PULMONARY FUNCTION TEST AND POLYSOMNOGRAPHY

In Partial Fulfillment of the Requirements in

RT 125 - RESPIRATORY CARE SEMINAR 2

Submitted to:
John Francis B. Ycong, RTRP, MD
Clinical Instructor

Submitted by:
Bangayan, Althea Mariel A.
Damasin, Guenevere L.
Galon, Audra Leigh B.
Kusain, Sittie Zirril
Pal, Angel Gianne I.
Sindatok, Sittie Farinah I.
Zerrudo, Krizelle Pearl P.

Date Submitted:
January 27, 2024
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TABLE OF CONTENTS

COVER PAGE..........................................................................................................................................
TABLE OF CONTENTS............................................................................................................................
INTRODUCTION......................................................................................................................................
OBJECTIVES............................................................................................................................................
TOPIC 1: PULMONARY FUNCTION TESTING.......................................................................................
TOPIC 2: POLYSOMNOGRAPHY...........................................................................................................
REFERENCES........................................................................................................................................
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INTRODUCTION

The lungs primarily exchange gases by adding oxygen and removing carbon
dioxide from the blood during circulation. The Pulmonary Function Test (PFT) assesses
lung performance, measuring volume, capacity, flow rates, and gas exchange through
noninvasive breathing tests. PFT helps diagnose conditions like Asthma and COPD,
guiding therapy decisions. Respiratory therapists play a key role in objectively
assessing patients using PFT results. On the other hand, sleep profoundly affects
overall health, influencing physical and mental well-being, immunity, metabolism, and
disease risk. Polysomnography, a comprehensive sleep test, diagnoses disorders such
as sleep apnea and narcolepsy. Sleep disturbances impact people of all ages, with
respiratory therapists understanding sleep study parameters like airflow and oxygen
saturation, crucial for interpreting results and optimizing patient care.

Chronic obstructive pulmonary disease (COPD) stands as the third leading global
cause of death, claiming 3.23 million lives in 2019, with nearly 90% of deaths among
individuals under 70 occurring in low- and middle-income countries. Additionally, COPD
ranks as the seventh leading contributor to poor health worldwide, primarily attributed to
factors such as tobacco smoking and household air pollution (World Health
Organization, 2023). Simultaneously, approximately one billion adults worldwide,
constituting around one-seventh of the global adult population, are estimated to suffer
from Obstructive Sleep Apnea (OSA). The prevalence of OSA is closely tied to the
escalating global rise in obesity, the predominant risk factor for this condition, over the
past four decades (Lyons et al., 2020). In the Philippines, lung disease, particularly
Chronic Obstructive Pulmonary Disease (COPD), affects 5 to 6 percent of individuals
aged 30 and above, with many cases undiagnosed due to low awareness (Tacio, 2022).
Smoking, the leading cause of COPD, is prevalent, impacting approximately 16 out of
every 1,000 Filipino males. Simultaneously, over 10 million adults in the Philippines
experience insomnia, contributing to one of the highest rates of sleep deprivation
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globally, as per 2014 statistics from Health Grades Incorporated (St. Luke’s Medical
Center, 2019).
The seminar "Breath of the Night: A Pajama Party Seminar on Elevating
Respiratory Health through Pulmonary Function Test and Polysomnography" addresses
the increasing cases of diseases requiring these tests. It aims to highlight the latest care
innovations, demonstrate effective respiratory care skills, and explain different
modalities and protocols in Pulmonary Function Tests and Polysomnography.
Attendees, including future healthcare professionals, can gain valuable knowledge for
their careers. The seminar may also contribute to improving the implementation of these
tests in the future. Additionally, it provides respiratory therapists with a better
understanding of how diseases affect the respiratory system and how these tests
contribute to diagnosis and treatment. Researchers can use the seminar as a reference
for further studies on Pulmonary Function Tests and Polysomnography.
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OBJECTIVES

General Objectives:

During the Pulmonary Function Test and Polysomnography seminar, participants

will comprehensively understand these tests and learn how to apply this knowledge to
real-life patients. This will enable them to maintain optimal health and well-being.
Furthermore, participants will be able to share the knowledge they have gained with
others for their benefit.

Specific Objectives:

To meet the general objective stated above, we specifically aim:

a. Define Pulmonary Function Test (PFT) and Polysomnography (PSG);

b. know the types or classifications;
c. know the history of development;
d. know the types of equipment that are used in testing;
e. discuss the use and effectiveness through articles/journal and book
references; and
f. introduce current trends and innovations in respiratory modalities.
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TOPIC 1: PULMONARY FUNCTION TESTING

A complete evaluation of the respiratory system includes a patient history,

physical examination, radiographic imaging, arterial blood gas analysis, and tests of
pulmonary function. There are three categories of pulmonary function tests, measuring
(1) dynamic flow rates of gases through the airways, (2) lung volumes and capacities,
and (3) the ability of the lungs to diffuse gases. A combination of these measurements
provides a quantitative picture of lung function. Although pulmonary function tests do
not diagnose specific pulmonary diseases, these tests identify the presence and type of
pulmonary impairments and the degree of pulmonary disease present.

Generally, the primary purposes of pulmonary function testing are to identify

pulmonary impairment and quantify the severity of pulmonary impairment if present.
Pulmonary function testing has diagnostic and therapeutic roles and helps clinicians
answer some general questions about patients with lung disease.

I. Indications

To identify and quantify changes in pulmonary function. The most common

purposes of pulmonary function testing are to detect the presence or absence of
pulmonary disease, to classify the type of disease as either obstructive, restrictive, or
both (mixed), and to quantify the severity of pulmonary impairment as mild, moderate,
severe, or very severe. Over time, pulmonary function tests help quantify the
progression or the reversibility of the disease.

· To evaluate the need and quantify therapeutic effectiveness. Pulmonary function

tests may aid clinicians in selecting or modifying a specific therapeutic regimen or
technique (e.g., bronchodilator medication, airway clearance therapy, rehabilitation
exercise protocol). Clinicians and researchers use pulmonary function tests to measure
changes in lung function objectively before and after treatment.
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To perform epidemiologic surveillance for pulmonary disease. Screening

programs may detect pulmonary abnormalities caused by disease or environmental
factors in general populations, in people in occupational settings, in smokers, or in other
high-risk groups. In addition, researchers have determined what normal pulmonary
function is by measuring the pulmonary function of healthy people.

To assess patients for risk for postoperative pulmonary complications.

Preoperative testing can identify patients who may have an increased risk for pulmonary
complications after surgery. Sometimes the risk for complications can be reduced by
preoperative respiratory care, or in some cases, the risk may be significant enough to
rule out surgery.

To determine pulmonary disability. Pulmonary function tests can also determine

the degree of disability caused by lung diseases, such as occupational asthma or coal
workers’ pneumoconiosis. Some federal entitlement programs and insurance policies
rely on pulmonary function tests to confirm claims for financial compensation.

II. Contraindications

There are also contraindications to pulmonary function testing. Patients with

acute, unstable cardiopulmonary problems, such as hemoptysis, pneumothorax,
myocardial infarction, pulmonary embolism, and patients with acute chest or abdominal
pain should not be tested. Patients who have nausea and who have recently vomited
should not be tested because there is a risk of aspiration. Testing for patients who have
had recent cataract removal surgery should be delayed because changes in ocular
pressure may be harmful to the eye. Pulmonary function testing requires patient effort
and cooperation. Patients with dementia or confusion may not achieve optimal or
repeatable results. Pulmonary function testing should not be performed if valid and
reliable results cannot be predicted. In patients who are acutely ill or who have recently
smoked a cigarette, the test validity of measuring the forced vital capacity (FVC) may be
hindered.
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Pathophysiological Patterns

Pulmonary function testing provides the basis for classifying pulmonary diseases
into two major categories, obstructive pulmonary disease, and restrictive pulmonary
disease. These two types of lung diseases sometimes occur together as a mixed
impairment.

