SLEEP CONTROL ROOM The AASM Manual for the Scoring of Sleep and Associated Events RULES, TERMINOLOGY AND TECHNICAL SPECIFICATIONS B ghhacig, ve % 8 2 8 P “ aS “ CEEp MEO” VERSION 2.4 SLEEP DISORDERS CENTERTable of Contents Contributors 4 Preface 6 I. User Guide 7 11. Parameters to be Reported for Polysomnography 8 IIL Technical and Digital Specifications 12 IV. Sleep Staging Rules Part L: Rules for Adults 17 Part 2: Rules for Children 33 Part 3: Rules for Infants 37 V. Arousal Rule 46 VI. Cardiac Rules 47 VII. Movement Rules 49 VIII. Respiratory Rules Part 1: Rules for Adults 56 Part 2: Rules for Children 62 IX. Home Sleep Apnea Testing (HSAT) Rules for Adults Part 1: HSAT Utilizing Respiratory Flow and/or Effort Parameters 66 Part 2: HSAT Utilizing Peripheral Arterial Tonometry (PAT) 71 X. Development Process 74 XI. Procedural Notes 75 XIL Glossary of Terms 87Contributors E lors VERSION 2.4 (2017) RichaedB. Bey, MD, Chir "i Brooks. MEd, RST. RPSGT Charlene E Gamal, MD Steen M Harding, MD Robin. Lloyd, MD Swart Quen, MD Mathew M Tresor, DO rally V, Vaya, MD Sherene M.Thomas, PAD, Stat VERSION 2.0.2-2.3 (2013-2016) Bieta Berry MD Rita Brooks MEW, RST, RPSGT ChateneE, Gamatdo, MD Susan Harding, MD Robin M.Loyd, MD Carole L. Mateus, MBBCh Badly ¥. Vaughn, MD VERSION 2.0-2.0.1 (2012-2013) Ricard B, Berry, aD Rita Brooks, MEd, RST, RPSGT Chetiene , Gamo, ND Susan M. Harding, ND Carole L Marcus, MBBC Biadley VVaugho, MD FIRST EDITION (2007-2011) Conrad be, MD Sonia Ancli-bae, PAD ‘Andrew L. Chesson, MD Swart. Quan, MD Consultants VERSION 2.2 (2014-2015) INFANT SLEEP STAGING Madeleine Grigg Domberges; MD University af New Mexico Schoo} of sodvine, Albuquerque, NMC Mark Scher, MD Case Western Reserve University, Cleveland, OH Task Forces FIRST EDITION (2007-2011) AROUSAL, Michael H. Bonnet, PRD, Chair Wright Sve University, Dayton, OF ASM | Scoring Manual Kori Dogheamii, MD Thomas Jefferson Usvorss 5) Phladelphio, Pa ‘Timothy Rovirs, PAD Wayne State University Dero, Mi ‘Stephen Sheldon, DO, FAAP Chitden’s Memorial Hospital, Chicago, It dward J Stepanski, PD Rush Universite Medien! Center, Chicago,IL Authur S. Walters, MD DY Hlewrnscence ineiate of JEK Medical Center Eaison, MS Merl S. Wise, MD Mesos Healthcare Sleep Disorders Comer, Memphis, TW Andrew L. Chesson Jr, MB ISU Health Sciencor Center in Shreveport ‘Shreveport, LA CARDIAC Sean M. Caples, DO, Chair Mayo Clini Collegeof Medicine, Rochester, MN Virend K. Somers, MD, PRD, Co-Chair Mayo Clinic Collegeof Medicine, Rocherter, MN Michael E. Adams, Researeh Astceiate Holston Volley Medical Cener, Kingsport, 28 Willan G, Cous, xD Northwesern Universtiy, Chicago, IL Parvin Dozostkar, MD Rotubow Babies and Children’s Hosptial, Cleveland, OF ‘Thomas Kara, MD Mayo Clinic College of Medeine, Rochester, MM Timothy | Morgenhaier, MD Maya Clinic College of Medicine Rochester, MN Carol L Rosen, MD Kainbow Babies amd Children’s Hosptial, Cleveland, OFF Edwasd J Stepanski, PHD Rush Universtiy Medica! Cener, Cheogo, I Win K. Shen, MD Mayo Clinie Collegeof Medicine, Rochester, MN Kalyanam shiv koray, MD avid Geffen Schoo of Medicine ot UCLA, Los Angeles, CA Conrad ther, MD Hennepin County Medica! Cemer and University 9f Minnesota Medical School. Minneapolis, MN DIGITAL, ‘Thomas Penzel, PD, Chie Eniversity Hosp, Department af Medicine, Sleep Laborators: Marburg, Germany Max Hirshkowitz, PD, Co-Chair Baylor College of Medicine and VAMC Houston. 10 ‘Nic Butkow, RESGT School of Clinical Pobsomnograps: Medjord, OR Ronahd D. Chervin, MD, MS University af Michigan Arm Arbor, Meie Kryger, MD University of Manitobo, Wnnipes, M8 Canada Clete A. Koshida, MD, PAD, RFSGT Stonjord University, Stanford. CA Beth A. Matow, MD, MS. Vander Universy, Nashville, TN Michael H. Silber, MECHE Mayo Clinic College of Medicine, Rachester. MV MiehaelV. Vitel, PhD Givers of Washington, Seo, HEE Andrew L. Chesson J MD (SU Boalt Sclenoes Center i Shreveport Shreveport La GERIATRIC Sonia Ancol-stal, PD, Chair Universite of California, San Digg, CA Donald L, Biwise, PhD Emory Universty Medlea! School, tanta, GA Susan Reig, MD, MPH Case Western Reserve University, Cleveland, OF Edwatd Stepanski, PAD Rush University Medical Center, Chicage, Michael V. Vito, PhD University 9f Washingiom, Seat, WA ‘Timothy 1. Morgentater, MD Mayo Clinic College of Medicine, Rocester, MN MOVEMENTS Artaur. Walters, MB, Chair PK Medica! Center, Bison, BS Richard P. Allen, PD lahna Hopkins University, Baltimore, MD Donald. Bliwise, PHD Briory University Medico! School, Alana, GA Sudhanso Chokroverty, MD, FRCP MU Neurostence Insitute a JFK Medial Center, Exison. NI Wayne A. Hening, MD, PhD CMDNI- RW Jolson Medical Skool, New Brunswick, SI (Clee A. Kushida, MD, PhD, RPST Sanford Univers, Stand, Ca Giles Lavigne, DMD, PhD, FRCD Universite de Montreal Sleep Disorder Laboratory, ‘Sacre Coeur Hospital, Monreal, QC Canada Daniel Peehiewti, MD University of lini, Urbane, IL Sonia Ancoli-sracl, PAD Univerity of California, an Diego, CA PEDIATRIC ‘Madeleine Grigg-Dambergee, MD, Chair Eniversiny of New Mexico Scat of Medicine, Abguergue 8MDavid Gezsl, MD, Co-Chair University of Lowel, Lovieile, KY atole L. Marcus, MBBCh Universiy of Pemnsyinania, Philadelphia, PA ‘Timothy |. Morgentler, MD Moyo Clinic College of Medicine, Rochester, MN Carel. Roser, MD Rolnbow Babies and Children's Hosp, Cleveland, OFF Stephen Sheldon, DO, FAAP (Children’s Memorial Hosptel. Chicoge, 1 StuactF Quan, MD Brighanr and Women’s Hospital and Harvard Medica! School, Boston. MA RESPIRATORY Richard B, Berry, MD, Chae University of Florida Health Science Center, Gasnevile, FL CCajcle L. Mateus, MBBCR University of Pemsyvonia, Philadelphia, Pt Sica Parthosseathy, MD SAVAHCS and Lniversity of Arizona, Tucson, AZ Conrad fbr, 10 Hemepin Coun Medica! Cemer and Univeriy 2f Menesora Medical School, Minneapois, MN Reene Mebra, MD, MS Case Western Reserve University Cleveland, OH Daniel Gottlieb, 4D 4 Bosion Healthcare System and Boston University School of Medicine, Boson, MA Kingman Sul, MD Care Western Roverve University Cleveland, OH Stuart F Quan, MD Brigham and Women's Hospital and Harvard Media! Schoo, Boston, Ma Sally L. Davidson Ward, AID (Children's Hospital of Lor Angeles, Keck Schoo! af Medicine. University of Southern California Les Angeles, CA David Gozal, MB (Corner Childrens Hospital and Uatversy of Chicago, Chicago, 1h ‘Vishosh K. Kapot, MD, MPH UW Medicine Sleep Center, Unversity of Washingion, Searle, WA Rohit Budhieaa, ID Southern arizona Ya Healtscare System. Southern “zona, Tueson, AZ ‘Sasan Redline, MD, MPH Brigham and Woren's Hospital. Beth kroe! Deaconess Melca! Center and Harvard Medieat Schoo, Boston, MA VISUAL (SLEEP STAGING) Michel, Silber, MBCHB, Chaie Mayo Clnie College of Modine, Rochesten UN Sonie Ancol rel, PD University of Colifornia, San Divgo. CA Michael H. Bonnet, PD Wrigh State Unisersty, Dayton, O Sudhansa Chokrovery, MD, FRCP AU Nenvoseiance Intinis ot JPK Medical Center Baison. NI Madeleine Grigg-Damberger, MD University of New Mexico Sehoo! of Medicine, Albuquerque. HOE Max Hirsbkowite, PAD Baylor College of Medicine ond VAMC, Houston, 12 Sheldon Kapen, MD Wayne Sto University Medical School and PAMC, Detroit MI Sharon Keenen, PAD, ABSM, RPSGT, REEGT The Schoo or Sleep Mediine, le, Palo Alto, CA Meir Keygen, MD University of Manitoba, Winnipeg, MB Canada ‘Thorss Penzel, PRD University Hospital, Department of Meicine ‘Sleep Laboratory, Marburg, Germany Mark Pressman, PRD Lankenow ond Paoli Hospitals, Wynnewood, P& ‘Conrad ther, MD Hennepin County Medica! Center-and University lof Minnesota Medea! School. MIN Acknowledgements The Americas Actcemy of Sleep Medicine acknowledges the 2016-2017 Board of Directors that served over the course ofthis project and provided direction and suppoct: Ronald Chervin, MD, MS lene Rosen, MD [Nathaniel Wats, MD, MS Kelly Carden, MD Dowglas Kish, MD David Kristo, MD Reman Malhotra, MD Jennifer Matia, PAD rie Okon, MD Kannan Kamas, MO James Rosey, MD ‘Terri Weaver, PRD, RN evome A. Barrett Executive Direcior All seoring schematics tht provide illustration of Seep slaging, respiratory and movement scoring rules were provided by Richard B. Ber, MD.Preface “Reve moving to this integration of biomedicine, information technology, wireless and mobile now —an era of digital medicine. Even my stethoscope is now digital. And of course, there's an app for that.” — Daniel Kraft, physician-seientst, inventor ‘The publication of The AASM Manual for the Scoring of Sleop and Associated Events in 2007 was a landmark event and the culmination of thousands of hours of hard work by many dedicated individuals ‘The 2007 manual resulted in standardization of sleep monitoring techniques and scoring, improving uniformity and reliability inthe disgnosis and treatment of sleep disorders across different sleep centers. Nonetheless, advances in sleep monitering technology and questions concerning interpretation ofthe 2007 rules form the basis of an initiative put forth by the ASM Board of Directors to once again update this critical document in sleep medicine. [Atthe same time, there has been an explosion of digital information technology and devices that has shified publication of nearly all documents away fron the printed page, This trend toward a digital format has been accelerated by the conveniences of publishing ontine, most notably, accessibility at any location using smartphones, tablets end computers. Given the need to update the 2007 Scoring Manual and address @ changed digital information landscape, the Board of Directors of the AASM mandated that the scoring maxual be published online with regular updates as necessary. A Scoring Manual Committee was established te oversee the content and to make recommendations when content changes ate indicated, need for clarification exists there is new technology or the literature suggests that updates are needed. The major goals for this initial revision of the scoring manual included conversion to a Web-hased format, standardization of structure and terminology, inclusion of material covered in the scoring manual FAQs from the AASM website, and updated figures as necessary. In addition, the committee was tasked with incorporating new rules for scoring respiratory events that resulted from the work of the Sleen Apnea Definitions Task Force. In true digital format, the first online version of The ASM Scoring Manual for Sleep and Associated Events was called Version 2.0. Electronic links quickly take the reader to notes and areas of interest. ‘The scoring manual is accessible not just on the computer, but also on the flexible viewing styles of mobile technology. Version 2.0 represented the first step in resolving issues and ambiguities in the scoring of sleep and associated events. This manual is an incremental work in progress, guided by feodback from the membership and the Board of Directors, wiich will continue through annual updates. IKisthe hope of the Scoring Manual Committee that the onfine manual will continue to advance the field of sleep medicine and improve the quality of care for patients with sleep disorders. 2012-2013 AASM Sconive Manual Conmerree: Richard B. Berry, MD, Chair Rita Brooks, MEd, RST, RPSGT Charlene E. Gamaldo, MD Susan M. Harding, MD Carole L. Marcus, MBBCh Bradley V. Vaughn, MD1. User Guide Organization of the Manual ‘The AASM Manual for the Scoring of Sleep and Associated Events is designed to guide users through the technical aspects of conducting routine polysomnography (PSG) testing as well as the analytic scoring and interpretation of PSG results. The rules ft PSG testing and scoring are divided over seven chapters (I[-VHI) of the manual. Chapter II specifies all of the parameters that should be reported in a routine PSG test. Chapter III details the digital and filter settings that are recommended for routine PSG recording. Chapters £V-VIII provide additional technical specifications as well as scoring rules for the major categories of testing: sleep staging, arousal, cardiac, movement, and respiratory. Chapter IX provides technical specifications and scoring rules for home sleep apnea testing including those utilizing respiratory flow and/or effort and those utilizing peripheral arterial tonometry (PAT). Chapter X (Development Process} details the process by Which the rules were developed. An outline of the evidence level and decision-making process for each rule may be found in chapter XI (Procedutal Notes), Lastly, chapter XU is ‘glossary of the terminology used throughout the manual. While the rules in raost chapters apply to patients of all ages, rules for adult and pediatric populations are separated in chapters IV (Sleep Staging Rules) and VIII (Respiratory Rules) due (o critical age-specific differences in testing and scoring, ‘The rules within cach chapter are organizad into categories designated by an upper case letter. The rules themselves are num bered and may have several components that are identified by lower ease letters IN EACH SECTION, ALONG WITH THE RULES, YOU WILL NOTICE: ‘The type of rule: Recoumenoen — These rules are recommended for the routine scoring of in-laboratory polysomnography or home sleep apnea testing cerns These are rules that may be used as alternatives tothe recommended rules at the discretion of the clinician or investigator, orriona ‘These are suggested rules for uncommonly encountered events, events not knawn to have pinysiologie significance or events for which there was no consensus decision. Scoring may be performed atthe discretion of the clinician or investigator Notes: If applicable, notes are positioned at the end of a category in order to provide additional information that is critical for carrying out the rules. Rules are followed by superscripts that signify the corresponding note (ex."'