Respiratory and Sleep Science 2

Module details

Title

Respiratory and Sleep Science 2

Type

Specialist

Module code

SPS127

Credits

30

Requirement

Compulsory

Aim of this module

This module provides trainees with the knowledge that underpins the third year specialist module in Respiratory and Sleep Science and gives trainees the tools to undertake learning in the workplace. 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 earlier 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 1,2,3,5	Competency Control infection risks in accordance with departmental protocols.	Action View
# 2	Learning outcome 1,2,3,5	Competency Minimise risks and hazards in compliance with health and safety policies.	Action View
# 3	Learning outcome 1,2,3,5	Competency Select suitable technology for each type of investigation, choosing and adapting the appropriate diagnostic technique, patient position, machine settings and transducer for each patient.	Action View
# 4	Learning outcome 1,2,3,5	Competency Set up equipment ready for use for each type of investigation.	Action View
# 5	Learning outcome 1,2,3,5	Competency Obtain a suitably completed request form, greet the 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
# 6	Learning outcome 1,2,3,5	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 of the results.	Action View
# 7	Learning outcome 1,2,3,5	Competency Gain informed consent for each investigation/consultation.	Action View
# 8	Learning outcome 1,2,3,4,5	Competency Initiate a consultation, elicit information, clarify as necessary, summarise, and empathise and use active listening techniques while taking a patient history.	Action View
# 9	Learning outcome 1,2,3,5	Competency Treat patients in a way that respects their dignity, rights, privacy and confidentiality.	Action View
# 10	Learning outcome 1,2,3,4,5	Competency Take appropriate action to respond to the specific needs of the patient, as defined by department protocol.	Action View
# 11	Learning outcome 1,2,3,5	Competency Assess the patient’s suitability for the proposed investigation and obtain a blood gas sample suitable for the assessment of blood gas status using a recognised technique.	Action View
# 12	Learning outcome 1	Competency Analyse and interpret a range of blood gas results and take appropriate action with the required degree of urgency in a range of conditions, including normal, Type 1 and Type 2 respiratory failure.	Action View
# 13	Learning outcome 1	Competency Identify requirements for long-term oxygen therapy, including ambulatory, and undertake assessments in accordance with national guidelines, titrating oxygen according to patient requirements and clinical indications.	Action View
# 14	Learning outcome 1	Competency Complete appropriate documentation based on the results of the assessment undertaken and the patient’s clinical needs, and identify further investigations and/or future management plans.	Action View
# 15	Learning outcome 2	Competency Assess the patient and undertake cardiopulmonary exercise testing using an appropriate protocol in patients with respiratory, vascular and cardiac disease.	Action View
# 16	Learning outcome 2	Competency Record results of cardiopulmonary exercise testing accurately in an appropriate format and analyse and technically interpret full cardiopulmonary exercise tests.	Action View
# 17	Learning outcome 3	Competency Assess the patient, determine the appropriate settings and obtain accurate baseline measurements of NIV therapy where appropriate. Initiate appropriate NIV therapy and monitor clinical status.	Action View
# 18	Learning outcome 4	Competency Undertake consultations with patients to explain and agree therapeutic strategies for the management of their sleep conditions.	Action View
# 19	Learning outcome 5	Competency Perform polysomnographic procedures in patients with various sleep disorders, in accordance with recognised protocol, scoring and technically interpreting each procedure.	Action View
# 20	Learning outcome 5	Competency Apply the polysomnography practice to Multiple Sleep Latency Test (MSLT) or Maintenance of Wakefulness Test (MWT) testing in accordance with established American Academy Sleep Medicine (AASM) guidelines.	Action View
# 21	Learning outcome 1,2,3,5	Competency Decontaminate equipment and leave in a suitable condition for reuse.	Action View

Assessments

You must complete:

