Respiratory and Sleep Science 1

Module details

Title

Respiratory and Sleep Science 1

Type

Specialist

Module code

SPS126

Credits

20

Requirement

Compulsory

Aim of this module

This rotation will enable trainees to perform a range of clinical diagnostic investigations undertaken to investigate disorders of or affecting the respiratory system, interact with patients and demonstrate safe, patient-centred practice. Trainees will be expected to build on the competence gained in the rotational module, explaining procedures to patients and gaining informed consent, enhancing and extending practical skills in undertaking diagnostic investigations, setting up and maintaining the equipment used, producing and interpreting results, and building their professional practice.

Competencies

#	Learning outcome	Competency	Action
# 1	Learning outcome 1	Competency Clinically interpret spirometry, bronchodilator response, lung volumes and gas transfer in a range of patient conditions and age groups.	Action View
# 2	Learning outcome 2,3,4	Competency Control infection risks in accordance with departmental protocols.	Action View
# 3	Learning outcome 2,3,4	Competency Minimise risks and hazards in compliance with health and safety policies.	Action View
# 4	Learning outcome 2,3,4	Competency Select suitable technology for type of investigation, choosing and adapting the appropriate diagnostic technique, patient position, machine settings and transducer for each patient.	Action View
# 5	Learning outcome 2,3,4	Competency Set up equipment ready for use for each type of investigation.	Action View
# 6	Learning outcome 2,3,4	Competency Obtain a suitably completed request form, greet patient, check patient ID and ensure that the patient’s identity is confirmed as correct and fully identified on each type of recording system.	Action View
# 7	Learning outcome 2,3,4	Competency Explain the procedure for each type of investigation to the patient and address any questions they may have relating to the procedure, including the process after the procedure and how the patient will be informed	Action View
# 8	Learning outcome 2,3,4	Competency Gain informed consent for each investigation.	Action View
# 9	Learning outcome 2,3,4	Competency Initiate a consultation, elicit information, clarify as necessary, summarise, and empathise and use active listening techniques while taking a patient history.	Action View
# 10	Learning outcome 2,3,4	Competency Treat patients in a way that respects their dignity, rights, confidentiality.	Action View
# 11	Learning outcome 2,3,4	Competency Take appropriate action to respond to the specific needs of the patient, as defined by department protocol.	Action View
# 12	Learning outcome 2	Competency Perform a method of challenge testing (direct or indirect) to obtain accurate test results for challenge testing.	Action View
# 13	Learning outcome 2	Competency Perform measurements of non- invasive respiratory muscle function to obtain accurate non-invasive respiratory muscle function measurements.	Action View
# 14	Learning outcome 3	Competency Perform actigraphy and analyse sleep diaries in the study of sleep and circadian accurate actigraphy recordings and sleep diaries.	Action View
# 15	Learning outcome 3	Competency Clinically interpret overnight pulse oximetry and limited multichannel recordings.	Action View
# 16	Learning outcome 4	Competency Instruct patients in the correct use of CPAP therapy and care of equipment, updating equipment records as appropriate.	Action View
# 17	Learning outcome 4	Competency Undertake a trial of CPAP therapy according to local and national protocols and download appropriate patient data from CPAP device.	Action View
# 18	Learning outcome 2,3,4	Competency Decontaminate equipment and leave in a suitable condition for reuse.	Action View
# 19	Learning outcome 5	Competency Produce a clear written report for challenge testing and assessment of non-invasive respiratory muscle function, interpreting the data and making recommendations for further investigation.	Action View
# 20	Learning outcome 7	Competency Carry out routine maintenance and calibration procedures on the equipment.	Action View
# 21	Learning outcome 7	Competency Complete equipment records accurately, and ensure that calibration records and fault reports are accurate, legible and complete for the equipment used for each type of investigation.	Action View

Assessments

You must complete:

• 5 case-based discussion(s)
• 5 of the following DOPS/ OCEs:

