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Curriculum standards

Knowledge guides

LG13: Sleep-related breathing disorders

Key presentations and conditions

Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.

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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 thelp manage patients with these presentations and conditions.

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Epidemiology, pathophysiology, and clinical sciences

Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.

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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 tinterpret the reported results of each investigation or procedure.

Advanced Trainees will know how texplain the investigation or procedure tpatients, families, and carers, and be able texplain procedural risk and obtain informed consent where applicable.

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Important specific issues

Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management and integrate these intcare.

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Presentations
  • Apnoeas / Gasping in sleep
  • Behavioural and learning problems
  • Cognitive impairment
  • Excessive sleepiness
  • Headaches
  • Impaired growth / failure thrive
  • Increased work of breathing
  • Mood changes
  • Poor concentration:
    • cognitive impairment
    • mood changes
  • Poor sleep quality
  • Snoring
  • Sudden waking with shortness of breath
Conditions
  • Sleep apnoea:
    • central
    • obstructive
    • treatment – emergent central sleep apnoea, such as continuous positive airway pressure (CPAP) inducing central apnoea
  • Sleep hypoventilation disorders
  • Sleep-related hypoxemia disorders

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • conduct an appropriate examination
  • consider the impact of illness and disease on patients and their quality of life when developing a management plan
  • establish a differential diagnosis
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • plan and arrange appropriate investigations
  • recognise the clinical presentation
  • take a comprehensicve clinical history
Manage
  • involve multidisciplinary teams
  • prescribe therapies tailored tpatients’ needs and conditions
  • provide evidence-based management
  • recognise potential complications of disease and its management, and initiate preventative strategies
Consider other factors
  • consider age-appropriate treatment options based on maturity, and mental understanding
  • identify individual and social factors and the impact of these on diagnosis and management
Conditions
  • Central sleep apnoea due high-altitude periodic breathing
  • Complex sleep apnoea
  • Congenital central alveolar hypoventilation syndrome
  • Late onset central hypoventilation with hypothalamic dysfunction, such as ROHHAD
  • Idiopathic central alveolar hypoventilation
  • Primary central sleep apnoea

