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The Sleep Technician Guide: Practical Aspects of Sleep Diagnostic
The Sleep Technician Guide: Practical Aspects of Sleep Diagnostic
Technician guide
Practical aspects of sleep diagnostic
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1. EEG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2. EOG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3. Chin EMG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4. Respiratory airflow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
5. Snore sensor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
6. ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
7. Respiratory effort. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
8. Position sensor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
1. Key rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3. Visual rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
4. Arousals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
5. Cardiac rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6. Movement rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
7. Respiratory rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Sleep is known to be a natural need and is also essential for all species. Nevertheless, it was
not considered as part of the medical curriculum until recently.
Whereas we spend a third of our lives sleeping, which means about 25 years for most of
us, only 30 minutes over the 8 years of teaching at medical school were dedicated to sleep
medicine until 2000. The same applies to allied professions such as nurses, technicians,
physiotherapists etc. who have to take care of patients suffering from sleep disorders. Until
recently, no appropriate information was provided to doctors and allied professions from
pathophysiology to treatments of sleep disorders.
Sleep medicine leads to holistic understanding of related conditions at the crossroads of
many medical specialities such as neurology, respiratory medicine, endocrinology, psychiatry,
occupational medicine, cardiology, ENT, sports medicine, paediatrics. Sleep medicine brings
strong evidence of its relevance.
This evolution of sleep medicine owes a lot to the improvement of sleep technology and skills
from sleep technicians.
Indeed, over the last few years, sleep studies were significantly simplified by information
technology allowing the gap to be bridged from research to bedside. 15 years ago,
electroencephalograms were just printed. More than 1000 pages (ie, 10 kilos of paper each
night) had to be visually analyzed for sleep interpretation. Today, data is directly recorded
on digital portable polysomnographs or in the software of the sleep lab. Patient's comfort
(which is critical in sleep medicine) and reports have also improved. A better understanding
of circadian rhythms and a better screening of sleep disorders are now achievable. Home
sleep studies (respiratory studies in particular) are now routine tests even if the need to have
multiple electrodes all night long is still a constraint for the patient.
A Sleep Technician guide was necessary and we have to be grateful to Maxime Elbaz (President
of the SFTS) and also to Philips Respironics for being the initiators of the project and making the
technological innovations of sleep recording and analysis accessible and educational.
I hope this guide will lead to new developments in sleep medicine for the patients thanks to a
new wave of sleep technicians working in collaboration with physicians.
Pr Damien Léger
Centre du Sommeil et de la Vigilance
Hôtel Dieu, Paris APHP
Paris Descartes Faculty.
Over the last 20 years, sleep studies have quickly evolved. Indeed, the period of analog
recordings has shown the essential role of the sleep technician, especially concerning the
good performance of recordings: amplifiers’ calibration, filters and gains setting and various
set-up configurations.
The advent of digital processing in the 90s launched a new and much more convenient way of
The role of the sleep technician is to provide the specialist with an accurate recording of the
electrical brain activity recorded over the scalp as well as cardio-respiratory variables.
The sleep technician should be able to pick out different artefacts which can hamper
sleep recording. Very recently, a diploma in sleep and wakefulness technologies allows the
technician to understand and examine what is being recorded, and also, with the help of a
sleep specialist, interpret the data. The technician’s task is not only to “apply electrodes,
Under the auspices of Philips Respironics, it becomes clear of the need for our first Sleep
Technician guide. This guide provides technical information about polysomnography at the
Sleep screening and diagnostics are illustrated with many pictures showing how to apply
Actigraphy, which is less known, is described as a very promising technique allowing a better
This manual summarises also the new scoring rules of the AASM 2007, illustrated with some
concrete examples.
Finally it will help the sleep technician in his everyday practice, enhance knowledge and create
Maxime Elbaz
President of the SFTS
Chief Technologist
Centre du Sommeil et de la Vigilance
Hôtel-Dieu, Paris
Growing awareness by the medical profession of the importance of sleep and its disorders
has led to a plethora of services for which there is a need for a consistent clinical approach.
The role of the sleep physiologist is to ensure the safe and accurate assessment of patients, to
aid diagnosis and effective titration of therapy.
Formal training in sleep medicine and its technology is not readily available in many countries
and the principal aim of this handbook is to act as a source material for all practitioners
working in this field.
Anwen Evans
RPSGT, Clinical Specialist Manager
First, sincere thanks to Maxime Elbaz and Pr Damien Léger (Hôtel-Dieu, Paris) who
this guide.
We would like to acknowledge all hospitals who largely contributed in making this project
possible by opening their doors and allowing us to meet their technicians: Hôpital Foch
Many thanks to Pr Escourrou for answering our questions, welcoming us and for supporting
this project.
Thanks to Joyce Black, Pamela Minkley and Emmanuel Billaud for providing us materials and
information.
We are also grateful to Alexander Hoffmann and Pr Ingo Fietze for their work on a German
Thanks to Dr Philippe Grunstein (MD FRCP Consultant Physician, Norfolk and Norwich
University Hospital, Associate Professor of Medicine) and Mrs Jane Taylor, Sleep Co
ordinator, for their precious help.
This book would not have been possible without the help of Anwen Evans (RPSGT). Many
thanks to her for reviewing early versions of this guide and for providing her helpful and
appreciated inputs.
Finally many thanks to you, our readers. May this guide be of a great support and interest in
Thanks to all.
Alexander Hoffmann, PhD, Market Development Manager Sleep Diagnostic and Cardio,
Central Europe.
For each measurement, you can find easily the tips symbolized by Tips
Level 4 systems are screening devices, whereas other systems are diagnostic devices
(cf. figure 1).
EEG
EOG Sleep parameters
Chin EMG
YES NO
NO YES
NO
References
[1] http://www.sign.ac.uk/pdf/sign73.pdf
[2] Hensley, M. J., Hillman, D. R. et al (2005), 'Guidelines for sleep studies in adults' [Internet],
Australasian Sleep Association and Thoracic Society of Australia and New Zealand.
Available from: http://www.sleepaus.on.net/guidelinesforadultsleepstudies.pdf.
[3] Chesson et al. (1997), ‘The indications for polysomnography and related procedures’,
Sleep, 20(6), 423-487.
[4] Douglas et al. (2003), ‘Home diagnosis of the obstructive sleep apnea/hypopnea
syndrome’, Sleep Med Rev, 7(1), 53-59.
[5] http://www.splf.org/s/IMG/pdf/RPC-SAHOS.pdf
Sleep diaries
A sleep diary is a record of an individual’s sleeping and waking time and is a useful tool in
evaluating the evolution of a sleep disorder and identifies sleep problems. Usually kept over
a period of several weeks [1] it is simple and easy to use and is self-reported or can be
recorded by a care-giver.