™*). Slezp Facility Accreditation AASM sleep facility accreditation requires compliance with all ofthe rnles, definitions, and notes in this manual. According 10 the AASM, rnles specified to be recommended, acceptable, or optional are alt acceptable methods for scoring. Based ‘on the diseretion of the clinician or investigator, a specific center or laboratory may use the acceptable rule in place of the recommended rule without any’ risk to accreditation. Optional rules may be followed in addition to the recommended and acceptable rules withont any risk to accreditation. For further information please contact the accreditation department at the AASM (accreditation@aasranet org)Il. Parameters to be Reported for Polysomnography Recommended parameters must be reported. Optional parameters may be monitored at the discretion of the Clinician or investigator and if monitored, should be reported. A. General Parameters 1. Btectroencephalogram (EEG) derivations aconmenoen 2, Blectrooculogram (EOG) derivations seconmenoes 3. Chin electromyogram (EMG) nscomtenoeo 4, Leg electromyogram (EMG) necowenoes 5. Airflow signals RECOMMENDED: 6. Respiratory effort signals RECOMMENDED 7. Oxygen saturation accowmenne 8. Body position RECOMMENDED 9. Blectrovardiogram (ECG) AecomMENoeD B, Sleep Scoring Data 1. Lights out clock time (hromin) econmenoeo 2. Lights on clock time (ar:min) netonenoeo 3. Total seep time (IST in min) necommenoeo 4. Total recording time (TRT; “lights out” t “lights on” in min) eCoMMENO=D 5. Sleep latency (SL; lights out to first epoch of any sleep in min) RECOMMENDED 6. Stage R latency (sleep onset to first epoch of Stage R in min) RECOMMENDED i 7. Wake after sleep onset (WASO; TRT - SL — TST, in min)"! RECOMMENDED: 8. Percent sleep efficiency (IST / TR * 100 ) RECOMMENDED 9. Time in each stage (in min) : RECOMMENDED 10, Percent of TST in exch stage (time in each stage / TST) * 100 necomenoeo Note {. Wake afler sleep onset includes all wake activity including time out of bed. Time with the patient disconnected from the recording equipment should be scored as stage W. Brief episodes of sleep during this time, # chey ocous, are not considered significant forthe stage scoring summary,C. Arousal Events 1. Number of arousals 2. Arousal index (Ar; number of arousals * 60 / TST) D. Cardiac Events 1 Average heart rate during sleep 2. Highest heart rate during sleep 3. Highest heart rate during recording 4, Occurrence of bradycardia (if observed); report lowest heart rate 5. Occurrence of asystole (if observed); report longest pause 6. Occurrence of sinus tachycardia during sleep (if observed); report highest heart rate 7. Occurrence of narrow complex tachycardia Gf observed); report highest heart rate 8. Occurrence of wide complex tachycardia (if observed); report highest heart rate 9. Occurrence of atrial fibrillation (if observed); report average heart rate 10, Occurrence of other arrhythmias (if observed) list arrhythmia Movement Events 1. Number of periodic limb movements of steep (PLMS) 2. Number of periodic limb movements of sleep (PLMS) with arousals, 3. PLMS index (PLMSI; PLMS x 60 / TST) | 4. PLDIS arousal index (PLMSArI; PLMS with arousals * 60 /TST) RECOMMENDED ‘RECOMMENDED RECOMMENDED commence Recomuenoeo RECOMMENDED10 F. Respiratory Events™! 1. Namber of obstructive apneas 2. Number of mixed apneas 3. Number of central apneas 4, Number of hypopneas 5, Number of obstructive hypopneas Number of central hypopneas 7. Number of apneas + hypopneas 8, Apnea index (Al; (# obstructive apneas + # contral apneas + # mixed apneas) x 60 / TST) 9. Hypopnea index (HI; # hypopneas x 60 / TST) 10. Apnea-hypopnea index (AHI; (# apneas +# hypopness) » 60/TST) 11. Obstructive apnea-hypopnea index (OAHI; (# obstructive apneas + # mixed apneas + # obstructive hypopneas) * 60 / TST) 12. Central apnea-hypopnea index (CAHI; (# central apneas + # central hypopneas) 60 / TST) 13, Number of respiratory effort-related arousals (RERAS) 14, Respiratory effort-related arousal index (RERA index; # of RERAS x 60 / TST) 15, Respiratory disturbance index (RDI; (# apneas + # hypopneas +# RERAS) x 60 / TST) 16. Number of oxygen desaturations 23% or 24% 17. Oxygen desaturation index 23% or 24% (ODI; # oxygen desaturations 23% or 24% * 68/ TST) 18, Arterial oxygen saturation, mean value 19, Minimum oxygen saturation during sleep" 20. Occurrence of hypoventilation during diagnostic study™ Adults Chiteren 21. Occurrence of hypoventilation during PAP titration Agus - Children 22. Occurrence of Cheyue-Stokes breathing in adults RECOMMENDED econmenoeD ecomeenoeD RECOMMENDED RECOMMENDED oPmionA, oPTioNAL RECOMMENDED23. Duration of Cheyne-Stokes breathing (absolute or as a percentage of total sleep time) or the number of Cheyne-Stokes breathing events. 24. Occurrence of periodic breathing in children 25. Occurrence of snoring ecoMMENDED Prion Note 1. Using supplemental oxygen may cause an underestimation of respiratory events which should be taken into consideration by the interpreting physician. Note 2. The criteria used to score a respiratory event as a hypopnea (either rule 14 or 18) should be specified in the PSG report | Note 3. Percent time spent below a given threshold of oxygen desaturation may be reported at the discretion ofthe clinician, Note 4, If electing to measure the arterial PCQ> or surrogate during sleep in cases where it is optional to do so, the ‘oceurrence/absence of hypoventilation must be included in the PSG report. Note 5. Reporting the occurrence of Cheyne-Stokes breathing in the PSG report is required only if' central apneas. and/or central bypopneas are present G. Summary Statements 1. Findings related to sleep diagnoses 2. EEG abnormalities 3.ECG abnormalities, 4. Behavioral observations 5, Sleep hypnogram RecoMMENDED ecoMMeNDeD RECOMMENDED nIll. Technical and Digital Specifications A. Digital Specifications for Routine PSG Recordings“ 1. Maximum Electrode Impedances: 5K ** REcoNweNDeD 2. Minimum Digital Resolution: 12 bits per sample RECOMMENDED 3. Sampling Rates EEGNSS BOG" EMG Eco” Airflow Oximetry, Transcutancous PCOn™* Nasal Pressure, End-Tidal COz, PAP Device Flow S* Esophageal Pressure Body Position” Snoring Sounds ™") sia Rib Cage and Abdominal Movements 4, Routinely Recorded Filter Settings EEGMNE BOGN? EMGN con Oronesal Thermal Flow, Thoracoabdominal Bel Signals Nasal Pressure PAP Device Flow Snoring 42 ASM | Scoring M 4 Desirable 00 Hz 500 Hz 500 Hz 500 Hz 100 Hz 25 He 100 Hz 100 Hz 1 Hz 500 Hz 100 Hz Low-Frequency Filter 03 He 03H 10 Hz 03 He OL Hz Direct current (DC) or $0.03 Hz, pe 10 He Minimal 200 Hz 200 Hz 200 Hz 200 Ha 25 He 10H. 25 Hz 25 He LHe 200 Hz 25 He High-Frequency 35 He 35H 100 Hz T0Hz IsHz 100 Hz pe Loo Hz [RECOMMENDED RECOMMENDED RECOMMENDED ECONMENDEO RECOMMENDED RECOMMENDED RECOMMENDED ecoMmeneD RECOMMENDED RECOMMENDED RECOMMENDED ‘RECOMMENDEDNote {, In the absence of clear preferences, use similar settings among leads to simplify technical implementation Note 2. This applies to measured EEG and EOG electrode impedance. Electrode impedarces should be rechecked during a recording when any pattern that might be artifactual appears. Note 3, For EEG, 500 Hz sampling rate could improve resolution of spikes in the BEG and bettsr maintain details of the waveform Note 4, For more detailed EEG analysis, sampling rate and high-frequency filter settings may be increased. In these circumstances, the sampling rate should be at least 3 times the highest frequency of interest Note 5. For EOG, using the 500 Hz desirable EEG sampling rate also allows the reftection of the EEG in this lead as, an EEG backup and may better define some artifacts in these leads Note 6. This applies to submental and leg EMG. Higher sampling rates better define waveforms; while the waveform itself is not an issue.a better-defined waveform can help avoid amplitude attenuation as the envelope of the rapidly oscillating signal is interpreted Note 7. For ECG, 500 Hz sampling rate can better define pacemaker spikes and ECG waveforms, however, pacemaker spikes can be seen at 200 Hz, and the evaluation of cardiac ischemia by ECG waveform is not ‘a common PSG issue. Higher frequencies may be required for complex waveform analysis and research applications, Note 8. For oximetry, 25 Hz sampling is desirable to assist with artifact evaluation Note 9. Fornasal pressure transducer technology (especially with settings which identify snoring occurring on top of the airflow waveform), this higher frequency may be of benefit for better definition of vibration and snoring, Note 10, The body position channel is exempt from the digital resolution standard. However, the recommended sampling rate of | Hz remains in effect. Note 11. For snoring sound, 500 Hz sampling rate can betier define amplitude variation by clearer waveforms with ‘more accurate amplitude determination as the envelope of the rapidly oscillating signal is interpreted. (as for EMG). If preprocessing of snoring results in a continuous sound loudness level or in a sound intensity level, then a much lower sompling rate is acceptable. That sampling rate is not specified because it depends on the preprocessing ofthe sound in order to produce loudness. Note 12, For rib cage and abdominal movements sing inductance plethysmography. cardiogenic oscillations can be better seen and may result in better attifact assessment at a higher sampling rate. Note 13. To accommodate older equipment, filter settings in the range of 30-35 Hz may be used to comply with the recommendations of 35 Hz. This applies most specifically in the context of EEG and EOG high filter settings. Note 14. For ECG, low-frequency seitings and wide bandwidth minimizes distortion in a 12 lead ECG; however in PSG recording with single-channel modified lead II used for identifying basic heart rates and dysthythmias, it may not be as necessary. Advanced cardiac assessment may be more optimal using ¢ low-frequency filter of 03 Hz for slower parts of the cardiac cycle. The channel is susceptible to artifacts at this setting due to patient movernent, perspiration, muscle activity and electrode displacement. Artifact is less likely at these settings when standard ECG leads are used for cardiac monitoring.B. PSG Recording Features L.A toggle switch permitting visual (on-screen), standard, negative $0 nV DE calibration signal for all. channels to demonstrate polarity, amplitude and time constant settings for each RECOMMENDED recorded parameter 2. A separate 50/60 Hz filter control for each channel RECOMMENDED 3. The capabitity of selecting sampling rates for each channel econmentoen 4. A method of measuring actual individual electrode impedance against a reference (the latter pc coyenoeD may be the sum of all other applied electrodes) 5. The capability of retaining and viewing the data iz the exact manner in which it was recorded by the attending technologist (i.e. retain and display all derivation changes, ecommenoeD sensitivity adjustments, filter settings, temporal resolution) 6. The capability of retaining and viewing the data in the exact manner it appeared when it was scored by the scoring