Sleep Medicine

The outpatient clinical rotation will expose fellows to a broad range of sleep disorders and give them the opportunity to provide continuity of care. Fellows will serve in the Cincinnati Children’s Pediatric Sleep Clinics, the University of Cincinnati University Sleep Clinics and the VA Sleep Clinics.

During pediatric rotations, the fellow will spend time in additional sleep clinics:

• Pediatric Sleep Apnea Clinics
• Pediatric Sleep Disorders Clinics
• Behavioral Sleep Medicine Clinic
• Pediatric Sleep and Neuromuscular Clinics

During adult rotations, the fellow will spend time in additional adult sleep clinics:

• VA sleep clinics
• VA walk-in sleep clinics (DIGMA)
• VA multidisciplinary sleep clinics (SIGMA)
• University Pointe / University of Cincinnati

The half-day schedule of the outpatient clinics will ensure adequate exposure to a broad range of sleep disorders. During the remaining half day, fellows will rotate monthly between the sleep laboratory and the inpatient / consultation sleep service.

The inpatient service portion of the fellowship provides fellows with the skills to manage patients with complex medical problems and sleep disorders, with an emphasis on multidisciplinary approaches to treatment.

The Division of Pulmonary Medicine has a 10-bed unit dedicated to the management of patients with sleep-disordered breathing and children with chronic respiratory failure. This unit admits 225 to 250 children a year. The sleep fellow will be involved in the admission and management of this group of patients. He or she will participate in rounds that include a faculty member, pediatric residents, pulmonary fellow, nursing staff, respiratory therapist and social worker.

Fellows will also be available for consultation on hospitalized patients with sleep disordered breathing. A faculty member from the sleep center will evaluate patients with the fellows and develop management plans. A similar in-patient setting with adult patients is available at University Hospital.

Fellows will complete designated rotations in the Sleep Laboratory. This experience will give fellows a better understanding of the role polysomnography plays in the management of patients with sleep disorders.

The rotation is intended to meet a number of goals. By the end of the rotation, fellows will:

• Understand the indication of polysomnography in the management of patients with sleep disorder
• Understand the indication of multiple sleep latency testing in the management of patients with sleep disorders
• Understand the role of actigraphy and other tests, such as maintenance of wakefulness testing, in the management of patients with sleep disorders
• Understand the limitations of tests provided by the Sleep Laboratory in the diagnosis and management of patients with sleep disorder
• Learn how to acquire study data in the sleep laboratory
• Learn how to use the equipment in the sleep laboratory
• Score electroencephalography and respiratory tracing in polysomnography
• Recognize and overcome artifacts in recorded data channels

Fellows will score 200 polysomnographies and 25 multiple sleep latency tests during this training period.

The neurophysiology elective gives fellows insight into the interaction between neurological disorders, such as seizures and neuromuscular disease, and sleep. A special emphasis is put on the electroencephalographic recording, recognition of epileptiform activity on EEG, the management of seizures and the understanding of the effect of pharmacological management of seizure disorder on sleep.

During the neurophysiology elective, the trainee attends one half-day clinic in the Division of Neurology dedicated to the management of patients with seizure disorder, metabolic abnormalities and neuromuscular disorder; the fellow is involved in the evaluation and management of patients admitted to the neurotelemetry unit. In addition, the fellow interprets 24-hour EEG studies and accompanies the attending neurologist during patients’ evaluations.

During the last two weeks of the rotation, the fellow should be able to obtain a medical and sleep history and perform neurological physical examination.

During the psychiatry rotation, fellows evaluate and manage patients’ mood disorders and other psychiatric illnesses that are likely to present to the sleep specialist with a variety of sleep complaints. The fellow will develop a number of skills:

• Recognizing the most common psychiatric disorders associated with sleep complaints
• Identifying the signs of psychiatric disorders that may resemble other medical conditions
• Conducting developmental and psychiatric histories to assess the possible psychiatric etiology of sleep disturbances
• Recognizing that psychiatric disorders frequently affect the sleep pattern
• Recognizing that chronic insomnia is more prevalent in patients with psychiatric disorders and may be a symptom of a mood disorder, developmental disorder or schizophrenia
• Discussing pharmacologic treatment and behavior therapy in the management of psychiatric sleep disturbances
• Understanding the pharmacological management of psychiatric disorder and its effect on sleep

During this two-week rotation, fellows will participate in daily rounds on the inpatient psychiatry unit and attend two half-day clinics in the Division of Psychiatry.

The ENT rotation will allow the fellow to demonstrate the ability to provide compassionate, appropriate and effective care for children with sleep-disordered breathing abnormalities. At the end of this rotation, the clinical fellow should be able to recognize that:

• Hypertrophy of tonsils and adenoids is the most common factor predisposing children to obstructive sleep apnea.
• Adenotonsillectomy is the most common treatment of obstructive sleep apnea in children.
• Adenotonsillectomy does not always relieve symptoms of obstructive sleep apnea, especially in children who are obese or have craniofacial abnormalities.
• The hypopharynx is a frequent site of obstruction in obstructive sleep apnea.
• The incidence of obstructive sleep apnea is increased in craniofacial syndromes associated with micrognathia and mid-face hypoplasia.
• Most children without underlying craniofacial disorders or obesity will have complete resolution of symptoms of obstructive sleep apnea following adenotonsillectomy.
• Macroglossia predisposes patients to obstructive sleep apnea.
• The risk of obstructive sleep apnea is greater in children with macroglossia, craniofacial syndromes and genetic disease.

Fellows will spend time in outpatient ENT settings observing patients who benefit from surgery to correct sleep apnea problems. Time will also be spent in the surgical arena, where fellows will observe procedures done to correct sleep apnea and sleep-disordered breathing abnormalities.