Pulmonology, Respiratory and Sleep Medicine

01Purpose and scope

• This manual supports the course Pulmonology, Respiratory and Sleep Medicine. It describes how physicians, advanced practice clinicians, respiratory therapists, sleep technologists and nurses in pulmonary practice carry out their work, from the first review of symptoms through testing, treatment, follow up and handoff.
• The scope covers outpatient pulmonary clinics, inpatient consults, the pulmonary function laboratory, attended and unattended sleep studies, home oxygen assessment and long term positive airway pressure care. It touches on thoracic oncology, interventional bronchoscopy and critical care only where those areas hand work to or receive work from general pulmonary practice.
• This guidance does not replace qualified professional judgment, approved procedures or required authorization. Scope of practice, device prescribing rules, oxygen qualification criteria and reimbursement requirements vary by jurisdiction and by payer, so check the current authoritative source for your location and your employer before acting on any rule described here.

02Core principles

• Start with the clinical question. A spirometry order, a polysomnography request and an arterial blood gas each answer a different question. Write the question down before selecting the test, because the question determines the test conditions, the timing and the interpretation.
• Measure before labeling. A diagnosis of chronic obstructive pulmonary disease, asthma or obstructive sleep apnea should rest on objective data and a documented clinical picture. Symptoms, exposure history and imaging matter, but a label built only on a cough or a smoking history is often revised later.
• Function matters as much as the number. A patient with a borderline ratio who walks freely at home may need a different plan from a patient with a similar number who desaturates on a six minute walk. Pair numeric results with symptoms, activity tolerance and quality of life measures.
• Treat breathing during sleep as part of whole body health. Sleep disordered breathing affects blood pressure, glucose regulation, mood, daytime alertness and motor vehicle safety. Ask about these domains even when the referral only mentions snoring.
• Protect staff and patients from exposure. Aerosol generating procedures, tuberculosis evaluation and oxygen equipment all carry specific risks that shape room setup, staffing and equipment choices.

03Planning and preparation

• Review the referral before the visit or test. Confirm the indication, the relevant history, current inhaler and other medications, recent imaging, prior pulmonary function results and any open safety concerns such as recent hemoptysis or unexplained weight loss. A short note on what the referring clinician wants answered prevents wasted testing.
• Screen for contraindications and precautions. For spirometry, the commonly used precautions include recent myocardial infarction or unstable cardiac disease, recent thoracic, abdominal or eye surgery, recent hemoptysis of unknown cause, and a recent pneumothorax. Confirm the patient can follow breathing instructions and has no active nausea that would make forced exhalation unsafe. Take the list from the laboratory protocol, which should match current professional guidance.
• Prepare the patient. Tell patients which medications to hold before testing and for how long, since short acting and long acting bronchodilators affect results differently. Ask about recent smoking, caffeine and vigorous exercise, and advise them to bring their inhalers and any home oxygen equipment.
• Prepare equipment and the room. Calibrate spirometers according to the manufacturer and laboratory schedule, and record the daily check. For sleep testing, confirm that the study type is appropriate: in lab polysomnography is generally used for complex cases, while home sleep apnea testing suits uncomplicated suspected obstructive sleep apnea in adults without significant comorbidity. Confirm the oximeter, the sensors and the pressure device work before the patient arrives.
• Set up consent and communication. Explain the test purpose, the time required, the expected sensations and the next steps. Document consent where the local policy requires it, and give the patient a contact number for questions about the device or the result.

