Sleep and breathing disorders

1. Neuroanatomy and neurobiology of sleep

Regulation of the sleep-wake cycle
1. Basic neural processes and transmitters that control wakefulness, non-rapid eye movement and rapid eye movement sleep states
Sleep architecture in a normal adult
1. Ageing process from foetal life to old age affects the sleep cycle
2. Sex differences in sleep

2. Physiology and pathophysiology of sleep and breathing

Factors that control breathing during sleep and wakefulness
Ventilatory response to hypercapnia and hypoxaemia (including loop gain), arousal and the apnoea threshold
Molecular mechanisms of hypercapnia and hypoxemia e.g. master regulators and signalling pathways involved
The pathophysiological concept of upper airway obstruction, arousability, muscle responsiveness, and loop gain
1. Functional anatomy of the upper airway
2. Morphologic and functional changes of upper airway muscles
3. Arousal threshold
Pathophysiology of central sleep apnoea (CSA)
1. Hypercapnic and non-hypercapnic CSA
2. Chemoresponsiveness
3. Apnoea threshold
Hypoventilation disorders
1. Chemoresponsiveness
2. Influence of respiratory mechanics and ventilation
  1. Sleep-related changes in respiratory mechanics in the aetiology of nocturnal hypoventilation
Differences in physiology and pathophysiology of sleep and breathing in the elderly and differences between sexes

3. Cardiovascular and homeostatic mechanisms and sleep

4. Physiology of arterial blood gas (ABG) and the acid-base status

Utility of ABG, capillary blood gas and venous blood gas

Diagnosis of A-B disorders: Henderson-Hasselbalch equation and the relationship between partial pressure of oxygen (PO₂), partial pressure of carbon dioxide (PCO₂), pH and bicarbonates (HCO3)
A-B disorders: importance of the D(A-a) difference, fraction of inspired oxygen (FiO2), the alveolar gas equation and measuring oxygen shunts

5. Definition of sleep-disordered breathing (SDB)

Obstructive sleep apnoea (OSA), CSA (idiopathic, high altitude periodic breathing, Cheyne-Stokes respiration, CSA in non-cardiac medical conditions, Treatment Emerged Central Sleep Apnoea (TECSA)),obesity hypoventilation syndrome (OHS), nocturnal hypoventilation, upper airway resistance syndrome,
Epidemiology of OSA, CSA and OHS
Clinical phenotypes of OSA (e.g. COMISA, females) and CSA and their relationship to the underlying pathophysiology

6. Assessment of the patient

Sleep history including:
1. Sleepiness and fatigue
2. Insomnia
3. Poor sleep quality
4. Nocturnal choking and gasping
5. Snoring
6. Morning headaches
7. Impotence
8. Low mood or labile mood
9. Cognitive impairment
10. Differential diagnosis of sleepiness and insomnia, g. consider lifestyle choices, sleep hygiene and medication
Signs
1. Clinical examination of the upper airway, nasal obstruction, tonsils and adenoids
2. Craniofacial disorders
3. Hypothyroidism
4. Obesity
Comorbidities, e.g. COPD, Interstitial Lung Diseases (ILD’s), chest wall disease, neuromuscular or neurological disorders, cardiovascular disease and endocrine or metabolic disorders

7. Evaluation of the impact of symptoms and establishment of the pre-test probability of SDB

Usage of questionnaires: Screening (NOSA, STOP-BANG score, Berlin questionnaire), sleepiness (Epworth sleepiness scale), QoL (SF-36, FOSQ, PHQ-9), insomnia (ISI, AIS)
Two-stage screening with limited sleep tests like nocturnal oximetry to further increase pre-test probability
Identification of high-risk patients, e.g. those with severe sleepiness, insomnia, unstable cardiac disease, nocturnal arrhythmia or baseline hypoxaemia or those who drive or have another occupational risk

8. Diagnosis of respiratory sleep disorder

Methodology of different sleep tests (oximetry, respiratory polygraphy and full polysomnography (PSG), home versus in-laboratory-based sleep studies)
Limitations of different sleep tests
Appreciation of which patients to refer for PSG, g. those with an unclear diagnosis on respiratory polygraphy, with comorbidities, a poor treatment response or a suspected non-respiratory sleep disorder such as narcolepsy or restless leg syndrome
Identification of cases that require further specialised examinations, g.ear-nose-throat (ENT) review of the upper airway
Review of cardiovascular, respiratory and metabolic disorders often associated with OSA
High cardio-metabolic and driving risks associated with untreated OSA
Value of making lifestyle improvements including weight loss, exercise, adherence to drug treatment for hypertension or diabetes, smoking cessation and alcohol reduction