Information gained provides insight into quality, quantity and sleep/wake schedule, as well as a
record of factors which are known to affect sleep and wakefulness.
It is a useful resource in the diagnosis and treatment of poor sleep hygiene, insufficient sleep
and circadian rhythm sleep disorders. Additionally, the sleep diary is useful in monitoring
efficacy of treatment. This data alone can help people self-diagnose, raising awareness of
factors which may be affecting their ability to obtain good sleep.
Sleep diaries may be used in conjunction with actigraphy and prior to the Multiple Sleep
Latency Test and Maintenance of Wakefulness Test.
The Berlin questionnaire is a validated screening tool for the probability of OSA (cf figure 4).
This 10-item scale assesses the risk (high or low) of having sleep apnoea based on the
responses to the questions. It consists of 3 categories:
• snoring
• somnolence
• overweight (BMI5>30) and high blood pressure
The Berlin Questionnaire, in English, performed with 62% sensitivity and 43% specificity at
the RDI6> 10 level [2].
The Epworth Sleepiness Scale (ESS) is a widely used tool, consisting of 8 situations whereby
the patient is asked to rate their likelihood of falling asleep. It is a simple self-reporting
questionnaire, easy and quick to complete.
The individual chooses a “score” for each situation from a 4 point scale, with 0 being “would
never doze” and 4 being “high chance of dozing”. The total score is obtained, providing the
individual’s subjective assessment of their level of sleepiness over time.
• 0 - 9: Average score, normal population.
• 10 - 24: Sleep specialist advice recommended.
The ESS obtained a relatively low sensitivity (66%) in the identification of an apnoea
hypopnoea index >5 at the suggested cutoff of 10. The results of the study showed only fair
discriminatory ability of the ESS as a screener for OSA. It is used to assess excessive daytime
sleepiness, and is useful as a serial measurement e.g. after the administration of treatment
(e.g. CPAP) to document improvement of symptoms [3]. However, it is important to note
that subjects with high risk of cardiovascular disease and with moderate-severe OSA may be
minimally symptomatic or asymptomatic [4]. In narcolepsy, the Epworth sleepiness scale has
both a high specificity (100%) and sensitivity (93.5%) when a cut-off ESS score > 10 is used [5].
The Scale should be completed independently by both the patient and their partner as
patients can underestimate the severity of their sleepiness.
540-545. 1991
©1990-1997
MW Johns
Societies, LLC.
The pulse oximeter is widely used in the domiciliary setting and is a useful screening tool,
helping to identify patients with Sleep Disordered Breathing.
An overnight measurement determines the frequency and extent of haemoglobin
desaturation during sleep and provides information regarding the severity of Obstructive
Sleep Apnoea.
Pulse oximetry is a well-established screening tool to determine a patient’s arterial oxygen
saturation and heart rate. A series of studies looking at the clinical utility, reproducibility and
adequacy of pulse oximetry for the diagnosis of sleep and breathing disorders have shown
that overnight pulse oximetry detects moderate to severe OSA well, but is less useful for
milder cases [7-8].
A sensor is placed usually on a fingertip or an earlobe, or in the case of a neonate, across a
foot, and a light containing both red and infrared wavelengths is passed from one side to the
other [1]. Based upon the ratio of changing absorbance caused by the difference in colour
between oxygen-bound and oxygen unbound blood haemoglobin, a measure of oxygenation
(the per cent of haemoglobin molecules bound with oxygen molecules) can be made.
Pulse oximeters also measure heart rate and brief increases are an indirect marker of
transient arousal from sleep. Reviewing oximeter tracings with the accompanying pulse rate
can indicate sleep fragmentation.
A more detailed overnight study will be required in patients who have a negative or
ambiguous overnight pulse oximetry result but whose symptoms are severe. Moreover, a
normal result cannot eliminate an OSA diagnosis, but it can be useful to prioritise access to
diagnostic studies for patients with a high pretest probability of OSA [9].
Good practice
1. Select a finger which is less prone to movement, on the non-dominant hand and prepare
the site by removing artificial nails and nail polish.
2. Position the sensor around the carefully chosen digit with the wire on the upper side of
the hand. The light emitter and receiver should be directly opposite one another over
the nailbed.
The light source must be above the nail (cf figure 6).
CAUTION:
• Finger nail polish may reduce light transmission and thereby affect SpO2 values.
• Excessive movement by the patient may interfere with the signal processing of the pulse
oximeter, producing erroneous values. To avoid it, tape the wire at the end of the finger
and around the wrist. Avoid taping over the probe causing constriction and consequent
inaccurate readings.
For overnight pulse oximetry in sleep medicine, it is important that the oximeter is set to the
shortest time interval for measurement – 5 seconds or less is regarded as being acceptable
[10].
Limitations (examples)
• Often, patients with OSA are distinguished from non-OSA groups by the number of
desaturation events/hour, with a saturation decrease of 4%. Such definitions may lead to
false-negative oximetry results especially in younger and less obese patients who may not
exhibit desaturations despite changes in PaO2 .
• Patients who only desaturate when sleeping in a supine position may not show desaturation
if, on the night of the recording, they avoided sleeping in this position.
• Some patients with minimal arterial oxygen desaturation have severe OSA.
• Alone, pulse oximetry does not provide information about other causes of excessive
daytime sleepiness such as narcolepsy and periodic limb movement disorder.
• Generally overnight pulse oximetry does not allow for easy differentiation of respiratory
events (hypopnoeas, Cheyne-Stokes respiration, obstructive or central apnoeas).
Another parameter is nasal airflow, provided by a nasal pressure cannula linked to a small
device able to determine the AHI.
It is an objective device designed to supplement other subjective methods such as
questionnaires and diaries. Together, these provide comprehensive screening to assess the
need and prioritisation for polysomnography.
Concerning the RUSleeping RTS, it has a 92% sensitivity and a 77% specificity when compared
to a polysomnography, if a cut-off AHI of 15 is used as the indication of OSA (based upon an
internal study of 25 patients).
Note: For further information about nasal cannula, see part C below.
Good practice
The nasal cannula should be placed directly underneath the patient’s nose, with each of
the two prongs just below each nostril. Put surgical tape 2 cm from the nose to secure the
stability of the cannula during the night.
[1] http://en.wikipedia.org/
[2] Ahmadi N, Chung SA, Gibbs A, Shapiro CM, 'The Berlin Questionnaire for sleep apnea in
a sleep clinic population: relationship to polysomnographic measurement of respiratory
disturbance', Sleep Breath 2008 Mar; 12(1):39-45.
