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.