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Atlas of

Polysomnography

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Atlas of
Polysomnography
SECOND EDITION

James D. Geyer, MD
Director, Sleep Program
Associate Professor of Neurology and Sleep Medicine
Alabama Neurology and Sleep Medicine
Tuscaloosa, Alabama

Paul R. Carney, MD
Wilder Professor and Chief
Division of Pediatric Neurology
Director, Comprehensive Pediatric Epilepsy Program
Departments of Pediatrics and Neurology
McKnight Brain Institute
University of Florida College of Medicine
Gainesville, Florida

Troy A. Payne, MD
Medical Director
St Cloud Hospital Sleep Center
St Cloud, Minnesota

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Library of Congress Cataloging-in-Publication Data
Atlas of polysomnography / James D. Geyer, Paul R. Carney, Troy Payne.—2nd ed.
p. ; cm.
Rev. ed. of: Atlas of digital polysomnography / James D. Geyer ... [et al.]. c2000.
Includes index.
ISBN-13: 978-1-6054-7228-7
ISBN-10: 1-6054-7228-X
1. Sleep disorders—Atlases. 2. Polysomnography—Atlases. I. Geyer, James D. II. Carney, Paul R. III. Payne, Troy.
IV. Atlas of digital polysomnography.
[DNLM: 1. Sleep—physiology—Atlases. 2. Polysomnography—Atlases. 3. Sleep Disorders—diagnosis—Atlases.
WL 17 A8844 2010]
RC547.A836 2010
616.8’498—dc22
2009028925

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To our families
and to the memory of Michael Aldrich

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Contributors

Monica Henderson, RN, RPSGT Sachin Talathi, PhD
Sleep Health Coordinator J. Crayton Pruitt Family Department of Biomedical
Department of Sleep Medicine Engineering
Alabama Neurology and Sleep Medicine University of Florida McKnight Brain Institute
Tuscaloosa, Alabama Gainesville, Florida

Jennifer Parr, RPSGT Julie Tsikhlakis, RN, BSN
Chief Sleep Technician Sleep Health Coordinator
DCH Sleep Center Department of Sleep Medicine
DCH Health System Alabama Neurology and Sleep Medicine
Northport, Alabama Tuscaloosa, Alabama

Betty Seals, REEGT
Director
DCH Sleep Center
DCH Health System
Tuscaloosa, Alabama

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for example. diaphragmatic include respiratory and leg movement channels during scoring EMG. the overall appearance of the stood by the technologist and the interpreter. If the sampling rate is inadequate. the illustrations were prepared from several sleep centers vii FM. EEG and EOG older analog amplifiers and paper recording. such as thoracic motion. differentiation from artifacts and benign EEG waveforms. a rational approach to management.4 The new scoring and staging While digital polysomnography provides a number of criteria are discussed in detail in the text and the waveforms are advantages as described above. Filters and sensitivities can be altered during Scoring of sleep stages has been standardized for many years3 review to assist with interpretation of the study. or thermocouple or indirectly with the recordings data can also be displayed using a variety of montages depend. features related to signal acquisi. For this varying signals. Furthermore. accurate diagnosis is an essential prerequisite for are distorted and scoring and interpretation may be erroneous. for rapidly varying signals. a sampling rate of atlas. Because of the differences in signal acquisition and display ment of a variety of sleep disorders. waveforms discipline. intrathoracic (esophageal) pressure. although transducers used for the recording now the standard of care and provide many advantages over of EEG. of these functions. not all digital recordings have the same appear- Digital amplifiers and computerized signal processing are ance. and printer resolution must be under. the analog signal generated by the transducer must laboratory to the next. tion. For slowly and transducers used in accredited sleep laboratories.indd vii 8/7/2009 3:28:01 PM . No atlas can provide examples of nor- be converted to digitized information. Digitized thermistor. can be assessed with respiratory inductance plethysmography. such as with numerous disorders now recognized and an ever-changing EEG and EMG. if the sampling rate for eye movement channels is recording of multiple physiologic functions during sleep. myogram (EMG) during sleep staging and then expanded to stretch sensitive transducers (strain gauges). presented in appropriate chapters. the For example.2 For example. This airflow can be monitored directly with a pneumotachograph. the sampling rate must be much higher. Polysomnography. and has recently been updated. and chin electro. the display can be racic and abdominal inductance recordings. Polysomnography complements eye movement. transducers true for the evaluation of brief electroencephalographic (EEG) and recording techniques for the assessment of respiration dur- transients such as epileptiform sharp waves and spikes and their ing sleep vary widely among sleep laboratories. EOG. electro-oculogram (EOG). usually set of diagnostic criteria and protocols. the clinical evaluation and assists with diagnosis and manage. Respiratory effort limited to EEG. section of the book has been significantly expanded. As with any medical 250 Hz or more. and EMG are largely standardized. As a result of these variations. display resolution.1 parameters. was too low. For digital signal polysomnographic display may be markedly different from one acquisition. A critical variable is the mal and abnormal polysomnography using all of the displays rate at which the signal is sampled and digitized. the sharp deflection associated with a rapid eye move- developed in the 1970s and is the most important laboratory ment may appear as a slower deflection characteristic of a slow test used in sleep medicine. Preface to the Second Edition Sleep medicine continues to evolve rapidly as a subspecialty 20 Hz may be sufficient. or nasal pressure. of tracheal sound or by the summation of signals from tho- ing on the purpose at hand. In addition. This is especially montages vary among laboratories.

Santiago TV. Westchester. American Academy of Sleep Medicine. 2nd Ed. Quan SF. Terminology and Technical Speci- ence and training tool for technologists. niques. Ancoli-Israel S. Boston: Butterworth-Heinemann. Rechtschaffen A. 2005. sleep-related move- ments. A Manual of Standardized Terminology. Parisi RA. 2007. and Clinical Aspects. Respiration and respiratory function: Technique of recording and evaluation. and artifacts are included. It also serves as a refer. 1994:127–139. Diagnostic and coding manual. FM. Kales A. Illinois: American Academy of Sleep Medicine.indd viii 8/7/2009 3:28:01 PM . 1st Ed. Iber C. This atlas is designed to aid the sleep medicine specialist 4. Los Angeles: Brain Information Service/Brain Research Institute. Chesson A. and parasomnias. Technical Considerations. Sleep Disorders Medi- cine: Basic Sciences. stages of sleep as well as polysomnographic findings character- istic of sleep-related breathing disorders. 2. 1968. In addition. The atlas covers nor. International Classification of Sleep Disorders. REFERENCES 1. A variety of time scales are used to illustrate their value. ed. In: Chokroverty S. Illinois: American Academy of Sleep Medi- mal polysomnographic features of wakefulness and the various cine. Scoring of Sleep and Associated Events: Rules. examples of cardiac arrhythmias. Westchester. viii PREFACE TO THE SECOND EDITION and electrodiagnostic/neurophysiology laboratories in order to 3. Tech- introduce the reader to several of the possible formats. and Scoring System for Sleep Stages of Human Subjects. fications. nocturnal seizures. The AASM Manual for the and those training in sleep medicine.

Alternatively. accurate diagnosis is an essential prerequisite for a ratio. digital ampli. an rate at which the signal is sampled and digitized. For example. If the sampling rate is inadequate. functions.indd ix 8/7/2009 3:28:01 PM . was developed In addition to digital polysomnography. A critical variable is the movements at 20. for example. waveforms are also be displayed using a variety of montages depending on distorted and scoring and interpretation may be erroneous. usually 250 from artifacts and benign EEG waveforms. breathing disorders.1 sis of behavior and polysomnographic findings assists with the As the array of sleep diagnoses has expanded. features related to signal acquisi- vide many advantages over older analog amplifiers and paper tion. esophageal pH. intrathoracic pressure can be monitored log amplifiers and bulky paper recordings that rarely consisted with intraesophageal pressure sensors that are easily inserted of more than eight channels. diagnosis of parasomnias. computer technology of the late and well tolerated. varying signals. and chin electromyogram rapidly expanding as the prevalence and importance of sleep (EMG) during sleep staging and then expanded to include disorders have become apparent.to 30-second intervals. the tech. Polysomnography complements the clini. the simultaneous analy- wide range of sleep disorders. ide level. advantages as described above. if the sampling rate for eye movement channels is too ix FM. nocturnal seizures. several other tech- in the 1970s and is the most important laboratory test used nical advances have improved the diagnostic value of sleep in sleep medicine. and transcutaneous CO2 monitoring can be included fiers. the sampling rate must be much higher. Polysomnography. or optical media. electro-oculogram (EOG). To assist with the diagnosis of sleep-related more sophisticated. of multiple physiologic functions during sleep. As with any medical disci. display resolution. and compact data storage on magnetic in selected situations without sacrificing standard channels. and printer resolution must be under- recording. Preface to the First Edition Sleep medicine is a relatively new medical subspecialty that is to EEG. the recording to assist with interpretation of the study. While sleep studies in the 1970s used ana. Digitized data can Hz or more. a sampling rate of 20 tion of brief electroencephalographic (EEG) transients such as Hz may be sufficient. such as thoracic motion. end-tidal carbon diox- noninvasive or minimally invasive transducers. such as the regular occurrence of periodic leg be converted to digitized information. recordings. for rapidly varying signals. For digital signal a compressed time scale that makes slow rhythms more read. For slowly expanded time scale can be used that permits easier identifica. the display can be limited example. electronic displays. For the purpose at hand. With the availability of 16 to 32 or more 1990s permits recording of dozens of channels using sensitive channels for a recording. the analog signal generated by the transducer must ily identifiable.2 While digital polysomnography provides a number of Digital amplifiers and computerized signal processing pro. respiratory and leg movement channels during scoring of these pline. Polysomnography can be combined with video cal evaluation and assists with diagnosis and management of a recording (video-polysomnography). digitized data can be displayed using stood by the technologist and the interpreter. Filters and sensitivities can be altered during review nal approach to management. acquisition. such as EEG epileptiform sharp waves and spikes and their differentiation and EMG. and other sleep- niques and equipment used for sleep recordings have become related behaviors.

ple has sensors for each nostril and another that is located over intrathoracic (esophageal) pressure. VA). In some cases. The montages. there is a 3-cm distance between electrodes. The array of pixels in the screen deter. to the right outer canthus and 1 cm inferior and lateral to the lyzed if a high resolution printout is obtained. sensitivities. and A-D sam- computer. from the neonatal EEG studies sors from EPM Systems (Midlothian. 3 cm below the left and right clavicles midway between the ing sleep vary widely among sleep laboratories.3 For example. and the software used for data pling rates used to generate the displays are specified in the acquisition and display. Technical Introduction. Display resolution is based on the characteristics of the PA).indd x 8/7/2009 3:28:01 PM . more. montages vary among laboratories. VA). The EEG electrodes were placed according to the Interna- Printer resolution is based on the characteristics of the tional 10–20 system. airflow can be monitored directly with a pneumotachograph. The studies were recorded using digital equipment movement. left outer canthus. the overall appearance of the belt that is placed around the patient. EOG. This thermocou- sensitive transducers (strain gauges). mines the maximum resolution. an additional system was used one laboratory to the next. be inadequate for identification of rapid EEG transients. although scoring of sleep stages has been standardized Thoracic and abdominal motion were recorded with respi- for many years. In addition. VA). or. Snoring sound was recorded with piezoelectric crystal sen- ders Center. diaphragmatic EMG. it may tion. stretch mocouple from Pro-Tech (Woodinville. screen displays and were printed with a Hewlett-Packard Laser While the lower resolution display may be sufficient for the Jet printer on 8. montages. Because of the differences in signal acquisition and display One chin EMG electrode was placed on the chin (mental) parameters.4 no consensus has been reached at this writing ratory effort sensors utilizing piezoelectric crystal sensors from concerning scoring criteria for respiratory events. for example. This sensor is placed FM. computer. Many of the recordings also include the second EKG chan- thermistor. These sensors are attached to a As a result of these variations. transducers The EKG was recorded with one electrode each placed 2 to and recording techniques for the assessment of respiration dur. the display monitor. shoulder and the neck. WA). a 1024 x 768 The illustrations were prepared based on 1600 x 1200 display provides lower resolution than a 1600 x 1200 display. in a few cases. although transducers used for the recording The submental electrode placement is generally at the mandi- of EEG. and two electrodes were placed under the chin (submental). printer. This system. filter settings. the sharp deflection associated with a rapid eye movement performed in the University of Michigan Electrodiagnostic may appear as a slower deflection characteristic of a slow eye Laboratory. Further. studies performed at the University of Michigan Sleep Disor. This backup belt was this atlas. and software. For from EPM Systems (Midlothian. the mouth. waveforms that The EOG electrodes were placed 1 cm superior and lateral are not adequately displayed on the monitor can be better ana. Respiratory effort can be Airflow was recorded with a single channel nasal/oral ther- assessed with respiratory inductance plethysmography. manufactured by the Telefactor Corporation (Conshohocken. not all digital recordings have the same appear. EPM Systems (Midlothian. or thermocouple or indirectly with the recordings nel recorded from a left leg EMG channel and a left ear elec- of tracheal sound or by the summation of signals from thoracic trode. x PREFACE TO THE FIRST EDITION low. all of the illustrations were prepared from the sleep placed between the thoracic and the abdominal belts.5 x 11 inch paper at 600 dot per inch resolu- assessment of slowly varying signals such as respiration. No atlas can provide examples of to assess respiratory effort. ance. polysomnographic display may be markedly different from For many of the recordings. and abdominal inductance recordings. EEG and EOG ble. Furthermore. and EMG are largely standardized. was also recorded with piezoelectric crystal sensors plays and transducers used in accredited sleep laboratories. or nasal pressure. labeled Backup in the normal and abnormal polysomnography using all of the dis.. Generally.

Diagnostic and coding manual. Respiration and respiratory function: Technique ume. 1994:127–139. and Healthdyne. Inc. Technical Considerations. 2nd Ed. Rechtschaffen A. The atlas covers nor- mal polysomnographic features of wakefulness and the various stages of sleep as well as polysomnographic findings character- istic of sleep-related breathing disorders. It also serves as a refer. examples of cardiac arrhythmias. In addition. eds. In: Chokroverty S. Current Practice of Clini- positive airway pressure (CPAP) or bilevel positive airway pres. PREFACE TO THE FIRST EDITION xi either 2 cm to the left or right of the trachea. Tech- This atlas is designed to aid the sleep medicine specialist niques. American Sleep Disorders Association. Gotman J. 4. Oximetry was recorded from a finger site. 3. sleep-related move- ments. which generated these of recording and evaluation. Pedley TA. Revised. ed. CO). 1968. included models manufactured by Respironics. Oximetry was recorded with an Ohmeda model 3740 (Lou. Many of the illustrations were obtained from studies of Minnesota: American Sleep Disorders Association. International Classification of isville. ence and training tool for technologists. cine: Basic Sciences. 2. The use of computers in analysis and display of EEG and patients who were undergoing a treatment trial of continuous evoked potentials. While most of the figures use a 30-second time base. les: Brain Information Service/ Brain Research Institute. 1990:51–83. and Scoring System for Sleep Stages of Human Subjects. Los Ange- and those training in sleep medicine. The CPAP and BPAP equipment. midway down the REFERENCES neck. nocturnal seizures. Boston: Butterworth-Heinemann. 1. Sleep Disorders Medi- signals. In: Daly DD. and Clinical Aspects. and parasomnias. Sleep Disorders. sure (BPAP) and include recordings of mask flow and tidal vol. Parisi RA. FM. A Manual of Standardized Terminology. and artifacts are included. 1997. a variety of shorter and longer time scales are used to illustrate their value. Kales A.indd xi 8/7/2009 3:28:01 PM . Rochester. New York: Raven Press. cal Electroencephalography. Santiago TV.

a special thanks goes to our wives and families for Sleep Center. and the St. Acknowledgments to the Second Edition As in all projects of this type. the University of Florida. and the other members of the xii FM. Lisa McAllister. their unwavering support. Fran DeStefano.indd xii 8/7/2009 3:28:01 PM . A special thanks goes to Leanne McMillan.Cloud Hospital Finally. thanks must go to the technical editorial and production staff at Lippincott Williams & Wilkins and support staff at each of our sleep centers: the DCH Sleep who provided important suggestions and support. Center. Tom Gibbons.

.. M. M.. We. thank Ken Morton. M.D.D. were vital to both the fellowship members of the editorial and production staff at Lippincott program in sleep medicine and the production of this text. RPSGT. M. Kirk Levy. Ph.B B. sleep medicine and clinical neurophysiology provided support.... Erasmo Passaro. were invalu. Ph. and A special thanks goes to Anne Sydor... nator at the University of Michigan Sleep Disorders Center. Ivo Drury. M.D. M. and Beth Malow. ering support. we would like to of the University of Michigan. Ph.. M. Acknowledgments to the First Edition Ronald Chervin.. Ahmad University of Michigan and Brenda Livingston. John Greenfield. Williams & Wilkins who provided important suggestions and The other members of the fellowship training programs in support.D. In particular.D. M. a special thanks goes to our families for their unwav- ideas. and interesting studies. M. M.. M.D. Department of Neurology. Robert MacDonald.D. Linda Selwa. Jaideep Kapur. a special thanks must go to able contributors to this project.D. and the other Wassim Nasreddine.D. sleep laboratory supervisor at the cal Neurophysiology Laboratory.D. Ph.D.D. M.D. thank and acknowl.... and Willie Anderson..Ch.D. Clini. xiii FM. therefore. The other faculty members the technical and support staff.D. Finally.. As in all projects of this type. M.indd xiii 8/7/2009 3:28:02 PM . L. edge the contributions of Sarah Nath. clinic coordi- Beydoun.D.

Geyer. Geyer. Payne. Troy A.indd xiv 8/7/2009 3:28:02 PM . Payne. Troy A. Geyer. and Paul R. and Paul R. Geyer. Carney xiv FM. Carney CHAPTER 9 CHAPTER 4 Electrocardiography 261 James D. Geyer. Polysomnography 1 and Paul R. Geyer. Geyer. James D. Payne. Troy A. Payne. Geyer. Carney CHAPTER 3 CHAPTER 8 Multiple Sleep Latency Test (MSLT)/ Artifacts 251 Maintenance of Wakefulness James D. Carney James D. Payne. and Paul R. Payne. Troy A. Carney and Paul R. Payne. Contents Contributors vi CHAPTER 5 Preface to the Second Edition vii Limb Movement Disorders 197 Preface to the First Edition ix James D. Troy A. and Paul R. Payne. Breathing Disorders 101 and Paul R. Troy A. Troy A. Carney CHAPTER 7 CHAPTER 2 Electroencephalographic Staging 17 Abnormalities 225 James D. Carney James D. Carney James D. Payne. Carney Acknowledgments to the First Edition xiii CHAPTER 6 CHAPTER 1 Parasomnias 209 Introduction to Sleep and James D. Acknowledgments to the Second Edition xii and Paul R. Troy A. Sachin Talathi. Geyer. Test (MWT) 89 and Paul R. Troy A.

Carney. and Paul R. Troy A. James D. and Monica Henderson CHAPTER 12 APPENDIX C Technical Background 301 Multiple Sleep Latency Test (MSLT) Protocol 317 James D. Troy A. Payne. Payne and Paul R. Geyer. Carney Paul R. Payne. Payne. CONTENTS xv CHAPTER 10 APPENDIX A Calibrations 287 Electrode Placement 313 James D. Geyer. Payne. and Paul R. Geyer.indd xv 8/7/2009 3:28:02 PM . Paul R. Geyer. Geyer. James D. Polysomnography Technology 309 and Paul R. and Jennifer Parr Index 323 FM. Troy A. Carney. Geyer. Geyer. Carney James D. and Julie Tsikhlakis APPENDIX B CHAPTER 11 Patient Calibrations for Nighttime Actigraphy 297 Polysomnography 315 James D. Carney Paul R. Geyer. Carney. Payne. James D. Troy A. Carney. Payne. Troy A. Carney Paul R. and Betty Seals APPENDIX D CHAPTER 13 Maintenance of Wakefulness Test (MWT) Recording Artifacts and Solving Protocol 321 Technical Problems with James D. Troy A. Troy A. Payne. Troy A.

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The term sleep architecture describes the structure of sleep. There are usually four or five cycles of sleep. MD OVERVIEW OF SLEEP STAGES AND CYCLES stage of sleep is characterized by a level on the vertical axis of the graph with time of night on the horizontal axis. and electromyographic (EMG) or muscle electrical is performed digitally. respiratory Sleep monitoring was traditionally by polygraph recording monitoring. If there is a with monitoring each of these types of activity will be discussed shift in sleep stage during a given epoch. NREM sleep is further stage sleep are obscured by artifact for more than one half of an divided into stages N1. Peri- ods of wake may also interrupt sleep during the night. and EKG. Carney. Each segment of time represented by one page is called brain wave activity. sider MT to be wake and do not tabulate it separately. The usual paper speed for Sleep is not homogeneous and is characterized by sleep sleep recording is 10 mm per second. posed of a segment of NREM sleep followed by REM sleep. sleep is staged in epochs. CHAPTER Introduction to Sleep and Polysomnography 1 James D. the length of REM sleep in each cycle usually increases. Payne. PhD Paul R. Some sleep centers con- sleep. Today most sleep recording ments. MD Sachin Talathi. Stages N1 and N2 what would otherwise be considered MT is surrounded by epochs are called light sleep and stage N3 is called deep or slow-wave of wake. it is scored as movement time (MT). each com. When an epoch of were recently combined into stage N3 sleep. skill set including a detailed knowledge of EEG. As the SLEEP ARCHITECTURE DEFINITIONS night progresses. The basic terminology and methods involved 30-second epochs or windows is still the standard. Expertise in only one of these areas using ink-writing pens which produced tracings on paper. It was does not confer the ability to accurately interpret the poly. When the tracings used to and rapid eye movement (REM) sleep. a 30-cm page corresponds to stages based on electroencephalographic (EEG) or electrical 30 seconds. The hypnogram is a convenient method of graphi. but the convention of scoring sleep in activity (1–3).indd 1 8/6/2009 4:01:10 PM . convenient to divide the night into epochs of time that corre- somnogram. an epoch. Each Common terms used in sleep monitoring are listed in 1 Chap01. the stage present for the below. N2. cally displaying the organization of sleep during the night. Sleep is composed of nonrapid eye movement (NREM) majority of the time names the epoch. electrooculographic (EOG) or eye move. and N3. spond to the length of each paper page. MD Troy A. REM sleep The monitoring of sleep is complex and requires a distinct is often highlighted by a dark bar. Stages N3 and N4 sleep epoch. the epoch is also scored as wake. Geyer.

The remains fairly constant.3) and is impacted by sleep dis- tion from lights out (start of recording) to lights on (termi. ciency (in percent) is usually defined as either the TST × 100/ SPT or TST × 100/TBT. This is the time dura. N3. sleep apnea. This • Stage N1. but relaxed. REM latency (usually <70 minutes) is noted in some cases of It is useful to determine not only the total minutes of each sleep apnea. They are more promi- nent in central than in occipital EEG tracings. Chronic insomnia (difficulty ening. The REM latency sleep is called the sleep latency. Bursts of alpha waves also • REM latency—time from first epoch of sleep to the first epoch are seen during brief awakenings from sleep—called arousals. state with • Sleep latency—time from lights out until the first epoch of the eyes closed. and any process that as a percentage of the sleep period time (%SPT). A sharp wave Chap01. Near the occupied by each sleep stage transition from stage N1 to stage N2 sleep. and R. This wake time is termed the WASO (wake after sleep initiating or maintaining sleep) is characterized by a long onset). Alpha activ- • Sleep efficiency—(TST × 100)/ TBT ity is prominent during drowsy eyes-closed wakefulness. 2 CHAPTER 1 Table 1-1. Alpha waves (8 to 13 Hz) are commonly • SPT (sleep period time) = TST + WASO noted when the patient is in an awake. (ethanol and many antidepressants). The amount of stages N3 of sleep monitoring (or lights out) until the first epoch of and R sleep is commonly decreased as well. WASO as % SPT—percentage of SPT high-amplitude negative waves (upward deflection on EEG occupied by sleep stages and WASO • Arousal index tracings) with a short duration—occur. and R as % TST—percentage of TST activity decreases with the onset of stage N1 sleep. SPT encompasses all sleep as well tive sleep apnea (OSA) there is often no stage N3 sleep and a as periods of wake after sleep onset and before the final awak. Therefore. N3. prior REM sleep depriva- sleep stage. R. In patients with severe obstruc- the sleep period time (SPT). and R • WASO (wake after sleep onset)—minutes of wake after first ranges are delta (<4 Hz). orders (Table 1-2). INTRODUCTION TO ELECTROENCEPHALOGRAPHIC TABLE 1-1 Sleep Architecture Definitions TERMINOLOGY AND MONITORING • Lights out—start of sleep recording EEG activity is characterized by the frequency in cycles per • Light on—end of sleep recording second or hertz (Hz). sleep stage varies with age (2. and MT is termed the total sleep time (TST). The total monitoring time or total recording time The normal range of the percentage of sleep spent in each (TRT) is also called total bedtime (TBT). depression. time spent in each sleep stage. The time from the first epoch is also affected by sleep disorders and medications. N3. while the amount of REM sleep N2. alpha (8 to 13 Hz). of REM sleep Alpha activity can also be seen during REM sleep. and the withdrawal of REM suppressant medications. One can characterize stages N1 An increased REM latency can be seen with REM suppressants to N3 and REM as a percentage of total sleep time (%TST). sleep with increasing age. amplitude (voltage). reduced amount of REM sleep. vertex sharp waves— • Stage N1. The amount of stage N1 sleep and time from the first sleep until the final awakening is called WASO also increases with age. The classically described frequency • TST (total sleep time) = minutes of stages N1. SPT = TST + WASO. an unfamiliar or uncom- Another method is to characterize the sleep stages and WASO fortable sleep environment. In adults there is a decrease in stage N3 nation of recording). Sleep effi. but also to characterize the relative proportion of tion. The total amount of sleep stages N1. N3. disturbs sleep quality. The time from the start sleep latency and increased WASO. and the direction of • TBT (total bedtime)—time from lights out to Lights on major deflection (polarity). N2. They are best recorded over the occiput and are sleep attenuated when the eyes are open. narcolepsy.indd 2 8/6/2009 4:01:10 PM . N2. N2. sleep but before the final awakening and beta (>13 Hz). A short of sleep until the first REM sleep is called the REM latency. theta (4 to 7 Hz).

amplitude of greater than 75 mV.1 15 Abdomen Variable 0. slow (delta) waves appear.1 15 Chest Variable 0. The K complex is a high-amplitude. but usually do not occur in tion of delta activity as less than 4 Hz.indd 3 8/6/2009 4:01:10 PM .1 35 Airflow (thermistor) Variable 0.3a 35a EOG 50 μV = 1 cm. Spindles frequently are superimposed on to determine if stage N3 is present (1) (see below). are narrower. As classically defined. 100 μV = 1 channel width 10 100 EKG 0. broad waves. 2 Hz (longer than 0. TABLE 1-3 Standard Sensitivity and Filter Settings Sensitivity Low Filter High Filter EEG 50 μV = 1 cm. negative voltage (by conven. a K com. These are of 0. biphasic wave of ity is defined for sleep staging purposes as waves slower than at least 0.1 15 SaO2 (%) 1 Volt = 0–100 or 50%–100% DC 15 Nasal pressure machine flow Variable DC or AC with low filter 15 setting of 0.3 35 EMG 50 μV = 1 cm. Because Chap01.5-second duration) with a peak-to-peak plex consists of an initial sharp. INTRODUCTION TO SLEEP AND POLYSOMNOGRAPHY 3 TABLE 1-2 Representative Changes in Sleep Architecture 20-Year-Old 60-Year-Old Severe Sleep Apneaa WASO% SPT 5 15 20 1% SPT 5 5 10 2% SPT 50 55 60 3% SPT 20 5 0 REM% SPT 25 20 10 a High interpatient variability.5 seconds. In contrast to the EEG defini- They may persist into stage N3. delta slow-wave activ- stage R. high-amplitude.5 to 1. and usually of lower amplitude. is defined as deflection of 70 to 200 milliseconds in duration K complexes. Sleep spindles are oscillations of 12 to 14 Hz with a duration As sleep deepens. 100 μV = 1 channel width 0.5-second duration. The amount of slow-wave tion an upward deflection) followed by a positive-deflection activity as measured in the central EEG derivations is used (down) slow wave.01 100 (to see snoring) a Note that these filter settings are different from traditional EEG monitoring settings. Sharp waves differ from K complexes in that they (Table 1-3). They are characteristic of stage N2 sleep. 100 μV = 1 channel width 0. not biphasic.

In a common approach. EMG1-EMG3). SLEEP STAGE CHARACTERISTICS ments are toward ROC and away from LOC. on transition to REM sleep. Because ROC is positioned above the eyes (and LOC below). However. movements (SEMs). If either of these leads fail. Phasic brief EMG bursts still may (4. ELECTROMYOGRAPHIC RECORDING EYE MOVEMENT RECORDING Usually. and a low-voltage mixed-frequency other. Therefore. a positive voltage is recorded. By standard convention. sleep. and an upward deflection in the LOC tracing. The chin EMG may also reach the Recording of eye movements is possible because a poten.5). their presence is a clue that REM sleep is present. by definition. a continuous series of closed) wakefulness and stage N1 sleep. eye move. The combination of REMs. three EMG leads are placed in the mental and submental The main purpose of recording eye movements is to identify areas. REM level long before the onset of REMS or an EEG meeting tial difference exists across the eyeball: front positive (+). REMs are sharper (more narrow deflec- a series of K complexes. In to the opposite mastoid (ROC-A1 and LOC-A2). Note that some characteristics are required (bold) and some Chap01. sleep is a reflection of the generalized skeletal-muscle hypoto- ment toward an electrode results in a downward deflection nia present in this sleep stage. Depending on the gain. one up and one down). The gain of the chin EMG is adjusted so and the left outer canthus (LOC). tions). Although they are not part of the criteria for scoring REM tracings usually causes in-phase defections.indd 4 8/6/2009 4:01:10 PM . which are typical of eyes-open wake and REM sleep. Eye movements are detected by EOG recording chin EMG amplitude from wakefulness to sleep and often a fur- of voltage changes. a reduction in the chin EMG is not required for stages graphs are calibrated so that a negative voltage causes an N2 to N3. settings. The voltage between two of these three is monitored (for REM sleep. pendular oscillating movements that are seen in drowsy (eyes- background EEG activity. differentiating the There are two common patterns of eye movements. eye movements produce out-of-phase deflections in the two eye tracings (e. a K com. To detect vertical as well as horizontal sleep. back criteria for stage R. Thus. with be seen during REM sleep. Sawtooth waves are notched-jagged waves of frequency in In the two-tracing method of eye movement recording. also called slow-rolling eye movements. the chin EMG is relatively reduced—the amplitude is some sleep centers use the same mastoid electrode as a reference equal to or lower than the lowest EMG amplitude in NREM (ROC-A1 and LOC-A1).. Note that movement of the eyes is usually conjugate. The chin EMG eye channels are recorded and the eye electrodes are referenced is an essential element only for identifying stage R sleep. the theta range (3 to 7 Hz) that may be present during REM large-amplitude EEG activity or artifact reflected in the EOG sleep. 4 CHAPTER 1 a K complex resembles slow-wave activity. one electrode is placed slightly above and one some activity in NREM sleep. When the eyes move toward an electrode.6). upward eye movement results in a downward deflection in the ROC tracing The basic rules for sleep staging are summarized in Table 1-4. However. upward eye move. the third at the outer corners of the eyes—at the right outer canthus (ROC) lead can be substituted. poly. a drop in activity is often seen slightly below the eyes (4. Slow eye two is sometimes difficult. ther reduction on transition from stage N1 to N3 may be seen. If the eye channels are calibrated with the same polarity EEG is consistent with stage R. are plex should stand out (be distinct) from the low-amplitude. stage R. a reduction in the negative (−). However. two that some activity is noted during wakefulness. Thus. SEMs high-voltage slow (HVS) waves would not be considered to be usually have disappeared. a rela- both eyes moving toward one eye electrode and away from the tively reduced chin EMG. EOG (eye movement) electrodes typically are placed example. The reduction in the EMG amplitude during REM upward pen deflection (negative polarity up).g. If the chin EMG gain is adjusted high enough to show eye movements. By stage N2 sleep.

