RT -113 POLYSOMNOGRAPHY FINALS

PLACEMENT OF LEADS FOR THE SLEEP STUDY

• It is important to place all the recording

channels in proper position to obtain
optimal data.
• If the sources of the signals are not placed
at defined places, the recording will be of
suboptimal quality and the data captured
would not be accurate and would
compromise the comparability of data
obtained from two different persons.
• To counteract these issues, the AAMS has
recommended appropriate places and
methods of hooking up the patients.

ELECTROENCEPHALOGRAM (EEG)
For recording an EEG, electrodes are placed
bilaterally in the frontal, central and occipital
positions. These are referenced to the
opposite mastoid (not the ear).

1. Frontal electrodes best pick the delta
activity (exhibit N3 sleep)
2. Central electrodes best pick the Vertex
waves, K complexes, spindles and sawtooth
waves (determine N1, N2 and REM stage)
3. Occipital electrodes best pick the alpha
activity that can be used to differentiate
wakefulness and sleep.
 To overcome the problem, EEG
electrodes should be placed
according to the International 10 –20
system.
 The figures 10 and 20 denote the
distance between the electrodes that
area measured in percentages (10%
or 20%) of the length and breadth of
the fixed anatomical points of the
scalp.
EEG: PLACING THE EEG ELECTRODES ACCORDING TO
10 -20 SYSTEM

The material required are:

1. Washable non -irritant marker;

2. Non -elastic measuring tape; 3. Abrasive
material to clean the area; 4. Electrodes;
and 5. Conductive gel.

MATERIALS REQUIRED:
FIGURE 6.4 Marking in the anteroposterior plane
 Electrodes
according to 10-20 system: If you are doing sleep
 Hydromarker
extended EEG montage (for seizure or
 Tape measure (non elastic)
parasomnia) is not required, only Fz, Cz and Oz
 Cotton tip applicator
markings is important
 Conductive gel

FIGURE 6.5 Pre-auricular

FIGURE 6.2 Nasion (the depressed area where
the nose meets forehead between eyes)

FIGURE 6.3 Inion (the protruded are on the lower FIGURE 6.6 Marking in the coronal plane: if you
part of back of skull (occipital bone) where it are doing sleep study where extended EEG—
meets neck). seizure or parasomnia) is not require, only C3
andC4 markings are important.
FIGURE 6.7A Markings on tne head
circumference: if you are doing sleep study
FIGURE 6.8 Makings for frontal and parietal
where extended EEG montage (for seizure or
electrodes: if you are doing sleep study where
parasomnia) is not required, only O1 and O2
extended EEG montage (for seizure or
markings are important.
parasominia) is not required, only F3 and F4
markings are important.

FIGURE 6.7B Markings on the head

circumference: if you are doing sleep study
where EEG montage (for seizure or parasomnia)
extended is not required, only O1 an O2
markings are important.
 ELECTROOCULOGRAM (EOG)
• Two EOG electrodes are placed, one cm below the outer
canthus of the left eye (EO1) and another (EO2) 1 cm
above the outer canthus of the right eye
o So like for example ito yung mata ng patient
o So with that your right eye since nag move siya
o So your right eye as what we have discussed during
previous lessons diba pag downward yung deflection
meaning that is a positive deflection kapag naman
upward yung deflection that is negative deflection
➢  = positive
➢  = negative
towards the right meaning mag mo-move down siya
➢ Positive – right eye
➢ Negative – left eye

o Dito natin ma iidentify kung ano na yung movement sa

o (Left eye) EO1 - Move ka ng 1cm and 1cm down
eye ni patient.
o (Right eye) EO2 - Move ka ng 1cm and 1cm up

• These electrodes are referenced to the opposite side of REMEMBER if ever si patient mag move ang eyes sa:
the mastoid. ➢ Right side
EO1 =  = negative deflection
o Meaning kung ito ay EO1 ikakabit mo siya sa M2 kasi
EO2 =  = positive deflection
opposite nga kasi left eye papunta sa right mastoid
and on the other hand E02 should be connected to
➢ Left side
your M1 EO1 =  = positive deflection
EO2 =  = negative deflection

• Before placing the electrodes, clean the area adequately

with an abrasive gel to improve conductance.

o Merong mga epoch na di gumagamit ng EOG 1 and EOG

2. Pag di kayo nakakita nito pwede LEOG and REOG
➢ EOG2/REOG
➢ EOG1/LEOG
o Ma’am paano pag mag move up and down. SAME
parin. Kapag nag move ang kaniyang eyes sa Right side
pwede mag move up, pag sa Left side towards down
➢ Right = 
➢ Left = 
 ELECTROMYOGRAM (EMG)
• Electromyogram is placed at two sites in the body.
• First is to measure the tone of the mentalis
submentalis muscle, which helps in scoring of the
sleep stage and another one to measure the periodic
limb movements during sleep (PLMS).
- Meaning doon natin siya ipiplace sa leg ng ating
patients

o So in this epoch we can see that its on the REM

stage ng sleep. Bakit REM? Kasi nag mo-move
nalang po dito are your LEOG and REOG and the
rest po is nag rerest na siya. Meaning masyado
ng maliliit yung kaniyang tracing or kaniyang
mga waveforms.