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

Perform a blood gas assessment using either arterial blood gas analysis or ear lobe capillary sampling	DOPS
Perform a long term oxygen therapy assessment on a patient in Type 2 respiratory failure	DOPS
Perform a long term oxygen therapy assessment on a patient in Type 1 respiratory failure	DOPS
Perform an ambulatory oxygen assessment in a patient who significantly desaturates on air	DOPS
Perform a full cardiopulmonary exercise test on a patient under investigation for respiratory symptoms	DOPS
Perform a full cardiopulmonary exercise test on a patient being assessed for fitness for surgical intervention	DOPS
Technically interpret results of a full cardiopulmonary exercise test	DOPS
Initiate non invasive ventilation NIV on a patient admitted to hospital with acute Type 2 respiratory failure	DOPS
Initiate NIV, in the outpatient setting, on a patient with chronic Type 2 respiratory failure	DOPS
Perform a full polysomnography on a patient with a respiratory sleep disorder	DOPS
Perform a full polysomnography on a patient with a nonrespiratory sleep disorder	DOPS
Provide a technical report on a full polysomnography study in a patient with a respiratory sleep disorder	DOPS
Provide a technical report on a full polysomnography study in a patient with a non respiratory sleep disorder	DOPS
Complete a home oxygen order form HOOF for a patient requiring long term oxygen therapy LTOT	OCE
Discuss the results of investigations with a patient requiring non invasive ventilation NIV. Describe the role of NIV and its implications to the patient and family.	OCE
Obtain consent from a patient requiring supplemental oxygen therapy	OCE
Obtain a history from a patient attending for initiation of NIV for chronic Type 2 respiratory failure	OCE
Prepare a patient for undertaking a full cardiopulmonary exercise test	OCE
Undertake a check of a resuscitation trolley ensuring effectiveness and appropriate stock levels	OCE

Learning outcomes

1. Perform and interpret assessments of blood gas status and identify the requirements for supplemental oxygen therapy.
2. Perform full cardiopulmonary exercise testing in the investigation of respiratory, vascular and cardiac disease.
3. Identify the requirement for and initiate non-invasive ventilation (NIV) in patients with both acute and chronic respiratory failure.
4. Discuss and agree management strategies for disorders of respiratory or sleep and demonstrate the communication skills required to discuss subjects that may be difficult and work with patients.
5. Perform, analyse and technically report polysomnographic sleep investigations in patients referred to a sleep service.

Learning outcomes

1. Describe the structure, function, mechanics and control of the cardiorespiratory system and discuss the pathophysiology of common causes of respiratory failure.
2. Describe and critically evaluate the role of field exercise testing in the assessment for ambulatory oxygen and the role of short- and long-term oxygen therapy in the treatment of disease.
3. Describe the role of non-invasive ventilation in the treatment of acute and chronic respiratory failure in a range of disorders.
4. Discuss the range of ventilators available for non-invasive ventilation and compare and contrast their modes of action and functions.
5. Discuss the principles underpinning the assessment and monitoring of patients receiving non-invasive ventilation in the acute and chronic setting.<
6. Explain the methods of measuring physiological changes during exercise and the physiological adaptations that occur with exercise training.
7. Compare and contrast the range of exercise tests available and their clinical application, including the application of cardiopulmonary exercise testing in the assessment of limitations to exercise.
8. Discuss the application of interpretation strategies to respiratory investigations.

Sleep Science

9. Discuss the physiology and structure of sleep throughout life and the pathophysiology of non-respiratory sleep disorders, relating changes in physiology due to neurodegenerative sleep disorders
10. Discuss the use and principles of sleep polysomnography in the assessment of sleep and disorders of sleep and the role of video-polysomnographic recording in differential diagnosis.
11. Discuss the use and principles of neurophysiological recording equipment and identification of the characteristics of the normal waveforms/variation, in the awake and sleep EEG.
12. Describe the normal structure and function and chemistry of the neural pathways relating to sleep and wakefulness, circadian rhythm generation and its interaction with body function.
13. Discuss the use of psychological tools to treat hyper and hypo-somnolence.
14. Define the uses and limitations of tests of vigilance and sleep maintenance.

