SLEEP LABORATORY By: Dr.Eng.Walid Tarawneh 1" Oct. 2017Sleep & Stages of Sleep C2 Steep is a normal state of rest that is characterized by unconsciousness, reduced activity, and limited sensory responsiveness. Sleep differs from other states of reduced consciousness. such as drug intoxication or coma, because it is spontaneous, periodic, and readily reversible. 1 Waketulness is characterized by consciousness, sensory responsiveness, and purposeful activity. CO The 100% sleep cycle consist of: Four Non-REM” Stages of Sleep, REM" Stage Wakefulness * REM: Rapid Eye Movement Normal circadian seep rhythm. Sleep urge is greatest a ight th 2 sal inceace at mi doy. Sep need increases throughout the vnabing hows and is epeished dating deen, Deere wa aanSleep Disorders ® Sleep is essential Without suffident sleep, the human body cannot function well, resulting in fatigue, confusion, depression, concentration problems, hallucinations, illness, and injury ® The quality and quantity of sleep are important indicators of overall health san, Se ean ™ Sleep disorders can be dassified into: comme I estas vil © Lack of sleep Sem pea © Disturbed sleep ceo { | © Excessive sleep ee eae os * Definitions ; = , oa © Sleep disorder Interference in sleep continuity and central "asain —— mre nervous system sleep/wake cycle that may be caused by ore respiratory and/or non-respiratory conditions re (© Sleep apneais a condition where a person doesnot get enough oxygen while steeping (usually for 10 seconds or more at one time). Usually this is caused by breathing problems where breaths stop or are not deep enough to maintain oxygen in the blood. [1]. © Sleep disordered breathing (SDB) includes various conditions caused by problems with respiration during sleep. The most common type of SDB, obstructive sleep apnea (OSA) affects many people. Deer, a aan tomer 3Obstructive Sleep Apnea (OSA) There are different types of sleep apnea, with the most common being obstructive sleep apnea (OSA) Obstructive sleep apnea (OSA); Is a disorder in which your breathing repeatedly stops (apnea) or gets very shallow (hypopnea) while sleeping. This can happen up to 30 times each hour during sleep, and can last for 10 to 30 seconds at a time. Person don't usually wake up fully during these interruptions, but they Keep him/her from geting the deep sleep needed. For People who have OSA, the muscles in the upper throat relax and create a blockage in your airway Untreated OSA nol only prevents you from geting enough sleep, but also can increase your risk for serious health problems such as high bloo pressure, heart attack, and stroke. Medical management: includes weight loss, oral appliarices, and various types of é r é r a atvay pressure PAP) therapy i ixed/continuous positive airway pressure q g CPAP) level posive arnay pressure IBIPAP], or auto-adjusting CPAP [APAP]) PAP involves the administration of air, usually through the nose, by an external device at a fixed pressure to maintain the patency of sore is ce enh . tne upper aay, eee aes eee wa aan tommeaySleep Studies ™ Sleep studies are tests performed in a sleep condition, usually overnight, in “HOME” or in a special test hospital rooms called “ SLEEP LAB”. These tests help the clinician to evaluate & diagnose a variely of sleep problems and figure out the best treatment. The most common of these problems is obstructive sleep apnea (OSA). The most common sleep study is called a Polysomnogram (PSG). During a PSG, sensors are attached to your body to measure and record detailed information while you sleep, including the following: Brain waves Heart rate and rhythm Breathing rate and effort Oxygen level Eye movements Muscle activity eoo0oo0ogo Deere, wa aan tombe 5Sleep Study Levels ‘Sieep studies can be performed only in special conditions and in a sleep status. ‘According to [283], the sleep studies are classified to the folowing levels; © Level |; (at hospital sleep lab) * Involve overnight testing in a sleep laboratory * Noeds a healthcare professional in attendance ‘+ Reference for the diagnosis of SDB, as it captures different types of physiological data. * Rolatively expensive test, because of equipment & trained personnel required © Levellll ; (at hospital sleep lab) * similar to a level | sleep study in the equipment & channels (both respiratory and sleep staging) used, but without a heath care professional in attendance © Level; (at home) * Some times callad oligosomnography * Portable device used by the patient et home * without a health care professional in attendance © Level Iv: (at home) * without direct medical supervision * Limited measurements (capturing of oxygen saturation or airiow) Used mainly for screening for OSA, rather than for diagnostic purposes. Deere, wa aan HOME OR SLEEP LAB tomer 8Example of level | & IllDisadvantages of Home Sleep Tests * Difficulties associated with direct medical intervention, such test is done without a health care professional in attendance. * The portable home test devices have certain measurement limitations * Home sleep tests are affected by night-to-night variability * Probability of occurrence of Data problems with unattended sleep tests (leads disconnect during the night) * Overnight home oximetry, is easy and Ok Mas. Ta Wirwert ute rex 77 inexpensive, but it often misses OSA sertfoap asus at youaresEquipment in Sleep Lab-(1) O Sensors & Signals > Note : All sensors must be securely attached and the wires must be bundled so the patient can sleep in any position and turn over as he/she sleep. ™ Scalp sensors to record brain activity ™ Sensors for measuring the eye movement to detect the Rapid Eye Movement [REM]. ® Chest sensors to record heart activity ™ Legs sensors to record movements ™ Breathing Sensors ™ Chest-abdomen sensors with strap to WAS } measure the effort it takes to breathe \ A A finger clip will to record oxygen in blood. Deere, wa aan tommeay 8Equipment in Sleep Lab-(2) Note:in sloop ab most of the monitoring and recording equipmont roquirod for sloop tost are preferably to be located outside the Equipment Patient test room > Polysomnography (PSO) system: A standard Polysomnogram inckides EEG, submenta electromyogram (EMG) and slectro- ‘oculogram (to detect rapid eye movement [REM] during sleep fo seep staging. PSG also typically Incudes ECG and monitoring ot respiratory ariow, effort, snoring, oxygen desaturation, and sleep postion. > When using an integrated polysomnography (PSG) system part ofthis eystem can be located inthe patient test room. > t1non integrated PSG system to be used the recommended equipment ae: Etectroencephalography (EEG), Electrooculography (EOG) , Nasal flow device , ‘Thoraco-abdominal movement device, ECG unit , Snoring device Electromyography (EMG), Pulse oximetry device, Patient Masks. ~ Respiratory effort may be monitored with an esophageal pressure monitor ‘and also may be assessed by intercostal ENG recordings . > others: + Sphyamomanometer anerold wall mounted * Portable video camera with recorder, CCTV monitor & Printer *+ Patient Bed electrical + Sleep Lab Control Panels & Clock omener Deere wa acnePortable medical devices and sleep tests Although the Portable sleep test devices are continually improving, with new capabilities to capture data and reduce artifact. but many of these new devices do not fit well in some levels of the sleep tests [4] because of accuracy and safety requirements. ™ Technical failures, either because of slipped sensors, insufficient recording time, or equipment related error has been observed in many sleep studies with portable devices [3]. The high technical failure rate observed in the home setting is likely because these were unattended studies. ™ On the other hand the expanded use of tele-health networks may provide improved access to sleep studies for individuals in remote communities in future. Deere, wa aanSleep Study Lab Area-(1) Isthis what we are looking for?Sleep Study Lab Area-(2) QO) Main requirements [5]; ™ Should be capable for monitoring over unusually long test times. = Should be located in a quiet zone with low traffic and away from other olinic and hospital activity, where Noise Criteria not to exceed NC 40 ™ Should have an access to the test area after normal clinic hours with space for waiting area and reception. ® Should have Preparation Room, where patients are prepped with the application of electrodes before entering the Sleep Study Room. {if space is limited the sleep test room can be used for patient preparation (6) ™ Should have a Sleep Test Room, organized like a normal bedroom with bathroom and shower with a bed, side table, wardrobe and chair. A private patient toilet is directly accessed from the room. ™ Should have an Control/Observation Room preferably adjacent to the test room with glass window in between. ™ The wiring link between the test room and observation room should be done via a central wall box (well isolated) Deere, wa aan omenSleep Study Lab Area-(3) O1 General design considerations