The typical patterns associated the epoch). high-frequency Slow-rolling eye movements Relatively high >50% alpha activity Stage N1 Low-amplitude mixed. Episodic REMs Relatively reduced (equal frequency or lower than the lowest in NREM) Sawtooth waves—may be present a Required characteristics in bold. Slow-rolling eye movements Chap01. The EOG tracings typically show The stage N1 EEG is characterized by low-voltage. Stage Wake Stage N1 During eyes-open wake. the EEG is characterized by high- frequency low-voltage activity.b Stage EEG EOG EMG Wake (eyes open) Low-voltage. >50% means slow wave activity present in more than 50% of the epoch. INTRODUCTION TO SLEEP AND POLYSOMNOGRAPHY 5 TABLE 1-4 Summary of Sleep Stage Characteristics Characteristicsa. During eyes-closed drowsy wake. Eye blinks. rapid eye movements. are helpful but not required. frequency <2 Hz. K complexes Sharp waves near transition to stage N2 Stage N2 At least one sleep spindle May be lower than wake May be or K complex <20% lower than wake Slow-wave activityb C Stage N3 (present) >20% slow-wave activity Usually low C Stage N4 (prior) >50% slow-wave activity Usually low Stage R Low-voltage mixed. Stage N1 is scored when less ferentiation from Stage R sleep. movements are usually present. c Slow waves usually seen in EOG tracings. The level of muscle tone is usu- ally relatively high. Slow-rolling eye movements May be lower than wake frequency < 50% alpha activity NO spindles.indd 5 8/6/2009 4:01:10 PM . REMs Relatively high attenuated alpha activity Wake (eyes closed) Low-voltage. frequency activity (4 to 7 Hz). mixed- REM. than 50% of an epoch contains alpha waves and criteria for the EEG is characterized by prominent alpha activity (>50% of deeper stages of sleep are not met. peak to peak amplitude >75 µV. high-frequency. REMs. b Slow wave activity. Both slow scanning and more rapid irregular eye with each sleep stage are discussed below. and the chin EMG activity is relatively high allowing dif.

The patient is asked to lie qui. Vertex waves are common in stage N1 sleep and are defined There usually are three to five episodes of REM sleep during by a sharp configuration maximal over the central derivations. Epochs of sleep otherwise meeting criteria Stage N2 for stage R and contiguous with epochs of unequivocal stage R (REMs present) are scored as stage R (see Advanced Staging Stage N2 sleep is characterized by the presence of one or more Rules). nightmares) are more common in the early morning hours. or a major body movement fol- sleep. the presence of REMs in the absence of a reduced chin EMG therefore. Stage R sleep is characterized by a low-voltage. In a pathologic state known est proportion of the TST and accounts for roughly 40% to 50% as the REM behavior disorder. muscle tone is present. the slow-wave amplitude is lower brations at the start of the study. The activity. stage N3. lowed by SEMs and low-amplitude. Alpha activity tude of the slow waves (and amount of slow-wave sleep) is usu- usually appears with eye closure. parasomnias occurring in REM sleep (for example. making detection of sleep onset difficult. First. SEMs can These include somnambulism (sleep walking) and night terrors. The examiner can usually be EEG. Bursts of alpha waves can occur during REM sleep. stage R). Slow-wave activity is defined such as widespread skeletal muscle hypotonia and sleep-related as waves with a frequency less than 2 Hz and a minimum peak-to- erections. (<6 seconds of a 30-second epoch). also must contain less than 20% of slow (delta) wave EEG activity Stage R is associated with many unique. mixed-frequency ally stage N2) and work backward. The ability of a EMG often is lower than during stages N1 and N2 sleep. usually means the patient is still awake. Not all epochs of REM sleep contain REMs. an epoch the frequency is often 1 to 2 Hz slower than during wake. Often the easiest method to determine sleep onset in dif- ficult cases is to find the first epoch of unequivocal sleep (usu. but K complexes or sleep spindles. and a relatively low-am- confident of the point of sleep onset within one or two epochs. Stage N2 occupies the great- to prevent the acting out of dreams. Some patients do not exhibit prominent alpha the high-voltage EEG activity is transmitted to the eye leads. is variable. and the level of amplitude > 75 mV peak-to-peak) is present for greater than 20% muscle tone (EMG) is equal or diminished compared to that in of the epoch. and the total amount of slow-wave sleep is reduced. density) also increases during the night. Frequently. differentiating wakefulness from mostly in the early portions of the night. the EEG has considerable high-frequency activity. The ampli- etly with eyes open and then with the eyes closed. Sawtooth waves also may occur in the EEG. When patients do not pro. one must differentiate wake from stage N1 by the EEG. 6 CHAPTER 1 often are present in the eye movement tracings. Several parasomnias stage N1 sleep can be difficult. the awake state. gresses.indd 6 8/6/2009 4:01:10 PM . mixed-frequency EEG. the presence of episodic REMs. (disorders associated with sleep) occur in stage N3 sleep and. Several points are helpful. and body of sleep. an arousal. be present during drowsy wake and stage N1 sleep. which tend to increase in length as the night pro- Vertex waves should be easily distinguished from the back. The number of eye movements per unit time (REM ground activity. plitude chin EMG. or deep sleep. but this patient to produce alpha waves can be determined from biocali. Typically. Skeletal muscle hypotonia is a protective mechanism peak amplitude of greater than 75 mV. In stage N1. can be predicted to occur in the early part of the night. Spindles may be present in the EEG. the EEG has mixed frequency with activity in the 4 to 7 Hz theta Stage R range. Stage N2 sleep ends with a sleep stage transition (to stage movements and even violent behavior can occur during REM W. ally highest in the first sleep cycles. Stage N3 (formerly stage N3 and N4) Arousals Stages N3 NREM sleep is called slow-wave. physiologic changes. delta. To qualify as stage N2. stage N3 occurs duce significant alpha activity. In older patients. Frequent arousals can cause daytime sleepiness by Chap01. However. In this case By contrast. In wake. Arousal from sleep denotes a transition from a state of sleep to Stage N3 is scored when slow-wave activity (frequency < 2 Hz and wakefulness. the night.

mixed-frequency EEG be scored bursts of alpha rhythm are a fairly common occurrence in REM as stage R regardless of whether REMs are present. sudden bursts of delta (slow-wave) activity Four special cases in which sleep staging is made difficult by in the absence of other changes do not qualify as evidence of atypical EEG. Note that according to the above recom. which may include theta. R&K recommend that any section a concurrent increase in EMG amplitude for an arousal to be of the record that is contiguous with uneqivocal stage R and dis- scored. Relatively little mination of the frequency of arousals has become a standard data is available to define a normal range for the arousal index. However. patients with OSA frequently have arousals The frequency of arousals usually is computed as the arousal coincident with apnea/hypopnea termination. normal subjects of variable ages had a mean arousal index accompanied by a change in pattern on any additional chan.indd 7 8/6/2009 4:01:10 PM . INTRODUCTION TO SLEEP AND POLYSOMNOGRAPHY 7 shortening the total amount of sleep. daytime the above definition. but not spindles. part of the analysis of sleep architecture during sleep testing. Similarly. however. changes are not considered evidence of arousal in either NREM or REM sleep. For example. the EMG is at the stage R level. Subsequently. increases in the chin EMG in the absence of EEG not contain spindles. shorter arousals may also have physiologic impor- tance. qualifying changes included a decrease age (9). variable. In REM sleep. The 3-second duration was chosen for methodologi. agree with the concept that respiratory arousals of sufficient tion (8). and the three indicators of stage R rent increase in the submental EMG amplitude. Chap01. arousals. Many disorders that are associated with exces. EOG. ADVANCED SLEEP STAGING RULES cal reasons. and/or frequencies greater than 16 Hz. but the criteria used to define them was als with the upper-airway resistance syndrome (UARS) (10). even if arousals arousal. or an increase als associated with respiratory events) as low as 10 per hour in alpha activity. most would orders Association or ASDA) has become the standard defini. frequency. Atypical Sleep Patterns require a concurrent increase in submental EMG lasting at least 1 second. The commit- well as duration. the EEG must mendations. how- Kales (R&K) scoring manual (1) as an increase in EMG that is ever. Scoring of arousal during REM does. sive daytime sleepiness also are associated with frequent. However.” of 3 seconds or longer duration. the required EEG changes must be accompanied by like pattern simultaneously. of 21 per hour and the arousal index was found to increase with nel. brief also can represent evidence of arousal in certain contexts. K complexes. Therefore. an arousal should frequency can cause daytime sleepiness in the absence of frank be scored in NREM sleep when there is “an abrupt shift in EEG apnea and arterial oxygen desaturation. Note that the above guidelines represent a consensus Thus. deter. EOG. In one study. the restorative function of sleep depends on continuity as on events likely to be of physiologic significance. For EEG channels. although the TST is relatively normal (7). (EEG. the shift in EEG frequency Staging of REM sleep also requires special rules (REM rules) to must follow at least ten continuous seconds of any stage of define the beginning and end of REM sleep. arousals were the object of has been associated with daytime sleepiness in some individu- considerable research. To be scored as an arousal. Normal young adults studied after adaptation nights frequently Movement arousals were defined in the Rechtschaffen and have an arousal index of 5 per hour or less. This is necessary sleep. arousals. represent the mild end of the OSA syndrome. and EMG patterns will be briefly mentioned. alpha. or slow waves. because REMs are episodic. Arousals in NREM sleep may occur without a concur. To be REM-like. providing (but not NREM) sleep. tee recognized that other EEG phenomena. index (number of arousals per hour of sleep). and EMG) may not change to (or from) the REM- however. such as delta bursts. Because cortical EEG changes must be present to meet are brief (1 to 5 seconds) with a rapid return to sleep. a respiratory arousal index (RAI) (arous- in amplitude. such events are also termed electrocortical sleepiness may result. A report from the Atlas Task Force of the American While some have argued that patients with this disorder really Academy of Sleep Medicine (formerly the American Sleep Dis. According to the ASDA Task Force. paroxysmal high-voltage activity. This extra requirement was added because spontaneous plays a relatively low-voltage.

responding to NREM sleep). commonly continues into sleep. chronic pain syndromes. Nonnutritive sucking ity. Sleep spindles begin to appear at 2 months and are prominent “pseudo-spindle” activity (14 to 16 Hz rather than usually seen after 3 to 4 months of age (17).indd 8 8/6/2009 4:01:10 PM . and indeterminant sleep. Traditionally. The presence of spindles. 21). In new. The point at which sleep staging fol- some serotonin reuptake inhibitors (fluoxetine and others) lows adult rules is not well defined. age 6 months. For selected cases. exhaled or transcutaneous borns. delta active sleep (corresponding to REM sleep).to tion (20. and indeterminant sleep are listed sleep. An epoch is considered to have high or low EMG if sensing devices may accurately detect an absence of airflow over one half of the epoch shows the pattern. patients with the REM sleep behavior disorder may have during active (REM) sleep begins to decrease. After about 3 months. and NREM sleep is noted at by thermistors or thermocouples. quiet sleep usually shows a pattern of tracé discontinu EEG patterns to allow staging according to R&K rules. sor to be useful. and any cause of nonrestorative As children mature. or near the nasal inlet and over the mouth (nasal-oral sensor) and mixed (M) (Table 1-5). However. (19). the sleep cycle sleep (15). The fol. The pattern of high chin activity during what otherwise appears to be REM NREM at sleep onset begins to emerge. By contrast. period does not reach the adult value of 90 to 100 minutes until adolescence. their signal is not proportional to flow and they have Chap01. Many sleep centers also find using a snore sen- 60-minute periodicity with about 50% active sleep. 8 CHAPTER 1 In alpha sleep. The change from active to quiet sleep is more activity allows sleep staging despite prominent alpha activ. brushes disappear and TA pattern replaces tracé discontinue. Emde. RESPIRATORY MONITORING and feeding. and arterial oxygen satura- usually 16 to 18 hours. more typically adult EEG patterns begin sleep (11. As the infant matures. quiet eyes open. and Parmelee (16). quiet sleep (cor. norm. K complexes usu- the usual 12 to 14 Hz) (13). Newborn infants typically have periods of sleep lasting 3 to The three major components of respiratory monitoring during 4 hours interrupted by feeding and total sleep in 24 hours is sleep are airflow. Behavioral observations are critical. tracé alternant (TA). prominent alpha activity persists into NREM of active sleep. delta brushes (fast waves of 10 to 20 Hz) are Anders. the presence of REM (active sleep) at sleep onset is the PCO2 may also be monitored. psychiatric disorders. Causes of the pattern include pain. Patients taking benzodiazepines may have very to appear. the percentage of REM While a reduction in the chin EMG is required for staging REM sleep starts to diminish and the intensity of body movements sleep. While temperature as in adults. Sleep is often defined as sustained eye closure. which is often a transitional sleep stage. Wakefulness is characterized by crying. In addition. SEMs are usually absent by the ally begin to appear at 6 months of age and are fully developed time stable stage N2 sleep is present. However. airflow at the nose and mouth was monitored REM occupies about 20% of sleep. and slow-wave in Table 1-6. In premature Newborn term infants do not have the well-developed adult infants. K complexes. HVS. The characteristics (apnea). They have cycles of sleep with a 45. Note that the sleep of premature infants is somewhat differ- Sleep Staging in Infants and Children ent from term infants (36 to 40 weeks gestation). likely to manifest indeterminant sleep. quiet sleep. Eye movement monitoring is used to detect both nasal and mouth breathing. This differs from TA as there is electrical quiescence (rather lowing is a brief description of terminology and sleep staging than a reduction in amplitude) between bursts of high-voltage for the newborn infant according to the state determination of activity. flow of air over the sensor. 12). It is common to use a sensor in ized as low-voltage irregular (LVI). but usually is possible after may have prominent slow and REMs during NREM sleep (14). airflow by the change in the device temperature induced by a The EEG patterns of newborn infants have been character. respiratory effort. patients on by 2 years of age (18). These devices actually detect sleep onset. the adult sleep cycle is 90 to 100 minutes. Infant sleep is divided into superimposed on the delta waves.

TA. No body movements except or quiet sleep grimaces. INTRODUCTION TO SLEEP AND POLYSOMNOGRAPHY 9 TABLE 1-5 EEG Patterns Used in Infant Sleep Staging EEG Pattern Low-voltage irregular (LVI) Low-voltage (14–35 μV)a.to high-voltage (50–150 μV) slow waves (0. microvolts. M EOG REMs No REMs A few SEMs and a few dysconjugate movements may occur EMG Low High Respiration Irregular Regular Postsigh pauses may occur Chap01. little variation theta (5–8 Hz) predominates Slow activity (1–5 Hz) also present Tracé alternant (TA) Bursts of high-voltage slow waves (0. M.5–3 Hz) with superimposition of rapid low-voltage sharp waves 2–4 Hz In between the high-voltage bursts (alternating with them) is low-voltage mixed- frequency activity of 4 – 8 seconds in duration High-voltage slow (HVS) Continuous moderately rhythmic medium.and low-voltage polyrhythmic activity Voltage lower than in HVS μV. HVS (rarely) HVS.indd 9 8/6/2009 4:01:10 PM . frowns startles and phasic jerks Burst of sucking Sucking may occur Body—small digit or limb movements EEG LVI. a TABLE 1-6 Characteristics of Active and Quiet Sleep Active Sleep Quiet Sleep Indeterminant Behavioral Eyes closed Eyes closed Not meeting criteria for active Facial movements: smiles.5–4 Hz) Mixed (M) High-voltage slow.

cautious about making the diagnosis of central apnea solely on itored. an airflow signal from the flow-generating abdominal movement. Of note. the end-tidal PCO2 will be elevated flow profile (airflow limitation). Changes in body position may require device is often recorded instead of using thermistors or nasal adjusting band placement or amplifier sensitivity. Probably the most sensitive method pressure underestimates airflow at low flow rates and overes. changes in tidal volume (28). Changes in the RIPsum are estimates of istor. In addition. 10 CHAPTER 1 a slow response time (22). In RIP. The nasal pressure versus flow relationship can geal balloons or small fluid-filled catheters. the nasal pressure signal varies fairly lin. children with sleep apnea. rarely used in clinical diagnostic studies. monitoring of impedance monitoring. The inductance of each coil varies with changes in the detect snoring if the frequency range of the amplifier is ade. pneumotachographs are be performed with belts attached to piezoelectric transducers. Instead. area enclosed by the bands. ate constants: a and b. is detecting movement of the chest and abdomen. Thus. This is often at the end of exhalation) is an estimate of arterial PCO2. inspiratory effort (23). this signal although small expiratory puffs rich in CO2 can Arterial oxygen saturation (SaO2) is measured during sleep sometimes be misleading (6. An alternative approach to measuring flow is to use respi. 23). the signal does not always accurately reflect the amount shape of the nasal pressure signal can provide useful informa. this is rarely stretched. Exact measurement of airflow (>45 mm Hg) (21). How- performed. The unfiltered nasal pressure signal also can signals. pressure. they do not accurately During long periods of hypoventilation that are common in detect decreases in airflow (hypopnea) or flattening of the air. of chest/abdomen expansion. Therefore. Airflow is ratory events. The sum of the two signals [RIPsum = detected (10% to 15% of patients). the chest and abdominal bands may move the rib cage and abdomen band signals (RIPsum) can be used paradoxically. The surface EMG flow (22. RIP belts are more accu- quate. a change in body position may alter the to estimate changes in tidal volume (26. exhaled CO2 is often mon. However. nasal to detect respiratory effort. denoted as SpO2 to specify the method of SaO2 determination. This flow signal originates from a pneumotachograph very obese patients may show little chest/abdominal wall move- or other flow-measuring device inside the flow generator. 21). changes in pleural or intrathoracic pressure). This device Respiratory effort monitoring is necessary to classify respi- can be placed in a mask over the nose and mouth. rate in estimating the amount of chest/abdominal movement itoring is that mouth breathing often may not be adequately than piezoelectric belts. In the midrange of typical pressure (reflecting changes in pleural pressure) associated with flow rates during sleep. 27). This may tance (usually a wire screen). Apnea usually causes an absence of fluctuations in the basis of surface detection of inspiratory effort. Chap01. Piezoelectric bands be completely linearized by taking the square root of the nasal detect movement of the chest and abdomen as the bands are pressure signal (25). The end-tidal PCO2 (value studies using pulse oximetry (finger or ear probes). During positive. respiratory-inductance plethysmog- nasal pressure via a small cannula in the nose connected to a raphy (RIP). The nasal pressure signal is actually proportional of the intercostal muscles or diaphragm can also be monitored to the square of flow across the nasal inlet (24). A simple method of detecting respiratory effort determined by measuring the pressure drop across a linear resis. However. 23). for detecting effort is monitoring of changes in esophageal timates airflow at high flow rates. ability of either piezoelectric belts or RIP bands to detect chest/ pressure titration. one must be In pediatric polysomnography.indd 10 8/6/2009 4:01:10 PM . A flattened profile usually means that airflow limitation is tance of coils in bands around the rib cage (RC) and abdomen present (constant or decreasing flow with an increasing driving (AB) during respiratory movement are translated into voltage pressure) (22. This can be easily handled (a × RC) + (b × AB)] can be calibrated by choosing appropri- by monitoring with both nasal pressure and a nasal-oral therm. During upper-airway narrowing ratory inductance plethysmography. In addition to changes in magnitude. or monitoring of esophageal pressure (reflecting pressure transducer has gained in popularity for monitoring air. and the pull on the sensors generates a signal. can be performed by use of a pneumotachograph. The changes in the sum of or total occlusion. In general. Thus. in clinical practice. This may be performed with esopha- early with flow. changes in the induc- tion. ment despite considerable inspiratory effort. The only significant disadvantage of nasal pressure mon. changes in the ever.

This delay is secondary dence of airflow flattening (airflow limitation) in the nasal to circulation time and instrumental delay (the oximeter aver. in the absence of esophageal pressure monitoring. the nasal pressure shows a ages over several cycles before producing a reading). However. as well as the mean SaO2 and the minimum is associated with an absence of snoring. such differentiation is hypopnea can induce arousal from sleep. Various flattened profile not seen in the thermistor. (snoring). including computing the number of desaturations. small expiratory all of the following criteria are present. a com- • At least 90% of the event’s duration must meet the amplitude bination is possible (mixed hypopnea) with both a decrease in reduction of criteria for hypopnea respiratory effort and an increase in upper-airway resistance. obstructive hypopnea may not always be associ- ated with chest-abdominal paradox. most sleep cen- ADULT RESPIRATORY DEFINITIONS ters usually report only the total number and frequency of hypopneas. an AHI of less than • The nasal pressure signal excursions (or those of the alterna- 5 is considered normal. Alternatively. Using long averaging a central hypopnea cannot always be classified with certainty. pressure signal. Finally. Note the ration. Oximeters may vary file (nasal pressure). chest-abdominal paradox (increased load). Note that the nadir in SaO2 commonly follows an obstructive hypopnea by the presence of airflow vibration apnea (hypopnea) termination by approximately 6 to 8 sec. tive hypopnea sensor) drop by more than 50% of baseline Hypopneas can be further classified as obstructive. and 90%. the sudden transition from a flattened nasal pressure profile to a average minimum SaO2 of desaturations. A hypopnea should be scored only if sensitive device. apnea is defined as absence of airflow at the mouth for The new requirements for an event to be classified as a 10 seconds or longer (20. a hypopnea can also be scored if all of these cri- apnea + hypopnea index (AHI) is the total number of apneas teria are present. more rounded profile at event termination. unless accurate measures of airflow and esophageal Respiratory events that do not meet criteria for either apnea or or supraglottic pressure are obtained. there is “inspiratory apnea. In addition. In central apnea. or evi- onds (longer in severe desaturations). there is an absence of inspira- • At least 90% of the event’s duration must meet the amplitude tory effort. considerably in the number of desaturations they detect and However. airflow can • There is more than 3% oxygen desaturation from pre-event fall (obstructive hypopnea). In adults. In clinical practice. In • The nasal pressure signal excursions (or those of the alterna- this case. ple. INTRODUCTION TO SLEEP AND POLYSOMNOGRAPHY 11 A desaturation is defined as a decrease in SaO2 of 4% or more usually not possible. If the upper airway narrows significantly. A mixed apnea is defined as an apnea with an initial reduction of criteria for hypopnea central portion followed by an obstructive portion. • The duration of the event is at least 10 seconds or mixed. • The event duration is at least 10 seconds An obstructive apnea is cessation of airflow with persistent • There is more than 4% oxygen desaturation from pre-event inspiratory effort. In both examples.indd 11 8/6/2009 4:01:10 PM . The cause of apnea is an obstruction in the baseline upper airway. puffs can sometimes be detected during an apparent apnea. If one measures airflow with a very hypopnea are as follows. there is chest-abdominal paradox during the event. their ability to discard movement artifact. A central hypopnea 85%. the time below 80%. 21). In the second exam- measures have been applied to assess the severity of desatu. Such events have been Chap01. The Alternatively. central. and hypopneas per hour of sleep. A hypopnea is a reduction in airflow for 10 seconds or longer (20). Because of the limitations in exactly determining the type of hypopnea. times may dramatically impair the detection of desaturations. In adults. airflow can fall from a baseline or the event is associated with arousal decrease in respiratory effort (central hypopnea). a round airflow pro- saturation during NREM and REM sleep. one usually identifies from baseline. and absence of chest-abdominal paradox. such as a pneumotachograph.” Many sleep centers regard a tive hypopnea sensor) drop by more than 30% of baseline severe decrease in airflow (to <10% of baseline) to be an apnea.

Periodic breathing is defined as three or more respiratory especially during REM sleep. Many sleep centers also give sepa. The signifi- cance of central apnea in older children is less certain. the 10-second One can also detect flow-limitation arousals (FLA) using an rule for adults does not apply. moderate (15 to worsening paradox during an event would still suggest a par- 29). Of note. but is associated with a crescendo of inspiratory thought to be abnormal if the event is greater than 20 seconds effort (esophageal monitoring) or a flattened waveform on nasal in duration or associated with arterial oxygen desaturation or pressure monitoring (27). there is a significant bradycardia (30–33). the respiratory rate accurate measure of airflow. abnormal (31). mild (5 to <15). PCO2 greater than 53 mm Hg or end-tidal PCO2 greater than For example. rary. However. Typically. An AASM task force recommended that such events be called primarily in premature infants and mainly during active sleep respiratory effort-related arousals (RERAs). when longer Chap01. 12 CHAPTER 1 called upper-airway resistance events (UARE). up to 30% of normal pauses of at least 3 seconds in duration separated by less than children had some central apnea. One paper suggested that a peak end-tidal desaturation. tened profile). Central apnea in infants is or hypopnea. such as nasal pressure. Nasal pressure monitoring is being rate AHI values for NREM and REM sleep and various body posi. Most do PEDIATRIC RESPIRATORY DEFINITIONS not consider central apneas following sighs (big breaths) to be abnormal. The exact defi. Central apnea in infants was discussed above. However. some One can use the AHI to grade the severity of sleep apnea. In one study. The recommended (30). an obstructive AHI greater than 1 is considered to the RERA index identified by esophageal pressure monitoring abnormal. some feel that the presence of criteria for a RERA is a respiratory event of 10 seconds or longer periodic breathing for more than 5% of TST or during quiet followed by an arousal that does not meet criteria for an apnea sleep in term infants is abnormal. one might also grade the severity of desaturation. i. In children. Some centers compute a RAI. Some central apnea is probably normal in children. sudden drop in esophageal pressure deflections. Such events in children (20 to 30 per minute) is greater than in adults are characterized by flow limitation (flattening) over several (12 to 15 per minute). Some patients have a much higher AHI during REM sleep lation are more easily detected (reduced airflow with a flat- or in the supine position (REM-related or postural sleep apnea). There is usually a mild decrease in the RERAs per hour of sleep. paradoxical breathing is not necessarily abnormal. ally the time required for two to three respiratory cycles. 10 seconds in an adult is usu- breaths followed by an arousal and sudden. hypopnea. Therefore. or RERA/FLA events. In fact. it is possible for the overall AHI to be mild. calcified in infants and young children. but for 45 mm Hg for more than 60% of TST should be considered the patient to have quite severe desaturation during REM sleep. restoration of a normal-round airflow profile..e. Central apneas. determined as the arousals during NREM sleep is obstructive hypoventilation rather per hour associated with apnea. Stan. Although controversial. dard levels include normal (<5). and severe (>30) per hour. in some sleep centers the RDI rowing with a stable reduction in airflow and an increase in = AHI + RERA index. Periodic breathing is seen (10). tial airway obstruction. when the event is obstructive (30–33). following arousal. In children with OSA.indd 12 8/6/2009 4:01:10 PM . used more frequently in children and periods of hypoventi- tions. the predominant event (29). Obstructive hypoventila- The AHI and respiratory disturbance index (RDI) are often used tion is characterized by a long period of upper-airway nar- as equivalent terms. Normative values have been published for the Because the AHI does not always express the severity of oxygen end-tidal PCO2. than a discrete apnea or hypopnea. where the RERA index is the number of the end-tidal PCO2. after the UARS 20 seconds of normal respiration. a cessation of airflow of any duration (usu- nition of hypopnea that one uses will often determine whether ally two or more respiratory cycles) is considered an apnea a given event is classified as a hypopnea or a RERA. and RERAs are arousals associated with arterial oxygen desaturation. but often tempo. suggested that the number of FLA per hour corresponded closely Therefore. One study Obstructive apnea is very uncommon in normal children. The rib cage is not completely respiratory events not meeting criteria for apnea or hypopnea.

most would recommend observation alone unless the severe. along with the sensitivity. tion that is one-half to 10 seconds in duration (35). A PLM arousal index of more than 25 per hour is considered fore. may suggest the presence of the restless legs syndrome. Chap01. a calibra- An LM is defined as an increase in the EMG signal of a tion voltage signal (square wave voltage) was applied and the least one fourth the amplitude exhibited during biocalibra. Usually. the movement must occur in a group of four or more head electrodes is also checked prior to recording. such events have been noted in normal children (34). body position (using low-light the number of movements. and ≥50 per hour severe (36).000 W or less than 90 seconds (measured onset to onset).indd 13 8/6/2009 4:01:10 PM . Electrodes with higher impedances should be a periodic leg movement in sleep. This procedure permits check- LM separately. Similarly.5). or those of any length associated with SaO2 or following (within 1 to 2 seconds) a PLM. eye movements during wakefulness with eyes closed and open. a voltage is applied. each leg is displayed on a separate channel. phasic activity that occur during REM sleep. To be scored as is acceptable. the patient video monitoring) and treatment level (CPAP. For example. although a few index is the number of PLM arousals per hour of sleep. bilevel pres- is asked to dorsiflex and plantarflex the great toe of the right sure) are usually added in comments by the technologists. In most sleep centers. It is (paper recording) or at least one half of the channel width on standard practice to perform amplifier calibrations at the digital recording. a video recording is also made on traditional trodes and amplifier settings. of the calf) of both legs is monitored to detect leg movements (LMs) (35). Of note. were documented on the LMs (PLMs) should be differentiated from bursts of spikelike paper. However. in digital recording. LMs that occur during wake or after an arousal are events are frequent. especially at sleep LEG MOVEMENT MONITORING onset. one can link an elec- trode on each leg and display both leg EMGs on a single trac. The amplitude should be 1 cm video tape or digitally as part of the digital recording. It also provides a record of the patient’s EEG and lines for the PLM index are more than 5 to less than 25 mild. During biocalibration. A elec- trode loop is taped in place to provide strain relief. are often considered abnormal. A summary of typical commands and their utility is listed in A PLM arousal is an arousal that occurs simultaneously with Table 1-7. most centers. There. Two electrodes are placed on the belly of the upper portion of the muscle of each leg about 2 to 4 cm apart. the PLMW (PLMwake) index is the number of PLMs per hour of wake. In addition to the standard physiological parameters moni- ing. polarity. The impedance of the a PLM. Recording from both legs is required to accurately assess tored in polysomnography. each separated by more than 5 seconds and less impedance is less than 5. 25 to less than 50 moderate. The latter is a clinical diagnosis made on the basis of patient The EMG of the anterior tibial muscle (anterior lateral aspect symptoms. An ideal movements. Periodic and filter settings on each channel. In and then the left leg to determine the adequacy of the elec. BIOCALIBRATIONS. resulting pen deflections. either not counted or tabulated separately. transducers. an LM must be preceded changed. LMs A biocalibration procedure is performed (Table 1-7) associated with termination of respiratory events are not while signals are acquired with the patient connected to the counted as PLMs. by at least 10 seconds of sleep.000 W although 10. To be considered although it is often a sine-wave voltage. start of recording. In traditional paper recording. The PLM arousal below 90%. if the AND TECHNICAL ISSUES number of recording channels is limited. frequent LMs during wake. Rough guide. Some may score and tabulate this type of monitoring equipment (4. INTRODUCTION TO SLEEP AND POLYSOMNOGRAPHY 13 than 20 seconds. The PLM index is the number of periodic LMs ing of amplifier settings and integrity of monitoring leads/ divided by the hours of sleep (TST in hours). POLYSOMNOGRAPHY.

