Sleep and Breathing Assessment

MULTIPLE CHOICE

     1.   According to the National Heart Lung and Blood Institute (NHLBI), approximately how many Americans suffer from some type of sleep disorder?

a.
10 million
b.
20 million
c.
30 million
d.
40 million

ANS:  D

According to the NHLBI, approximately 40 million Americans suffer from some type of sleep disorder.

REF:   pg. 438           OBJ:   2

     2.   What test is used to diagnose sleep disorders?

a.
Overnight oximetry
b.
Polysomnography
c.
Electroencephalogram (EEG)
d.
Leg twitch study

ANS:  B

Respiratory therapists (RTs) represent a major segment of the workforce responsible for conducting a diagnostic sleep study, or polysomnogram (PSG), in sleep disorder centers (SDCs) throughout the country.

REF:   pg. 438           OBJ:   8

     3.   What stage of sleep is characterized by large eye rolls and low-amplitude waves on EEG recordings?

a.
REM
b.
NREM stage 1
c.
NREM stage 2
d.
NREM stage 3

ANS:  B

As they drift to sleep, children and adults normally begin with stage 1 non–rapid eye movement (NREM) sleep. During stage 1 NREM, the eyes roll slowly and low-amplitude waves (i.e., those seen at the vertical height of the EEG tracings) are noted.

REF:   pg. 438           OBJ:   4

     4.   Which phase of sleep is characterized by delta or slow waves?

a.
Stage 1 NREM
b.
Stage 2 NREM
c.
Stage 3 NREM
d.
REM

ANS:  C

Stage 3 NREM (formerly stages 3 and 4) is considered the deepest stage of sleep and represents approximately 25% of the sleep period. The EEG demonstrates delta-wave, or slow-wave, sleep, which is characterized by high-amplitude waves.

REF:   pg. 438           OBJ:   4

     5.   In which stage of sleep is “restorative sleep” thought to occur?

a.
Stage 1 NREM
b.
Stage 2 NREM
c.
Stage 3 NREM
d.
REM

ANS:  C

Stage 3 NREM (formerly stages 3 and 4) is considered the deepest stage of sleep and represents approximately 25% of the sleep period. The EEG demonstrates delta-wave, or slow-wave, sleep, which is characterized by high-amplitude waves. “Delta sleep” is thought to represent restorative sleep.

REF:   pg. 438, Table 19-4                        OBJ:   4

     6.   In which stage of sleep does the brain show electrical activity similar to wakefulness on EEG tracings?

a.
Stage 1 NREM
b.
Stage 2 NREM
c.
Stage 3 NREM
d.
REM

ANS:  D

During rapid eye movement (REM) sleep, the brain is active and dreaming almost always occurs. EEG tracings demonstrate low-voltage, random, fast waveforms that are very similar to the brain wave activity seen when adults are awake.

REF:   pg. 439           OBJ:   4

     7.   A patient comment regarding the lack of dreaming could mean that the patient is not spending a significant period of sleep in which stage?

a.
Stage 1 NREM
b.
Stage 2 NREM
c.
Stage 3 NREM
d.
REM

ANS:  D

The patient is spending less time in REM, as dreaming almost always occurs in REM.

REF:   pg. 439           OBJ:   5

     8.   During which stage of sleep are skeletal muscles partially paralyzed, thus greatly affecting ventilation and maintenance of the upper airway?

a.
Stage 1 NREM
b.
Stage 2 NREM
c.
Stage 3 NREM
d.
REM

ANS:  D

Electromyographic (EMG) monitoring demonstrates skeletal muscle tone at its lowest level during the REM stage, producing a paralyzing effect. This partial paralysis results in a further decrease in minute ventilation in healthy adults and in children, producing associated episodes of hypoxemia and hypercapnia.

