ERS Annual Congress Amsterdam

26–30 September 2015

EDUCATIONAL MATERIAL

Educational Skills Workshop 25, 27

Hands-on polysomnography
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Wednesday, 30 September 2015

ESW25 08:00–10:20
ESW27 10:40–13:00

Room L001 RAI

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 Educational Skills Workshop 25, 27
Hands-on polysomnography
AIMS: To introduce and provide an overview of polysomnography, including wiring up,
troubleshooting signals, scoring studies, and interpreting the report.

TARGET AUDIENCE: Absolute beginners and anyone wishing to refresh their understanding of full
polysomnographic sleep studies, including physicians, nurses, allied health professionals, students,
and researchers with a professional interest in sleep medicine.

CHAIRS: R. L. Riha (Edinburgh, United Kingdom)

FACILITATORS: S. De Lacy (London, United Kingdom), E. Hill (Edinburgh, United Kingdom),

A. Morley (Glasgow, United Kingdom)

WORKSHOP PROGRAMME PAGE

Four 30-minute workstations run simultaneously on the following topics:

Workstation 1 – Approach to full polysomnography, setting up and wiring up:

the basic techniques
10-20 system EEG Placement 5

Workstation 2 – Data acquisition: what can go wrong? What does it look like
when it goes right?
PSG Artifact Recognition and Resolution 17

Workstation 3 – Scoring sleep using AASM guidelines. A brief introduction to scoring

respiratory events, arousals and limb movements. 73

Additional resources 132

Faculty disclosures 133

Faculty contact information 134

Answers to evaluation questions 135

 ERS monograph
Obstructive Sleep Apnoea
Edited by Ferran Barbé and Jean-Louis Pépin
ISBN 978-1-84984-059-0

Comprehensive and up-to-date chapters provide the reader with a concise overview of obstructive
sleep apnoea, making this book a useful reference for pulmonologists concerned with the management
of this disease.

To buy printed copies, visit the ERS Bookshop at the ERS International Congress 2015
(Hall 1, Stand 1.D_12).

If you’re an ERS member, you automatically have full online access to the ERS Monographs.

Find out more ERSPUBLICATIONS.COM

 The International 10-20 EEG system: A brief introduction

Dr Andrew Morley
Royal Hospital for Sick Children
79 Hardgate Rd
G51 4SX Glasgow
UNITED KINGDOM
andrew.morley@ggc.scot.nhs.uk

SUMMARY

The non‐invasive method for recording electrical activity of the brain Electroencephalography
(EEG) in relation to sleep is a key element of any Polysomnography assessment. This
workstation will focus on how to set‐up an EEG sleep montage in accordance with the
American Academy of Sleep medicine.

This element of the workshop will be mainly a practical session. It will provide small group
teaching, hands‐on experience with equipment and will ensure that all participants will be fully
involved.

EVALUATION
1. Why should you perform bio‐calibrations before the start of a polysomnography sleep
study?
a. To check the reliability of signals.
b. Confirm the polarity of signals.
c. Establish a baseline reference for the study.
d. All of the above.

2. An eye movement to the left should result in ______ when using standard convention
for polarity.
a. An upward deflection of the signals for both channels
b. An upward deflection of the signal for the LOC channel and a downward deflection
on the ROC channel
c. A downward deflection of the signal for LOC channel and an upward deflection on
the ROC channel.
d. A downward deflection of the signal for both channels.

3. The total circumference of the head is 48cm. What is the distance from Oz to O2
a. 24cm
b. 9.6cm
c. 2.4cm
d. 4.8cm

4. Which electrode site is found half way between M1 & M2

a. Fz
b. Cz
c. Oz
d. Fpz

5. For EEG electrodes what is the recommended level for impedance?

a. < 1K Ohms
b. <5 k Ohms
c. < 10k Ohms
d. ≤ 10 k Ohms

5
Slide 1 ___________________________________
___________________________________
10-20 system EEG Placement
___________________________________
Andrew Morley
___________________________________
(BSc Hons, RPSGT)

Chief Respiratory (Sleep) Physiologist, 
Royal Hospital for Sick Children, Glasgow
___________________________________
___________________________________
___________________________________

Slide 2 Conflict of interest disclosure ___________________________________

x I have no, real or perceived, direct or indirect conflicts of interest that relate to this

presentation.
 I have the following, real or perceived direct or indirect conflicts of interest that relate to
this presentation:
___________________________________
Affiliation / financial interest Nature of conflict / commercial company name

Tobacco-industry and tobacco corporate affiliate

related conflict of interest

Grants/research support (to myself, my institution or

department):
___________________________________
Honoraria or consultation fees:

Participation in a company sponsored bureau:

Stock shareholder:
___________________________________
Spouse/partner:

Other support or other potential conflict of interest: ___________________________________

This event is accredited for CME credits by EBAP and speakers are required to disclose their potential conflict of
interest going back 3 years prior to this presentation. The intent of this disclosure is not to prevent a speaker with a
conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any
commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with
information on which they can make their own judgment. It remains for audience members to determine whether the
speaker’s interests or relationships may influence the presentation.
Drug or device advertisement is strictly forbidden.
___________________________________
___________________________________

Slide 3 ___________________________________
10-20 EEG Placement
AIMS
___________________________________
• Demonstrate the International 10‐20 EEG system
___________________________________
• Understand steps required to set‐up a10‐20 EEG montage for a 
Polysomnography sleep study. 
___________________________________
• Give each delegate a practical experience setting up a Sleep EEG montage 
using the 10‐20 EEG system.
___________________________________
___________________________________
___________________________________

6
Slide 4 ___________________________________
10-20 EEG Placement
Workshop Plan
___________________________________
• This session is going to be a  mainly practical session.
___________________________________
• Brief presentation :  10‐20 basics

• Split into pairs and have a go.
___________________________________
• Slides from the session are available as part of the workshop 
materials – via website
___________________________________
___________________________________
___________________________________

Slide 5 ___________________________________
10-20 EEG Placement
Focus
___________________________________
• Head measuring 
___________________________________
• Location of EEG, EOG, EMG 

• Skin preparation / application (incl. differing techniques)
___________________________________
___________________________________
___________________________________
___________________________________

Slide 6 ___________________________________
10-20 EEG Placement
___________________________________
What is the 10-20 system?

___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

7
Slide 7 ___________________________________
10-20 EEG Placement
What is the 10-20 system?
___________________________________
• An internationally recognised method that allows EEG electrode placement to be standardised.

