Presentations: Sleep Apnea, AAA, pneumothorax, pleural effusion, PICS

what is sleep apnea?

a disorder where breathing is repeatedly interrupted or paused during sleep

SA: pauses can last a few seconds to minutes and are long enough to (3)

- disrupt sleep

- decrease blood oxygen levels

- increase blood CO2 levels

SA: 3 types of sleep apnea

obstructive, central, complex

obstructive sleep apnea =

- Muscles in the throat relax causing the airway to narrow or close, not allowing enough air in.

- Briefly wakes up to reopen airways

- Most common type

central sleep apnea =

- less common

- brain fails to send signals to respiratory muscles

complex sleep apnea =

when obstructive sleep apnea becomes central sleep apnea

sleep apnea symptoms that happen while asleep (4)

- Breathing that starts and stops

- Frequent loud snoring (more common in men)

- Gasping for air

- Night Sweats

sleep apnea symptoms that may go unnoticed (5)

- Daytime sleepiness and tiredness

- Dry mouth

- Waking up often during the night to urinate

- Difficulty with concentration

- Mood changes

sleep apnea symptoms in women (3)

- fatigue

- headache

- insomnia

7 risk factors of sleep apnea

- Older age: > 40 years old

- Obesity

- Large tonsils narrowing the airways

- Family history and genetics

- Heart or kidney failure: increased fluid buildup in the neck

- Lifestyle habits: alcohol + smoking

- Sex: men more common than women

obstructive sleep apnea is present in what percentage of men and women?

- 33.9% men

- 17% women

obstructive sleep apnea affects 936 million adults between the ages of

30-69

obstructive sleep apnea is most common in what generation?

middle-aged and elderly

what nationalities is sleep apnea most seen in?

hispanics, africans, and asian

history of sleep apnea includes

- Frequent loud snoring, gasping for air /choking in sleep, daytime exhaustion, patient stopping/starting breathing multiple times during their sleep

- Greater than 4 obstructive breathing events in one hour classify pt for the possibility of sleep apnea

mild, moderate, severe sleep apnea =

- Mild: 5-15 events per hour of sleep

- Moderate: 15-30 events per hour of sleep

- Severe: greater than 30 events per hour of sleep

physical assessment of risk factors of sleep apnea =

narrowed airway, measure neck circumference, look for deviated septum

SA: home-based sleep studies pros and cons =

- Pros: cost effective, comfort

- Cons: technician doesn't place leads; thus, may be placed incorrectly,

what is the gold standard with diagnosing SA?

polysomnography

SA: polysomnography =

- Completed in a lab for at least 6 hours

- A minimum of 12 channels of recording electroencephalography, electrooculogram, electromyogram, oronasal airflow, chest wall effort, body position, snore microphone, ECG , and oxyhemoglobin saturation

- heart rate, respiratory abnormalities, gas exchange, heart rhythm, oxygen saturation and muscle tone and contraction are measured

- 1st half= monitoring patients sleeping

- 2nd half = given PAP machine and monitor effects to determine proper settings needed

sleep apnea can increase the risk of (9)

- AFIB

- Pulmonary Hypertension

- Cor pulmonale

- Stroke

- Heart failure

- Type 2 diabetes

- Obesity

- Metabolic syndrome

- Depression

SA: upper airway partially or completely collapses leading to

airflow blockage

- individual will continue to try to breathe despite air not being able to pass through

SA: hypoxia and hypercapnia, causing

- The brain wakes the body to reopen these airways

- This cycle repeats itself dozens of time per night

SA: the constant drops in oxygen supply activate the

sympathetic nervous system

- ↑ HR and ↑ BP

SA: one of the most significant consequences is the risk of Afib, because

- Constant changes in intrathoracic pressure and oxygen levels during apneic events stretch atrial walls and disrupt normal conduction (Leading to Atrial remodeling and arrhythmias)

SA: simple treatment =

lifestyle changes such as quitting smoking, change sleep positions, weight loss

SA: continuous positive airway pressure (CPAP) =

·Treats moderate to severe sleep apnea

·Worn during sleep to prevent apnea and snoring

oDelivers air pressure through mask to keep airways open

·Most people find this device uncomfortable to use: with practice, patients may learn to adjust the tensions on the straps to make it more comfortable