[3] Hardinge FM, Pitson DJ, Stradling JR, 'Use of the Epworth Sleepiness Scale to demonstrate
response to treatment with nasal continuous positive airways pressure in patients with
obstructive sleep apnea', Respir Med 1995; 89(9):617-20.
[4] http://www.hkma.org/bhme/10bhme/Shao-guang%20HUANG.pdf
[5] Johns, MW, 'Sensitivity and specificity of the multiple sleep latency test (MSLT), the
maintenance of wakefulness test and the Epworth Sleepiness Scale: failure of the MSLT as
a gold standard', Journal of Sleep Research 2000 Mar; 9(1):5-11.
[6] http://www.cdha.nshealth.ca/
[7] Stradling et al., 'Adequacy of oximetry alone studies for the diagnosis of sleep and
breathing disorders', Jl Ambulatory Monitoring 1989; 2(3):197-201.
[8] Ryan PJ, et al., 'Validation of British Thoracic Society guidelines for the diagnosis of the
sleep apnoea/hypopnoea syndrome: Can polysomnography be avoided?', Thorax 1995; 50:
972-975.
[9] http://www.splf.org/s/IMG/pdf/RPC-SAHOS.pdf
[10] Farre R, Montserrat JM, Ballester E, et al., 'Importance of the pulse oximeter averaging
time when measuring oxygen desaturation in sleep apnea', Sleep 1998; 21:386-390.
Actigraphy is a general term for a system that records and analyzes movement. The
recording instruments for actigraphy are small, computerized devices that record and store
data [1].
Actigraphs are generally watch-shaped and worn on the wrist of the non-dominant arm
but they can also be worn on the ankle or on the toes (cf. figure 9).
Actigraphy has become an increasingly important and widespread method for measuring rest/
activity patterns in both clinical and research settings.
How it works?
With each subject movement an accelerometer generates a variable voltage that is digitally
processed and sampled. The data is later read to a computer where it can be analysed.
An actigraph records physical activity over time in 'counts'. The definition of these counts
can differ from one actigraph to another. In the Actiwatch, the data logged is the sum of the
captured counts from the individual 1-second intervals making up the epoch period.
A shift worker :
Actigraphy is useful for assessing sleep-wake patterns and disturbed sleep over a period of
time. It is used to clinically evaluate insomnia [2], circadian rhythm sleep disorders, excessive
sleepiness, sleep disturbances associated with periodic limb movement disorder (leg
actigraphs can be used). It is especially useful when self-reporting is not an option, as with
patients who cannot accurately or reliably self-report sleep information.
Some actigraphs can also record body temperature or light. Actigraphy plays an important
role by providing a complementary objective record of rest-wake activity over days or
weeks. Moreover, the actigraphy device is easily incorporated into the patient’s lifestyle
with a minimum of interaction. By combining the results of subjective diaries with objective
actigraphy data, a more complete picture of the patient’s rest/activity patterns over time and
sleep history is obtained.
General conclusions are presented here but the reader is encouraged to go to the reviews
for further information.
For systems that have been assessed, studies have shown that actigraphy is indicated for
delineating sleep patterns, and to document treatment responses in normal infants and
children (in whom traditional sleep monitoring by polysomnography can be difficult to
perform and/or interpret), and in special paediatric populations [3].
Actigraphy can be used as a reliable indicator of sleep in young infants [4].
Moreover, actigraphy, when added to simplified polygraphy, may assist in the diagnosis of OSA
[5].
Clinicians should use subjective data as an adjunct to actigraphic data when evaluating total
sleep time and sleep efficiency. This may be especially important in patients with disorders of
excessive somnolence (e.g. the obstructive sleep apnoea syndrome, upper airway resistance
syndrome, periodic limb movement disorder and narcolepsy) [6].
Subjective data appear to be less sensitive than actigraphy for documenting sleep
fragmentation, particularly in patients with insomnia [7].
References
[1] Butkov N., Lee-Chiong T., 'Fundamentals of Sleep Technology', Lippincott Williams &
Wilkins, 2007.
[2] Sadeh A, Hauri PJ, Kripke DF, et al., 'The role of actigraphy in the evaluation of sleep
disorders', Sleep 1995; 18(4):288-302.
[3] American Sleep Disorders Association, 'Practice parameters for the use of actigraphy in
the clinical assessment of sleep disorders', Sleep 1995 May; 18(4):285-7.
[4] So, K., Buckley, P., Adamson, TM., Horne, RS. 'Actigraphy correctly predicts
sleep behavior in infants who are younger than six months, when compared with
polysomnography', Pediatr Res Oct 2005; 58(4):761-765.
[5] Elbaz M. et al., 'Utility of actigraphy in the diagnosis of OSA', Sleep 2002 ;25(5):527-31.
[6] Kushida et al., 'Comparison of actigraphic, polysomnographic, and subjective assessment
of sleep parameters in sleep-disordered patients', Sleep Medicine 2001; 2:389-396.
[7] Chambers MJ., 'Actigraphy and insomnia: a closer look.Part I.', Sleep 1994; 17(5):405-408.
Tips
• It is essential to be well prepared; have your equipment and materials prepared and close
to hand.
Kodan is a trademark of Schülke & Mayr. NuPrep and Ten20 are trademarks of D.O. Weaver & Co. EC2 is a
trademark of Grass Product Group.
Biocalibration
Biocalibrations are a series of exercises performed prior to initiating a study, to verify correct
intput derivations and signal quality [1]. It is important to record them to facilitate scoring
and interpretation.
EEG Relax with the eyes At least 30 Alpha waves are typically prominent in
open and then with seconds each the occipital channels with eyes closed.
eyes closed.
EOG • Move the eyes left Several times Prominent deflections and opposite
and right, then up during 30 signals.
and down. seconds period
• Blink the eyes.
Chin EMG • Grit your teeth. • 5-10 seconds • EMG amplitude must increase.
• Relax. • Be sure the EMG tracing shows an
adequate amount of baseline muscle
tone (at least 0.5 cm in amplitude).
Leg EMG •Flex your left toe/leg. • 5-10 seconds Burst of activity in the recording for
•Flex your right toe/leg. each each leg.
Note: Yawning, swallowing and chewing may also increase muscle tone in the chin region.
Sleep is divided into two states: NREM and REM, defined by a combination of parameters
including electroencephalography (EEG), electro-oculography (EOG) and electromyography
(EMG).
NREM is divided into three stages (N1, N2 and N3) [AASM 2007].
