RSPT 2147 – Pulmonary Rehabilitation & Sleep-Disordered Breathing

Vocabulary flashcards summarizing key terms, disorders, assessments, diagnostic criteria, and treatment principles for pulmonary rehabilitation, obstructive & central sleep apnea, and polysomnography.

Pulmonary Rehab Referral Requirements

Physician-signed orders,
patient demographics,
insurance,
most recent History&Physical,
and prior diagnostic testing.

Common Obstructive Diseases in Pulmonary Rehab

COPD (including alpha-1 antitrypsin deficiency),
persistent asthma,
diffuse bronchiectasis,
and cystic fibrosis.

CBABE Acronym

Cystic Fibrosis, Bronchiectasis, Asthma, Bronchitis (chronic), Emphysema – major obstructive diseases.

Common Restrictive Disorders in Pulmonary Rehab

Interstitial lung diseases,
pulmonary fibrosis,
occupational/environmental lung disease,
sarcoidosis,
connective tissue diseases,
hypersensitivity pneumonitis,
ARDS survivors,
kyphoscoliosis.

Additional Rehab Candidates

Lung cancer,
pulmonary hypertension,
pre/post thoracic or abdominal surgery,
pre/post LVRS,
ventilator dependency,
and obesity-related respiratory disease.

PFT Criteria for COPD Rehab

FEV1 < 80 % predicted
and FEV1/FVC < 70 %.

Interview Process Purpose

Establishes trust/credibility and gathers comprehensive medical, social, and respiratory history.

Key History Elements obtained during interview

Respiratory and surgical history,
comorbidities,
medication list,
oxygen use,
allergies,
smoking/alcohol/drug use,
occupational exposures,
social support.

Physical Assessment Components

Vital signs,
height/weight/BMI,
breathing pattern,
accessory muscle use,
breath sounds,
cardiac exam,
digital clubbing,
extremity evaluation,
frailty,
grip strength.

Symptom Assessment Areas
(for success in pulmonary rehab)

Dyspnea,
fatigue,
cough,
sputum,
wheeze,
hemoptysis,
chest pain,
GERD,
pain,
anxiety,
depression.

Exercise Assessment Tests
(for success in pulmonary rehab)

Six-minute walk,
shuttle walk,
cardiopulmonary exercise test (CPET).
Used to help develop the exercise prescription

Other assessment elements
(for success in pulmonary rehab)

Musculoskeletal and exercise (balance, fall risk, ambulatory assistive devices)
Pain
ADL (activities of daily living)
Nutrition
Supplemental oxygen
Education
Psychosocial

Exercise Prescription Elements

Mode,
frequency,
duration,
intensity (per AACVPR/ACSM),
SpO2 targets,
oxygen titration,
strength training,
progression plan.

Comprehensive Treatment Plan

Physical concerns,
exercise prescription,
nutrition, psychosocial issues,
comorbidities,
oxygen;
each must include assessment, intervention, and goal

Pulmonary Rehab Interventions

Energy conservation,
coordinated breathing with movement,
breathing techniques,
oxygen use,
medication review,
Borg scale monitoring,
diet counseling,
smoking cessation,
relaxation.

What variables are measured during Polysomnography (PSG)

EEG, EOG, chin EMG, ECG,
airflow (nose/mouth),
Ventilatory effort by inductive plethysmography
Oxygen saturation by pulse oximetry (SpO2)

Obstructive Sleep Apnea (OSA)

Recurrent collapse of the upper airway during sleep causing effort without airflow, desaturation, arousals, and fragmented sleep.

Untreated OSA Consequences

Increased risk of pulmonary hypertension,
systemic hypertension,
arrhythmias,
stroke,
heart failure,
myocardial infarction,
and mortality.

Typical OSA Symptoms

Snoring,
witnessed apneas,
gasping/choking,
excessive daytime sleepiness,
morning headaches,
nocturnal GERD,
nocturia,
cognitive decline,
erectile dysfunction.

OSA Treatment Goals

Normalize oxygenation and ventilation,
eliminate apneas/hypopneas/snoring,
restore sleep architecture,
and relieve symptoms.

What is important to remember about OSA treatment goals?

Treatment should be personalized based on severity and patient preference.

Behavioral therapy should be pursued in the care of all patients.

Medical and surgical therapy must be tailored to the individual patient.