·Could get the Inspire Sleep Apnea Treatment that replaces CPAP

oImplanted device that monitors breathing patterns-> stimulates muscles of the airway during sleep

SA: other possible therapy treatments for sleep apnea

- auto CPAP

- BPAP

- oral appliances

SA: surgical treatments for sleep apnea =

- tissue removal

- tissue shrinkage

- jaw repositioning

- implants

- nerve stimulation

- tracheostomy

SA: PT involvement treatments include

- respiratory muscle training

- postural therapy

- orofacial exercises/myofunctional therapy

what is an abdominal aortic aneurysm (AAA)?

abdominal aortic dilation of 3 or > cm

- small (less than 5cm) or large (more than 5 cm)

AAA: the aorta begins where and extends down into what?

begins in the L ventricle and extends down into the abdomen supplying blood to the body

AAA: occurs when what?

the walls of the aorta weaken over time, leading to ballooning of the aorta forming a bulge

AAA: if left untreated, what will happen?

will get bigger and eventually rupture

- life threatening

AAA: risk factors (10)

•Smoking

•Hypertension

•Coronary Artery Disease

•PAD

•Atherosclerosis

•Older age (65-75)

•Family history ( MOST IMPORTANT)

• Male sex. AAAs are much more common in men, occurring up to four to six times more often.

•Obesity

•Previous MI

AAA: what is the most important risk factor?

if someone has a family history!

AAA: symptoms and clinical presentations of an unruptured AAA

- Symptoms are normally absent unless the aneurysm gets bigger or ruptures

- Most common symptom is belly pain or discomfort

- Ascending : typically asymptomatic, but may cause dull chest pain

- Descending: may cause back pain

Other symptoms:

- Pain in chest, abdomen, lower back, or flank

- Pulsating feeling in belly

- "Cold foot" or black/blue painful toe

- Fever or weight lost

AAA: symptoms and clinical presentations of a ruptured AAA

- Sudden or severe pain

- Extreme drop in blood pressure

- Signs of shock

AAA: physical exam that is done for the diagnosis of an AAA

- palpation

- listen to the heart

- check pulse

- looking for risk factors

AAA: what 3 diagnostic tests can be performed?

- ultrasound

- ECG

- MRI

AAA: other possible causes of pain in the chest, abdominal flank, and/or back pain (7)

- Mesenteric Ischemia - reduced/blocked blood flow to the intestines

- Peptic Ulcer disease - ulcers of the stomach and/or duodenum

- Diverticulitis - inflammation of diverticula in the large intestine

- Pyelonephritis - bacterial infection in one or both kidney

- Ureteric colic - kidney stones

- Myocardial Infarction

- MSK related LBP

AAA: non-surgical interventions

- For small AAA (<4cm), asymptomatic, remaining same size.

- Medication management

AAA: surgical interventions (2)

Open surgical repair

- Transabdominal or retroperitoneal approach – GOLD STANDARD

Endovascular repair

- Using femoral arterial approach

- Less invasive

- Recommended for patients with CV or other comorbidities considered high risk for open surgery

- Better survival rates for ruptured AAA compared to an open surgical repair

AAA: the goal for the non-surgical treatment for a small AAA is to

slow the growth and lower chance of rupture or dissection

AAA: 4 lifestyle managements

- Smoking cessation

- Improved diet - to aid in lower cholesterol and high BP

- Manage stress - control high BP; avoid heavy weightlifting, stop the use of stimulants (cocaine)

- Physical Activity

AAA: 3 medication managements

- Aspirin - if other cardiovascular risks are present

- Blood Pressure Management (Beta Blockers, ACE inhibitors, ARBs)

- Statin - cholesterol control

AAA: what is the ascending aortic aneurysm surgical treatment

open heart surgery

AAA: open surgical repair (OSR) =

Large abdominal incision under general anesthesia; the aneurysm is opened, replaced with a sewn-in synthetic graft, and the aortic wall is wrapped around it

AAA: advantages of OSR

Long-term durability; usually requires periodic check-ups every ~5 years

AAA: disadvantages of OSR

Major surgery with higher short-term risk (≈4% 30-day mortality), longer hospital stay (1-2 weeks), slower recovery, and not suitable for patients with serious heart, lung, or kidney disease