I. Obstructive Pulmonary Disease

The primary problem in obstructive pulmonary disease is an increased airway

resistance (Raw). Raw is the difference in pressure between the ends of the airways
divided by the flow rate of gas moving through the airway, according to the following
formula:

There is an inverse relationship between Raw and flow rate V . If the pressure
difference is constant, a reduced flow rate indicates an increase in Raw. Because the
radius of the airways normally lessens slightly during expiration, flow rates are usually
measured during expiration. According to Poiseuille’s law (see Chapter 6), Raw is
inversely related to the radius (r) of the airways:

II. Restrictive Pulmonary Disease

The primary problem in restrictive lung disease is reduced lung compliance,

thoracic compliance, or both. Compliance is the volume of gas inspired per the amount
of inspiratory effort; effort is measured as the amount of pressure created in the lung or
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in the pleural space when the inspiratory muscles contract. Compliance is calculated
according to the following formula:

There is a direct relationship between compliance (C) and volume (V). If the
pressure difference is constant, a reduced inspiratory volume indicates a reduction in
compliance. Reduced lung compliance is usually the result of alveolar inflammation
(pneumonia), swelling (pulmonary edema), or scarring (pulmonary fibrosis); a reduced
thoracic compliance may be the result of thoracic wall abnormalities, such as
kyphoscoliosis, or exogenous pressure exerted on the thoracic cavity, such as ascites
or pregnancy. Neuromuscular diseases also can result in reduced lung volumes and
restrictive-type pulmonary impairments, mainly by affecting the function of the
inspiratory muscles. In these circumstances, lung compliance and thoracic compliance
may be normal, but the patient is unable to generate enough sub-atmospheric pressure
to take a full, deep breath.

Infection Control

Pulmonary function testing carries a low risk of transmitting infectious

microorganisms to patients and technicians. Direct and indirect contact can facilitate
transmission, and standard precautions should be followed due to potential exposure to
saliva, mucus, or blood containing hazardous microorganisms. Patients with oral lesions
or active respiratory infections pose the highest risk, particularly those with
compromised immune systems. It is recommended for practitioners to wear gloves
when handling contaminated equipment and to use personal respirators or surgical
masks when testing patients with airborne diseases, especially if coughing is induced.
Hand hygiene should be practiced between patients and after contact with equipment.
While routine cleaning of testing instruments' interior surfaces is unnecessary, the
mouthpiece, nose clips, tubing, and any parts in direct contact with patients should be
disposed of, sterilized, or disinfected between patients. Equipment surfaces with visible
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condensation from exhaled air should also be treated before reuse. Manufacturer
recommendations should be followed when cleaning and disinfecting instruments, and
recalibration may be necessary. The use of low-resistance, in-line barrier filters is
debated but may be appropriate when cleaning certain inaccessible parts. Filters
provide visible assurance to patients.

Principles of Measurement and Significance

For tests of pulmonary function, these general principles should be considered: test
sensitivity and specificity, validity, and reliability.
● Sensitivity and specificity assess a test's ability to detect disease or its absence,
with some tests being highly sensitive but not specific, leading to abnormal
results in apparently healthy individuals, especially in pulmonary function tests.
● Validity in pulmonary function testing relies on adherence to procedures, patient
effort, and equipment accuracy, ensuring the test measures what it's intended to
measure.
● Reliability is about consistency, requiring multiple performances to minimize
variability; maintaining validity and reliability is crucial for accurate diagnoses and
avoiding misdiagnosis and poor outcomes.

THREE BASIC TESTS: Spirometry, Lung Volumes, and Diffusing Capacities

★ Spirometry

Spirometry is a method of measuring air entering and leaving the lungs,

assessing forced airflow and volume during inspiration and expiration. The primary goal
is to evaluate the lungs' ability to move large air volumes quickly to detect airway
obstruction. Various measurements target different airway sizes and identify obstruction
in different lung regions. Spirometry measures flow rates as a surrogate for airway
resistance and can also identify restrictive patterns of pulmonary disease.

Spirometry is an effort-dependent test that requires careful patient instruction,

understanding, coordination, and cooperation.

a. Forced Vital Capacity (FVC)

● FVC is the most common test for pulmonary mechanics, often performed
under baseline conditions.
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● Patients should abstain from short-acting bronchodilators for 4 hours and

long-acting bronchodilators for 12 hours before baseline spirometry.
● After baseline testing, FVC may be performed again to assess the
effectiveness of bronchodilator treatment.
● FVC is repeated during bronchial provocation testing.
● FVC measurements can be obtained using various types of spirometers,
including mechanical or electronic ones.
● Forced expiratory VC is sometimes followed by a forced inspiratory VC to
create a flow-volume loop.
● For validity, each patient must perform a minimum of three acceptable
FVC maneuvers.
● For reliability, the largest FVC and second largest FVC from the
acceptable trials should not vary by more than 0.15 L.
● The largest and second-largest FVC from acceptable trials should not vary
by more than 0.15 L for reliability.
● To start an FVC trial, the patient should inhale rapidly and completely to
TLC from the resting FRC level.
● A satisfactory start of expiration is defined by an extrapolated volume at
the zero time point less than 5% of FVC or 0.15 L.
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● An acceptable FVC trial is smooth, continuous, and complete,

disqualifying factors include cough, inspiration, Valsalva maneuver, leak,
or obstructed mouthpiece.
● Complete exhalation or a minimum exhalation time of 6 seconds is
required for adults and children older than 10 years.
● For children younger than 10 years, a 3-second exhalation is acceptable.
● An end-expiratory plateau must be evident in the volume-time curve, with
less than 0.025 L exhaled during the final second of exhalation.
● The largest acceptable FVC (BTPS) from three valid trials is considered
the patient's FVC.

b. Forced Expiratory Volume in 1 second (FEV1)

● During FVC testing, additional measurements include FEV1, which
represents the volume exhaled in the first second of FVC.
● Validity of FEV1 requires it to originate from a set of three acceptable FVC
trials.
● The first second of forced exhalation begins at the zero time point.
● Reliability of FEV1 demands that the largest and second-largest FEV1
from acceptable trials should not vary by more than 0.15 L.
● The largest FEV1 (BTPS) measured is considered the patient's FEV1.
● The largest FEV1 may come from a different trial than the largest FVC.
● The FEV1/FVC ratio is calculated by dividing the patient's largest FEV1 by
the patient's largest VC and converting it to a percentage (by multiplying
by 100).
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● The FEV1 and VC values used for the ratio do not have to come from the
same trial; the VC should be the largest one measured, even if measured
as a slow VC or during inspiration.

c. Forced Expiratory Flow Between 200 ml and 1200 ml of Forced Vital

Capacity and Forced Expiratory Flow Between 25% and 75% of Forced Vital
Capacity
● FEF200-1200 and FEF25%-75% are measurements of average flow rates
during specific intervals of FVC.
● Both measurements are obtained on a volume-time spirogram as the
slope of a line connecting points in their subscripts.
● For FEF200-1200, the 200-ml and 1200-ml points are identified on the
spirogram.
● A straight line is drawn connecting these points and extended to intersect
two vertical time lines 1 second apart on the graph.