Indicative content

Structure, function, mechanics and control of the cardiorespiratory system

• Blood gas physiology
• Acid-base balance
• Ventilation
• Gas transport and exchange

Oxygen therapy and assessment

• Principles and role of short- and long-term oxygen therapy in the treatment of disease
• Evidence base for oxygen prescription and assessment of patients for long- term oxygen therapy
• Process for ordering oxygen therapy
• National guidelines for assessment of long-term oxygen therapy and ambulatory oxygen in adults
• Protocols for the performance and assessment for oxygen therapy in adults
• Methods of oxygen delivery and interfaces
• Ordering of oxygen therapy using home oxygen order form (HOOF)
• Long-term follow-up of patients using oxygen therapy
• The use of hypoxic challenge in patients wishing to fly

Cardiorespiratory responses to exercise

• Normal response to exercise, to include:
  • muscles – structure, metabolism, substrates
  • cardiac response to exercise – control of response, cardiac frequency and stroke volume, cardiac output
  • ventilatory response to exercise – control of response, breathing frequency, tidal volume, ventilation perfusion ratio during exercise
  • circulatory response to exercise – redistribution of blood flow to muscles
• Limitations to exercise subjects in normal subjects
• Exercise response in disease, to include:
  • cardiac and respiratory (obstructive and restrictive disease) – patterns of response, major limiting factors and assessments of symptoms
  • other disorders – obesity, unfitness, malingering, deconditioning
  • contraindications to exercise testing and safety during exercise tests
  • recognition of indications to terminate the exercise test prematurely, e.g. symptoms
• Common protocols used in cardiopulmonary exercise testing
• Uses and limitations of cardiopulmonary exercise testing and its value in clinical practice

Respiratory failure

• Assessment of respiratory failure and control
• Differentiation of Type 1 and Type 2 respiratory failure
• Acute and chronic respiratory failure
• Metabolic disorders
• Treatment pathways for patients in respiratory failure
• Diagnostic procedures used in the assessment of patients with respiratory failure

 

Non-invasive ventilation

• Role of non-invasive ventilation in the treatment of acute and chronic respiratory failure in a range of disorders
  • Airway
  • Chest wall
  • Muscle disorders
• Clinical indications for NIV
  • Acute
    • Protocols for initiation and withdrawal
    • Monitoring
    • Requirements for invasive ventilation
  • Chronic
    • Assessment for domiciliary ventilation
    • Nocturnal and diurnal monitoring of patients for domiciliary ventilation
    • Long-term monitoring
• Modes of ventilation (positive and negative)
  • Pressure support
  • Volume support
  • Spontaneous Intermittent mechanical ventilation
• Interfaces
• Operational parameters
  • IPAP
  • EPAP
  • Respiratory rate
  • Rise time
  • Vt

Field exercise testing

• Indications for performing field exercise tests
  • Objective assessment of exercise capacity
  • Assessment of symptoms
  • Unexplained dyspnoea on exertion
  • Assessment of disability
  • Desaturation on exercise
  • Serial monitoring
  • Assessment for ambulatory oxygen
• Field exercise protocols
  • Equipment
  • How to decide the most appropriate protocol to use
  • Advantages and disadvantages of each protocol
  • Six-minute walk, incremental shuttle walk, endurance shuttle walk
  • Manual calculation of results and predicted values
• Measurements
  • Heart rate, oxygen saturation
  • Assessment of symptoms: Borg scale, Visual Analogue Scale, Rating of Perceived Exertion
  • Observation of full cardiorespiratory exercise tests
• Interpretation and reporting of results
  • Common patterns of results in disease: cardiac vs respirator disease
  • Symptoms
  • Obstructive vs restrictive lung disease

Full cardiopulmonary exercise testing

• Indications for performing full cardiopulmonary exercise tests
  • Assessment of symptoms
  • Differentiation of cardiac versus respiratory impairment
  • Unexplained dyspnoea
  • Assessment for surgery
• Exercise protocols
  • Maximal vs submaximal
  • Advantages and disadvantages
  • Cycle ergometer vs treadmill
  • How to decide on the most appropriate protocol
• Principals of equipment
• Gas analysis
• Volume measurement
• Blood gases
• Quality control and calibration
• Graphical representation of results
• Measurements
  • Ventilation and frequency
  • Oxygen uptake and carbon dioxide output
  • Heart rate and oxygen pulse
  • Respiratory exchange ratio
  • Oxygen saturation
  • Assessment of symptoms
• Exercise facilities
  • Health and safety requirements
  • BLS/ALS, resuscitation equipment and oxygen
• Concepts of interpretation of results
  • Graphs and flow charts
  • Common patterns of results in disease: cardiac vs respiratory
  • Symptoms
  • Breathing reserve
  • Cardiac reserve
  • Obstructive vs restrictive lung disease
  • Cardiac disease
  • Use of anaerobic threshold in interpretation