technologist (ic. retain and display all derivation changes, sensitivity RECOMMENDED adjustments, iter settings, temporal resolution) 7.A filter design for data collection which functionally simulates or replicates conventional (analog-style) frequency response curves rather than removing all activity and harmonics RECOMMENDED within the specified bandwidth 8. An electrode selector provess with the flexibility for choosing and/or changing electrode econntenneo {input signal derivations without relying on a common reference electrode C. Use Systems with the Following PSG Display and Display Manipulation Features 1. The display for scoring and review of sleep study data must meet or exceed the following. mecoumenoeo criteria: 15 inch screen size, 1,600 pixels horizontal and 1,050 pixels vertical 2. Histogram with stage, respiratory events, leg movement events, O;saturation,and arousals, —— aeeoyuenoso with cursor positioning on histogram and ability to jump to the page Ability (o view a screen on a time seale ranging from the entire night to windows as small gs; guile EcOMMENDED 4. Recorded video data must be synchronized with PSG data and have an accuracy of 3¢east—pecowenoeo one video frame per second 5, Page automatic turning and automatic scrolling coomiona, 6. Chanucl-off control key or toggle oPonA 7. Channelinvert control key or toggle comnona 8. Change order of channel by click and drag omnia 9, Display setup profiles (including colors) which may be activated at any time ‘rmiona 10, Fast Fourier Transformation or spectral analysis on specifiable interval (omitting segments | gmrguas marked as data artifact)D. Perform the Following Digitai Analyses of PSG 1, Ability to display whether sleep stage scoring was performed visually or computed by the system 2. Ability to tum off and on, as demanded, highlighting of EEG patterns used to make sleep stage decisions (for exampie sleep spindle, K complex, alpha activity) 3. Ability to turn off and on, as demanded, highlighting of patterns identifying respiratory ‘events (for example apneas, hypopneas, desaturations) 4. Ability to turn offand on, as demanded, highlighting of patterns identifying identifying the movement analysis (for example PLMs) ‘RECOMMENDED CoPrionaL E. Perform the Following Calibrations to Document Appropriate System Response 1. Perform and document an impedance check of the EEG, EOG and EMG electrodes 2, Record # minimum of 30 seconds of EEG with patient awake lying quietly with eyes open™ 3. Record a minimum of 30 seconds of BEG with patient lying quietly with eyes closed™* | 4. Ask the patient to look up and down without moving head (x5) 5. Ask the patient to look left and right without moving head (5) sk the patient to blink (5) 7. Ask the patient to grit teoth and/or chew (S seconds) "* | 8. Ask the patient to simulate a snore or hum (S seconds) 9. Ask the patient to breathe normally and assure that airflow and effort channel signals are synchronized 10. Asicthe patient to perform a breath hold (10 seconds)®? 11. Ask the patient to breathe normally and upon instruction to take a breath in and out—check polarity and mark the record IN and OUT accordingly” 12. Ask the patient to breathe through the nose only (10 seconés,"7 13. Ask the patient fo breathe through the mouth onty (10 seconds)? 14, Ask the patient to take a deep breath and exhale slowly (prolonged expiration—10 seconds) 15. Ask the patient to flex the Left foot/raise toes on left foot (»5)™* 16. Ask the patient to flex the right foot/raise toes on ‘ght foot (x8) IT. Ask the patient to flex/extend the fingers on the left hand, as appropriate, if upper extremity EMG is recorded ™* ‘ReCoNWENDED ecommendeD ‘REcOMMENDED ‘RECOMMENOED RECOMMENDED RECOMMENDED | RECOMMENDED EcoMmeNceD ‘oPTONAL 1516 aital Specification 18, Ask the patient to flex/oxtend the fingers on the right hand, as appropriate, if upper’ coprionat extremity EMG is recorded“! 19. Adjust EKG signal to provide a clear waveform—the R wave should deflect upward” ‘oPmONAL 20, Perform and document a repeat impedance check of the EEG, EOG and EMG electrodes at the end of the PSG recording™ RECOMMENDED 21. Repeat physiological calibrations at the end of the PSG recording®!! ecommeneo Note |. Perform physiological calibrations for all patients to the extent thatthe patient is able to cooperate and complete the requested maneuvers. Note 2. Document all calibrations. Verify that the signal appropriately responds to the requested patient maneuvers Repeat calibrations as needed to document a working signal forall recording parameters, Note 3. Measured EEG, £OG and EMG channel impedances should be 5 K {or less and relatively equal Limbs EMG impedances of 10 K 9 or less are acceptable, but impedances of $ K {7 or fess are preferred. Recheck impedances during the recording when eny pactern that might be artifact appears, Note 4. Check EEG channels for blocking, 60 Hz, EKG, and sweat or respiratory artifact and make any necessary adjustments to assure @ readable EEG recording, Note 5, Adjust chin EMG to an adequate sensitivity while patient is awake. In an awake relaxed patient the chin EMG signal should be visible (atleast 1-2 min armplitude). During chewing or teeth gritting maneuvers the chin EMG signal should be at last double the size ofthe baseline signal ‘Note 6. Check the integrity of the snore microphone or sensor by asking the patient to simulate a snore and hum, Adjust as necessary to provide a clear signal with activity. Activity should be negligible with quiet breathing. Note 7. Adjust all respiratory channels to provide a large clean signal with each respiration. Observe and document the signal direction during inhalation and exhalation. Airflow and effort and signals should be in phase with respect to each other. Adjust belt position to attain a readable signal on all airflow and effort channels. Assure that airflow and effort signals respond appropriately to a 10 second breath hold. Note 8. Adjust limb EMG signal to reflect « low background: check signal with bilateral limb movements to verify & noticeable deflection with movement, Note 9. If recording the flexor digitorum superficialis, the patient should flex the fingers at the base (avoid bending at the distal two joints) Ifrecording the extensor digitorum communis, the patient should extend their fingers back without moving their wrist Note 10, Compare heart rate (HR) (o EKG signal (heatt rate is collected from pulse oximetry) to assure HR accuracy, Note 11, Repeat the impedance check and physiological calibrations aftr lights on in the morning,IV. Sleep Staging Rules Part 1: Rules for Adults A. Technical Specifications for Electroencephalogram (EEG) 1. The recommended EEG derivations are: iS? Recomenaea 2. F4-MI b. CMI ©. O2MI Backup electrodes should be placed at F3, C3, 01 and M2 to allow display of F3-M2, C3-M2 and O1-M2 if electrodes ‘malfunction during the study. (sce Figure 1A) 2, Acceptable EEG derivations are:!S2° Acgreranus a. FeCe b. C202 © CMI Backup electrodes should be placed at Epz, C3, O1, and M2 to allow substitution of Fpz for Fz, C3 for Cz or C4, O1 for ‘Oz and M2 for Mt if electrodes malfunction during the study. (See Figure 1B) 3. BEG electrode position is determined by the International 10-20 System. (see Figure 1) AECOMNENC A. RECOMMENDED B. Acosprante Figure 4. mages Imustrating the placement of electrodes utlized in the recommended (A) and acceptable (B) derivations: Toreloctreencephlography (€6) aunng polysomrography ‘The electrode piacement ‘ang nomenclature follow {he International 10% System. Illustration may rot be to scale, Note 1 Ata minimum, frontal, central, and occipital dervations (3 EEG channels) are requited to stage sep. Note 2, Ml and M2 refer to the left and right mestoid processes, Ml isthe standard reference electrode for recording If M1 fails during the recording, backup electrodes should be used and referenced to M2. Note 3. Fe-Cais not appropriate for measuring the amplitude of frontal activity for determination of slow wave activity When using the acceptable BBG derivations and the acceptable EOG derivations (Figure 2), the El-Fpe derivation should be used to measure frontal slow wave amplitude’ Used inthis way, Fpz will be the active electrove recording frontal activity and El the reference electrode in a referential derivation, When using the aeceptabie EEG derivations and the recommended EOG derivations, EEG amplitude to determine slow wave activity should be measured using the C4-MI derivation (C3-MD2 if either C4 or MI electrodes malfunction). When using the recommended E3G derivations and recommended EOG derivations. the ERG amplitude is measured using the derivation F4-ML L s - Contant 012047 Ammrican Acadory ofS 718 IV, Sleep Staging Rules Fy ful B, Technical Specifications for Electrooculogram (EOG) 1. Tae recommended EOG derivations and electrode positions are:™! (see Figure 2A) RECOMENDED. a Derivations: B1-M2 and £:2-M2 Electrode positions: Elis placed 1 em below and {em lateral tothe left outer canthus and E2 is placed 1 em above and J cm lateral to the right outer canthus 2, Acceptable BOG derivations and electrode positions are:)® (ee Figure 2B) accertacte a. Derivations: £1-Fp2 and £2-Fpz b. Electrode positions: El is placed 1 em below and I cm lateral to the outer canthus of the left eye and E2 is placed Lem below and 1 cm lateral to the outer canthus ofthe right eye [A RECOMMENDED Lert | Figure 2. A Rocommended ‘and B. acceptable erivations for ‘alectoaculogram (EO) Husteation ‘may not be to scale. (22017 American Academy of Sleep Masi. ila rserved Note |. When using the recommended EOG derivations, ifthe M2 reference electrode fails, BL and E2 should be referenced to MI \ Note 2, When using the recommended electrode derivations, conjugate eye movements result in out-of phase 75 lV, measured over the frontal regions b. Delta waves are 0-3.99 Hz ©. Theta waves are 47.99 Hz 4, Alpha waves are 8-13 Hz e, Beta waves are greater than 13 HzFigure 4. In this epoch, there is an Feta Initial segmem meedng eriteria for i (32 seconds), a second cont segment meeting erteria for stage NI (07 seconds} aca final segment meeting cntora for stage N2 Oat (7 seconds). The epoch is scores as sleep as the majority of the epoch is Ene sioep. The epoch is scored as stage Ni as the majorty of slnep is stage Ni. came The following epoch would be scores fas stage N2 unless there was evidence chin ene ‘of a shif to anothe sleep stage. (See subsequent sections in this chapler for defritions of alpha rhythm, LAME, and K complex} Note 1 When referring to scoring, use the term “Stage R,” and when referring to the physiological state, use the term “REM sleep” ., REM Sleep Behavior Disorder), E. Scoring Stage W™IS:8.N9s 1. Score in accordance with the following definitions: necowenoeo Alpha rhythm (posterior dominant rhythm in adults and older children): An EEG pattern consisting of trains of, sinusoidal 8-13 Iz activity recorded over the occipital region with eye closure and attenuating with eye opening, Eye blinks: Conjugate vertical eye movements ata frequency of 05-2 Hz present in wakefulness with the cyes open or closed Reading eye movements: Trains of conjugate eye movements consisting ofa slow phase followed by a rapid phase in the ‘opposite direction as the individual reads Rapid eye movements (REMs): Eye movements recorded in the EOG derivations consisting of conjugate, irregular, sharply peaked eye movements with an initial deffection usually lasting <500 msec. While rapid eye movements are characteristic of stage R sleep, they may also be seen in wakefulness with eyes open when individuals visually scan the environment Slow eye movements (SEM): Conjugate, reasonably regular, sinusoidal eye movements with an initial deflection that usually lasts >500 msee, Slow eye movements may be seen during eyes closed wake and stage NI 2. Seore epochs as stage W when more than 50% of the epoch contains EITHER 2a or 2b or BOTH: (cee Figure 5) neccimenoeo 4, Alpha rhythm (posterior dominant rhythm) over the occipital region (individuals generating alpha rhythm with eye closure) b. Other findings consistem with stage W (all individuals) i, Bye blinks (0.5 to 2 Ha) ii, Rapid eye movements associated with normal or bigh chin muscle tone iii, Reading eye movementsfh NO wow iV yon’ wh L aan, ernarcermanaracer ttl rc tangs Ewe “wthhennyniadl mf \ pcre AK A cea marry Pog HY Neyastoiy | mM Kea cnn Figure 5. An