● The volume of air measured between these timelines represents FEF200-

1200 in liters per second, and the volume must be corrected to BTPS.
● FEF25%-75% measures flow during the middle portion of FVC, covering
the time needed to exhale the middle 50%.
● For FEF25%-75%, the VC of the best curve is multiplied by 25% and 75%,
and the corresponding points are identified on the tracing.
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● A straight line is drawn connecting these points, and the line is extended
to intersect two vertical time lines 1 second apart on the graph.
● The volume of air measured between these time lines represents
FEF25%-75% in liters per second, and the volume must be corrected to
BTPS.

d. Peak Expiratory Flow (PEF)

● PEF is challenging to identify on a volume-time graph of FVC.
● Peak flow is determined as the slope of the tangent to the steepest portion
of the FVC curve.
● PEF is easily identified on a flow-volume graph as the highest point.
● PEF is sometimes measured independently of FVC using a peak flow
meter.
● Peak flow meters indicate only the greatest expiratory flow rate.
● Validity of PEF rate requires preceding inspiration to TLC and maximal
effort.
● Principles ensuring reliability in FVC measurements should apply to PEF
rate measurements.
● The two largest repeated PEF rate measurements should agree within
5%.
● Instantaneous flow rates such as FEF25%, FEF50%, and FEF75% of FVC
during FVC are graphed on a flow-volume curve.
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● Following FVC with a forced inspiratory VC produces a flow-volume loop.

● On the flow-volume loop, maximal forced inspiratory flow rate at 50%
(FIF50%) of VC can be measured and compared with FEF50%.

e. Maximal Voluntary Ventilation (MVV)

● Maximal Voluntary Ventilation (MVV) is an effort-dependent test in which
the patient is instructed to breathe deeply and rapidly for at least 12
seconds.
● MVV reflects patient cooperation, effort, diaphragmatic and thoracic
muscle ability, and airway patency.
● The patient is seated during the test to minimize the risk of
hyperventilation-induced fainting or coughing.
● Systems incorporating rebreathing may reduce the effects of
hyperventilation.
● After a demonstration of the expected breathing pattern, the patient is
instructed to breathe as rapidly and deeply as possible for at least 12
seconds.
● MVV is measured on a spirogram or electronically for the specific duration
(t) and volume (V), converted to liters per minute.
● Recorded values should be in BTPS conditions.
● Validity of MVV depends on a maneuver duration of at least 12 seconds, a
breathing frequency of at least 90 breaths/min, and an average volume of
at least 50% of FVC.
● Measured MVV should be compared to the subject’s FEV1 × 40 and
predicted value for MVV.
● If measured MVV is less than 80% of either of those values, a repeat test
is recommended for accuracy.
● Reliability is achieved when there is less than 20% variability between the
two largest trials.
● The largest MVV (BTPS) should be reported.

f. Other Values Obtained during Spirometry

● Tidal Volume, Expiratory Reserve Volume, and Inspiratory Capacity
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★ Lung Volumes and Capacities

There are four lung volumes and four lung capacities, where each capacity is
made up of two or more volumes. The volumes include tidal volume (VT), inspiratory
reserve volume (IRV), expiratory reserve volume (ERV), and residual volume (RV). The
capacities are TLC, IC, FRC, and VC.

Lung volumes like VT, IC, IRV, ERV, and VC can be directly measured using a
spirometer or pneumotachometer. However, since residual volume (RV) cannot be
exhaled, indirect methods like helium dilution, nitrogen washout, and body
plethysmography are used to measure RV, FRC, and TLC. Helium dilution and nitrogen
washout measure the gas in the lungs at the test's start, assuming it's in unobstructed
airways. The body plethysmographic technique measures all the gas in the thorax at the
resting expiratory volume.
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★ Diffusing Capacity

The third main aspect of testing lung function focuses on how well the lungs
transfer gases across the alveolar-capillary membrane. Carbon monoxide (CO) is
commonly used to measure DL. The diffusing capacity of the lung for carbon monoxide
(DLCO) is measured in ml/min/mm Hg under standard conditions. CO is chosen
because it shares important characteristics with O2, such as similar molecular weights
and solubility coefficients. Like O2, CO binds chemically with hemoglobin (Hb) and
quickly diffuses into the pulmonary blood, maintaining a low pulmonary capillary partial
pressure of CO (P2 in the formula above).

Single-Breath Technique
There are different techniques to measure the lung's diffusing
capacity for CO, including steady-state, intrabreath, and rebreathing
methods. However, the single-breath method (DLCOSB) is the most
common due to its speed and reliability. In this method, the patient
exhales fully, inhales a specific volume of air containing a small
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concentration of CO and He, holds their breath for 10 seconds, and then
exhales rapidly, releasing at least 1 liter of air.

Interpretation of Pulmonary Function Report

Interpreting a pulmonary function report requires an understanding of the various

parameters measured during pulmonary function tests (PFTs) and their implications for
lung function. A general guide to interpreting a pulmonary function report:

1. Spirometry Results:
● Forced Vital Capacity (FVC): This represents the total air forcefully
exhaled after a maximal inhalation. A reduced FVC may suggest
restrictive lung disease.
● Forced Expiratory Volume in 1 second (FEV1): This measures the
air volume forcefully exhaled in the first second. The FEV1/FVC
ratio is crucial. A reduced ratio may indicate obstructive lung
disease.
2. Flow-Volume Loop:
● The shape of the flow-volume loop can provide additional
information. For example, a flattened loop may suggest airflow
obstruction, while a reduced loop may indicate restrictive lung
disease
3. Lung Volumes:
● Total Lung Capacity (TLC): The total volume of air in the lungs at
maximal inflation. Increased TLC may suggest hyperinflation
(common in obstructive lung diseases), while decreased TLC may
indicate restrictive lung disease.
● Residual Volume (RV): The volume of air remaining in the lungs
after maximal exhalation. Elevated RV may indicate air trapping, as
seen in conditions like COPD.
4. Diffusing Capacity (DLCO/DLCOc):
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● This measures the ability of the lungs to transfer gases (commonly

carbon monoxide) from the inhaled air into the bloodstream.
Reduced DLCO may indicate problems with gas exchange, often
seen in conditions such as interstitial lung disease.
5. Interpretation Considerations:
● Obstructive Lung Disease: Characterized by a decreased
FEV1/FVC ratio, indicating difficulty in expelling air quickly (e.g.,
asthma, chronic bronchitis, or emphysema).
● Restrictive Lung Disease: Characterized by reduced lung volumes
(e.g., pulmonary fibrosis), limiting the ability of the lungs to expand
fully during inhalation.
● Mixed Patterns: Some conditions may show characteristics of both
obstructive and restrictive patterns.
6. Comparisons and Trends:
● Compare the patient's results to predicted or normal values based
on age, sex, and height. Monitoring changes over time is crucial for
assessing disease progression or response to treatment.
7. Clinical Correlation:
● Consider the patient's medical history, symptoms, physical
examination findings, and other diagnostic tests to form a
comprehensive clinical interpretation.
8. Follow-up Recommendations:
● The report may provide recommendations for further testing,
consultations, or interventions based on the findings.

