Presentations
- Acute hypercapnia
- Acute-on-chronic and chronic hypercapnia
- Chest pain
- Chest tightness
- Dyspnoea
- Hypoxaemia
- Nocturnal hypoventilation
- Orthopnoea
- Sleep-disordered breathing
- Snoring
- Somnolence
- Sputum production
- Tachypnoea
- Wheeze
Conditions
- Acute pulmonary oedema and left-heart failure
- Central sleep apnoea syndromes
- Chest wall disorders, including kyphoscoliosis
- Chronic obstructive pulmonary disease
- Decompensation
- High spinal cord injuries
- Neuromuscular diseases, including motor neurone disease
- Obesity hypoventilation syndrome
- Obstructive sleep apnoea
- Sedative / Drug-induced hypoventilation
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 disorders of ventilation:
- brainstem disease
- cerebral palsy
- congenital central alveolar hypoventilation, and other disorders of ventilatory control
- encephalitis
- hypothyroidism
- paraneoplastic phenomena
- stroke
- Respiratory muscle disorders:
- cervical spine injury
- Guillain-Barré syndrome
- muscular dystrophy
- myasthenia gravis
- myotonic dystrophy
- phrenic nerve or diaphragmatic palsy
- poliomyelitis
- polymyositis
- Thoracic cage disorders:
- ankylosing spondylitis
- chest trauma, flail chest
- pectus excavatum
- thoracoplasty
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
- Pathophysiological mechanisms of hypercapnic respiratory failure, and apply these towards obtaining diagnoses, and tailoring personalised treatment options and prescriptions:
- comorbid role of left heart failure in contributing towards acute hypercapnia
- differentials for normal versus high A-a gradient in workup of undifferentiated hypercapnia
- Recognise the often-multifactorial contributors towards acute hypercapnic respiratory failure, and the significant morbidity and mortality associated with this presentation
Core investigations
- Blood gas analysis, including interpretation of arterial, venous, and capillary samples
- Capnography, including exhaled and transcutaneous samples
- Chest x-ray
- CT scan, including high resolution protocols
- Diagnostic sleep studies (level 1-3 sleep studies)
- Fluoroscopy for diaphragmatic assessment
- Lung function tests:
- cough peak flow
- gas transfer assessment
- plethysmography
- respiratory muscle testing, such as maximal inspiratory and expiratory pressures, sniff nasal inspiratory pressures
- spirometry (erect and supine)
- Oximetry, including continuous / overnight studies (level 4 sleep study)
- Positive airway pressure device downloads
- Relevant serological biomarkers
Investigations (understand basics for interpretation)
- Electrocardiography and Holter monitoring
- Lumbar puncture
- Maintenance of wakefulness tests and mean sleep latency tests
- MRI
- Nerve conduction studies / electromyography
- Pleural / Diaphragmatic ultrasound
- Polysomnography, including positive airway titration studies
- Relevant histological biomarkers (e.g., muscle biopsy)
- Trans-thoracic echocardiogram
- Appreciate novel therapies in the area of motor neurone disease and muscular dystrophies
- Appreciate the circuitry for acute and chronic non-invasive ventilation (NIV), with appreciation of the role of correct mask interface and controlled leak in delivering effective therapy
- Appreciate the role of multidisciplinary teams (e.g., respiratory failure service, MND team, sleep trained physicians) and additional subspecialties (e.g., neurology, palliative care) in providing comprehensive care to patients with hypercapnic respiratory failure
- Be able to identify the significant factors contributing towards undifferentiated or first presentation of acute hypercapnia, and integrate all into the management approach
- Differentiate the need for acute only versus chronic NIV, based on evidence base (e.g., chronic obstructive pulmonary disease, obesity hypoventilation)
- Identify bulbar involvement in motor neurone disease, and approach management accordingly
- Identify patients suitable for invasive ventilation, non-invasive ventilation and supportive care
- Identify poor NIV tolerance or suboptimal comfort, and troubleshoot to improve patient experience and usage
- Referral to sleep trained physicians for patients with complex respiratory failure and non-respiratory sleep disorders
- Utilise blood gas analysis, oximetry, capnography, polysomnography, and lung function tests in determining suitability of commencing NIV for a spectrum of respiratory failure disorders