epoch of stage W with both alpha rhythm (posterior dominant rhythm) and REMs. Note the EMG activity inthe chin ‘channel 2.2017 American Acne of Sep Medicine. ght reserve Note 1. Stage W represents the waking state, ranging from full alertness through early stages of drowsiness. Electrophysiological and psychophysiological markers of drowsiness may be present during stage W and may persist into stage NI Note 2. In stage W. the majority of individuals with eyes closed will demonstrate alpha rhythm (posterior dominant rhythm). The BEG pattern with eyes open consists of low-amplitude activity (chiefly beta and alpha frequencies) without the hythmicity of alpha rhythm. Atout 10% of individuats do not generate an alpha ‘hythm upon eye closure, and a further 10% may generate a limited alpha rhythm. In these individuals, the ‘occipital EEG activity is similar daring eye opening and eye closure | Note 3. ‘The BOG during wakefulness may demonstrate rapid eye blinks ata frequency of about 0.5-2 Hz. The ‘earliest sign of drowsiness is the absence of eye blinks. As drowsiness develops, slow eye movements may develop, even in the presence of continued posterior dominant rhythm, Ifthe eyes are open, voluntary rapid ‘eye movements of reading eye movements may be seen. | Note 4. The chin EMG during stoge W is of variable amplitude but is usually higher than during sleep stages. Note $. Time with the patient disconnected from the recording equipment should be scored as stage W. Brief episodes of sleep during this time, if they occur, are not considered significant forthe stage scoring, summary F. Scoring Stage NJ 1. Score in accordance with the following definitions: Reconmenoeo Slow eye movements (SEM): Conjugate, reasonably regular, sinusoidal eye movements with an initial deflection that usually lasts >500 msec. Slow eye movements may be seen during eyes closed wake and stage NI Low-amplitude, mixed-frequeney (LAMF) EEG activity: Low-amplitude, predominantly 47 Hz activity Vertex sharp waves (V waves): Sharply contoured waves with duration <0 5 seconds (as measured atthe base ofthe wave), maximal over the central region and distinguishable from the background activity. They are most often seen Goring traosition o stage NI sleep but can occur in either stage NI or N2 sleep. These waveforms typically first appear at 4-6 months post-term, Sleep onset: The st&rtof the first epoch scored as any stage other than stage W. (In most individuals this will usually be the first epoch of stage NI) 2. In individuals who generate alpha rhythm, score stage NI if the alpha rhythm is attenuated and replaced by low- amplitude, mixed-frequency activity for more than 50% of the epoch. SiS REconmenbeD. 213.{n individuals who do not generate alpha rhythm, score stage NI commencing with the earliest of ANY of the following phenomena: 85 pecommeneD 2. BEG activity in range of 47 Hz with slowing of background frequencies by 21 Hz from those of stage W b. Vertex sharp waves «Slow eye movements 4. An epoch is scored as stage N1 if the majorigy of the epoch meets the criteria for stage NI (EEG showing LAMF EEG activity) in the absence of evidence for another sleep stage. Subsequent epochs with au EEG showing LAMF EEG activity are scored as stage NI until there is evidence for another sleep stage (usually stage W, stage N2 or stage R). (Gee Figure 6) recomenoeo Chin EMG } Stage 179.6, Transition from siage W to stage Nt in @patiant who does not generate alpha rhythm {posterior dominant rhytam) wih eye closure. It is aseumed the EEG in epochs 52 and 62 do ot mest citaria FS. {hat Is, stage N1 cannot be sceved based on the EEG criteria ‘A. Epoch 52 continues to be scored as stage W since the slow eye movement occurs in the latter part ofthe epoch, Stage N1 is considered fo start with the occurrence of the siow eye movement. Therefore, epoch 63 is scored as stage N¥ BB. Epoch 62's scored as stage NI since the sovr eye movement occurs inthe frst hat ofthis ‘epoch. Epoch 63 continues as stage N1 untl there is evidenas of stage N2 with the appearance ‘ofa K carmplex in the first half of epoch 8. £2011 Americas Academy ot leap Madlcne Aight esered 5. When an arousal interrupts stage N2 sleep, score subsequent segments of the recording as stage NI if the EEG exhibits low-amplitude, mixed-frequency activity without one or more K complexes and/or sleep spindles until there is evidence for another stage of sleep (see G. Scoring Stage N2), RECOWMENDEO 6. When an arousal interrupts stage R sleep and is followed by a low-amplitude, mixed-frequency BEG without posterior dominant rhythm AND with slow eye movements, score the segments of the record containing the eye movements 3s stage NL even if the chin EMG activity remains low (at the stage R level). Continue to score stage Ni until there is evidence for another stage of sleep, usnally stage N2 (see G.2) or stage R (Gee 1.2 and 1.3). ecommenoeo Note |, Vertex sharp waves may be present but are not required for scoring stage NI | Note 2. The BOG wil often show sow eye movements in stage NI, but these are no required for scoring Note 3. During stage NI. the chin EMG amplitude is variable, but often lower than in stage W. Note 4. As slow eye movements often commence before attenuation of alpha thydtim., sleep latency may be slightly shorter for some individuals who do not generate alpha rhythm campared to those who do Note 5, Theta frequency (4-7 Hz) waveforms that are of pathological origin (such as those resulting from neurological impairment, envephalopathy or epilepsy) should not be considered toward the determination of Stage NI sleep. In a person with a slow backercund BEG in the awake state further non-pathological slowing of the background activity of >t Hz from thet seen in the wake state would be considered evidence of Stage NI sleep,Scoring Stage N2 1. Score in accordance with the following definitions: nécoumenoso K complex: A well-delineated, negative, sharp wave immediately followed by a positive component standing out from the background EEG, with cotal duration 20.5 seconds, usually maximal in amplitude when recorded using frontal derivations, For an arousal to be associated with a K complex, the arousal must ether be concurrent with the K complex of commence no more than I second after termination of the K complex. (see V. Arousal Rule) Sleep spindle: A train of distinct sinusoidal waves with frequency 1-16 Hz (most commonly 12-14 Hz) with @ duration 205 seconds, usually maximal in amplitude in the central derivations 2. Begin scoring stage N2 (in absence of criteria for N3) if EITHER OR BOTH of the following occur during the first half of that epoch or the last half of the previous epoch:*»**? Recoweenceo 4 One or mote K complexes unassociated with arousals| 'b. One or more sleep spindles 3. Score a given epoch as stage N2if the majority ofthe epoch meets criteria for stage N2. If the waveforms in rule 6.2.4 oF G.2.b are followed by an arousal in the same or subsequent epoch (soe Figure 7), the segment of the recording preceding the arousal is considered stage N2 (see rule G.6.b).8!* necommeenoe> A Epoch 8, Epoch Epoch so si 9253 eo 61 62 63 m i 72 73 cor et tt ca ik Foo fia yi onan Arm th com ey era hi cst pep Aa coe a fn EG aetna! cinengpememmmntnnn! ngs tema Ne N2 NTN N2_N2 NT ND No NT ONT NE Stage Stage Stage Figure 7. Start and continuation ofetage N2, The EEG is assumed to show LAME unless otherwise depicted, ‘A. Siart of N2. Epoch 50 is scared as stage N2 2s there is aK complex (unassociated with an arousal in Ye fist half ofthe epoch (rule G.2). Epoch 51 is stage N2 as ths stage Cantinues fr the majority of the apoch (ule G.3). Felawing an arausal, epoch $2 8 scored as stage NI ((ule G.6.0) until there is evidence for another stage of sleep, AK complex Is noted in the last aif of epoch 52 and epoch 83 is scored as stage N2 (ule G.2). BB. At the end of epoch 6, there Is @K complex associated with an arousal. Epoch 62 Is scored as siago NI (rule G.6). AK ‘complex associated with an a'0usal i not considered evidence for stage N2. Epoch 63 is soored as stage N2 by rule G2. 6. AK complex occurs in the fast halt o epch 70 but stage N2 is considered to be present only upto the arousal in epocn 71 Epoch 71 Is scorad as stage Nas the majrity ofthe epoch folaws the arousal. Epach 72 is scored as stage N1 as the K complex ‘does not occur until the second half of fe epach. 4. Continuc to score epochs with low-amplitude, mixed-frequency EEG activity without K complexes or sleep spindles as stage N? if they are preceded by epochs containing EITHER of the following and there is no intervening arousal: RECOMMENDED ‘a. K complexes unassociated with arousals », Sleep spindles 5. Epochs following an epoch of stage N3 that do not meet criteria for stage N3 are scored as stage N2 if there is no intervening arousal and the epoch does not meet criteria for stage W or stage R. (see Figure 8) RECOMMENDED 2324 IV.Sleep Staging Rules F (hin EMG Stage NS Stage N2 Figure 8. Transition trom stage N& to stage N2. The vertical cistance between the fines in F4-M1 is 75 uN. Epoch 201 does not have sufficient slow wave activity to meet ertena for stage N3. There iso intervening arousal. Epoch 201 is scored as stage N2. 12.207 American AesYemy ot Slap Modine. Alright reer. End scoring stage N2 sleep when ONE of the following events occurs:"5%* RECOMMENDED 4. Transition to stage W b. An arousal followed by low-amplitude, mixed-frequency EEG (change to stage NI until a K complex nassociated with an arousal or sleep spindle occurs) (see Figure 7). This assumes thatthe epoch does not meet criteria for stage R (rule 1.3) (Gee Figure 110). ©. A major body movernent followed by slow eye movements and low-amplitude, mixed-frequency EEG without non-arousal associated K complexes or sleep spindles (score the epoch following the major body movement as stage NI; score the ‘epoch as stage N2 if there ate no slow eye movements; the epoch containing the body movement is scored using the major body movement rules under section 1) (see Figure 9) 4. Transition to stage N3 ¢. Transition to stage R. oring Manual V.ging Rules Figure 9. End of stage N2 due toa major body movement. The EEG ie ascumed to Contain ow-amplitude, mixed-trequency activity unless otherwise depicted ‘A. Epoch 52 continues tobe scored as stage N2 as tho major body movement is NOT tollowed by siow eye movements. Epoch 51 Is scored according to the major body movement rules (section J). As epoch $1 does not contain alpha activity and an epoch of stage W does not precede or fellow the epoch, the mejor body movement is scored the samme as the epoch that follows it (stage N2; rule J), B. Epoch 62 is scored as stage I (elage N2 ends follouing tha major body movement} as the body movement is followed by slow eye movements and low- amplitude, mixed-frequency EEG (rule G.8.c) Epoch 63 ls seared as stage N2 as a I complex unassociatad with an arousal acsurs in the fst half of the epoch. ©2017 Ararican Academy of Slop Meticne. Alright reserve. Note t An epoch of stage N2 meeting criteria in rule G.2 is termed definite stage N2. [f there is a conflict between a stage N2 and stage R scoring,rule, the stage R rule takes precedence (sec L4). Note 2, Continue to score stage NI for epochs with arousal-associated K complexes unless they contain sleep spindles or K complexes not associated with arousals Note3. For the purposes of scoring N2 sleep, arousals are defined according to the arousal role in chapter V. (V.A.1). [Note 4. For scoring epochs with » mixture of K complexes and/or sleep spindles and REMSs, see rule (7. Note 5. ‘The EOG usually shows no eye movement activity during stage N2 sleep, but slow eye movements may persist in some individuals. Note 6. In stage N2, the chin EMG is of variable amplitude, but is usually lower than in stage W, and may be as low as in stage R sleep, fac ASM | Scoring Manual Versi 25IV. Steep Staging Files H. Scoring Stage N3! 1. Score in accordance with the following definition: Y=? necommenoeo Slow wave activity: Waves of frequency 0.5 Hz~2 Hz and peak-to-peak amplitude >75 nV, measured over the frontal regions referenced to the contralateral ear or mastoid (F4-MI, F3-M2). 