Thoughts from the group. Bernardo, can we actually go to the questions? So you're saying that this is BUILDS, correct? That's correct. And then in your commentary, could you kind of scroll down? Yep. Second sentence, actually. Yep. First paragraph. It says, a toxic BUILDS breathing is characterized by a variable blah, blah, blah. And then choice A is incorrect. Because you're not talking about obstructive sleep apnea. Choice A. I appreciate it. Thank you. This should be, it's in, the letter should be changed. That is correct. I remember doing this for a board review or something. And people use BIOTS to describe two different kinds of breathing sometimes. So I do think it's important to stipulate which of the two you're referring to and not just call it BIOTS breathing in the answer. I actually think we can keep both questions, even though they're both sort of in this relatively niche area. If we can get a good overnight oximetry for Carolyn and then a blown up version for Bernardo. The other thing I think we can do to make them discrete questions and keep them both in the product is, Carolyn, can I ask to identify the abnormality? And Bernardo, I think you can just ask for the treatment. Kill the first half of your question and just say, which of the following treatments would you recommend? Yeah, but you're trying to get into the argument for BIOTS whether BiPAPST or ASV should be used. And that's a complicated argument because both of them are different. Peter, I look at it into the presentation, the vignette. Look at the transcontinuous CO2. But either way, you're going to get into that argument. I like just staying with the type of breathing because it's really what this is about, recognizing the pattern and not necessarily that you're going to have a problem with BiPAPST versus ASV because it is arguable what you would treat. And it would be empiric what turns out to be the best. And don't we have a cluster breathing that we can show in the commentary, Bernardo? You've got one of those that would be really helpful. What if we give the patient an ejection fraction of 40% also? Oh, no. That's another one I'm trying to make into the video. I'm just trying to make it so ASV would not be a plausible answer. I'm trying to salvage both questions for use in the product is what I'm trying to do. I think there's value in adding the treatment options in the discussion to say why you would do this and why, based on the transcutaneous, this would be beneficial. But we could leave the question as the type of breathing. I mean, that's what I would do. I agree. But I think then you'd have a hard time putting, because if both, unless we can change Carolyn's, because I think, again, they're testing different things. I think Carolyn's, to me, is a harder question in many ways, because it's something that a couple of us on this call, including myself, like, I don't know. So I think it's an important thing to teach and keep and seek. But I would love for both of the questions not to ask, what is this? And the answer for both is BIOPS. I think the answer for mine was not BIOPS. You weren't paying attention. Fair enough. Carolyn's question is more on how to look at the oximetry and different conditions. And so I don't know if there are other questions on oximetry, but that whole question could be, again, going back to Carolyn's question, all of those different conditions with oximetry examples would be the greatest teaching. That would be a great question to have it like that. Let's plan to keep both. Let's plan to keep both, then. Carolyn's will focus more on the overall hypoxia. I agree. I agree with Peter, though. If we're not comfortable that BiPAP ST is clearly the choice, then I would just change the question to what type of breathing pattern is present, and then just cut off the second half, leaving the discussion in treatment options, but don't have them in the answer choices. So Peter, do you think that it's debatable? Yep. Oh, come on. I agree with you, Bernardo. You and I are the same. I think this is a great question. I have not taught you well enough. Well, maybe you taught me well enough. So look at the transcontinuous CO2. How can you put it on ASP? I know if you talk to Shabahiri, who studies, and if you go for the respironics ASP, it has a pressure support that is fixed. And that is what saved us to think about putting a pressure support and a ventilation in this patient. But if you use the ResMed, it doesn't have that safety issue. And this patient has a transcontinuous CO2. I could do it with the Philips device. Correct, because it has a safety pressure support fixed in the background, and very few people know about it, that it has been placed on that for a safety issue. For people that may not be aware of the transcontinuous. It's too complicated. You don't want to get into this. OK, good. But wait, but if this group, so I actually would have not have put, for the reasons that Bernardo, and I have never learned anything formally from Dr. Gayle. I've heard him speak many times, so I can't. But I wouldn't put this patient on ASV for exactly the reasons. Like, I would not want to put a patient with a significantly abnormal PCO2 at baseline on adaptive servo ventilation as the first line of defense. I might use like AVAPs, but I don't know that I'd use ASV in this patient. But you can control the rate. You can control the rate with a Philips device. Yeah, but Peter, you're a master in these devices. This is not something