Perform a bronchial hyper reactivity study	DOPS
Perform measurements of maximal inspiratory and maximal expiratory mouth pressures and sniff nasal pressures	DOPS
Initiate CPAP in a patient with OSAHS including selection of appropriate interface and consumables	DOPS
Undertake an assessment of somnolence using the Epworth sleepiness score in a patient presenting with somnolence and a patient who is not reporting excessive somnolence	DOPS
Clinically interpret a set of full lung function tests in a patient with a chest wall deformity or neuromuscular disorder. Relate findings to the patients clinical history.	DOPS
Clinically interpret results of overnight oximetry or multichannel sleep study in a patient with obstructive sleep apnoea, including suggestions for further management	DOPS
Initiate actigraphy with a patient providing instructions for its use and for completing a sleep diary	DOPS
Clinically interpret data obtained from a bronchial hyper reactivity study providing suggestions for future management further investigations as appropriate	DOPS
Clinically interpret results of non invasive muscle function relating results to the patients clinical history	DOPS
Plot results of quality control data for full lung function testing equipment calculating coefficient of variation and relating findings to literature	DOPS
Explain the purpose and procedure of a muscle function study to a patient	OCE
Obtain a clinical history from a patient attending for assessment of bronchial hyper responsiveness	OCE
Describe the DVLA requirements with regards to driving in the presence of sleepiness to a patient attending a sleep clinic	OCE
Explain the results of a sleep study, consistent with significant obstructive sleep apnoea, to a patient discussing future management of the condition	OCE
Advise a patient on the appropriate use, including technique and frequency, of their inhaled medication	OCE

Learning outcomes

1. Clinically interpret spirometry, bronchodilator response, lung volumes and gas transfer in a range of patients, including those with more complex conditions. Such conditions may include, but not be limited to, patients with scoliosis, sensory limitations and learning disabilities, and neuromuscular compromised patients.
2. Plan, prepare and undertake a range of respiratory investigations, including challenge testing and non-invasive respiratory muscle function measurements.
3. Plan, prepare and undertake complete overnight pulse oximetry and limited multichannel recordings in a variety of patient conditions to obtain a range of subjective measurements of sleepiness in patients presenting with excessive daytime sleepiness.
4. Plan, prepare and undertake trials of the effectiveness of CPAP therapy to assess patients’ interface requirements and commence ventilation using appropriate settings.
5. Interpret data from challenge testing, non-invasive respiratory muscle function measurement and assessment of the response to respiratory pharmacotherapy.
6. Interpret data from overnight pulse oximetry and limited multichannel sleep recordings and produce high-quality reports, including recommendations for further management.
7. Carry out routine maintenance, calibration and quality assurance procedures on the equipment used to undertake spirometry, lung volumes, gas transfer, challenge testing and assessment of non-invasive muscle function, and assess the response to respiratory pharmacotherapy, measurement of overnight pulse oximetry and CPAP equipment.

Learning outcomes

1. Describe the change in lung function from birth to adulthood and old age and the adaptation of respiratory investigations in the young cohort.
2. Recall the anatomy, physiology and common pathophysiological changes of the respiratory system.
3. Describe the features of a normal chest X-ray and identify common abnormalities.
4. Discuss the public health issues that impact on patient’s commonly referred to a respiratory and sleep diagnostic service.
5. Recognise the role of health promotion, behavioural change models and the role of the healthcare scientist in supporting behavioural change.
6. Explain the importance and strategies for patient education and self-management of respiratory and sleep disorders.

Respiratory Science

7. Describe the full range of challenge tests described in the literature and the theory and application of intrinsic and extrinsic challenge testing, including the assessment of occupational disorders.
8. Explain and evaluate the methods for measuring airway function and mechanics and describe the role of respiratory mechanics (muscle and chest wall) and its assessment in clinical practice.
9. Explain and evaluate the role of respiratory muscle assessment in lung function testing and the patterns of results associated with respiratory muscle disorders.
10. Critically evaluate the role of advanced respiratory investigations and therapeutics in the investigation and management of patients with respiratory diseases.

Sleep Science

11. Explain the physiology and structure of sleep and the clinical aspects of normal human sleep, including the normal cardiorespiratory changes during sleep.
12. Discuss the structure and physiology of the larynx, pharynx and nasal airways, and their relevance to sleep maintenance and airway patency during sleep.
13. Describe and evaluate the tools, techniques and equipment used to assess and treat respiratory and neurological sleep disorders.
14. Explain the use of continuous positive airway pressure (CPAP) and non-invasive ventilation in the treatment of obstructive sleep apnoea or obesity hypoventilation syndromes.
15. Describe the theory, practice, parameters, advantages and limitations of non-ventilator techniques used in treating obstructive sleep apnoea/hypopnoea syndrome (OSAHS).
16. Discuss the effects and consequences of daytime sleepiness and sleep deprivation on whole body function, mental agility and memory consolidation, including the DVLA for fitness to drive regulations.