2. Score stage N3 when 220% of an epoch consists of slow wave activity, irrespective of age." RECOMMENDED Note 1. Stage N3 represents slow wave sleep and replaces the Rechtschatten and Kales nomenclature of stage 3 and stage 4 sleep Note 2. K complexes would be considered slow waves if they meet the definition of slow wave setivity. Note 3. Pathological wave forms that meet the slow wave activity criteria, such as those generated by metabotic encephalopathies, epileptic, or epileptiform activity. are not counted as slow wave activity of sleep. Similarly, waveforms produced by artifact or those of non-cerebral origin should not be incladed in the scoring of slow waves, Note 4, Sleep spindles may persist in stage N3 sleep. Note 5. Eye movements are not typically seen during stage N3 sleep, Note 6, In stage N3, the chin EMG is of variable amplitude, often lower than in stage N2 sleep and sometimes as low as in stage R sleep I. Scoring Stage R 1. Score in accordance with the following definitions: recomeenoeo Rapid eye movements (REMS): Eye movements recorded in the FOG derivations consisting of conjugate, irregular, sharply peaked eye movements with an initial deflection uevally lasting <500 msec. While rapid eye movements are characteristic of stage R sleep, they may also be seen in wakefulness with eyes open when individuals visually scan the environment. Low chin EMG tone: Baseline EMG activity in the chin derivation no higher than in any other sleep stage and usually at the lowest level of the entire recording, Sawtooth waves: An EEG pattern consisting of trains of sharply contoured or triangular, often serrated, 2-6 Hz. waves maximal in amplitude over the central head regions and often, but not always, preceding a burst of rapid ey movements, ‘Transient muscle activity: Short irregular bursts of EMG activity usually with duration <0.25 seconds superimposed ‘on low EMG tone. The activity may be seen in the chin or anterior tibial EMG derivations, as well as in EEG or EOG deviations, the later indicating activity of eranial nerve innervated muscles (facial and scalp muscles), The activity is ‘often maximal when associated with rapid eye movements. 2. Score stage R sleep in epochs with ALL of the following phenomena (definite stage R):S!NENLNANSSE RECOMMENDED 2, Low-amplitude, mixed-frequency (LAME) EEG activity without K complexes or sleep spindles b. Low chin EMG tone for the majority of the epoch and concurrent with REMs ¢. REMS at any position within the epoch 3. Score segments of sleep preceding and contiguous with an epoch of definite stage R (as defined in 1.2), In the absence of rapid eye movements, as stage R if ALL of the following are present: (see Figures 10, [I and 12) RecoMMeNDeD a. The EEG shows low-amplitude, mixed-frequency activity without K complexes or sleep spindles™* b. The chin EMG tone is low (atthe stage R level) ¢. There is no intervening arousal (see Figure |1C) 4. Slow eye movements following an arousal or stage W are absent™® 26 Aanwal Version 2 20%Figure 10. Start of stage R. ‘A. Epoch 52s an epoch of define stage F. Epoch 53 is scored as stage R by rule L5 (REM continuation re) B. Epoch 61 is scored as stage NI as alpha is reslaced by low-amoltude, mixed-frequency (LAME) EEG activity. ASEM 's present inthe second half of the epoch. While not required for scoring stage NI, the presence of the SEM prevents the epoch from being ‘scored as stago R rule 1.0}. Epoch 62 Is scared as stage R by rule 13. C. Epoch 71 is ecored as stage F as the majority of the epoch meets tho erteria of rule L3. c. Epoch 6 mom 2% ww Ime tae Le | ane fe yp cet att ‘ cays Ho 1 eye pA ewe cane 1 Chin Ms #5 : wa RR NEMA wa RR Stage Stage Stage Figure 11, Startof stage A, [A. Transition from definite stage N2 (epoch $0) to definite stage R (egoch 59). The EEG of the majority of epoch 1 and all of exoch 52 has low-amplitude, mixed: trequency (LAMF) EEG without sisep szindles or K complexes and chin EMG is atthe stage A level ‘As the epochs 51 and 52 are contiguous with definite stage R (Enoch 53}, they are scored as stage R. 'B. Epoch 60 's an epoch of dofinite stage N2. Epoch 61 is scored as stage N2 by the stage N2 continuation rule. Epochs 62 and 63 are scored as stage R as the EEG has LAMF activity without K complaxss or slsep spindles, the chin EMG is at the stage R level, land the enachs are contiguous with an epoch of definite stage R (epoch 64), Note that, using rule G.2, epoch 62 would be scored a3 slage N2. However, the stage R rule (18) takes precedence . Using rule G.5.b, epoch 71 would be scored as slage N1 (arousal ends stage N2). However, REM rule LS takes precedence and ‘9pochs 72 and 75 ate coored ae stage R. sn eademy of Seep Meccine. Alig reserve.I. Sleep Staging Rules Pixi A Epoch 8. Epoch so st 5288 so 61 e683 rou egg SE com t att tt Coan a nt eran ara tS ew al crnenamteeet tt on ehapetad tt a a Stage Stage Figure 12. Scoring stage Fi. A-A\transiton oetween detiniteatage N2 fepach 60) and definite stage R {epoch 53). Epach 52 ie ecored ae stage A as the EES. ‘shows low-amplitude, mixed-requency (LAMF) without K comploxes or sleep spindles and the chin EMG falls tothe stage R level at the end of epoch 51 B.A transition betwoan definite stage N2 (epach 60) andl datnite st et K complex o sleep spindle, . Epoch 72 is scored as siage R as the majority of epoch 72 (allowing the sleep spincie in the first half ofthe epoch) has an EEG with LAME activity without K complexes or sleep spindles, the chin EMG is atthe stage R level, and this portion ofthe record is Contiguous with definite stage A (epoch 73). Note that, by rule G2. epach 72 would be scored as stage N2. However, rule |.3 takes precedence over rule G.2, As the majority of epoch 72 meets rule erteria, the opoch is scored as stage R. i 12 (epoch 63), Stage N2 is considered to continue until the 4. If the majority of an epoch contains a segment of the recording meeting criteria for stage R (1.2, L.3, 15), the epoch is scored as stage R. Stage R rules take precedence over stage N2 rules. (see Figure 11, epoch 62 and Figure 12, epoch 72) necommenoeo 5. Continue to score segments of sleep that follow one or more epochs of definite stage R (as defined in 1.2), in the absence of rapid eye movements, as stage R if ALL of the following are present: (ee Figures 13-17) necomwenoeo a, The EEG shows LAMF EEG activity without K complexes or sleep spindles b. The chin EMG tone is low (at the stage R level for the majority ofthe epoch «. There is no intervening arousalROR OR NB RAR NT ND Stage Stage Figure 13. Continuation and end of stage R. The EEG is assumed to contain low- amplitude, mxed-frequency activity unless otherwise depicted ‘A. Epoch 50's definite stage A (rule 2). Epochs 51 and $2 continue to be scored as stage A as the chin EtG remains low and the EEG doos nat contain K ‘complexes or sleep spindles. Epoch 52 is scored as stage Ras the chin EMG tone does net incroase unt the last half of the epoch. Epoch 63 ie soored as stage N2 diven hat the K complex ie unassosiated with an arousal in the fst half ofthe epoch, 8B. Epoch 69 is cefnite stage Rand Epoch 61 continues to be scored as stage Ras the chin one remains low and the EEG contains low-amplitude, mixed-trequency activity. Epoch &2 is not scored as stage Fas the chin tone isnot low forthe majority of the epoch. Epoch 62 is scored as stage N1 given the low-ampltude mixed: requaney EEG pattem and the absence of K complexes or sleep spindies in the fst haif ofthe epoch £62017 Amarcan Academy of Soup Messing Al gh raaeve. A Epoch 8. Epoch so Si 8258 oo 6 2 8 02M 02. et wwe ental I come mi pS cays At a hin Ea er a OR NT Ne AOR OR ND Stage Stage Figure 14, End of Stage A due to an arousal. The EEG is assumed to contain lw amplitude, rixed-trequency activity unless otherwise depicted, A. Stage Fis itarrupted by an arausal followed by slow aye movements and low- ‘amplitude, mxec-requency EEG. Thus, epoch 52s scored as stage Ni BB. Stage Fi interrupted by an arousal folawed by low-ampitude, mixed frequency EEG without slow eye movements. Epoch 62 continues to be scored as stage Aas the EEG shows a low-amplitude, mined frequency pattern, anc the majority ofthe epoch contains low chin EMG tone. Compare the offocts of an arousal interrupting stage R wih one interrupting N2 (Figure 7) {22017 Amecan Academy o Sep Medins Alights rasvveeae ny chin ewe Figure 15, End of stage R due to 2 major body movement. The EEG is assured 10 contain low-amplluce mixed-trequency activly unless otherwise depicted 'A.Epach 52 continues as stage Fas the EEG contains low-ampiltude mixed- frequency activity, the chin EMG tone is tow, and siow eye movemenis do NOT follow the ajar Body movement, Noto that # Epach St was scored as stage W based an the appearance af alpha activity, slage F would end (movernent rules in). B, Epoch 62 is not scored as stage F evan ifthe EEG exhibits low-amplitude rixed-frequency activity and the chin ane remains low because slaw eye rmavement folaw the major body movement. A Epoch B. Epoch sos) 5298 661 2 63 ROR Ne Ne ROA OR NO Stage Stage Figure 16. Transition rom stage R to stage N2. Tha EEG | assumed to contain ow-amplitude, mixed-trequency activity uniess otherwise depicted. A. Epoch 50 is dofinto stage A. Epoch 51 is scored a stage A by rule LS (Continuation of stage Fre). Epoch 52 's an epoch of dofite stage N2 given the K Complex inthe first half of the eaoch. BB. Epoch 62s scored as siage Fas the K complox dos not eccur untl the second part of the epoch {©2017 Amerean Acosamy ol Sleep Meizine AN ght rseresA Epooh Epoch c. Epoch D. Epoch sos 82 8 60 Bt e288 m7 279 eo 2 a — wn Fo FS cesn oom eva i ae eve yy AA Cnn ena - - ' ‘ ' a R R RR RON ON2) OR RN AR Stage Stage stage stage Figure 17, Mixture of REMs and K complexes, ‘A. Epoch St is scored as stage R os the majority of the epoch is considered stage A (tule |7.b).Epochs 51 and $2 are scored as stage Ribyrule 1. B. Epochs 60 and 61 are scored as stage Pas the majority ofthe epochs are considered stage R (ule 78), C. Epoch 71 is scored as NI 2s the chin EMG is not at the stage F level for the majority ofthe epoch. Epoch 72 is an epach of finite stage N2. Note that rule 3 does not appiy for epoch 72 as he chin EMG is not atthe stage Ravel 'D. The majority of pach 80 is considered stage R (rule 17.) $0 the epoch is scored as stage R. Most of epoch 81 Is considered stage N2 (rule 7.2) 50 the epoch is scored as stage N2. Epach 82 is red as stage R by Tule 3. FUle IS lakes precedence over the stage N2 rule G.2. Epoch 83 is an epoch of definite stage R. 6. End scoring stage R sleep when ONE OR MORE of the following occur: RECOMMENDED a. There is a transition to stage W or N3 ', An increase in chin EMG tone above the level of stage R is seen for the majority of the epoch and criteria for stage NI are ‘met (ee Figure 13, epoch 62) © An arousal occurs followed by low-amplitude, mixed-frequency EEG and slow eye movements (Score the epoch as stage N{j if there are no slow eye movements and chin EMG tone remains low, zontinue to score as stage R) (see Figure 14) 4. A major body movement Followed by slow eye movements and low-amplitule, mixed-frequency EEG without non-arousal associated K complexes or sleep spindles (Scare the epoch following the majcr body movement as stage NI; if no slow ‘eye movements are present and the EMG tone revnains low, continue to score as staye R; the epoch containing the body movernent is scored using the criteria under heading J) (sce Figure 15) «. One or more non-arousal associated K complexes or sleep spindles are present in the frst half of the epoch in the absence of rapid ee movements, even if chin EMG tone remains low (Score the epoch as stage N2) (see Figure 16) 7. Score segments of the record with low chin EMG activity and a mixture of REMs and sleep spindles and/or K complexes as follows: §!82-8-SNSNS pecomMeNDED a, Segments between two K complexes, two sleep spindles, or a K complex and sleep spindle without intervening REMs are considered t be siage N2. b, Segments of the record containing REMs without K complexes or sleep spindles and chin tone at the REM level are considered to be stage R. .If the majority of an epoch contains a segment considered to be stage N2, itis scored as stage N2. Ifthe majority of an epoch contains a seyment considered to be stage R, itis scored as stage R. (see Figure 17)leep Staging Rules Note 1. Bpochs detined by rule 12 are called epochs of definite stage R. Note 2. Low-amphtude, mixed-frequency activity in stage R rese:mbles that seen in stage NI. In some individuals, 4 greater amount of alpha activity can be seen in stage R than in stage NJ. The alpha frequency in stage R often is 1-2 Hz slower than during wakefulness Note 3. Sawtooth waves or transient muscle activity are strongly supportive ofthe presence of stage R sleep and may be helpful shen the stage isin doubt, however, they are not required for scoring stage R Note 4. For scoring epochs with low chin EMG tone and a mixture of REMs and K complexes or sleep spindles see 1 Note 5, Slow eye movements can occur during stage R but slow eye movements following an arousal in combination ‘with an BEG showing LAMB activity suggests a transition to stage NI even ifthe chin tone remains low. Note 6. Segments ofthe record with low chin EMG activity and a mixture of REM and sleep spindles and/or K complexes usually occur during the frst REM period of the night J. Scoring Epochs with Major Body Movements 1, Score in accordance with the following definition: RecowmenDeD ‘Major body movement: Movement and muscle artifact obscuring the EEG for more than half an epoch to the extent that the sleep stage cannot be determined. 