1968. Atlas of Sleep Medicine in Infants and placement of sleep disruption. 22. Johnson LC. Bundlie SR.15:174–184. JAMA 1987. benzodiazepine hypnotic. Roth T. Rush AJ. Monitoring and staging human 1995. Patterson AL. Los delta changes during chronic use of short acting and long acting Angeles: Brain Information Service/Brain Research Institute. MA. Alpha-delta sleep. look down Integrity of eye leads. sleep behavior disorder. PA: Hanley and Belfus. Dement WC. Boston. Kryger MH. Electroencephalography of Human 14. 2000:1197–1215. Butkov N. Rapid eye movement of Sleep Medicine. Armonk.12:159–165. Roth T. 4. Boysen PG. left toe Leg EMG. sleep. Polysomnography.23:263–271. Guillemenault C. Deep breath in. look left. polarity. Sleep apnea. Principles and Practice 15. Performance and sleepiness as a function of frequency and 19. et al.110–112. and arousals: Scoring rules and examples. 781–787. et al. University of 5. Schenck CH. Keenan SA. Butler F. Clerk A. Fluoxetine and oculomotor activ- Sleep: Clinical Applications. Block AJ. Dement WC. A Manual of Standardized Terminology 13. PA: WB Saunders. Ashland OR. eds. sleepiness: The upper airway resistance syndrome. In: Lee-Chiong TL. Williams RL. Metcalf D. oxygen desaturation in normal subjects: A strong male predominance. 9. 2002: 17. Evolution of sleep spindles in 605–637. Mathur R. Anders T. 55:662–667. A cause of excessive daytime MH. Ornitz E. 14 CHAPTER 1 TABLE 1-7 Biocalibration Procedure Eyes closed EEG: alpha EEG activity EOG: slow eye movements Eyes open EEG: attenuation of alpha rhythm EOG: REMs. look up. PA: WB Saunders. Wynne JW. PA: Hanley and 18. Sleep 1997. Techniques and Criteria for Scoring of State of Sleep and Wakefulness in 1999:151–169. Parmalee A. Spinweber CL. Mondale J. Trivedi M. Sleep Medicine. amplitude Eye movements should cause out-of-phase deflections Grit teeth Chin EMG Breathe in. Children. Riter S. eds. American Sleep Disorders Association—The Atlas Task Force: EEG 20. 2nd Ed. New York: Wiley. Rechschaffen A.104: Philadelphia. Philadelphia.18:330–333. Psychophysiology 1971. Principles and Practice of Sleep Medicine. 1971. et al.257:1786–1789. Bonnet MH. Detection of respiratory 11. 21. Electroencephalogr Clin Neurophysiol 1983. Butkov N. Neuropsychopharmacology 3. Hawkins DR. 2003. Sleep spindle and Techniques and Scoring System for Sleep Stages of Human Sleep. et al. Douglas NJ. Berry RB. UCLA.indd 14 8/6/2009 4:01:10 PM . Atlas of clinical polysomnography. Sleep Medicine Pearls. Rechtschaffen A. 2000:1217–1230. 1.34:233–237. Seidel WR. Chap01. Sleep 1995. Kaplan A. Sleep Disorders Medicine. Sateia MJ. Frequency of EEG arousals from nocturnal N Engl J Med 1979. In: Kryger 10. hypopnea. Hauri P. Psychophysiology 1986.38:175. Sleep 1992. 6. Armitage R. et al. ity during sleep in depressed patients. Stoohs R. amplitude reference to evaluate LMs REFERENCES 12. A Manual of Standardized Terminology. Hursch CJ. Chest 1993. ed. Karacan I. Los Angeles: Brain Information Service. hold breath Apnea detection Wiggle right toe. breathe out Airflow. Monitoring respiratory and cardiac function. S. Sheldon SH. Philadelphia. Kales A.20:1175–1184. K complexes. eds. Media 1996. et al. MA: Butterworth-Heinemann. 7. Carskadon California Los Angeles. chest. Electroencephalogr Clin Neurophysiol 1973. abdomen movements adequate gain? Tracings in phase? (polarity of inspiration is usually upward). 8. eds. Emde R. Electroencephalogr Clin Neurophysiol 1975. blinks Look right. Detrojan M. childhood.26:49. 1974. 2. Walsleben JA. Philadelphia. 1999. sleep in normal subjects. Ahmed MM. Synapse events during NPSG: Nasal cannula/pressure sensor versus thermistor. Caraskadon MA.330:513–517. Ontogenesis of spontaneous Belfus. In: Kryger MH. Tanguay P. Newborn Infants. Norman RG. Polysomnographic techniques: An overview. NY: Futura. In: Chokroverty 16.

INTRODUCTION TO SLEEP AND POLYSOMNOGRAPHY 15

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Chap01.indd 15 8/6/2009 4:01:10 PM

Chap01.indd 16 8/6/2009 4:01:10 PM

CHAPTER

2 Staging
James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD

17

Chap02.indd 17 8/6/2009 8:07:01 PM

18 CHAPTER 2

FIGURE 2-1 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 60-second page.
Clinical: 55-year-old man.
Staging: Stage wake. Biocalibration of eye movements. The patient is instructed to look up and down, left
and right, and to open and close the eyes. The representations of these eye movements insure that the eye
movement is properly recorded and provide a reference for identification of rapid eye movements during
REM sleep and wakefulness.

Chap02.indd 18 8/6/2009 8:07:01 PM

STAGING 19

FIGURE 2-2 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 60-second page.
Clinical: 55-year-old man.
Staging: Stage wake. Biocalibration of breathing and leg movements. The representations of these activi-
ties insure that they are recorded properly and assist in the identification of breathing and leg move-
ment abnormalities during sleep.

Chap02.indd 19 8/6/2009 8:07:03 PM

20 CHAPTER 2

* ^
FIGURE 2-3 Polysomnogram: Standard montage; 30-second page.
Clinical: 47-year-old woman.
Staging: Stage wake. Eyes are open. There is a well-modulated posteriorly dominant 9-Hz alpha rhythm
which is attenuated when eyes are open (*) and becomes more prominent with eye closure (∧).

Chap02.indd 20 8/6/2009 8:07:05 PM

STAGING 21 FIGURE 2-4 Polysomnogram: CPAP montage. Wakefulness with eyes open and rapid eye movements. Chap02. Clinical: 23-year-old man. Staging: Stage wake.indd 21 8/6/2009 8:07:06 PM . The alpha rhythm attenu- ates when the eyes are open. a small amount of alpha activity can be seen from the occipital deriva- tions during the last few seconds of the page. 30-second page.

Clinical: 17-year-old man. 30-second page. In this patient. There is a well-modulated 8-Hz alpha rhythm. 22 CHAPTER 2 FIGURE 2-5 Polysomnogram: Standard montage. Staging: Stage wake. the alpha rhythm is well represented in the central derivations. The alpha rhythm is most prominent posteriorly but its scalp topography varies across individuals. Chap02.indd 22 8/6/2009 8:07:08 PM .

STAGING 23 FIGURE 2-6 Polysomnogram: Standard montage with intrathoracic pressure monitoring.indd 23 8/6/2009 8:07:09 PM . 30-second page. Chap02. Staging: Stage wake. Clinical: 29-year-old man. Slow eye movements with continued alpha activity indicate that the subject is drowsy and approaching the transition to stage N1 sleep.

Staging: Stage wake. 24 CHAPTER 2 * * FIGURE 2-7 Polysomnogram: Standard montage.indd 24 8/6/2009 8:07:11 PM . Clinical: 39-year-old woman. intermittent prominent theta activity (*) is consistent with brief episodes of sleep (microsleep). Although alpha activity is present during the majority of the epoch. Chap02. 30-second page.

Chap02. Transition from wakefulness to stage N1 sleep with slow eye movements. The alpha rhythm is present during the first 6 seconds. becomes intermittent for the next 11 seconds. and is fully replaced by theta activity during the final 13 seconds. Clinical: 34-year-old man. STAGING 25 FIGURE 2-8 Polysomnogram: Standard montage with intrathoracic pressure monitoring. 30-second page. Staging: Stage N1 sleep.indd 25 8/6/2009 8:07:12 PM .

26 CHAPTER 2 FIGURE 2-9 Polysomnogram: CPAP montage.indd 26 8/6/2009 8:07:14 PM . Clinical: 37-year-old man. Staging: Stage N1 sleep. 30-second page. Chap02.

Chap02. Clinical: 37-year-old man. Staging: Stage N1 sleep with prominent theta activity. There are slow eye movements and a gradual reduction of EMG activity.indd 27 8/6/2009 8:07:16 PM . 30-second page. STAGING 27 FIGURE 2-10 Polysomnogram: CPAP montage.

Alpha activity characteristic of wakefulness is present during the final third of the epoch. Several seconds of stage N1 sleep are followed by an awakening. Staging: Stage N1 sleep with an arousal (*) followed by movement artifact. 30-second page.indd 28 8/6/2009 8:07:17 PM . Clinical: 29-year-old man. Chap02. The respiratory and EEG channels are obscured by artifact for sev- eral seconds. 28 CHAPTER 2 * FIGURE 2-11 Polysomnogram: Standard montage.

EEG: Rhythmic moderate to high amplitude 4.to 5-Hz activity.indd 29 8/6/2009 8:07:18 PM . referred to as hypnagogic hypersyn- chrony (*). a K complex (∧) indicates the transition to stage N2 sleep. Near the end of the epoch. is a prominent feature of drowsy wakefulness and stage N1 sleep between the ages of 6 months and 6 years. Clinical: 5-year-old girl. Staging: Stage N1 sleep. Chap02. STAGING 29 * ^ FIGURE 2-12 Polysomnogram: Standard montage. It becomes less prominent during late childhood and adolescence. 30-second page.

indd 30 8/6/2009 8:07:19 PM . Chap02. 30 CHAPTER 2 * * ^ FIGURE 2-13 Polysomnogram: Standard montage. Staging: Stage N1 sleep. 30-second page. These transients are seen in most persons during stage N1 sleep and occasionally during stage N2 sleep. There are positive occipital sharp transients (POSTs) (*) and vertex waves (∧). Clinical: 55-year-old man.

Chap02. 7.5-second page. STAGING 31 * * * FIGURE 2-14 Polysomnogram: Standard montage.indd 31 8/6/2009 8:07:20 PM . Clinical: 55-year-old man. Staging: Stage N1 sleep with several POSTs (*).

Chap02. Clinical: 62-year-old man. Staging: Stage N2 sleep with a K complex (*) and repetitive POSTs (∧). 32 CHAPTER 2 * ^ FIGURE 2-15 Polysomnogram: Standard montage.indd 32 8/6/2009 8:07:20 PM . 30-second page.

30-second page. Clinical: 34-year-old man. Staging: Stage N2 sleep with sleep spindles (*).indd 33 8/6/2009 8:07:21 PM . STAGING 33 * FIGURE 2-16 Polysomnogram: Standard montage. Chap02.

Chap02. 34 CHAPTER 2 ^ * ^ FIGURE 2-17 Polysomnogram: CPAP montage.indd 34 8/6/2009 8:07:21 PM . Clinical: 38-year-old woman. 30-second page. Staging: Stage N2 sleep with K complexes (*) and sleep spindles (∧).

STAGING 35 * ^ FIGURE 2-18 Polysomnogram: Standard montage. A vertex wave (∧) is also evident. 30-second page. Clinical: 44-year-old woman. although they are most prominent in stage N1 sleep. Chap02.indd 35 8/6/2009 8:07:22 PM . Staging: Stage N2 sleep with a K complex (*). they can be seen occasionally in stage N2 sleep.

Chap02. Clinical: 57-year-old man. A transient with features intermedi- ate between a K complex and a vertex wave is evident (**). Staging: Stage N2 sleep with a K complex (*) and vertex waves (∧). 36 CHAPTER 2 ^ ** * ^ FIGURE 2-19 Polysomnogram: Standard montage. 60-second page.indd 36 8/6/2009 8:07:23 PM .

STAGING 37 * ^ ^ FIGURE 2-20 Polysomnogram: Standard montage. 60-second page. Staging: Stage N2 sleep with K complexes (*) and sleep spindles (∧). Chap02.indd 37 8/6/2009 8:07:23 PM . Clinical: 44-year-old woman. The individual waves of the sleep spindles cannot be distinguished with the 60-second display.

Staging: Stage N2 sleep with sleep spindles (*) and a vertex wave (∧). The expanded EEG montage demonstrates the frontocentral topography of the sleep spindle and the parasagittal topography of the vertex wave. 38 CHAPTER 2 * ^ FIGURE 2-21 Polysomnogram: Expanded EEG montage. 30-second page. Clinical: 24-year-old man. Chap02.indd 38 8/6/2009 8:07:24 PM .

indd 39 8/6/2009 8:07:25 PM . Clinical: 24-year-old man. STAGING 39 * ^ * * * FIGURE 2-22 Polysomnogram: Expanded EEG montage. 30-second page. Chap02. Staging: Stage N2 sleep with frequent sleep spindles (*) and K complexes (∧).

30-second page. 40 CHAPTER 2 * FIGURE 2-23 Polysomnogram: EEG channels only. Chap02. Staging: Stage N2 sleep with sleep spindles and vertex waves. is within normal limits. with greater amplitude in the right temporal derivations than in the left temporal deriva- tions. Clinical: 24-year-old man.indd 40 8/6/2009 8:07:26 PM . The asymmetric topography of the initial spindle (*).

indd 41 8/6/2009 8:07:26 PM . Clinical: 24-year-old man. 30-second page. Some spindles (*) are better represented in temporal derivations than in other derivations. Staging: Stage N2 sleep with sleep spindles and K complexes. Chap02. STAGING 41 * FIGURE 2-24 Polysomnogram: EEG channels only.

30-second page. Staging: Stage N2 sleep with K complexes and sleep spindles.indd 42 8/6/2009 8:07:27 PM . The presence of delta waves (*) presages the transition to stage N3 sleep. Chap02. 42 CHAPTER 2 * FIGURE 2-25 Polysomnogram: CPAP montage. Clinical: 67-year-old man.

Other features of stage N2 sleep are present including K complexes and POSTs. Chap02. Clinical: 68-year-old man with excessive daytime sleepiness and chronic obstructive pulmonary disease (COPD). Respiratory: Normal respirations. Staging: Stage N2 sleep.indd 43 8/6/2009 8:07:28 PM . EEG: Asymmetric sleep spindles occurring first on the right (*) and then on the left (∧). 30-second page. STAGING 43 * ^ FIGURE 2-26 Polysomnogram: Expanded EEG montage with CO2 monitoring.

POSTs are prominent in the occipital derivations.indd 44 8/6/2009 8:07:29 PM . Chap02. 44 CHAPTER 2 * FIGURE 2-27 EEG channels from an expanded EEG montage polysomnogram. Staging: Stage N2 sleep. EEG: Asymmetric sleep spindles (*) most prominent over the left hemisphere especially channels Fp1-F3 and F3-C3. Clinical: 68-year-old man with excessive daytime sleepiness and COPD. 10-second page.

STAGING 45 FIGURE 2-28 Polysomnogram: Standard montage. 30-second page. The delta waves characteristic of slow wave sleep are prominent by the end of the first year of life. Clinical: 10-month-old girl. Chap02. Staging: Stage N3 sleep.indd 45 8/6/2009 8:07:30 PM .

Chap02.indd 46 8/6/2009 8:07:32 PM . Clinical: 2-year-old boy. 46 CHAPTER 2 FIGURE 2-29 Polysomnogram: Expanded EEG montage. Staging: Stage N3 sleep. 30-second page.

STAGING 47 FIGURE 2-30 Polysomnogram: Standard montage. Chap02. 30-second page.indd 47 8/6/2009 8:07:34 PM . Clinical: 4-year-old boy. Staging: Stage N3 sleep.

indd 48 8/6/2009 8:07:35 PM . Clinical: 4-year-old boy. 30-second page. Staging: Stage N3 sleep. 48 CHAPTER 2 FIGURE 2-31 Polysomnogram: Standard montage. Chap02.

indd 49 8/6/2009 8:07:37 PM . Chap02. STAGING 49 FIGURE 2-32 Polysomnogram: Standard montage. Clinical: 6-year-old boy. Staging: Stage N3 sleep. 30-second page.

Clinical: 8-year-old girl. Staging: Stage N3 sleep. 50 CHAPTER 2 FIGURE 2-33 Polysomnogram: Standard montage. 30-second page. Chap02.indd 50 8/6/2009 8:07:39 PM .

Chap02. STAGING 51 FIGURE 2-34 Polysomnogram: Standard montage.indd 51 8/6/2009 8:07:41 PM . Staging: Stage N3 sleep. 30-second page. Clinical: 10-year-old boy.

52 CHAPTER 2 FIGURE 2-35 Polysomnogram: Standard montage. 30-second page. Staging: Stage N3 sleep.indd 52 8/6/2009 8:07:43 PM . Chap02. Clinical: 18-year-old man.

Clinical: 18-year-old man. Staging: Stage N3 sleep.indd 53 8/6/2009 8:07:45 PM . 30-second page. Chap02. STAGING 53 FIGURE 2-36 Polysomnogram: Standard montage.

indd 54 8/6/2009 8:07:47 PM . The delta waves are diffusely distributed with greater ampli- tude in anterior derivations. Clinical: 29-year-old man. 54 CHAPTER 2 FIGURE 2-37 Polysomnogram: Expanded EEG montage. Staging: Stage N3 sleep with delta activity. Chap02. 30-second page with 1-second lines.

Delta activity originating in prefrontal regions is well repre- sented in the eye movement channels. 30-second page.indd 55 8/6/2009 8:07:48 PM . Chap02. STAGING 55 FIGURE 2-38 Polysomnogram: CPAP montage. Clinical: 35-year-old woman. Staging: Stage N3 sleep with delta activity.

56 CHAPTER 2 FIGURE 2-39 Polysomnogram: CPAP montage. Clinical: 35-year-old woman.indd 56 8/6/2009 8:07:50 PM . Chap02. Staging: Stage N3 sleep with nearly continuous delta activity. 60-second page.

Clinical: 35-year-old woman. Staging: Stage N3 sleep with delta activity.indd 57 8/6/2009 8:07:52 PM . 120-second page. Chap02. STAGING 57 FIGURE 2-40 Polysomnogram: CPAP montage.

30-second page. Clinical: 48-year-old man. a pattern referred to as alpha-delta sleep. Unlike alpha activity characteristic of wakefulness.indd 58 8/6/2009 8:07:54 PM . 58 CHAPTER 2 FIGURE 2-41 Polysomnogram: Standard montage. Chap02. Staging: Stage N3 sleep with alpha activity during delta sleep. The clinical significance of this finding is uncertain. the alpha activity of alpha-delta sleep is diffusely distributed and does not have a posterior maximum.

STAGING 59 FIGURE 2-42 Polysomnogram: Standard montage. Chap02.indd 59 8/6/2009 8:07:56 PM . Clinical: 48-year-old man. Staging: Stage N3 sleep with alpha activity during delta sleep. 60-second page.

Chap02. 60 CHAPTER 2 FIGURE 2-43 Polysomnogram: CPAP montage with CO2 monitoring. The alpha activity is nearly continuous during the second half of the epoch. Staging: Stage N3 sleep with alpha activity during delta sleep. Clinical: 57-year-old man. 30-second page.indd 60 8/6/2009 8:07:58 PM .

Staging: Stage R sleep. such as this one. Chap02. Clinical: 35-year-old woman. that do not contain rapid eye movements are sometimes referred to as tonic REM sleep. Sawtooth waves (*) characteristic of REM sleep are evident. Epochs of REM sleep. STAGING 61 * FIGURE 2-44 Polysomnogram: CPAP montage.indd 61 8/6/2009 8:08:00 PM . 30-second page.

60-second page. Chap02. 62 CHAPTER 2 * FIGURE 2-45 Polysomnogram: CPAP montage. Clinical: 35-year-old woman. Staging: Stage R sleep with sawtooth waves (*).indd 62 8/6/2009 8:08:01 PM .

STAGING 63 FIGURE 2-46 Polysomnogram: CPAP montage. Several rapid eye movements occur in a cluster accompanied by limb twitches and irregular respirations. Epochs containing such clusters of rapid eye movements and muscle twitches are sometimes referred to as phasic REM sleep.indd 63 8/6/2009 8:08:01 PM . Clinical: 35-year-old woman. Staging: Stage R sleep. 60-second page. Chap02.

and poorly formed sawtooth waves. 30-second page. 64 CHAPTER 2 FIGURE 2-47 Polysomnogram: Standard montage. brief bursts of EMG activity. Chap02. Staging: Stage R sleep. There are rapid eye movements. Clinical: 59-year-old man.indd 64 8/6/2009 8:08:03 PM .

Clinical: 64-year-old man.5-second page.indd 65 8/6/2009 8:08:05 PM . STAGING 65 * FIGURE 2-48 Polysomnogram: CPAP montage. Staging: Stage R sleep with sawtooth waves (*). 7. Chap02.

indd 66 8/6/2009 8:08:05 PM . rapid eye movements were present in preceding and succeeding epochs. Chap02. 30-second page. Clinical: 39-year-old woman. Staging: Stage R sleep with sawtooth waves (*). indicating that this epoch should be scored as REM sleep. 66 CHAPTER 2 ^ * FIGURE 2-49 Polysomnogram: Standard montage with intrathoracic pressure monitoring. Although a single K complex (∧) is present.

30-second page. Chap02. The amount of posterior dominant alpha activity during REM sleep varies widely among individuals.indd 67 8/6/2009 8:08:06 PM . Clinical: 41-year-old man. Staging: Stage R sleep with alpha activity (*). STAGING 67 * FIGURE 2-50 Polysomnogram: CPAP montage.

68 CHAPTER 2 FIGURE 2-51 Polysomnogram: Standard montage. 30-second page. most prominent in the O2-A1 derivation.indd 68 8/6/2009 8:08:07 PM . Staging: Stage R sleep with a small amount of posteriorly dominant alpha activity. Clinical: 55-year-old man. Chap02.

STAGING 69 FIGURE 2-52 Polysomnogram: CPAP montage. Staging: Stage R sleep with phasic eye movements. Chap02. 30-second page. Clinical: 61-year-old man.indd 69 8/6/2009 8:08:08 PM . The amount of EMG activity is probably above normal. EMG: Bursts of EMG activity accompany the eye movements.

70 CHAPTER 2 FIGURE 2-53 Polysomnogram: Standard montage with intrathoracic pressure monitoring. followed by the appearance of rapid eye movements. Chap02. Clinical: 24-year-old man. Staging: Transition from NREM sleep to REM sleep. During the transition into REM sleep.indd 70 8/6/2009 8:08:10 PM . 30-second page. the EMG tone decreases to complete muscle atonia about midway through the epoch.

STAGING 71 * FIGURE 2-54 Polysomnogram: Standard montage. 30-second page. Staging: Stage R sleep with sawtooth waves (*). Chap02. Clinical: 49-year-old man.indd 71 8/6/2009 8:08:12 PM .

72 CHAPTER 2 FIGURE 2-55 Polysomnogram: Expanded EEG. are often recorded by lateral frontal or anterior temporal (T1 and T2) electrodes. such as these. Horizontal rapid eye movements. while vertical eye movements may be recorded by prefrontal (Fp1 and Fp2) electrodes. The potentials produced by rapid eye movements are recorded by the lateral frontal electrodes.indd 72 8/6/2009 8:08:12 PM . Clinical: 38-year-old man. Chap02. F7 and F8. Staging: Stage R sleep with representation of rapid eye movements in channels Fp1-F7 and Fp2-F8. 60-second page.

Chap02. Staging: Stage R sleep without eye movements.indd 73 8/6/2009 8:08:14 PM . Clinical: 49-year-old man. 30-second page. STAGING 73 FIGURE 2-56 Polysomnogram: Standard montage.

74 CHAPTER 2

FIGURE 2-57 Polysomnogram: Standard montage; 30-second page.
Clinical: 49-year-old man.
Staging: Stage R sleep with a cluster of rapid eye movements.

Chap02.indd 74 8/6/2009 8:08:16 PM

STAGING 75

FIGURE 2-58 Polysomnogram: Standard montage; 30-second page.
Clinical: 49-year-old man.
Staging: Stage R sleep with frequent rapid eye movements.

Chap02.indd 75 8/6/2009 8:08:18 PM

76 CHAPTER 2

* ^
FIGURE 2-59 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 28-year-old man.
Staging: Transition from NREM sleep to REM sleep. There are elements of REM sleep including sawtooth
waves (*) and decreased muscle tone. There are also several sleep spindles (∧). Features of REM and
NREM sleep are often intermixed for a few seconds or minutes before and after a period of REM sleep.

Chap02.indd 76 8/6/2009 8:08:20 PM

STAGING 77

FIGURE 2-60 Polysomnogram: Standard montage; 60-second page.
Clinical: 5-week-old girl.
Staging: Stage R sleep with incomplete atonia.
Respiratory: Irregular respirations during REM sleep. Such variations in frequency and amplitude of respi-
rations are normal at this age during REM sleep.

Chap02.indd 77 8/6/2009 8:08:20 PM

78 CHAPTER 2

FIGURE 2-61 Polysomnogram: CPAP montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 22-year-old woman treated with fluoxetine.
Staging: Stage N3 sleep with alpha activity (alpha-delta sleep).
EOG: Slow eye movements. Slow eye movements are usually confined to drowsy wakefulness and stage
N1 sleep. However, fluoxetine and other antidepressants may cause such eye movements to occur in
all stages of sleep.

Chap02.indd 78 8/6/2009 8:08:22 PM

STAGING 79

FIGURE 2-62 Polysomnogram: Standard montage; 60-second page.
Clinical: 49-year-old man.
Staging: Awakening with a position change.

Chap02.indd 79 8/6/2009 8:08:24 PM

Chap02. Stage N3 sleep. and an arousal.indd 80 8/6/2009 8:08:26 PM . Staging: Elements of stage N2 sleep. Clinical: 55-year-old man. Respiratory: Hypopnea with an associated arousal. 30-second page. REM sleep. 80 CHAPTER 2 FIGURE 2-63 Polysomnogram: Standard montage.

EEG: Trace discontinue with delta brushes. Chap02. This discontinuous EEG pattern is a normal feature of NREM sleep (quiet sleep) at this age. Clinical: 30-week conceptional age patient. STAGING 81 FIGURE 2-64 Neonatal recording: 30-second page.indd 81 8/6/2009 8:08:28 PM . Respiratory: Normal respirations.

Chap02. Respiratory: Normal respirations. Clinical: 30-week conceptional age patient.indd 82 8/6/2009 8:08:30 PM . 82 CHAPTER 2 FIGURE 2-65 Neonatal recording: 30-second page. EEG: Trace discontinue with delta brushes during NREM sleep.

Chap02. STAGING 83 FIGURE 2-66 Neonatal recording: 30-second page. Respiratory: Partially obscured by artifact. Clinical: 42-week conceptional age patient in NREM sleep. The tracé alternant pattern is a normal feature of NREM sleep at this age.indd 83 8/6/2009 8:08:32 PM . EEG: Tracé alternant with bursts of higher amplitude delta and theta activity separated by periods of moderate amplitude mixed frequency activity.

EEG: Continuous mixed frequency background activity. Chap02. REM sleep is the most common sleep onset pat- tern in neonates and makes up about 50% of newborn sleep. 84 CHAPTER 2 FIGURE 2-67 Neonatal recording: 30-second page. Clinical: 30-week conceptional age patient in R sleep (active sleep). Respiratory: Slightly irregular respirations.indd 84 8/6/2009 8:08:34 PM .

Clinical: 4-month-old patient in NREM sleep. EEG: Symmetric sleep spindles and vertex waves. Chap02. STAGING 85 FIGURE 2-68 Infant recording: 15-second page.indd 85 8/6/2009 8:08:36 PM .

86 CHAPTER 2 FIGURE 2-69 Polysomnogram: Standard montage. 60-second page. Eye leads: Slow eye movements on eye channels. Chap02. Clinical: 49-year-old man with some snoring and excessive daytime sleepiness.indd 86 8/6/2009 8:08:37 PM . Also just recently started an SSRI for depression and has developed restless sleep. The PLM index was 63. Staging: Stage N2 sleep. Discontinuation of the SSRI and switching to another antidepressant dramatically improved the restless sleep and daytime sleepiness.7. Leg leads: PLMs.

EOG. snore sensor. Periodic limb movements (327.indd 87 8/6/2009 8:08:40 PM .54). intercostal EMG. body position. EKG: unRarkable. frontal. There is no evidence of a sleep-related breathing disorder. The findings indicate periodic limb movements with associated arousals.54).7% (4%–8%) Sleep latency: 43 minutes Stage N2 sleep: 65.9 RERA Index: 1.5 minutes Analysis—see detailed analysis tables EEG/Sleep Stage Stage N1 sleep: 15. and behavior unless otherwise noted. The tracing was recorded in 30-second epochs. submentalis EMG. Clinical correlation is advised. respiration. EEG.2% (23%–31%) Respiratory AHI: 1 NR AHI: 0. TR: DD: DT: Chap02.5 Impression: Sleep disturbance with hypersomnolence (780.51).5 minutes Stage N3 sleep: 0% (4%–20%) Sleep efficiency: 87. Study Description: Polysomnogram Equipment: Central. EKG.2 Minimum Oxygen Saturation: 93% Snoring: moderate. oxygen saturation. abdominal motion. thoracic motion. Limb Movement PLM Index: 46. airflow.3 (9 RERA) Total Respiratory Events: 7 (7 obstructive) Arousal Index: 15. A normal polysomnogram does not exclude the possibility of obstructive sleep apnea or other sleep disorders.8 R AHI: 2 Supine AHI: 0. This is a summary report. EKG.5 PLM Arousal Index: 11. MD The physician reviewed the record in its entirety. EMG activity. Please see the additional tabular report from this study for more detailed analysis. STAGING 87 Unremarkable Respirations and Frequent PLM’s Patient: Account Number: Medical Records: Study Number: Date of Study: Date of Birth: Requesting Physician: Referring Physician: Indications for Study: Sleep disturbance with hypersomnolence (780. and pulse oximetry were recorded throughout the study. Recommendations: The patient will be scheduled for a follow-up visit.2% Stage R sleep: 19.5 minutes. The interpretation is based on this information in addition to the available clinical history and physical examination.1% (45%–63%) R latency: 130. Sleep Time: 423. and occipital EEG. including sleep staging. Sleep Study Summary Report: Record Time: 485. anterior tibialis EMG. ______________ .

Chap02.indd 88 8/6/2009 8:08:40 PM .

Geyer. MD Paul R. Carney. MD Troy A. Payne. Multiple Sleep Latency CHAPTER Test (MSLT) / Maintenance 3 of Wakefulness Test (MWT) James D. MD 89 Chap03.indd 89 8/6/2009 4:06:41 PM .

Clinical: 32-year-old man with excessive daytime sleepiness. Calibration test. Chap03.indd 90 8/6/2009 4:06:42 PM . 90 CHAPTER 3 FIGURE 3-1 Multiple Sleep Latency Test: 30-second page. Staging: Wakefulness.