History Development

The development of pulmonary function testing has been a gradual process,

marked by key advancements and contributions in the understanding of respiratory
physiology. Here is a more detailed overview of the history and development of
pulmonary function tests (PFTs):
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● Early 19th Century: Spirometry Beginnings In the 1840s, John Hutchinson

introduced the concept of spirometry, which involved having individuals breathe
into a bell inverted over water to measure lung volumes.
● Late 19th Century: Vital Capacity Defined Sir Francis Galton made contributions
to the understanding of lung function and introduced the concept of vital capacity.
● Early 20th Century: Gas Spirometer In the early 1900s, John Scott Haldane
developed the gas spirometer, a device that measured the amount of oxygen and
carbon dioxide exchanged during respiration.
● 1920s: Krogh and Maximal Breathing Capacity In 1928, Albert Krogh introduced
the concept of maximal breathing capacity, which measures the maximum
volume of air breathed in and out during a specified period.
● 1950s: Tissot Spirometer Maurice Tissot developed the Tissot spirometer, an
improved device for measuring lung volumes with greater precision.
● 1961: ATS Standardization of Spirometry The American Thoracic Society (ATS)
published standards for spirometry in 1961, providing guidelines for equipment,
procedures, and interpretation.
● 1970s: Computerization of PFTs The integration of computers into pulmonary
function testing began in the 1970s, allowing for more automated and
standardized measurements.
● 1980s: Body Plethysmograph Introduction The body plethysmograph, a chamber
that measures lung volumes based on pressure changes, was introduced and
became a standard tool in pulmonary function testing.
● 1994: Global Lung Function Initiative (GLI) The GLI was established to develop
reference values for lung function across diverse populations and ethnic groups.
● 2005: ATS/ERS Guidelines for Lung Function Testing In 2005, the ATS and the
European Respiratory Society (ERS) jointly published updated guidelines for
standardizing lung function testing.
● Recent Years: Technological Advances Ongoing advancements in technology
have led to the development of digital spirometers, portable devices, and more
sophisticated testing methods.
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Articles/ Journal and Book References Discussing its Use and Effectiveness

Pulmonary function tests (PFT) is an important diagnostic tool for epidemiology

and clinical evaluation of respiratory diseases. It is also an important method for
preoperative evaluation of pulmonary function. It is of great value in early diagnosis,
severity classification, disease progression and evaluation of curative effect of
respiratory diseases. PFTs are a significant tool for diagnosing and monitoring
pulmonary involvement in pSS patients. Typically, PFTs will detect a restrictive pattern
of ventilatory failure, characterized by reduced TLC and FVC, with a normal FEV1/FVC
ratio [2,27] and an often reduced DLCO. (Fei et al., 2019)
The diagnostic accuracy of PFTs, including spirometry, lung volumes, and
diffusing capacity tests, are widely recognized for their diagnostic accuracy in identifying
various respiratory disorders such as asthma, chronic obstructive pulmonary disease
(COPD), interstitial lung disease, and others.( Ponce and Sankari , 2023). Monitoring
disease progression of PFTs are effective tools for monitoring the progression of
chronic respiratory diseases and evaluating the impact of treatment interventions. Serial
PFT measurements can provide valuable information about changes in lung function
over time. (Sarkar et al., 2023)
Assessment of Treatment Response. Studies have demonstrated the utility of
PFTs in assessing the response to pharmacological and non-pharmacological
interventions. Changes in lung function parameters can reflect the effectiveness of
therapeutic measures. The prognostic value of PFT results often have prognostic
implications. For example, in COPD, the severity of airflow limitation as measured by
spirometry is associated with long-term outcomes and mortality. Occupational and
Environmental. Pulmonary rehabilitation (PR) has proven to be effective in respiratory
patients following mechanical ventilation (Chou et al., 2019) and in patients with the
most common pulmonary disease, chronic obstructive pulmonary disease, at all stages
and recovering from acute exacerbations (Puhan et al., 2005)
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Protocols, clinical/critical guidelines in the practice

● Prior to starting the test, the patient is interviewed by the Respiratory therapist
and is given instructions and guidelines for abstinence in preparation for the
actual testing. These guidelines are the following:
o No coffee, iced/hot tea, chocolates, anything with caffeine, and alcohol
6 hours before the test
o No bronchodilators or any pulmonary drug 6 hours before the test
o No steroids 12 hours before the test.
o No heavy meals 2 hours before the test
o No vigorous workout or strenuous physical activity 30 mins. before
testing. If a patient admits to this (e.g. climbing the stairs for 3 floors),
have them rest for at least 30 mins.
o For smokers, no smoking should be done 24 hours before the test.
o The patient should also wear comfortable, non-fitting clothes. Any
restrictive clothing worn at the time of the test should be removed.
● It is vital to stress the importance of following these reminders as non-compliance
could alter the PFT results. Once the patient arrives for their scheduled PFT, an
interview with the patient is done to take note of important patient information and
assessment as well as to make sure the patient has followed the reminders and
is fit to continue with testing. One very important assessment is noting the height
and weight of the patient as lung function depends on these two measurements.
In the instance that the patient has a spine injury, the RT may measure the arm
span of the patient in the place of their height. The demographic data of the
patient is encoded to the PFT machine.
● An active demonstration of the breathing maneuver by the RT is recommended.
This is because these tests are effort-dependent and patients can be encouraged
and influenced to follow correct execution when the RT is firm, enthusiastic, and
encouraging. Nose clips are not generally necessary when an open-circuit
spirometer is used. Nose clips are helpful when a slow vital capacity is to be
performed and are required when a close circuit spirometer is used.
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Steps on different Pulmonary Function Tests

a. SVC (Slow vital capacity)
● For this maneuver, have the patient put on the mouthpiece, seal their lips,
and then instruct them to perform 3 normal tidal breaths. Have the patient
inhale maximally until lungs are filled with air. Then, instruct the patient to
slowly exhale for 6 seconds. Then have them remove the mouthpiece.
Have the patient rest for a few seconds while also assessing then for any
signs of lightheadedness or untoward reactions.
b. FVC (Forced vital capacity)
● The patient is instructed to put on the mouthpiece and to seal their lips
around the mouthpiece while making sure that there are no leaks. Then,
the patient performs 3 normal tidal breaths. After that, the patient is
instructed to breathe deep and fast (maximal inspiration to TLC level for 1-
2 seconds). Then instruct the patient to blow fast and hard (maximal
expiration to RV) for 6 seconds (Some subjects with obstructive disorders
may require expirations of 15 or more seconds. It is recommended that
expirations greater than 25 seconds not be encouraged). Then instruct the
patient to breathe deep again then have them remove the mouthpiece. It
is important to assess the patient for lightheadedness or any untoward
reactions to the test.

Criteria for FVC Test Acceptability

● A test for FVC can be considered acceptable if there is:

○ Relating to the start of the expiratory effort-
■ No excessive subject hesitation or false start by the subject,
■ Not a back-extrapolated volume exceeding 5% of the FVC
volume or 0.15 liter, whichever is greater.
○ Relating to the presence of artifacts during the maneuver:
■ No cough during the first second of the maneuver (affecting
FEV1) or that, in the technologist’s opinion, interferes with the
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accuracy of the test results.

■ No Valsalva maneuver performed before or during the forced
expiration.
■ No variable effort demonstrated by the subject during the
maneuver.
■ No volume loss because of a leak in the system.
■ No obstruction of the spirometer mouthpiece. This can be caused
by the
■ No premature termination of the forced expiration. This can be
caused by the subject's tongue or by falling of the subject's
dentures.
○ Relating to the end of the expiratory effort:
■ No expiratory test maneuver performed for less than six seconds
unless a volume plateau is present on the volume/time curve
display
Source: Madama, V. (1998). Pulmonary Function Testing and Cardiopulmonary Stress Testing. (2nd Edition). Delmar Publishing
Team.