2. If alpha rhythm is present for part of the epoch (even <15 seconds duration), score as stage W. RECOMMENDED 3. If no alpha rhythm is discernible, but an epoch scoreable as stage W either precedes or follows the epoch with a major body movement, score as stage W. RecommendeD 4. Otherwise, score the epoch as the same stage as the epoch that follows it. RECOMMENDED 4 rireIV. Sleep Staging Rules Part 2: Rules for Children A. Ages for Which Pediatric Sleep Staging Rules Apply 1. Pediatric steep staging rules can be used to score sleep and wakefulness in children 2 months post-term or older.®'°* RECOMMENOED | Note 1, For infants less than 2 months post-term, refer to (V. Sleep Staging Rules Part 3: Rules for fants Note 2, There is no precise upper age boundary for pediatric sleep staging rules; refer to discussion in the Pediatric Task Force review paper! Reference 1. Grigg-Damberger M, Gozal D, Marcus CL, et al. The visual scoring of sloep and arousal in infants and children. J Clin Sleep Med. 2007;3(2):201-240, B, Technical Specifications 1, See TV. Sleep Staging Rules Part 1: Rules for Adults and III. Technical and Digital Specifications for technical considerations other than those in the note below." REcoMnuenoeD Note 1. Adult electrode derivations for EEG, EOG and chin EMG are acceptable for recording sleep except that the distance between the chin EMG olectrodes often needs to be reduced fram 2.cm to 1 em and the distance | from the eyes in EOG electrodes often need to be reduced from 1 cm to 0.5 em in children and infants with small head size. C. General Scoring of Sleep Stages 1. The following terminology should be used when scoring sleep sa children 2 months post-term or older: neconweNoeD a, Stage W (Wakefulness) b. Stage NI (NREM 1) ©. Stage N2 (NREM 2) 4. Stage N3 (NREM 3) €. Stage N(NREM) £ Stage R (REM) Not all sleep waveforms are well developed by 2 months post-term, therefore, the following possible scenarios may apply: HENAN 2. [fall epochs of NREM sleep contain no recognizable sleep spindles, K complexes or high-amplitude 0.5-2 Hz slow Wave activity, scare all epochs as stage N(NREM), REcoMmenoeo 3. If some epochs of NREM sleep contain sleep spindies or K complexes, score those as stage N2 (NREM 2). Ifin the remaining NREM epochs, there is no slow wave activity comprising more then 20% of the duration of epochs, score as stage N(NREM). RECOMMENDED 4. If some epochs of NREM sleep contain greater than 20% slow wave activity, score these as stage N3 (NREM 3). [fin the remaining NREM epochs, there are no K complexes or spindles then score as stage N (NREM). necovwenoeo 5. If NREM is sufficiently developed that some epochs contain sleep spindles or K complexes and other epochs contain sufficient amounts of slow wave activity, then score NREM sleep in this infant as either stage NI, N2 or N3 as in an older child or adult. Recowmence>34 IV, Sleep Staging Rules Note | Sleep spindles may be seen by age 6 weeks 3 months post-term and are present in all normal infants by age 2-3 months post-term. At this age the «pindles are asynchronous between the hemispheres but become more synchronous over the first year of life Now 2. K complexes ate usually present by age 3-6 months post-term. Note 3. EEG activity of 0 5-2 Hz with a typical amplitude of 100-400 win the frontal regions may frst appear by 2 months of age and is usually present by age 4~S months post-ierm. The criteria for siaw wave activity are the same as for adults (amplitude >75 pV of 0.5-2 He ). Note 4. NREMsleep can be scored as stage NI. N2 of N3 in most infants by age 5~6 months post-term and ‘occasionally in infants as young as 4 months post-tetm, Note 5. In infants younger than 6 months post-term. non-FEG parameters are helpful in distinguishing NREM sleep from REM sleep. In REM sleep these parameters include the presence of irregular respiration. loss of chin muscle tone, transient musele activity (muscle twitches), and rapid eye movements. In NREM sleep, they consist of regular respiration. absence of eye movements, and preserved chin muscle tone D, Seoring Stage W L. Score in accordance with the following definitions: Ni"! necowmenseo Fiye bsinks: Conjugate vertical eye movements ata frequency of 0.5-2 He present in wakefulness with eyes open or closed Reading eye movements: Trains of conjugate eye movements consisting of a slow phase followed by a tapid phase in the ‘opposite direction as the child reads or visually scans the environment, Rapid eye movements (REM9): Eye movements recorded in the EOG derivations consisting of conjugete, irregular, sharply peaked eye movements with an initial deflection usually lasting <500 msec. While rapid eye movernents are characteristic of stage R sleep, they may also be seen in wakefulness with eyes open when individuals visually scan the environment Posterior dominant rhythm (PDR): The dominant reactive BEG rAythen over the oceipital regions in relaxed wakefulness with eyes closed which is slower in infants and young children and attenuates with eye opening or attention. Frequency is 3.54.5 Hz when first seen in infants 3-4 months post-lerm, 5-6 Hz by 5-6 months, and 7.5-9.5 Hz by 3 years of age and amplitude is usually >50 iV, In older children ard adults, posterior dominant rhythm is often referred to as alpha rhythm. **? (see Table 1) Table 1. nial age of waveform appearance, * Waveform Age of Initial Appearance | Step pines | 6 weeks 3 months posttenn | K complexes | 3-6 months postterm ! | Slow wave actity - | 2-5 months postterm i | Poster dominant rhythm i Frequenny of 35-45 He | 3-4 months posttem Fiequeney of 5-6 H2 5-6 months post term | roneny 028-95 | sym Mean fhequeney of 9 Hz Mesa trequeney of 10 Ha va x sharp waves 4-6 months postterm yprngochypersyacheony CHE) 3-6 mont poses2. Score epochs as stage W when more than S0% of the epoch contains EITHER or BOTH: AecoMenne 4. Age-appropriate pasterior dominant rhythm over the occipital region (individuals generating alpha rhythm with eye closure) b. Other findings consistent with stage W (all individuals) i. Bye blinks (0.5-2 Hz) ii, Rapid eye movements associated with normal or high chin muscle tone ili, Reading eye movements Note 1, The PDR in infants and children typically contains inter ined slower EEG rhythms including: a. Posterior slow waves of youth (PSW) which are intermittent runs of bilateral but often asymmetric Hz slow waves superimposed, riding upon, or fused with the PDR, are usually <120% of PDR voltage, block with eye opening and disappear with drowsiness and sleep. PSW are uncommon in children <2 years of age, have a maximal incidence between ages 8-I4 years and are uncommon after age 21 years. b, Random or semi-rhythmic occipital slowing: <100 uv, 2 5~4.5 Hz rhythmic or arrhythmic activity lasting <3 seconds; a normal finding in EEGs of children ages 1-15 years. especially prominent in ages 5-7 years; the amount of intermixed slowing decreases and its frequency increases Wit Note 2. Spontaneous eye closure in infants signals drowsiness increasing age. Note 3. ‘The highest amplitude and sharpest component of reading eye movements in children is usually surface- negative in the oceipital derivations, typically lasting 150-250 msec, and having amplitudes up to 65 nV Scoring Stage NI 1, Score in accordance with the following definitions: neconmenoeo Slow eye movements (SEM): Conjugste, seasonably regular, sinusoidal eye movements with an intial deflection that usually lasts >500 msec. Slow eye movements may be seen during eyes closed wake and stage NI Low-amplitude, mixed-Srequency (LAMF) activity: Low amplitude, predominantly 4-7 Flz activity, Vertex sharp waves (V waves): Sharply contoured waves with duration <0.5 seconds (as measured atthe base of the ‘wave), maximal over the central region and distinguishable from the background activity. They are most often seen during transition to stage NI sleep but can occur in either stage NI or N2 sleep. These waveforms typically first appear at 4-6 months post-term. Sleep onset: The start ofthe first epoch scored as any stage other than stage W. (In most subjects this will usually be the first epoch of stage NIL) Hypnagogic hypersynchrony (HH): Paroxysmal bursts or nuns of diffuse, high-amplitude, sinusoidal, 75-350 uv, 3-45 Hz waves which begin abruptly, are usually widely distributed but often are maximal over the central, frontal, or frontocentral scalp regions. These waveforms can occur in stage NI and N2. 12.In individuals who generate posterior dominant rhythm (PDR), score stage N1 if the PDR is attenuated or replaced by low-amplitude, mixed-frequency activity for more than 50% of the epoch. !29°4 RECOMMENDED 3. In individuals who do not generate a posterior dominant rhythm, score sta of the following phenomena:"* necommenoen a. Activity in the range of 4-7 Fiz with slowing of background frequencies by >I-2 Hz from those of stage W b. Slow eye movements ©. Vertex sharp waves, 4. Hlypnagogic hypersynchrony € Diffuse or occipital-predominant, high-emplitude, rhythmic 3-5 Hz activity NI commencing with the earliest of ANY1W. Sleep Staging Rules Note 1. In most individuals sleep onset will be the frst epoch of stage NI, but in infants younger than 2 months post- term, this is often stage R. Note 2. Drowsiness in infants up to 6-8 months of age is characterized by the gradual appearance of diffuse. high- amplitude (often 75-200 uV) 3-S Hz activity which is typically of higher amplitude, more diffuse, and | Hz slower than the waking EEG backgrountl activity Note 3. Drowsiness in children & months to 3 years is characterized by either diffuse runs or bursts of rhythmic or | | | semi-thythmie bisynchronous 75200 pV, 3-4 Hz activity often maximal over the occipital regions and/or higher amplitude (200 pV) 4-6 Hz theta activity maximal over the frontocentral or ventral regions. Note 4. Sleep onset from 3 years on is often characterized by a 1-2 Hz slowing of the PDR frequency andor the PDR often hecomes diffusely distributed then is gradually replaced by relatively low-voltage, mixed-frequency EEG activity. Note 5. Hypnagogic hypersynchrony is a distinctive EEG pattern of drowsiness and stage NI that often disappears ‘with deeper stages of NREM sleep. HH is seen in approximately 30% of infants at 3 months post-term, 95% of all normal children ages 6-8 months, and is less prevalent after age 4-S years, its seen in only 10% of healthy children by age 11 and israrcly Seen after age 12 years, F, Scoring Stage N2 1. Same as the adult rules found under the adult sleep staging rules heading G.»!™S2 ReconsenoED I Note 1. Sleep spindles are ususlly are frst seen in infants 46 weeks post-term as brie bursts of low-amplitude,less- sinusoidal [2-14 Hz activity maximal over the vertex region, are usually well-developed and are present ij | all normal infants 8-9 weeks Note 2. Eighty percent of children <13 years of age have two independent scafp iocations and frequency ranges for sleep spindles: 10.0-12.75 Hz over the frontal and 12,5-14.75 Hz maximal over the central or centroparietal | region, | | Note 3. K complexes are usually present 5~6 months post-term and are maximal over the pre-frontal and frontal segions, as they are in adults. G. Scoring Stage N3 1, Same as the adult rules found under the adult sleep staging rules heading HS! AecoNweNoeD [ | Note 1. Slow wave activity in pediatric populations is often of high amplitude (100-400 pV), 9.5-2.0 Hz activity, | ‘maximal over the recommended derivations in the frontal scalp regions and first appears as early as 2 | months, more often 3—4.