Apnea with desaturation or distress on or off the device — observed apneas with a falling SpO₂ or respiratory distress — assess and escalate per the Respiratory red flags.

Excessive somnolence / difficult to arouse — a marked new somnolence (possible CO₂ retention, oversedation, or a neurologic cause) — escalate/transfer.

Acute sleep-wake reversal with agitation — screen for delirium and a treatable acute cause; escalate the workup (route to Cognitive).

Insomnia from uncontrolled pain or dyspnea — treat the underlying cause; do not mask a decompensation with a sedative.