To identify these different states and stages, including wakefulness, electrodes are placed on
the scalp in a symmetrical pattern. The electrodes measure very small voltages caused by
synchronized activity in very large numbers of synapses in the brain’s outer layers (cerebral
cortex). Electroencephalogram (EEG) data is represented by waveforms classified according
to their amplitude and frequency.
Amplitude refers to the vertical height of the wave, measured in microvolts.
Frequency refers to the number of waves in a 1 second span, measured as cycles per second
or Hertz (Hz).
A time constant is the time required for the current or voltage to rise or fall two-thirds of
its amplitude.
Filters are used to pass certain frequencies and attenuate others.
• High-pass filter: a filter that passes frequencies above a certain value and attenuates
frequencies below that value.
• Low-pass filter: a filter that passes frequencies below a certain value and attenuates
frequencies above that value.
wakefulness, best seen over the Occipital region and the Occipital leads (O1-M2 or O2-M1
leads).
Theta waves have a frequency of 4-7 Hz and are the predominant brain waves of stage N1.
Spindles have a frequency of 12-14 Hz with a duration of at least 0.5 seconds and along with
K-complexes are seen in N2 sleep and are usually maximal over the Central region (C4-M1,
C3-M2).
Delta waves have a slow frequency of 0.5-2 Hz and an amplitude >75 μV. These dominate
in N3 sleep and are maximal over Frontal regions (F1-M2 or F2-M1). K complexes are also
The Central EEG location (C3-M2, C4-M1) is used to record the majority of brain waves, to
distinguish between the various sleep stages and are considered to be the main scoring leads.
M1 and M2 (left and right mastoid processes) are silent electrodes used as references.
See the International 10-20 electrode placement system for site locations [3]:
The letters F, T, C, P and O stand for Frontal, Temporal, Central, Parietal and Occipital
respectively. A "z" (zero) refers to an electrode placed on the midline. Even numbers (2, 4,
6, 8) refer to electrode positions on the right hemisphere, whereas odd numbers (1, 3, 5, 7)
Two anatomical landmarks are used for the essential positioning of the EEG electrodes:
first, the nasion which is the point between the forehead and the nose; second, the inion
which is the lowest point of the skull from the back of the head and is normally indicated by a
prominent bump.
Usually: 3 electrodes + 2 references (mastoid processes) + 1 ground (in the middle of the forehead).
2) If necessary, wipe off any excess of hair gel or spray with a piece of gauze moistened in
alcohol (Kodan Spray).
2) If necessary, wipe off any excess of hair gel or spray with a piece of gauze moistened in
alcohol (Kodan™ Spray).
3) Patient’s skin preparation for electrode application (also available for EOG,
ECG and EMG)
3) Patient’s skin preparation for electrode application (also available for EOG, ECG
and EMG)
Prepare each site by first lightly abrading the area where the electrode will be placed. Use
a small dot of NuPrep7(abrasive skin preparation gel) and a piece of gauze. Abrasion is
Prepare each site by first lightly abrading the area where the electrode will be placed. Use
important to decrease the skin’s resistance and ensure quality signals.
a small dot of NuPrep™7(abrasive skin preparation gel) and a piece of gauze. Abrasion is
important to decrease the skin’s resistance and ensure quality signals.
Wipe off the abrasive cream, which is non conductive, with a piece of gauze moistened in
alcohol (Kodan Spray):
4) Electrode application
Fill the electrode cup8 with a conductive paste Ten209 (you can also use the electrode
cream EC2) and apply firmly to the prepared site. The thick electrolyte adheres the
electrode to the skin surface. Further adhesion can be gained by applying a small dot of
EC2 onto a gauze swab which is then placed over the electrode.
Apply the filled cup on the appropriate site, and follow this by placing the swab (as
described above) on top.
Ref. 1016339: EEG/ EMG/ EOG Leads 72’’ (1.80 m) (recommended for leg EMG)
Finally, connect the wires to the diagnostic device, according to the chosen leads.
The Electro-oculography (EOG) picks up eye activity, based on recording the electropotential
difference between the cornea and the retina (the cornea has a positive voltage output, while
the retina has a negative polarity).
There are two reasons for recording EOG. The first is to record rapid eye movement of REM
sleep and the second to assess sleep onset which is associated with rolling eye movements.
Two electrodes may be placed (the ground electrode is the one used for EEG). The
recommended derivations are E1-M2, E2-M1, but others are possible (please refer to the
AASM Guidelines).
Ground
• E1 is placed 1 cm below the left outer canthus
EOG_R
(E2) • E2 is placed 1 cm above the right outercanthus
EOG_L
(E1)
Place the two EOG electrodes using the same skin preparation techniques described for
EEG.
For each site: light abrasion with NuPrep (the area around the eyes is very sensitive) and
cleaning with Kodan spray.
2) Electrode application
Fill each electrode cup with Ten20. Apply the electrodes to the prepared sites, secure
with tape and trail the wire toward the others.
Finally, connect the two wires (Right and Left EOG) to the diagnostic device.
Avoid placing the EOG electrodes directly over the temples, otherwise you will record
ECG activity.
Examples of quality signals, when the patient looks left, then right:
The Electromyography (EMG) records chin muscle tone at the mentalis and submentalis
muscles.
Chin EMG is a mandatory recording parameter for staging sleep (REM vs. NREM) and is
essential to determine onset of REM. Muscle tone decreases during sleep with maximal
decrease occuring during REM.
Recorded simultaneously, EEG, EOG and chin EMG provide the basis for classifying the
different states and stages of sleep.
Figure 15: Characteristic EEG, EOG and EMG patterns for wakefulness, REM sleep and
NREM sleep. Each of the nine patterns was made over a period of about three seconds [5].
Once again, many derivations are possible… In the example below, two leads are placed.
According to the AASM guidelines, three leads should be placed: 2 for recording and the
third as back up lead in case one fails. The ground is the same as the one used for EEG (in the
middle of the forehead).
EMG_C
1) Patient’s
the twoskinEMGpreparation for electrode application
Place electrodes using the same skin preparation techniques described for
EEG.
Place the two
site: EMG electrodes using the samebyskin preparation techniques described for
For each abrasion with NuPrep (begin shaving the patient if necessary) and cleaning
EEG.
with Kodan spray.
For each site: abrasion with NuPrep™ (begin by shaving the patient if necessary) and cleaning
with Kodan™ spray.
2) Electrode application
2) Electrode application
Apply the electrode cream (Ten20 or EC2) filled cup to the appropriate site, and secure
the electrode with tape.
Apply the electrode cream (Ten20™ or EC2™) filled cup to the appropriate site, and secure
the electrode with tape.