Criteria for FVC Test Reproducibility

After the first three acceptable tests have been recorded, tests are reproducible and
testing may be ended if both of the following are true:
● The two largest FVC values are within 0.2 liter of each other.
● The two largest FEV1 values are within 0.2 liter of each other.
If both of these criteria are not met, testing must continue until:
● Both criteria are met with the performance of additional acceptable test
maneuvers.
● A total of eight tests has been performed.
● The patient cannot or should not continue.
At minimum, the best three maneuvers should be saved.
Source: Madama, V. (1998). Pulmonary Function Testing and Cardiopulmonary Stress Testing. (2nd Edition). Delmar Publishing
Team.
 28

c. MVV (Maximum voluntary ventilation)

● Have the patient put on the mouthpiece and properly seal their lips.
Instruct them to perform 3 normal tidal breaths. Then, instruct the patient
to breathe as deep and fast as possible (panting maneuver) for at least
12 seconds. It can be noted that coaching with a cadence of ”in-out-in-out”
may help the patient maintain a regular, steady rhythm.Then, have them
remove the mouthpiece.

A test for MVV may be considered acceptable if:

● A volume/time tracing demonstrates the breathing pattern to be regular in
volume or breathing rate.
● The end-expiratory baseline on a volume/time tracing remains fairly constant.
○ The only exception to this is if the subject‘s baseline changes because
of air trapping. Air trapping is demonstrated by a baseline that shifts
gradually from the FRC level upward toward the TLC level during the
time of the maneuver.
● A value for MVV is measured for the subject that is at least as large as the
volume determined by multiplying the measured value for FEV1 by 35
○ FEV1 x 35
Source: Madama, V. (1998). Pulmonary Function Testing and Cardiopulmonary Stress Testing. (2nd Edition). Delmar Publishing
Team.

Criteria for MVV Test Reproducibility for Selecting MVV test data for Reporting

● Reproducibility is achieved when the largest and second largest values

measured for MVV are within 10% of each other.
● The best test for MVV is the one that demonstrates the largest MVV value.
Source: Madama, V. (1998). Pulmonary Function Testing and Cardiopulmonary Stress Testing. (2nd Edition). Delmar Publishing
Team.

● What are the risks?

 29

○ The subject may feel a little lightheaded, faint, tired, have chest
pain/tightness, or cough for a short period after the test or even during the
test. Furthermore, infection can happen but is easily avoided by changing
mouthpieces and other equipment between patients and by using filters.

Current trends, innovations in the respiratory modalities

● Standard for Pulmonary Function Tests gets an update
○ In 2021, important changes were recommended regarding the interpretive
strategies for routine lung function tests by the European Respiratory
Society and the American Thoracic Society (ATS) for the first time since
2005.
1. The new guidelines' definition of bronchodilator responsiveness
(BDR) was discussed. Previously, responsiveness was defined as
a forced vital capacity (FVC) of 12% or more and an increase of at
least 200 mL from baseline determined by FVC or forced expiratory
volume in the first second (FEV1). Now, BDR positive represents
an improvement in lung function of 10% or more of the expected
value of FVC or FEV1. The 10% cutoff was set because it
corresponds to the 95th percentile for response. It was also stated
that evidence supports using predicted value rather than baseline
score as a guidepost because it reduces bias caused by age,
height, and gender.
2. The guideline recommends that clinicians use Z ratings to define
the degree of lung blockage, which quantifies the difference
between expected and actual pulmonary function. Meredith
McCormack, MD, MHS, associate professor of pulmonary and
critical care medicine at Johns Hopkins University, explained that Z
scores are presented in standard deviations after accounting for
age, height, gender, and, in some situations, race and ethnicity. In
the previous guideline, the degree of airflow obstruction was
expressed as a percentage when comparing test results to
 30

predicted FEV1.
3. Another recommendation was adding FeNO testing to usual care. It
was expressed that Nitric oxide promotes healthy blood flow and
smooth muscle relaxation, but too much of it may lead to
hyperresponsiveness and worsen asthma. Because the excess is
evident in the breath of affected patients, FeNO testing may be
helpful in asthma management. This approach was supported by
an ATS guideline issued in 2011 and another in 2021, which
demonstrated that adding FeNO testing in treatment planning
lowers asthma exacerbation and oral steroid use. Furthermore, it
was suggested that FeNO testing be added to usual testing on
patients with asthma whose treatment is being considered.
 31

TOPIC 2: POLYSOMNOGRAPHY

Definition
● A sleep study is used to objectively assess changes in physiological parameters
that occur during sleep. These changes affect almost all body systems, including
the brain, heart, respiratory, gastrointestinal, genitourinary, endocrine, and
musculoskeletal tone between the two states of consciousness, wakefulness and
sleep. Various techniques are used to assess these changes in physiological
parameters that occur during sleep, such as electroencephalogram,
electrooculogram, electromyogram, electrocardiogram, respiration, and oxygen
saturation.
● Polysomnography, a sleep study, can be conducted at a sleep disorder unit
within a hospital or a sleep center. The study records brain waves, oxygen level
in the blood, heart rate and breathing, and eye and leg movements.
● The objective evidence of different pathologies occurring during sleep is provided
by polysomnography.

Why is polysomnography required?

○ It can help us in measuring the severity of some sleep disorders.
○ Treatment of sleep disorders
○ Used to ensure the effect of treatment in certain conditions
○ Useful research tool to understand the physiological changes occurring in
various organs of the body.

STAGES OF SLEEP
Sleep may be divided into two major stages:
● rapid eye movement sleep (REM)
● non-rapid eye movement sleep (NREM)

Non-rapid eye movement sleep (NREM)

 32

● N1 sleep- characterized by theta waves in EEG; slow eye movement, and

diminution of muscle tone

● N2 sleep - theta waves, sleep spindles, and K complexes in EEG; absent eye
movements and low muscle tone

● N3 sleep - more than 20% of epoch has delta waves

Rapid Eye Movement (REM)

● Characterized by low-voltage, mixed-frequency activity in EEG, rapid eye
movement, and muscle atonia
 33

HISTORY
● 1924: German Psychiatrist, Hans Berger, discovered the electroencephalogram
(EEG)
● First person to record and demonstrate the cortical electrical activity via
electrodes applied to the human scalp could depict alpha activity during
wakefulness and slowing of waves during sleep
● 1935 - 1938: researchers from Harvard Medical School and University of
Chicago (USA) described the features of NREM sleep
● 1953: Two researchers, Eugene Aserinsky and Nathanial Kleitman, developed
the electrooculogram and published their findings regarding REM sleep.
● 1959: Atonia during REM sleep was described by Michael Jouvet in cats
● It was proposed that an electromyogram should be recorded during sleep
study
● 1959: Pickwickian syndrome was first described using the EEG, breathing, and
pulse.
● 1965: Kulho et al expanded our knowledge regarding the Pickwickian syndrome,
using the EEG, and respiratory movements monitoring via a belt, heart rate, and
carbon-di-oxide content during expiration
● 1966: apnea and sleep fragmentation were described after monitoring the oro-
nasal airflow, chest wall movement, and EEG.
● 1974: polysomnography (PSG) was used for the first time to describe the
simultaneous recording of an EEG, EOG, EMG, and respiratory channel.
TYPE OF SLEEP STUDIES AND SLEEP MONITORING DEVICES:
 34

LEVEL IV: An elementary machine that contains only one or two channels for recording
at least one or two respiratory parameters throughout the night. It records one of the
following parameters during sleep
● Oxygen saturation
● Respiratory flow
This machine can be used for screening of obstructive sleep apnea. However, the
AASM does not approve it for diagnosing obstructive sleep apnea.