that is where, I would say that the general knowledge should be, ASV is not a ventilatory mode, if you took to Lisa Wolff will also agree with that, I think. And then you have to come to talk to the godfather to learn the truth. Put Peter's cell number in the commentary and have them call him in case they have any follow up questions. Sunita and Vahid, are you comfortable? Again, then we would be talking about is getting rid of the first part of the question and just saying what treatment would you recommend to the patient with the correct answer being BiPAP ST. Sunita and Vahid, Caroline, you're not comfortable with that. I think there are two parts to this question. One, what is the diagnosis? What is the breathing pattern? And what is the best way of treating some with this? And I think issues on top of it. So it's really not, it's really, you only need to answer one of the questions correctly as it's written. Because if you know one, the other one is irrelevant, the way the question is written. So it's a compound question that we shouldn't include, I don't think. I mean, there are two challenges to the reader here. One is, what is the diagnosis? And what's the best way of treating it? If you know one of them, you're done. Theoretically, David, theoretically. But I agree, Vahid is right, that somebody could recognize the breathing pattern, but not, but pick ASB. They say, oh, this is sort of, maybe this is the cluster breathing, central apnea, I don't know. ASB sounds right, right? So. You know, it actually is OK the way he's written it, because it doesn't say you have to use this. It says, what initial one would you recommend? And there's nothing wrong with saying that is initial attempt to diagnose. But it adds nothing to the question, Peter, because you're really only asking people what the first part is. Correct. Because the second part will follow, because you don't have a choice. I'm OK with this. The second part. I would, I'm going to, I'll talk to my editorial staff with my guesses. We're going to probably truncate this to a one-part question. I'm OK with whichever part it is, but it does need to be a one-part question. Now, if the choices were what kind of breathing is, what kind of treatment, and your options were A, diagnosis A, treatment A, diagnosis A, treatment B, diagnosis B, treatment A, diagnosis B, treatment B, then you have to actually know both. But as it is, you only have to know one answer, and you're going to get the whole thing. So there's just no reason to ask the second part of the question. You can just put that in the discussion, which you already have. So consensus, first part or second part to be eliminated? Which is the first part? David, so in that case, the treatment should be eliminated from the questions, then. That's at this group's, like, I would pick a half and ask that one. If the group, I actually think the second one, if we're confident that BiPAP ST is a better treatment, then I actually think it's a more challenging question to ask that, because then you have to go through two lines of logic. You've got to recognize it and then figure how to treat it. But if the group's like, doesn't have consensus, and Peter is advocating pretty strongly against, like, hey, BiPAP, you could say, which of the following is the correct initial therapy? Then Peter would probably be on board for that also. But I guess that's what I want the group to think. Can I look at that and say, I should put this patient on Bi-level ST as the first therapy? If so, I kind of like it as, what initial therapy should you use? And the learner's left to now go through two lines of logic to get there. It's a hard question, but I think it's an awesome question. But the group needs to be comfortable with that. I think you could figure out that answer from looking at the PSG. Well, the question is the treatment, then. Yeah, I think you could figure out the treatment. Perfect. Let's do treatment as answer options. And that will be beautifully attached to the Caroline's question about the pattern of breathing. So I think it's going to be perfect for both questions. Right, so they're not too similar. Yep. Yep. Good. Can we go back to the stem? Can you scroll up a little bit? So just a couple of minor points. So the patient is listed as obese. But she has a neck circumference, or overweight, but a neck circumference of 14.3 inches, which is a tiny neck. It's listed as overweight, which is fine for that neck circumference. OK, so let's keep the neck circumference low. She's a lady. She's built like a lady. She's a lady. Yes, her type. Yes, she is. Her type of obesity. Yes, she is. And I guess the ASV has to be spelled out right in the answers. It'll have to be in sort of the abbreviation. That's a good question. I don't know. Is that a standard abbreviation for us? Yes. Do you know, either Jean or Megan? I do not know, but I'll make a note to ask Mark. I think with terms of B and C, I would either have them both as BPAP or both as bilevelPAP, but don't use bilevelPAP in one and BPAP in the other. Oh, yeah. Definitely, yeah. No, I agree. Let's just have both questions, and they'll both be a little different, and I think that's great. And I've learned something. As Lynn Marie said several times yesterday, I always love when I learn something. That's the best part about being in these meetings. Thank you.

medical case

question wording

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treatment options

breathing patterns