REF:   pg. 439           OBJ:   4

     9.   What occurs during REM that results in sleep-disordered breathing (SDB)?

a.
Hypotension
b.
Rise in heart rate
c.
Fall in respiratory rate
d.
Upper airway narrowing

ANS:  D

For patients with SDB in REM, the soft tissues of the oropharynx relax because of partial paralysis, resulting in upper airway obstruction to air flow.

REF:   pg. 440           OBJ:   3 | 4

   10.   Which of the following would be most suggestive of a patient who is liable to have SDB?

a.
One with a smoking history
b.
An obese patient
c.
A very tall and thin patient
d.
A patient with a history of hypertension

ANS:  B

Results of the physical examination frequently are nonspecific and unremarkable for the patient with SDB. On inspection, patients most commonly present with obesity or with a normal body habitus, normal skin coloring, a normal respiratory rate, and no discernible features of SDB.

REF:   pg. 446           OBJ:   3 | 4

   11.   To meet the definitive criteria for sleep apnea, how many seconds of air flow cessation during sleep must be documented?

a.
4 seconds
b.
6 seconds
c.
8 seconds
d.
10 seconds

ANS:  D

By far the most common problem found in SDB is sleep apnea. Sleep apnea is defined as the cessation of air flow for at least 10 seconds during sleep caused by an obstruction in the airway.

REF:   pg. 446           OBJ:   7

   12.   What is the first sign of SDB?

a.
Snoring
b.
Excessive daytime sleepiness (EDS)
c.
Hypercarbia
d.
Cyanosis

ANS:  A

Snoring, the first sign of an SDB, may be noted in children and in adults.

REF:   pg. 448           OBJ:   3

   13.   What is the most common complaint of patients with obstructive sleep apnea?

a.
Snoring
b.
Headache
c.
Bedwetting
d.
EDS

ANS:  D

Although patients often may be unaware of snoring, they are aware of the other common symptom associated with sleep apnea and other SDBs, which is EDS. Excessive daytime sleepiness, or excessive daytime somnolence, is defined simply as difficulty in maintaining wakefulness. In contrast to those with sleep apnea, patients with EDS are very conscious of the fact that they have difficulty remaining awake during the day.

REF:   pg. 441           OBJ:   3 | 4

   14.   Which of the following will assist the RT in predicting sleep apnea?

a.
Epworth Sleepiness Scale (ESS)
b.
Berlin Questionnaire
c.
Inspection of the chest
d.
Electrocardiogram (ECG)

ANS:  A

The ESS is a simple, eight-item questionnaire that is intended to measure daytime sleepiness; it is essential for initial screening of sleep disorders.

REF:   pg. 441           OBJ:   5

   15.   Which of the following would not be part of the montage monitored during a polysomnogram study (PSG)?

a.
SpO2
b.
ECG
c.
EEG
d.
EMG of right and left arm

ANS:  D

The PSG page, or screen, is called a montage. A typical montage includes a minimum of 17 channels of information, or tracings, similar to an ECG tracing (see Figure 19-5). In fact, the ECG channel is always monitored during a PSG study, along with four channels that reflect the EEG tracings to identify NREM or REM sleep stages, two channels that document right and left eye movement, one channel that monitors chin movement, two channels that record right and left leg movement, and seven additional channels that record snoring, air flow, thoracic and abdominal movement, SpO2, heart rate, and body position (see Figure 19-6).

REF:   pg. 444           OBJ:   9

   16.   A patient has an apnea-hypopnea index (AHI) of 15. What would this be considered?

a.
Normal
b.
Mild sleep apnea
c.
Moderate sleep apnea
d.
Severe sleep apnea

ANS:  B

An AHI of less than 5 means that the sleep study documented fewer than five hypopneas and/or apneas per hour, which is within the normal range. An AHI of 5 to 20 is termed “mild” sleep apnea, and an AHI of 20 to 40 indicates “moderate” sleep apnea. An AHI of more than 40 denotes “severe” sleep apnea in the adult population.