For the EMG there is two electrode that should be

placed. One on the leg and also another in the chin
area.

Figure 6.16 Placement of leg EMG electrodes

- Divide lower leg into three (imaginary). Kung saan
ang center doon mo ilalagay.

- Another way to apply leg EMG electrode is. Let

your patient dorsiflex his or her foot. For example,
kasi dalawa yung ilalagay natin, one on the right
and one on the left. So kapag I dorsiflex kasi niya
For example diba sabi ko kanina your EOG1 should be ang foot niya, all you have to do is kapain mo, may
muscle yan siya diyan and kung ano yung muscle na
place doon sa M2 (right mastoid) and your EOG2 sa
M1 (left mastoid). But in cases for example dili siya gumagalaw diyan na area, place the electrode
mabutangan sa mastoid you can just place EOG1 and diyan.
EOG2 sa FPz. That is an alternative.
Figure 6.15 Placement of chin EMG electrodes
- One side of the chin electrode works as a back-up
ELECTROOCULUGRAM (EOG) of the other one.
EO1 Left eye - So ang gagawin is that, usually 2 or 3 ang nilalagay.
EO2 Right eye For this picture 3 ang nilagay.
M1 Left mastoid
M2 Right Mastoid
EOG1 LEOG
EOG2 REOG
Fig. 6.15 continuation
- First is to palpate angle of the mandible. From
that angle of the mandible kanang jawline nimo,
with that you measure
o First you measure 1 cm above the
lower border of the mandible and
you place it there. Usually nilalagyan
ng plaster para di madaling
matanggal
o Another is dito sa baba naman you
measure pababa ng 2 cm
o And another sa kabila(right) 2cm
and sa kabila (left) naman 2cm

PLACEMENT OF MEASURES OF
RESPIRATIONS

Nasal airflow Respiratory Effort

Oxymeter Snore microphone

➢ Placement of Measures of Respirations: NASAL AIRFLOW

ELECTROCARDIOGRAM (ECG) • Nasal airflow is measured using a thermistor and a
• For the ECG, usually two leads are used—I and II. pressure transducer.
• Opposed to the traditional ECG recording, where these • Pressure transducer is usually attached to a cannula
electrodes are placed on the limbs, for sleep study, that is kept close to the nostrils
electrodes are usually placed on the chest.
• Place one electrode at the junction of the chest with the
right shoulder, another at a similar location on the left
side, and the third below the apex of the heart. This point
should align the right shoulder and left hip