• Ensures inter‐electrode spacing is equal 
___________________________________
•Electrode placements proportional to skull size & shape 

• Covers all brain regions 
___________________________________
F = Frontal  T = Temporal 
P = Parietal  O = Occipital 
___________________________________
• Numbering system 

Odd = left side, Even = right side, Z = midline 

___________________________________
___________________________________

Slide 8 ___________________________________
10-20 EEG Placement
Routine EEG Montage
___________________________________
• 16 Channel ( + references e.g. Cz, Ground) ___________________________________
M
M11
M1 M2
M2 ___________________________________
___________________________________
___________________________________
___________________________________

Slide 9 ___________________________________
10-20 EEG Placement
American Academy of Sleep Medicine
___________________________________
• Utilises 10‐20 for polysomnography studies
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

8
Slide 10 ___________________________________
10-20 EEG Placement
Sleep Montage
___________________________________
Sleep PSG montage 
(8 Channels + References & ground) ___________________________________
Recommended Back‐up
• F3‐M2  • F4‐M1
• C3‐M2 
• O1‐M2
• C4‐M2 
• O2‐M1  ___________________________________
(There are other acceptable derivations.)

“A minimum of 3 EEG derivations are required 
___________________________________
in order to sample activity from the frontal 
central and occipital regions”
The AASM Manual for the Scoring of Sleep and Associated Events. Version 2.0

___________________________________
___________________________________

Slide 11 ___________________________________
10-20 EEG Placement
Why a minimum of 3 EEG derivations?
___________________________________
F4‐M1 – best for slow waves
___________________________________
C4‐M1 – best for spindles ___________________________________
O2‐M1 – best for alpha rhythm
___________________________________
___________________________________
___________________________________

Slide 12 ___________________________________
10-20 EEG Placement
Preparation
___________________________________
___________________________________
___________________________________
Be prepared
___________________________________
___________________________________
___________________________________

9
Slide 13 ___________________________________
10-20 EEG Placement
Preparation
___________________________________
You will need:
• Measuring tape
• Wax pencil ___________________________________
• Measurement ‘cheat sheet’
• Alcohol wipes
• Scarify skin – Stick / blunt needle
• Abrasive paste ___________________________________
• Conductive paste/gel
• Collodion glue
• Razor?
Measurement
30.0
31.0
10%
3.0
3.1
20%
6.0
6.2
___________________________________
32.0 3.2 6.4
33.0 3.3 6.6
34.0 3.4 6.8
35.0
36.0
37.0
3.5
3.6
3.7
7.0
7.2
7.4
___________________________________
___________________________________

Slide 14 ___________________________________
10-20 EEG Placement
Skin Preparation
___________________________________
How ?

• Isopropyl alcohol wipes to clean (removes grease) 
___________________________________
• Abrasive paste & cotton tip to reduce skin impedance (removes dead skin cells)

___________________________________
___________________________________
___________________________________
___________________________________

Slide 15 ___________________________________
10-20 EEG Placement
Why is it important
___________________________________
Need to have good electrical contact
Impedance < 5kOhms ___________________________________
Consequences of poor placement ___________________________________
• ECG artifact
• Movement artifact High impedance
• High impedance
• Electrode popping
• Movement artifact
___________________________________
• Sweat sway

___________________________________
___________________________________

10
Slide 16 ___________________________________
10-20 EEG Placement
Why bother?
___________________________________
“Garbage In, Garbage Out” ___________________________________
Computers will unquestioningly process the most
nonsensical of input data (garbage in) and produce
nonsensical output (garbage out).
___________________________________
Sleep study signal pathway ___________________________________
Patient Sensor Headbox Amplifier Computer

___________________________________
___________________________________

Slide 17 ___________________________________
10-20 EEG Placement
What is the 10-20 system?
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 18 ___________________________________
10-20 EEG Placement
Four Skull Landmarks
___________________________________
• Nasion
• Inion
Nasion ___________________________________
• Left Pre‐auricular point
• Right Pre‐auricular point
___________________________________
Inion
___________________________________
Pre-auricular point
( Left & right)
___________________________________
___________________________________

11
Slide 19 ___________________________________
10-20 EEG Placement
Measurement of Cz
___________________________________
• Measure the distance from pre‐auricular point to pre‐
auricular point  ___________________________________
• Mark the midpoint (50%) with a vertical line 

• This cross represents Cz which has been correctly aligned 
in the horizontal & vertical planes 
M M
___________________________________
___________________________________
___________________________________
___________________________________

Slide 20 ___________________________________
10-20 EEG Placement
___________________________________
Measurements - T3, C3, Cz, C4, T4
• Reapply the tape transversally between the pre‐auricular points 
• The midpoint (50%) should cross with previous point marking for Cz, confirming its location. ___________________________________
• Mark 10%, 20%, 20%, 20%, 20%, 10%  = T3,C3, Cz, C4, T4 

___________________________________
M M

___________________________________
___________________________________
___________________________________

Slide 21 ___________________________________
10-20 EEG Placement
___________________________________
Measurements - Fpz, Fz, Cz, Pz, Oz

• Reapply the tape along the midline from nasion to inion 
___________________________________
• Mark 10%, 20%, 20%, 20%, 20%, 10%  = Fpz, Fz, Cz, Pz, Oz 

M M
___________________________________
___________________________________
___________________________________
___________________________________

12
Slide 22 ___________________________________
10-20 EEG Placement
Measurements - Fp1, F7, T3, T5, O1, Oz
___________________________________
• Measure the distance between Fpz & Oz by applying the tape around the head via T3. 

• Mark at 10%, 20%, 20%, 20%, 20%, 10%  = Fp1, F7, T3, T5, O1, Oz

___________________________________
___________________________________
___________________________________
(Repeat the process using T4 to mark O2)

___________________________________
___________________________________

Slide 23 ___________________________________
10-20 EEG Placement
Measurement - F3
___________________________________
• Measure Fp1 to C3 and mark midpoint

• Measure Fz to F7 and mark midpoint 
___________________________________
• Mark 50% = F3
___________________________________

(Repeat the process using Fp2 to C4 & Fz to F8 to mark F4)
___________________________________
___________________________________
___________________________________

Slide 24 ___________________________________
10-20 EEG Placement
Measurements M1 & M2
___________________________________
• M1 & M2 are the reference electrodes  (formally known as A1 & A2) 

• M1 & M2 are placed on the mastoid (M) process. 
___________________________________
• These are the bony prominences behind the ears. 
___________________________________
___________________________________
M2

___________________________________
___________________________________

13
Slide 25 ___________________________________
10-20 EEG Placement
___________________________________

C3
___________________________________
F3

O1
___________________________________
M1

___________________________________
You have now completed a 10‐20 EEG montage !!
___________________________________
___________________________________

Slide 26 ___________________________________
10-20 EEG Placement
Electro-oculogram
___________________________________
• Recording of the movement of the corneo‐retinal potential difference,
not the movement of eye muscle. ___________________________________
• Electrodes are placed at outer canthus of eyes offset 1cm above/below the horizontal

• Right out and up / Left out and down ___________________________________
___________________________________
___________________________________
___________________________________

Slide 27 ___________________________________
10-20 EEG Placement
Electromyogram (Chin EMG)
___________________________________
• 3 electrodes 
___________________________________
• 1 on mentalis 

• 2 on submentalis – 2 cm apart (1cm in Paediatrics) 
___________________________________

1 Mentalis
___________________________________
2 Submentalis
___________________________________
___________________________________

14
Slide 28 ___________________________________
10-20 EEG Placement
___________________________________
___________________________________
M2
M1
___________________________________
___________________________________
You have now completed the EOG & EMG elements of a sleep montage setup !!