Example of chin EMG quality signal, when the patient grits his/her teeth:
Similar to managing the face and scalp electrodes, it is also necessary to effectively manage
the body electrodes and sensors – linking them to a unique point of attachment (e.g. on the
patient’s shoulder). You can use a spiral bound jacket.
The wires may be threaded up through the patient’s night clothes, making sure that they
are not pulled tight and sufficient slack to allow for movement. As previously, bundle them
together, securing with tape or Velcro strips every 10-15 cm.
The recognition of sleep disordered breathing requires the recording of both airflow and
respiratory effort.
Thermal sensors (thermistors, thermocouples) are commonly used to record airflow. The
non-quantitative signals are based on the variation between the temperature of inhaled and
exhaled air.
When using the thermistor or thermocouple, a sensor is placed above the upper lip and
usually uses three wires to sense temperature changes. A wire is positioned in front of
each nare and the third one is positioned in front of the mouth. Exhaled air, warmed by the
body, heats the sensor. Inhaled air, drawn from the environment, cools the sensor. These
temperature changes are then converted to a signal that denotes airflow fluctuations and is
recorded as airflow on the polysomnogram.
Oronasal thermal sensors are recommended to score apnoeas (see the AASM
recommendations), and they are useful, when used with a pressure sensing device, to detect
airflow from the mouth.
Limitations:
Some potential problems may arise when using these devices. Environmental conditions
can adversely affect the accuracy of the readings e.g when the temperature differentiation
is minimal, a warm room, or a room that has an oscillating fan or a fan directed toward the
patient. Interpretation of the signals may be difficult and results inaccurate. If a thermal-based
sensor is used with a positive pressure device, the air flowing through the mask may become
so diluted that it becomes useless or difficult to interpret.
Moreover, recording snoring or flow limitations with these devices is also difficult.
10 Ref. P1274 : Airflow Thermistor Large Adult 1.5 mm
Ref. P1336: Airflow Thermistor Pediatric
Ref. P1337: Airflow Thermistor Neonatal
Tips
The small mouthpiece that extends down should be placed in front of the closed
mouth, so it can detect airflow when the mouth is open.
The small mouthpiece that extends down should be placed in front of the closed mouth,
so it can detect airflow when the mouth is open.
OK
OK
It is recommended to tape it as described below (see pressure sensing devices).
If we only look at the temperature flow signal we may miss important diagnostic information.
Indeed, the pressure sensor is extremely accurate and very sensitive to changes in the
airflow.
That’s why the sensor recommended to identify hypopnoeas is a nasal air pressure
device.
This pressure sensing device uses a nasal cannula connected to a very sensitive pressure
transducer and produces a qualitative signal quite comparable to the pneumotachograph
(most accurate quantitative way of measuring airflow but unrealistic to use in a clinical
setting).
The oral/nasal prongs may be used to monitor oral breathing. The tip of the oral cannula
should be trimmed to lie where the upper and lower lips meet.
Goodpractice
Good practice
The cannula11 placement is quite the same as described above for the thermal sensor.
The
Put cannula placement is quite
the the
nosesame as described
cannulaabove
11
forduring
the thermal sensor.
surgical tape 2 cm from to ensure stability the night.
Put surgical tape 2 cm from the nose to ensure cannula stability during the night.
Tips
• Always check polarity of nasal pressure sensors:
Yes, but…
A nasal pressure cannula is much more sensitive than a simple 02 cannula, especially in terms
of detection of snoring. Moreover, it is better to use a nasal pressure cannula with a filter.
• Can both end-tidal CO2 and the nasal pressure airflow system be used at the
same time?
Since both end-tidal CO2 and the nasal pressure airflow system use a nasal cannula, it would
be necessary to use a dual lumen cannula. These are commercially available.
5. Snore sensor
Snoring is the low frequency sound produced by vibrations of the upper airway during sleep.
Habitual heavy snoring is the most commonly reported symptom of Upper Airways
Resistance Syndrome (UARS) and Obstructive Sleep Apnoea and Hypopnoea Syndrome
(OSAHS).
1.Microphone
A microphone can simply record the sounds produced when the patient is snoring.
Good practice
Secure the snore microphone to the patient’s neck, lateral to the larynx, to obtain the
Secure the snore microphone to the patient’s neck, lateral to the larynx, to obtain the
maximum signal output (the Pro-Tech logo should be facing away from the patient).
maximum signal output (the Pro -Tech logo should be facing away from the patient).
The lead wire should be looped and securely taped in place to provide additional strain
The lead wire should be looped and securely taped in place to provide additional strain relief
relief in the event of the patient pulling on the wire.
in the event of the patient pulling on the wire.
A piezo snoring sensor allows you to record snoring vibrations from the side of the neck by
converting these vibrations into different voltages.
Piezo
Good practice
Locatethe
thesensor
sensoronto
ontothetheneck
neckininan
anarea
areathat
thatgives
givesmaximum
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signalon
onthe
therecording
recording
Locate
device.The
Thesensor
sensorand
andlead
leadwire
wireshould
shouldbebecarefully
carefullysecured
securedininposition
positionusing
usingsurgical
surgicaltape.
tape.
device.
Many placements are possible on the throat, but avoid placing the sensor directly over the
Many placements are possible on the throat, but avoid placing the sensor directly over the
carotid artery, otherwise you will record ECG and pulse sounds may obscure the airflow
carotid artery, otherwise you will record ECG and pulse sounds may obscure the airflow
soundsyou
youwish
wishto
torecord.
record.
sounds
Connect the sensor tothe
thediagnostic
diagnosticdevice.
device.
Connect the sensor to
Tips
Tips
Tolocate
locatethe
thebest
bestposition,
position,place
place22fifingers onthe
thepatient’s
patient’sthroat
throatand
andask
askhim/her
him/hertotohum.
hum.
To ngers on
The sensor should be placed and secured over the area with the strongest vibration.
The sensor should be placed and secured over the area with the strongest vibration.
When the signal from airflow sensor cannula is unfiltered, snoring is superimposed on the
As the frequency of snoring (10-70 Hz) is higher than the airflow’s frequency (0.05 Hz-5 Hz),
The PTAF Lite14 is a small pressure-sensing transducer having two different outputs.
The filtered output signal consists of the nasal pressure airflow waveform without the
superimposed snoring. When snoring with flow limitation occurs with the filtered signal, a
The Electrocardiography (ECG) is the record of the electrical potential changes in the cells
created by heart’s activity via skin electrodes.