AAA: what is the descending aortic aneurysm surgical treatment

less invasive endovascular procedures

AAA: endovascular repair (EVAR) =

Minimally invasive catheter-based repair through groin arteries; a stent graft is placed inside the aneurysm to reroute blood flow and reduce wall pressure

AAA: advantages of EVAR =

Lower short-term mortality (≈1% within 30 days), shorter hospital stay (~1 week), and faster recovery

AAA: disadvantages of EVAR =

Requires lifelong imaging surveillance, higher chance of needing additional procedures (e.g., for leaks or stent movement), and no proven long-term survival advantage over open repair

AAA: side effects of OSR

- Arrhythmia, pain, bruising and swelling at incision site, bleeding, infections, blood clots, stroke, damage to surrounding blood vessels or organs, insomnia, depression, loss of appetite, memory problems, and muscle pain in chest

- More side effects because this is open heart surgery

AAA: side effects of EVAR

- Local groin would complications, hematoma, infection, lymphocele, contrast nephropathy, ischemia from clot formation, renal artery occlusion, limb occlusion, and access artery injury

- Lymphocele is a collection of lymph fluid in a cyst like structure

- Contrast Nephropathy is an acute kidney injury that occurs after an injection of a contrast fluid

- Less side effects because this is a minimally invasive surgery

AAA: a ruptured aneurysm, if it does not cause sudden death, will present with

shooting pain in the abdomen or low back, pulsatile mass in the abdomen, tachycardia, and severe hypotension

AAA: almost half of the patients with a ruptured AAA do not survive, and those who reach the hospital have what mortality rate?

80-90%

(so only 10-20% of people survive)

AAA: physical therapy interventions =

- Aerobic training – Moderate-intensity exercise is safe and beneficial for patients with small AAAs (< 5.5 cm)

- Prescription example – Treadmill, cycling, or similar modes 3×/week for ~45 min at 60–80% HRR, progressing as tolerated

- Resistance training – Low-resistance, high-repetition exercises can complement aerobic work if no contraindications

AAA: precautions of PT interventions

monitor blood pressure closely; avoid excessive systolic surges (keep <180 mmHg)

AAA: outcome of PT interventions

improves functional status and cardiovascular fitness, though not proven to slow aneurysm growth

AAA: PT interventions - education specific =

- Promote smoking cessation – the most significant modifiable risk factor for AAA formation and progression

- Encourage cardiovascular risk management – control blood pressure, cholesterol, weight, and inactivity to address common comorbidities

- Screen and monitor – identify symptoms early and support ongoing surveillance, as no therapy slows AAA growth

- Provide education – increase awareness of AAA, screening importance, and healthy lifestyle behaviors

what is pneumothorax?

presence of air in the pleural cavity between the lungs and the chest wall

- this can impair oxygenation and/or ventilation leading to collapsing of the lungs

PT: what 2 classifications?

spontaneous and non-spontaneous

PT: spontaneous pneumothorax =

occurs with no previous underlying condition or lung disease

-Secondary spontaneous is when it is developed from an underlying disease such as COPD and CF

PT: non-spontaneous pneumothorax =

usually develops after a trauma to the chest

-Ranks second to rib fractures as common sign of chest injury

-Often missed in patients on initial chest X-ray

- Usually managed by chest tube, although not required - depends on severity

PT: spontaneous pneumothorax typically occurs in who? and from what?

- young adults (20-30)

- ruptures from blebs and bullae

PT: effects on breathing =

- Chest expands → lungs pulled outward

- Lung recoil pulls inward

- With air in pleural space, lung collapses → impaired mechanics

- ↑ size → ↓ lung volume

PT: non-spontaneous pneumothorax is cased by what?

- playing contact sports

- car accidents

- rib fractures

PT: signs and symptoms =

- Tachycardia

- Tachypnea

- Acute onset of chest pain

- Shortness of breath

- Cough

- Hypoxia, hypotension, tracheal deviation to the opposite side (tension pneumothorax)

PT: how does diagnosis occur?

- often visible on chest xray

- chest CT is more sensitive for small pneumothorax

- thoracic ultrasonography emerging as an alternative rapid and accurate diagnostic tool

- history and physical exam

- ABGs

PT: what is the hallmark finding on a chest xray?

displaced visceral pleural line with absent lung markings

PT: what do you look for during the history and physical exam?