___________________________________
___________________________________

Slide 29 ___________________________________
10-20 EEG Placement
Calibration (Checking the signals)
___________________________________
• Eyes closed for 30 seconds
Ask the patient to close his/her eyes & lie quietly.

• Eyes open for 30 seconds

Ask the patient to open his/her eyes & look straight ahead.
___________________________________
• Look right & left
Ask the patient without their head to look to the right then to the left several times.

• Look up & down

Ask the patient without moving their head to look up then down several times.

• Blink eyes
___________________________________
Ask the patient to blink their eyes 5 times.

• Clench jaw
Ask the patient clench their jaw.

• Flex foot
Ask the patient to point & flex their foot. Repeat for other foot. Repeat for each leg and document on study.
___________________________________
• Breathe in & out
Ask the patient to breathe normally, and then take a breath in and out. Check polarity and mark IN & OUT on study.

• Snore sound
Ask the patient to imitate a snore sound. ___________________________________
___________________________________

Slide 30 ___________________________________
10-20 EEG Placement
___________________________________
Practical Session
___________________________________
Your turn !!! ___________________________________
___________________________________
___________________________________
___________________________________

15
Slide 31 ___________________________________
Further Reading
___________________________________
The AASM annual for the Scoring of Sleep and Associated Events: Rules, Terminology and technical Specifications. Version 2.1
American Academy of Sleep Medicine (2014)

Sleep Medicine Textbook (European Sleep Research Society (ESRS)

Claudio Bassetti, Zoran Dogas, Philippe Peigneux, Regensburg, (2014)

Essentials of Polysomnography.
William H. Spriggs; Jones & Bartlett Publishers (2008)

Essentials of Sleep Technology

___________________________________
Richard S. Rosenberg; American Academy of Sleep Medicine (2010)

Atlas of Clinical Polysomnography Second Edition (Two-volume Set)

Nic Butkov Media matrix , (2011)

The ten twenty system of the International Federation. Electroencephalography and Clinical
___________________________________
Jasper, H.H. , Neurophysiology, 1958, 10:371-375.

Polysomnographic technique: An overview. In: Sleep disorders medicine, 2nd ed. Boston
Chokroverty S. Butterworth Heinemann (1999)

Fundamentals of EEG technology, Volume 1: Basic concepts and methods.

___________________________________
Tyner F, Knott J, Mayer W Jr. New York: Raven Press; (1983).

Sleep medicine.
Lee-Chiong T, Sateia M, Carskadon M, (Hanley & Belfus, 2002)
___________________________________
___________________________________

Slide 32 ___________________________________
Further Training
• Practical Polysomnography – Edinburgh, UK
___________________________________
– Various dates

• Edinburgh Sleep Medicine Course – Edinburgh, UK ___________________________________

– March 2016

• European Sleep School – Orihuela Costa, Spain ___________________________________

– Various dates

• International Sleep Medicine Course – Cardiff, UK

– June 2016
___________________________________
___________________________________
___________________________________

Slide 33 ___________________________________
Any Questions?
___________________________________
___________________________________
Andrew.morley@ggc.scot.nhs.uk
___________________________________
___________________________________
___________________________________
___________________________________

16
 PSG Artifact Recognition and Resolution

Prof. Dr Simone De Lacy

European Sleep School
Orihuela Costa
SPAIN
simonedelacy@hotmail.co.uk

SUMMARY

Recording physiological signals using surface electrodes and sensors invariably includes picking up
extraneous signals from other sources, be they externally or internally generated. Recognition of these
‘unwanted’ intrusions to desired physiological signals is an important part of the PSG analysis.

Some of these artifact can be addressed and resolved, using various techniques and software
capabilities. Others are indeed evidence of sleep or physiological pathologies and should be identified
and reported.

EVALUATION
1. The major determinant of signal impedance is:
a. The length of the electrode lead
b. The preparation of the stratum corneum
c. The thickness of the skull
d. The material used on the electrode surface

2. A low frequency filter set at 0.3 Hz will do all of the following except:
a. Reduce the amplitude of delta activity
b. Leave faster frequencies intact
c. Reduce the amplitude of sleep spindles
d. Reduce respiratory artifact

3. A ‘Low Pass’ filter set at 35 Hz will do all of the following except:

a. Increase the amplitude of sleep spindles
b. Reduce muscle artefact
c. Leave alpha, delta and theta frequencies intact
d. Reduce external electrical artifact

4. Which of the following is an example of physiological artifact on an EEG channel:

a. ECG signal on C4:M1
b. Electrode ‘popping’
c. 50 Hz frequencies
d. 0.1 Hz frequencies

5. All of the following might be used to reduce signal artifact except:

a. Cleaning and scarification of the skin
b. Notch filters
c. Cooling the patient by lowering the ambient temperature
d. Waking the patient to remove and replace a dislodged mastoid electrode

17
PSG: Artifact Recognition and Resolution

Simone de Lacy
BSc RPSGT EST

Director, European Sleep School, Spain

18
 Conflict of interest disclosure
I have no, real or perceived, direct or indirect conflicts of interest that relate to this
presentation.

Affiliation / financial interest Nature of conflict / commercial company name

Tobacco-industry and tobacco corporate affiliate related None

conflict of interest

Grants/research support (to myself, my institution or None

department):

Honoraria or consultation fees: None

Participation in a company sponsored bureau: None

Stock shareholder: None

Spouse/partner: None

Other support or other potential conflict of interest: None

This event is accredited for CME credits by EBAP and speakers are required to disclose their potential conflict of interest going
back 3 years prior to this presentation. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any
significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to
the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgment.
It remains for audience members to determine whether the speaker’s interests or relationships may influence the presentation.
Drug or device advertisement is strictly forbidden.
19
 AIMS

• To recognise common artefact in PSG recordings

• To determine if the artefact is physiological or extraneous

• To learn how to minimise, resolve or report it.