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • conduct an appropriate examination
  • consider the impact of illness and disease on patients and their quality of life when developing a management plan
  • establish a differential diagnosis
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • plan and arrange appropriate investigations
  • recognise the clinical presentation
  • take a comprehensicve clinical history
Manage
  • involve multidisciplinary teams
  • prescribe therapies tailored tpatients’ needs and conditions
  • provide evidence-based management
  • recognise potential complications of disease and its management, and initiate preventative strategies
Consider other factors
  • consider age-appropriate treatment options based on maturity, and mental understanding
  • identify individual and social factors and the impact of these on diagnosis and management
  • Assessment process for oxygen therapy
  • Association of excessive sleepiness and other daytime symptoms with sleep-disordered breathing (SDB) syndromes
  • At-risk populations including children / adolescents with Down syndrome, Prader-Willi syndrome, neuromuscular diseases and cerebral palsy
  • Central role of adenotonsillectomy in treating the majority of children with obstructive sleep apnoea (OSA), including other indications, contraindications, and predictors of postoperative compromise
  • Clinical diagnosis and management of OSA complicated by respiratory failure and/or right heart failure (e.g., where SDB overlaps with other diseases, such as gross obesity or neuromuscular disease)
  • Clinical features of OSA and the differential diagnoses of OSA symptoms
  • Delivery systems and use of oxygen therapy in CPAP and non-invasive positive pressure ventilation (NIPPV)
  • Epidemiology of SDB
  • Explain the effects of age, gender, obesity, and race on prevalence of SDB, and recognise lesser known associations
  • Indications and application of non-invasive versus invasive ventilation for hypercapnic respiratory failure
  • Indications and guidelines for use of oxygen therapy related sleep breathing disorders
  • Lifestyle implications of SDB
  • Other treatment options for OSA, including:
    • CPAP
    • lifestyle changes, such as weight loss
    • oral appliances
    • positional therapy
    • upper airway or mandibular / maxillary surgery
  • Pathophysiology of SDB, including the different theories of causation of both central and OSA, and sleep hypoventilation syndromes
  • Physiology of ventilatory drive and gas exchange
  • Potential adverse effects of oxygen therapy
  • Public health implications of SDB, including impact on:
    • cardiovascular morbidity and mortality
    • cognitive performance, and emotional / psychological health
    • diabetes, metabolic syndrome, obesity, and other comorbid medical conditions
  • Relative strengths and weaknesses of full polysomnography (PSG) versus limited sleep study systems for diagnosing and managing OSA
  • Role of cough assist devices and sputum clearance in patients with neuromuscular weakness
  • Role of high-flow nasal cannula (HFNC) therapy, especially in CPAP and bi-level positive airway pressure (BPAP) intolerant groups
  • Role of PSG and limited sleep studies in optimising non-invasive ventilator settings, patient-machine synchrony, and triggering and mask interface
  • Role of sleep studies in diagnosis, with reference techniques used for assessing relative contributions from upper airway obstruction versus ‘pump’ failure, and monitoring hypoventilation with transcutaneous CO2
  • Role of sleep-related hypoventilation in acute and chronic hypercapnic respiratory failure, including neuromuscular / chest wall disease, reduced central drive, and diseases that chronically increase respiratory load, such as obesity
  • Role of telemonitoring and remote monitoring of NIPPV in patients with hypercapnic respiratory failure
  • Role of tracheostomy in airway management
  • Role played by common contributors SDB in a clinical context
  • Use of NIPPV in managing both acute and chronic hypercapnic respiratory failure
Investigations
  • Assess and recognise typical and atypical features of sleep-disordered breathing
  • Distinguish between different causes of hypoventilation syndromes
  • Evaluate clinical investigations and circumstances formulate individual treatment strategies
  • Indication and limitations of oximetry in patients with SDB breathing, including importance of sampling rates and averaging time
  • Interpret PSG findings in patients on ventilatory support and make recommendations about treatment settings, including interpretation of pressure determination studies and instructions on how make adjustments
  • Interpret PSG study data, including oximetry and TcCO2
  • Measure oxygen saturation and arterial oxygen tension
  • Perform the relevant neurological, respiratory, cardiovascular, and general physical examinations
  • Recognise the role of multidisciplinary teams in the management of patients with hypoventilation syndrome, such as dieticians, neurologists, nurses, and physiotherapists
  • Recognise when patients’ symptoms are not consistent with a sleep breathing disorder
  • Select and interpret appropriate respiratory function tests and radiology investigations
  • Take a thorough sleep history from patients, as well as bed environment
  • Use and interpret the International Classification of Sleep Disorders (ICSD-3)
Procedures
  • Apply oxygen delivery systems, such as nasal prongs and masks
  • Assist with the management of weaning from a ventilator with NIPPV
  • CPAP:
    • adjustment of device settings and cleaning procedures
    • monitor patient progress and usage / compliance
    • role of auto-titrating machines, such as automatic positive airway pressure (APAP) systems, and their limitations in paediatrics, especially in regard size of patients and tidal volumes
    • selection and application of nasal and full-face masks
    • trouble shooting treatment problems
    • use of chin straps
    • use of humidification in circuits
  • NIPPV:
    • adjustment of device settings with an understanding of various modes and settings, including:
      • pressure control (PC)
      • spontaneous timed (ST)
      • volume assure pressure support (VAPS), such as iVAPS and AVAPS
    • monitoring patient progress
    • selection and application of masks
    • troubleshooting treatment problems
    • use of humidification circuits in NIPPV
  • Oral appliance therapy
  • PSG
  • Apply a multidisciplinary approach in the management of sleep-related breathing disorders
  • Assess the contribution of SDB respiratory failure, with particular reference 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
  • Manage basic tracheostomy care, and refer for specialist assistance when indicated
  • Manage complications from hypercapnic respiratory failure, and/or heart failure
  • Manage CPAP side effects, and apply strategies timprove CPAP compliance
  • Manage the transition from in-hospital 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 another specialist is indicated
  • Weigh and synthesise history and examination information produce provisional and differential diagnoses, and formulate and undertake management plans