Clinical: 32-year-old man with excessive daytime sleepiness. Staging: Wakefulness. Chap03.indd 91 8/6/2009 4:06:44 PM . MULTIPLE SLEEP LATENCY TEST (MSLT) / MAINTENANCE OF WAKEFULNESS TEST (MWT) 91 FIGURE 3-2 Multiple Sleep Latency Test: 30-second page.

Chap03. Staging: Wakefulness with rapid eye movements. 92 CHAPTER 3 FIGURE 3-3 Multiple Sleep Latency Test: 30-second page. Clinical: 32-year-old man with excessive daytime sleepiness.indd 92 8/6/2009 4:06:46 PM .

Clinical: 24-year-old woman with excessive daytime sleepiness. Theta activity (*) is evident in C3-A2 and C4-A1 derivations. MULTIPLE SLEEP LATENCY TEST (MSLT) / MAINTENANCE OF WAKEFULNESS TEST (MWT) 93 * FIGURE 3-4 Multiple Sleep Latency Test: 30-second page. Chap03. Staging: Stage N1 sleep with slow eye movements and attenuation of the alpha rhythm.indd 93 8/6/2009 4:06:48 PM .

Chap03. He then enters stage N1 sleep with attenuation of alpha activity and the appearance of central theta activity. 94 CHAPTER 3 FIGURE 3-5 Multiple Sleep Latency Test: 30-second page. The patient is awake for the first third of the epoch. Staging: Transition from wakefulness to stage N1 sleep. Clinical: 48-year-old man with excessive daytime sleepiness.indd 94 8/6/2009 4:06:49 PM . Slow eye movements are prominent throughout the epoch. with a prominent alpha rhythm.

Clinical: 27-year-old man with excessive daytime sleepiness. Chap03. Staging: Stage N2 sleep with a K complex (*) and sleep spindles (∧).indd 95 8/6/2009 4:06:51 PM . MULTIPLE SLEEP LATENCY TEST (MSLT) / MAINTENANCE OF WAKEFULNESS TEST (MWT) 95 ^ * FIGURE 3-6 Multiple Sleep Latency Test: 30-second page.

96 CHAPTER 3 FIGURE 3-7 Multiple Sleep Latency Test: 30-second page. Staging: Stage N3 sleep with intermixed alpha activity (alpha-delta sleep). Clinical: 32-year-old man with excessive daytime sleepiness. Chap03.indd 96 8/6/2009 4:06:52 PM .

Chap03.indd 97 8/6/2009 4:06:54 PM . Clinical: 32-year-old man with excessive daytime sleepiness. MULTIPLE SLEEP LATENCY TEST (MSLT) / MAINTENANCE OF WAKEFULNESS TEST (MWT) 97 FIGURE 3-8 Multiple Sleep Latency Test: 30-second page. Staging: Stage N3 sleep with intermixed alpha activity (alpha-delta sleep).

Clinical: 22-year-old man with excessive daytime sleepiness and episodes of cataplexy. 98 CHAPTER 3 FIGURE 3-9 Multiple Sleep Latency Test: 30-second page.indd 98 8/6/2009 4:06:56 PM . Chap03. Staging: Stage R sleep with alpha activity posteriorly.

Chap03. MULTIPLE SLEEP LATENCY TEST (MSLT) / MAINTENANCE OF WAKEFULNESS TEST (MWT) 99 FIGURE 3-10 Multiple Sleep Latency Test: 30-second page. Clinical: 30-year-old woman with excessive sleepiness. Staging: Stage R sleep with alpha activity posteriorly.indd 99 8/6/2009 4:06:58 PM .

indd 100 8/6/2009 4:07:00 PM . Staging: Sleep onset with transition from wakefulness to stage N1 sleep. Clinical: 32-year-old man with excessive daytime sleepiness. Chap03. 100 CHAPTER 3 FIGURE 3-11 Multiple Sleep Latency Test: 30-second page.

Carney. Payne. MD Troy A. Geyer.indd 101 8/6/2009 4:10:22 PM . CHAPTER 4 Breathing Disorders James D. MD Paul R. MD 101 Chap04.

Chap04. Pulse oximetry: Frequent oxygen desaturations. Clinical: 46-year-old obese man with severe obstructive sleep apnea. Apneas occurred repeatedly while the patient was supine and in the right lateral decubitus position.indd 102 8/6/2009 4:10:22 PM . 102 CHAPTER 4 FIGURE 4-1 Strip chart: Position chart and pulse oximetry. which are most prominent during REM sleep.

This finding can be seen with hypoventilation or with conditions associated with ventilation- perfusion mismatch. Chap04. BREATHING DISORDERS 103 FIGURE 4-2 Strip chart: Pulse oximetry and position.indd 103 8/6/2009 4:10:24 PM . Pulse oximetry: Obstructive sleep apnea with prolonged oxygen desaturations when supine.

Further improvement of the obstructive sleep apnea is evident at CPAP levels 4.0) is the baseline portion of the recording with no CPAP. ranging from 5 cm of water (setting 2. The initial half of the night (labeled CPAP setting 1.indd 104 8/6/2009 4:10:25 PM .0 and 5. CPAP is applied at four different settings.0) to 11 cm of water (setting 5.0). and CPAP settings.0. Continued moderate obstructive sleep apnea is present with CPAP at levels 2. position. 104 CHAPTER 4 FIGURE 4-3 Strip chart: Pulse oximetry.0 and 3. Chap04.0. Pulse oximetry: Severe obstructive sleep apnea.

0) to 9 cm of water (setting 4. position.0.0. Further improvement of the obstructive sleep apnea is evident at CPAP level 4. BREATHING DISORDERS 105 FIGURE 4-4 Strip chart: Pulse oximetry. Pulse oximetry: Severe obstructive sleep apnea. ranging from 5 cm of water (setting 2. and CPAP settings. CPAP is applied at three different settings.indd 105 8/6/2009 4:10:27 PM .0 and 3. The initial half of the night (labeled CPAP setting 1.0) is the baseline portion of the recording with no CPAP.0). Continued moderate obstructive sleep apnea is present with CPAP at levels 2. Chap04.

Clinical: 30-year-old woman with retrognathia and suspected obstructive sleep apnea.indd 106 8/6/2009 4:10:29 PM . and an oxygen desaturation. Staging: Stage R sleep with an arousal. Chap04. arousal. 60-second page. Respiratory: Obstructive apnea with paradoxical respirations followed by a snort. 106 CHAPTER 4 FIGURE 4-5 Polysomnogram: Standard montage.

120-second page. Chap04. Staging: Stage N2 sleep with frequent arousals.indd 107 8/6/2009 4:10:30 PM . BREATHING DISORDERS 107 FIGURE 4-6 Polysomnogram: Standard montage. arousals. Respiratory: Repeated obstructive apneas with paradoxical respirations followed by snorts. and oxygen desaturations. Clinical: 30-year-old woman with retrognathia and suspected obstructive sleep apnea.

120-second page. Chap04.indd 108 8/6/2009 4:10:32 PM . 108 CHAPTER 4 FIGURE 4-7 Polysomnogram: Standard montage. Clinical: 46-year-old obese man with suspected obstructive sleep apnea. Respiratory: Repeated obstructive apneas with increasing effort followed by arousals and oxygen desaturations. Staging: Stage N2 sleep with arousals.

60-second page. BREATHING DISORDERS 109 FIGURE 4-8 Polysomnogram: Standard montage. Clinical: 30-year-old woman with retrognathia and suspected obstructive sleep apnea. and an oxygen desaturation.indd 109 8/6/2009 4:10:34 PM . snoring. Respiratory: Obstructive apnea with decreased chest wall motion followed by an arousal. Chap04. Staging: Stage N2 sleep and arousals.

60-second page. The oxygen desaturation at the beginning of this page is a result of the apnea from the preceding page of the record. Chap04. Staging: Stage R sleep with rapid eye movements. Clinical: 58-year-old obese man with a low-lying soft palate and suspected obstructive sleep apnea. 110 CHAPTER 4 FIGURE 4-9 Polysomnogram: Standard montage. Respiratory: Prolonged obstructive apnea with increasing effort followed by an oxygen desaturation.indd 110 8/6/2009 4:10:36 PM .

a snort. BREATHING DISORDERS 111 FIGURE 4-10 Polysomnogram: Standard montage. Clinical: 29-year-old obese woman with a thick neck and suspected obstructive sleep apnea. Staging: Stage N2 sleep with an arousal.indd 111 8/6/2009 4:10:38 PM . 60-second page. and an oxygen desaturation. Chap04. Respiratory: Obstructive apnea with in-phase respiratory effort in the thoracic and abdominal channels followed by an arousal.

Staging: Stage N2 sleep with transition into REM sleep.indd 112 8/6/2009 4:10:40 PM . Although the epoch does not meet scoring criteria for REM sleep due to the absence of rapid eye movements. Respiratory: Obstructive apnea with decreased but in-phase respiratory effort followed by an arousal and an oxygen desaturation. 112 CHAPTER 4 * FIGURE 4-11 Polysomnogram: Standard montage. the reduction in chin EMG activity and the occurrence of sawtooth waves (*) are consistent with REM sleep. Chap04. Clinical: 42-year-old man with a low-lying soft palate and suspected obstructive sleep apnea. 60-second page.

Staging: Stage R sleep with rapid eye movements and arousals. Clinical: 42-year-old man with a low-lying soft palate and suspected obstructive sleep apnea. EEG: Sawtooth waves (*) in REM sleep. Chap04.indd 113 8/6/2009 4:10:41 PM . Respiratory: Obstructive apnea with increasing respiratory effort followed by an arousal. BREATHING DISORDERS 113 * FIGURE 4-12 Polysomnogram: Standard montage. 60-second page.

Chap04. 114 CHAPTER 4 FIGURE 4-13 Polysomnogram: Standard montage. Respiratory: Obstructive apneas with increasing respiratory effort followed by arousals. Clinical: 42-year-old man with a low-lying soft palate and suspected obstructive sleep apnea. Staging: Stage R sleep with rapid eye movements and arousals.indd 114 8/6/2009 4:10:41 PM . EEG: Sawtooth waves in REM sleep. snorts. 120-second page. and oxy- gen desaturations.

Staging: Stage R sleep with rapid eye movements and bursts of leg EMG activity. BREATHING DISORDERS 115 FIGURE 4-14 Polysomnogram: Standard montage. Chap04.indd 115 8/6/2009 4:10:43 PM . Clinical: 12-year-old with large tonsils and suspected obstructive sleep apnea. Respiratory: Obstructive apnea with decreased but in-phase respiratory effort followed by an arousal. 30-second page.

The oxygen desatu- ration at the beginning of this page was caused by an apnea from the preceding page of the record. Staging: Stage R sleep with rapid eye movements. Chap04. 120-second page.indd 116 8/6/2009 4:10:45 PM . Clinical: 12-year-old with large tonsils and suspected obstructive sleep apnea. 116 CHAPTER 4 * FIGURE 4-15 Polysomnogram: Standard montage. There is also a brief post-arousal central apnea (*). Respiratory: Prolonged obstructive apnea with decreased but in-phase respiratory effort followed by an arousal and an oxygen desaturation.

Chap04. Staging: Stage N2 sleep with arousals. 60-second page. BREATHING DISORDERS 117 FIGURE 4-16 Polysomnogram: Standard montage. The oxygen desaturation at the beginning of this page is a result of an apnea from the preceding page of the record. Clinical: 29-year-old moderately obese woman with excessive daytime sleepiness and suspected obstruc- tive sleep apnea.indd 117 8/6/2009 4:10:46 PM . Respiratory: Mixed apnea followed by an arousal and an oxygen desaturation.

indd 118 8/6/2009 4:10:48 PM . The oxygen desaturation at the beginning of this page is a result of an apnea from the preceding page of the record. Clinical: 22-year-old obese man with marked retrognathia. 118 CHAPTER 4 FIGURE 4-17 Polysomnogram: Standard montage. 120-second page. Chap04. Respiratory: Mixed apnea with in-phase respiratory effort at the beginning and end of the apnea fol- lowed by an arousal and an oxygen desaturation. Staging: Stage N3 sleep with arousals.

Clinical: 42-year-old woman with multiple sclerosis. restless legs syndrome. Staging: Stage N1 sleep with arousals.indd 119 8/6/2009 4:10:50 PM . 120-second page. Chap04. and suspected obstructive sleep apnea. BREATHING DISORDERS 119 FIGURE 4-18 Polysomnogram: Standard montage. Respiratory: Repeated mixed apneas with arousals and minimal oxygen desaturations.

The oxygen desaturation on this page was caused by an apnea from the preceding page of the record. Staging: Stage N1 sleep with arousals. an arousal. Respiratory: Mixed apnea with increasing effort and paradoxical respirations followed by a snort. Chap04. an oxygen desaturation. 120 CHAPTER 4 FIGURE 4-19 Polysomnogram: Standard montage. Clinical: 52-year-old man with snoring and excessive daytime sleepiness.indd 120 8/6/2009 4:10:52 PM . and snoring. 60-second page.

Respiratory effort. as measured by the esophageal pressure monitor (Pes). Clinical: 44-year-old woman with snoring and excessive daytime sleepiness. increases with the second obstructed breath and then decreases after the arousal and resumption of breathing. Staging: Stage N1 sleep with arousals. Chap04. 30-second page. BREATHING DISORDERS 121 FIGURE 4-20 Polysomnogram: Standard montage with intrathoracic pressure monitoring. Respiratory: Mixed apnea with an initial portion without respiratory effort followed by two obstructed breaths. There is minimal oxygen desaturation from 94% to 91%.indd 121 8/6/2009 4:10:54 PM .

Clinical: 77-year-old thin man with severe polyneuropathy and excessive daytime sleepiness. Staging: Stage N2 sleep with an arousal. 60-second page. 122 CHAPTER 4 * ^ FIGURE 4-21 Polysomnogram: Standard montage. Respiratory: Hypopnea (onset at *) with decreased airflow and respiratory effort followed by an arousal (∧).indd 122 8/6/2009 4:10:56 PM . Chap04.

indd 123 8/6/2009 4:10:56 PM . The oxygen desaturation at the beginning of this page was caused by an apnea from the preceding page of the record. 60-second page. EEG: Sawtooth waves (*) and alpha activity during REM sleep. Chap04. Respiratory: Hypopnea with minimal airflow and decreased respiratory motion followed by an arousal and an oxygen desaturation. Staging: Stage R sleep with rapid eye movements. BREATHING DISORDERS 123 * FIGURE 4-22 Polysomnogram: Standard montage. Clinical: 64-year-old obese woman with cognitive impairment.

Clinical: 41-year-old woman with excessive daytime sleepiness and intractable headaches. Staging: Stage N2 sleep. 124 CHAPTER 4 FIGURE 4-23 Polysomnogram: Standard montage. 120-second page. and 7. Respiratory: Repeated hypopneas with paradoxical respirations followed by arousals and oxygen desaturations.indd 124 8/6/2009 4:10:57 PM . Respiratory artifact from the A1 electrode is apparent in chan- nels 2. 5. EEG: Alpha intrusion into stage N2 sleep. Chap04.

BREATHING DISORDERS 125 FIGURE 4-24 Polysomnogram: Standard montage. an arousal. Respiratory: Prolonged hypopnea with minimal airflow and paradoxical respiratory effort followed by a snort. Chap04.indd 125 8/6/2009 4:10:59 PM . and an oxygen desaturation from 93% to 71%. Clinical: 41-year-old woman with excessive daytime sleepiness and intractable headaches. 120-second page. Staging: Stage R sleep with an arousal.

Clinical: 57-year-old man with excessive daytime sleepiness.indd 126 8/6/2009 4:11:01 PM . are common in normal individuals. 126 CHAPTER 4 FIGURE 4-25 Polysomnogram: CPAP montage. Chap04. 60-second page. Respiratory: Decreased airflow and respiratory effort without an arousal or oxygen desaturation occur- ring during phasic REM sleep. Reductions in ventilation accompanying phasic REM sleep. which often resemble hypopneas. Staging: Stage R sleep.

indd 127 8/6/2009 4:11:03 PM . BREATHING DISORDERS 127 FIGURE 4-26 Polysomnogram: Standard montage with intrathoracic pressure (Pes) monitoring. is apparent in several breaths preceding the arousal. Clinical: 37-year-old man with fatigue. 60-second page. Chap04. There is only minimal oxygen desaturation associated with this event. Staging: Stage N3 sleep with an arousal. Respiratory: Increasing respiratory effort best appreciated in the Pes channel.

128 CHAPTER 4

FIGURE 4-27 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 60-second page.
Clinical: 29-year-old woman with excessive daytime sleepiness.
Staging: Stage N2 sleep with alpha intrusion.
Respiratory: Hypopnea with an associated oxygen desaturation from 94% to 88%. The change in the
respiratory effort is most clearly seen with the intrathoracic pressure (Pes) monitor.

Chap04.indd 128 8/6/2009 4:11:05 PM

BREATHING DISORDERS 129

FIGURE 4-28 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 60-second page.
Clinical: 29-year-old woman with excessive daytime sleepiness.
Staging: Stage N3 sleep with an arousal.
Respiratory: Hypopnea followed by an arousal then a post-arousal central apnea. Intrathoracic pres-
sure monitoring shows increasing effort during the hypopnea and no effort during the post-arousal
central apnea.

Chap04.indd 129 8/6/2009 4:11:07 PM

130 CHAPTER 4

FIGURE 4-29 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 60-second page.
Clinical: 36-year-old man with suspected upper-airway resistance syndrome.
Staging: Stage N3 sleep.
Respiratory: Decreased airflow with a high baseline intrathoracic pressure and a gradual increase in
intrathoracic pressure. There is no arousal or oxygen desaturation with this event.

Chap04.indd 130 8/6/2009 4:11:09 PM

BREATHING DISORDERS 131

FIGURE 4-30 Polysomnogram: Standard montage; 60-second page.
Clinical: 49-year-old man with unrefreshing sleep.
Staging: Stage N1 sleep.
Respiratory: Decreased airflow and respiratory effort. There is no arousal or oxygen desaturation. Such
events are thought to be of little clinical significance.

Chap04.indd 131 8/6/2009 4:11:11 PM

132 CHAPTER 4

* ^
FIGURE 4-31 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 26-year-old man with excessive daytime sleepiness and several motor vehicle accidents.
Staging: Stage N2 sleep with an arousal.
Respiratory: There is a high baseline negative intrathoracic pressure with a progressive increase in intratho-
racic pressure from −20 (*) to −29 (∧) cm of water.

Chap04.indd 132 8/6/2009 4:11:13 PM

BREATHING DISORDERS 133

FIGURE 4-32 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 60-second page.
Clinical: 31-year-old woman with excessive fatigue and chronic headaches.
Staging: Stage N2 sleep.
Respiratory: Snoring with a persistently elevated negative intrathoracic pressure at −22 cm of water.
There is no associated hypopnea, arousal, or oxygen desaturation.

Chap04.indd 133 8/6/2009 4:11:14 PM

Clinical: 49-year-old man with suspected upper-airway resistance syndrome. These events. 134 CHAPTER 4 * ^ FIGURE 4-33 Polysomnogram: Standard montage with intrathoracic pressure (Pes) monitoring. There is a subsequent arousal but no oxygen desaturation.indd 134 8/6/2009 4:11:15 PM . Staging: Stage N2 sleep with an arousal. 60-second page. are characteristic of the upper-airway resistance syndrome. Chap04. sometimes referred to as upper-airway resistance events. Respiratory: Negative intrathoracic pressure increases gradually over several breaths from −12 (*) to −19 (∧) cm of water.

There is a subsequent arousal but no oxygen desaturation. Staging: Stage N2 sleep with an arousal. Clinical: 49-year-old man with upper-airway resistance syndrome. 120-second page.indd 135 8/6/2009 4:11:16 PM . Chap04. BREATHING DISORDERS 135 * ^ FIGURE 4-34 Polysomnogram: Standard montage with intrathoracic pressure (Pes) monitoring. Respiratory: Negative intrathoracic pressure increases gradually from −12 (*) to −19 (∧) cm of water.

Clinical: 17-year-old woman with mild retrognathia. Staging: Stage N3 sleep with alpha intrusion and an arousal. excessive daytime sleepiness associated with recent weight gain.indd 136 8/6/2009 4:11:17 PM . Snoring is minimal. 136 CHAPTER 4 FIGURE 4-35 Polysomnogram: Standard montage with intrathoracic pressure monitoring. Respiratory: Negative intrathoracic pressure increases gradually over several breaths followed by an arousal but no oxygen desaturation. The increased respiratory effort preceding the arousal would be more difficult to appreciate without the Pes monitoring. 60-second page. Chap04.

Respiratory: Snoring increases in amplitude for several breaths and then is followed by an arousal (*). and headaches. which is difficult to detect in the thoracic and abdominal channels. unrefreshing sleep. Staging: Stage N2 sleep with an arousal. The increase in snoring is inferential evidence of increased respiratory effort. BREATHING DISORDERS 137 * FIGURE 4-36 Polysomnogram: Standard montage. Chap04. 60-second page. Clinical: 39-year-old man with snoring.indd 137 8/6/2009 4:11:19 PM .

138 CHAPTER 4 FIGURE 4-37 Polysomnogram: Standard montage. Respiratory: Snoring increases in amplitude over several breaths accompanied by subtle evidence of increased respiratory effort in the thoracic and abdominal channels. Clinical: 24-year-old man with snoring and hypertension.indd 138 8/6/2009 4:11:20 PM . Chap04. Staging: Stage N1 sleep. 30-second page.

Blocking of the intrathoracic pressure signal does not allow quantitation of inspiratory force. Chap04.indd 139 8/6/2009 4:11:22 PM . Staging: Stage N2 sleep. Clinical: 24-year-old man with snoring and hypertension. 60-second page. Respiratory: Snoring increases over several breaths without a subsequent arousal. BREATHING DISORDERS 139 FIGURE 4-38 Polysomnogram: Standard montage.

30-second page.indd 140 8/6/2009 4:11:24 PM . Respiratory: Snoring with otherwise normal respirations. Chap04. Clinical: 39-year-old man with loud snoring and excessive daytime sleepiness. Staging: Stage N2 sleep. 140 CHAPTER 4 FIGURE 4-39 Polysomnogram: Standard montage.

indd 141 8/6/2009 4:11:26 PM . Chap04. Clinical: 47-year-old woman with fatigue and snoring. 30-second page. BREATHING DISORDERS 141 FIGURE 4-40 Polysomnogram: Standard montage. Staging: Stage N3 sleep. Respiratory: Snoring with otherwise normal respirations.

30-second page. Clinical: 45-year-old man with snoring and hypertension. Staging: Stage N3 sleep. Respiratory: Normal respirations except for pronounced snoring.indd 142 8/6/2009 4:11:27 PM . 142 CHAPTER 4 FIGURE 4-41 Polysomnogram: Standard montage. Chap04.

Chap04. Respiratory: Normal respirations except for loud snoring.indd 143 8/6/2009 4:11:29 PM . 60-second page. BREATHING DISORDERS 143 FIGURE 4-42 Polysomnogram: Standard montage. Clinical: 45-year-old man with snoring and hypertension. Staging: Stage N3 sleep.

Staging: Stage N2 sleep with an arousal. 144 CHAPTER 4 FIGURE 4-43 Polysomnogram: Standard montage with intrathoracic pressure monitoring.indd 144 8/6/2009 4:11:31 PM . Respiratory: Central apnea with no effort on intrathoracic pressure monitoring followed by a snort and an arousal. Clinical: 54-year-old man with excessive daytime sleepiness and congestive heart failure. 30-second page. These central apneas resolved with CPAP treatment. Chap04.

Respiratory: Central apnea with no effort on intrathoracic pressure monitoring. Chap04. Staging: Stage N2 sleep with an arousal (*).indd 145 8/6/2009 4:11:33 PM . BREATHING DISORDERS 145 * FIGURE 4-44 Polysomnogram: Standard montage with intrathoracic pressure monitoring. Clinical: 33-year-old man with witnessed episodes of apnea. 30-second page.

indd 146 8/6/2009 4:11:33 PM . Chap04. Respiratory: Sleep onset central apnea. Clinical: 41-year-old man with frequent nocturnal movements. 146 CHAPTER 4 FIGURE 4-45 Polysomnogram: Periodic limb movements montage. Staging: Transition from wake to stage N1 sleep. 30-second page. Brief central apneas that occur in the transition from wakeful- ness to sleep are common in normal persons.

BREATHING DISORDERS 147 FIGURE 4-46 Polysomnogram: Standard montage. Staging: Stage R sleep. Clinical: 46-year-old woman with excessive daytime sleepiness. 120-second page. Chap04. Respiratory: Central apnea with no associated arousal or oxygen desaturation. Brief central apneas are common during REM sleep in normal individuals.indd 147 8/6/2009 4:11:35 PM .

148 CHAPTER 4 FIGURE 4-47 Polysomnogram: Expanded EEG montage with CO2 monitoring. Chap04. Respiratory: Central apnea followed by an oxygen desaturation and tachycardia. Staging: Stage R sleep. 30-second page. Clinical: 39-year-old man with hypertension and several motor vehicle accidents which related to sleepiness.indd 148 8/6/2009 4:11:37 PM .

Brief central apneas are common during REM sleep in normal individuals. BREATHING DISORDERS 149 FIGURE 4-48 Polysomnogram: Standard montage. 60-second page. Staging: Stage R sleep.indd 149 8/6/2009 4:11:39 PM . Respiratory: Central apnea during phasic REM sleep without associated arousal or oxygen desaturation. Chap04. Clinical: 51-year-old man with snoring and witnessed apneas.

Respiratory: Central apnea followed by an arousal. 60-second page. Chap04. Clinical: 5-week-old infant girl with frequent witnessed apneas.indd 150 8/6/2009 4:11:41 PM . Staging: Stage R sleep with an arousal. 150 CHAPTER 4 FIGURE 4-49 Polysomnogram: Standard montage.

Staging: Stage N2 sleep with arousals. 60-second page. BREATHING DISORDERS 151 FIGURE 4-50 Polysomnogram: Standard montage with CO2 monitoring. Clinical: 52-year-old obese man with witnessed apneas.indd 151 8/6/2009 4:11:43 PM . The capnogram indicates that CO2 is highest with the first breath following the apnea and then rapidly returns to normal (60 to 41 torr). Chap04. Respiratory: Central apnea.

The central apneas are followed by oxygen desaturations from 95% to 88%. Respiratory: Periodic breathing with two normal breaths followed by a central apnea. Clinical: 55-year-old man with snoring and frequent pauses in breathing.indd 152 8/6/2009 4:11:45 PM . 152 CHAPTER 4 FIGURE 4-51 Polysomnogram: CPAP montage. 60-second page. Staging: Stage N2 sleep. Chap04.

Staging: Stage N2 sleep. Clinical: 55-year-old man with snoring and frequent pauses in breathing. Respiratory: Periodic breathing consisting of two normal breaths with snoring followed by a cen- tral apnea. The central apneas are followed by oxygen desaturations from 95% to 88%.indd 153 8/6/2009 4:11:47 PM . BREATHING DISORDERS 153 FIGURE 4-52 Polysomnogram: CPAP montage. 60-second page. Chap04.

Respiratory: Central apnea and Cheyne-Stokes respirations with an EEG arousal (*) occurring at the onset of breathing and movement (∧) occurring at the apex of the respiratory cycle. Staging: Stage N2 sleep with an arousal. 154 CHAPTER 4 * ^ FIGURE 4-53 Polysomnogram: CPAP montage.indd 154 8/6/2009 4:11:48 PM . Chap04. Clinical: 59-year-old man with congestive heart failure and excessive daytime sleepiness. 60-second page.

120-second page. but instead. Clinical: 67-year-old man with frequent witnessed apneas.indd 155 8/6/2009 4:11:49 PM . Respiratory: Central apnea and Cheyne-Stokes respirations with an EEG arousal (*) and movement occur- ring at the apex of the respirations. occurs at the apex of the respiratory cycle. differs from the pattern usually seen with obstructive apnea in which the arousal coincides with the resumption of breathing. Chap04. This pattern in which the arousal does not accompany resumption of breathing. BREATHING DISORDERS 155 * FIGURE 4-54 Polysomnogram: Standard montage. Staging: Stage N2 sleep with an arousal.

Staging: Stage R sleep. 156 CHAPTER 4 FIGURE 4-55 Polysomnogram: CPAP montage. 120-second page.indd 156 8/6/2009 4:11:50 PM . Patients with Cheyne-Stokes respirations and central apneas in NREM sleep may show this pattern in REM sleep and wakefulness. Chap04. Respiratory: Cyclic variation in respiratory effort and airflow without arousals or oxygen desaturations. Clinical: 64-year-old woman with a recent myocardial infarction and excessive daytime sleepiness.

Chap04.indd 157 8/6/2009 4:11:52 PM . Staging: Stage N1 sleep. Clinical: 44-year-old man with recent weight gain and excessive daytime sleepiness. BREATHING DISORDERS 157 FIGURE 4-56 Polysomnogram: Standard montage. 30-second page. Respiratory: Post-arousal central apnea.

Chap04. Staging: Stage R with an arousal. Clinical: 44-year-old man with recent weight gain and excessive daytime sleepiness. Respiratory: Obstructive apnea followed by an arousal and then a post-arousal central apnea. The oxygen desaturation at the beginning of this page is a result of an apnea from the preceding page of the record. 60-second page. 158 CHAPTER 4 FIGURE 4-57 Polysomnogram: Standard montage.indd 158 8/6/2009 4:11:54 PM .

Clinical: 57-year-old man with disturbed. Chap04. poor quality sleep. Staging: Stage N2 sleep followed by an arousal. Respiratory: Post-arousal central apnea. BREATHING DISORDERS 159 FIGURE 4-58 Polysomnogram: Standard montage. 60-second page.indd 159 8/6/2009 4:11:56 PM .

Chap04. Clinical: 22-year-old man with possible nocturnal seizures. Staging: Stage N2 sleep. Respiratory: Normal respirations. 160 CHAPTER 4 FIGURE 4-59 Polysomnogram: Expanded EEG montage. 30-second page.indd 160 8/6/2009 4:11:57 PM .

BREATHING DISORDERS 161 FIGURE 4-60 Polysomnogram: CPAP montage with CO2 monitoring. Staging: Stage N3 sleep. Clinical: 48-year-old obese man with witnessed apneas. Chap04. Respiratory: Normal respirations.indd 161 8/6/2009 4:11:59 PM . 30-second page.

Respiratory: Hypopnea with increasing snoring followed by an arousal and a mild oxygen desatura- tion. Clinical: 65-year-old man with obstructive sleep apnea. Hypopneas were eliminated at higher levels of CPAP. 162 CHAPTER 4 FIGURE 4-61 Polysomnogram: CPAP montage. Chap04. The oxygen desaturation at the beginning of this page is a result of an apnea from the pre- ceding page of the record. Staging: Stage N1 sleep.indd 162 8/6/2009 4:12:01 PM . Nasal CPAP was set at 7 cm of water for this portion of the recording. 30-second page.

30-second page. The oxygen desaturation at the beginning of this page was caused by an apnea from the preceding page of the record. Staging: Stage N1 sleep with an arousal. BREATHING DISORDERS 163 FIGURE 4-62 Polysomnogram: CPAP montage. Obstructive apneas were eliminated with higher levels of CPAP. Chap04. Clinical: 42-year-old woman with obstructive sleep apnea. Nasal CPAP was set at 7 cm of water for this portion of the recording. Respiratory: Obstructive apnea followed by a snort and an arousal.indd 163 8/6/2009 4:12:03 PM .