LEVEL III: (HSAT – Home Sleep Apnea Test)

These devices have at least a minimum of four channels, including:
● Pulse oximeter - To check the Oxygen Saturation.
● Nasal airflow - oxygen movement and airflow
● Chest or abdominal movements - respiratory effort
● Electrocardiogram - Heart rate

LEVEL II: also called "comprehensive portable polysomnography." It contains all

channels recorded in the Level I sleep study, except for the video. This device has:
● Pulse oximeter
● Nasal airflow: recorded by either thermistor, pressure transducer, or both.
● Chest and abdominal movements: one belt for each.
● Electrocardiogram: 2 electrodes that can record any Leads I, II, or III.
● Electro-encephalogram: 2 channels of EEG are present.
● Active electrodes are placed at either of the following positions: frontal,
central, and occipital on both sides of the head—right and left.
● Electro-oculogram: 2 electrodes; one for the right eye and the other for the left
eye.
● Referred to the mastoid electrode of the opposite side.
● Electromyogram: 1 channel for recording chin electromyogram
● Two are placed on the anterior tibialis muscles of each leg.
● Body position.
 35

● During these studies, Auto-PAP may be used to titrate PAP pressure in patients
with sleep apnea.

LEVEL I: This study is done using devices that are used in type II studies. The only
difference is that Level I sleep study is done in the sleep laboratory, and a sleep
technologist attends the whole research.
● Video recording that is synchronized to the recording of other data.
● Audio recording that is synchronized to the recording of other data
● Pulse oximeter.
● Nasal airflow:
● Chest and abdominal movement
● Electrocardiogram
● Electro-encephalogram
● Electro-oculogram
● Electromyogram
● Body Position
● Auto-PAP
The following are the optional channels that may be added depending on the need:
● Capnograph: End-tidal carbon dioxide or using finger capnograph.
● Channel for pH monitoring in the pharynx
● Esophageal pressure monitor

ELECTRICAL CONCEPTS

Basic Concepts of Electricity

Current is represented as (I) in the electrical literature. It can be of two types:
alternating current (AC) where the current produces a sine wave with negative and
positive polarities, and direct current (DC) where sine waves are not produced. During
DC flow, electrons move in a single direction while during an AC current, electrons
change their direction with time resulting in oscillations. These oscillations are
measured as they occur in a unit time (second) and are expressed as frequency and
measured in Hertz (Hz).
 36

Further, the potential difference between two electrodes placed on any charged
surface is recorded in Volts (V). Since electrodes are placed over the body, they are not
able to assimilate with the underlying surface. Therefore, some resistance is always
present during measurement of electrical activity in the underlying area. This resistance
is denoted as R and measured in Ohms (Ω). Voltage equals current multiplied by
resistance (V=IR). This means that increasing resistance will lower the potential
difference (V) for a given current.
● Dipole: Dipole refers to two points where one has a negative charge and
the other has a positive charge. Positivity of the other is relative to the first.
For example, if point A is having -90 mV charge (electrical potential) and
point B carries the potential of –70 mV, B is considered positive relative to
A (because it has +20 mV difference as compared to A). As the electrical
current flows from the negative to the positive side, the direction of current
will be from A to B. If we attach a galvanometer to these points, it will
show a deflection.
● Amplifiers: These devices serve two purposes: amplification and
differential discrimination. These are the devices that amplify the signals
coming to them. This is important because signals generating inside the
body are so tiny that it is nearly impossible to detect them. This is
quantified as amplifier gain, which is denoted as the ratio between input
and output voltage (Vout/Vin). The sensitivity of an amplifier is calculated
as the ratio of input voltage to the vertical amplitude of waveform and is
measured as μV/mm. In other words, how many microvolts are covered in
an amplitude of 1 mm of the waveform? As expected, the vertical
waveform decreases in size with increasing sensitivity. Sensitivity is
chosen so as different waveforms appear distinctly in leads, at the same
time, waveforms from nearby channels do not overlap with each other.
● Differential Discrimination: Differential Discrimination refers to the
capacity of the amplifier to detect the potentials at two inputs and to reject
the potential that is identical at two places. The body is a conductive
environment where a number of organs are functioning and emitting
 37

electrical currents. Most of this current is generated in the nerves (somatic

or autonomic) or the muscles. Since, salt water is a good conductive
medium and is present through- out the body—within and outside the
cells, these potentials traverse the whole body
○ For example, the electrical activity of the heart is picked up as an
ECG and muscles also discharge electrical potentials that can be
measured with the help of an EMG, and the brain is continuously
working and generating electrical potentials that can be measured
as an EEG. Although their strength (measured as the amplitude of
the wave in Volts) decreases as we go farther from the organ that is
emitting that current.It results in the appearance of physiological
artifacts in the electrical channels of the polysomnography. To
remove these artifacts, we use the devices that filter all potentials
that are equidistributed in all channels.
● Polarity: Polarity refers to the appearance of the final output as either
negative or positive. It depends on the relative difference in the potential
between two electrodes from which recordings are acquired. If the input to
both electrodes is positive then the output is positive; if the input to one is
negative and to the other is positive, then the output is the arithmetic sum
of the two, and if it is negative in both, then final output is negative.
Conventionally, positive polarity in the EEG is represented as downward
deflection and vice versa. Depending upon the reference electrode used,
channels may be either unipolar or bipolar. Because of the polarity, the
output from unipolar and bipolar electrodes will be different.
● Ground: Grounding is done for two purposes: to increase the safety of the
patient by grounding the machine and to improve the quality of signal
acquisition by grounding the patient. Since machines are attached to an
electrical source for the power and patients are connected to machines
through electrodes, any short-circuit inside the machine may allow the
current from an external source to enter inside the patient’s body and
causing the injury. Hence, proper grounding of the machine is of
 38

paramount importance. Another grounding, that is, (patient’s grounding)

helps in providing a common reference point to the machine to find out the
actual potential difference between the two electrodes in question. Hence,
the ground electrode should be placed at a site where we expect minimal
endogenous electrical activity. One such site is the forehead and it is
usually placed at the FPz location. Placement of the ground electrode at
this location lacks the activity of the cerebral hemispheres. In addition,
because of its proximity to the eyes, a ground electrode helps in finding
out the unequal impedance.
● Filters: Filters are used to attenuate the waves of a particular frequency
from the tracing. Notch filter helps in attenuating electrical interference of
60 Hz that enters into the channel. Once it is turned on, it removes
electrical interference from all leads. However, it is important to realize
that this filter should not be used routinely as it may obscure important
signals. If the filter is kept turned on since the outset, this information may
be missed and we may not obtain good quality data. Filters are used to
improve the display of waves of physiological interest and to minimize
artifacts. During calibration, a constant current is applied to the filters and
is usually of 50 μV. The time spent in falling back of the signal to 37% of
its maximum amplitude (peak) is known as “time constant,” and it has an
inverse relationship with low -frequency filters (LFFs). Therefore,
increasing the low-frequency filter will reduce the time-constant, and as a
result, a waveform will die prematurely.

PHYSIOLOGY AND RECORDING OF ELECTRICAL POTENTIALS

Electrical activity is recorded using surface electrodes that are placed over the
area of interest. To improve the contact between the surface and the electrode (which
reduces impedance), a conductive gel is applied after scrubbing the area to remove the
dead skin. During the recording of an electrical activity, we actually measure the
potential difference between two electrodes and the result is displayed as a waveform.
When conducting a sleep study and gathering electrical data from the scalp (EEG), eye
 39

(EOG), muscles (EMG), and heart (ECG), we do not obtain the activity of an individual
cell. It must be remembered that an electrode records the electrical signals generated
inside the body and, hence, during the study, we do not allow any external current to
flow inside the body.