o For this ECG compared sa normal ECG we just

have to make use of 3 electrodes
o Placed on the chest area only
o Same placement for patients naka hook sa
cardiac monitor diba tatlo lang yung nilalagay
same parin dito
o Apex of the heart – 5th intercostal space left
midclavicular line or just below the nipple line
 ➢ Placement of Measures of Respirations: RESPIRATORY
o Some facilities gumagamit ng pressure transducer
alone and some also gumagamit ng pressure
transducer + thermistor
o So the difference between the two:
˃ Thermistor
- recommended for patients to detect
apnea, especially those patients na may
suspected OSA, CSA, and other forms of
apnea.
- Use to evaluate kung meron bang airflow
or wala sa nose ni patient.
- Paano siya maka detect, any changes in the
temperature as the patient inhale or
exhale will lead to normal signal.
- Problem of thermistor is it is not sensitive
for partial flow obstruction
˃ Pressure Transducer
- Maganda ito especially in evaluating if si
patient mo may hypopnea
- Can detect hypopnea and also mga airflow
resistance
- Can also be used for measurements of
end-tidal C02 pwede yan siya diyan ikabit
such us capnograph
How to place thermistor and pressure transducer:
- Almost the same on how to place the nasal
cannula
- Meron siyang sensor diyan, all you have to
do papasok mo lang yan sa nares ng patient
din ilalagay mo lang sa back of the px ear din
sa baba din pwede mor in sikipan.
- And sometimes nilalagyan ng plaster para di
ma tanggal but make sure patient is not
allergic.
EFFORT
• Respiratory effort is measured by either an elastic
belt or an RIP belt which is placed over the chest and
abdomen.
- Meaning dalawa yung ilalagay natin na
respiratory belt.
- 1 on the chest and 1 on the abdomen
• These belts should not be too loose or too tight. In the
former case, they will fail to record the movement,
while in the latter case, they will produce discomfort.
- Too loose = di ma measure ng Mabuti yung
respiratory effort nip x
- Too tight = medyo uncomfortable si px
• A rule of thumb is to lengthen the belt to the two-
third of the circumference of the chest and abdomen,
and then using its elastic property, tie it around the
chest and abdomen.
- Usually mura lang kag gataod ug belt kay px,
tama lang ang fit nito kay px
• The belly should not be twisted as it will not only
produce discomfort, but in case of an RIP belt, also
interfere with proper signal generation.
o RIP = Respiratory Inductance Plethysmography
o RIP belts for the chest it should be placed at
- Men = the level of the nipples especially
- Women = put it below the breast
o RIP belts for the abdomen should be placed at
the level of the navel (pusod)
- In obese patients put it below the ribcage
para hindi ma slide
➢ Placement of Measures of Respirations: OXYMETER
• Two kinds of oximeter probes are usually supplied
Microphone
along with the machine—ones that have free ends
o Yellow portion should be attached to
that get fixed with the help of an adhesive tape.
- Dalawa kasi ginagamit natin sa hospital. the patient’s skin.
- Isa yung parang portable na pulse ox pero may o Since we are not going to use
wire, The other one is hindi siya portable na conducting gel here, we have to make
pulse ox but an adhesive one use of plaster

• This tape get adhered to the finger, thus, it prevents

it from falling off.
• However, many companies supply a two- pronged
sensor that may fall off during a study.
- Lagyan ng plaster sa wire ng px para di matanngal
• To prevent misplacement, such probes are usually
fixed on the finger with the help of an adhesive tape.
BODY POSITION SENSOR
• Body position sensor is usually placed over the chest and
it gets fixed to the respiratory chest belt.
- Usually gamay lang ni na device tapos pwede
ibutang kauban sa chest respiratory belt
• Most of the sensors have a diagram over them that guides
you regarding their placement.
• Please ensure that you place it correctly to obtain correct
data.
• A loose sensor may give you spurious data that may
influence the interpretation and management plan.

o Body position sensor = ma detect niya ang

position ni patient
o But in other facilities – video data is use and gina
check every hour ang position ni patient

o Ito yung example nung clip na meron siyang

wire, make sure na yung light dito may light siya
diyan and dito sa baba siya yung mag absorb ng
light. Principle is called Spectrophotometry

o Another one is – ilalagay mo siya yung mag emit

ng light tapos I plaster mo lang.

Example of how the px is hook on different

➢ Placement of Measures of Respirations: SNORE electrodes
MICROPHONE
Is very important especially for us to detect the snoring sound
of the px, while the px is asleep
• It should be placed on either side of the midline close
to the Adam's apple.
• This should be firmly fixed at that place with surgical
tape so that it does not fall off during sleep.
 REMEMBER
➢ EEG
- International 10-20 system
- Different placement and different name of
those
- Left side = Odd numbers
- Right side = Even numbers

➢ EOG
- Right side = 1cm outer = 1cm Upward
- Left side = 1cm to the side = 1cm downward

➢ EMG
- Leg EMG
o Anterior Tibialis Muscle = divide leg into
three equal parts, then locate center sa 2/3.
Then ask px to dorsiflex and flex the foot of
px kung ano naga contract that’s the
location where EMG electrode can be put.

- Chin EMG
o Remember jawline nip x and then sa center
1cm above place 1 EMG, then sa baba non
measure 2cm down, 2cm right, and 2cm left

➢ ECG
- 1 on the right shoulder, 1 on the left, and 1 just
below apex of the heart

➢ MEASURES OF RESPIRATION
- Thermistor and Pressure Transducer
- Same lang pag place sa nasal cannula
- Thermistor
o detect apnea, but not hypopnea, ETC02,
Capnography can be attached
- Pressure Transducer
o detect hypopnea
- Pulse OX
o Clip na part the same with portable pulse ox
- Snore Microphone
o Important for px na naga snore
o Ask px to produce sound, tas sa Adam’s
apple may vibrations diyan when px
produce soun

➢ BODY POSITION SENSOR

- Place sa chest respiratory belt and place it in the
proper position