Pharmacology and Therapeutics

17. Explain the pharmacology, mode, sites and duration of actions of major drug classes used to treat respiratory disease and disorders of sleep.
18. Describe the effects of the common pain relief medications and of recreational drugs, including alcohol, on sleep.
19. Describe the process of drug deposition within the respiratory tract and how it is influenced by disease.
20. Describe the different delivery systems for respiratory medications.

Indicative content

Anatomy and function of respiratory and sleep systems

• Development, structure and function of the normal chest and lung
• Airways
  • Upper and lower, including larynx, pharynx and nasal airways
• Lungs
• Chest wall
  • Respiratory muscle function
  • Lung mechanics
• Gas exchange
  • Ventilation
  • Perfusion
  • Ventilation and perfusion matching
• Normal and abnormal flora of the respiratory tract
• The importance of infection as a cause of respiratory disease
• Acid-base balance
• Allergy
• Control of ventilation during wakefulness and sleep
• Nervous system
  • Central nervous system anatomy chemistry and sleep related physiology
  • Sympathetic and parasympathetic nervous system
  • Non-adrenergic non-cholinergic
  • Receptors
  • Drug/receptor interactions

Chest X-ray

• Normal X-ray
• Indications, limitations
• Common abnormalities

 

Drugs

• Bronchodilators; short and long acting
• Inhaled and oral corticosteroids
• Leukotriene receptor antagonists
• Immunosuppressants
• Antibiotics
• Cromoglycates

 

Pharmacology

• Pharmacokinetics
• Aerosol kinetics
• Toxicological responses to drugs
• Absorption, clearance and dissolution in the lung and the systemic circulation
• Roles of drug in the management of respiratory diseases and sleep disorders
• Respiratory drugs
• Other inhaled drugs
• Common non-respiratory drugs affecting the respiratory system

Delivery devices

• Metered dose inhalers
• Dry powder devices
• Volume holding devices/large volume spacers
• Nebulisers

 

Guidelines for assessing response to pharmacotherapy

• Protocols for the assessment of response to respiratory and sleep medication
• Advantages and disadvantages of techniques
• Interpretation of response to treatment

 

Public health issues in relation to respiratory disease and sleep disorders

 

Health promotion

• Smoking
• Alcohol
• Obesity
• Nutrition
• Social deprivation
• Occupation
• Exercise
• Mental health
• Sleep hygiene

Extrinsic challenge testing, including the assessment of occupational disorders

• Pathophysiology of hyper-responsiveness
  • Role of inflammatory cells
  • Changes in bronchial smooth muscle
  • Pathways that cause airways narrowing
  • Effect of pharmacological therapies
• Hyper-responsive disease processes
  • Causes of hyper-responsiveness
  • Changes in hyper-responsiveness
  • Hypersensitivity and hyperactivity
  • Effects of genetics and the environment
• Indications and contraindications for challenge testing
• Pharmacological challenges
  • Direct action
    • Methacholine
    • Histamine
  • Indirect action
    • Mannitol
    • Adenosine 5-monophosphate
    • Bradykinin
    • Tachykinins
    • Leukotrienes
    • Sodium metabisulphide
  • Physical challenges
    • Exercise
    • Cold and dry air
    • Mannitol
    • Hypertonic saline
    • Distilled water
    • Allergen
  • Pharmacology and/or mode of action of bronchoconstricting agents (to include all of those mentioned previously)
    • Chemical composition, particle size, pharmacokinetics
    • Receptors
      • Binding sites
    • Site of action
    • Side effects and drug interactions
    • Normal response to inhalation of agent
  • Delivery devices/equipment for the above methods
  • Calibration, verification, cleaning, maintenance, test protocols and guidelines
    • Dosimeter
    • Nebuliser
    • Yan
    • Inhaler
    • Cold air production unit
    • Bicycle/treadmill and dry air (cylinder/Douglas bag)
  • Measuring the response
    • End point
    • Remedial action in the event of patient distress
  • Hypersensitivity reactions and risk of anaphylaxis
  • Recovery
    • Use of bronchodilators
  • Advantages and disadvantages
  • Calculation of results (by formula and graph, where applicable)
    • PD20, PC20, PD15, PC15, PD35, and PC35 (related to appropriate test)
    • Dose response curves
    • % drop from baseline tests
  • Interpretation
  • Reporting the results
  • Application of above techniques in the determination of occupational hyper- responsiveness

Methods for measuring airway function and mechanics

• Bedside and clinic tests
  • Patient history and examination, e.g. obvious wasting, dyspnoea, impairment of cough, paradoxical movement of chest wall,
  • Imaging
  • Blood gases
  • Vital capacity
  • Flow volume curves
  • Lung volumes
  • Gas transfer
  • Overnight pulse oximetry