04Recommended workflow

1. 1
   : Confirm identity, the indication and the reason for the test against the order. Check that the requested test matches the clinical question you wrote during planning. If it does not, contact the ordering clinician before proceeding.
2. 2
   : Take a focused history. For a respiratory visit, cover the onset and pattern of symptoms, sputum, exertional limitation, exposures such as occupation, mold, birds or wood smoke, smoking history in pack years, prior infections and current medications including inhaler technique. For a sleep visit, cover bed partner observations, witnessed apneas, nocturia, morning headache, dry mouth, reflux, drowsiness while driving and shift work.
3. 3
   : Perform the examination and the baseline measures. Record vital signs, resting oxygen saturation, weight and body mass index, neck circumference when relevant, airway and oral findings, chest examination, and signs of right heart strain or fluid overload when they are present. Use validated tools such as the Epworth Sleepiness Scale or the STOP-BANG questionnaire where the clinic uses them, and record the scores exactly as completed.
4. 4
   : Run the test under standard conditions. For spirometry, the patient sits upright, uses a nose clip, seals the mouthpiece and performs at least the number of acceptable efforts required by the laboratory protocol. For a bronchodilator response test, give the medication, wait the protocol interval and repeat the test. For sleep testing, apply the sensors, confirm signal quality before the patient leaves the room where that is possible, and document lead off or technical problems in real time.
5. 5
   : Review the raw data before interpretation. For spirometry, inspect the flow volume and volume time curves for cough, glottic closure, early termination and variable effort. For sleep studies, check the channel quality, the recording duration, sleep time, and the event definitions in use. Do not interpret a study that has not been checked for technical adequacy.
6. 6
   : Interpret the result in context. Compare measured values with predicted values using the reference equations adopted by your laboratory, and note the lower limit of normal method used. For sleep studies, report the apnea hypopnea index, the oxygen desaturation index, the time spent with low saturation and the position and sleep stage dependence of events. Link each abnormal finding to the clinical question.
7. 7
   : Decide and communicate the plan. Options may include an inhaler change, a pulmonary rehabilitation referral, a home oxygen assessment, a titration study for positive airway pressure, a mandibular advancement device referral, or further imaging. Explain the reasons in plain language and state what the patient should watch for and when to call.
8. 8
   : Close the loop. Send the report to the referring clinician, confirm the first follow up appointment, arrange device delivery or supply ordering when applicable, and set a reminder for adherence data review. If a result is critical, such as a severe hypoxemia finding or a suspected pneumothorax, follow the escalation policy immediately rather than waiting for the routine report.

05Quality checks, risk controls and compliance

• Spirometry quality depends on acceptability and repeatability criteria described in current technical standards from recognized respiratory societies. Record the number of acceptable and repeatable efforts, flag tests that fail these criteria, and repeat the test while the patient is still in the laboratory when that is feasible. A test that does not meet criteria should not be used to make a definitive diagnosis without a documented explanation.
• Sleep study scoring should follow the current scoring manual adopted by the laboratory, which is typically the manual published by the American Academy of Sleep Medicine in the United States or the equivalent body in your country. Have a physician or a trained scorer review the study, record the scoring version used, and perform periodic inter scorer comparisons where the laboratory has enough volume to make this meaningful.
• Oxygen carries a fire risk. Post no smoking and no open flame signs, keep oxygen cylinders secured and at a safe distance from heat and ignition sources, and teach patients and family members to keep tubing away from stoves and candles. Document the oxygen prescription with flow rate, delivery method and the situations in which it should be used, including exertion and sleep.
• Aerosol generating procedures, including some nebulizer treatments, induced sputum collection and bronchoscopy, require room ventilation, personal protective equipment and an infection control plan that matches the hospital or clinic policy. Tuberculosis screening and isolation decisions follow national and local public health rules, so check the current guidance from your public health authority.
• Opioids and benzodiazepines are sometimes used for breathlessness at the end of life or in advanced lung disease. Their use carries respiratory depression risk, particularly with sleep disordered breathing. Prescribing and dispensing must follow your jurisdiction's controlled substance rules and the clinic's stewardship policy.
• Patient records contain protected health information. Follow the privacy rules that apply in your country, such as the HIPAA Privacy Rule in the United States, and limit access to sleep and pulmonary data to people with a treatment, payment or operations need. Driving restrictions for excessive sleepiness are set by licensing authorities and differ by jurisdiction, so provide the relevant information and reference the official rules rather than making assumptions.