ELECTROENCEPHALOGRAM (EEG)
● EEG records the sum of the electrical state (depolarized or hyperpolarized) of the
neurons that lie under it. While recording data from electroencephalography
channels during polysomnography, we place six electrodes on the scalp, three
on either side of the scalp, placed in frontal, central, and occipital positions.
These electrodes are the active electrodes. They are referred to the
opposite mastoid, that is, electrodes from the right side of the scalp are referred
to the left mastoid (e.g., F2-M1; C2-M1 and O2-M1) and vice versa.

ELECTROOCULOGRAM (EOG)
● This is used for recording eye movements. Two active electrodes are placed
near the outer canthi of the eyes and they are
referred to the opposite mastoid. Eyeballs
have a difference in the electrical potential
between the cornea and the retina. The
cornea of the eye is positive relative to the
retina. Thus, when the eyes move towards
the left, the cornea of the left eye having
positive potential, comes close to the electrode placed near the outer canthus of
the left eye and this electrode will show a positive deflection.

ELECTROMYOGRAM (EMG)
● An EMG is recorded from two sites: the submental
muscles and the anterior tibialis muscles of both
legs. However, in special cases where a
movement disorder is suspected, an EMG may be
 40

recorded from the affected area, for example, masseter muscles during bruxism
or arms in a suspected REM sleep behavior disorder. An EMG records the sum
of electrical activity in the underlying muscles.

ELECTROCARDIOGRAM (ECG)
● An ECG depicts the sum of the electrical activity of the heart during its pumping
process. The heart has its own conduction system that is present below the
endocardium. The conduction system of the heart is specialized where impulses
generated in the sinoatrial (SA) node traverse down to the atrioventricular (AV)
node and then to the ventricles. Upon activation of the conduction system,
changes akin to the skeletal muscles occur that result in contraction and
relaxation.

RESPIRATORY DATA

AIRFLOW MEASURES: Airflow is usually recorded using two different modalities:

● Thermocouple or thermistor - made up of a combination of two metals , which
expand, or contract as the temperature change. With that temperature change,
these metals also change their property that generates the signals. Since they
can detect a small change in the temperature, they are sensitive to detect apnea,
where, by definition, air does not flow through the oro-nasal passage
● Pressure transducer - Detects the changes in the pressure of air column, which
is transmitted to a piezoelectric detector, which in turn generates an electrical
signal. The electrical signal produced by piezoelectric sensors is proportional to
the degree of pressure applied; hence, these sensors provide a waveform that is
concordant to the depth of respiration. Because of this quality, pressure
transducers are optimal for recording airflow limitation.
 41

CHEST AND ABDOMINAL MOVEMENTS: Recording of the chest and abdominal

movements help to differentiate obstructive sleep apnea from central sleep apnea. For
measuring the chest and abdominal movements belts are tied around the chest and
around the abdomen.
● During inspiration, chest and abdomen both expand
● Expiration, abdomen and chest deflate.
There are elastic belts that are made up of nylon and they are connected to a small
sensor from both sides. Piezoelectric strain gauge, the simplest type of sensor, emits
current when a change in the strain occurs in the belts during the respiratory movement.

OXYGEN SATURATION: Pulse oximetry is based on the principle of differential

absorption of infrared (940 nm) and red (660 nm) lights by oxyhemoglobin and
deoxyhemoglobin. Oxyhemoglobin absorbs a greater amount of infrared light and less
of red lights (that is why it appears red), while the deoxyhemoglobin possesses the
opposite quality.
● For pulse oximetry used during a sleep study, a fast sampling rate oximeter is
recommended to improve sensitivity as patients with OSA usually have
intermittent hypoxemia.

BODY POSITION
● Body position monitoring is crucial during PSG to monitor sleep-disordered
breathing (SDB) accurately. It allows technicians to track changes in breathing
patterns in different positions (supine, lateral, and prone) and determine the
severity of SDB. The body position sensor uses a gyroscope to detect the
body's position and sends signals indicating whether the patient is lying on their
right, left, supine, prone, or upside. These signals are then converted into
waveforms and displayed in the polysomnography report. It's important to ensure
that the sensor is correctly oriented to the patient to accurately capture their body
position.
 42

VIDEO DATA
● Most sleep laboratories that deal with suspected sleep seizures and parasomnias
use video recording synchronized with other data channels. In a dark sleep
environment, infrared light is emitted from the camera, and its sensors record the
reflected signals. The camera's focus and direction can be controlled from the
monitoring room using special software, allowing sleep technicians to capture
even the smallest movements during sleep activities.

CARBON DIOXIDE MONITORING

● In pediatrics, end tidal PCO2 (ETCO2) is commonly used during PSG
monitoring. For adult patients, the AASM recommends using arterial PCO2,
ETCO2, or transcutaneous PCO2 to detect hypoventilation during a diagnostic
sleep study, and arterial PCO2 or transcutaneous PCO2 during PAP titration.
● Both ETCO2 and transcutaneous PCO2 are noninvasive methods to predict
arterial PCO2.
○ ETCO2 is measured using infrared spectroscopy but may be inaccurate
during sleep studies or when a patient is on a noninvasive PAP device.
○ Transcutaneous PCO2 is obtained through the skin and provides a good
alternative to ETCO2 during PAP titration. The sensor may need to be
repositioned during a sleep study, and the best locations for
measurements are the forehead, forearm, chest, or abdomen.

PREPARATIONS TO THE SLEEP STUDY

1. The room for sleep recording is important for the study's quality. It should be
quiet, comfortable, and have good ventilation and natural light. It needs a
comfortable bed, TV, and attached bathroom. It should be spacious and have a
couch for a family member. The room should be air-conditioned, soundproof, and
have thick curtains for daytime recordings. A temperature of around 22°C is
ideal, and there should be a way for the patient to communicate with the sleep
technician.
 43

2. Polysomnography machines need a 240V electrical supply and contain

components that can create electromagnetic fields. This can cause a small
amount of current to flow through the leads attached to the patient, potentially
affecting them. To prevent this, manufacturers ground the machine by attaching
a wire to the motherboard chassis, redirecting unwanted current to the ground.
Without proper grounding, the current may flow towards the patient, posing a
safety risk. Regular checks by an electrical engineer are necessary to ensure the
ground wire is working properly and has minimal resistance.
3. Before a sleep study, it's important to prepare the patient to avoid the "first night
effect," where the equipment and wires can disrupt sleep. Providing a printed
flyer explaining the study's purpose and procedure, along with "Dos and Don'ts
before the sleep study," can help the patient prepare. Using visuals to explain the
procedure and advising the patient to arrive 8-10 hours before bedtime can also
minimize the "first night effect." Additionally, allowing the patient to engage in
leisure activities in the sleep laboratory can help them acclimate to the new
environment.

PLACEMENT OF LEADS FOR THE SLEEP STUDY

EEG (ELECTROENCEPHALOGRAM)
1. Frontal electrodes are best for capturing delta activity, which is characteristic of
N3 sleep.
2. Central electrodes are best for capturing Vertex waves, K complexes, spindles,
and sawtooth waves, which help determine N1, N2, and REM stages.
3. Occipital electrodes are best for capturing alpha activity, which can be used to
differentiate. wakefulness and sleep.
EOG (ELECTROOCULOGRAM)
● Two EOG electrodes are placed: one 1
cm below the outer canthus of the left
eye (EO1) and another 1 cm above the
outer canthus of the right eye (EO2).
These electrodes are referenced to the
 44

opposite side of the mastoid. Before placing the electrodes, clean the area with
an abrasive gel to improve conductance. Placing one electrode above and below
has special value, as the cornea is positively charged compared to the retina,
and the eyes show conjugate movement, meaning both eyes move together.