20
 SIGNAL ARTIFACT

• Signal artifact refers to extraneous signals appearing within desired or

pure signal waveforms
• Some artifact is extrinsic: environmental or equipment related
• Some artifact is intrinsic (i.e. generated within the body;
physiological/ Pathological)
• Artifact needs to be recognised and resolved

4
21
 INTRINSIC AND EXTRINSIC ARTIFACT
Extrinsic Artifact
• High impedance
• Electrode ‘popping’
• Mains interference
• Polarity reversal
• Over amplification
• Incorrect referencing
Intrinsic Artifact
Physiological:
• Eyes movements, Blinks
• Muscle/ movement
• Heart: ECG pick-up
• Sweat: LF artifact
• Respiration: LF artifact
Pathological:
Bruxism, excessive spindling, muscle
fasciculation, seizure activity, etc

This is not strictly artifact but definitely needs to be recognised

5
22
 ARTIFACT RESOLUTION

• Differential Amplification
• Referencing
• Impedance
• Polarity
• Filtering
• Ground and Reference Electrodes

23
 DIFFERENTIAL AMPLIFICATION
Differential amplifiers reduce or eliminate environmental noise by inverting and
subtracting the reference electrode signal from the exploring electrode signal.

Both electrodes carry the same background noise but only the exploring electrode
will pick up the additional EEG signal which will be retained after differential
amplification.

Environmental
Noise [EN]
EEG - EN
EEG + EN
+
Differential
Amplifier
EN
-
C4

M1

7
24
 EXPLORING & REFERENCE ELECTRODES

• Exploring electrodes obtain a signal from a specific area, e.g.

central, frontal or occipital
• Reference electrodes are placed in EEG inactive areas e.g.
mastoid process and are used to compare with the exploring
electrode on the opposite side of the skull

F4:M1

C3:M2

8
25
 PATIENT GROUND &
2ND REFERENCE ELECTRODES

PGND:
2nd Reference Electrode

26
 RE-REFERENCING

• Some systems allow you to add additional channels to your montage

by referencing the signal between any of the electrodes

• If both M1 and M2 electrodes should be lost:

-F3 and C3 could be re-referenced to O2
-F4 and C4 could be re-referenced to O1

27
 REF-REFERENCING

In this example, although A(M)2 and A(M)1 are intact, a new channel has been
created by selecting F3 on the montage and referencing to O2.
The new channel F3O2 appears at the top of the display
28
 IMPEDANCE

• Impedance is the resistance to the flow of an electrical current

• The lower the impedance the better the signal quality
• High impedance decreases the amplitude of a signal
• Skin preparation is a major determinant of electrode impedance

AASM recommended impedance < 5kΩ (EMG may be as much as 10kΩ)

12
29
 FACTORS INFLUENCING IMPEDANCE [Ω]
• Stratum corneum (outermost layer of
epidermis- mainly dead skin cells and
sebum)
• Skull thickness
• Length, gauge and continuity of the
electrode wire

• To reduce the impedance you abrade

the skin thus reducing the thickness
of the stratum corneum

13
30
 ELECTRODE ‘POPPING’ & SWEAT SWAY

• Electrode ‘popping’ occurs when the electrode has partially lost

contact with the skin and air forms a barrier to the conduction of the
signal

• Sweat between the skin and the electrode will also affect the signal
baseline ‘Sweat Sway’

31
 SIGNAL POLARITY

• A negative output signal causes an upward deflection on the visible

trace
• A positive output signal produces a downward deflection on the
visible trace
• Occasionally the signal is very obviously inverted from the outset or
sometimes spontaneously inverts during the recording- this needs to
be recognised

15
32
 FILTERS

• Filters give us the ability to focus on only the signal

frequencies that we want to see
• They attenuate (reduce) unwanted signals
• Different filters can be applied to each channel to allow
us to view the desired frequency range of each type of
signal, EEG, EMG, ECG etc
• They can also be used (carefully) to remove signal
artifact but caution should be applied as some of the
desired physiological can be lost through over-filtering

16
33
 EEG FREQUENCIES

• Beta: ≥14 Hz
(normal, waking anterior)
• Alpha: 8 – 13 Hz
(normal, waking posterior)
• Theta: 4 – 7 Hz
(normal drowsy, light sleep)

• Spindles & K complexes

• Delta: <4Hz
(normal deep sleep)

34
 LOW FREQUENCY FILTER (LFF)

• Also known as the ‘high pass’ filter

• The LFF allows higher frequencies to pass unchanged
• Lower frequencies are attenuated (reduced)
• LFF can be used to reduce respiratory artefact and sweat sway
• LFF should be used with caution as it may also attenuate desired
frequencies such as slow wave sleep if applied inappropriately

18
35
 LFF ON EEG

• LFF can be used to reduce respiratory artefact and sweat sway

• LFF should be used with caution as it may also attenuate desired
frequencies such delta waves
LFF set at 0.3 (AASM)

19
36
 HIGH FREQUENCY FILTER (HFF)

• Also known as the ‘low pass’ filter

• The HFF allows slower waves to pass through
unchanged and attenuates higher frequencies
• The HFF can eliminate muscle artefact or external
electrical artefact in EEG channels
• It may also remove desired high frequencies such as
arousals or sleep spindles

20
37
 HFF ON EEG

• The HFF can eliminate muscle artefact or external electrical artefact in EEG channels

• It may also remove desired high frequency waveforms such as sleep spindles

NB: HFF is usually set at 35Hz for EEG/EOG (AASM) 21

38
 50HZ/NOTCH FILTER

• 50Hz artifact is a high frequency artifact which can be caused by high

signal impedance, interference from external electrical equipment
and poor application of electrodes 50Hz noise due to poor electrode application

• Notch filters attenuate specific frequencies (in reality they attenuate a

small range around the desired frequency)
• A 50Hz filter will also attenuate important signals in this range such as
muscle activity or epileptiform activity

22
39
 FILTER SETTINGS (AASM)

LFF Hz HFF Hz

EEG 0.3 35
EOG 0.3 35
EMG 10 70
ECG 0.3 70
Respiration 0.1 15
Snoring 10 100

23
40
 ECG PICK-UP & ELIMINATION

• ECG is a much larger amplitude signal than EEG and may be picked up
if the mastoid electrodes are positioned too low on an obese patient

• Some systems have the ability to differentially reference channels to

the ECG channel which will help cancel out any extraneous ECG pick-
up on the EEG, EOG and EMG.