 

Interpretation

• Application of various respiratory tests in the confirmation of disease
• Awareness of clinical guidelines ,e.g. COPD, asthma
• Clinical report writing techniques
• The role of the respiratory physiologist in the multidisciplinary team

Lifestyle changes

• Smoking cessation strategies
• Exercise prescription
• Weight management
• Pulmonary rehabilitation

 

Sleep physiology

• Normal sleep and sleep throughout life, including in paediatrics, children, pregnancy and the elderly
• Theories for why we sleep and experimental evidence
• Circadian rhythm sleep/wake timing and distribution and its effect on other body systems
• Stages of sleep and their characteristics
• Melanopsin
• Melatonin
• Pineal gland
• Suprachiasmatic nucleus
• Genetics of circadian rhythms
• Sleep/wake areas of the brain
• Reticular activation system
• Brainstem, anterior and posterior hypothalamus
• Neurochemicals associated with sleep/wakefulness and their mechanisms of action
• Brain electrical activity during sleep, pyramidal cells in the cortex

Structure of sleep

• Normal sleep architecture
• Standard hypnogram
• Staging of sleep according to Retschaffen and Kales, as well as AASM characteristics of REM and non-REM sleep
• Sleep and other organs

Sleep disorders

• Clinical aspects of normal human sleep
• Phenomena including vertex sharp waves, sleep spindles, K complexes and positive occipital sharp transients of sleep (POSTs)
• Sleep deprivation and drug-induced sleep
• Different sleep stage scoring, including:
  • Rechtschaffen and Kales
  • AASM
• Parasomnias, insomnias, hypersomnias
• Assessment of excessive daytime sleepiness
• Multi-sleep latency test (MSLT), wakefulness test, Stanford sleepiness scale

 

Sleep deprivation

• Theories of sleep homeostasis
• S process
• Adenosine
• Consequences of human sleep deprivation
• DVLA guidelines
• Sleep synchronisation
• Daytime sleepiness and vigilance testing
• Sleep history recording
  • Sleep diary
  • Actimeter
  • Vigilance tasks

Sleep pathophysiology

• Pathophysiology of non-respiratory sleep disorders, including the more common
  • Insomnias
  • Hypersomnias
  • Parasomnias
  • Sleep disorders related to other medical conditions
• The role of sleep in endocrine regulation and the interactions between them
• Discuss the relationships between sleep and the metabolic syndrome
• Epidemiology of common sleep disorders
• Effect of other medical disorders on sleep
• Non-REM disorders
• Restless legs and periodic limb movement disorder
• Sleep walking and night terrors
• Nocturnal enuresis
• REM disorders
  • Nightmares
  • Narcolepsy
  • REM behaviour disorder
• Other sleep disorders
  • Sleep apnoea
  • Circadian rhythm disorders
  • Insomnia
  • Primary hypersomnolence

Sleep polysomnography

• Principles of polysomnography and individual components of measurement
  • Oximetry
  • Respiratory effort
  • Airflow
  • Body position
  • Sound
  • Limb movement
  • EEG
  • EOG
  • EMG
  • ECG
  • TcCO2
  • Oesophageal pressure and pH
  • Principles of each sensor, e.g. thermocouple vs thermister, piezo vs RIP
• Equipment set-up, calibration, recording and infection control
• Signal analysis, sleep staging, event and arousal quantification
• Cardiac arrhythmia identification
• Differential diagnosis of sleep disorders using polysomnography
• Sleep study reporting
• Parasomnias identification and classification
• Electrode/transducer placement
• Differential diagnosis using the
  • Electroencephalogram
  • Electrooculogram
• Submental muscle
• Respiratory effort and movement
• Oronasal airflow

