5.3 Alternative Therapies & Emergency Response

When PAP Is Not the Answer

PAP is first-line, but adherence is imperfect and some anatomies or preferences call for another approach. Domain 4 expects you to know the alternatives to PAP and the indication for each, because the exam frequently presents a PAP-intolerant patient and asks for the next best option.

Oral Appliance Therapy

Mandibular advancement devices (MADs) are custom dental appliances that hold the lower jaw forward, enlarging the retroglossal airway. Indications:

• Mild-to-moderate OSA, or severe OSA when the patient cannot tolerate PAP
• Primary snoring without significant apnea
• Patient preference after informed counseling

MADs are titrated by a qualified dentist, and follow-up sleep testing confirms efficacy. They are generally less effective than optimal CPAP but adherence is often higher, so net effectiveness can be comparable in milder disease. The exam trap is offering a MAD as first-line for severe OSA in a PAP-tolerant patient — there, optimal CPAP wins. Reserve the MAD for mild-to-moderate disease or genuine PAP intolerance.

Positional and Behavioral Therapy

Positional Therapy

Positional OSA is present when the supine AHI is at least twice the non-supine AHI and non-supine breathing is near-normal. For these patients, keeping them off the back — with positional alarms, wearable vibratory devices, sewn-in tennis-ball variants, or trained avoidance — can substantially reduce events. The exam point: positional therapy only helps the supine-dependent subgroup; it does nothing for a patient whose events are equally bad in every position.

Worked example: supine AHI 36, non-supine AHI 9 — supine is four times non-supine and lateral breathing is near-normal, so this is textbook positional OSA and positional therapy is specifically indicated.

Weight and Behavioral Measures

These are adjuncts: they improve outcomes alongside primary therapy but rarely replace PAP or an appliance in moderate-to-severe disease.

Surgical Options and Hypoglossal Nerve Stimulation

Surgery targets a specific anatomic site of obstruction and is patient-specific:

Hypoglossal Nerve Stimulation (HGNS)

Hypoglossal nerve stimulation (HGNS), or upper-airway stimulation, is an implanted device that senses respiration and delivers mild stimulation to the hypoglossal nerve, protruding the tongue and opening the airway during inspiration. It is an option for selected patients with moderate-to-severe OSA who fail or cannot tolerate PAP, typically with a body mass index below the device threshold and without concentric palatal collapse on drug-induced sleep endoscopy.

Device titration is performed during an in-lab sleep study to set effective stimulation amplitude — a sleep technologist directly supports this, watching airflow and effort channels as amplitude is stepped up to find the setting that opens the airway without arousing the patient.

Remember the gatekeeping criteria: HGNS is never first-line for newly diagnosed OSA, the patient must have failed or be unable to tolerate PAP, the BMI must sit below the device threshold, and concentric palatal collapse on drug-induced sleep endoscopy is a contraindication the exam likes to test because the stimulated tongue alone cannot relieve a circumferential collapse. UPPP and MMA, by contrast, physically enlarge fixed soft-tissue or skeletal narrowing rather than recruiting muscle tone.

Recognizing and Responding to In-Lab Emergencies

The technologist is often the only clinician at the bedside overnight, and current BLS/CPR certification is a stated RPSGT eligibility requirement. The exam expects a consistent response framework: recognize the pattern, protect airway and patient, activate emergency response, then document accurately.

Cardiac Events

• The single ECG/EKG channel is for rhythm recognition, not diagnosis, but you must recognize dangerous patterns: marked sustained bradycardia, wide-complex tachycardia, frequent multiform ectopy, prolonged pauses or asystole, or ECG changes with chest pain.
• Response: assess responsiveness, activate EMS or the in-facility code protocol, begin BLS/CPR if pulseless, and apply an AED if available.

Seizures

• Recognize generalized tonic-clonic activity and its EEG correlate. Do not restrain the patient and do not place objects in the mouth — both are guaranteed-wrong answers.
• Protect the head, clear hazards, time the seizure, turn the patient to a lateral recovery position when movement stops, and ensure airway and oxygenation. Activate emergency response for a seizure lasting more than 5 minutes or for repetitive seizures (status epilepticus risk).

Falls and Parasomnias

• Sleepwalking, confusional arousals, and REM sleep behavior disorder can produce sudden unsafe motor activity. Set up safety before lights-out: bed in low position, rails or padding as indicated, clear floor pathways, secured leads, and a means to monitor and reach the room quickly.
• During an event, prioritize preventing injury — guide rather than forcefully restrain, reduce hazards, and gently reorient. Document the behavior, time, sleep stage, and any injury.