10. OSA management

Distinguish mild, moderate and severe cases of OSA from normal results and upper airway resistance syndrome integrating additional biosignals to apnoea hypopnea index (AHI) parameters such as nocturnal hypoxic burden, or indices of autonomic dysfunction, etc
Integrating the multicomponent grading system for OSA: the Baveno classification
Lifestyle interventions including weight loss, exercise, smoking cessation, alcohol reduction, avoidance of night sedation and sensible sleep hygiene measures
Role of ENT intervention
Role and types of mandibular advancement splints and other oral devices
Definition of positional sleep apnoea and the role of positional devices
Other non-CPAP therapies: muscles rehabilitation and pharmaceutical approaches
Indications for positive airway pressure (PAP) therapy
Differences between fixed level CPAP, variable (automatic) CPAP (automatic positive airway pressure (APAP)), and bi-level positive pressure (BPAP) therapy
Identification of patients to refer for these interventions depending on local pathways
PAP-related side effects such as interface problems, airway drying and sleep disturbance
Issues leading to poor adherence and how these may be addressed
TECSA: identify OSA patients at high risk of developing TECSA, how to diagnose and treat
Treatment of comorbidities
Different ways of monitoring positive pressure therapy: clinic visits, data downloads from devices and telemonitoring
Follow-up including assessment of the efficacy of therapy in controlling OSA and also the impact on comorbidities and health-related quality of life
Importance of explaining the rationale and likely outcomes of treatment to patients and of providing advice about medico-legal aspects such as driving
Awareness and importance of following local guidelines on the diagnosis and management of OSA

11. CSA

Classification of the aetiology of CSA: idiopathic, heart failure-related and induced by a cerebrovascular cause (e.g. a cerebrovascular accident, opioid or other drug use and high altitude)
Differential symptoms and signs of OSA and CSA
Pathophysiology of different types of CSA
Recognition of which patients to refer for sleep studies

12. Management of CSA

Impact of CSA on underlying pathology
CSA in chronic heart failure
Importance of optimising therapy for heart failure
Role of CPAP in specific patients including those with mixed OSA and CSA
Adaptive servo-ventilation use in heart failure patients with reduced and with preserved left ventricular ejection fraction
Other forms of CSA
CPAP or adaptive support ventilation (ASV) in patients with opioid-induced SDB
Awareness of trials in progress to assess O2 therapy in patients with CSA and the further role of ASV

13. OHS

Pathophysiology
Symptoms, clinical presentation and classification
Consequences (vascular disease, polycythaemia and cor pulmonale)
Indications for CPAP and non-invasive ventilation (NIV); application or supervision of a mask and interface
Description of the illness and risk of obesity and offer advice about how to decrease body mass index through physical activity, training and diet
Pharmacotherapy as add on in weight reduction programmes
Role of bariatric surgery, preoperative assessment surgical risk and postoperative management in OHS patients

14. Neuromuscular disease

Neuromuscular diseases that cause respiratory failure
Neuromuscular conditions associated with respiratory muscle weakness
Methods to assess respiratory muscle weakness: spirometry, mouth pressures, peak cough flow, sniff inspiratory pressure, diaphragm electromyographic studies and and diaphragmatic ultrasound
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
Perioperative assessment and management of neuromuscular disease patients

16. Chronic respiratory failure

17. NIV

Treatment of ventilatory failure
Types of positive pressure ventilation and different modes,g. bi-level positive airway pressure, volume ventilation, assured volume ventilation (average volume assured pressure support and intelligent volume assured pressure support) and other NIV modes
Principles of therapy titration with sleep studies and ABG measurement
Monitoring of NIV adherence and concepts of its improvements
Assessment of compliance and reasons for poor and good compliance
Indications for tracheostomy ventilation and which patients to refer for this
Potential role of NIV in palliative care and the importance of palliative therapy
Use of advance directives in end-stage diseases

18. Asthma/COPD/ILD and sleep

Prevalence of SDB in asthma COPD and ILD’s
Symptoms, clinical presentation, pathophysiology and treatment of asthma, COPD restrictive and ILD’s
Influence of comorbid respiratory disorders on breathing during sleep
Impact of drug therapy on sleep quality
Understand the role of PAP therapy in overlap syndrome (COPD-OSA) asthma and ILD’s

19. Endocrine and metabolic disorders and SDB

20. Non-respiratory sleep disorders

Consideration of non-respiratory sleep disorders and identify which patients to refer for further investigation
Insomnia
1. Primary and secondary insomnia and management techniques including the role of cognitive behavioural therapy for insomnia and medication
2. Presence of insomnia in some OSA phenotypes (e.g., COMISA) and its impact on comorbidities, on the choice of and adherence to therapy
Other conditions:
1. Restless leg syndrome
2. Narcolepsy, benign idiopathic hypersomnolence, parasomnias and associated conditions

21. Assessment of excessive sleepiness

Principles of the tests for assessing excessive daytime somnolence in patients with respiratory and non-respiratory sleep conditions, their advantages, their limitations and which patients to refer for these, including:

Sleep questionnaires
Sleep diary
Multiple Sleep Latency Test (MSLT)
Maintenance of Wakefulness Test (MWT) OSLER wake test

22. Circadian disorders

Principles of circadian rhythms and their impact on the sleep-wake cycle across a range of ages and influence of sex
Molecular basis of the circadian rhythm and its dysfunction in disease
Impact of circadian disruption such as shift work and jet lag
Interactions between work and SDB e.g. shift work
Other circadian disorders such as delayed and advanced sleep phase disorders
Role of interventions such as melatonin and bright-light therapy
Identification of patients to refer for actigraphy and the advantages and disadvantages of this investigation

News in sleep and breathing disorders

Activities and events

Respiratory sleep certified training programme

Learning resources

CPD framework

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