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