06Collaboration and documentation

• Pulmonary care is team work. Respiratory therapists often run spirometry and oxygen assessments, sleep technologists set up and monitor studies, nurses coordinate education and device follow up, and physicians interpret complex data and make treatment decisions. Agree on who signs each report and who answers patient calls about device problems before the service opens.
• Write notes that another clinician could act on without asking you a question. A useful report states the indication, the technical quality, the key values, the interpretation, the plan and the responsible clinician. For a sleep report, state the study type, total recording time, sleep time, the event indices with their definitions, the lowest saturation and the time below a set threshold, and the recommendation.
• Use shared language for severity and status. Where your system uses standardized staging or grading tools, such as the GOLD classification for airflow limitation, record which tool and version you used. Avoid vague phrases such as mild or moderate without the underlying values.
• Communicate results to referring clinicians with a short summary at the top and the full report attached. If a result changes management in a major way, such as a new diagnosis of interstitial lung disease or a finding that affects fitness for work, speak to the clinician directly and document the conversation.

07Measures and continuous improvement

• Track a small set of indicators that reflect the actual work. Useful measures include the proportion of spirometry tests that meet acceptability criteria, the proportion of sleep studies that are technically adequate, the time from referral to first visit, the time from sleep study to the follow up visit, the rate of repeated tests, the no show rate and the completeness of oxygen and device prescriptions. Set local targets based on your own baseline and your payer requirements rather than copying numbers from other settings.
• For positive airway pressure, adherence is often measured as hours of use per night and the proportion of nights used over a period. Many payers use a threshold for continued coverage, commonly around four hours per night on most nights, but the exact rule depends on the payer and jurisdiction, so confirm it before using it in your reports. Review device data at an early follow up visit and again after several weeks, and note the reasons for non use.
• Review audit results on a regular schedule. Pick a sample of reports, check them against the scoring manual and the laboratory protocol, and feed the findings back to the team. Discuss one or two cases at each review, focusing on decisions that could have gone differently.
• Revise protocols when evidence or local data show a gap. Update the spirometry preparation sheet when a common error appears, such as patients who did not hold a bronchodilator as instructed. Keep version numbers on all protocols so staff know which version applies to a given test.

08Common mistakes and how to prevent them

• Interpreting a spirometry result without checking the tracings. A borderline ratio or a low FEV1 can come from poor effort. Inspect each curve, confirm the criteria and document any doubt before drawing a conclusion.
• Diagnosing asthma or COPD from one test without context. Variable airflow obstruction can be documented in several ways, and a single post bronchodilator value may not answer the question. Link the result to symptoms, prior tests and the clinical course.
• Missing a home oxygen need at night. Some patients desaturate during sleep even when resting daytime saturation looks acceptable. Review overnight oximetry or the sleep study oxygen data before closing the file.
• Choosing a home sleep test for a patient who needs in lab testing. Patients with significant heart or lung disease, opioid use, suspected central apnea, or a high likelihood of other sleep disorders often need attended testing. Screen for these before choosing the test type.
• Prescribing positive airway pressure without a follow up plan. Device delivery alone does not produce benefit. Schedule an early adherence and symptom check, address mask problems and pressure intolerance, and record the outcome.
• Letting equipment drift out of calibration. A spirometer or oximeter that is not checked on schedule can produce results that look normal but are not reliable. Keep the calibration log up to date and remove equipment that fails the check.
• Writing reports that only state the diagnosis. A bare label without values, quality statements and a plan is hard for the next clinician to use. Include the data and the reasoning.

09Practical checklist

• Confirm the clinical question and the indication before scheduling the test.
• Screen for spirometry or sleep test precautions and document the screen.
• Check that equipment calibration and sensor checks are current and recorded.
• Give the patient written preparation instructions, including medications to hold.
• Record symptoms, exposures, medications and the relevant examination findings.
• Review raw tracings or sleep channels for technical quality before interpreting.
• Interpret results against the reference values and scoring manual used by the laboratory.
• Link each abnormal result to the clinical question and a specific next step.
• Explain the plan in plain language and give clear return or emergency instructions.
• Send the report to the referring clinician and confirm the follow up appointment.
• Arrange device, oxygen or supply follow up and set a date for adherence review.
• Verify that oxygen safety, infection control and controlled substance rules were followed.
• Review local indicators each quarter and adjust protocols where the data point to a gap.

★Learning sources

• Micro Degree: Pulmonology, Respiratory and Sleep Medicine
• Micro Degree: Healthcare Administration Practice
• Micro Degree: Physiotherapy Assistant Operations
• Micro Degree: Cardiac Care Support