• An ECG signal will also be present on the Leg EMG if only one
electrode is placed on each leg instead of two

41
Same epoch with ECG Elimination applied to all EEG channels

42
IDENTIFYING AND RESOLVING INTRINSIC AND EXTRINSIC
ARTIFACT
Extrinsic Artifact Intrinsic Artifact
• High impedance Physiological:
• Electrode ‘popping’ • Eyes movements, Blinks
• Mains interference • Muscle/ movement
• Polarity reversal • Heart: ECG pick-up
• Over amplification • Sweat: LF artifact
• Incorrect referencing • Respiration: LF artifact
Pathological:
Bruxism, excessive spindling, muscle
fasciculation, seizure activity, body
rocking, head banging, sleep walking,
RBD…
26
43
 EXTRINSIC ARTIFACT

HF artifact on C3M2 & O1M2 Channels

Cause: Poor electrode contact M2 (electrode common to both channels)

Solutions: 1. Reapply electrode
2. Apply 50Hz notch filter to M2
27
3. Reference C3 and O1 to M1 electrode 44
 Extrinsic Artifact:
LF artifact on O1M2

Cause: Sweat & O1 lead too tight, being pulled on inspiration, affecting
impedance
Solutions: 1. loosen the lead from the bundle at the top of the head
2. Apply LFF to this channel
28
45
 Extrinsic Artifact:
Inverted ECG signal

Cause: ECG Electrodes correctly positioned but leads plugged into wrong
polarity port + / -

Solutions: 1. Invert signal display for this trace

2. Swap ECG leads into correct polarity port - / + on patient interface
29
46
 Extrinsic Artifact:
K Complex with arousal V’s electrical artifact M2

47
 Extrinsic Artifact:
Irregular abdominal effort signal

Cause: Abdominal band too loose, gain turned up too much to compensate

Solutions: 1. Tighten Abdominal belt and then reduce gain

31
48
 Extrinsic Artifact:
Periods of airflow and effort cessation alternating with periods of airflow with
‘paradoxical’ respiratory effort

Cause: Abdominal band polarity reversed (piezo-electric belts)

Solution: Reverse polarity of abdominal belt (see below)

32
49
 Extrinsic Artifact:
LF artifact on C3M2channel

Cause: Air trapping or poor contact of C3 electrode causing electrode ‘popping’

Solutions: 1. Reapply electrode if necessary

2. Remove trace from recording view if C4-M1 giving good signal
33
50
 Extrinsic Artifact:
LF artifact on C3M2 and O1M2 channels

Cause: Air trapping or poor contact of M2 electrode causing electrode ‘popping’

Solutions: 1. Reapply electrode if necessary, inject more gel into electrode
34
2. Re-reference C3 and O1 to M1 51
 INTRINSIC ARTIFACT EXAMPLES

Physiological Artifact: Eye movement pick-up on EEG

Eyes open left to right Eyes open up and down Eye blinks

35
52
 Physiological Artifact:
HF muscle activity on EEG, EOG and EMG signals

Jaw clenching during bio-calibration

36
53
 Physiological Artifact:
ECG pick-up on single channel leg EMG

Cause: One electrode on L leg, one on R leg gives summation of EMG

activity on both legs but also acts as 2 lead ECG channel.
Solutions: Use 2 electrodes on each leg, separate L Leg EMG from R Leg
Alternatively, record using 2 electrodes on 1 leg only-but this may miss or
underestimate severity of PLMD 37
54
 Physiological Artifact:
ECG pick-up on EEG, EOG (and Leg EMG Channel)

Cause: M1 and M2 electrodes situated on soft tissue rather

than mastoid bone

Solutions: - Reposition M1 and M2 electrodes

- 2nd Reference to ECG channel 38
55
 Physiological Artifact:
LF Sweat artifact on O2M1 EEG

Cause: Patient too hot, sweat affecting impedance

Actions: 1. Cool the patient down
2. Apply LFF to this channel 39
56
 Pathological Artifact:
Cyclical, HF artifact all AC channels

Cause: Bruxism: Cyclical muscle activity picked up on EEG, EOG & EMG

Actions: None, Tech comment and print epoch for PSG report
40
57
 Pathological Artifact:
Episodes of HF simultaneous ‘artifact’ all channels

Cause: Rhythmic Movement Disorder , body rocking sometimes seen in ADHD

and psychological disturbances
Actions: None necessary, Tech comment and print for PSG report
58
 Pathological Artifact:
Cyclical bursts of faster EEG waveforms

Cause: Excessive sleep spindles: often seen in benzodiazepine use

Actions: None necessary, Tech comment and print for PSG report
42
59
 Pathological Artifact:
Atypical waveforms on ECG channel

Cause: Cardiac arrhythmia: Intermittent and runs of PVCs,

Solutions: None necessary, Tech comment and print epoch for PSG report
NB: A prolonged run of PVC’s may be cause for emergency protocol
initiation especially if there is no mention of cardiac problems in the
patient’s notes. 43
60
 Pathological Artifact:
HF artifact superimposed on LF waveforms during N3 sleep

Cause: Movement: Movement during N3 sleep e.g. position change or even sleep walking
This is muscle activity on delta waveforms.
Note patient is in N3 sleep before and after 14 second event
Actions: None necessary, Tech comment and print epoch for PSG report
44
61
 Pathological Artifact:
High amplitude spike and wave artifact on EEG
High muscle tone on Chin and Leg EMG

Cause: Seizure: Characteristic spike and wave activity on EEG

Actions: Follow protocol for seizures, Tech comment and print epochs for PSG
report 45
62
NB Prolonged seizures (>5mins) can be life threatening
 Pathological Artifact:
Irregular, prolonged bursts of HF activity on Leg EMG

Cause: REM Behaviour Disorder: Limb movements due to lack of REM atonia
Actions: Tech note and print epoch for PSG report
46
63
A FEW TECHNICAL
TIPS-:

64
 ELECTRODE INTEGRITY & ORIENTATION

O2 O1

The electrode wires should C4 C3

be kept as short as possible, M2

M1

in good condition and all of F4 F3

equal length and type R.EOG

L.EOG

48
65
Electrode orientating and gathering:
Always ask yourself –”where does the headbox end up in relation to the patient?”
Gather up and direct electrode wires towards this. This is not only more comfy for
the patient (they not lying on a bunch of wires) but it also reduces pulling and
displacement of the sensors and gives a longer ‘umbilicus’.

Soft Velcro loop

holds electrodes in place- take some
time to equalise these so they have
equal tension and make sure you ask
the patient to twist their head round
and make sure nothing is pulling
Orientating leads towards CZ
and gathering at the top of the head
pointing directly towards the head box
headbox

66
 Electrode Application Tips
Electrode gluing with gauze
-Advantages include, makes gluing a bit quicker, mainly much less glue in hair and on
your fingers!
Electrode head fits 10-20 Paste
Ring of collodion on the gauze with a in middle of glue filled electrode
space for the electrode head.