$ months post-term. U, Scoring Stage R 1, Same as the adult rules found under the adult sleep staging rules heading J. necommenben | note The cominuus. low anplide, mind-equncy EEG ectviy of sage Rin infsand cide sees j Adults although the dominant frequencies increase with age: approximately 3 Hz activity at 7 weeks post- | term, 4-5 Hz activity with bursts of sasvtooth waves at S months, 46 Hz at 9 months, and prolonged runs or bursts of notched 5-7 He. theta activity at I-$ years of age may populate the background activity. By 5-10 | years of age, the low-amplitude, mixed-frequency activity in stage R is similas 10 chat of adults.IV. Sleep Staging Rules Part 3: Rules for Infants A. Ages for Which Infant Sleep Staging Rules Apply 1 Infant sleep staging rules should be used to score sleep and wakefulness in infants 0-2 months post-term (37-48 weeks conceptional age). !25' pecommenoeo Note |, Conceptional age (CA) is gestational age (GA) at birth plus the number of weeks postpartum. GA is the me elapsed between the fist day ofthe mother’ ast menstrual period andthe day of delivery expressed | completed weeks, Ifthe pregnancy was achieved using assisted reproductive technology, GA is calculated by adding 2 weeks to the CA. Chronological age (or postnatal or legal age) isthe time elapsed since birth (can be expressed in days, months, or years) | Note 2, At birth, an infant is classified as one of the following: premature (<37 weeks gestation); full-term (37-42 ‘weeks): or post-term (born after 42 weeks). A neonate isa child during the first 28 days after births an infant | isa child age 1 to 12 months. | Note3, Knowing an infos CA is crucial for interpreting the normale, immunity or abnormality ofan EEG or | PSG because the brain and the EEG continue to develop and mature at a similar tate independent of whether | the infantis in utero or post-delivery. |" 4, For premature infants (<37 weeks CA) refer to discussion in the Pediatric and Infant Scoring Task Foros | review paper. | References 1. Engle WA; American Acaderny of Pediatrics Committee on Fetus and Newborn, Age terminology during the perinatal period. Pediatrics. 2004;114(5) 1362-1364 Srigg-Dambenger M, Gozal D, Marcus CL, etal. The visual scoring of sleep and arousal in infants and children. J Clin ep Med. 2007:3(2):201-240. B, Technical Specifications 1 2 2 4. See IV. Sleep Staging Rules Part 1; Rules for Adults and IH, Technical and Digital Specifications for technical considerations other than those helow. RECOMMENDED Adult electrode derivations for KEG, EOG and chin EMG are acceptable when recording sleep except that the distance between the chin EMG electrodes often needs to be reduced from 2 em to 1 em and the distance from the eyes in EOG electrodes often need to be reduced from 4 to 0.$ cm because of small infant head sizes, ecowwenoeo Since sleep spindles are often asynchronous in ebildren until 2 years of age, and may be more prominent in the midline central (C3-Cr, C4-Cz) and central derivations (C3-M2, C4-MI), simultaneous display of the recommended and backup electrodes and Cz (midline central) may be considered (e.g. montage to consider: F4-M1, C4-M, O2-MI, F3- M2, C3-M2, O1-M2, C4-Cz, C3-C7)."! OPTIONAL Since behavioral patterns are extremely useful, synchronized video and audio recording is highly desirable. oPTONAL — | Note Since udimentany sleep spindles fist appear at 2048 werks CA a the midline cena (C2, ete) regon | | and are often asynchronous, simultaneous display of left, right and midline central EEG channels may be considered (¢,., C3-Cz, C2-C4), In infants this age, sleep spindles are often low voltage 12-14 He, not the wider range of 11-16 Hz seen at later ages. 37WW. Sloop Staging Rul C. General Scoring of Sleep Stages 1. The following terminology should be used when scoring sleep in infants 0-2 months post-term (31-48 weeks Ca):°" RECOMMENDED 4, Stage W (Wakefulness) ». Stage N (NREM) Stage R (REM) 4. Stage T (Transitional) 2. Score epochs using the following rules: RecowmenneD 4 Score sleep stages in 30-second, sequential epochs commencing at the start of the study b. Assign a stage to each epoch ¢. Iftwo or more stages coexist, assign the stage comprising the greatest portion of the epoch 4. If two or more PSG characteristics are discordant for stage R or stage N sleep, score the epoch as stage T (Transitional) sleep €. Score sleep onset asthe first epoch of sleep®® 3. Sleep and wakefulness in infants 38 10 48 weeks CA are scored based on behavioral observation; regularity oF irregularity of respiration; and EEG, FOG, and chin EMG patterns defined in Tables 1-6. ecommenoeD 4, Score sleep based on behavioral characteristics as defined in Table 1. RecommeNDED Table 1. Behavioral charecteristics of sip stages. Stage | Behavioral Gharacteristies | Wake | Calmoransive with eyes open, scanning eye movements; Brief exe closure can occu with erying Iw | Byes closed, few movements, sucking R Eyes closed, REM seen unger closed eyelids, squirming, sucking grimacing, smal! movements of the fae o limbs 5. Score sleep based on the respiration characteristics as defined in Table 2.56 peconmienoeD Table 2. Respiration characteristics of sleep stages. Stage Rospiration Characteristics Woke | Irregular epi, and shallow N Regular ik Irregular, some central pauses (may or may not mee criteria For spaesWV, Sleep Staging Rules ¥ 6. Score sleep based on the EEG characteristics as defined in Table 3, (sve also Figure 1) RECOMMENDED Table 3. EEG characteristics of seep stages. Ni" Patterns | EEG Characteristics Stage(s) Discontinuees | ‘This EEG pattern in fl-tren infants is generally only seen in stage N sleep. tis i ‘harasteried bya lees 3allernating “uns of bilterally symmetecal synchronous high | trace alternant ras"! | voltage 90-130 pV) bursts of 1-3 He delta activity lasting 3-6 seconds (range 3-8 in : seconds) ale-aling with periods of tower amplitude 25-80 uV) 4-7 Ha tetaaetivity (range 412 seconds, i Continuous | tow satageiegutarc.v CBMs low vokge mined equeny actcy with elt and predominant mx. | aust. Continuous synchronous syminetricslpredomirantly high voltage 1-3 Hz delta eetivity. | Nyracely R { | Bath high voltage low and tows voliage polychythmic components; dese areiniermingled Wake, Mixed (M0) | ih lite perioisty The amplitude slower than seen inthe HVS patern, acy S| ‘Waveforms of interest | Sleep spindles 12.N15 1210 44H, asynchronous, most prominent in midline central (CZ) and central derivations. | | 0 only stage N sleep oh voltage sow tS) fea er nha te A pA pa aggre RS ant ob py ea A pe rata Ln ORS Wan PR part rf alt na Low voltage ireguiar (Lvl) FM en ne ng ent ne A poe nena MY a ee nett pl annem CEM pt Nt ban A Mixed (8) PMN eg eee enh ati yee yy anette ar Cla Aan ene nyt na OAR fell a Al pinta Wa Aa lee ON an nal pln AIAN oa Me PN Traoe alternant (TA) ren EY ota een NN Pe Figure 4. Sample 90 second tracings of EEG characteristics of sleep stages. 192011 amences Academy ol leap Megane Al ight overved 7. Score sleep in accordance with the following definitions and based on the LOG characteristies as defined in Table 4, necomenoe0 Bye blinks: Conjugate vertical eye movements at @ frequency of 0.5~2 Hz present in wakefulness with eyes open or closed. 39Scanning eye movements: Trains of conjugate eye movements with eyes open consisting ofa slow phase followed by a rapid phase in the opposite direction as the infant visually scaas the environment or follows objects." Rapid eye movements (REM): Eye movements recorded in the EOG derivations consisting of conjugate, iregular, sharply peaked eye movements with an initial deflection usually lasting <500 msec, While rapid eye movements are characteristic of stage R sleep, they may also be seen in wakefulness with eyes open when individuals visually scan the environment Table 4. E0G characteristics of sleep stages. | Stage EOG Characteristics | ‘Wake | Eye blinks, REMs, seanning eye movements; ransient eye closures may be seen in yekefulness especially when the infantis erying | N Eyes closed, not moving R yes closod with RENS 8. Score sleep in accordance with the following definitions and based on the chin EMG patterns as defined in ‘Table 5. secommenne9 Low chin EMG tone: Baseline EMG activity in the chin derivation no higher than in any ether sleep stage and usually at the lowest level of the entire recording, ‘Transient muscle activity: Short irsegulae bursts of EMG activity usually with duration <0.25 seconds superimposed on low EMG tone. The activity may be seen in the chin or anterior tibial EMG derivations, as well as in BEG or EOG deviations, the latte indicating activity of eranial nerve innervated muscles (facial and scalp muscles). The activity is often maximal when associated with rapid eye movements Table 5. Chin EMG pattems of slaep stages. Stage | Chin EMG Patterns Wake Prosent, movement artic: N Present cout be lower than wake ie dow, TMA may oveur ‘Table 6 provides a summary of Tables J to 5. Table 6. Summary of state characteristics, '* | Stage Behavioral Respiration | EEG | £0G ‘Chin EMG reopen cing / ie bts aa feeding Tregul: (tori ning cye movements | Reduced movement | a TABVS.seep | Beteewih | porte [Gece | sop [Tansey | Bs . | eset cetatet teen a twtons I ugg vontwamy | " Sraemens EU fapansy —— esdedwinas | V7 + low soltage regular, M = mined, TA ~ trace alereant, HVS =bigh votage slow, REMs= rapid eye movementsNote 1 Note 2, Note 3, Note 4, Note 5. Note 6 Note 7, Note 8 Note 9. Note 10. Note 11 Note 12 Note 13 Note 14 Note IS. Note 16. (W. Steep Staging Putes IfNREM is sufficiently developed 50 that some epochs contain sleep spindles or K complexes and other epochs contain sufficient amounts of slow wave activity, then score NREM sleep in this infant as either stage Ni, N2 or N3 as in IV. Sleep Staging Rules Part 2: Rules for Children, C.S. Stage N is analogous to the previously uscd terminology of “quict slecp,” stage R is analogous to the previously used terminology of “active sleep.” and stage T is analogous to the previously used terminology of “indeterminate sleep.” Up until 2 to 3 months post-term, the first epoch of sleep in infants is often stage R. ‘The wransition to sleep in an infant is characterized by relative immobility, absence of focused attention, and intermitient eye closure, Ifan infant's eyes are closed for more than 3 minutes, the infantis considered asleep. Theta and delta activity, especially over the frontal derivations, may increase in amplitude in transitions between W and sleep onset. Regularity or integularity of respiration during slcep is the most reliable PSG characteristic in differentiating stage N and stage R sleep, respectively. Periodic breathing is common during stage R sleep and may rarely occur during stage N sleep in normal infants. ‘The BEG pattems of transitional sleep may contain any of the EEG characteristics outlined in Table 3 Pathological EEG waveforms, such as those from spike and slow wave, projected rhythms or those generated due to underlying pathology, should not be included in defining stage or state as noted in Table 3 Itis permissible to look at preceding and following epochs to identify the trace alternant (TIA) pattern, ‘Trace alternant (TA) first appears at 37 weeks conceptional age (CA), is the predominant EEG pattern in stage N slcep at 40 weeks CA and unlikely to be seen after 44 weeks CA. After 42 weeks CA, interburst intervals (IBIS) of TA last only 1-2 seconds and the [BI is of higher amplitude. TA after 44 weeks CA is replaced by high voltage slow (HVS) activity High voltage slow (HVS) activity is the more mature EEG pattern of stage N sleep at term. Itis characterized by continuous synchronous symmetrical 100-150 wl 1-3 Hz delta activity which often has an occipital or central predominance Since rudimentary sleep spindles first appear at 43 to 48 weeks CA at the midline central (Cz, vertex) region and are often asynchronous, simultaneous display of lef, right and midline central EEG channels may be considered (€ ,. C3-Cz, Cz-C4). In infants this age, sleep spindles are often low voltage 12-14 Hz, not the ‘wider range of 11-16 Hz seen at later ages. Since sleep spindles are often asynchronous in children until 2 years of age, simultaneous display of the recommended and backup electrodes may be considered (€.g, montage to consider: F3-M2, F4-MI, C3-M2, (C4-MI, O1-M2, 