To show changes that may occur in the signal, electrodes have to cross the heart. That’s why
leads may be placed in all three positions or in RA (right arm) and LA (left arm) or RA and LL
(left leg). The left leg electrode must be placed below the level of the heart.
Another lead is placed four intercostals spaces up on the left rib cage or at the level of the
seventh rib.
RA RA
ECG ECG
LL RL LL
Note: The ground electrode is the one used for EEG. Nevertheless, if EEG is not included in the
sleep study (e.g. for a respiratory polygraphy), RL (Right Leg) using torso electrode placement is
recommended to place the ground electrode. Do not use 2 ground electrodes!
1) Patient’s
the twoskinECGpreparation for electrode application
Place electrodes using the same skin preparation techniques described for
EEG.
Place the two
site: ECG electrodes using the samebyskin preparation techniques described for
For each abrasion with NuPrep (begin shaving the patient if necessary) and cleaning
EEG.
with Kodan spray.
For each site:
For each site: abrasion with NuPrep™ (begin by shaving the patient if necessary) and cleaning
2) Electrode application
with Kodan™ spray.
Snap the electrode to the lead before applying to the patient’s skin.
2) Electrode application
Peel off the backing from the electrode and apply each of the adhesive electrodes15 gel side
down on to the prepared sites. Secure them with tape if necessary.
Snap the electrode to the lead before applying to the patient’s skin.
Feed the wires through the patient’s night clothes and bundle with the other sensors.
Peel off the backing from the electrode and apply each of the adhesive electrodes15 gel side
down on to the prepared sites. Secure them with tape if necessary.
Feed the wires through the patient’s night clothes and bundle with the other sensors.
Breathing, and breathing events, can be assessed by measuring chest and abdominal wall
movement. The essential task is to demonstrate respiratory effort to distinguish between an
obstructive apnoea (respiratory effort) or central apnoea (lack of effort).
There are a variety of methods currently used in PSG to evaluate respiratory effort.
1. Oesophageal manometry
Another measure of respiratory effort can be obtained by measuring changes in chest and
abdominal volume, known as plethysmography.
Thoracic belt
Abdominal belt
Advantages:
This method is quite simple and inexpensive.
Limitations:
This method is subject to “trapping artefact”. It is fairly easy to imagine how a portion of
elastic belt may become “trapped” as a person turns from one side to another, resulting in
variable tension along the belt circumference. Thus this method can both significantly under
and/or overestimate the actual degree of chest or abdominal movement. Additionally, the
piezo crystal is only located on a very small section of the belt. So when the patient is lying
on the top of the piezo crystal, the effort signal can be dampened or not detected. This may
produce erroneous readings or unexplained changes in polarity resulting in false paradoxical
breathing events being recorded.
Tips
Tips
Ask the patient to fold their arms to assess whether the thoracic belt is tight enough.
Ask the patient to fold their arms to assess whether the thoracic belt is tight enough.
Advantages:
The signal produced is linear and is a fairly accurate representation of the change in cross
sectional area. In addition, RIP does not rely on belt tension and is not affected by belt
trapping.
Be careful:
There are conditions that can decrease the accuracy of a zRIP™ device. If the belts are placed
too tight, causing the actual cross-sectional change of the chest or abdomen to be restricted,
it will not reflect the patient’s true breathing efforts. If the belts are placed too loosely, the
belts will have a tendency to move and may overlap one another.
Another consideration is belt placement. For example, if a zRIP™ effort belt is placed around the
hips, there will be little to no change in the cross-sectional area during diaphragmatic excursions.
Cover80%
80%ofofthe
thepatient’s
patient’scircumference,
circumference,the
theother
other20%
20%allows
allowsfor
forbelt
beltstretching.
stretching.
Cover
Note: Mathematical summing of the chest and abdominal signals is particularly useful as a
screen for paradoxical breathing. The more “out of phase” the signals are becoming, the smaller the
sum channel will be.
Chest
Figure A shows normal breathing.
Abdomen
Figure A Figure B demonstrates what
Sum
Complete addition summing occurs during phase shifting,
Chest which is causing the sum channel
Figure B Abdomen
to show alterations in the
Sum
Phase shift and decrease in sum
waveform.
Figure C and D demonstrate
Chest what occurs with a patient who
Figure C
Abdomen
is having paradoxical breathing
Sum
Exact paradox (phase and amplitude)
at night, causing the sum
channel to be flat.
Figure D
Some obstructive apnoeas are position-dependent. When conducting and reporting on a PSG
or CPAP titration study, it is important to know whether the patient has slept in all positions
– to accurately gauge the true severity and appropriate titration.
Thanks to a gravity switch, the body position sensor provides a signal that is directly
proportional to the patient's sleeping position (supine, prone, left, right or upright).
The limb movement sensor is useful to diagnose PLMS (Periodic Limb Movements in Sleep),
leg movement associated with a respiratory event and limb activity associated with nocturnal
seizures.
This sensor is placed on the wrist or ankle and produces a signal that is directly proportional
to the hand or leg movement. Usually a piezo element converts every movement to a small
Good practice
Good practice
1. Select an appropriately sized strap, usually the large PLM strap for the foot and the small
1. Select an appropriately
for the wrist.sized strap, place
usually
thethe large PLM element
strap forinto
the foot and thepocket
small
PLM strap Carefully PLM Sensor the sensor
PLM strap forassembly.
the wrist.Secure
Carefully
intoplace
placethe PLM Sensor element
of the strap by closing the Velcro flap.into the sensor pocket of
the strap assembly. Secure into place by closing the Velcro® fl ap.
2. Place the strap assembly around the patient's ankle or wrist. Straps should be slightly
2. Place
snug,the
butstrap
not toassembly around the patient's ankle or wrist. Straps should be slightly snug,
the point of patient discomfort.
but not to the point of patient discomfort.
3. Run the lead wires up the patient’s legs or arms to the recorder. Tape the wire leads to
3. Run the lead wires
reliefuptothe
thepatient’s
sensors.legs ormay
armsalso
to the recorder. Tape
up the
the wire leadslegs
to
provide strain Tape be used further patient’s
provide
or armsstrain relief to
thethe sensors.
from Tape
being may also
to prevent wires pulled on.be used further up the patient’s legs or
arms to prevent the wires from being pulled on.
EMG_R EMG_L
Good practice
Good practice
1) Patient’s skin preparation for electrode application
Place the EMG electrodes using the
for same skin preparation techniques described for EEG.
1) Patient’s skin preparation electrode application
For each leg, abrasion with NuPrep (begin by shaving the patient if necessary) and
Place the EMG electrodes using the same skin preparation techniques described forcleaning
EEG.
with Kodan spray (alcohol).