To remove use acetone with cotton wool to soak gauze off.

67
 Take time to equalise and sort all wires out:-
Try not to have one pulling more than another.
Try not to trap hair in the velcro loop

Make sure there are none swinging in the breeze.

They should all be attached at either end to the patient and the headbox!
Unless they are colour coded, apply and plug-in as you go. 68
The quick release leg loop- to prevent the loss of leg electrodes

Quick release on kick

69
 Golden Rules:
• Keep your equipment in good working
• Check and replace any faulty electrodes/sensors
• Good skin preparation and careful cleaning &
application of electrodes and sensors is paramount
• Always perform bio-calibration
• Re-check impedances prior to lights out and during the
study
• Don’t wake the patient up to change electrodes unless
really necessary
• Only use filters to attenuate artifact as a last resort

70
 FURTHER READING

• The AASM annual for the Scoring of Sleep and Associated

Events: Rules, Terminology and technical Specifications Version
2.1.
American Academy of Sleep Medicine (2014)
• Essentials of Polysomnography 2nd Edition.
William H. Spriggs; Jones & Bartlett Publishers (2014)
• Essentials of Sleep Technology
Richard S. Rosenberg; American Academy of Sleep Medicine (2010)
• Sleep Medicine Textbook,
European Sleep Research Society (2014)

71
ANY QUESTIONS?

72
 Scoring sleep using AASM guidelines: A brief introduction

Ms. Elizabeth Hill

Paediatric Respiratory Physiology
Department of Respiratory&Sleep Medicine
Royal Hospital for Sick Children
9 Sciennes Road, Scotland
EH9 1LF Edinburgh
UNITED KINGDOM
lizzie.hill@nhslothian.scot.nhs.uk

SUMMARY

Early pioneers used EEG to “look inside” the brain using sleep. Over time, this was developed into
polysomnography (PSG), which was first used to define sleep stages in the 1960s. PSG is now the
recognised gold-standard technique for measuring sleep, allowing classification of sleep stages,
assessment of sleep architecture and diagnosis of sleep disorders.

This workshop aims to review the criteria for scoring of sleep stages as described in The AASM Manual
for Scoring of Sleep and Associated Events Version 2.1 (American Academy of Sleep Medicine, 2014).
The benefits and drawbacks of these guidelines will be discussed. Delegates will have the opportunity
to apply the current guidelines in small groups during a practical exercise, identifying sleep stages using
real-world examples.

EVALUATION

1. Which of the following statements is not true regarding alpha rhythm?

a. The frequency is 8-13Hz
b. It is commonly observed during stage W with the eyes closed
c. It can be seen most clearly on the frontal EEG
d. Around 10% of individuals do not generate alpha rhythm

2. According to the AASM V2.1 guidelines, when scoring stage N1:

a. The EEG shows a low voltage, mixed frequency pattern of 4-7Hz
b. Vertex sharp waves may be seen, predominantly on the central EEG
c. N1 should not be scored after N3, unless there is an intervening arousal
d. All of the above

3. Stage N2 should be scored:

a. When a spindle or K complex is present in the first half of an epoch
b. After a page of N3 if it does not meet the criteria for W, N3 or R
c. Both A and B
d. Neither A nor B

4. Which of the following is a scoring criteria for stage N3?

a. Absence of sleep spindles
b. Slow waves of 0-2Hz and ≥75µV in ≥20% of the epoch
c. Low voltage, mixed frequency EEG
d. Transient muscle activity

73
5. Which of the following features are not required to score “Definite Stage R”?
a. Very low chin EMG tone (atonia)
b. Sawtooth waves on the central EEG
c. Rapid eye movements on the EOG
d. Low amplitude, mixed frequency EEG without spindles or K complexes

74
 SCORING SLEEP USING AASM GUIDELINES:
A BRIEF INTRODUCTION

Lizzie Hill
BSc RPSGT EST

Specialist Respiratory Clinical Physiologist, Royal Hospital for Sick Children, Edinburgh
Final Year PhD Research Student, The University of Edinburgh

75
 Conflict of interest disclosure
I have no, real or perceived, direct or indirect conflicts of interest that relate to this
presentation.

Affiliation / financial interest Nature of conflict / commercial company name

Tobacco-industry and tobacco corporate affiliate related None

conflict of interest

Grants/research support (to myself, my institution or None

department):

Honoraria or consultation fees: None

Participation in a company sponsored bureau: None

Stock shareholder: None

Spouse/partner: None

Other support or other potential conflict of interest: None

This event is accredited for CME credits by EBAP and speakers are required to disclose their potential conflict of interest going
back 3 years prior to this presentation. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any
significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to
the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgment.
It remains for audience members to determine whether the speaker’s interests or relationships may influence the presentation.
Drug or device advertisement is strictly forbidden.
76
 AIMS

• To review criteria for staging sleep as defined by international

guidelines (AASM V2.1, 2014).

• To discuss the benefits and drawbacks of these guidelines.

• To apply the current AASM guidelines by identifying sleep

stages during a practical exercise.

77
 EXPERIENCE
• Completely new to scoring?

• A little experience of scoring PSG?

• Regularly scoring PSG?

• RPSGT (Registered Polysomnographic Technologist)?

• EST (ESRS Somnologist – Technologist)?

78
 INTRODUCTION

• Early pioneers used EEG to “look inside” brain using

sleep

• Developed into polysomnography

• Rechtshaffen & Kales used PSG to define stages of

sleep

• PSG now standard technique for measuring sleep

Deak & Epstein, 2009

79
 POLYSOMNOGRAPHY
• Objective measurement of sleep & wake
(overnight or during the day)

• Gives information on
– Duration/amount of sleep
– Patterns of sleep
– Quality of sleep
– Behaviours during sleep

• Information from PSG can be used to define sleep

stages

80
 POLYSOMNOGRAPHY
Sensors applied in standard positions
Workstation 1

Studies scored using

standard rules by
skilled technolologist
This workstation

81
AASM MONTAGE

82
 SCORING SLEEP STAGES
• Based on unit of epoch
– 30s in most labs

• Each epoch reviewed in turn and assessed as a

whole for its sleep stage

• In some situations, the page before or after can

influence the decision

• To score a certain stage of sleep at least half the

epoch (15 seconds) must be classified as that stage

83
 SCORING POLYSOMNOGRAPHY

Scroll through study several times:

– Sleep staging – 30s epoch
– EEG arousals – 30s epoch
– Respiratory events – 2min / 5min epoch
• 10min epoch to screen for Cheyne-Stokes

– Periodic leg movements – 5min epoch

84
 SCORING CRITERIA

• Each stage of sleep defined by certain

characteristics
– Rechtschaffen and Kales (1968)

