Sleep Medicine

Educational Plan: A competency based development of knowledge and skills in Allergy and Immunology through clinical experience, bedside teaching, didactic conferences and readings to achieve competence, proficiency and the foundation for mastery. 

Educational Methods:

1. The NMFF Pulmonary Sleep Clinic is located in the medical specialties clinic on Galter 18. The clinics are open on Tuesday mornings and Wednesday afternoons.
2. The NMFF Neurology Sleep Clinic is located on Galter 20th floor, and clinics are open on Monday and Friday mornings.
3. The non invasive ventilation training – there are two clinics Thursday AM at the Rehabilitation Institute of Chicago third floor and Thursday afternoon at the lois insolia ALS clinic on Galter 20th floor.
4. Sleep study reading takes place on the 15th floor of the avenues hotel 160 east Huron st. Sleep study reading occurs on Monday afternoon, Tuesday morning, Wednesday morning, Thursday morning and Friday afternoon. Sleep studies are performed 7 nights a week.

During the Sleep Medicine rotation, residents will spend time as follows:

1. 1-2 half day a week interpreting sleep studies
2. Residents should arrange to spend part/ all of an evening with the sleep technicians observing sleep study preparation and performance.
3. Participation in the sleep clinics is expected for 3-5 half day clinics per week.
4. Residents should arrange to spend one half day with one of the hospital based DME clinical liaisons to understand requirements for ordering CPAP – BiPAP and oxygen
5. Residents should arrange to spend one half day with the lab manager to review mask fitting and options.

Sleep educational conferences include the following:

1. Thursday 9:00 AM Zee Lab research meeting fifth floor Abbot hall.
2. Friday 4:00 PM sleep core lecture fifth floor Abbot hall.

During this rotation residents are expected to develop:

1. Communication skills that will facilitate clinical interaction with patients and their families and thus ensure the accurate and complete sleep history.
2. Competency in the physical examination of patients with sleep disorders.
3. Competency in the ordering of sleep studies and understanding sleep study reports
4. Competency in the interpretation of CPAP down loads
5. Demonstrate basics in teaching patients about good sleep hygiene cognitive behavioral therapy.
6. Ability to work as a member of a sleep medicine team.

Methods of Assessment:

1. Expectations discussed at the beginning of the rotation
2. Evolution of skills in sleep clinic
3. Competency-based staff evaluations
4. Conference and clinic attendance and participation

Additional Evaluation Tools: Click here

Goals and Objectives:  Review the 6 core competencies that apply to your clinical rotations.Click here.

Goals and Objectives:  Review the 6 core competencies that apply to your clinical rotations.Click here.

Basic Mechanisms of Sleep:

Describe the basic physiology of sleep

1. The contribution of CNS structures to sleep:
   • Thalamus, hypothalamus, suprachiasmatic nuclei, brainstem, brainstem nuclei, reticular activating system, locus coeruleus, and the ascending and descending motor inhibitory pathways
2. The characteristics of the Circadian Rhythms and their relationship to sleep timing and medical disorders
3. The role of Sleep Deprivation and the relationship of sleep loss to over all health
4. The changes in the cardiovascular/ pulmonary system that occur during normal sleep and with sleep-disordered breathing

Pulmonary Physiology during Sleep:

Describe the pathophysiology of and treatments for various sleep-disordered breathing including:

1. Obstructive sleep apnea (OSA)/ Obesity-hypoventilation syndrome (OHS)
2. Central sleep apnea (CSA)/ Cheyne stokes respirations (CSR)

Pharmacology of Sleep:

Discuss the pharmacology of various medications as they relate to the sleep wake cycle including:

1. Sedatives
2. Stimulants
3. OTC agents

Disorders of Hypersomnia:

Appropriately identify, and define disorders of hypersomnia including;

1. Narcolepsy
2. Primary/ CNS hypersomnia
3. Hypersomnia associated with chronic disease including OSA

Disorders of insomnia:

Appropriately identify, define and develop treatment plans for disorders of insomnia including;

1. Co-Morbid insomnia
2. Psychophysiology issues in sleep and insomnia
3. Sleep hygiene plans
4. Cognitive behavioral therapy

Movement disorders in sleep:

Appropriately identify, and define movement disorders of insomnia including;

1. Restless leg syndrome
2. Bruxism

Parasomnia in the adult:

Describe the pathophysiology of and treatments for various sleep-disordered breathing including:

1. NREM/ REM parasomnia
2. Sleep eating/ night eating syndromes
3. Differentiate nocturnal seizure from parasomnia
4. Identify parasomnia triggers
5. Define a safe sleep environment as part of parasomnia care.

