Free RST Therapeutic Interventions and Titration Questions and Answers — Questions and Answers
Question 1: A patient on CPAP at 15 cm H2O continues to have obstructive hypopneas and reports significant discomfort exhaling against the pressure. According to AASM guidelines, which of the following is the most appropriate next step?
- Increase CPAP to 16 cm H2O and reassess after 15 minutes.
- Add supplemental oxygen at 1 L/min.
- Switch to bilevel PAP with an initial IPAP of 12 cm H2O and EPAP of 8 cm H2O.
- Switch to bilevel PAP with an IPAP of at least 15 cm H2O and an EPAP of 11 cm H2O. (Correct answer)
Correct answer: Switch to bilevel PAP with an IPAP of at least 15 cm H2O and an EPAP of 11 cm H2O.
AASM guidelines suggest considering a switch to bilevel PAP when CPAP pressures reach 15 cm H2O and respiratory events persist, or if the patient is intolerant of high CPAP pressures. When switching from CPAP, the IPAP should be set at or above the previous CPAP level, and the EPAP should be set lower to provide pressure support (a difference of at least 4 cm H2O is recommended), making it easier for the patient to exhale.
Question 2: During a PAP titration, a patient begins to exhibit frequent central apneas after obstructive events have been eliminated at a CPAP pressure of 10 cm H2O. This phenomenon is best described as:
- Obesity Hypoventilation Syndrome
- Treatment-Emergent Central Sleep Apnea (Correct answer)
- Cheyne-Stokes Respiration
- High-Altitude Periodic Breathing
Correct answer: Treatment-Emergent Central Sleep Apnea
Treatment-emergent central sleep apnea (TECSA), previously known as complex sleep apnea, is characterized by the emergence of central apneas or hypopneas during the application of PAP therapy after obstructive events have resolved.
Question 3: According to the AASM Manual, which of the following criteria defines an OPTIMAL PAP titration?
- The RDI is reduced by at least 75% from baseline, and SpO2 remains above 88%.
- The RDI is <10/hour for at least 30 minutes, including some supine sleep.
- The RDI is <5/hour for at least a 15-minute duration, including supine REM sleep, with SpO2 >90%. (Correct answer)
- All apneas and hypopneas are eliminated, but snoring and RERAs persist at an acceptable level.
Correct answer: The RDI is <5/hour for at least a 15-minute duration, including supine REM sleep, with SpO2 >90%.
An optimal PAP titration is defined by the AASM as one that reduces the Respiratory Disturbance Index (RDI) to less than 5 events per hour for at least a 15-minute duration. This period must include REM sleep in the supine position (the position where events are often most severe), and the SpO2 must be maintained above 90% at the selected pressure.
Question 4: A patient is being titrated on bilevel PAP for hypoventilation. The technologist has increased the IPAP to augment ventilation, but the SpO2 remains at 87% for over 5 minutes despite the absence of discrete apneas or hypopneas. What is the recommended intervention?
- Increase the EPAP to improve oxygenation.
- Switch the patient to ASV mode immediately.
- Decrease the pressure support (IPAP-EPAP difference).
- Add supplemental oxygen, starting at 1 L/min. (Correct answer)
Correct answer: Add supplemental oxygen, starting at 1 L/min.
The AASM guidelines recommend adding supplemental oxygen during a PAP titration if the SpO2 remains ≤88% for 5 minutes or longer after respiratory events have been resolved. The initial rate should be 1 L/min and titrated up in 1 L/min increments every 15 minutes to maintain an SpO2 between 88% and 94%.
Question 5: Adaptive Servo-Ventilation (ASV) is a therapeutic option for specific types of sleep-disordered breathing. However, its use is contraindicated in which of the following patient populations due to increased mortality risk?
- Patients with treatment-emergent central sleep apnea.
- Patients with idiopathic Cheyne-Stokes respiration.
- Patients with heart failure and a left ventricular ejection fraction (LVEF) of ≤ 45%. (Correct answer)
- Patients with central sleep apnea due to long-term opioid use without alveolar hypoventilation.
Correct answer: Patients with heart failure and a left ventricular ejection fraction (LVEF) of ≤ 45%.
The SERVE-HF trial demonstrated an increased risk of cardiovascular mortality in patients with chronic, symptomatic heart failure (NYHA 2-4) with a reduced left ventricular ejection fraction (LVEF ≤ 45%) and moderate to severe predominant central sleep apnea who were treated with ASV. Therefore, ASV is contraindicated in this specific population.
Question 6: During a split-night study, what is the minimum duration of PAP titration recommended by the AASM to consider the study adequate for determining a therapeutic pressure?
- At least 1 hour of titration time.
- At least 2 hours of titration time.
- At least 3 hours of titration time. (Correct answer)
- At least 4 hours of titration time.
Correct answer: At least 3 hours of titration time.
For a split-night polysomnogram, the AASM recommends that the titration portion should be at least 3 hours in duration. This allows sufficient time to adequately adjust the pressure, observe the patient in various sleep stages and positions, and achieve a good or optimal titration.
Free RST Therapeutic Interventions and Titration Questions and Answers
A patient on CPAP at 15 cm H2O continues to have obstructive hypopneas and reports significant discomfort exhaling against the pressure.
According to AASM guidelines, which of the following is the most appropriate next step?