OSA vs CSA on PSG

OSA: respiratory effort present without airflow;

CSA: no effort and no airflow — both may show desaturation.

Central Sleep Apnea (CSA)

Group of disorders with reduced or absent respiratory drive from brainstem resulting in absent effort and airflow during sleep.

Secondary Causes of CSA

Stroke, neuromuscular disease (e.g., ALS, Guillain-Barré), congestive heart failure,
chronic opiate use,
Chiari malformation,
congenital central hypoventilation.

CSA Characteristic Breathing

Periodic breathing with waxing-waning tidal volume and frequency; Cheyne-Stokes respiration pattern.

Disorders Linked to CSA

Commonly associated with congestive heart failure and stroke.

CSA Symptoms & Patterns

Frequent arousals,
insomnia,
daytime fatigue,
and Cheyne-Stokes respiration noted on monitoring.

CSA Treatment Options

Behavioral counseling,
positional therapy,
CPAP,
BiPAP,
adaptive servo-ventilation,
risk factor management.

Gold Standard for Sleep Apnea Diagnosis

Overnight polysomnography (sleep study).

Split-Night Study

Single-night Polysomnography where first portion diagnoses Sleep Disordered Breathing and second portion titrates CPAP.

Define AHI

Apnea-Hypopnea Index

(AHI) Scale

Normal <5,
Mild 5–15,
Moderate 15–30,
Severe >30 events/hour.

STOP-BANG Questionnaire

A useful and efficient screening tool validated in multiple populations but may be less useful in specific groups
Eight-item screening tool for OSA risk assessing
Snoring,
Tiredness,
Observed apneas,
Pressure (BP),
BMI,
Age,
Neck size,
Gender.

CPAP Titration Goal

Eliminate all apneas and minimize hypopneas during PSG.

BiPAP Titration Guidelines

Recommended minimum of IPAP-EPAP differential = 4 cmH2O

Recommended maximum IPAP-EPAP differential = 10cmH2O

Recommended maximum IPAP = 30cmH2O

Raise IPAP to abolish hypopneas and snoring

Raise EPAP to abolish obstructive events

First-Line Therapy for OSA

Continuous Positive Airway Pressure (CPAP).

Name treatment options for sleep apnea

Behavioral intervention
Positional therapy
Medical intervention
Oral appliance therapy
surgical intervention
Medications

Name Behavioral interventions that may be useful for Sleep Apnea

Weight loss if obese

Avoidance of alcohol, sedatives, and hypnotics

Avoid sleep deprivation

Name Positional therapy options that can help with sleep apnea

If sleep study notes OSA occurs only supine—avoid

Tennis ball at nape of neck will discourage position

Typically useful only in mild OSA.

Oral Appliance Therapy

Mandibular advancement or tongue-retaining devices to enlarge upper airway, useful in mild-to-moderate OSA or CPAP-intolerant patients.

Name Medical interventions that can help with sleep apnea

Positive pressure therapy (FIRST LINE FOR OSA)

CPAP alleviates upper airway obstruction in most patients

CPAP titration should stop all apneic episodes and reduce number of hypopneas

Bilateral pressure therapy (BIPAP)

Surgical Treatments for OSA

UPPP,

multi-level airway surgeries,

maxillomandibular advancement,

upper airway stimulation.

Medications for Sleep apnea

Proven at best minimally effective for most patients with OSA

Antidepressants and trazodone

At this time, no drugs are recommended to treat OSA

OSA Pathophysiology

Anatomical narrowing and reduced pharyngeal dilator tone during REM cause airway collapse, negative intrathoracic pressure swings, sympathetic activation.

Central Sleep Apnea-Cheyne Stoke Respiratory Pathophysiology

Chronic hyperventilation from pulmonary congestion lowers PaCO₂ below apnea threshold, causing periodic breathing with neurohumoral activation.

Cheyne-Stokes Respiration

Crescendo-decrescendo tidal volume pattern alternating with central apneas, common in CSA with heart failure or stroke.

Name 2 types of CSA

Overlap Syndrome

Hypoventilation syndromes

Overlap syndrome

COPD patients with coexisting OSA

Patients are typically obese smokers with moderate to severe nocturnal oxyhemoglobin desaturations

Hypoventilation syndrome

Patients with neuromuscular disorders such as ALS or muscular dystrophy

Obesity hypoventilation syndrome

Spinal cord injury with diaphragm dysfunction