Circadian Rhythm Disorders:

Describe the pathophysiology of and treatments for various sleep-disordered breathing including:

1. delayed and advanced sleep phase, shift work, non-24 hour cycle, free running rhythms, and jet lag
2. Role of Bright Light Therapy
3. Role of Melatonin therapy

Patient Care: Residents are expected to provide patient care that is compassionate, appropriate and effective for the promotion of health, prevention of illness, treatment of disease and at the end of life.

Obtaining a Sleep History:

Demonstrate the ability to:

1. Conduct, record and interpret a comprehensive clinical medical and sleep history
2. Understand how to use standard sleep questionnaires required as part of a sleep history including:
   • Epworth Sleepiness Scale ( hypersomnia assessment )
   • Cleveland sleep habits questionnaire ( general sleep complaint review)
   • STOP BANG – ( OSA preoperative risk assessment )
   • RLSQ – (restless legs screening questionnaire)

Circadian Rhythm Disorders:

Identify, diagnose, and develop a management plan for chronologic abnormalities associated with disorders of the timing of the sleep-wake pattern, including, but not limited to the following diagnostic tools:

1. Horne – Ostberg questionnaire
2. AASM standard Sleep Log
3. Actigraphy

Sleep Disordered Breathing:

Identify, diagnose, and develop a management plan for SDB and specifically understand the importance of these diagnostic tools:

1. Diagnostic polysomnography
2. PAP titration
3. PAP download interpretation

Disorders of Excessive Somnolence

Identify, diagnose, and develop a management plan for sleepiness associated hypersomnia disorders and specifically understand the importance of these diagnostic tools:

1. Multiple Sleep Latency Test
2. Maintenance of Wakefulness Test
3. Driving History

Insomnia

Identify, diagnose, and develop a management plan for sleep disruption associated using the following diagnostic tools:

1. AASM standard Sleep Log
2. Medication history – identify medications with insomnia as a side effect
3. Medication history – identify appropriate  vs inappropriate use and timing oh hypnotic agents
4. Sleep hygiene evaluation

Parasomnias:

Identify, diagnose, and develop a management plan for parasomnias associated with the following diagnostic techniques:

1. Video polysomnogram
2. Extended montage EEG
3. Bed partner reports

Healthy Sleep Practices:

Identify the reality of “insufficient sleep syndrome” and the impact of a 24/ 7 modern world on sleep habits. Diagnostic tools may include:

1. AASM sleep logs
2. Review of Shift Work  Schedules
3. Review Jet Travel Schedules
4. Eliminate artifact from recordings when they are identified

Practice-Based Learning: Residents are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices.

1. Develop strategies for routine primary care to identify patients at risk of sleep disorders.
2. Investigate and implement methods to improve compliance with treatment
3. Learn to use EMR based techniques for documenting compliance with therapy
4. Develop techniques to coordinate and facilitate patient care in concert with Durable Medical Equipment providers and home based respiratory therapists.

Interpersonal and Communication Skills:  Residents are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of health care teams.

1. Provide effective and professional consultation to other physicians and health care professionals and sustain therapeutic and ethically sound professional relationships with patients, their families, and colleagues.
2. Use effective listening, nonverbal, questioning, and narrative skills to communicate with patients and families
3. Interact with consultants in a respectful, appropriate manner
4. Maintain comprehensive, and timely electronic medical records

Professionalism: Residents are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession, and society.

1. Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues
2. Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues
3. Adhere to principles of confidentiality, scientific/academic integrity, and informed consent

Systems-Based Practice: Fellows are expected to demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care.

1. Understand, access and utilize the sleep resources, providers and systems necessary to provide optimal care such as:
   • Sleep Laboratory
   • Home Care providers
   • Respiratory Therapy
2. Understand the limitations and opportunities inherent in various practice types and delivery systems, and develop strategies to optimize care for the individual patient such as:
   • Unique PAP device choice
   • Individualized mask fittings
   • Personalized sleep hygiene regimens
   • Addressing specific shift work and / or circadian timing issues as they relate to sleep scheduling
3. Apply evidence-based, cost-conscious strategies to prevention, diagnosis, and disease management such as:
   • Portable diagnostic monitoring
   • Auto titration
   • Home based pulse oximetry.
4. Collaborate with other members of the health care team to assist patients in dealing effectively with complex systems and to improve systematic processes of care such as:
   • ENT
   • Psychiatry/ Psychology
   • Pediatrics
   • Neurology

References:

[1-17]

• Wilson, J.F., In the clinic. Insomnia. Ann Intern Med, 2008. 148(1): p. ITC13-1-ITC13-16.
• Balkin, T.J., et al., Sleep loss and sleepiness: current issues. Chest, 2008. 134(3): p. 653-60.
• Yumino, D. and T.D. Bradley, Central sleep apnea and Cheyne-Stokes respiration. Proc Am Thorac Soc, 2008. 5(2): p. 226-36.
• Billiard, M., Diagnosis of narcolepsy and idiopathic hypersomnia. An update based on the International classification of sleep disorders, 2nd edition. Sleep Med Rev, 2007. 11(5): p. 377-88. (Click Science Direct link.)
• Sullivan, S.S. and C.A. Kushida, Multiple sleep latency test and maintenance of wakefulness test. Chest, 2008. 134(4): p. 854-61.
• Zamarron, C., V. Garcia Paz, and A. Riveiro, Obstructive sleep apnea syndrome is a systemic disease. Current evidence. Eur J Intern Med, 2008. 19(6): p. 390-8. (Click Science Direct link.)
• Reading, P., Parasomnias: the spectrum of things that go bump in the night. Pract Neurol, 2007. 7(1): p. 6-15.
• Oertel, W.H., et al., State of the art in restless legs syndrome therapy: practice recommendations for treating restless legs syndrome.22 Suppl 18: p. S466-75. Mov Disord, 2007.
• Franklin, K.A., et al., Effects and side-effects of surgery for snoring and obstructive sleep apnea--a systematic review. Sleep, 2009. 32(1): p. 27-36. (Click View full text link)
• Barion, A. and P.C. Zee, A clinical approach to circadian rhythm sleep disorders. Sleep Med, 2007. 8(6): p. 566-77. (Click Science Direct link.)
• Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-607.
• Garcia-Touchard, A., et al., Central sleep apnea: implications for congestive heart failure. Chest, 2008. 133(6): p. 1495-504.
• Eckert, D.J., A. Malhotra, and A.S. Jordan, Mechanisms of apnea. Prog Cardiovasc Dis, 2009. 51(4): p. 313-23. (Click Science Direct link.)
• Doghramji, P.P., J.A. Lieberman, 3rd, and M.L. Gordon, Stay awake! Understanding, diagnosing, and successfully managing narcolepsy. 56(11 Suppl Stay): p. S17-31; quiz S32. J Fam Pract, 2007.
• Rubins, J.B. and K.M. Kunisaki, Contemporary issues in the diagnosis and treatment of obstructive sleep apnea. Postgrad Med, 2008. 120(2): p. 46-52.
• Benes, H., et al., Definition of restless legs syndrome, how to diagnose it, and how to differentiate it from RLS mimics. Mov Disord, 2007. 22 Suppl 18: p. S401-8.
• Mullington, J.M., et al., Cardiovascular, inflammatory, and metabolic consequences of sleep deprivation. Prog Cardiovasc Dis, 2009. 51(4): p. 294-302. (Click Science Direct link)