02-MI, C3-Cz, Cz-C4). Scanning eye movements can be seen as early as 2 weeks post-term. Stage T (Transitional) is scored when 3 NREM and 2 REM or 2 NREM and 3 REM characteristios are present In epoch(s) contiguous and following an epoch of definite stage R (e.g. containing REMS).1, Sleep Staging Rules | “ D. Scoring Stage W 1. Score epochs as stage W if either a, , or ¢ is present for the majority ofthe epoch: (Figure 2) neoomwenoeD a. Byes are wide open (for the majority of the epoch) b, Vocalization (whimpering, erying, etc) or actively feeding € All of the following are met, i. Byes are open intermittently REM or scanning eye movements i, Sustained chin EMG tone with bursts of musele activity iy. Irregular respiration v. EEG: LVI or M%? remy [enV \ oi tens into woe] RO es AUS Ne a — Wh ae oa oe iy NG cin NA Figure 2. & 20 second tracing of stage W in an infant. EEG: mixed frequency pattern; EOG: REM present; Chin EMG: present (igh); Respiration: eregular; Behavior: eyes open, moving head. The thermal sensor is an eronasal low sensor Note 1. Wake is most reliably scored by behavioral observations, because many ofthe distinctive EEG features of ‘wakefulness are not seen until after 2 months post-term. Note 2. W (Wakefulness) is characterized by an BEG background of continuous, symmetrical, irregular, low-to- medium amplitude mixed frequencies which may include: a) iregular theta and delta activity (to 100 nV) maximal in O1, 02; b) diffuse irregular alpha and beta activity (to 30 pV); c) shythmic theta activity (to 50 uV), often maximal in C3, C2, C4; or d) artifacts from body movements, and eye movernents, Note 3. This may have superimposed frequent movement artifacts. Scoring Manual Version 2.4 * nvet nW, Sleep Staging Rules E. Scoring Stage N (NREM) 1, Score stage N if four or more of the following are present, including regular respiration, for the majority of the epoch:¥i™ (Figures 3 and 4) ecowmenoeo 4. Eyes closed with no eye movements . Chin EMG tone present ¢, Regular respiration (post sigh respiratory pauses may occur) 4. Trace alvernant (TA), high voltage slow (HVS), or sleep spindles present €. Reduced movement relative to wake en ove A Re mote ool North coun my OK TAN A in AN wae eee a a I pa a ee mW perenne SSO a = TA oy cn ecw | fmm ISM BSS BASS SDDS SEP BEBE MSDE EERE SB is Pie VAAN RIAD NAA DAD DD a eS Figure 3. & 30 second tracing of stage N sleep in an infant. EEG: Trace alternant; EG: no REMs:; Chin EMG: present; Respiration: regular, Behavior eyes closed, no movements. The thermal sensor is an oronasal flow sensor. 12207 american Acadamy oSeep Meine Al nan reseed com ey ntl A Dalia Tea lal tonawenan Me Sree POA Neen ay er NA AL RD ON And, Baan NOR ene fA One Anat REESE REP RRERREE PREEE EEE ERRE EEE EP PEED EPPA Pt SN NR RAN oe striae NII NCIC ne Oe ee ON Figure 4, A 20 second tracing of stage N sleep in an infant, EEG: HVS; EOG: no aye movements; Chin EMG: present; Rospiration:requler; Behavior: eyes closed, no movements. The thermal sensor isan oronasal flow sensor. 22017 American Reader of Sep Meine Alleah served Note 1. Chin EMG in stage N is variable: itis generally lower than Wake and higher than in stage R. That is, ifchin EMG activity is present (higher than stage R) ths is evidence for stage N (Table 5). However, stage N can still be scored with low EMG tone provided at lest four other criteria for stage N including regalar respiration are met, Note 2, Regulatity or irregularity of respiration during sleep is the most reliable PSG characteristic in differentiating stage N and stage R sleep, respectivelyMy FB Sleep Staging Aules Scoring Stage R 1. Score stage R sleep (definite R) in epochs with 4 or more of the following criteria present, including irregular respiration AND rapid eye movement: ™! (Figure 5) RecommenoeD a. Low chin EMG (for the majority of the epoch)" b. Byes closed with atleast one rapid eye movement (concurrent with low chin tone) «Irregular respiration 4. Mouthing, sucking, twitches or brief head movements €. EEG exhibits a continuous pattern without sleep spindles*® 2. Score segments of sleep contiguous with and following an epoch of definite R (as defined in F.1) in the absence of rapid eye movements, as stage Rif ALL of the following are present: nEcommenne> a, The EEG shows low or medium amplitude mixed frequency activity without trace alternant or steep spindles, bb The chin muscle tone is Low for the majority of the epoch ¢. There is no intervening arousal (see chapter V. Arousal Rule, same rule as for children and adults) Fen AP Pad pe Nl ert pm nagar, eta] ht a NM UY A pet [Rr Nayln,y cass prnmrtpanhlitin Asap lid Mor rrorrnny Sat patareorsn Tha cr ay a Woe pete yl ne Poet fal, od MeN fa BEN Bs PEEP EEE PEER EEEEEPE PEPE REDE EE PPE EEE EEE EEE EERE PEEL tens VAP AAR AAA es AANA \ MIRA IS Figure 5. A.30 seconc tracing of stage A sleep in an infant. EEG: LUI; EOG: REMs; Chin EMG: low Respiration: regular; Behavior eye movements noted with small movemeris a! mouth. The thermal sensor is an oronasal ow sensor (02017 American Academy a Seed Mens All NGS reserved. Note |. In infants, the first epoch of sleep is most commonly stage R. Given the difficulty in determining sleep onset, an epoch of definite stage R is required to begin scoring this sleep stage, Note 2. Epochs of stage R sleep containing periods without atonia (sustained activity or transient muscle activity in | the chin EMG) are not uncommon in infants. Bursts of muscle activity during stage R often ovcur associated | vvith movements. The intervening chin EMG activity between movements is usually low. | Note 3. Continuous BBG pattern includes low voltage irregulat (LV1), high voltage slow (FIVS), and mixed (M) (Table 3),V. Sleep Staging Rules G. Scoring Stage T 1. Score an epoch as stage N, stage R or stage W if only one PSG characteri state“! pecommendeo is discordant for the sleep 2. Score an epoch as stage T (transitional) if it contains either 3 NREM and 2 REM characteristics or 2 NREM and 3 REM characteristics. (Table 6, Figure 6) recommenoeo Pa ok a ae ea net ENA TR CM i ee Alten een ntl CEM hn ee At AR DU Ae IY AA Tent OEE rr at Ny Vs WN Vy v wn Figure 6. 8.0 second tracing of Transitional (7) sleep in an infant. EEG: LVI: EOG: no REM; Chin EMG. absent (low) Rospiration: irregular; Behavioral: no movements, eye closed. Thies characteristics of stage A (LVI, Chin EMG absent, regular respiration} and two characteristics of NREM (no movment, no REMe) are soon in thie epoch. This aseumes that the epoch was ‘ot immeciataly preceded by an epoch of definite A. The thermal sensor isan gronasal low sensor. Note 1. Transitional (7) or indeterminate sleep is common in infants because of discordant features (contains physiological markers of more than one sleep state) Note 2. The terminology Transitional (T) sleep is favored over indeterminate sleep as the sleep stage most often } ‘occurs in transitions from stage W to stage R sleep, before awakening an at slozp onset : sh AL Reference ‘The following reference applies to content throughout chapter IV. Sleep Staging Rules Part 3: Rules for Infants. 1. Anders T, Emde R, Parmele A. A Manual of Standardized Terminology, Techniques and Criteria for Scoring of States of Sleep and Wakefulness in Newborn Infants. Los Angeles, CA: UCLA Brain Information Service/BRI Publications Office, NINDS Neurological Information Network: (971V. Arousal Rule A, Scoring Arousals 1 Score arousal during sleep stages NI, N2, N3, or Rif there is an abrupt shift of EEG frequency including slpha, theta and/or frequencies greater than 16 Hz (but not spindles) that Insts 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 a least 1 sscond.*1S28%°5°S gecounenoeo Note 1 Arousal scoring should incorporate information from the frontal, central, and occipital derivations Note2. Arousal scoring can be improved by the use of additional information in the recording such as respiratory events and/or additional EEG channels, Scoring of arousals, however. cannot be based on this additional information alone and such information does not modify any of ihe arousal scoring rules. Note 3. Arousals meeting all scoring criteria but occurring during an awake epoch in the recorded time between lights out” and “lights on” should be scored and used for computation of the arousal index. Note 4, The 10 seconds of stable sleep requited prior to scoring an arousal may begin in the preceding epoch, including a preceding epoch that is scored as stage W. Note 5 An arousal may stil be scored if it immediately precedes a transition (o stage W. That is, both the arousal and transition to wake are scoredVI. Cardiac Rules A. Technical Specifications Use a Note 1 Note 2 Note 3, Note 4, ingle modified electrocardiograph Lend Il and torso electrode placement. (see Figuee J) RECOMMENDED Figure 1. Diagram of Lead placement (9 torso curing cardiac recercing | Ilystration may not bbe to scale, 102017 Anwrtean Academy of Seep Medi. lah reversed. Additional leads may be placed if clinically indicated at the discretion of the practitioner. Tnereasing the image size on the display may improve detection of arrhythmias. White classically Lead IT is derived from electrodes 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. Standard ECG electrode applications are superior to BEG electrodes in minimizing artifact. 1 Sleep Meckelne AASM | Mi48 B. Cardiac Rule Scoring Cardiac Events*'** 41. Score sinus tachycardia during sleep for a sustained sinus heart rate of greater than 90 beats per minute for adults. 2. Seore bradycardia duriug sleep for a sustained heart rate of less than 40/minute for ages 6 years through adult." neconmeiden 3. Score asystole for cardiae pauses greater than 3 seconds for ages 6 years through adult. nécommenoeo 4. Score wide complex tachycerdia for a rhythm lasting a minimum of 3 consecutive beats at a rate greater than 100 per minute with QRS duration of greater than or equal to 120 msec. RECOMMENDED 5. Score narrow complex tachycardia for a rhythm lasting a minimum of 3 consecu per minute with QRS duration of less than 120 msec. Recommenn€ e beats ata rate of greater than 100 6. Score atrial fibrillation i P waves by rapid os there are irregularly irregular QRS complexes associated with replacement of consistent lations that vary in size, shape, and timing. necowmenoeo Note 1. Significant arshythmias such as heart block should be reported if the quality of the single lead is sufficient for accurate scoring, Note 2. Ectopic beats should be reported if felt to be clinically significant. Note 3, Sinus rates vary according to age in children, with faster rates in young children as compared to adults. For typical sinus rates in childten, refor to the Cardiac Task Force review paper! Note 4, Sustained sinus bradycardia or tachycardia is defined by more than 30 seconds of a stable rhythm to distinguish it from transient responses, associated sleep disordered breathing events or arousels. Reference 1. Caples $M, Rosen CL. Shen WK, etal. The scoring of cardiac events during sleep. J Clin Sleep Med, 2007;3(2):147-154,Vil. Movement Rules ‘A. Technical Specifications* 1. For monitoring leg movements (LMG), surface electrodes should be placed longitudinally and symmetrically in the middle of the anterior tibialis muscle so that they are 2~3 em apart or 1/3 of the length of the anterior tibialis muscle, whichever is shorter. Both legs should be monitored for the presence ofthe leg movements. Separate channels for ‘each leg are strongly preferred. Combining electrodes from the 2 legs to give { recorded channel may suffice for some clinical settings, although it should be recognized that this strategy may reduce the number of detected LMs. (Gee Figure 1) Recomwenoeo Figure 1. Placement ofelectrodes on the anterior tibialis muscle fer monitoring leg movements. llustration may not be to scale, 122017 american Academy of Sion Modine, sah rsered 2. For monitoring leg movements, use of 60 Hz (notch) filters should be avoided. Impedances need (o be less than 10,000 ©. Less than 5,000 © is preferred but may be difficult to obtain, RecoMenveD 3, Movements of the upper limbs may be sampled using a similar method as for legs if clinically indicated. (see Figures 2 and 3) oPtionaL Figure 2. Placement of, lectredes on the faxor digitorum superticials for detecting Wansiont ‘usele activity in REM sleep. ihustration may = - Fat be to scale 02017 americen cacony ot ieop Mecielne Ak ighinreserne