For each leg, abrasion with NuPrep™ (begin by shaving the patient if necessary) and cleaning
with Kodan™ spray (alcohol).
2) Electrode application
2) Electrode application
Fill the electrode cups with Ten20.
Example of quality signal (when the patient is asked to move his feet):
In PSG, some hypopnoeas are defined by desaturations, and oximetry is useful to measure the
Good practice
Good practice
Select a finger which is less prone to movement, on the non-dominant hand and prepare
Select a fiby
nger which isartificial
less prone
nailstoand
movement,
the site removing nail polish.on the non-dominant hand and prepare the
site by removing artifiaround
cial nails
theand nail polish.
Position the sensor carefully chosen digit with the wire on the upper side of
Position
the hand. The light emitter and receiverchosen
the sensor around the carefully should digit with the wire ononetheanother
upper side
be directly opposite overofthe
the hand. The light emitter and receiver should be directly opposite one another over the
nailbed.
nailbed. Excessive movement by the patient may
Excessive
interfere movement by the patient may interfere
with the signal processing of the pulse
with the signal processing of the pulse oximeter,
oximeter, producing erroneous values. To avoid
producing erroneous values. To avoid this,
this, use tape to secure the wire at the enduse
of
tape
the finger, around the wrist. Avoid tapingfiover
to secure the wire at the end of the nger,
around the itself
wrist.asAvoid taping over the probe
the probe this may cause constriction
itself as this may cause constriction and
and consequent inaccurate readings.
consequent
Alternative inaccurate readings.
sites may be the toe or ear lobe.
Alternative sites may be the toe or ear lobe.
Connect the wire to the diagnostic device.
Connect the wire to the diagnostic device.
Pulse Transit Time (PTT) is not a measure but a calculation. It refers to the time it takes a
pulse wave to travel between two arterial sites. In other words, PTT is the time between the
heartbeat and the arrival of the blood pressure wave to peripheral site such as the finger.
Study data has shown that PTT can provide a non-invasive estimate of inspiratory effort and
a measure of arousals that can be used to document obstructive sleep apnoea/hypopnoea
syndrome, central sleep apnoea, RERAs (Respiratory Effort Related Arousal) and response to
treatment.
Calculating PTT involves the use of an ECG for the recognition of the R wave and oximetric
photoplethysmography (e.g. pulse oximeter) to assess the arrival of the pulse wave in the
periphery.
PTT is calculated as the interval between the ECG R wave and the subsequent arrival of the
pulse wave at the finger (usually the point on the pulse waveform that is 50 percent of the
height of the maximum value).
An acute rise in blood pressure causes vascular tone to increase causing the arterial wall
to stiffen, the pressure wave to travel faster and the PTT to decrease. When arterial blood
pressure falls, vascular tone decreases, which increases PTT value. Thus, PTT is inversely
proportional to blood pressure.
PTT was validated as an indirect way of assessing repiratory efforts during sleep [11, 12]. As it
is non-invasive, it seems to be really useful in paediatrics [13].
A second drawback of PTT is that a reliable assessment of PTT is not possible in patients with
cardiac arrhythmias. Extra systole produces acute variations in PTT despite the absence
of a respiratory event or microarousal.
Watemberg et al. [15] demonstrated that adding video recording to routine EEGs increases
diagnostic yield of routine EEGs in children with frequent paroxysmal events.
Tips
• The troubleshooting enquiry should begin with checking all impedances, which should be
within the recommended values.
• Next, methodically check the pathway, starting with the patient and follow the path of
the signal to the recording device.
• If the artefact is generalised (involving most channels), the likely source is the ground
electrode.
• If the artefact is localised (limited number of channels), ask the question “Which channels
have this artefact in common, and what is common to the channels involved?”
• If the artefact is isolated to a single channel, the source of the problem is easily identified
and usually rectified by reapplying the specific electrode.
• The artefact may have a common factor e.g reference electrode M1 or M2.
• Often, artefacts originate from the side of the head or face on which the patient is lying,
causing direct pressure on the electrode.
AFTER CORRECTION:
In this example, the source of the artefact is the reference (M2) electrode, shared by both
channels. Note that the chin EMG also shows a relatively high level of muscle activity; this is
not considered as an artefact, because the chin EMG is specificially intended for recording
muscle activity in the chin region, which is normally elevated during wakefulness and NREM
sleep.
Glossary
SL: Sleep Latency
TST: Total Sleep Time
REM: Rapid-Eye Movements sleep
WASO: Wake time After Sleep Onset
SWS: Slow Wave Sleep
OSA: Obstructive Sleep Apnoea
PLMS: Periodic Limb Movements of Sleep
Z-drugs: nonbenzodiazepine drugs with effects similar to benzodiazepines which are used in
the treatment of insomnia.
MAO’s: MonoAmine Oxidase (antidepressant)
SSRI’s: Selective Serotonin Reuptake Inhibitors (antidepressant)
References
[1] Butkov N., Lee-Chiong T., 'Fundamentals of Sleep Technology', Lippincott Williams &
Wilkins, 2007.
[2] http://www.aolhealth.com/sleep-disorders/learn-about-it/sleep-mechanics
[3] http://www.bem.fi/book/13/13x/1302ax.htm
[4] http://ee.ucd.ie/~smeredith/EOG_index.html
Why?
AASM’s goal was to create a manual that reflected current knowledge and that would provide
more comprehensive standardized specifications and scoring rules for characterizing natural
sleep as commonly performed in polysomnography.
Current R&K (Rechtschaffen and Kales) scoring rules were developed in 1968 [2] and left too
much room for variability between scorers.
The principal participants in the scoring manual development process included a supervising
steering committee, 8 task forces leaders, 8-12 task force members and the administrative
staff of the AASM.
This manual intended to better reflect current scientific evidence and expertise in the field of
sleep (cf table 6).
Notes:
• For new systems purchased the society recommends systems that are capable of AASM standards,
from a technical perspective (sampling rates) and from a scoring perspective. Any replacement
equipment purchased after July 1, 2008 must be in full compliance with all technical requirements.
• For new sleep lab accreditation, staff must have basic knowledge of AASM scoring rules.
• You must notice in the sleep report which rules (R&K or AASM) were used.
Recommended These rules are recommended for the routine scoring of PSG.
Alternative These are rules that may be used as alternatives to the recommended
rules at the discretion of the clinician or investigator.
Optional These are suggested rules for uncommonly encountered events, events
not known to have physiologic significance or events for which there
was no consensus decision. Scoring may be performed at the discretion
of the clinician or investigator.
Electrode impedances should be rechecked during a recording when artefact suggests high
impedance.
