The Lady Cilento Children's Hospital Brisbane (LCCH), Queensland, is the largest children's hospital in Australia with well-developed sub-specialities in all aspects of paediatric medicine. It is a tertiary centre and the referral centre for the most complex paediatric cases throughout Queensland. The sleep unit at LCCH undertakes 24 sleep studies every week ranging from complex ventilation titration to respiratory physiological studies. The unit runs two special sleep clinics every week on Wednesday afternoon and Thursday afternoon. In addition there is neuromuscular clinic every Wednesday morning. Being a tertiary centre referral unit, the spectrum of sleep related breathing disorders is wide often mixed with other comorbidities. The unit has a very large follow up of children with neuromuscular respiratory problems including children requiring non-invasive ventilation.
I attended OPD's, sleep clinics and in-patients (including daily reviews of sleep study patients) with the consultants in order to gain understanding of complex sleep related problems in children and their management. I also attended the neuromuscular-respiratory clinic. This helped me understand the pattern of various presentation and approach to a child presenting with neuromuscular disorders and respiratory sleep related issues. That also includes amongst other things understanding the principles of non-invasive ventilation. I also attended various teaching activities in the department.
I was also involved with the in-patient care of children with neuromuscular-respiratory problems including children on NIV. I also attended the daily reviews of sleep study patients with the sleep doctors (including review of the studies then discussion with the families).
During the proposed duration approximately I was able to observe about 100 sleep studies (including titration studies).
During the course of my fellowship I acquired the following skills:
- How to set up a sleep study in children: all studies were full Polysomnography. Since India has no organized paediatric sleep labs most paediatric pulmonologist have inadequate training in this aspect. I had observed, interacted and sometimes assisted the paediatric sleep physiologist in setting up sleep studies. This is quite important since if this step is not done properly it would lead to poor quality studies which would be difficult to interpret. Many children with neuromuscular disorders are on non-invasive ventilator and hence require titration studies. This requires a bit additional set up but extremely important.
- Paediatric sleep scoring: I learnt how to score a sleep study using paediatric ASM sleep scoring rules. The nuances of paediatric sleep scoring can be understood only after observing a few. I also scored a few practice studies with the help of the consultants and sleep scientist.
- Interpretation: After scoring the sleep studies have to be interpreted with the clinical background of the child. The sleep reporting by fellows and consultants helped me understand interpretation and clinical relevance of the study.
- Further management/treatment: Last but not the least is the advice to the patients and parents which might be in the form of no treatment, need for surgery (adenoidectomy and tonsillectomy), non-invasive ventilation, etc. In some case the adjustment of the setting of the ventilation is done with the help of titration studies.
- Non-invasive ventilation (NIV): Many patients would need NIV in the form of CPAP and BiPaP. The initiation of these is quite different from the adults and those from the intensive care settings. With the help of the clinical nurse specialists I learnt how to initiate NIV in children. I also learnt about the different interfaces available for paediatric NIV. I also learnt how to adjust the ventilator settings with the help of sleep studies.
- Others: I could also look around different things going on in the department and the hospital, of which few are unique to the LCCH. I observed a few videoflouroscopic swallow studies, specialized lung function testing like Multiple Breath Washouts, MIP/MEP, SNIP, etc. These investigations are required for children with neuromuscular weakness.
At the end I would like to thank all the staff of the department of Respiratory & Sleep Medicine at the Lady Cilento Children's Hospital Brisbane, Queensland, Australia for their cooperation and support. I need to thank my mentor Dr Nitin Kapur for all his help. I also need to thank the APSR for proving the opportunity and funding for the fellowship.
Dr Ankit Parakh
(Left to right) Dr Ankit Parakh & Sleep nurses
(Left to right) Dr Ankit Parakh, Dr Nitin Kapur Consultant Pediatric Respiratory & Sleep
(Left to right) Dr S Suresh Consultant Pediatric Respiratory & Sleep, Dr Ankit Parakh
(Left to right) Dr SaiKiran Sleep Fellow, Gordon Williams Chief Sleep Scientist, Dr Ankit Parakh, Dr David Kilner Consultant Pediatric Respiratory & Sleep
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(Left to right) Dr Nitin Kapur, Dr Ankit Parakh, Dr Alan Isles Director Pediatric Respiratory & Sleep, Dr Leanne Gauld Consultant Pediatric Respiratory & Sleep, Dr Brent Masters Consultant Pediatric Respiratory & Sleep