Hypopneas resolved at higher levels of CPAP. 164 CHAPTER 4 FIGURE 4-63 Polysomnogram: CPAP montage. The oxygen desaturation at the beginning of this page was caused by an apnea from the preceding page of the record.indd 164 8/6/2009 4:12:04 PM . 60-second page. Staging: Stage N1 sleep with arousals. and oxygen desaturations. Respiratory: Two hypopneas are followed by snorts. Chap04. arousals. Clinical: 53-year-old man with obstructive sleep apnea.

Staging: Stage N2 sleep. Respiratory: Snoring with no associated hypopneas or apneas with CPAP at 5 cm of water. Clinical: 28-year-old man with obstructive sleep apnea. 30-second page. The snor- ing resolved with higher levels of CPAP. BREATHING DISORDERS 165 FIGURE 4-64 Polysomnogram: CPAP montage. Chap04.indd 165 8/6/2009 4:12:06 PM .

The beginning of the hypopnea is marked (*).indd 166 8/6/2009 4:12:08 PM . Chap04. Clinical: 28-year-old man with obstructive sleep apnea. 166 CHAPTER 4 * FIGURE 4-65 Polysomnogram: CPAP montage. Staging: Stage R sleep with an arousal. Respiratory: Hypopnea followed by an arousal and movement. 60-second page.

Staging: Stage R sleep. BREATHING DISORDERS 167 FIGURE 4-66 Polysomnogram: CPAP montage.indd 167 8/6/2009 4:12:09 PM . Brief reductions in ventilation often accompany phasic REM sleep in normal persons Chap04. Respiratory: Decreased respiratory effort and airflow without an arousal or an oxygen desaturation during phasic REM sleep. Clinical: 35-year-old man with obstructive sleep apnea. 60-second page.

a snort. 168 CHAPTER 4 * ^ FIGURE 4-67 Polysomnogram: CPAP montage. and a brief post-arousal central apnea (∧). Clinical: 49-year-old morbidly obese man with obstructive sleep apnea and poorly controlled hypertension. Staging: Stage R sleep. 120-second page. Respiratory: Prolonged obstructive apnea (*) followed by an arousal. Chap04. right leg movement.indd 168 8/6/2009 4:12:11 PM .

60-second page.indd 169 8/6/2009 4:12:11 PM . Clinical: 53-year-old thin woman with obstructive sleep apnea. BREATHING DISORDERS 169 FIGURE 4-68 Polysomnogram: CPAP montage. Chap04. Respiratory: Central apnea with no associated arousal or oxygen desaturation. Staging: Stage R sleep with frequent rapid eye movements.

Respiratory: Normal respirations with CPAP at 11 cm of water. 60-second page.indd 170 8/6/2009 4:12:13 PM . Chap04. 170 CHAPTER 4 FIGURE 4-69 Polysomnogram: CPAP montage. Clinical: 58-year-old man with obstructive sleep apnea. Staging: Stage N2 sleep.

7 cm. 9 cm) were inad- equate and apneas continued to occur (*). Six CPAP settings were used during the study.indd 171 8/6/2009 4:12:15 PM . apneas became much less frequent and there was marked REM sleep rebound (increased amounts of REM sleep). CPAP settings. Chap04. At the fourth CPAP setting (11 cm). BREATHING DISORDERS 171 FIGURE 4-70 Strip chart: Pulse oximetry. and sleep staging. position. The first three settings (5 cm.

Clinical: 61-year-old man with obstructive sleep apnea and continued excessive daytime sleepiness despite nasal CPAP. Respiratory: CPAP mask leak seen as a sharp dip below the baseline at the end of breaths on the mask flow channel. 172 CHAPTER 4 FIGURE 4-71 Polysomnogram: CPAP montage. Staging: Stage N2 sleep. Chap04.indd 172 8/6/2009 4:12:17 PM . 60-second page.

Staging: Stage N1 sleep. BREATHING DISORDERS 173 FIGURE 4-72 Polysomnogram: CPAP montage. Respiratory: CPAP mask leak seen as a sharp dip below the baseline at the end of breaths on the mask flow channel. Clinical: 27-year-old man with obstructive sleep apnea. Lip quiver recorded in the snore channel coincides with the mask leak. 30-second page.indd 173 8/6/2009 4:12:19 PM . Chap04.

Respiratory: CPAP mask leak with lip quiver recorded in the snore channel and associated with oral air flow. Chap04.indd 174 8/6/2009 4:12:20 PM . Clinical: 27-year-old man with obstructive sleep apnea. which coincides with the mask leak. 30-second page. 174 CHAPTER 4 FIGURE 4-73 Polysomnogram: CPAP montage. Staging: Stage N2 sleep.

at six different settings.indd 175 8/6/2009 4:12:22 PM .0) to 15 cm of water (setting 7. and position. BREATHING DISORDERS 175 FIGURE 4-74 Strip chart: Pulse oximetry. ranging from 5 cm of water (setting 2. apneas and associated hypoxemia were almost completely eliminated.0) is the baseline portion of the recording with no CPAP. CPAP settings.0). Chap04. When CPAP is applied. The initial half of the night (labeled CPAP setting 1. Obstructive sleep apnea with severe oxygen desaturations during REM sleep.

There are also frequent oxygen desaturations caused by obstructive sleep apnea. 176 CHAPTER 4 * FIGURE 4-75 Strip chart: Pulse oximetry. CPAP settings. position. Chap04. and sleep staging.indd 176 8/6/2009 4:12:24 PM . Prolonged oxygen desaturation during REM sleep (*) in a patient with obesity hypoventilation syndrome.

BREATHING DISORDERS 177 FIGURE 4-76 Strip chart: Pulse oximetry. Chap04. PAP titration in a patient with obstructive sleep apnea.indd 177 8/6/2009 4:12:24 PM . PAP settings. and sleep staging. position.

position. 178 CHAPTER 4 FIGURE 4-77 Strip chart: Pulse oximetry. and sleep staging. PAP titration in a patient with obstructive sleep apnea. PAP settings.indd 178 8/6/2009 4:12:25 PM . Chap04.

position. and sleep staging. PAP settings. PAP titration in a patient with obstructive sleep apnea with marked improvement in sleep depth and respirations. BREATHING DISORDERS 179 FIGURE 4-78 Strip chart: Pulse oximetry. Chap04.indd 179 8/6/2009 4:12:26 PM .

60-second page. Chap04. 180 CHAPTER 4 LOC ROC Chin F3 F4 C3 C4 O1 O2 EKG LAT RAT Snorer Nasal Pressure Airflow Chest Abd Intercostal EMG SaO2 FIGURE 4-79 Polysomnogram: CPAP montage. Respiratory: Apnea primarily during phasic REM sleep. Clinical: 37-year-old man with obstructive sleep apnea.indd 180 8/6/2009 4:12:27 PM . Staging: Stage R.

Clinical: 39-year-old man with witnessed apneas and a recent myocardial infarction. Chap04. 120-second page. At least 90% of the event’s duration meets the amplitude reduction criteria for apnea. Staging: Stage N2 sleep. There is continued or increased effort throughout the entire period of absent airflow (From The AASM Manual for Scoring Sleep. 2007). BREATHING DISORDERS 181 FIGURE 4-80 Polysomnogram: Polysomnogram montage. Obstructive apnea––There is a drop in the peak thermal sensor excursion by ≥90% of the baseline. The event lasts at least 10 seconds.indd 181 8/6/2009 4:12:28 PM . Respiratory: Apneas and hypopneas are seen in this recording made with respiratory inductance plethysmography (RIP) recording.

The patient screamed “Help. Chap04. Staging: Stage R. Respiratory: Obstructive apneas are seen in this recording made with RIP recording. most in the last half of the night. 150-second page. usually of being smothered or held down. 182 CHAPTER 4 FIGURE 4-81 Polysomnogram: Polysomnogram montage. Snoring.” She then said “I had a terrible dream” and sat up in bed on video monitoring.indd 182 8/6/2009 4:12:30 PM . Clinical: 53-year-old female with bad dreams. Help.

Respiratory: The hypopnea is scored by the alternative method. 30-second page. BREATHING DISORDERS 183 FIGURE 4-82 Polysomnogram: Polysomnogram montage. Clinical: 41-year-old man with loud snoring. and morning headaches. Chap04. Staging: Stage N1 sleep.indd 183 8/6/2009 4:12:31 PM . night sweats.

Respiratory: The hypopnea is scored by the standard method. 184 CHAPTER 4 FIGURE 4-83 Polysomnogram: Polysomnogram montage. Chap04. 60-second page. and morning headaches. Staging: Stage N2 sleep.indd 184 8/6/2009 4:12:32 PM . night sweats. Clinical: 41-year-old man with loud snoring.

Hypopnea––The nasal pressure signal excursion drops by ≥30% of baseline. 2007). there is no ≥4% desaturation and therefore. 120-second page. BREATHING DISORDERS 185 FIGURE 4-84 Polysomnogram: Polysomnogram montage. 2007). Clinical: 52-year-old man with loud snoring and nocturnal reflux. Chap04. Respiratory: RERA––There is a sequence of breaths lasting at least 10 seconds characterized by increasing respiratory effort or flattening of the nasal pressure waveform leading to an arousal from sleep when the sequence of breaths does not meet criteria for an apnea or hypopnea (From The AASM Manual for Scoring Sleep. The duration of this drop occurs for a period lasting at least 10 seconds. In this example. it cannot be a hypopnea. Staging: Stage N2 sleep. There is a ≥4% desaturation from pre-event baseline.indd 185 8/6/2009 4:12:34 PM . At least 90% of the event’s duration meets the amplitude reduction criteria (From The AASM Manual for Scoring Sleep.

30-second page. Clinical: 56-year-old woman with fatigue and reported fibromyalgia. Chap04. Respiratory: Obstructive apnea. Staging: Stage R. 186 CHAPTER 4 FIGURE 4-85 Polysomnogram: Polysomnogram montage.indd 186 8/6/2009 4:12:37 PM .

indd 187 8/6/2009 4:12:39 PM . Staging: Stage N2 sleep with arousals. Respiratory: Periodic central apneas with oxygen desaturations. 120-second page. Chap04. Clinical: 68-year-old man with poor sleep and heart failure. BREATHING DISORDERS 187 FIGURE 4-86 Polysomnogram: Polysomnogram montage.

188 CHAPTER 4 FIGURE 4-87 Polysomnogram: Polysomnogram montage. Clinical: 8-year-old boy with poor sleep and heart failure. 60-second page. Respiratory: ETCO2 monitoring. Chap04. Staging: Stage N3.indd 188 8/6/2009 4:12:40 PM .

______________________ . EKG. The physician reviewed the record in its entirety. Clinical correlation is advised. EKG: PVCs.7% (4%–8%) Sleep latency: 43 minutes Stage N2 sleep: 65.8 (69 RERA) Total respiratory events: 64 (63 obstructive) Arousal index: 19.5 minutes Analysis––see detailed analysis tables EEG/Sleep stage Stage N1 sleep: 15.2% (23%–31%) Respiratory AHI: 9.8 Impression: Obstructive sleep apnea (327.54). The tracing was recorded in 30-second epochs.indd 189 8/6/2009 4:12:43 PM .5 minutes Stage N3 sleep: 0% (4%–20%) Sleep efficiency: 87. abdominal motion. and pulse oximetry were recorded throughout the study.1 NREM AHI: 4. including sleep staging. Recommendations: The patient will be scheduled for a follow-up visit along with a CPAP titration. Sleep Study Summary Report: Record time: 485.2% Stage R sleep: 19. thoracic motion. EKG. Please see the additional tabular report from this study for more detailed analysis. The interpretation is based on this information in addition to the available clinical history and physical examination. and occipital EEG. submentalis EMG. Limb movement PLM index: 0 PLM arousal index: 0. Study Description: Polysomnogram Equipment: Central. Obstructive sleep apnea may be related to other medical conditions. TR: DD: DT: Chap04. BREATHING DISORDERS 189 Sample Report: Obstructive Sleep Apnea Patient: Account Number: Medical Records: Study Number: Date of Study: Date of Birth: Requesting Physician: Referring Physician: Indications for Study: Sleep disturbance with hypersomnolence (780. airflow.7 Minimum oxygen saturation: 90% Snoring: loud. EEG. snore sensor. This is a summary report. body position.1% (45%–63%) REM latency: 130. EOG. anterior tibialis EMG. frontal. sleep time: 423.D.23). oxygen saturation.1 RERA index: 9. intercostal EMG. and behavior unless otherwise noted.6 REM AHI: 28 Supine AHI: 9. The findings indicate obstructive sleep apnea consisting apneas and hypopneas with associated arousals and oxygen desaturations which was most prominent during REM sleep. EMG activity. respiration. M.5 minutes.

5 minutes Analysis––see detailed analysis tables EEG/Sleep stage Stage N1 sleep: 11% (2%–9%) Sleep latency: 25 minutes Stage N2 sleep: 78. Clinical correlation is advised. snore sensor. Study Description: Polysomnogram Equipment: Central.9% (50%–64%) REM latency: 264. sleep time: 355.1% (20%–27%) Respiratory AHI: 35. Limb movement PLM index: 0. The tracing was recorded in 30-second epochs.7 PLM arousal index: 0. airflow.5 minutes.7 Supine AHI: 35.D.23). M. This is a summary report.3% Stage R sleep: 10.54) and witnessed apneas.1 REM AHI: 66. submentalis EMG. anterior tibialis EMG. oxygen saturation. and occipital EEG. Please see the additional tabular report from this study for more detailed analysis. intercostal EMG.5 minutes Stage N3 sleep: 0% (7%–18%) Sleep efficiency: 90.6 RERA index: 0 (0 RERA) Total respiratory events: 211 (211 obstructive) Arousal index: 35. EOG.indd 190 8/6/2009 4:12:43 PM . body position. EMG activity. Sleep Study Summary Report: Record time: 393. EKG. and behavior unless otherwise noted. ____________________ . Recommendations: The patient will be scheduled for a follow-up visit along with a CPAP titration. EEG.6 NREM AHI: 32. including sleep staging. EKG: unremarkable. EKG. The physician reviewed the record in its entirety.8 Impression: Obstructive sleep apnea (327. thoracic motion.3 Minimum oxygen saturation: 80% Snoring: moderate. 190 CHAPTER 4 Sample Report: Severe Obstructive Sleep Apnea Patient: Account Number: Medical Records: Study Number: Date of Study: Date of Birth: Requesting Physician: Referring Physician: Indications for Study: Sleep disturbance with hypersomnolence (780. respiration. abdominal motion. The interpretation is based on this information in addition to the available clinical history and physical examination. and pulse oximetry were recorded throughout the study. The findings indicate severe obstructive sleep apnea consisting of apneas and hypopneas with associated arousals and oxygen desaturations. Obstructive sleep apnea may be related to other medical conditions. TR: DD: DT: Chap04. frontal.

0 Wake Time During SPT: 13.5 100% 96.5 Total Sleep Time (TST): 355.0 3. Sleep Maintenance is time asleep as a percentage of sleep period time. Chap04. BREATHING DISORDERS 191 Sample Report: Long Form Diagnostic Polysomnographic Report Patient: Date: DOB: PSG Study #: Age: Referring Physician: Physician: Sex: Account #: PSG Tech: Medical Record #: Scored by: Sleep Architecture Summary Lights Out: 11:12:54 PM Lights On: 05:46:24 AM Total Record Time: 413.3% Sleep Maintenance: 96.6% Total Stage N2: 280.indd 191 8/6/2009 4:12:43 PM .0% 10.5% Total Stage N1: 39 11.5 Latency to Persistent Sleep: 25 Sleep Efficiency: 90.1% 9.8% Total Movement Time: 0 0.9% 76.0% Total Stage R: 36 10.5 Latency to REM Sleep: 264.5% Latency to Sleep Onset: 25 Latency to Persistent Sleep: 25 Latency to Stage N2: 29. Awakenings are defined as 30 seconds or more.5% a Sleep efficiency is time asleep as a percentage of time in bed.0% Total Wake Time: 38 WASO: 13.5 78.0 minutes # REM Episodes: 1 a # of Awakenings : 5 Time (minutes) % of TST % of SPT Time in Bed (TIB): 393.1% Total Stage N3: 0 0% 0.

7 315.3 SaO2 < 90% for 3.5 20.4 94.0% Spontaneous: 31 5.0 Other: 0 0.8 Time @ 70%–79% (minutes) 0.6 1.0 0.0 Total: 209 35.7 Average O2 Saturation (%) 96.6 380.5 100.0 0.0 0.9 7.0 0.0 0.0 0.3 46.2 28.5 Time @ 80%–89% (minutes) 1.0 0.3% of the total sleep time.8 Min O2 Saturation (%) 88 86 80 80 Max O2 Saturation (%) 99 99 98 99 Time @ 90%–100% (minutes) 36.0 Time £ 88% (minutes) 0.3 4.8 4.0 0.0% Snore: 0 0. Bruxism: 0 0.0% Respiratory Events: 173 29.0 0.7 22.1 7.8 92.indd 192 8/6/2009 4:12:43 PM .0% LM: 5 0.0 Time @ 60%–69% (minutes) 0.4 12. 192 CHAPTER 4 Positional Summary Arousal Summary Time (minutes)a %TST Arousal Caused By: Number Index Left: 0 0.0 Time @ 50%–59% (minutes) 0.8 Prone: 0 0.2 a Positional times are given for TST.2 Right: 0 0. Chap04.9 94.0 Supine: 355.3 Respiratory Events Summary Oxygen Saturation Summary Wake NREM REM Total Record Total O2 Desaturations: 13 108 28 149 O2 Desaturation Index: 20.

0 20.1 0 66.9 RERA (NREM): 0 0 Apnea (REM): 13.6 Chap04.6 RDI: 0 32.0 RERA (REM): 0 0 Number of Respiratory Events––Position and Sleep Stage NREM REM Non-supine Supine Non-supine Supine TOTAL Obstructive Apnea: 0 33 0 21 54 Mixed Apnea: 0 0 0 0 0 Central Apnea: 0 0 0 0 0 All Apneas: 0 33 0 21 54 Hypopneas: 0 138 0 19 157 Apneas + Hypopneas: 0 171 0 40 211 RERA: 0 0 0 0 0 A/H INDEX: 0 32.indd 193 8/6/2009 4:12:43 PM .6 Hypopnea (REM): 14. BREATHING DISORDERS 193 Oximetry Histogram SaO2 Histogram 30 % 20 T i m 10 e 0 50 60 70 80 90 100 % O2 Respiratory Event Durations Average Maximum (seconds) (seconds) Apnea (NREM): 15.2 21.1 0 66.7 35.7 35.4 28.7 31.5 Hypopnea (NREM): 17.

Positional RDI Left: 0 Right: 0 Prone: 0 Supine: 35.9 31.7 0 26.6 a RDI denotes the average number of all respiratory events (Apnea + Hypopnea + RERA) per hour of sleep.indd 194 8/6/2009 4:12:44 PM .7 0 35.1 66.5 Obstructive Apnea: 33 21 0 54 54 Mixed Apnea: 0 0 0 0 0 Central Apnea: 0 0 0 0 0 All Apneas: 33 21 0 54 54 Hypopneas: 138 19 0 157 157 Apneas + Hypopneas: 171 40 0 211 211 RERA: 0 0 0 0 0 Apnea Index: 6.6 35.6 Other Respiratory Patterns Yes No Cheyne Stokes: Hypoventilation: Hypopnea rule used: Alternative Chap04.1 66.5 26.6 a RDI : 32.7 0 35.1 Hypopnea Index: 25.6 35.1 9.5 36 0 355. 194 CHAPTER 4 By Sleep Stage By Position NREM REM Non-supine Supine TOTAL Sleep Time (minutes): 319.5 A/H INDEX: 32.5 355.2 35 0 9.

0 a Index is number per hour of sleep. during wake time.indd 195 8/6/2009 4:12:44 PM . No pauses observed.8 Isolated Limb Movements: 2 0. Lowest heart rate: 55 bpm.7 TOTAL Limb Movements: 6 1. Chap04.3 Periodic Limb Movements: 4 0. Heart Rate Summary Wake NREM REM TOTAL Average Heart Rate (bpm) 69 69 70 69 Minimum Heart Rate (bpm) 58 55 55 55 Maximum Heart Rate (bpm) 91 91 90 91 Cardiac Events: Occurrence of the following arrhythmias was observed: BPM Bradycardia: N/A Lowest heart rate observed: 55 Asystole: N/A Longest pause observed: Sinus Tachycardia During Sleep: N/A Narrow Complex Tachycardia: N/A Highest heart rate observed: 91 Wide Complex Tachycardia: N/A Atrial Fibrillation: N/A Other Arrhythmias Observed: Technologist Comment Section Highest heart rate: 91 bpm. BREATHING DISORDERS 195 Limb Movements Summary Number Indexa LM Arousals: 5 0.

Chap04.indd 196 8/6/2009 4:12:44 PM .

indd 197 8/6/2009 4:13:49 PM . Payne. CHAPTER 5 Limb Movement Disorders James D. MD 197 Chap05. Carney. MD Troy A. MD Paul R. Geyer.

198 CHAPTER 5

FIGURE 5-1 Polysomnogram: Standard montage; 60-second page.
Clinical: 58-year-old woman with a low back injury and frequent nocturnal leg movements.
Staging: Stage N1 sleep.
EMG: Unilateral (left) periodic leg movements.

Chap05.indd 198 8/6/2009 4:13:50 PM

LIMB MOVEMENT DISORDERS 199

FIGURE 5-2 Polysomnogram: Standard montage; 120-second page.
Clinical: 40-year-old woman with restless legs syndrome and a right lumbar radiculopathy.
Staging: Stage N3 sleep.
EMG: Unilateral (right) periodic leg movements.

Chap05.indd 199 8/6/2009 4:13:52 PM

200 CHAPTER 5

FIGURE 5-3 Polysomnogram: Standard montage; 120-second page.
Clinical: 62-year-old man with excessive daytime sleepiness and a history of kicking his wife at night.
Staging: Stage N2 sleep with K complexes. The K complexes accompany some but not all of the periodic
limb movements.
Respiratory: Snoring with otherwise normal respirations.
EMG: Bilateral periodic leg movements starting slightly earlier on the left side.

Chap05.indd 200 8/6/2009 4:13:53 PM

LIMB MOVEMENT DISORDERS 201

FIGURE 5-4 Polysomnogram: CPAP and PLM montage; 30-second page.
Clinical: 68-year-old man with obstructive sleep apnea and peripheral neuropathy.
Staging: Stage N2 sleep.
Respiratory: Normal respirations.
EMG: Right periodic leg movements and fragmentary myoclonus in both right and left leg channels.

Chap05.indd 201 8/6/2009 4:13:55 PM

202 CHAPTER 5

FIGURE 5-5 Polysomnogram: Standard montage; 30-second page.
Clinical: 64-year-old man with excessive daytime sleepiness and frequent nocturnal leg movements.
Staging: Stage N2 sleep.
Respiratory: Effort increases with the arousal.
EMG: Bilateral periodic leg movements with an associated arousal.

Chap05.indd 202 8/6/2009 4:13:57 PM

LIMB MOVEMENT DISORDERS 203

FIGURE 5-6 Polysomnogram: CPAP montage; 120-second page.
Clinical: 39-year-old man with obstructive sleep apnea.
Staging: Stage N2 sleep.
Respiratory: Normal respirations while using CPAP.
EMG: Asymmetric periodic leg movements. The compressed time base facilitates identification of the
periodicity of the movements.

Chap05.indd 203 8/6/2009 4:13:59 PM

Respiratory: Normal respirations. EKG: A transient increase in the heart rate accompanies the periodic leg movements. Clinical: 44-year-old woman with excessive daytime sleepiness and low back pain. The compressed time base facilitates identification of the periodicity of the movements.indd 204 8/6/2009 4:14:01 PM . 204 CHAPTER 5 FIGURE 5-7 Polysomnogram: Expanded EEG montage. despite no definite EEG evidence of an arousal. Staging: Stage N2 sleep. Chap05. 60-second page. EMG: Periodic leg movements with associated tachycardia.

Clinical: 44-year-old woman with excessive daytime sleepiness and low back pain. Respiratory: Normal respirations. EKG: A transient increase in the heart rate accompanies the periodic leg movements.indd 205 8/6/2009 4:14:03 PM . 30-second page. despite no definite EEG evidence of an arousal. Chap05. EMG: Periodic leg movements associated with tachycardia. LIMB MOVEMENT DISORDERS 205 FIGURE 5-8 Polysomnogram: Expanded EEG montage. Staging: Stage N2 sleep.

30-second page. 206 CHAPTER 5 FIGURE 5-9 Polysomnogram: Expanded EEG montage. Respiratory: Normal respirations. EMG: Periodic leg movements with arousals and tachycardia. EKG: A transient increase in the heart rate occurs with the arousal and periodic leg movement. Staging: Stage N2 sleep. Clinical: 58-year-old man with excessive daytime sleepiness.indd 206 8/6/2009 4:14:05 PM . Chap05.

EMG: Frequent leg movements during wakefulness are typical of restless legs syndrome. LIMB MOVEMENT DISORDERS 207 FIGURE 5-10 Polysomnogram: Standard montage. Respiratory: Normal respirations. Staging: Stage wake. Clinical: 32-year-old woman with restless legs syndrome. Chap05. 30-second page.indd 207 8/6/2009 4:14:08 PM .

indd 208 8/6/2009 4:14:10 PM .Chap05.

CHAPTER 6 Parasomnias James D. Geyer. MD 209 Chap06.indd 209 8/6/2009 4:15:14 PM . MD Paul R. Carney. Payne. MD Troy A.

Bursts of EMG activity occur at a rate of about 1/second in the EEG. 30-second page. Behavior: Bruxism. Respiratory: Normal respirations. chin EMG. Staging: Stage N1 sleep.indd 210 8/6/2009 4:15:14 PM . Chap06. and EOG channels. 210 CHAPTER 6 FIGURE 6-1 Polysomnogram: Expanded EEG montage. Clinical: 41-year-old man with witnessed apneas and tooth grinding.

PARASOMNIAS 211 FIGURE 6-2 Polysomnogram: Standard montage. and morning headache. Respiratory: Normal respirations. Clinical: 26-year-old woman with excessive daytime sleepiness. 60-second page. Rhythmic bursts of EMG activity occur about every 4 seconds. tooth grinding. Staging: Probable stage N1 sleep but difficult to stage because of artifact. Chap06.indd 211 8/6/2009 4:15:16 PM . Behavior: Bruxism.

indd 212 8/6/2009 4:15:18 PM . Clinical: 47-year-old woman with excessive daytime sleepiness. Behavior: Movements of the left leg (*) occur rhythmically at a rate of about 1/second. 212 CHAPTER 6 * FIGURE 6-3 Polysomnogram: Standard montage. Staging: Stage N1 sleep. Movement artifact is evident in the thoracic and abdominal channels. Chap06. 30-second page. Respiratory: Normal respirations. characteristic of rhythmic movement disorder.

Staging: Stage wake. 120-second page. PARASOMNIAS 213 * * * * FIGURE 6-4 Polysomnogram: Standard montage. Movement artifact is evident in the thoracic and abdominal channels. with a brief period of quiescence between the runs of movement. Behavior: Movements of the left leg (*) occur rhythmically at a rate of about 1/second. Respiratory: Normal respirations. Clinical: 47-year-old woman with excessive daytime sleepiness. This pattern is characteristic of rhythmic movement disorder.indd 213 8/6/2009 4:15:19 PM . Chap06.

EEG: Arousal (*) with delta activity associated with screaming and inconsolable fear. Staging: Stage N3 sleep with an arousal. characteristic of sleep terrors.indd 214 8/6/2009 4:15:20 PM . Respiratory: Normal respirations. The EEG following the arousal consists of a mixture of delta and faster frequencies. Clinical: 7-year-old boy with nocturnal episodes of inconsolable fear. 30-second page. 214 CHAPTER 6 * FIGURE 6-5 Polysomnogram: Standard montage with intrathoracic pressure monitoring. Chap06. This EEG pattern commonly accompanies arousals from slow-wave sleep in children with arousal disorders.

30-second page. Clinical: 38-year-old woman with sleep talking. The EEG following the arousal consists of a mixture of theta and delta frequencies. PARASOMNIAS 215 * FIGURE 6-6 Polysomnogram: Expanded EEG montage. Staging: Stage N3 sleep. Respiratory: Normal respirations. Chap06.indd 215 8/6/2009 4:15:21 PM . EEG: Spontaneous arousal (*) from stage N3 sleep associated with sleep talking.

Sleep talking can occur with arousals from any stage of sleep. Staging: Stage N2 sleep. 30-second page. EEG: An arousal (*) is followed a few seconds later by a full awakening and sleep talking. 216 CHAPTER 6 * FIGURE 6-7 Polysomnogram: Expanded EEG montage. Respiratory: Normal respirations. Chap06. Clinical: 51-year-old man with frequent nocturnal arousals.indd 216 8/6/2009 4:15:21 PM .

the EEG shows continued delta activity intermixed with faster frequen- cies. Respiratory: Normal respirations. PARASOMNIAS 217 * FIGURE 6-8 Polysomnogram: Expanded EEG montage with intrathoracic pressure monitoring. 30-second page. the EEG shows delta activity that is more rhythmic and synchronous than the delta activity that usually occurs in slow-wave sleep. Clinical: 53-year-old man with confusional arousals. The observed behavior was typical of a confusional arousal. associated with moving and crying. Rhythmic. synchronous delta activity sometimes precedes or accompanies arousals from slow-wave sleep in patients with arousal disorders. Chap06. In the 5 to 6 seconds preceding the arousal.indd 217 8/6/2009 4:15:22 PM . EEG: Following the arousal (*). Staging: Stage N3 sleep.

Clinical: 45-year-old with excessive daytime sleepiness.indd 218 8/6/2009 4:15:24 PM . Staging: Stage R sleep. 218 CHAPTER 6 FIGURE 6-9 Polysomnogram: RLS montage. Increased phasic and tonic EMG activity during REM sleep is characteristic of patients with REM sleep behavior disorder. Chin EMG activ- ity is tonically increased. EMG: Increased phasic EMG activity is most prominent in the LAT1-LAT2 derivation. 30-second page. Respiratory: Normal respirations with occasional snoring. Chap06.

PARASOMNIAS 219 FIGURE 6-10 Polysomnogram: Standard montage. Clinical: 63-year-old man with excessive daytime sleepiness and mild parkinsonism. EMG: Phasic EMG activity which is most prominent in the right leg. Staging: Stage R sleep with bursts of rapid eye movements. Chap06.indd 219 8/6/2009 4:15:25 PM . 30-second page. The amount of activity is excessive for an adult. Epochs of REM sleep with excessive phasic EMG activity are common in patients with REM sleep behavior disorder. Respiratory: Mildly irregular breathing accompanying the bursts of rapid eye movements.

Respiratory: Normal breathing. Clinical: 42-year-old man with a history of poliomyelitis. EMG: Excessive phasic EMG activity which is most prominent in the left leg.indd 220 8/6/2009 4:15:27 PM . Epochs of REM sleep with excessive phasic EMG activity are common in patients with REM sleep behavior disorder. The amount of activity is excessive for an adult. 30-second page. 220 CHAPTER 6 FIGURE 6-11 Polysomnogram: CPAP montage. Staging: Stage R sleep with rapid eye movements. Chap06.

Chap06. Respiratory: Normal respirations.indd 221 8/6/2009 4:15:29 PM . Tonic increases in chin EMG activity. 30-second page. with or without excess phasic EMG activity in the limbs. are common during epochs of REM sleep in patients with REM sleep behavior disorder. EMG: Markedly increased chin EMG tone during REM sleep. Clinical: 62-year-old man with a history of fighting behavior in his sleep. Staging: Stage R sleep with rapid eye movements. PARASOMNIAS 221 FIGURE 6-12 Polysomnogram: Standard montage.