EMG (ELECTROMYOGRAPHY)
● An electromyogram is placed at
two sites on the body. The first
measures the tone of the
mentalis-submentalis muscle to
score the sleep stage, and the
second measures periodic limb
movements during sleep (PLMS).

ECG (ELECTROCARDIOGRAM)
● In an ECG for a sleep study, two leads are
typically used, placed on the chest instead of the
limbs. One electrode is positioned at the junction
of the chest and the right shoulder, another at a
similar location on the left side, and the third below
the apex of the heart, aligning with the right
shoulder and left hip.

PLACEMENT OF MEASURES OF RESPIRATIONS

1. Nasal Airflow - - The cannula should be securely taped to
the face to prevent it from moving during the study. Some
companies provide cannulas with a built-in thermistor
placement, which reduces the number of instruments in the
nostrils.
 45

2. Respiratory Effort - Respiratory effort is measured using an elastic or RIP belt

placed around the chest and abdomen. It is important to ensure that the belts are
neither too loose nor too tight.
3. Oxymeter - The oximeter machine comes with two types of probes: one with free
ends that are secured with adhesive tape, and another with
a two-pronged sensor that may fall off during use. The
adhesive tape should be placed along with the nasal
cannula to prevent the probe from falling off.
4. Snore Microphone - The tracheostomy tube should be
placed on either side of the midline near the Adam’s apple
and firmly secured with surgical tape to prevent it from
falling off during sleep.

BODY POSITION SENSOR

● The body position sensor is typically placed on the
chest and secured to a respiratory chest belt. Sensors often have a diagram for
guidance on placement. It is important to ensure correct placement to obtain
accurate data, as a loose sensor may provide unreliable data that could affect
the interpretation and management plan.

Articles/Journal and Book References discussing its use and effectiveness.

A sleep study, a polysomnogram (PSG), is essential to many sleep evaluations.

PSGs that are attended (Type I) are the standard for diagnosing sleep-related breathing
disorders (SRBD), such as obstructive sleep apnea (OSA) and many other sleep
disorders. The study involves recording several physiological parameters
simultaneously during sleep and wakefulness, including the electroencephalogram
(EEG), to identify wake versus sleep and its stages. The polysomnogram (PSG) is
valuable because of the physiological data gathered during sleep. PSGs can potentially
diagnose many conditions due to their extensive evaluation. Obstructive sleep apnea
(OSA) is diagnosed by measuring reductions in airflow during sleep. A diagnostic PSG
would ideally involve supine sleep during REM. Obstructive apneas (OAs) are scored
 46

when there is at least a 90% reduction in airflow for ten or more seconds (typically
scored based on the oronasal thermal flow channel) with continued respiratory muscle
activity. The evaluation of respiratory muscle activity is done using RIP belts. EEG,
EOG, and submental EMG criteria evaluate sleep stage scoring (Gerstenslager &
Slowik, n.d.).

The wake and sleep stages are denoted as stage W for wake, stages N1, N2,
and N3 for the non-rapid eye movement (NREM) stages of sleep, and stage R for REM
sleep, according to the AASM scoring manual. In the new classification, stage N3
replaces stages 3 and 4. Sleep is scored in 30-second sections, known as epochs.
PSGs were traditionally recorded on paper, and an epoch of sleep was a standardized
length of paper given a standard recording time. Nowadays, digital PSG has almost
entirely replaced paper recording, and sleep is scored in sequential epochs that can be
manipulated on the screen. If more than one sleep stage occurs in an epoch, the epoch
is generally scored based on the sleep stage occupying most of the epoch.
Polysomnograms (PSGs), despite being the standard for diagnosing multiple sleep
disorders, have several limitations. For example, the first-night effect due to poor sleep
because of a new sleeping environment may lead to underestimating OSA due to the
potential for decreased REM sleep being captured. Sleep complaints significantly
impact patients both physically and psychologically and, when left undiagnosed or
untreated, correlate with suffering in many patients. The PSG itself is technically
complex and time-consuming due to its many monitoring systems, which are also the
source of its high clinical utility in diagnosing and managing a wide range of sleep
disorders. A PSG is a powerful tool for diagnosing and subsequently managing sleep
disorders when appropriately executed with adequate training, interpretation, and
patient preparation.
47
 48

CONCLUSION

Pulmonary Function Tests (PFTs) and Polysomnography serve distinct purposes

in evaluating respiratory and sleep functions, respectively. PFTs encompass non-
invasive assessments measuring lung capacity, airflow, and gas exchange to diagnose
conditions such as asthma and chronic obstructive pulmonary disease. On the other
hand, Polysomnography is a comprehensive sleep study monitoring physiological
parameters during sleep, including brain activity, eye movements, muscle activity, and
respiratory patterns, aiding in the diagnosis of sleep disorders like sleep apnea and
narcolepsy. Together, these tests contribute crucial insights into the diagnosis and
management of respiratory and sleep-related conditions, playing integral roles in
assessing overall pulmonary and sleep health.
 49

REFERENCES

American Lung Association. (2023, March 10). Spirometry.

https://www.lung.org/lung-health-diseases/lung-procedures-and-tests/spirometry

Chest Daily News. (2022, November 14). Guideline update changes best

practices for assessing lung function.

https://chestdailynews.chestnet.org/guideline-update-changes-best-practices-for-

assessing-lung-function/

Gerstenslager, B., & Slowik, J. M. (n.d.). Sleep study - statpearls - NCBI bookshelf.

National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK563147/

Gupta, R., BaHammam, A. S., & Pandi-Perumal, S. R. (2021). Clinical atlas of

polysomnography. AAP Apple Academic Press.

Kacmarek, R. M., Faarc, R. M. K. P. R., Stoller, J. K., & Heuer, A. (2020). Egan’s

Fundamentals of respiratory care. Mosby.

Li, F., Huang, Z., Wang, X. F., Xu, H., Yu, H., Chen, Y. B., Huang, J., Wang, J.

J., & Lei, W. (2019). Safety and use of pulmonary function tests: a retrospective

study from a single center over seven years’ clinical practice. BMC Pulmonary

Medicine, 19(1). https://doi.org/10.1186/s12890-019-1019-z

Lyons, M. M., Bhatt, N., Pack, A. I., & Magalang, U. J. (2020). Global burden of

sleep‐disordered breathing and its implications. Respirology, 25(7), 690–702.

https://doi.org/10.1111/resp.13838
 50

Madama, V. (1998). Pulmonary Function Testing and Cardiopulmonary Stress

Testing. (2nd Edition). Delmar Publishing Team.

Moini, J., Ahangari, R., Miller, C. L., & Samsam, M. (2020). Respiratory

problems. In Elsevier eBooks (pp. 147–172). https://doi.org/10.1016/b978-0-12-

819751-6.00007-4St. Luke’s Medical Center. (2019, July 1). St. Luke’s launches

first ever Comprehensive Insomnia Management Program in PH. Retrieved

January 26, 2024, from https://www.stlukes.com.ph/news-and-events/news-and-

press-release/st-lukes-launches-first-ever-comprehensive-insomnia-

management-program-in-ph

World Health Organization: WHO & World Health Organization: WHO. (2023,

March 16). Chronic obstructive pulmonary disease (COPD).

https://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-

disease-(copd)

Ponce, M. C. (2023, August 28). Pulmonary function tests. StatPearls - NCBI

Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK482339/

Ranu, H. (2011, May 1). Pulmonary function tests. PubMed Central (PMC).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3229853/

Tacio, H. D. (2022, November 17). HEALTH: A slow-motion death called chronic

obstructive pulmonary disease. Edge Davao.

https://edgedavao.net/health/2022/11/17/health-a-slow-motion-death-called-

chronic-obstructive-pulmonary-disease/
51