients to refer for polysomnography, e.g. those in whom diagnosis unclear on respiratory polygraphy, or poor treatment response or if non-respiratory sleep disorder suspected, e.g.narcolepsy, restless leg syndrome
Identify cases where further specialised examinations are needed, e.g. ear, nose and throat review of upper airway
Review cardiovascular, respiratory and metabolic disorders often associated with OSA
Clearly explain the high cardiometabolic risks associated with untreated OSA
Discuss the value of making improvements to lifestyle including weight loss, adherence to drug treatment for hypertension or diabetes, smoking cessation, alcohol reduction, physical exercise Module 9: Nocturnal capnography Role of capnography in patients with nocturnal hypoventilation
Understand limitations of overnight transcutaneous total carbon dioxide and end-tidal carbon dioxide tension monitoring
Appreciate use of capnography to establish ventilator settings Module 10: OSAHS management Distinguish mild, moderate and severe cases of OSA from normal results and upper airway resistance syndrome
Explain lifestyle interventions including weight loss, physical activity, exercise training, smoking cessation, alcohol reduction, avoidance of night sedation, sensible sleep hygiene measures
Understand role of ear, nose and throat intervention
Understand role and types of mandibular advancement splint or other oral device
Understand definition of positional sleep apnoea and role of positional devices
Appreciate indications for CPAP therapy
Understand differences between fixed level CPAP, variable CPAP and bi-level positive pressure therapy
Depending on local pathways appreciate which patients to refer for these interventions
Understand CPAP related side-effects such as interface problems, airway drying, sleep disturbance
Appreciate issues leading to poor adherence and how these may be addressed
Understand different ways of monitoring positive pressure therapy: clinic visits, data downloads from devices, telemonitoring
Appreciate follow-up involves assessment of efficacy of therapy in controlling OSA but also impact on comorbidities and health-related quality of life
Importance of explaining rationale of treatment and likely outcomes to patient and advise on medico legal aspects, such as driving
Pre-peri and post-operative assessment and management of patients with OSAHS
Be aware of and follow local guidelines on diagnosis and management of OSAHS Module 11: CSA Classify aetiology of CSA: idiopathic, due to heart failure, cerebrovascular cause, e.g. cerebrovascular accident, opioid or other drug use, altitude
Differential symptoms and signs of OSA and CSA
Understand the pathophysiology of different types of CSA
Recognise which patients to refer for sleep studies Module 12: Management of CSA Understand impact of CSA on underlying pathology CSA in chronic heart failure: Appreciate importance of optimising therapy for heart failure
Understand role of CPAP in some patients including those with mixed OSA and CSA
Understand that ASV should not be used in heart failure patients with left ventricular ejection fraction <45% Other forms of CSA: Understand that CPAP or ASV may be of value in opioid-induced SDB
Appreciate further trials in progress assessing oxygen therapy in CSA and further role of ASV Module 13: Obesity hypoventilation syndrome Recognise symptoms, clinical presentation, and pathophysiology of obesity hypoventilation
Explain consequences (vascular disease, polycythaemia, cor pulmonale)
Assess indications for CPAP, NIV, application or supervision of mask and interface
Explain condition and the risks of obesity, and offer advice on how to decrease body mass index through physical activity, training and diet
Understand role of bariatric surgery, pre-operative assessment surgical risk, and peri-/post-operative management in OHS patients Module 14: Neuromuscular disorders Understand neuromuscular diseases causing respiratory failure
Neuromuscular conditions associated with respiratory muscle weakness
Appreciate methods to assess respiratory muscles weakness: spirometry, mouth pressures, peak cough flow, sniff inspiratory pressure, diaphragm EMG studies
Symptoms and signs of nocturnal hypoventilation and the probability of respiratory failure
Role of NIV versus invasive ventilation
Cough augmentation (cough assist) techniques
Use of NIV
Peri-operative assessment and management of neuromuscular disease patients Module 15: Chest wall disorder Recognise chest wall deformities causing respiratory failure, e.g. scoliosis, thoracoplasty Symptoms and signs of nocturnal hypoventilation and the probability of respiratory failure, indications for sleep study
Role of NIV versus invasive ventilation, and cough augmentation (cough assist) techniques
Use of NIV Module 16: Chronic respiratory failure Causes of respiratory failure
Principles of interpretation of blood gas analysis
National and international guidelines for treatment of acute and chronic hypercapnic respiratory failure
Indications of additional oxygen treatment
Indications for long-term (home) mechanical ventilation in COPD, neuromuscular disease, chest wall disorders Module 17: Assisted ventilation Treatment of ventilatory failure
Describe types of positive pressure ventilation and different modes, e.g. bi-level positive airway pressure, volume ventilation, assured volume ventilation (AVAPS, iVAPS) ventilation, and other NIV modes; appreciate types of interface
Understand principles of titration of therapy with sleep studies and arterial blood gas measurement
Recognise the concepts of compliance and adherence
Assessment of compliance and reasons for poor and good compliance
Understand indications for tracheostomy ventilation and who to refer for this
Understand NIV may have a palliative role, and importance of palliative therapy
Use of advance directives in end-stage diseases Module 18: Asthma/COPD and sleep Prevalence of SDB in asthma and COPD
Appraise symptoms, clinical presentation, pathophysiology and treatment of asthma, COPD
Relate the influence of comorbid respiratory disorders on breathing during sleep
Appreciate impact of drug therapy on sleep quality
Understand role of CPAP therapy in overlap syndrome (COPD+OSAHS) and asthma Module 19: Endocrine and metabolic disorders and SDB Appreciate increased prevalence of OSAHS in endocrine disorders (e.g. hypothyroidism), acromegaly metabolic disorders (e.g. diabetes mellitus, metabolic syndrome and renal failure)
Understand impact of treatment of OSAHS on underlying endocrine/metabolic disorder Module 20: Non-respiratory sleep disorders Consider presence of non-respiratory sleep disorders and referral for sleep specialist assessment Insomnia: Recognise primary and secondary insomnia, management techniques including role of cognitive behavioural therapy and medication
Recognise presence of insomnia in some OSAHS phenotypes and its impact on implementation and adherence with therapy, e.g. CPAP
Other conditions to be aware of include restless leg syndrome
Narcolepsy, benign idiopathic hypersomnolence, parasomnias and associated conditions
Recognise which patients to refer for further investigation Module 21: Assessment of excessive sleepiness Understand the principles of sleep questionnaires, sleep diary, Multiple Sleep Latency Test, Maintenance of Wakefulness Test, Osler wake test in assessing excessive daytime somnolence in respiratory and non-respiratory sleep conditions, their advantages, imitations, and who to refer for these Module 22: Circadian disorders Understand principles of circadian rhythm and impact on sleep wake cycle across age range
Appreciate impact of circadian disruption such as shift work and jet lag
Understand interaction between shift work and SDB
Be aware of other circadian disorders such as delayed and advance sleep phase disorder
Appreciate role of interventions such as melatonin and bright light therapy Actigraphy Understand who to refer for actigraphy (and pros and cons of this investigation) Module 23 Appreciate the medico-legal, societal and economic impact of respiratory sleep disorders, including implications of sleep disorders on driving and occupation
OSAHS: obstructive sleep apnoea–hypopnoea syndrome; ASV: adaptive servo-ventilation; NIV: noninvasive ventilation; AVAPS: average volume-assured pressure support; iVAPS: intelligent volume-assured pressure support.