- Family Hx

- History of trauma

- Diaphoresis and cyanosis

- Decreased/absent breath sounds

- Rapid HR

PT: what do you look for with the ABGs?

hypoxia, respiratory acidosis, hypercarbia

PT: treatment options include

- observation without oxygen

- administering supplemental oxygen

- simple aspiration or small bore catheter insertion

PT: observation without oxygen =

- Asymptomatic patients with minimal pneumothorax

- Air is reabsorbed spontaneously

PT: administering supplemental oxygen =

- Treats possible hypoxemia

- Associated with increased rate of pleural air absorption

- High nasal flow nasal cannula/noninvasive ventilation should not be used with symptomatic patients due to risk of air leaks and worsening pneumothorax

PT: simple aspiration or small bore catheter insertion =

A needle is inserted through the chest wall into the pleural space and a syringe is used to withdraw the air to help the lung re-expand

PT: another main treatment option is a

chest tube

- inserted into the pleural space and is connected to a device with one-way flow for air removal

PT: a one way valve insertion (heimlich valve) =

- Allows complete evacuation of air that is not under tension and prevents re-entry

- Attaches to chest tube or catheter at one end and connects to a suction device or is left open to the atmosphere at the other end

- Used to avoid hospital admission and treat spontaneous pneumothorax

PT: what is a thoracostomy with continuous suction?

Air is drained from the pleural space using a chest tube connected to a suction system to help re-expand the collapsed lung

PT: what are the 2 surgical options?

- thoracic pleurodesis

- apical pleurectomy

PT: what is a thoracic pleurodesis?

draining of pleural fluid and air followed by either mechanical abrasion or instilling a chemical irritant to induce inflammation and fibrosis leading to adhesions between the visceral and parietal pleura

- eliminates pleural space by inducing adhesions between visceral and parietal pleura to prevent recurrent/persistent pneumothorax

PT: what is a apical pleurectomy?

removal of the apical part of the pleura and is often done in conjunction with a bullectomy

PT: pharmacological management primarily focuses on

pain control from the PT itself and invasive procedures

- local anesthetic, intravenous or oral pain medications, regional anesthesia techniques such as intercostal nerve blocks (VATS)

PT: what are the 3 chest tube drainage systems?

- suction

- water seal

- clamping

PT: chest tube suction =

- actively pulls air and fluid from chest

- most management starts suction

PT: chest tube water-seal =

- passively drains to let air and fluid escape

- once lungs appear fully expanded via CXR switch from suction to water seal

PT: chest tube clamping =

- temporarily done to stop draining

- done before tube removal

PT: complications of a chest tube include

- Bleeding

- Infection

- Dislodgement

- Leakage

- Injury to intra-abdominal or intrathoracic organs

- Adhesions between lung and plural

PT: chest tube management includes

- Interprofessional approach

- Monitoring volume and type of fluid draining

- Monitor vitals

- Keep insertion site clean and dry

- Regular dressing changes

- Ensure drainage system is kept below chest level

- Regularly checking chest tube for kinks

PT: uncomplicated PT can resolve in about

10 days

PT: prognosis of primary PT =

typically benign and may not require medical attention

PT: prognosis of secondary PT =

depends on severity of the underlying disease, along with the size of the PT

PT: prognosis recurrences =

- Recurrences usually occur within the first 6 months, but can happen for up to 3 years

- Risk factors for recurrence include smoking, COPD, AIDS, pulmonary fibrosis, younger age, and increased height- to- weight ratio

PT: patients with tension PT become ______ _____ quickly, and if not treated as an emergency may result in ______

hemodynamically unstable ; death

PT: PT relevance =

- recognize early signs (SOB, acute onset of chest pain, decreases in O2 levels)

- education (stop smoking)

- deep breathing exercises

- ambulation (monitor vitals)

what is pleural effusion?

restrictive lung disease resulting in abnormal amount of fluid in the pleural cavity

PE: pressure will rise in the lungs which can lead to

reduced ability in inhalate and potentially atelectasis/total lung collapse

PE: hallmark signs

decreased breath sounds, dyspnea, dullness to percussion, decreased tactile fremitus