Curriculum standards
Knowledge guides
LG 13: Sleep-related breathing disorders
Key presentations and conditions
Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.
Less common or more complex presentations and conditions
Advanced Trainees will understand these presentations and conditions.
Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.
Epidemiology, pathophysiology, and clinical sciences
Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.
Investigations, procedures, and clinical assessment tools
Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.
Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.
Important specific issues
Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management and integrate these into care.
Presentations
- Awaking gasping or choking
- Cognitive impairment
- Driving or occupational risk
- Early morning headaches
- Excessive daytime sleepiness
- Impaired sleep quality
- Loud snoring
- Mood changes
- Poor concentration
- Witnessed apnoea
Conditions
- Familiarity with the International Classification of Sleep Disorders (ICSD-3)
- Isolated snoring
- Sleep apnoea:
- central
- obstructive
- treatment-emergent central sleep apnoea
- Sleep hypoventilation disorders, such as obesity hypoventilation
- Sleep-related hypoxemia disorders
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients’ needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Conditions
- Central sleep apnoea due to high-altitude periodic breathing
- Congenital central alveolar hypoventilation syndrome
- Idiopathic central alveolar hypoventilation
- Primary central sleep apnoea
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Hypoventilation
- Indications and application of non-invasive ventilation (NIV) versus invasive ventilation for hypercapnic respiratory failure
- Physiology of ventilatory drive and gas exchange
- Role and pathophysiology of sleep-related hypoventilation in acute and chronic hypercapnic respiratory failure, including obesity, neuromuscular / chest wall disease, reduced central drive, and diseases that chronically increase respiratory load, such as chronic obstructive pulmonary disease (COPD)
- Role of cough assist devices and sputum clearance in patients with neuromuscular weakness
- Role of tracheostomy in airway management
- Use of bilevel non-invasive positive pressure ventilation in managing both acute and chronic hypercapnic respiratory failure
Oxygen therapy
- Assessment process for oxygen therapy
- Delivery systems and use of oxygen therapy in continuous positive airway pressure (CPAP) and NIV
- Indications and guidelines for use of oxygen therapy related to sleep breathing disorders
- Potential adverse effects of oxygen therapy
Sleep apnoea
- Awareness of new technologies in the management of obstructive sleep apnoea (OSA)
- Central role of CPAP in treating OSA, including side effects, factors affecting compliance, and strategies for improving compliance with treatment
- Clinical diagnosis and management of OSA complicated by respiratory failure and/or right heart failure, such as where sleep-disordered breathing (SDB) overlaps with other diseases, such as gross obesity or COPD
- Clinical features of OSA and the differential diagnoses of OSA symptoms
- Epidemiology of SDB and effects of age, gender, obesity, and race on prevalence of SDB, and recognise lesser-known associations
- Occupational and lifestyle implications of SDB
- Pathophysiology of central sleep apnoea and the different types, such as:
- Cheyne–Stokes respiration
- hypercapnic
- non-hypercapnic
- Pathophysiology of OSA and the different phenotypes, as well as its impact upon treatment choice
- Public health implications of SDB, including impact on:
- cardiovascular morbidity and mortality
- diabetes, metabolic syndrome, obesity, and other comorbid medical conditions
- driving, work performance, and emotional / psychological health
- Role of upper airway surgery in the management of snoring and OSA
- Understand the concept of loop gain
Investigations
- Evaluate clinical investigations and circumstances to formulate patients’ individual treatment strategies
- Interpret polysomnography (PSG) findings in patients on ventilatory support, and make recommendations about treatment settings
- Interpret PSG raw data, including:
- scoring respiratory events
- sleep staging and arousals
- oximetry and PTtcCO2 monitoring
- Recommend participation in PSG reporting concordance program at training site
- Select and interpret appropriate respiratory function tests and radiology investigations
- Understand the definition of hypoventilation during wakefulness and sleep (including NREM and REM), how to distinguish the different types of hypoventilation, and how to assess with PSG
- Understand new technology for measuring sleep, such as wearables and nearables, and their strengths and weaknesses
- Understand the different types of sleep studies (level 1 to 4), and the strengths and weaknesses of each
- Understand the role of PSG and limited sleep studies in optimising NIV settings, patient-machine synchrony, and triggering and mask interface
- Understand the role of telemonitoring and remote monitoring of NIV in patients with hypercapnic respiratory failure
Procedures
- Assist with weaning from invasive to NIV
- Apply oxygen delivery systems, such as nasal prongs, masks, and high-flow circuits
- CPAP and auto-titrating positive airway pressure (APAP):
- adjustment of device settings
- interpretation of machine data
- prescribe CPAP based on ambulatory APAP titration
- selection and application of nasal and full-face masks
- troubleshooting treatment problems
- use of chin straps
- use of humidification circuits
- Non-invasive bilevel positive-pressure ventilation:
- adjustment of device settings
- interpretation of machine data
- monitoring patient progress
- selection and application of masks
- troubleshooting treatment problems
- use of humidification circuits
- Oral appliance therapy
- Apply a multidisciplinary approach in the management of sleep-related breathing disorders, recognising the roles of other medical, nursing, and allied health professionals
- Assess the contribution of SDB to respiratory failure, with particular reference to nocturnal hypoventilation
- Explain the public health implications of the high prevalence of SDB in a local context (hospital / local community) and on a national / international scale
- Identify Australian and Aotearoa New Zealand ‘Fitness to Drive’ guidelines and local driver licensing requirements, and assess and advise patients with SDB regarding fitness to drive
- Manage basic tracheostomy care, and refer for specialist assistance when indicated
- Manage complications from hypercapnic respiratory failure and/or heart failure
- Manage the transition from in-hospital to home care, applying knowledge of available support services and home care teams
- Recognise the role of community, rehabilitation, and palliative care services in the management of patients with chronic respiratory failure
- Recognise when referral to another specialist is indicated
- Synthesise history and examination to produce provisional and differential diagnosis, and formulate and undertake management plans
- Understand current available weight loss strategies