REF:   pg. 444           OBJ:   7

   17.   Which of the following diagnostically defines the presence of moderate sleep apnea?

a.
AHI of 3
b.
AHI of 12
c.
AHI of 32
d.
AHI of 44

ANS:  C

An AHI of less than 5 means that the sleep study documented fewer than five hypopneas and/or apneas per hour, which is within the normal range. An AHI of 5 to 20 is termed “mild” sleep apnea, and an AHI of 20 to 40 indicates “moderate” sleep apnea. An AHI of more than 40 denotes “severe” sleep apnea in the adult population.

REF:   pg. 444           OBJ:   7

   18.   How would you diagnose central sleep apnea (CSA)?

a.
Obesity
b.
Patient complains of EDS
c.
Excessive snoring
d.
10-second apnea without respiratory effort during sleep

ANS:  D

CSA consists of 10 seconds of apnea in the absence of thoracic-abdominal effort.

REF:   pg. 446           OBJ:   7

   19.   A reduction in air flow of between 4% and 50% of baseline air flow for at least 10 seconds during sleep defines which of the following?

a.
Apnea
b.
Respiratory effort-related arousal (RERA)
c.
Arousal
d.
Hypopnea

ANS:  D

A term that is associated closely with all types of apnea is hypopnea, which is defined as a reduction in air flow of between 4% and 50% of baseline air flow for at least 10 seconds, with at least a 4% reduction in SpO2 and/or an EEG arousal of at least 3 seconds.

REF:   pg. 446           OBJ:   10

   20.   If, upon assessment, the Mallampati score is class 4, the patient would be at high risk for which type of SDB?

a.
CSA
b.
OSA
c.
Mixed sleep apnea (MSA)
d.
SIDS

ANS:  B

Scoring of the Mallampati assessment from direct visualization is a follows: Class 1: full visibility of tonsils, uvula, and soft palate; class 2: visibility of hard and soft palate and upper portion of tonsils and uvula; class 3: soft and hard palate and base of the uvula are visible; class 4: only hard palate is visible (see Figure 19-10).

REF:   pg. 447           OBJ:   10

   21.   Which of the following are considered symptoms of obstructive sleep apnea (OSA)?

1. Morning headaches

2. Memory loss

3. Hyperactive behavior

4. Difficulty swallowing

a.
1, 2, 3
b.
2, 4
c.
1, 3
d.
1, 2, 3, 4

ANS:  A

Symptoms and signs of OSA in adults may include loud snoring, periods of apnea (as reported by sleep partners), chronic morning tiredness regardless of the length of sleep, EDS, morning headaches, recent weight gain, limited attention, memory loss, changes in judgment or personality, lethargy or sluggishness, hyperactive behavior, the need to take naps, depression, slowed responses, frequent falling asleep while driving, high blood pressure, automatic behavior (performing actions by rote), and swelling of the feet or legs.

REF:   pg. 448           OBJ:   7

   22.   Cheyne-Stokes breathing is associated most closely with which type of SDB?

a.
CSA
b.
OSA
c.
Mixed sleep apnea (MSA)
d.
Sudden infant death syndrome (SIDS)

ANS:  A

The most common sign of CSA is the presence of Cheyne-Stokes respirations.

REF:   pg. 449           OBJ:   7

   23.   With what pattern of SDB is SIDS thought to be associated?

a.
CSA
b.
OSA
c.
MSA
d.
RERA

ANS:  A

SIDS is thought by some experts to be associated with CSA, but no clinical evidence that the two are linked has been presented to date.

REF:   pg. 450           OBJ:   11

   24.   What is the peak age of incidence for SIDS?

a.
Birth to 1 month
b.
2 to 4 months
c.
4 to 8 months
d.
8 months to 1 year

ANS:  B

Although the cause is unknown, most reported cases of SIDS occur in the first 6 months of life, with a peak incidence reported at between 2 and 4 months of age.

REF:   pg. 450           OBJ:   11