Clinical: 62-year-old man with a history of fighting behavior in his sleep. 30-second page. Chap06. 222 CHAPTER 6 FIGURE 6-13 Polysomnogram: Standard montage. EMG: Transiently increased chin EMG tone with leg movements and talking during REM sleep. Respiratory: Normal respirations.indd 222 8/6/2009 4:15:31 PM . The behaviors and polysomnographic features are typical of REM sleep behavior disorder. Staging: Stage R sleep with rapid eye movements.

indd 223 8/6/2009 4:15:33 PM . and made punching and thrashing movements. the patient talked.” Staging: Stage R sleep with rapid eye movements. EMG: Markedly increased chin EMG tone and leg movements during REM sleep. Clinical: 62-year-old man with a history of “fighting in his sleep. Chap06. The behaviors and polysomnographic features are typical of REM sleep behavior disorder. During this REM period. 30-second page. screamed. Respiratory: Normal respirations. PARASOMNIAS 223 FIGURE 6-14 Polysomnogram: Standard montage.

This resolved after effective treatment of the obstructive sleep apnea. The patient awoke with reports of a nightmare about drowning. Staging: Stage R sleep with rapid eye movements with an arousal. 120-second page. The obstructive sleep apnea was isolated to REM sleep in this patient. 224 CHAPTER 6 FIGURE 6-15 Polysomnogram: Standard montage. He stated that this was a common dream.indd 224 8/6/2009 4:15:35 PM . Clinical: 57-year-old man with a history of Post-traumatic stess disorder (PTSD) and frequent nightmares. Respiratory: Hypopnea. This was associated with recurrent hypopneas. Chap06.

MD Paul R. Payne. CHAPTER Electroencephalographic 7 Abnormalities James D.indd 225 8/6/2009 4:16:26 PM . MD 225 Chap07. Geyer. Carney. MD Troy A.

and excessive daytime sleepiness. K complexes. 30-second page. snoring. and POSTs. Chap07. 226 CHAPTER 7 * FIGURE 7-1 Polysomnogram: Standard montage with intrathoracic pressure monitoring. Staging: Stage N2 sleep. EEG: Subtle right hemispheric sharp waves (*) during stage N2 sleep with sleep spindles. Clinical: 29-year-old woman with complex partial seizures. Respiratory: Snoring with normal respirations.indd 226 8/6/2009 4:16:26 PM .

epilepsy. The sharp wave can also be seen in the O2-avg derivation. and excessive daytime sleepiness.indd 227 8/6/2009 4:16:27 PM . ELECTROENCEPHALOGRAPHIC ABNORMALITIES 227 * FIGURE 7-2 Polysomnogram: Standard montage. Chap07. Staging: Stage R sleep. EEG: Right hemispheric sharp and slow waves most prominent in the C4 electrode (*). Clinical: 44-year-old man with a right frontal glioma. Respiratory: Normal respirations. 30-second page.

Respiratory: Normal respirations. When compared to the previous figure with a 30-second time base. EEG: Right hemispheric (electrode C4) sharp and slow waves. and excessive daytime sleepiness. 228 CHAPTER 7 FIGURE 7-3 Polysomnogram: Standard montage. Chap07. Clinical: 44-year-old man with a right frontal glioma. 60-second page. Staging: Stage R sleep.indd 228 8/6/2009 4:16:28 PM . the abnormality is more difficult to identify because of time compression. epilepsy.

Respiratory: Normal respirations. When compared to the previous two figures. ELECTROENCEPHALOGRAPHIC ABNORMALITIES 229 * FIGURE 7-4 Polysomnogram: Standard montage. Chap07. EEG: Right hemispheric (electrode C4) sharp and slow waves (*). 120-second page. and excessive daytime sleepiness. the abnormality is almost impossible to identify because of time compression. Clinical: 44-year-old man with a right frontal glioma.indd 229 8/6/2009 4:16:30 PM . Staging: Stage R sleep. epilepsy.

indd 230 8/6/2009 4:16:31 PM . Respiratory: Normal respirations. 30-second page. Staging: Stage N2 sleep. The expanded EEG mon- tage permits localization of the discharge. 230 CHAPTER 7 * FIGURE 7-5 Polysomnogram: Expanded montage. EEG: Right frontal sharp and slow waves maximal at electrodes F4 and C4 (*). Clinical: 4-year-old with symptomatic generalized epilepsy and witnessed apneas. Chap07.

EEG: A left frontal spike and wave is maximal at electrode Fp1 (*). 30-second page. O2-A1) but has a subtle representation in the LOC (left eye) channel. It is not seen in the standard sleep staging channels (C3-A2.indd 231 8/6/2009 4:16:32 PM . Clinical: 28-year-old with frontal epilepsy and episodes of apnea and snoring. Respiratory: Normal respirations. ELECTROENCEPHALOGRAPHIC ABNORMALITIES 231 * FIGURE 7-6 Polysomnogram: Expanded EEG montage with intrathoracic pressure monitoring. C4-A1. Chap07. Staging: Stage N1 sleep. O1-A2.

As commonly occurs with focal seizures. This page is difficult to stage because of seizure activity. Staging: Stage N2 sleep. Respiratory: Increased respiratory effort at the onset of seizure activity.indd 232 8/6/2009 4:16:32 PM . Clinical: 18-month-old boy with seizures and apnea. the frequency of the ictal activity gradually decreases and the amplitude gradually increases. Chap07. 232 CHAPTER 7 * FIGURE 7-7 Polysomnogram: Expanded EEG montage. 60-second page. EEG: Onset (*) of a focal seizure with medium amplitude rhythmic sharp waves maximal in channels F7-T3 and C3-P3.

120-second page. Clinical: 18-month-old boy with seizures and apnea. Staging: Stage N2 sleep. Respiratory: Increased respiratory effort at the onset of seizure activity. ELECTROENCEPHALOGRAPHIC ABNORMALITIES 233 * FIGURE 7-8 Polysomnogram: Expanded EEG montage. Chap07.indd 233 8/6/2009 4:16:33 PM . This page is difficult to stage because of seizure activity. EEG: Onset (*) of a focal seizure with medium amplitude rhythmic sharp waves maximal in channels F7-T3 and C3-P3. The evolution of ictal activity is readily apparent with the compressed time base.

high amplitude spike. Clinical: 18-year-old patient with primary generalized epilepsy and excessive daytime sleepiness. 30-second page.indd 234 8/6/2009 4:16:35 PM . Chap07. Respiratory: Normal respirations. 234 CHAPTER 7 FIGURE 7-9 Polysomnogram: Expanded EEG montage with intrathoracic pressure monitoring. EEG: Generalized. Staging: Stage N1 sleep. and wave discharges are recorded in all EEG channels and in the EOG channels. The very high amplitudes are cut off in the display.

ELECTROENCEPHALOGRAPHIC ABNORMALITIES 235 FIGURE 7-10 Polysomnogram: Standard montage with CO2 monitoring. Chap07. 30-second page. EEG: Multifocal independent spike and wave discharges and generalized spike and wave discharges. Clinical: 7-year-old boy with symptomatic generalized epilepsy and episodes of apnea.indd 235 8/6/2009 4:16:37 PM . Respiratory: Normal respirations. Staging: Stage N3 sleep. Staging is difficult with such severe EEG abnormalities.

236 CHAPTER 7 * FIGURE 7-11 Polysomnogram: CPAP montage. At the end of the seizure (*). there is generalized delta activity during the postictal phase. EEG: Generalized spike and wave discharges.indd 236 8/6/2009 4:16:39 PM . Staging: Unable to accurately stage because of generalized spike and wave discharges during this generalized tonic-clonic seizure and subsequent postictal slowing. Artifact: The tidal volume channel has artifact caused by the mask being pulled from the patient’s face during postictal confusion. 30-second page. Clinical: 17-year-old man with epilepsy and obstructive sleep apnea. Respiratory: Ictal and postictal obstructive apnea associated with an arousal and an oxygen desaturation. Chap07.

Staging: Stage N1 sleep. slow spike and wave discharges. Respiratory: Normal respirations. Chap07. and a slow and asynchronous background. ELECTROENCEPHALOGRAPHIC ABNORMALITIES 237 FIGURE 7-12 Polysomnogram: Expanded EEG montage. Staging is difficult because of the severely abnormal EEG. 30-second page. Clinical: 15-month-old patient with Turner syndrome and infantile spasms.indd 237 8/6/2009 4:16:40 PM . generalized spike and wave discharges. EEG: Hypsarrhythmia.

238 CHAPTER 7 FIGURE 7-13 Polysomnogram: Standard montage. greater on the right. Respiratory: Apnea followed by a snore and an arousal.indd 238 8/6/2009 4:16:42 PM . Although the tumor is in the right frontal region. Staging: Stage N1 sleep with an arousal. EEG: Asymmetric delta activity. Chap07. during the arousal. the pathologic delta activity is present over the entire right hemisphere and can also be seen in the LOC channel. 30-second page. Clinical: 48-year-old patient with a right frontal glioma and loud snoring.

indd 239 8/6/2009 4:16:44 PM . ELECTROENCEPHALOGRAPHIC ABNORMALITIES 239 FIGURE 7-14 Polysomnogram: Standard montage. Respiratory: Apnea followed by a snore and an arousal. during the arousal. the pathologic delta activity is present over the entire right hemisphere and can also be seen in the LOC channel. EEG: Asymmetric delta activity. Chap07. Although the tumor is in the right frontal region. greater on the right. Clinical: 48-year-old patient with a right frontal glioma and loud snoring. Staging: Stage N1 sleep with an arousal. 60-second page.

EEG: Left hemisphere breach rhythm with higher amplitude and higher frequency EEG activity especially over the frontotemporal regions. 240 CHAPTER 7 FIGURE 7-15 Polysomnogram: Expanded EEG montage. Chap07. Staging: Stage N2 sleep. Clinical: 49-year-old woman status post left frontotemporal arteriovenous malformation resection with excessive daytime sleepiness and disrupted sleep. 30-second page. Respiratory: Normal respirations.indd 240 8/6/2009 4:16:45 PM .

EEG: Generalized 3 Hz spike and wave discharges. ELECTROENCEPHALOGRAPHIC ABNORMALITIES 241 FIGURE 7-16 EEG. Clinical: 8-year-old boy with episodes of staring.indd 241 8/6/2009 4:16:47 PM . 10-second page. Staging: Stage wake. Chap07.

Clinical: 7-year-old boy with a nocturnal seizure. 10-second page. Benign rolandic epilepsy. 242 CHAPTER 7 FIGURE 7-17 EEG.indd 242 8/6/2009 4:16:50 PM . EEG: Centrotemporal spikes are present on an otherwise unremarkable background. Chap07.

Clinical 3-year-old boy with myoclonic seizures and developmental delay. ELECTROENCEPHALOGRAPHIC ABNORMALITIES 243 FIGURE 7-18 EEG.indd 243 8/6/2009 4:16:52 PM . Chap07. 10-second page. Dravet syndrome or severe myoclonic epilepsy of infancy. EEG: Spike and wave and polyspike and wave discharges with background slowing.

Early myoclonic encephalopathy. 10-second page. 244 CHAPTER 7 FIGURE 7-19 EEG. EEG: Generalized slowing with intervening periods of suppression of the background rhythms. Clinical: Neonate with encephalopathy and myoclonus.indd 244 8/6/2009 4:16:54 PM . Chap07.

Chap07. Clinical: Partial seizure activity occurring in a patient with an intracranial mass. EEG: Prolonged seizure activity with an approximately 5 Hz spike and wave and rhythmic theta activity morphology. Epilepsia partialis continua (EPC). ELECTROENCEPHALOGRAPHIC ABNORMALITIES 245 FIGURE 7-20 EEG.indd 245 8/6/2009 4:16:55 PM . 10-second page.

246 CHAPTER 7 FIGURE 7-21 EEG.indd 246 8/6/2009 4:16:57 PM . EEG: Generalized arrhythmic slowing and a hypsarrhythmia pattern with intermittent suppression of the background rhythms. Clinical: Infant with infantile spasms. Chap07. 10-second page.

10-second page. Stage: Stage wake. Chap07. Juvenile myoclonic epilepsy (JME).indd 247 8/6/2009 4:16:59 PM . Clinical: 14-year-old boy with morning myoclonus and generalized seizures. ELECTROENCEPHALOGRAPHIC ABNORMALITIES 247 FIGURE 7-22 EEG. EEG: Spike and wave and polyspike and wave discharges superimposed on an otherwise unremarkable background activity.

EEG: The EEG typically shows a generalized spike and wave pattern. 248 CHAPTER 7 FIGURE 7-23 EEG. atonic. Lennox-Gastaut syndrome is characterized by a combination of clinical seizures.indd 248 8/6/2009 4:17:01 PM . Clinical: Lennox-Gastaut syndrome. 10-second page.5 Hz. The EEG reveals a slow spike wave complex with a frequency of 1 to 2. and generalized paroxysmal fast activity (GPFA). Chap07. and generalized tonic-clonic seizures. atypical absence. including myoclonic. multifocal spikes. tonic axial.

indd 249 8/6/2009 4:17:02 PM . Chap07. 10-second page. EEG: Seizure activity with centrally predominant rhythmic activity. ELECTROENCEPHALOGRAPHIC ABNORMALITIES 249 FIGURE 7-24 EEG. Clinical: Neonate with seizures.

Chap07. EEG: EPC with left frontally predominant spike activity.indd 250 8/6/2009 4:17:04 PM . 10-second page. 250 CHAPTER 7 FIGURE 7-25 EEG. Clinical: 10-year-old girl with partial status epilepticus.

Geyer. MD 251 Chap08. MD Paul R. MD Troy A. Payne. CHAPTER 8 Artifacts James D.indd 251 8/6/2009 4:18:10 PM . Carney.

252 CHAPTER 8 * FIGURE 8-1 Polysomnogram: Standard montage. Chap08. Clinical: 47-year-old man with witnessed apneas.indd 252 8/6/2009 4:18:10 PM . Respiratory: Mixed apnea followed by an arousal. 60-second page. The oxygen desaturation on this page is a result of the apnea on the preceding page of the record. Artifact: Cardioballistic artifact in the abdominal effort channel (*). Staging: Stage N1 sleep with an arousal.

Artifact: Cardioballistic artifact in the intrathoracic pressure channel (*).indd 253 8/6/2009 4:18:11 PM . Respiratory: Normal respirations. Staging: Stage N1 sleep. Chap08. Clinical: 43-year-old woman with upper-airway resistance syndrome. ARTIFACTS 253 FIGURE 8-2 Polysomnogram: CPAP montage with intrathoracic pressure monitoring. 30-second page.

Clinical: 42-year-old man with an artificial eye and excessive daytime sleepiness. Staging: Stage R sleep. EOG: Unilateral rapid eye movements. 254 CHAPTER 8 FIGURE 8-3 Polysomnogram: Standard montage.indd 254 8/6/2009 4:18:13 PM . Chap08. Respiratory: Normal respirations. 30-second page.

indd 255 8/6/2009 4:18:15 PM . Artifact: Swallow artifact in the intrathoracic pressure monitor. Chap08. 30-second page. Clinical: 33-year-old woman with snoring and excessive daytime sleepiness. Respiratory: Normal respirations. ARTIFACTS 255 FIGURE 8-4 Polysomnogram: Standard montage with intrathoracic pressure monitoring. Staging: Stage N1 sleep.

Clinical: 4-month-old patient with apneic episodes. The rhythmic activity is also evident in the thoracic channel. Artifact: Apparent diffuse rhythmic delta activity caused by patting the baby’s chest. Chap08. Staging: Difficult to stage because of artifact. 60-second page. 256 CHAPTER 8 FIGURE 8-5 Polysomnogram: Standard montage with expanded EEG and CO2 monitoring.indd 256 8/6/2009 4:18:17 PM .

Clinical: 57-year-old man with excessive daytime sleepiness. Artifact: Severe 60 Hz artifact caused by a laptop computer. Staging: Difficult to stage because of severe 60 Hz artifact. ARTIFACTS 257 FIGURE 8-6 Polysomnogram: Standard montage with expanded EEG. Chap08.indd 257 8/6/2009 4:18:19 PM . 60-second page.

Clinical: 32-year-old man with loud snoring and excessive daytime sleepiness. Artifact: Rhythmic face rubbing artifact. 258 CHAPTER 8 FIGURE 8-7 Polysomnogram: Standard montage. Chap08.indd 258 8/6/2009 4:18:21 PM . 30-second page. Staging: Stage wake.

30-second page. ARTIFACTS 259 * ^ FIGURE 8-8 Polysomnogram: Standard montage. Artifact: Sweat artifact resulting in a wandering baseline with blocking in the O1-avg (*) and EOG (∧) channels. Chap08. Clinical: 47-year-old obese man with loud snoring and witnessed apneas. Staging: Stage wake. Respiratory: Normal respirations.indd 259 8/6/2009 4:18:23 PM .

Chap08.indd 260 8/6/2009 4:18:23 PM .

MD Paul R. Geyer. MD 261 Chap09. CHAPTER 9 Electrocardiography James D. Payne. MD Troy A. Carney.indd 261 8/6/2009 4:19:08 PM .

EKG: Frequent premature ventricular complexes (PVCs) with couplets (*). 30-second page. Staging: Stage N2 sleep. Chap09.indd 262 8/6/2009 4:19:08 PM . Clinical: 56-year-old man with snoring and excessive daytime sleepiness. Respiratory: Intermittent snoring. 262 CHAPTER 9 * FIGURE 9-1 Polysomnogram: CPAP montage.

30-second page.indd 263 8/6/2009 4:19:09 PM . Clinical: 48-year-old woman with intermittent snoring and witnessed apneas. EKG: Narrow premature complexes (*) without definite P waves. Chap09. ELECTROCARDIOGRAPHY 263 * * FIGURE 9-2 Polysomnogram: Standard montage. Staging: Stage N1 sleep. Respiratory: Normal respirations.

264 CHAPTER 9 * FIGURE 9-3 Polysomnogram: Standard montage. Respiratory: Normal respirations. Chap09. Staging: Stage N1 sleep. EKG: Narrow premature complexes (*) without definite P waves. Clinical: 48-year-old woman with intermittent snoring and witnessed apneas.indd 264 8/6/2009 4:19:10 PM . 10-second page.

ELECTROCARDIOGRAPHY 265 FIGURE 9-4 Polysomnogram: Standard montage. 30-second page. and an oxygen desaturation. Respiratory: Apnea followed by an arousal. Clinical: 27-year-old man with obstructive sleep apnea. EKG: Ventricular bigeminy.indd 265 8/6/2009 4:19:10 PM . Staging: Stage N2 sleep. Chap09. snoring.

indd 266 8/6/2009 4:19:12 PM . Clinical: 31-year-old man with obstructive sleep apnea. 266 CHAPTER 9 FIGURE 9-5 Polysomnogram: CPAP montage. Respiratory: Normal respirations. Chap09. 30-second page. Staging: Stage N2 sleep. EKG: Ventricular trigeminy.

ELECTROCARDIOGRAPHY 267 FIGURE 9-6 Polysomnogram: CPAP montage. Chap09. Staging: Stage N2 sleep.indd 267 8/6/2009 4:19:14 PM . EKG: Ventricular quintigeminy. Clinical: 71-year-old man with obstructive sleep apnea. Respiratory: Normal respirations. 30-second page.

Chap09. Respiratory: Mild variations in respiratory effort. 60-second page. Clinical: 69-year-old man with obstructive sleep apnea and atrial fibrillation. EKG: Atrial fibrillation. 268 CHAPTER 9 FIGURE 9-7 Polysomnogram: CPAP montage. Staging: Stage N2 sleep.indd 268 8/6/2009 4:19:16 PM .

EKG: Atrial fibrillation.indd 269 8/6/2009 4:19:18 PM . Chap09. Staging: Stage R sleep. Clinical: 52-year-old man with excessive daytime sleepiness and intermittent atrial fibrillation. ELECTROCARDIOGRAPHY 269 FIGURE 9-8 Polysomnogram: Standard montage. 30-second page.

EKG: Bradycardia with the apnea. Chap09. Respiratory: Apnea followed by an arousal and an oxygen desaturation. Clinical: 40-year-old woman with obstructive sleep apnea. The oxygen desaturation on this page was caused by an apnea from the preceding page of the record.indd 270 8/6/2009 4:19:19 PM . Staging: Stage R sleep with an arousal. 270 CHAPTER 9 FIGURE 9-9 Polysomnogram: Standard montage. 30-second page. There is a 3-second asystole at the end of the apnea.

EKG: Wide complex tachycardia with a rate of more than 160 beats/minute accompanies the second arousal (*).indd 271 8/6/2009 4:19:21 PM . ELECTROCARDIOGRAPHY 271 * FIGURE 9-10 Polysomnogram: Standard montage. Chap09. Respiratory: Mixed apneas followed by arousals. Staging: Stage R sleep with arousals. Clinical: 50-year-old man with obstructive sleep apnea and hypertension. 60-second page.

Staging: Stage R sleep with an arousal. 272 CHAPTER 9 * FIGURE 9-11 Polysomnogram: Standard montage. Clinical: 50-year-old man with obstructive sleep apnea and hypertension. Respiratory: Mixed apnea followed by an arousal. EKG: Wide complex tachycardia with a rate of more than 160 beats/minute accompanies the arousal (*). Chap09. 30-second page.indd 272 8/6/2009 4:19:22 PM .

Clinical: 58-year-old man with obstructive sleep apnea.indd 273 8/6/2009 4:19:23 PM . EKG: Ventricular tachycardia. Chap09. Staging: Stage R sleep with an arousal. ELECTROCARDIOGRAPHY 273 FIGURE 9-12 Polysomnogram: Standard montage. Respiratory: Mixed apnea followed by an arousal. 30-second page.

indd 274 8/6/2009 4:19:25 PM . Clinical: 69-year-old man with excessive daytime sleepiness and third-degree AV block. Staging: Stage N2 sleep. 30-second page. EKG: Third-degree AV block. Chap09. Pacemaker spikes precede several of the QRS complexes and can also be seen in the backup respiratory channel. 274 CHAPTER 9 FIGURE 9-13 Polysomnogram: Standard montage. Respiratory: Normal respirations.

60-second page. Chap09. Clinical: 40-year-old man with obstructive sleep apnea. ELECTROCARDIOGRAPHY 275 FIGURE 9-14 Polysomnogram: Standard montage. Tachycardia occurs with the arousal. Staging: Stage R sleep with arousals. Respiratory: Repeated apneas followed by arousals.indd 275 8/6/2009 4:19:26 PM . EKG: Bradycardia accompanies the apnea. The pulse oximetry channel is contaminated by artifact.

276 CHAPTER 9 FIGURE 9-15 Polysomnogram: CPAP montage.indd 276 8/6/2009 4:19:28 PM . EKG: Bradycardia accompanies the apnea. Staging: Stage R sleep with an arousal. Clinical: 59-year-old man with obstructive sleep apnea. 30-second page. Occasional PVCs are evident. Respiratory: Apnea with paradoxical respirations followed by an arousal and an oxygen desaturation. while tachycardia occurs with the arousal. Chap09.

Clinical: 71-year-old man with obstructive sleep apnea and hypertension. ELECTROCARDIOGRAPHY 277 FIGURE 9-16 Polysomnogram: Standard montage. 30-second page. EKG: Sinus arrhythmia. Respiratory: Mixed apnea associated with an arousal and an oxygen desaturation from 93% to 87%.indd 277 8/6/2009 4:19:30 PM . Staging: Stage N2 sleep with an arousal. Chap09.

Clinical: 38-year-old obese woman with obstructive sleep apnea. snorts. Respiratory: Repeated apneas with associated arousals. 278 CHAPTER 9 FIGURE 9-17 Polysomnogram: Standard montage. and oxygen desaturations. EKG: Sinus arrhythmia and first-degree AV block. Chap09. Staging: Stage N2 sleep with an arousal.indd 278 8/6/2009 4:19:32 PM . 30-second page.

10-second page. ELECTROCARDIOGRAPHY 279 FIGURE 9-18 Polysomnogram: Standard montage.indd 279 8/6/2009 4:19:34 PM . and oxygen desaturations. Staging: Stage N2 sleep with an arousal. snorts. EKG: Sinus arrhythmia and first-degree AV block. Respiratory: Repeated apneas with associated arousals. Chap09. Clinical: 38-year-old obese woman with obstructive sleep apnea.

Respiratory: Variable respiratory effort characteristic of phasic REM sleep. 30-second page. Clinical: 46-year-old man with excessive daytime sleepiness.indd 280 8/6/2009 4:19:36 PM . 280 CHAPTER 9 FIGURE 9-19 Polysomnogram: Standard montage. EKG: Bigeminy occurring in conjunction with phasic REM sleep. Staging: Stage R sleep. Chap09.

Clinical: 49-year-old woman with snoring and excessive daytime sleepiness. Respiratory: Normal respirations. EKG: Supraventricular tachycardia. 60-second page. Chap09.indd 281 8/6/2009 4:19:37 PM . ELECTROCARDIOGRAPHY 281 FIGURE 9-20 Polysomnogram: Standard montage. Staging: Stage N2 sleep.

Staging: Stage wake. Chap09.indd 282 8/6/2009 4:19:39 PM . EKG: EKG artifact not ventricular tachycardia. 282 CHAPTER 9 FIGURE 9-21 Polysomnogram: Standard montage. Clinical: 55-year-old woman with snoring and excessive daytime sleepiness. 30-second page. Respiratory: Normal respirations.

Staging: Stage N2 sleep. Chap09.indd 283 8/6/2009 4:19:40 PM . 30-second page. EKG: The EKG is bad resulting in a waveform suggestive of ventricular tachycardia. Respiratory: The changes in the nasal pressure waveform suggest a respiratory event related arousal. Clinical: 35-year-old man with excessive daytime sleepiness. ELECTROCARDIOGRAPHY 283 FIGURE 9-22 Polysomnogram: Standard montage.

Clinical: 58-year-old woman with heart failure and apneas. 284 CHAPTER 9 FIGURE 9-23 Polysomnogram: Standard montage.indd 284 8/6/2009 4:19:42 PM . Respiratory: Central apnea. Staging: Stage N1 sleep. EKG: Supraventricular tachycardia. Chap09. 30-second page.

Chap09.indd 285 8/6/2009 4:19:44 PM . snoring. The oxygen desaturation is secondary to the hypopnea from the preceding page. ELECTROCARDIOGRAPHY 285 FIGURE 9-24 Polysomnogram: Standard montage. and excessive daytime sleepiness. EKG: Narrow complex tachycardia. 30-second page. Staging: Stage N2 sleep. Clinical: 47-year-old man with COPD. Respiratory: Hypopnea.

Staging: Stage N2 sleep. Clinical: 62-year-old man with snoring and fatigue. EKG: Ventricular tachycardia. 286 CHAPTER 9 FIGURE 9-25 Polysomnogram: Standard montage. Respiratory: Hypopnea.indd 286 8/6/2009 4:19:45 PM . Snoring: There is artifact from snoring in the chin EMG and in the EEG channels. 30-second page. Chap09.

MD Paul R. MD 287 Chap10. Carney. Payne. CHAPTER 10 Calibrations James D.indd 287 8/6/2009 4:24:00 PM . Geyer. MD Troy A.

Chap10. 288 CHAPTER 10 FIGURE 10-1 Machine calibrations.indd 288 8/6/2009 4:24:00 PM .

indd 289 8/6/2009 4:24:01 PM . CALIBRATIONS 289 FIGURE 10-2 Breath hold. Chap10.

Chap10.indd 290 8/6/2009 4:24:03 PM . 290 CHAPTER 10 FIGURE 10-3 Grit teeth.

CALIBRATIONS 291 FIGURE 10-4 Foot flex.indd 291 8/6/2009 4:24:04 PM . Chap10.

292 CHAPTER 10 FIGURE 10-5 Eyes open.indd 292 8/6/2009 4:24:06 PM . Chap10.

Chap10.indd 293 8/6/2009 4:24:07 PM . CALIBRATIONS 293 FIGURE 10-6 Eyes closed.

indd 294 8/6/2009 4:24:08 PM . Chap10. 294 CHAPTER 10 FIGURE 10-7 Eye movements.

indd 295 8/6/2009 4:24:10 PM . CALIBRATIONS 295 FIGURE 10-8 Calibration sequence at 120-second page. Chap10.

Chap10.indd 296 8/6/2009 4:24:12 PM .

Carney. MD Paul R. MD 297 Chap11. Geyer. Payne.indd 297 8/6/2009 4:30:17 PM . MD Troy A. CHAPTER 11 Actigraphy James D.

298 CHAPTER 11 FIGURE 11-1 Actigraphy in a normal subject. Chap11.indd 298 8/6/2009 4:30:18 PM .

Chap11. ACTIGRAPHY 299 FIGURE 11-2 Actigraphy in a patient with insomnia.indd 299 8/6/2009 4:30:19 PM .

Chap11.indd 300 8/6/2009 4:30:21 PM .

the other variables listed above are used to identify specific Polysomnography is the recording of multiple physiologic sleep-related disorders. MD Troy A. a downward stage.000. MD Paul R. MD INTRODUCTION management of sleep disorders. Carney. • Esophageal manometry If input 1 is negative compared to input 2. the output would be zero (CMRR would be infinity). In addition to these channels. and EOG data are used to identify the sleep If input 2 is negative compared to input 1. • Airflow (nasal and oral) Common mode rejection ratio (CMRR): This ratio refers to • Respiratory effort (thoracic and abdominal) the ability of an amplifier to reject in-phase potentials and amplify • Limb movements out-of-phase potentials.indd 301 8/6/2009 4:31:09 PM . Ideally. • CPAP/BiPAP If input 1 is positive compared to input 2. functions during sleep. The EEG. The CMRR is measured by connecting • Snore sensors both input channels of an amplifier to the same signal source. Good amplifiers have a CMRR between 1. Geyer. CHAPTER 12 Technical Background James D. a downward • Esophageal pH signal is displayed. EMG. Payne.000 and 10. Any potentials shared • Electromyography (EMG) between the two signals are removed leaving only the differ- • Pulse oximetry ence between the signals. Standard polysomnography usually includes the following variables. 301 Chap12. Special studies may include the following. an upward signal • CO2 monitoring is displayed. • Expanded EEG Polarity: Standard EEG polarity convention is as follows. SIGNAL PROCESSING • Electroencephalogram (EEG) • Electrooculogram (EOG) Differential amplifier: A differential amplifier amplifies the • Electrocardiogram (EKG) difference between two input signals. Accurate sleep staging is necessary for the diagnosis and signal is displayed.

an upward signal attenuated. LEOG and REOG = left and right electrooculogram sequent digital filtering can be performed as needed. the cutoff does not occur at a distinct Abbreviations used: single frequency but over a range of frequencies with a vari. This may have a signifi- and allows all frequencies above the cutoff frequency to pass cant effect on the interpretation of epileptiform discharges in unchanged. For EEG. little filtering is performed prior to digitization. Given these and other problems associated with the use of the 60 Hz notch filter. The phase shift caused by decreasing recording. little filtering is performed prior to digitization. Pes = intrathoracic (esophageal) pressure monitor ing other frequencies. the low frequency filter attenu. the high frequency filter atten- uates all frequencies above the cutoff frequency of the filter SLEEP MONTAGES and allows all frequencies below the cutoff frequency to pass unchanged. is displayed. 302 CHAPTER 12 If input 2 is positive compared to input 1. the cutoff frequency is defined as 60 Hz notch filter has a minimal effect on the signals recorded the frequency at which the output is reduced by 30%. the cutoff does not occur at a distinct expanded EEG studies. In digital during polysomnography. In reality. Sub. opportunity to attenuate artifacts. all EEG activity in that range is also attenuated. the 60 Hz filter attenuates SaO2 = pulse oximetry a range of frequencies around 60 Hz.indd 302 8/6/2009 4:31:09 PM . High frequency filter: Ideally. lff = low frequency filter in Hz 60 Hz notch filter: Ideally. EKG = electrocardiogram able attenuation. the cutoff frequency is defined as hff = high frequency filter in Hz the frequency at which the output is reduced by 30%. For EEG. In reality. sequent digital filtering can be performed as needed. Filters Phase shift: Shift of a waveform either earlier or later in time Filters allow the technologist and polysomnographer an caused by filtering. it should be used only when absolutely necessary. When 60 Hz noise is sens = sensitivity in microvolts/millimeter Chap12. the high frequency filter is to the right or later in time. Increasing the low frequency filter attenuates the signal and ates all frequencies below the cutoff frequency of the filter shifts it to the left or earlier in time. Sub. the 60 Hz notch frequency filter N/O airflow = nasal/oral airflow removes 60 Hz noise from electrical sources without affect. In digital LAT and RAT = left and right anterior tibialis surface EMG recording. The phase shift secondary to the high frequency filter and the able attenuation. single frequency but over a range of frequencies with a vari. Low frequency filter: Ideally. In reality. The low frequency filter may cause a significant phase shift.