– AASM Manual for the Scoring of Sleep and Associated Events (2007)
• Version 2.0 2012
• Version 2.0.1, 2.0.2 2013
• Version 2.0.3 January 2014
• Version 2.1 July 2014

85
 AASM VERSION 2.1 - 2014

• Current version of
guidelines

• Published July 2014

• Online & print versions

86
 BENEFITS OF AASM GUIDELINES

• Standardised international guidelines

• Comprehensive manual
– Setting up lab
– Training staff
– Reference guide
– Lab accreditation

• Flexible online format

– Updated annually

87
 LIMITATIONS OF AASM GUIDELINES

• Staggered implementation → variation between

centres

• Frequent revisions → “shifting goalposts”

– Many changes related to US Medicare reimbursement

• Based on scoring full PSG

– AASM also recommends use of portable monitoring
Collop et al, JCSM, 2007
– Transferable to limited studies?
– ERS Task Force TF-2014-02 (2014-2016)

88
SCORING SLEEP STAGES

89
 ADULT SLEEP
• Comprises 2 states
– NREM : non-rapid eye movement sleep
– REM : rapid eye movement sleep

• Alternate cyclically over a period of sleep

– Ultradian rhythm

• Sleep stages with distinct, measurable features

90
 INFANT SLEEP

• 2 distinct stages:
– Active sleep (REM)
– Quiet sleep (NREM)

• Normal for infants < 3

months to have sleep-
onset REM (active sleep)

• NREM (quiet sleep)

becomes clearly
demarcated aged 3 – 6
months
91
 SCORING SLEEP STAGES

This session based on adult scoring rules –

AASM Version 2.1 (2014)

92
 STAGE W
• Alpha rhythm / posterior dominant rhythm
– 8-13Hz
– Majority of individuals(~10% do not generate alpha)
– clearest on occipital EEG

AND / OR

• Other findings consistent with W

– Eye blinks
– Rapid eye movements (REMs) with normal/high chin EMG
– Reading eye movements
93
 STAGE W – EYES OPEN

From AASM

94
 STAGE W – EYES CLOSED Eye blinks

Alpha rhythm

From AASM

95
 STAGE N1

Appearance of any of:

• Low amplitude, mixed frequency EEG (LAMF)

– 4-7Hz

• Vertex sharp waves (V waves)

– Central EEG
– <0.5s duration

• Slow eye movements (SEMs)

96
 STAGE N1

• Score N1 if majority of stage meets criteria

for N1 in the absence of evidence for any
other sleep stage

• Keep scoring N1 until there is evidence of

another sleep stage
– Usually W, N2 or R

97
 STAGE N1

From AASM

98
 STAGE N2

Characteristic waveforms:

• Sleep spindle
– fast burst (≥0.5s) of 11-16Hz activity
– clearest on central EEG

• K complex
– -ve EEG deflection followed by +ve (≥0.5s)
– clearest on frontal EEG

99
 STAGE N2
• Start scoring N2 if a K complex and/or sleep spindle
is present in the first half of the epoch or last half of
preceding epoch
– “Definite stage N2”

• Continue to score N2 in absence of spindle/K-

complex if no arousals

• Epochs after a page of N3 are scored as N2 if they

do not meet criteria for W, N3 or R
– Do not score N1 after N3

100
 STAGE N2

• Stop scoring N2 when

– Transition to stage W, N3 or R
– Arousal followed by LAMF (N1)
– Major body movement followed by SEM and LAMF
(N1)

101
 K complex
STAGE N2 Sleep spindles

From AASM

Low voltage, mixed frequency background EEG

102
 STAGE N3
• Slow waves in ≥20% (≥6s) of epoch
– 0-2 Hz
– ≥75µV in amplitude in frontal EEG
– Irrespective of age

• Do not confuse K complexes with slow waves

– K complexes separated in time
– slow waves tend to occur in runs
– K complexes develop into slow waves at transition from N2 to N3

• Spindles can persist into N3

103
 STAGE N3
Delta activity / slow waves

From AASM

104
 STAGE R
Characteristic waveforms:

• Bursts of rapid eye movements (REMs) on EOG

• Very low amplitude EMG (atonia)

• Sawtooth waves
– clearest on central EEG
– Often precede bursts of REMs
Adapted from AASM

• Phasic twitches on EMG

– Transient muscle activity
105
 STAGE R
• “Definite stage R” scored in epochs with ALL of
– LAMF without spindles/K complexes
– Low chin EMG tone (atonia)
– REMs

• Pages before and after “Definite stage R” scored as

R in absence of REMs with ALL of
– LAMF without spindles/K complexes
– Low chin EMG tone (atonia)
– No arousal
– No SEMs

• R takes precedence over N2

106
 STAGE R
• Stop scoring R if ANY of
– Transition to W or N3
–  EMG tone and meets criteria for N1
– Arousal followed by LAMF and SEMs (N1)
– Major body movement followed by LAMF and SEMs
without a sleep spindle or K complex (N1)
– Sleep spindle or K complex in first half of epoch in absence
of eye movements (even if chin EMG still low)

107
 Burst of rapid eye movements
STAGE R
Delta activity / slow waves

From AASM

Phasic twitch

Loss of muscle tone (atonia)

108
 HYPNOGRAM
• Once scored, all sleep stages collated to produce
hypnogram

• Visual representation of sleep architecture

109
 NORMAL SLEEP
• Normally enter sleep through NREM in adults

• Cycles with REM sleep at approx. 90 minute

intervals (90 – 110 minutes)

• 4-5 REM periods in young adults

• Short awakenings are normal

110
 SLEEP ARCHITECHURE

• Normal

• Severe OSAHS

• Treatment with
CPAP
111
 PRACTICAL SESSION

• Split into groups of 3 – 4

• Set of laminated sample epochs

• Assess each example as a group

– EEG frequency
– Distinct, measurable features

• Decide which sleep stage to score

112
 EXAMPLE 1
Delta activity / slow waves

From AASM

113
 EXAMPLE 2
Delta activity / slow waves

From AASM

114
 EXAMPLE 3
Delta activity / slow waves

From AASM

115
 EXAMPLE 4
Delta activity / slow waves

From AASM

116
 EXAMPLE 5
Delta activity / slow waves

From AASM

117
 EXAMPLE 6
Delta activity / slow waves

From AASM

118
 EXAMPLE 7
Delta activity / slow waves

From AASM

119
 EXAMPLE 8
Delta activity / slow waves

From AASM3.73

120
 EXAMPLE 9
Delta activity / slow waves

From AASM

121
 EXAMPLE 10
Delta activity / slow waves

From AASM

122
 EXAMPLE 11
Delta activity / slow waves

From AASM

123
 EXAMPLE 12
Delta activity / slow waves

From AASM

124
 EXAMPLE 13
Delta activity / slow waves

From AASM

125
 EXAMPLE 14
Delta activity / slow waves

From AASM

126
 EXAMPLE 15
Delta activity / slow waves

From AASM

127
 CONCLUSION
• Electrophysiological changes during sleep can be
measured using polysomnography.

• Distinct, measurable electrophysiological features

are used to define different stages of sleep.

