Critical Care Fellowship Clinical Rotations

The VA Hospital serves as a key training site for fellows specializing in sleep medicine for adult patients. 
During the first week of the sleep fellowship, our fellows spend a day learning the essential components of conducting sleep studies, including the patient hookup for polysomnography (PSG) and PAP titration studies.

From Monday to Friday, fellows dedicate half of each day to reviewing sleep studies conducted in our eight-bed sleep lab. This includes a diverse range of studies, such as baseline polysomnography (PSGs), split-night studies, positive airway pressure (PAP) titrations, and multiple sleep latency tests (MSLTs). Occasionally, we also conduct maintenance of wakefulness tests (MWTs).

Additionally, the fellows participate in a weekly actiwatch clinic, where they analyze 10 to 15 actigraphs per month. Each Friday morning, fellows meet with their assigned attending physician to discuss the week's sleep studies and review the corresponding reports. Throughout the day, fellows have direct access to their attending physicians for guidance on any questions that arise while interpreting the sleep studies.

During the other half of the day, the fellows participate in various clinics. 

EEG: During the first three months of their fellowship, our fellows attend the Neurology EEG unit twice a month on Wednesday mornings. Here, they receive in-depth education about EEGs from a neurologist's perspective.

CBTi Clinic: We work closely with our mental health team, which includes a psychologist integrated into our sleep clinic. The psychologist helps conduct Cognitive Behavioral Therapy for Insomnia (CBTi) in both group and individual sessions. Based on the fellows’ interest in learning CBTi, in addition to routine lectures, we arrange rotations in this clinic for fellows to observe and conduct CBTi sessions alongside the psychologist.

Routine sleep clinic: Routine clinic sessions are held once a week for the entire day, during which the fellow encounters a range of sleep disorders, including simple obstructive sleep apnea (OSA), PAP follow-ups, insomnia, and excessive daytime sleepiness. This structure enables fellows to effectively manage a wide array of sleep disorders.

PAP Clinic: AVAPS/ASV: In the PAP clinic, patients come in for PAP downloads, which include CPAP, BPAP, APAP, as well as ASV and AVAPS. Fellows learn not only how to operate and troubleshoot these devices but also how to correct elevated AHI and ensure patient comfort.

REMEDE clinic: The REMEDE clinic was established a couple of years ago to accommodate patients with central sleep apnea and Cheyne-Stokes respiration, providing alternative treatment options for those who have failed BPAP therapy and where better CHF management has not resolved the CSA. Fellows gain a better understanding of the various causes of central sleep apnea (CSA) and how to manage them based on their primary etiology.

Currently, we have 15 follow-up patients, along with occasional new patients for REMEDE evaluation. Fellows can observe and conduct REMEDE activations and routine follow-ups. The Electrophysiology service places the device, allowing fellows to observe the procedure as well.

Sleep Endoscopy: While patients can be evaluated for alternative treatments for sleep apnea in any sleep clinic, the sleep endoscopy clinic offers fellows the opportunity to discuss hypoglossal nerve stimulation therapy, what a sleep endoscopy entails, and what to expect post-implant.

Parasomnia Clinic: One notable clinic is the parasomnia clinic, where they spend half a day assessing a range of disorders, including REM Behavior Disorder, Exploding Head Syndrome, and sexsomnia, along with several other cases encountered this past month.

Mild Sleep Apnea Clinic: During the time of the PAP recall, this clinic was established to explore alternative treatments for mild obstructive sleep apnea (OSA) beyond PAP therapy. The fellows encounter various types of mandibular advancement devices fabricated by the dental sleep physician. They are involved in troubleshooting these devices, evaluating side effects, and monitoring patient tolerance during follow-up visits.

Additionally, fellows consider other alternatives such as nasal EPAP, positional therapy for OSA, and the potential use of auto-adjusting positive airway pressure (APAP) for symptomatic patients with significant comorbidities, where PAP therapy may be beneficial.

Hypoglossal Nerve Stimulation Clinic

This clinic is conducted both virtually and in person. Here, fellows encounter patients who have been implanted with the hypoglossal nerve stimulation (HGNS) device. During the pre-activation visit, they assess patients to rule out neuropraxia and other factors that may delay activation. Following activation, a two-week follow-up is scheduled to ensure that the up-titration is progressing as recommended. 

Face-to-face visits are conducted to activate the device and for routine follow-ups. These visits ensure adequate device usage, troubleshoot any issues, facilitate download of the remote, and allow for planning a repeat sleep study if appropriate.

Hypersomnia Clinic: The hypersomnia clinic sees patients with narcolepsy, idiopathic hypersomnia, and Traumatic brain injury-related hypersomnia. This virtual clinic enables fellows to utilize telehealth while gaining insights into effective treatments for these conditions and addressing daytime sleepiness. Under the supervision of their attending, fellows dispense controlled medications by completing specialty pharmacy forms, while also discussing potential results and side effects.

DISE: Once a month, we conduct a drug-induced sleep endoscopy on approximately 8 to 10 patients. Fellows observe their attending perform these procedures, and those whose primary specialty is pulmonary are encouraged to participate as well.

Otolaryngology Clinic: For a few HGNS patients with unsatisfactory results, an awake endoscopy is conducted by the ENT service. Fellows are encouraged to observe these procedures to learn about the different electrode configurations and the associated movements of the tongue.

Sleep Consult in-patient setting: In addition to the outpatient clinic and procedure exposure with DISE, our fellows also see patients admitted for other reasons who have co-morbid OSA and/or CSA. By integrating outpatient clinic exposure with inpatient consultations, fellows gain a comprehensive understanding of sleep disorders in various contexts. They typically see 3-6 consults per week. The variability in consult numbers keeps the experience dynamic, ensuring that fellows remain engaged and adaptable in their training

Texas Children's Hospital Sleep Lab (Pediatric Teaching Site)

The Texas Children’s Sleep Center is one of the largest pediatric sleep medicine clinical care centers in the United States, featuring 23 pediatric sleep laboratory beds and a home sleep testing system. It is one of the few centers in the country that has earned accreditation from the American Board of Sleep Medicine. The sleep center includes both sleep clinics and a sleep lab located within the hospital.

It is a tertiary referral center for medically complex children.

The physician team includes Neurology, Pulmonary, Behavioral Sleep Medicine, and Otolaryngology.

Our fellows spend 4-5 months at the sleep center during their fellowship. From Monday to Friday, they dedicate half a day to reviewing sleep studies for patients ranging from 1 week to 18 years of age. They assist in managing sleep issues in complex cases, including:

• Congenital heart disease
• Craniofacial abnormalities
• Neuromuscular disorders
• Prader-Willi Syndrome
• Genetic syndromes
• Beckwith-Wiedemann Syndrome
• Achondroplasia
• Obesity hypoventilation
• Pulmonary hypertension

In addition to their home base rotations, fellows participate in weekly clinics. The clinical experience encompasses:

• Behavioral Sleep Medicine: Helping patients and their families complete PSG, improve adherence to PAP therapy, and address behavioral insomnia and circadian rhythm disorders.
• Otolaryngology Services
• Neuromuscular Clinic
• Bariatric Multidisciplinary Clinic
• Multidisciplinary OSA Clinic (MOSA): The MOSA team includes surgeons, sleep medicine specialists, pulmonologists, social workers, dietitians, and psychologists.

Fellows have the opportunity to review the DISE conducted by the ENT service and manage HGNS therapy in patients with Down Syndrome. Since the sleep center is located within the hospital, our fellows see up to five inpatient consultations per week and follow up with a PSG and titration study if required.