1 hff = 15 19. RAT-EMG sens = 200 lff = 10 hff = 70 12.3 hff = 35 9.3 hff = 35 5. Intercostal EMG sens = 200 lff = 10 hff = 70 21. SaO2 sens = ×2 DC — Chap12. LAT-EMG sens = 200 lff = 10 hff = 70 11. Snore1-Snore2 sens = 1. N/O airflow sens = 100 lff = 0. O1-A2 sens = 100 lff = 0. Nasal pressure 16.3 hff = 35 6.1 hff = 15 18. EKG sens = 1.1 hff = 15 20. TECHNICAL BACKGROUND 303 Montage for Standard Polysomnogram Channel Amplifier Settings Filter Settings 1. Abdominal motion sens = 500 lff = 0. F4-A1 sens = 100 lff = 0.1 hff = 15 17. LEOG sens = 100 lff = 0.3 hff = 35 7. Chin-EMG sens = 50 lff = 10 hff = 70 4. O2-A1 sens = 100 lff = 0. C3-A2 sens = 100 lff = 0.000 lff = 1 hff = 15 13. Thoracic motion sens = 500 lff = 0. Backup motion sens = 500 lff = 0.000 lff = 1 hff = 15 14. C4-A1 sens = 100 lff = 0. REOG sens = 100 lff = 0.3 hff = 15 2.3 hff = 35 8.3 hff = 35 10.indd 303 8/6/2009 4:31:09 PM . LAT-A1 sens = 1.3 hff = 15 3. F3-A2 sens = 100 lff = 0.000 lff = 10 hff = 70 15.

Chin-EMG sens = 50 lff = 10 hff = 70 4.3 hff = 35 7. O1-A2 sens = 100 lff = 0.3 hff = 35 10.000 lff = 1 hff = 15 13.3 hff = 35 9. LEOG sens = 100 lff = 0.3 hff = 15 2. RAT-EMG sens = 200 lff = 10 hff = 70 12.3 hff = 35 5. F4-A1 sens = 100 lff = 0.3 hff = 35 7. EKG sens = 1.000 lff = 1 hff = 15 Montage for CPAP Trial Channel Amplifier Settings Filter Settings 1.3 hff = 35 10.indd 304 8/6/2009 4:31:09 PM .3 hff = 35 9.3 hff = 35 8. REOG sens = 100 lff = 0. C4-A1 sens = 100 lff = 0.3 hff = 35 5. REOG sens = 100 lff = 0. LAT-EMG sens = 200 lff = 10 hff = 70 11. RAT-EMG sens = 200 lff = 10 hff = 70 12. O1-A2 sens = 100 lff = 0. LAT-EMG sens = 200 lff = 10 hff = 70 11.3 hff = 15 3. C3-A2 sens = 100 lff = 0. O2-A1 sens = 100 lff = 0.3 hff = 15 2. F3-A2 sens = 100 lff = 0. C4-A1 sens = 100 lff = 0. LAT-A1 sens = 1. 304 CHAPTER 12 Montage for Multiple Sleep Latency Test Channel Amplifier Settings Filter Settings 1.3 hff = 35 8. Chin-EMG sens = 50 lff = 10 hff = 70 4.3 hff = 35 6. F4-A1 sens = 100 lff = 0.3 hff = 15 3.3 hff = 35 6. F3-A2 sens = 100 lff = 0.000 lff = 1 hff = 15 (continued ) Chap12. C3-A2 sens = 100 lff = 0. O2-A1 sens = 100 lff = 0. EKG sens = 1. LEOG sens = 100 lff = 0.

EKG sens = 1. LAT-A1 sens = 1. Abdominal motion sens = 500 lff = 0. LEOG sens = 100 lff = 0. C4-A1 sens = 100 lff = 0.000 lff = 10 hff = 70 15.1 hff = 15 (continued ) Chap12.3 hff = 35 9.3 hff = 15 2.1 hff = 15 21. O2-A1 sens = 100 lff = 0. F3-A2 sens = 100 lff = 0.1 hff = 15 18. TECHNICAL BACKGROUND 305 Montage for CPAP Trial (continued ) Channel Amplifier Settings Filter Settings 14. Thoracic motion sens = 500 lff = 0. Nasal pressure 16.1 hff = 15 19. Tidal volume sens = ×2 lff = 50% 17. C3-A2 sens = 100 lff = 0.3 hff = 15 3. RAT-EMG sens = 200 lff = 10 hff = 70 12.indd 305 8/6/2009 4:31:09 PM . REOG sens = 100 lff = 0.1 hff = 15 17.3 hff = 35 10. Backup motion sens = 500 lff = 0. Thoracic motion sens = 500 lff = 0.3 hff = 35 6. Snore1-Snore2 sens = 1. Mask flow sens = ×2 lff = 50% 16.3 hff = 35 8. Oral airflow sens = 100 lff = 0.000 lff = 1 hff = 15 13. SaO2 sens = ×2 DC — Montage for Polysomnogram with Intrathoracic Pressure Monitoring Channel Amplifier Settings Filter Settings 1. F4-A1 sens = 100 lff = 0.3 hff = 35 5.1 hff = 15 20. LAT-EMG sens = 200 lff = 10 hff = 70 11. O1-A2 sens = 100 lff = 0. Chin-EMG sens = 50 lff = 10 hff = 70 4.000 lff = 10 hff = 70 15. Snore1-Snore2 sens = 1.000 lff = 1 hff = 15 14.3 hff = 35 7. N/O airflow sens = 100 lff = 0.

C3-P3 sens = 100 lff = 0.3 hff = 35 3.3 hff = 35 14. P3-O1 sens = 100 lff = 0. F4-A1 sens = 100 lff = 0. C4-P4 sens = 100 lff = 0. F4-C4 sens = 100 lff = 0. Pes sens = ×2 lff = 50% Montage for Suspected Parasomnias or Seizures Channel Amplifier Settings Filter Settings 1. REOG sens = 100 lff = 0.3 hff = 35 (continued ) Chap12. SaO2 sens = ×2 DC — 22.1 hff = 15 19.1 hff = 15 20.3 hff = 35 17. Fp2-F8 sens = 100 lff = 0.3 hff = 35 2. Chin-EMG sens = 50 lff = 10 hff = 70 20. Fp2-F4 sens = 100 lff = 0.3 hff = 35 4. Intercostal EMG sens = 200 lff = 10 hff = 70 21. T3-T5 sens = 100 lff = 0. Fp1-F3 sens = 100 lff = 0.3 hff = 35 13. T4-T6 sens = 100 lff = 0. F8-T4 sens = 100 lff = 0.3 hff = 35 16. T6-O2 sens = 100 lff = 0. Backup motion sens = 500 lff = 0.3 hff = 35 6.indd 306 8/6/2009 4:31:09 PM .3 hff = 35 15. F7-T3 sens = 100 lff = 0.3 hff = 15 19. Fp1-F7 sens = 100 lff = 0. F3-C3 sens = 100 lff = 0.3 hff = 15 18. T5-O1 sens = 100 lff = 0. Abdominal motion sens = 500 lff = 0.3 hff = 35 11. 306 CHAPTER 12 Montage for Polysomnogram with Intrathoracic Pressure Monitoring (continued ) Channel Amplifier Settings Filter Settings 18.3 hff = 35 10.3 hff = 35 21.3 hff = 35 8.3 hff = 35 9.3 hff = 35 5.3 hff = 35 7. P4-O2 sens = 100 lff = 0.3 hff = 35 12. F3-A2 sens = 100 lff = 0. LEOG sens = 100 lff = 0.

LAT-A1 sens = 1. Snore1-Snore2 sens = 1. SaO2 sens = ×2 DC — Montage for Suspected REM Sleep Behavior Disorder Channel Amplifier Settings Filter Settings 1. T5-O1 sens = 100 lff = 0. Nasal pressure 32. Fp2-F4 sens = 100 lff = 0. O2-A1 sens = 100 lff = 0.1 hff = 15 34. Intercostal EMG sens = 200 lff = 10 hff = 70 37. P3-O1 sens = 100 lff = 0. EKG sens = 1.1 hff = 15 36. F4-C4 sens = 100 lff = 0. C3-A2 sens = 100 lff = 0.000 lff = 10 hff = 70 31.000 lff = 1 hff = 15 30. C3-P3 sens = 100 lff = 0.3 hff = 35 4.000 lff = 1 hff = 15 29. Backup motion sens = 500 lff = 0.1 hff = 15 33. Fp1-F7 sens = 100 lff = 0.3 hff = 35 26.3 hff = 35 6. Thoracic motion sens = 500 lff = 0.3 hff = 35 (continued ) Chap12.3 hff = 35 9. TECHNICAL BACKGROUND 307 Montage for Suspected Parasomnias or Seizures (continued ) Channel Amplifier Settings Filter Settings 22. Abdominal motion sens = 500 lff = 0. C4-A1 sens = 100 lff = 0. LAT-EMG sens = 200 lff = 10 hff = 70 27.1 hff = 15 35. RAT-EMG sens = 200 lff = 10 hff = 70 28.3 hff = 35 7.3 hff = 35 10. N/O airflow sens = 100 lff = 0. T3-T5 sens = 100 lff = 0. F3-C3 sens = 100 lff = 0. Fp1-F3 sens = 100 lff = 0.3 hff = 35 8.indd 307 8/6/2009 4:31:09 PM .3 hff = 35 5.3 hff = 35 3. O1-A2 sens = 100 lff = 0.3 hff = 35 24.3 hff = 35 23.3 hff = 35 25. F7-T3 sens = 100 lff = 0.3 hff = 35 2.

1 hff = 15 39. C4-A1 sens = 100 lff = 0.1 hff = 15 38.1 hff = 15 40.000 lff = 1 hff = 15 34. F3-A2 sens = 100 lff = 0.3 hff = 35 29. LED-EMG sens = 200 lff = 10 20. Abdominal motion sens = 500 lff = 0.000 lff = 1 hff = 15 33. RAT1-EMG sens = 200 lff = 10 hff = 70 19.3 hff = 15 23.3 hff = 35 30. RAT-EMG sens = 200 lff = 10 hff = 70 32.3 hff = 35 25. C4-P4 sens = 100 lff = 0.3 hff = 35 28.3 hff = 35 26.3 hff = 35 16. F4-A1 sens = 100 lff = 0. F8-T4 sens = 100 lff = 0. Backup motion sens = 500 lff = 0. LEOG sens = 100 lff = 0. EKG sens = 1. LAT1-EMG sens = 200 lff = 10 hff = 70 18. C3-A2 sens = 100 lff = 0.indd 308 8/6/2009 4:31:09 PM .3 hff = 35 12.3 hff = 35 13. SaO2 sens = ×2 DC — Chap12. 308 CHAPTER 12 Montage for Suspected REM Sleep Behavior Disorder (continued ) Channel Amplifier Settings Filter Settings 11. O2-A1 sens = 100 lff = 0. Nasal pressure 36.3 hff = 15 22.3 hff = 35 27. REOG sens = 100 lff = 0. Chin-EMG sens = 50 lff = 10 hff = 70 24. O1-A2 sens = 100 lff = 0.000 lff = 10 hff = 70 35. N/O airflow sens = 100 lff = 0. RED-EMG sens = 200 lff = 10 hff = 70 21. T4-T6 sens = 100 lff = 0. Fp2-F8 sens = 100 lff = 0. Snore1-Snore2 sens = 1. LAT-EMG sens = 200 lff = 10 hff = 70 31.3 hff = 35 17.1 hff = 15 37. P4-O2 sens = 100 lff = 0. T6-O2 sens = 100 lff = 0. LAT-A1 sens = 1.3 hff = 35 14.3 hff = 35 15. Thoracic motion sens = 500 lff = 0. Intercostal EMG sens = 200 lff = 10 hff = 70 41.

Method for reducing or eliminating the artifact: This artifact is Description: Obscuration of the background EEG and occasion. One can see a manifestation of the snore registering in the chin Muscle (EMG) Artifact EMG channel. very difficult to reduce but should be recognized as a normal ally EOG by myogenic (muscle) artifact. Carney. Re-referencing electrodes can also Electrode Pop Artifact decrease artifact. Description: Very sharp. however. can result in high-frequency artifacts in other channels. MD Jennifer Parr. be seen in Description: A representation of the EKG in the EEG chan. Method for reducing or eliminating the artifact: Re-reference Loose Electrode the EEG channels to A1 + A2. RPSGT ARTIFACTS IN POLYSOMNOGRAPHY The artifact in the EEG channels should be time locked to the RECORDINGS EKG. Geyer. a channel. multiple channels if that electrode is used as a component of nels secondary to volume conduction of the EKG waveform. Description: High-frequency noise superimposed on high-am- plitude slow activity with possible superimposed electrode pops. physiologic occurrence. Method for reducing or eliminating the artifact: Ask the patient to relax. The deflection may. Payne. Recording Artifacts and CHAPTER Solving Technical Problems 13 with Polysomnography Technology James D.indd 309 8/6/2009 4:31:49 PM . opening the jaw slightly can dramatically reduced EMG artifact. 309 Chap13. MD Paul R. MD Troy A. Vibration Artifact Method for reducing or eliminating the artifact: Reprep and Description: The vibration caused by leg movements or snoring repaste the electrode to decrease the impedance. spikelike deflection originating from a mechanically or electrically unstable electrode. The deflec- tions should have no electrical field and should be isolated EKG in the EEG Channel Artifact to a single electrode.

Use of filtering to decrease the artifact from the tubing.indd 310 8/6/2009 4:31:49 PM . Method for reducing or eliminating the artifact: This artifact is predominantly in the temporal regions. Description: An electric dipole is created by the eye. can result in alteration of physiologic waveforms. Method for reducing or eliminating the artifact: This artifact is very difficult to reduce but should be recognized as a normal Blink Artifact physiologic occurrence. Method for reducing or eliminating the artifact: Tighten the loose belt. it may no and field depending upon the direction of gaze) predominate longer be able to monitor changes in temperature between slow wave. Movement of the tongue may result in a slow wave. room temperature by lowering the air-conditioner temperature Method for reducing or eliminating the artifact: Drain water or by turning on a fan. When the thermocouple moves. Cardioballistic Artifact Description: A pulse wave may be seen in the chest belt or abdominal belt that has only a slight delay behind the EKG Swallow Artifact channel. Method for reducing or eliminating the artifact: This artifact is Method for reducing or eliminating the artifact: Place thermo- very difficult to reduce but should be recognized as a normal couple in proper position. with the cor- nea being electropositive and the retina being electronegative. One can see the swal- very difficult to reduce but should be recognized as a normal low occurring during the arousals. physiologic occurrence. there may be an M-shaped sweat artifact most prominently in the O1-A2 channel. One can see the Description: In the airflow channels. A representation of the pulse wave may be seen in Description: The glossokinetic potential occurs because the tip airflow channels. accurately reflect movement. physiologic occurrence. Misplaced Thermocouple Artifact Eyelid movement also creates an electrical potential. tongue. 310 CHAPTER 13 Method for reducing or eliminating the artifact: Reprep and belt is no longer tight enough or in the appropriate location to repaste the electrode to decrease the impedance. inhalation and exhalation. nasal pressure monitors. Eye and Description: The airflow-sensing thermocouple can move from eyelid movement create a frontally (with variable amplitude its proper position. Rectus Spike Artifact Loose Belt Artifact Description: The electric potential created by the rectus eye mus- Description: Effort channels begin to flatten without any evident cles can create a small spikelike discharge in the frontal and movement despite continued respiratory effort because the frontotemporal EEG derivations. Chap13. and in esophageal of the tongue is more electrically negative than the base of the pressure-monitoring channels. waveform with each breath as the water moves backward and Method for reducing or eliminating the artifact: Decrease the forward in the tubing. Sweat Artifact Humidifier Condensation or Drainage in the Continuous Positive Air Pressure Tubing Description: Slow delta frequency rolling or swaying deflections are superimposed on the background EEG.

• Nasal dryness—increase heated humidification. spray. unnecessary electrical equipment. Sixty-Hertz Artifact • Sore nose—loosen headgear. educate patients on the possibility that this may occur. over-the-counter nasal decongestant sprays. tach electrodes. • Patient reports that pressure is too high. Chap13. try a new style of mask. change to C-flex by Respironics. EOG. mask style. sure. or over-the-counter nasal decongestant sprays. meditation. sedative medications. change to a bilevel pressure system. bilevel pres- spray. EKG. electrical wiring. or anxiolytic medications at bedtime if necessary. • Nosebleeds—increase heated humidification. nasal saline This may be superimposed on baseline EEG. and spray. EMG waveforms. and when occurring on an physiologic occurrence. • Poor seal/mask leak—tighten headgear. CONTINUOUS POSITIVE AIR PRESSURE • Claustrophobia—educate patients on the possibility of COMPLICATIONS AND POTENTIAL claustrophobia and that it will likely improve over time. CPAP adjust- ment periods during wakefulness.indd 311 8/6/2009 4:31:49 PM . if no improvement try a new Description: Lighting. topical antibiotic ointment. nasal steroid spray. Check ground lines. which occurs at approximately 60 Hz. RESPONSES select mask for patient comfort. refit mask. nasal steroid • Air swallowing (aerophagia) and gas—chin strap. nasal saline Method for reducing or eliminating the artifact: Reprep or reat. but study shows that setting is correct—change to C-flex produced by Respironics. • Nasal drainage—treat with nasal saline spray. RECORDING ARTIFACTS AND SOLVING TECHNICAL PROBLEMS WITH POLYSOMNOGRAPHY TECHNOLOGY 311 Method for reducing or eliminating the artifact: This artifact is • Nasal congestion—increase heated humidity. • Difficulty exhaling—use lowest possible CPAP setting. and machinery can pro. duce electrical artifact. infrequent basis. nasal spine very difficult to reduce but should be recognized as a normal saline spray. Turn off lighting and any • Allergy to mask material—change to a hypoallergenic mask.

indd 312 8/6/2009 4:31:49 PM .Chap13.

and O2.4. Geyer.indd 313 8/6/2009 5:10:10 PM . This are designated Fp1 and Fp2. 10% mark above the preauricular points and the tation above the bridge of the nose.2. Measure the patient’s head across from left to right ing one-half the head circumference and vertically preauricular points. in the front of the ears.2. This location is called directly through the center mark at the top of the Oz. Then measure 5% over to the left and 5% over head.3.1. 1. All material should be assembled on a tray and positioned 1. Calculate 5% of the head circumference and make the inion and make a mark 10% above the nasion. APPENDIX Electrode Placement A James D. 1. The preauricular points are the small indentations head. 1.2. circumference of the patient’s head. be 10% of the total head circumference. Payne. below the forehead. Calculate 10% of the distance between the two for easy access during hookup.2. Repeat The inion is the small bony protrusion at the back of the the same procedure on the opposite side of the head. 313 Appendix A.8. you should have a 10% mark above 1. MD Julie Tsikhlakis. a mark 5% to the left and 5% to the right of the 1. center mark at the top of the head (Cz). Carney. Calculate 10% of the distance between the nasion and 1.7. The nasion is the inden.2. This spacing should location is called FPz. The midpoint between the two preauricular to the right. The first measurement is made by applying the the nasion. preauricular points and make a mark 10% above 1.2.2. MD Paul R. tape through these four landmarks. and 10% tape measure across the top of the head measur. marks above each preauricular point. Make a mark 10% above the inion.2.2.9. 1. These locations are designated O1 points is identified as Cz. Center the 10% mark above the inion by calculat- 1. Then locate the 30% sites are plotted according to the International 10/20 mark by measuring half the distance between the system of electrode placement. RN. MD Troy A. holding the measuring tape intersecting that 10% mark.2. The patient’s head is measured and electrode placement the left preauricular point. measure the A mark is made of the top of the head.2. At this time. a 10% mark above the inion. Holding the ing the distance from the nasion to the inion.1. These locations center the 10% mark in line with the nose. BSN 1. Look down the bridge of the patient’s nose and FPz on the patient’s forehead.5.6.

Gloves should be worn. The jack box should the entire electrode.8. larynx. Examine the condition of the electrodes. It is then plugged into the appropriate socket.1.12. They 1. 314 APPENDIX A 1. repeat the same pro. after the study. Electrode leads should be plugged into the electrode jack full leaving the remainder on the gauze to cover box in the appropriate pen sockets.11.5. 1. Calculating half of these devices are plugged directly into the electrode jack that distance.4. try to balance the impedances between the two loca- 1. The snoring sensor should be placed to the side of the the tube onto the gauze pad for each electrode. Electrode paste is a thick substance which area over the respiratory muscles. This will help minimize artifact caused by voltage electrodes.2. finger.11. To locate C3. Leg EMG electrodes are placed in close proximity of the 1.3. Surface electrodes are applied by using electrode 1.14. The pressure transducer should be applied in a fashion from Fp2 to O2. The paste should be squeezed from 1. Respiratory sensors include nasal/oral thermocouple and O1 holding the tape through the 30% mark and piezocrystal respiratory effort bands. measure the distance between Fp1 1. Intercostal EMG electrodes (if used) are placed in the paste.4.1. Oximetry is used for measuring and recording blood oxy- and the electrode providing a pathway for the gen saturation levels. ridge of the anterior tibialis muscle. Press the electrode into the paste to obtain a cap 1. Appendix A. Electrode application to the patient’s leg and routed through the patient’s bed- 1.5.2. imbalances between two similar electrode locations.13. cedure on the right side of the head.10.5. To locate electrodes site C4. Too much 1.7. They are then plugged into the jack box. If unable to achieve read- paste can cause the electrode to shift during the ings below 30 kW without overscrubbing the electrode study.indd 314 8/6/2009 5:10:10 PM . Impedances should be checked. Press this on the patient’s be placed in the jack box holder. path of the patient’s oral and nasal outflow tracts. measuring 1. should be secured in place with tape. Check for frayed or loose connections. which serves as an interface between the patient 1. holding the tape through the similar to nasal cannula oxygen in order to monitor nasal 30% mark above the right preauricular point. intersect the 30% mark. pressure. 1. Exact sensor location should be obtained from 1. The leads from above the left preauricular point. They should be placed holds electrodes in place and is easily removed in close proximity to each other. scalp with the gauze over the electrode.6.2.9. 1.10. The thermocouple should be placed directly in the site is the placement for electrode C3. The leads are taped 1. sites. The electrodes cups are filled with conductive gel clothes. A probe is attached to the patient’s electrical signals. the transducer package instructions. This intersect box. Facial electrodes are applied using infant pellet tions.

11. 1. Payne. D. or make test to verify that all the channels being recorded are work.13. ask the patient to make 1. R.indd 315 8/6/2009 5:10:36 PM .2. be clearly documented on the recording.10. Patient Calibrations APPENDIX for Nighttime Polysomnography B James D. ing properly. move your eyes to the L. Patient calibrations are performed before the start of each 1. With eyes open. MD Monica Henderson. the commands should only. U.13. D.9.13. 1. R.3. the technician should docu. RPSGT 1. 1. start of the test.1. Ask the patient to hold his or her breath for 10 seconds. L.13.5. Ask the patient breathe through his or her nose only for that he or she is unable to stay awake during the pretrials. or grit his or her teeth. With eyes closed. 30 seconds. D = down U. Ask the patient to open his or her eyes and then to blink three times.4.6. be repaired. a chewing motion. RN.8. If a snore sensor is being used. a patient may be so sleepy 1. Ask the patient to relax with his or her eyes open and three snoring noises. R = right 1. The patient should be instructed to do these 1. D. Ask the patient to point the toes on his or her left foot simple exercises.7. when these situations occur. MD Troy A. stare straight ahead for 30 seconds. L. U. Abbreviations 1. MD Paul R. 1. Ask the patient to breathe through his or her mouth ment that the patient is unable to complete the pretrials and only for 30 seconds.12. toward the end of the bed. R. D. use better judgment as to what pieces of equipment need to 1. As these are done.2. 1. Ask the patient to smile. U = up 1.3. 1. L = left U. 1. If a piece of equip.1. Geyer. Ask the patient to close his or her eyes for 30 seconds. 1. Carney. it should be repaired prior to the only.13.4. R. 1. Ask the patient to point the toes on his or her right foot ment is malfunctioning. toward the end of the bed. 315 Appendix B. Occasionally. move your eyes to the L.

Appendix B.indd 316 8/6/2009 5:10:37 PM .

immediately following 1. Sleep logs may be obtained for the one week before the the patient’s arising in the morning. nologist near the end of the overnight polysomnogram 1.17.5. After arising in the morning. Geyer.16.4.1.14. 1.4.5. The patient’s arising time should be noted on the night 1. 1. or CPAP retitration.13. 1. A urine drug screen should be obtained. the patient should toilet.indd 317 8/6/2009 5:11:14 PM . dress in street clothes. LEOG-A2 personal routines.10. Carney.6. MSLT Montage 1.7. and limb EMG electrodes should be removed 1. APPENDIX Multiple Sleep Latency Test (MSLT) Protocol C James D. REM suppressant medications and stimulant medi. should be withdrawn following the polysomnogram or CPAP retitration. They are not allowed to consume caffeine itinerary and other necessary information.3.9. 1. C3-A2 cations.17. and eat breakfast. tinuously monitored visually by technicians to insure ratory monitoring devices. The MSLT procedure is explained to the patient. Payne. 1. respi. airflow.1. Submental EMG 1. 1. which is completed by the night tech. 2 weeks prior to the study if possible. 1. including Provigil/Nuvigil and traditional 1.5 to 3 hours after the ending of the as well as any loose scalp or facial electrodes.12.11. The technologist conducting the MSLT is responsible 1. The daytime technologist conducting the MSLT upon 1.17. ter probe. MD Paul R. 1. MSLT to assess the patient’s recent sleep-wake schedule. The MSLT should be conducted at the sleep laboratory amphetamine-based medications.17. REEGT 1. patient’s nighttime sleep study and every 2 hours afterward. sleep onset REM periods have occurred.2. REOG-Al 1. summary sheet.17.15. Between naps the patient should be out of bed and con- 1. Perform five nap opportunities at 2-hour intervals. 1. oxime. Patients may “freshen up” and attend to minimum daily 1. The night postsleep questionnaire. should be completed. The first nap begins 1. explain the day’s between naps. for replacing necessary electrodes as well as measuring A shorter four nap test may be performed if at least two impedances on those left attached. After completion of the polysomnogram. C4-Al 317 Appendix C.8.2. and answer during the day. Patients are not allowed to remain in bed or sleep arriving should introduce his/her self. MD Troy A. chest respiration belts.17. that no napping occurs. MD Betty Seals.3. any appropriate questions the patient may have.

8. asking the movement and respiratory documentation.6.3.10.21. Moving eyes only.23. 318 APPENDIX C 1.6.21. O2-Al nap time in this scenario could be as long as 40 minutes. a sleep latency of 20 minutes.21. 15 minutes: First scorable epoch of sleep (even if 1.5. Swallow another 5 minutes (in other words. A 50-mV standard calibration is performed for all 1.21. A quiet and dark room.28.21.28. 20 minutes after first epoch of sleep if first REM 1.000W are replaced and your eyes closed. Moving eyes only.1. the first page of the first epoch of sleep (whether nap #1. Ol-A2 from the first page of scorable REM). look down 1. 1. Moving eyes only. Duration of nap acceptable.17. look up minute before end of nap. 1. patient for his subjective opinion of his sleepiness 1. 1.28.25. ment plugged in.28.23. 1.indd 318 8/6/2009 5:11:14 PM . No caffeine should be ingested on the day of the test.2. The absence of sleep on a nap opportunity is recorded as minimal interruptions.28.7. The maximum 1.3.22.5 minutes of the nap. Any noise inter.28.28. and let yourself fall asleep”). Sleep onset is defined as 1. If the patient has not had a scorable epoch of REM until 1.9. technologist performs the following 1. EKG 1. The duration of 15 minutes is determined by 1. and to 1. keep trodes more than 10. should be used.24.2.21. of sleep.1. instructing the 1.23.28. Moving eyes only.28. continues for 15 minutes after the first recorded epoch 1.5.9.28. 1. to lie still with eyes closed.5.2. 1. Blink several times the last 4.21.21.28. look right 1.21. 0 second: Lights out and begin test makes adjustments in tracing. 10 minutes: Patient prepares for bed and gets 1.7. Technologist starts polygraph or computer and 1. The electrodes are visually inspected for good patient to get into a comfortable position for adherence and any loose electrodes are replaced.3.5. REM latency is the time of the first epoch 1.1.8.8.26.21. conducive to sleep and with 1.5.4. Prior to testing: 15 minutes.19.5. 20 minutes: No scorable epochs of sleep 1. 30 seconds: 60 cycle check and good-night phrase 1. the patient uses CPAP. Patient is placed in bed at naptime and equip- CPAP during the naps. In order to assess the occurrence of REM sleep. the test sleep should be documented.27. with the exception of leg 1.5.21. 15 minutes: Subdue physical activity wakefulness. 6 minutes: Presleep questionnaire. Time procedure of sleep to the beginning of the first epoch of REM 1.1. look left epoch occurs in second epoch of last anticipated 1. 30 minutes: Suspend tobacco smoking sleep regardless of the intervening stages of sleep or 1. ruptions especially those producing arousals or delayed 1. 2 minutes: Patient calibration.5. stage N1 or a combination of sleep stages).6. End nap after: Condition patient biocalibrations: 1.2.20.23.18.17. If rechecked.28.17.1.5. When tracing is 1.28.4.5. falling asleep.28. the patient should use the 1. Eyes open for 30 seconds 1.5. Perform machine and patient calibrations prior to 1.25. MSLT Instruction Summary “clock time” and is not determined by a sleep time of 1. Grit teeth Appendix C.3. 4 minutes: Patient hooked up recording channels. Eyes closed for 30 seconds not until the second epoch of 19th minute) 1. the test should be run 1. add at least 5 minutes 1. An impedance check is performed and any elec- try to fall asleep (“relax and please lie still.7.5. Patient calibration is conducted in the same way as the into bed nighttime polysomnogram.28.4.

connecting tubing. eters for clinical use of the multiple sleep latency test and the 1.7. An all-channel calibration is 1. condition.1. Discard disposable equipment such as the nasal calibrations and turn off polygraph or exit com.4. Amplifier calibration is done at the beginning of the MSLT and then discharge him or her from the lab.32.30.3.30.32. Assure that all paste residue has been removed mined from lights out to the first scored epoch by using a wet washcloth on the skin and a fine.35. from head of bed.2. puter. rity. 1. 30-second epoch).30. Remove any lint from CPAP equipment filter. Carefully sort wires and group them together by 1.1. Reference 1. 1. of 10 minutes. etc. Leave patient suites in clean and orderly to avoid irritation of patient’s skin.” (1986) by Carskadon et al. 1.5.35. 1.5. Return any equipment and all cleaned 1. 1.32. 1.30.36. General cleanup checklist: 1. and at the end of the day.indd 319 8/6/2009 5:11:14 PM .32. Remove any remaining tape and wash elec. Gently remove all sensors from patient. cies are based on “Guidelines for the multiple 1. 1. MULTIPLE SLEEP LATENCY TEST (MSLT) PROTOCOL 319 1. scoring guidelines.33.4.6. Sleep 28(1):2005. Carefully soak each electrode site with warm 1. When patient is ready to leave. Knock and enter the patient’s room. After the polysomnogram: done and also an individual amplifier calibration.33.35. Rinse well and allow to dry. MSLT laten- removed. Inform remove and empty humidifier.2.30.1.1. Take care 1.35. of any stage of sleep. End of study: cleaning and disinfecting. place in designated “dirty equipment area” for 1. rinse and allow to 1.32. Mean sleep latency (arithmetic mean of all naps Inspect wires at this time to insure their integ.32. Latency from lights out to the first epoch of soak in disinfectant solution for a minimum sleep. Sleep stage scoring should be based on the AASM patient’s skin. 1. and get patient out of bed. maintenance of wakefulness test. Should include the start and end times of each 1. Practice param- area. or nap opportunities). 1. cannula or disposable oximeter probe.1.35. ask him or her if he sleep latency test (MSLT): a standard measure of or she has a follow-up appointment.29. do post test machine 1. The sleep latency is deter- 1. Return patient preparation box to appropriate Standards of Practice Committee of the AASM. If CPAP and/or oxygen equipment was used.31.4. At the end of the last nap. nap or nap opportunity. gauze. REM latency is scored from toothed comb after all electrodes have been sleep onset to the first epoch of REM.34. him or her to the front desk to schedule a follow-up 1. Number of sleep-onset REM periods (defined and disinfected wires to their storage area for as greater than 15 seconds of REM sleep in a future use.3.3. them that they must stay out of bed and awake until the nasal cannula. If not. trodes with soap and water.32.31.2. Discard all used tape.31.30. and any other equipment and start of the next nap at approximate (time). disconnect jack box 1.2. collars. Scoring: water until the electrode lifts away from the 1.32. take sleepiness. Stock patient preparation box as needed. MSLT Report lengths and application sites. Appendix C.

