Titration quiz 1

Your patient is ordered to have a BiPAP titration. They've reached a pressure of 18/14cm and begin exhibiting central apneas in the presence of a mask leak of 30 LPM. Which of the following would be the most appropriate action?

• Increase IPAP/EPAP x 1-2cm

• Increase IPAP by 1cm

• Add a back-up (ST) with a breath rate of 12BPM

• Correct the high mask leak.

Answer explanation

Before adjusting settings or transitioning to an advanced mode of therapy, the mask leak must first be adjusted to a clinically accepted level (preferably under 24LPM).

Your patient is ordered to have a BiPAP to ASV titration (following the protocol). They've reached a BiPAP pressure of 18/12cm and begin exhibiting central apneas (>5/hr., more than 50% events are central), assuming your mask leak is low, the starting ASV pressure according to Intermountain protocol should be:

• EPAP 5, min/max PS 3-15

• EPAP 5, min/max PS 3-10

• EPAP 7, min/max PS 3-15

• EPAP 7, min/max PS 3-10

Answer explanation

In the absence of a more specific order, the Intermountain sleep protocol states when the ending CPAP pressure is 9-12cm, start ASV EPAP 7, min/max PS 3-10. In this case, CPAP=EPAP which would be 12cm.

Your patient is having an ASV titration. They begin having central events once the reach a pressure of EPAP 8, min/max PS 3-10. With each breath cycle, the PSmax is "maxing out" at 18cm on the TXResmed controller. Their mask leak is low. What would be the most appropriate action? *The patient is not having obstructive events

• Increase the MaxPS by 1cm after waiting 20 mins.

• Decrease the MaxPS by 1cm after waiting 20 mins.

• Increase the EPAP by 1cm after waiting 20 mins.

• Decrease the MinPS by 1cm after waiting 20 mins.

Your patient is ordered to have a CPAP titration. They begin having clear central events in sleep with no obstructive events and upon waking to use the restroom, they say "I'm having a hard time breathing out" when they put their mask back on. They're at a CPAP of 10cm, no mask leak is present, and you've already added EPR 2-3. What would be the most appropriate thing to do?

• Unhook the patient and send them home cuz nothin else can be done.

• Lower the CPAP pressure 4cm and leave it there until lights on.

• Start BiPAP @ 14/10cm.

• Start ASV EPAP 7cm, min/max PS 3-10cm

Answer explanation

Our protocol allows for a transition/trial of BIPAP or BIPAP ST if the patient complains of pressure intolerance or treatment-emergent centrals occur. Temporarily lowering CPAP pressure can be effective in some instances, but not for the rest of the night and especially if the patient has proven they need 10cm CPAP. ASV cannot be used within our protocol without a specific order.

Your patient is ordered to have a baseline PSG. Once asleep, they begin having significant respiratory events in sleep. Additionally, their Spo2 has been varying between 65% and 74% for the last 8 minutes. You've verified proper probe placement. What should you do?

• Wake the patient and ask them if they want a snack.

• Begin supplemental oxygen @ 2LPM

• Start the patient on ASV EPAP 5, min/max PS 3-10cm.

• Call a "code blue" and wait for the code team to arrive.

Answer explanation

When no therapeutic interventions are ordered, the Intermountain sleep protocol allows for the introduction of supplemental oxygen when specific criteria is met. (See protocol in Sharepoint)