• Classifying sleep stages allows us to examine sleep

architecture.

• International guidelines for sleep staging are

available.

128
 FURTHER READING

• The AASM annual for the Scoring of Sleep and

Associated Events: Rules, Terminology and
technical Specifications Version 2.1.
American Academy of Sleep Medicine (2014)

• Essentials of Polysomnography 2nd Edition.

William H. Spriggs; Jones & Bartlett Publishers (2014)

• Essentials of Sleep Technology

Richard S. Rosenberg; American Academy of Sleep Medicine (2010)

129
 FURTHER TRAINING

• Practical Polysomnography – Edinburgh, UK

– Various dates

• Edinburgh Sleep Medicine Course – Edinburgh, UK

– March 2016

• European Sleep School – Orihuela Costa, Spain

– Various dates

• International Sleep Medicine Course – Cardiff, UK

– June 2016

130
 Any questions?

lizzie.hill@ed.ac.uk
lizzie.hill@nhslothian.scot.nhs.uk

www.ed.ac.uk/clinical-sciences/sleep-research
uk.linkedin.com/in/lizziehillsleeptechservices

131
 Recommended reading list and E-learning resources
1. The AASM annual for the Scoring of Sleep and Associated Events: Rules, Terminology and
technical Specifications. Version 2.1 American Academy of Sleep Medicine (2014)
2. Bassetti C., Dogas Z., Peigneux P., Sleep Medicine Textbook (European Sleep Research
Society (ESRS), Regensburg, (2014)
3. Spriggs W. H.; Essentials of Polysomnography, Jones & Bartlett Publishers (2008)
4. Rosenberg R. S. Essentials of Sleep Technology, American Academy of Sleep Medicine
(2010)
5. Butkov N., Atlas of Clinical Polysomnography Second Edition (Two‐volume Set), Media
matrix, (2011)
6. Jasper, H.H. The ten twenty system of the International Federation. Electroencephalography
and Clinical, Neurophysiology, 1958, 10:371‐375.
7. Chokroverty S., Polysomnographic technique: An overview. In: Sleep disorders medicine, 2nd
ed. Boston Butterworth Heinemann (1999)
8. Tyner F, Knott J, Mayer W Jr., Fundamentals of EEG technology, Volume 1:
Basic concepts and methods. New York: Raven Press; (1983).
9. Lee‐Chiong T, Sateia M, Carskadon M, Sleep medicine, Hanley & Belfus, 2002
10. Spriggs W. H, Essentials of Polysomnography 2nd Edition. Jones & Bartlett Publishers (2014)
11. Sleep Medicine Textbook; European Sleep Research Society (2014)

132
 Faculty disclosures

There are no faculty disclosures for this workshop.

133
 Faculty contact information

Prof. Dr Simone De Lacy Dr Andrew Morley

European Sleep School Royal Hospital for Sick Children
Orihuela Costa 79 Hardgate Rd
SPAIN G51 4SX Glasgow
simonedelacy@hotmail.co.uk UNITED KINGDOM
andrew.morley@ggc.scot.nhs.uk
Ms. Elizabeth Hill
Paediatric Respiratory Physiology Dr Renata L. Riha
Department of Respiratory&Sleep Medicine Department of Sleep Medicine
Royal Hospital for Sick Children Royal Infirmary Edinburgh
9 Sciennes Road, Scotland 51 Little France Crescent
EH9 1LF Edinburgh EH16 4SA Scotland, Edinburgh
UNITED KINGDOM UNITED KINGDOM
lizzie.hill@nhslothian.scot.nhs.uk rlriha@hotmail.com

134
 Answers to evaluation questions
Please find all correct answers in bold below

WS2. Data acquisition: what can go wrong? What does it look like when it goes right
– Prof. Dr Simone De Lacy

1. The major determinant of signal impedance is:

a. The length of the electrode lead
b. The preparation of the stratum corneum
c. The thickness of the skull
d. The material used on the electrode surface

2. A low frequency filter set at 0.3 Hz will do all of the following except:
a. Reduce the amplitude of delta activity
b. Leave faster frequencies intact
c. Reduce the amplitude of sleep spindles
d. Reduce respiratory artifact

3. A ‘Low Pass’ filter set at 35 Hz will do all of the following except:

a. Increase the amplitude of sleep spindles
b. Reduce muscle artefact
c. Leave alpha, delta and theta frequencies intact
d. Reduce external electrical artifact

4. Which of the following is an example of physiological artifact on an EEG channel:

a. ECG signal on C4:M1
b. Electrode ‘popping’
c. 50 Hz frequencies
d. 0.1 Hz frequencies

5. All of the following might be used to reduce signal artifact except:

a. Cleaning and scarification of the skin
b. Notch filters
c. Cooling the patient by lowering the ambient temperature
d. Waking the patient to remove and replace a dislodged mastoid electrode

WS3. Scoring sleep using AASM guidelines: A brief introduction - Ms. Elizabeth Hill
1. Which of the following statements is not true regarding alpha rhythm?
a. The frequency is 8-13Hz
b. It is commonly observed during stage W with the eyes closed
c. It can be seen most clearly on the frontal EEG
d. Around 10% of individuals do not generate alpha rhythm

2. According to the AASM V2.1 guidelines, when scoring stage N1:

a. The EEG shows a low voltage, mixed frequency pattern of 4-7Hz
b. Vertex sharp waves may be seen, predominantly on the central EEG
c. N1 should not be scored after N3, unless there is an intervening arousal
d. All of the above

3. Stage N2 should be scored:

a. When a spindle or K complex is present in the first half of an epoch
 b. After a page of N3 if it does not meet the criteria for W, N3 or R
c. Both A and B
d. Neither A nor B

4. Which of the following is a scoring criteria for stage N3?

a. Absence of sleep spindles
b. Slow waves of 0-2Hz and ≥75µV in ≥20% of the epoch
c. Low voltage, mixed frequency EEG
d. Transient muscle activity

5. Which of the following features are not required to score “Definite Stage R”?
a. Very low chin EMG tone (atonia)
b. Sawtooth waves on the central EEG
c. Rapid eye movements on the EOG
d. Low amplitude, mixed frequency EEG without spindles or K complexes