Appendix C.indd 320 8/6/2009 5:11:14 PM .

1. Respiratory monitoring devices and tibialis electrodes 1.10. EKG scalp or facial electrodes. Submental EMG summary sheet.10. may be withdrawn on the clinical considerations as decided by the sleep 2 weeks prior to the study if possible unless the study is specialist). Patients may “freshen up” and attend to minimum daily an individual basis by the sleep specialist.15.indd 321 8/6/2009 5:13:18 PM .1.10.2. night before the MWT please see 1.6. 1. which is completed by the night tech. O2-Al may be removed from the patient as well as any loose 1. 1. Perform machine and patient calibrations prior to nap 1. MD Paul R.4. 1.11.12.5.5. 1. Ol-A2 1. including modafanil and tradi- lowing the polysomnogram or CPAP retitration (based tional stimulant based medications.8. usual wake-up time. MD 1. Carney. If the patient does have a sleep study on the being performed to assess the effectiveness of treatment.10. The use of medications and tobacco may be decided on 1. immediately following 1. The first trial may begin 1. REOG-Al 1. The daytime technologist conducting the MWT upon especially those producing arousals or delayed sleep may arriving may introduce his/her self.8.10. A urine drug screen may be obtained. The technologist conducting the MWT is responsible #1. 1. No caffeine may be ingested on the day of the test. conducive to sleep and with min- impedances on those left attached. Any noise interruptions 1. personal routines. and answer 1.4. Geyer. for replacing necessary electrodes as well as measuring 1.2–1.9. Payne. C4-Al or CPAP retitration.14.4. 321 Appendix D. MD Troy A.5 to 3 hours after the patient’s 1. 1. may be used. MWT Montage 1. any appropriate questions the patient may have.10. C3-A2 nologist near the end of the overnight polysomnogram 1.3.10. The MWT may be conducted at the sleep laboratory fol. itinerary and other necessary information. The patient’s arising time may be noted on the night 1.10. 1.7. The night postsleep questionnaire.10. Maintenance of APPENDIX Wakefulness Test (MWT) Protocol D James D.2. A quiet and dark room. 1.6. LEOG-A2 the patient’s arising in the morning.3. Stimulant medications.7.13. may be completed. imal interruptions. explain the day’s be documented.

25.25. Patient calibration is conducted in the same way as the placed one foot off the floor and 3 feet laterally removed night time polysomnogram with the exception of leg from the patient’s head).25.19.19.1.5. and Standards of Practice Committee of the AASM.1.3. Sleep latency. The following data may be noted patient for his subjective opinion of his sleepi. the first page of the first epoch of sleep (whether 1.1. Amplifier calibration is done at the beginning of the 1.8. 1. Trials may be run every 2 hours. Sleep 28(1):2005.19.19. ness 1. asking the 1.indd 322 8/6/2009 5:13:18 PM . Time Procedure is done and also an individual amplifier calibration.19. MWT instruction summary 1. 1. An all channel calibration 1.19.3.1. just out of vision. lux at the corneal level (a 7.2.9. 30 seconds: 60 cycle check and start phrase 1. Start and stop times for each trial.19. 10 minutes: Patient prepares for the test (includ. The room may be dark with a light source positioned stage N1 or a combination of sleep stages). 40 minutes: No scorable epochs of sleep Appendix D. ing going to the restroom if needed) 1. movement and respiratory documentation. Four 40-minute trials may be run. instructing the 1.22. potentially dangerous activities.1.19. 1. 322 APPENDIX D 1. or one epoch of any other stage of sleep. Total sleep time.6. after unequivocal sleep (three consecutive epochs of stage N1 sleep). Clinicians might recommend that patients with a mean 1.18. End a trial after 40 minutes if no sleep is recorded.23.10 to 0.19.1.26. patient to sit in a comfortable chair with the 1.13 tive sleep in a 30-second epoch. Sleep onset is defined as 1. 1. 1. 6 minutes: Presleep questionnaire. MWT Report 1.25. 0 second: Begin test 1.4.1.16. 1. 1. The is defined as greater than 15 seconds of cumula- light source may deliver an illumination of 0. mean of the four trials). Mean sleep latency (the arithmetic head supported such that the neck is not uncom.10. Prior to testing: MWT and at the end of the day.17. Reference long as possible (“relax and please sit still.2. 4 minutes: Patient hooked up 1. 1. fortably flexed or extended and to stay awake as 1. 15 minutes: Subdue physical activity sleep latency on MWT avoid driving or engaging in other 1.21.1.25.5.19. 2 minutes: Patient calibration.1.25. Practice param- stay awake as long as possible looking straight eters for clinical use of the multiple sleep latency test and the ahead but not at the light”). Sleep slightly behind the patient’s head.20.19.4.1. 30 minutes: Suspend tobacco smoking 1. 1. Stages of sleep achieved for each trial.21. 1.20.5 watt night light can be used.25. maintenance of wakefulness test.24.7.

166 Breach rhythm. 119. 152–153 323 Index. 6–7 cardiac events. Neonate) upper-airway resistance events Arousal Bigeminy. face rubbing. 98–99 Artifacts Cheyne-Stokes respiration. 58. 58 decreased airflow Bradycardia Alpha waves flow-limitation arousals (FLA). 7 Breathing disorders stage N2 sleep. 270. 265. 214–215 238–239 hypopnea. 302 sweat artifact. 158 240 stage N1 sleep. 86 obstructive apnea. cardioballistic Apnea Artificial eye. 270–279 first-degree. NREM sleep. eye movements. 254 Abdominal effort channel. 13. 147. 8. 28. 263–268. 12 Brain tumors. 8 mixed apnea. those followed by a “t” denote tables. 12 alpha waves. 148 common mode rejection ratio (CMRR). 275–276 arousals. 2 delta waves. 12 (see also Electrocardiography (EKG)) third-degree. 10–12 (see also Central Atrial fibrillation. 227–229. position change.indd 323 8/7/2009 1:20:58 PM . 25. frequency range. 150 eye movements. 10 arousal. 195t stage N3 sleep. 19 respiratory monitoring. 268. 279 flow-limitation arousals (FLA). EEG abnormalities. 67–68. 257 144–145 differential amplifier. 20–24 cardioballistic artifact. 5–6. 11–12 mixed apnea. arteriovenous malformation. 154–156 stage wake. 256 monitoring. 301 swallow artifact. 6. 93–94 theta waves. 19 alpha activity. A Antidepressants. 259 periodic breathing. 102–105 respiratory effort-related arousals (see also Obstructive sleep apnea B (RERAs). 280 (UARE). 150 procedure. 11 (see also Mixed apnea) Awakening. 2. 157. 5. 58–60. 78 respiratory effort-related arousals obstructive sleep apnea. 258 intrathoracic pressure monitoring. 79. unilateral REMs. 96–97 stage R sleep. 167 central apnea breathing. 96–97 Arteriovenous malformation. 269 Airflow apnea) Atrioventricular block decreased EKG abnormalities. 7 Biocalibration obstructive sleep apnea. 14t delta activity. Index Page numbers in italics denote figures. 18 Alpha-delta sleep post-arousal central apnea. 252–253 expanded EEG montage with CO2 Amplifier chest patting. 7 (RERAs). 12 alpha-delta sleep. 78 unilateral rapid eye movements. 255 oxygen desaturation. 274 hypopneas. 78. 124. 11 obstructive sleep apnea (OSA). 58. 301 laptop computer. 159 leg movements. 240 central apneas stage R sleep. 12 central apnea. 128 wakefulness. 252 central apnea. 12 (OSA)) Baby (see Infant. 7. 254 artifact. 143 hypopnea. 187 filter.

. 152–153 262 hypoventilation. 108. 187 premature ventricular complexes (PVCs). 324 INDEX Breathing disorders (Continued) RIP recording. 181 closed eyes. 218 intrathoracic pressure (Pes) monitoring. 119 epilepsy. 252–253 oxygen desaturation. 109 144–145 stage R sleep. 60 obstructive sleep apnea oxygen desaturation. 175 paradoxical respiration. 203. 201. 291 montage. 112 standard montage with CO2 intrathoracic pressure monitoring. laptop. 294 Continuous positive airway pressure (CPAP) snoring. 210–211 stage R sleep. 266–268 chest wall motion. 158 central apnea. 256 stage R sleep. 236 respiratory effort. 5 CPAP level. 182 Chin electromyography periodic limb movements montage. 318 desaturation. 147. 161 maintenance of wakefulness test (MWT). 137–143 hypopnea. 113–114 fighting behavior. 133 sleep patterns. 172. 149 stage N1 sleep. 26–27 oxygen desaturation. post-arousal central apnea. 221–223 REM sleep. 317. 42 PAP titration. 163–170 oxygen desaturation. 150 stage N2 sleep. 164 C snoring. 286 stage R sleep and arousal. 154–156 pulse oximetry. 122–125 grit teeth. 67. 156 intrathoracic pressure (Pes) monitoring. 289 Common mode rejection ratio (CMRR). 161. 165 obstructive sleep apnea. 160 expanded EEG montage with CO2 stage N1 sleep. stage wake. 144. 108 intrathoracic pressure monitoring. 295 Computer. 183–184 eye movements. 293 Confusional arousal. 290 central apnea. 157. 235 obesity hypoventilation syndrome. 162. 120 Central apnea postictal confusion. 189–190 bruxism. 164 mixed apnea Carbon dioxide monitoring. 152–154. 6 arousal and movement. central apnea. 163–164. 195t 130. 148. 146 REM sleep. 162 foot flex. 43. 126. 166 stage wake. 7 heart rate. 210 post-arousal central apnea. 102–105 Cheyne-Stokes respiration.indd 324 8/7/2009 1:20:58 PM . 304t–305t standard montage. 60 paradoxical respiration. 151 multiple sleep latency test (MSLT) arousals and minimal oxygen chest patting. 132 open eyes. 110 stage R sleep and arousal. 165. Calibrations stage R sleep identification. 150 CPAP level. 126 in-phase respiratory effort. 104–105 nocturnal seizures. 167 154–156 upper-airway resistance syndrome. 106–107 151 stage N3/N4 sleep. 4 128–129 breath hold. 256 protocol. 321 arousal. 185 calibration sequence. 276 CPAP level. 149 snoring. 301 nasal pressure signal excursion. machine calibrations. 288 complications and responses. 61–63. 159 staging 115–116 REM sleep. 159 sawtooth waves. 217 scoring. 181–182. 134–135 stage N1 sleep. 173–174 obstructive sleep apnea monitoring. 146 sample report. 103 periodic limb movements montage. 55–57. 151 upper-airway resistance syndrome sleep stage characteristics ETCO2 monitoring. 186 periodic breathing. 104–105.. 180 Chest patting artifact. 69 pulse oximetry. 177–179 standard montage with CO2 monitoring. 176 in-phase respiratory effort. artifact from. 21 respiratory effort and airflow. 117 Cardioballistic artifact. 6 hypopnea Bruxism. 148 stage N2 sleep. 118 staging. 166–170. 157. 292 hypopnea. 188 intrathoracic pressure (Pes) monitoring. stage N3 sleep. 311 127. movement arousals. 121 Cheyne-Stokes respiration. fatigue and fibromyalgia. 8 monitoring. 257 RIP recording. arousals. 65. 111–112. 253 Index. 34. 78 phasic REM sleep.

277–279 frontal. 8 periodic leg movement (EKG)) staging. 18. 2 ventricular bigeminy. 204–206 Hypopnea. 268–269 Electrooculography (EOG). 8 (see also Airflow) RLS montage. 282 intrathoracic pressure monitoring. 122–126 Electrocardiography (EKG) unilateral. 4 bruxism. 123 Fragmentary myoclonus. 302 stage N3 sleep benign rolandic epilepsy. 217 infantile spasms. 242 CPAP trial. 227–229. 245 307t–308t Differential amplifier. 54–57 glioma. 283–286 obstructive apnea. 235 snoring. 185 bradycardia. 243. 218 respiratory effect (see Respiratory vibration artifact. 226 high frequency filter. 227–229 nasal and oral airflow. 8 ventricular quintigeminy. 7. 200. NREM sleep. 238–239 limb movements (see Limb movements) hypopnea. 309–310 (see also Artifacts) Turner syndrome. 248 phase shift. 301 partial status epilepticus. 201 phy (EKG)) stage wake. 6 epilepsy. trace discontinuity. 250 frequency range. 183–184 first-degree AV block. 309 H effect) frequent leg movement. 304t slow wave sleep. 1 fighting behavior. 42 arteriovenous malformation. 246 low frequency filter. 13. 4 Electroencephalography (EEG)) chin EMG G electromyography (EMG). 1–4 (see also Electromyography (EMG). epilepsia partialis continua Decreased airflow (see Airflow) 262–264 (EPC). 302 characteristics. 310 Lennox-Gastaut syndrome. 281. 237 Focal seizures. 6. 237. 96 juvenile myoclonic epilepsy multiple sleep latency test. 302 tracé alternant pattern. 266 F slow-wave activity. 3t Digital polysomnography seizures. 4–6. 81–82 partial seizure activity. 1 CPAP level. 274 partial status epilepticus. 214–215 tachycardia. 162 Index. 302 multiple sleep latency test. 4–7. 239 abnormalities Filters stage N2 sleep. INDEX 325 D premature ventricular complexes (PVCs). 275–276 benign rolandic epilepsy. 294 infants and children. 242 scoring. 58–60 complex partial seizure. 231 electroencephalography. 278–279 CO2 monitoring. 45 (JME). 240 60 Hz notch filter. 231 Delta waves stage wake. 250 settings. 258 stage N1. 113–114. 236 ventricular trigeminy. 306t–307t sweat artifact. 164 bigeminy. 207 Heart rate (see Electrocardiography snore sensors. 247 parasomnias. 5t (see also Staging) asymmetric. 242 REM sleep behavior disorder. sawtooth waves.indd 325 8/7/2009 1:20:58 PM . 29 E tachycardia. 271–273. 304t–305t alpha activity. 302 bilateral. CPAP montage. 234–236 intrathoracic pressure monitoring. 236 chest patting. 221–223 stage N1 sleep. 245 Delta brushes. 267 seizure. 270. 83 nocturnal seizure. 81–82 sinus arrhythmia. 232–233. 166 atrial fibrillation. 238–239 305t–306t expanded EEG montage. 210 Glioma electrooculography (EOG). 286 stage R sleep. 280 Epilepsy nasal pressure signal excursion. 232. 238. 234 arousals. 265 Eye movements. 198–199 arousal and movement. 54. 241 Frontal epilepsy. 202 Hypnagogic hypersynchrony. 256 third-degree AV block. 227–231. 279 artifacts. 203 High frequency filter. 249 First-degree atrioventricular block. 233 electrocardiography (see Electrocardiogra. 3 Electroencephalography (EEG) Face rubbing artifact.

81–83 respiratory effort. 163–164. 249 Infantile spasms. Mixed apnea Non-rapid eye movement (NREM) sleep 127. for CPAP trial. 198–207 Muscle movements oxygen desaturation. 237. 93 oxygen desaturation. 172. 305t–306t in-phase respiratory effort. 37. 189–190 Index. stage R sleep. 118 chin EMG. 304t–305t movement arousals. 70. 103 Left frontal spike and wave. CPAP mask leak. 130. 8 central apnea. 85 rapid eye movements. fragmentary. 174 REM sleep. 160. 173–174 standard montage. 4 RIP recording. 236 Maintenance of wakefulness test (MWT) Nasal and oral airflow. 96. 6 (see also Sleep protocol. 121 intrathoracic pressure monitoring. 136 for REM sleep behavior disorder. 242 Intrathoracic pressure (Pes) monitoring. 244 periodic breathing. 128–129 oxygen desaturation. 84 sleep staging. 92 in-phase respiratory effort. 173. 127. 306t–307t trace discontinuity. 104–105 expanded EEG montage. 175 stage N2 sleep wakefulness to stage 1 transition in. artifact. 133 307t–308t upper-airway resistance syndrome. 6 epilepsy. 176 Movement time (MT). 200. 119 Cheyne-Stokes respirations. 108 K complexes. periodic breathing. 111–116 Limb movement disorders. 85 76 for parasomnias. 303t Obesity hypoventilation syndrome. 321–322 Neonate (see also Infant) NREM sleep. 304t vertex waves. 1 snoring. 9t 94. 195t monitoring (see Electromyography paradoxical respiration. 100 seizures. 130. 201. 302 Myoclonus. 165. 257 calibration test. 8. 18. for multiple sleep latency test. 181–182 Low frequency filter. respiratory effort. 132 arousal. 95 stage N1 sleep. 167 Lip quiver. 158 alpha activity. 7 70. 90–91 hypoventilation. 12 oxygen desaturation. 246 Mask leak. 186 K Multiple sleep latency test (MSLT) arousals and oxygen desaturations. 8 negative intrathoracic pressure. 305t–306t paradoxical respiration. 96–97 stage N2 sleep. types. 3–4. 132–136 Montages 70. 106–107 periodic (see Periodic limb movement) (EMG)) respiratory effort and airflow. 201 sample report. 226 stage N3 sleep. 100 pulse oximetry. 144–145 arousals and minimal oxygen characteristics. 317–319 chest wall motion. 232–233. 203. 1 Obstructive sleep apnea (OSA). 39–41. 172–174 Nocturnal seizures. for seizures. 98–99 266–268 L wakefulness stage R sleep. 256 protocol. 12 wakefulness to stage 1 transition in. 276 Laptop computer. 43 stage N2 sleep. 306t–307t O 134–135 for standard polysomnogram. 110 Limb movements. 76 non-rapid eye movement (NREM) sleep. 166–170. postictal confusion. 8 slow eye movements. 4 hypopnea. 76 for intrathoracic pressure monitoring. REM sleep. 136 305t–306t symmetric sleep spindles and rapid eye movement (REM) sleep. 236 CPAP montage.indd 326 8/7/2009 1:20:58 PM . 132–136 chest patting. CPAP. 92 myoclonic encephalopathy. 120 infants and children. 117 desaturation. 109 spindles) stage N1 sleep CPAP montage children. 11 montages. 326 INDEX I M N Ictal activity. 231 rapid eye movements. 8 Infant (see also Neonate) calibration test. 34. 90–91 Negative intrathoracic pressure. 42 94. 156 filters. 234 desaturation.

176 stage N3 sleep. 302 staging Periodic limb movements polarity. 123 obstructive apnea. phasic and tonic EMG activity. 168 hypopnea. 156 stage N1 sleep. 221–223 respiratory effort. 76 Parasomnias sixty-hertz artifact. 252 central apnea. EEG. 11 134–135 R stage N2 sleep. 30 Respiratory effort (see also Breathing central apnea. 301–302 infants and children. 313–314 obesity hypoventilation syndrome. 310–311 intrathoracic pressure monitoring. 152–153. 5 obstructive sleep apnea artifacts Cheyne-Stokes respiration. 309–310 settings. 310 eye movement recording. 77 P rectus spike artifact. 270. 2t stage N1 sleep swallow artifact. 302 Rapid eye movement (REM) sleep. 175–179 stage R sleep. 158. 265 humidifier condensation. 12 filters. 159 atrial fibrillation. 2. 7 rhythmic movement disorder. 277–279 obstructive sleep apnea. 171. 310 chin EMG. 4. 13 bruxism. 121 262–264. 61. periodic breathing. 18. 12–13 differential amplifier. 124. 167. 310 desaturation. 110. 128 Index. 175 EEG channel. 203 variables. 207 stage N1 sleep. 136 movement (REM) sleep) behavior disorder. 126 (see also Rapid eye alpha activity. 6 obesity hypoventilation syndrome. 309 neonate. 63. 180 stage R sleep. 114–116. 11 stage R sleep. 311 latency. 213 common mode rejection ratio (CMRR). 147. 204–206 stage N3 sleep. 309 montage. 309 fighting behavior. loose belt. 6 stage N3 sleep. 212 vibration. 280 central apnea. 67 intrathoracic pressure monitoring. 67 central apnea hypopnea. 180 stage N3 sleep. 210–211 sweat artifact. 11. 106. 310 leg movements. 268 tachycardia. 128 Phase shift. 123. 116.indd 327 8/7/2009 1:20:59 PM . 117. 122. 309 incomplete atonia. 157 adult. 175. hypopnea. 202 Positive occipital sharp transients (POSTs). 198–199 stage R sleep. 218 Periodic breathing 301 poliomyelitis. 301 sawtooth waves. 162–164 electrode pop. 214–215. 200. 224 muscle (EMG) artifact. 112. 63. 111–112. 217 patient calibrations. 187 respiratory effort. 301–302 stage R sleep. 156 CPAP montage. 107–109. 301 sleep patterns. 307t–308t mixed apnea bigeminy. 310 CPAP pulse oximetry. 102. 84 stage N2 sleep. 4 167. 12 cardioballistic artifact. 310 movement arousal. 315 obstructive sleep apnea. 70. 149 characteristics stage N2 sleep. 80. 219 stage wake. 218–224 signal processing parkinsonism. 216 electrode placement. 147–149 upper-airway resistance syndrome. 146 Post-arousal central apnea disorders) restless legs syndrome. 129 bilateral periodic leg movements. 102–103. 12 in mixed apnea. 127 Pulse oximetry. 171 stage N2 sleep. 276 loose electrode. 128 Premature ventricular complexes (PVCs). 118 Polarity. 125. 12. 2. 149. 8 asymmetric. 113–114. 236 blink artifact. 125 Phasic REM sleep. 202 unilateral. 126–127 misplaced thermocouple artifact. 158. 276 stage N2 sleep. 63 stage N1 sleep. 119–121. 220 central apnea. INDEX 327 Oxygen desaturation Pes monitoring Posterior dominant alpha activity. 12 stage N2 sleep. 1 stage R sleep. 200 stage N2 sleep. 310 hypopnea. 130. 8 bilateral. 4 periodic breathing. 176 Polysomnography stage wake.

306t–307t stage N2 sleep. 213 stage N1. 217 Signal processing Snoring. 119–121 upper-airway resistance syndrome. 139–140. 32–44. 5 Stage N2 sleep Rhythmic movement disorder.indd 328 8/7/2009 1:20:59 PM . 126. 117 stage R sleep Sleep onset central apnea. 61–63. 301–302 central apnea. 121 arterial oxygen saturation (SaO2). 96–97 right frontal. 95 CPAP montage. 146 multiple sleep latency test (MSLT). 71. 187 Right hemispheric sharp waves. 232. 1 slow eye movements. 113–114. 6. 10 94. 1–2. 96. 199. 7–8 staging. EEG. 216 montage for. 6. cycles. 230 stage N3 NREM sleep. 93 127. 76 parasomnias. 200–206 frequency range. obstructive apnea. 25–31. 96. 167 staging. 6. 174 Lennox-Gastaut syndrome. 124. 107–109. 212 phasic REM sleep. 76. 118. focal seizure. 137–138 children. 4 Sleep montages (see Montages) mixed apnea. 200. 128 Right frontal sharp and slow waves. 132 Seizures (see also Epilepsy) children. 226 infants. 3 negative intrathoracic pressure. 328 INDEX Respiratory effort (Continued) architecture. 111–112. 6. 249 Sleep talking. 233 stage N2 sleep. 173 monitoring. 6 central apnea. 65 Sleep spindles myocardial infarction. 181 standard montage. 216 upper-airway resistance syndrome. 159. 42 stage R. 230 alpha waves. 198 theta waves. 6 arousal. 212. 301 tachycardia. 5–6 alpha waves. 80 neonate. loud snoring and nocturnal reflux. 6 hypopnea. 160 Sleep terrors. 123 characteristics. 136 respiratory monitoring wakefulness to stage 1 transition in. 1 rhythmic movement disorder. 156 respiratory effort. 127. 146. 214–215. 39–43. CPAP level. 185 airflow. 85 obstructive sleep apnea. 129 right hemispheric. 27. 25. 8. 226 staging. 226 Sawtooth waves. 207 stage awake. 165 mixed apnea. 6. 230 stage N2. 215. 118 301 hypopnea. 8 theta waves. 128. 28 Restless legs syndrome. 100 mixed apnea. 111–116. 34. 45. 302 Stage N1 sleep parasomnias. 66. 8. 37–44. snoring. 165 myoclonic seizure. 184–185 S Sleep apnea. 281–282 96–97 filters. 10 bruxism. 157 snoring. 2t. obstructive (see Obstructive k complexes. 162. 8. 93–94 unrefreshing sleep. nocturnal. 80 Sleep limb movement disorders. 58–60. 54–60. 130 Index. 78 snoring. 210–211 obstructive apnea. 137–143 limb movement disorders. 8 nocturnal seizures. 214 134–135 Sharp waves Slow waves Stage N3 sleep medium amplitude. 45–60. 9t wakefulness. 6–7 snoring. 232–233 atypical patterns. 277–279 hypopnea. 298–299 mixed apnea. 233 NREM sleep. 137. 122. 215 actigraphy. EEG. 248 REM sleep. 124. 191t multiple sleep latency test (MSLT) intrathoracic pressure (Pes) monitoring. REM sleep sleep apnea (OSA)) limb movement disorders. 37. 85 170. 8–10 10–11 parasomnias myocardial infarction. 141–143 Sinus arrhythmia. 33–34. 172. 226 stage R sleep. 226–229 stage N3. 151–155. 6 delta waves. 163. 144–145. 13. differential amplifier. 160 complex partial. 217 polarity. 133. 162 multiple sleep latency test (MSLT). 243 95. 280 arousal. 25. 119. 227–229 delta waves. 183 staging. 163. 232. 199 common mode rejection ratio (CMRR). 138 seizure activity. 131 infants.

275–276 staging. brain. 18 stage R sleep. 71. 83 movements. 123 stage N3 sleep. 78 stage N3 sleep. 310 Teeth grinding. 80 NREM sleep. 237 stage N1 sleep. 67–68. 281–282 W sweat artifact. 96–97 waves. 13. 79. 96. 217 snoring. 290. 7. 146. 3 nasal pressure waveform. 84 stage N1 sleep. 92 stage wake. 54–60. 5. 315 Wakefulness (see also Maintenance of tracé alternant pattern. 256 Tachycardia Ventricular trigeminy. 30–31 stage N2 sleep. 80 V stage N1. Turner syndrome. 283 Vertex waves infants and children. 27. 238. 215 central apnea. 112 seizure activity. 6–7 REM sleep. 148. 93–94 delta and theta activity. 266 frequency range. 273 arousals. 6. 285–286 infant. 130 hypopnea. 18–24. 78 activity. 214–215 T nasal pressure waveform. 267 stage N3 sleep. 4 Tonic REM sleep. 81–82 frequency range. 265 stage N2 sleep. 124. 2 tracé alternant pattern. 7 delta brushes. 8 hypopnea. 6. 6. 7 Third-degree atrioventricular block. 83 238–239 slow eye movements. 6 slow-wave activity. 7 alpha-delta sleep. 83 claustrophobia. 45. 61–77. 93–94 stage R sleep. 78 Wide complex tachycardia. 215 infants. 255 central apnea. 311 movement arousals. 2 sawtooth movement arousals. 23 Tumors. 204–206 stage N3 sleep. 32–44. 35–36. 2 stage N1 sleep. 283 chest patting. 6. 64–66. restless legs syndrome. 25. 271–273 stage N1 sleep. 61 infants and children. 40 stage N1. 259 hypopnea. 20–24 Sweat artifact. 286 delta mixed apnea. 86 Upper-airway resistance syndrome alpha continuous mixed frequency background arousal. 25. 284 stage wake. 4 REM sleep. INDEX 329 Staging U Waves awake state. 239 obstructive sleep apnea. stage N1 sleep. 21 stage N3 sleep. 6. 156 theta stage wake. 5–6. 6. 207 tracé alternant pattern. 4 arousals. 93–94 calibration test. 45–60. 8 rapid eye movements. 245 biocalibration. 81–83 stage N2 sleep. 42 periodic leg movements. 4 REM sleep. 2 central apnea. 25. 38. 156 frequency range. 274 electromyographic recording. 23 Cheyne-Stokes respirations. 98–99 Swallow artifact. 90 113–114. 85 seizure.indd 329 8/7/2009 1:20:59 PM . 253 arousals. 58–60. 283 stage N2 sleep. 143 stage N2 sleep. EEG abnormalities. 227–229. 7 alpha-delta sleep. 83 Theta waves wakefulness test (MWT) ) trace discontinuity. 85 Ventricular tachycardia stage R sleep. 58 frequency. 28. 76. 128 symmetric sleep spindles and vertex Ventricular quintigeminy. 58. 8 stage N3 sleep. 8 seizure activity. 80 Ventricular bigeminy. 25. 6. 236 mixed apnea. 2 alpha activity. 245 Tracé alternant pattern open eyes and rapid eye stage N1 sleep. 27. 25–31. 134–135 frequency range. 28 271–272 Index. 61–62.