Sampling rate and filter settings for digital signals must be appropriate for signal content (cf
tables).
Airflow 100 Hz 25 Hz
Oximetry 25 Hz 10 Hz
Body position 1 Hz 1 Hz
EEG 0.3 Hz 35 Hz
EOG 0.3 Hz 35 Hz
EMG 10 Hz 100 Hz
ECG 0.3 Hz 70 Hz
Respiration 0.1 Hz 15 Hz
Snoring 10 Hz 100 Hz
Digital PSG recording features and rules for PSG display (examples)
The rules and specifications in the visual scoring of sleep retain much of the framework of
R&K, based on the accumulated validity and reliability of this scoring system, with some new
definitions and rule modifications as well as with new rules for paediatric visual scoring.
EEG
What changes?
• Addition of F3 and F4 (frontal) to standard EEG derivations
• Renaming of reference sites A1 and A2 (ear lobe) to M1 and M2 (mastoid)
Recommended a.F4-M1
derivations b.C4-M1
c.O2-M1
+ backup electrodes (if electrodes
malfunction during the study):
d.F3-M2
e.C3-M2
f.O1-M2
Alternative a.Fz-Cz
derivations b.Cz-Oz
c.C4-M1
+ backup electrodes (if electrodes
malfunction during the study):
d.Fpz-C3
e.C3-O1
f.C3-M2
What changes?
LOC & ROC sites are named E1 and E2.
E2 E1
1 cm 1 cm
Right Left ¬
What changes?
The electrode placement for chin EMG is now clearly defined, which was not in the
previous R&K manual.
2) The standard chin EMG derivation consists of either of the electrodes below the mandible
referred to the electrode above the mandible. The other inferior electrode is a backup
electrode to allow for continued display of EMG activity if one of the primary electrodes
malfunctions.
Backup electrode
( or )
1cm
2cm
What changes?
• Stages 1,2 and 3 are renamed N1,N2 and N3.
• N stands for Non-REM.
•Stage N3 represents slow wave sleep and replaces the R&K nomenclature of stage 3 and stage 4 sleep.
• REM is renamed stage R.
• Movement Time (MT) has been eliminated.
• “3- minute rule” for stage 2 is eliminated.
• Frontal leads are recommended for scoring slow wave (N3) sleep.
• Each stage now includes more detailed definitions and rules as well as procedural notes
(figures are included in the manual to give some examples of the rules).
• The biggest impact will be noticed in the scoring of N2. N2 sleep can be scored as soon
as one or more K-complexes unassociated with arousal or one or more trains of sleep
spindle occur in the first half of the epoch or the last half of the previous epoch.
• Major body movements are now either scored as stage W (if more than 15 seconds of
alpha is present for any part of the epoch or if an epoch of stage W precedes or follows
the movement) or scored as the same stage as the following epoch.
• Scoring by Epochs
• Score sleep stages in 30 second sequential epochs
• Assign a stage to each epoch
• If 2 or more stages coexist during a single epoch, assign the stage comprising the greatest
portion of the epoch.
Stage W (Wakefulness)
Low Frequency Filter
Subjects who generate when > 50 % of the epoch has alpha rhythm over the occipital
alpha rhythm region
Subjects who generate If alpha rhythm is replaced low amplitude, mixed frequency
alpha rhythm activity for >50 % of the epoch
Subjects who do not With the earliest of any of the following phenomena:
generate alpha rhythm • Activity of 4-7 Hz with slowing by 1 Hz from W
• Vertex sharp waves
• Slow eye movements
Stage N2 (NREM2)
START scoring N2 Either a K complex without arousal or a spindle is present
in the first half of the epoch or the last half of the previous
epoch
Stage R (REM)
START scoring R Low amplitude, mixed frequency EEG
+ Low chin EMG tone
+ Rapid eye movements
What changes?
• Dominant posterior rhythm (DPR) replaces the terms “alpha rhythm”.
For further information about children, please refer to the AASM manual.
4. Arousals
• No significant changes
Score arousal during sleep stages N1, N2, N3 or R if there is an abrupt shift of EEG frequency
including alpha, theta, and/or frequencies greater than 16 Hz (but not spindles) that lasts
at least 3 seconds, with at least 10 seconds of stable sleep preceding the change. Scoring
of arousal during REM requires a concurrent increase in submental EMG lasting at least 1
second.
While classically placed on the right arm and left leg, the electrodes may be placed on the
torso, aligned in parallel to the right shoulder and left hip.
Modified lead II
Classic lead II from AASM rules
Scoring rules
Specifications are given regarding definitions of sinus tachycardia, bradycardia, asystole, wide
Examples:
• Score sinus tachycardia for sustained heart rate greater than 90 beats per minute for adults.
• Score sinus bradycardia for sustained heart rate of less than 40 beats for ages 6 through
adult.
• Score asystole for pauses greater than 3 seconds for ages 6 through adult.
Minimum duration of a leg movement (LM) is 0.5 second, maximum duration is 10 seconds.
Periodic limb movements (PLM) series is defined by a minimum of 4 LMs, minimum period
length between LMs to include them as part of a PLM series is 5 seconds, maximum length is
90 seconds.
Leg movements on 2 different legs separated by less than 5 seconds between movements are
Scoring criteria for Alternating Leg Muscle Activation (ALMA), Hypnagogic Foot Tremor
(HFT), Excessive Fragmentary Myoclonus (EFM), bruxism and REM Behavior Disorder (RBD)
Technical considerations
Detection Recommended sensor Alternative sensor
Apnoea Oronasal thermal sensor Nasal air pressure transducer
Scoring of apnoeas
Note: Respiratory effort-related arousal and hypoventilation rules are considered as optional.
Score Cheyne Stokes breathing if there are at least 3 consecutive cycles of cyclical crescendo
and decrescendo change in breathing amplitude (figure) and at least 1 of the following:
• 5 or more central apnoeas or hypopnoeas per hour of sleep
• The cyclic crescendo and decrescendo change has duration of at least 10 consecutive
minutes.
[1] Iber C, Ancoli-Israel S, Chesson AL, Quan SF, 'The AASM Manual for the Scoring of Sleep
and Associated Events: Rules, Terminology, and Technical Specifications', Westchester, Ill:
American Academy of Sleep Medicine; 2007.
[2] Rechtschaffen A, Kales A, eds, 'A Manual of Standardized Terminology, Techniques, and
Scoring System for Sleep Stages of Human Subjects', US Department of Health, Education,
and Welfare Public Health Service --NIH/NIND; 1968.
RIT.CO.006.E*JUNE 2009