 

Role of respiratory mechanics (muscle and chest wall)

• Anatomy of the respiratory muscles, to include
  • principal inspiratory muscles and accessory muscles and outline of expiratory muscles
• Innervation and blood supply of muscles of respiration
• Lung mechanics, to include action of muscles during the breathing cycle and pressure changes during respiration
• Control of respiration, to include brain centres, reflexes and chemoreceptors
• Physiology of muscle contraction
• Load/capacity ratio of respiratory muscles
• Respiratory muscle fatigue
• Tension time index

Assessment of respiratory mechanics in clinical practice

• Mouth pressures
  • Maximal inspiratory and expiratory mouth pressures
  • Protocol for testing
  • Measurement technique and acceptability criteria
  • Normal values and reference equations
  • Advantages and disadvantages
  • Equipment
• Nasal pressures
  • Maximal inspiratory sniff pressures
  • Measurement technique and acceptability criteria
  • Normal values and reference equations
  • Advantages and disadvantages
  • Equipment
  • Sniff, Pdi (transdiaphragmatic pressure) and Poes (oesophageal pressure)
  • Method of measurement
  • Advantages and disadvantages
• Non-volitional tests
  • Phrenic nerve stimulation
  • Magnetic stimulation

• Others measurements of respiratory muscle function
  • Whistle mouth pressure
  • Cough gastric pressure
  • Respiratory muscle endurance
  • Inspiratory threshold loading
  • Respiratory muscle fatigue

Respiratory sleep diagnostics and therapy

• Assessment of sleep disordered breathing
  • Overnight oximetry
  • Multichannel sleep studies
  • Sleep questionnaires
• Principles of operation of equipment for the assessment of sleep- disordered breathing
  • Pulse oximetry and heart rate measurement
  • Multichannel sleep equipment to include measurements of airflow, chest and abdominal wall movement, position, leg movements and sound
• Use, delivery modes and available interfaces of CPAP in the treatment of sleep disordered breathing
  • Autotitrating vs fixed pressure
  • Comfort modes
  • NIV vs CPAP
  • Compliance data
• Interpretation of diagnostics sleep studies
  • National and international guidelines
  • AHI, ODI, pulse rises
  • Appreciate the indications for further investigations
  • Therapeutic thresholds
  • Lifestyle issues
• Assessment of therapeutic intervention
  • Compliance data and analysis
  • Assessment of sleep investigations and symptoms post treatment
• DVLA guidelines
  • Implications for category 1 and 3 driving
  • The role of the clinical scientist in the patients awareness of the DVLA guidance

Co-morbidities associated with obstructive sleep apnoea (OSA)

• Hypertension and cardiac arrhythmias
• Type II diabetes
• Depression
• Excessive daytime somnolence (EDS)
• Hypothyroidism

 

Factors leading to nocturnal hypoventilation +/– carbon dioxide retention

• Brainstem abnormalities
• Acquired secondary loss of ventilatory drive
• Chest wall abnormalities
• Tests for NIV assessment

 

Common respiratory and sleep conditions and associated pathophysiology

• COPD
• Asthma
• Pneumonia
• Pleural disease
• Lung cancer
• Respiratory failure
• Tuberculosis
• Pulmonary embolism and DVT
• Interstitial lung disease
• Obstructive sleep apnoea
• Obesity hypoventilation syndrome
• Cystic fibrosis
• Bronchiectasis
• Respiratory failure and cor pulmonale
• Pulmonary hypertension

Activities

• Identify a patient admitted with acute respiratory failure and, with permission, follow their admission, management and treatment and reflect on your learning from this experience.
• Take part in a multidisciplinary meeting and reflect on the way the multidisciplinary team contributes to the care of patients with diseases affecting the respiratory system or resulting in disorders of sleep.
• Attend a range of secondary care services and outpatient clinics that patients with respiratory diseases and/or sleep disorders may attend, and discuss the role of the multiprofessional team in the care of patients with respiratory disease and disorders of sleep. This may include medical/neurology/psychology outpatients, and physiotherapy.
• Attend a range of primary care and community clinics and contrast the services provided with those provided in secondary care.
• Visit relevant diagnostic departments whose investigations impact on the assessment, diagnosis and management of a patient with respiratory diseases and/or sleep disorders. This may include radiology, pathology service and genetics laboratories.