Patient Preparation Room ideally, it should be done in a separate room (if preparation is not in the sleep test room) Should have adequate ventilation Should have storage space for supplies ‘Should have a sink to clean and disinfect electrodes and other materials. Sleep Test Room = Space not less than 11 m? (not including the bathroom), total space approx.19 m2 5] = Aminimum of 0.60 m of available clear space on three (3) sides of the bed = Should be single occupancy, private, comfortable well sound isolated ceiling and walls. = Ambient temperature in the room should be controlled = Provided with a privacy door, that opens inwards and directly to a corridor or common use area, so patient can access the Test Room via the preparation room without passing through control or other sleep test rooms. = The room should be preferably sunlight free to create a time free environment. Should have a mechanism for visual monitoring and video recording of patients during sleep. Deere, wa aan tommeaySleep Study Lab Area-(4) = Control / Observation Room * Space approx. 9 m? * Should be located away from traffic area, to protect the patient privacy during test * Should have two-way communication system with the sleep test room * Should be equipped with the polygraphic equipment for recording and storing physiological parameters * Phone numbers of important contacts should be visibly posted near the workstation * Preferably to be adjacent to the sleep test room with glass window in between = Additional spaces * Physician/consultation room/office Reception and waiting area. Nourishment Room for patient and staff. Clean Linen Storage Room Housekeeping Aides Closet Deere, wa aan tomer 18Safety in sleep lab O) The sleep lab area should meet all safely regulations Q Provisions should be made [7] for; ® Emergency medical intervention and Emergency plans for Cardiac, Neurologic, Psychiatric and Environmental emergencies. ™ Fire safety * Evacuation * Code Blue ® Infection Control * Hazardous waste ® Electrical and mechanical safety ® Noise isolation O. The sleep laboratory should be equipped with emergency equipment like emergency cart with defibrillator (Automated External Defibrillator) tocar a “The use of patient room as preparation area Deere, wa aanRooms Layout (1) UO TEST ROOM [5] Main Room data; Cling Height : 275 mm Wall Finish : GIWB ( noise transmission TEC) TEMP: 210-2496 Minimum % Outside Air: 2 Minimum Air Changes. :4 Relative Humidiy/Cooling- Heating: 60%-20% Room Pressure: Neutral (0) Noise Ctlteris: NO 40, Nurse Call Yos Data : Yes CCTV: Yo: ‘Telephone: Yes Battery Operated Clock: Yes Intercom: Yes Sprinkler: Yes: SPECIAL EQUIPMENT: Polysomnography (PSG) system Bedhead uni with O2, VAC& Medical AIR 4bar Camera, Portable, Digital Video with Recorder BIPAP Sieop Study System ‘Monitor, Physioioge, Respiratory Gas Oximeter, Pulse Bed, Electric, Sloop Study Full Size Deere, wa aan tomer 08Rooms Layout (2) O) CONTROL ROOM [5] Main Room data; Gelling Height : 278 mm Wall Finish - GWB ( noise transmission TBC) TEMP :21°.24°C Minimum % Outside Air: 2 ‘Minimum Air Changes/Hr Relative Humidity/Cooling Healing: 60% 20% Room Pressure: Neutral (0) Noise Criteria: None(it not adjacent to test room) Battery Operated Clock: Yes SPECIAL EQUIPMENT: Polysomnography (PSG) system Camera, Portable, Digital Video with Recorder PC work station tommeay 8Rooms Layout (3) C) compound Sleep lab Configuration Deere, wa aan rocaPND a FR wo DN References . Medical Policy ~ 2.01.53 Polysomnography and Home Sleep Study for Diagnosis of Obstructive Sleep ‘Apnea Feb. 14, 2017. . An assessment of sleep disordered breathing diagnosis using level | versus level Ii sleep studies. Final report, University of Alberta, November 2010 . Level | and Level Ill Sleep Studies for the Diagnosis of Sleep Disordered Breathing (SDB) in Adults, final report University of Alberta, July 2013 . Collop NA, Tracy SL, Kapur V, Mehra R, Kuhlmann D, Fleishman SA, et al. Obstructive sleep apnea devices for out-of-center (OC) testing: technology evaluation. J Clin Sleep Med 2011:7(5):531-48 .. Department of Veterans Alfairs; PULMONARY MEDICINE SERVICE, design guideline, NOVEMBER 29, 2011 ). Helen Kalinowski,APSGT, How to start a sleep disorder center - Clinical Practice Parameters and Standards — Sleep Medicine 4th Edition, October 2016 . Evidence-Based Design Meets Evidence-Based Medicine: The Sound Sleep Study, Va Idating aco us tic ‘quidelines for healthcare facilties Deere, wa aan tommemr 2