Video-polysomnography

• Differentiation between epileptic and non-epileptic sleep events with respect of timing, waveforms and behaviour patterns from video- polysomnography

Electroencephalography

• Origin of the electroencephalogram related to brain structure and functions
• Different electrode derivations
• Internal and external
• Derivation
• Bipolar, common reference and average, source derivation
• Montage design

 

Instrumentation

• Amplifiers, filters, signal average, delay lines and triggers
• Internal and external calibration procedure on neurophysiological recording equipment

 

Disorders of sleep

• Differentiation between epileptic and non-epileptic attacks and classification of seizures (in known epilepsy)
• Uses of ambulatory neurological and respiratory recorders in sleep disorders
• Hypersomnias
• Parasomnias
• Sleep apnoea
• Periodic movements of sleep

Multiple Sleep Latency Test (MSLT), Maintenance of Wakefulness Test (MWT) and vigilance tasks

• Issue patient instructions
• Undertake calibration and signal maintenance
• Terminate naps appropriately
• Undertake scoring, interpreting and report generation
• Re-process equipment, undertake infection control

Multiple Sleep Latency Test

• Principles of polysomnography and individual components of measurement (review); principles of MSLT protocol and behavioural control
• Preparation of the patient
• Equipment set-up, calibration, recording and infection control
• Signal analysis, sleep staging, terminating naps, terminating study
• Differential diagnosis of sleep disorders using MSLT

 

Maintenance of Wakefulness Test

• Principles of polysomnography and individual components of measurement (review); principles of MWT protocol and behavioural control
• Preparation of the patient
• Equipment set-up, calibration, recording and infection control
• Signal analysis, sleep staging, terminating naps
• Differential diagnosis of sleep disorders using MSLT

 

Vigilance testing

• Clinical application of vigilance testing
• Examples of different tests, including but not restricted to:
  • Osler
  • Psychovigilance test (PVT)

 

Actigraphy, sleep diaries, sleep history, questionnaires

• Prepare equipment
• Issue patient instructions
• Download data, accept/reject results
• Undertake reaction time tests
• Interpret and report results including scoring, interpreting and report generation
• Recommend behaviour strategies for circadian rhythm adjustment
• Re-process equipment, undertake infection control

 

Non-invasive set-up

• Use of a range of NIV machines and interfaces
• Simulation of common faults and rare occurrences and outcomes of these
• Assessment and interpretation of blood gases
• Assessment of outcomes
• Long-term follow-up

Biochemical assessments

• Restless legs
  • FBC
  • Ferritin levels
  • Thyroid function
• Narcolepsy
  • HLA typing
  • Urine drug screening
  • CSF hypocretin

 

Sleep therapeutics

• CPAP and NIV treatment (review)
• Sleep hygiene and behavioural therapies (review)

 

Light therapy

• Melanopsin, melatonin, suprachiasmatic nucleus
• Timing and exposure of light and melatonin for treatment of sleep phase disorders
• Central sleep neuroanatomy, including activation and suppression pathways and structures with note of transmitter and inhibitory
• Drugs for treatment of unwanted movements in sleep, mechanisms of action and pros and cons of use
• Drugs for the treatment of cataplexy
• Effect of pharmacotherapy and recreational drugs on EEG and sleep architecture

Activities

• Identify a patient with clinical indications requiring non-invasive ventilation and, with permission, meet and discuss the impact of NIV on the patient and their family, and reflect on your learning from this meeting.
• Attend a meeting at which the outcome of a clinical audit, research, innovation or service development is presented and discuss with your training supervisor how evidence-based practice is implemented with respect to respiratory and/or sleep investigations.
• Observe exercise electrocardiogram (ECG) procedures identifying common arrhythmias and artefacts.
• Attend chronic disease management clinics in primary care and discuss the role of primary care in the diagnosis and treatment of respiratory and/or sleep disorders and how to ensure effective communication between care providers.
• Observe a range of electroencephalogram (EEG) studies undertaken within neurophysiology and discuss the similarities and differences between the service provided by a neurophysiology and a respiratory and sleep service.