POLYSOMNOGRAPHY:

INTERPRETATION HYPNOGRAM
Prof. Dr. J. Verbraecken
Dept Pulmonary Medicine and Multidisciplinary Sleep
Disorders Centre UZA
One 30-seconds epoch (PSG)
 Definition Sleep cycle
A complete REM stage plus the NREM sleep time
proceding this phase

Average duration in adults: 90 minutes

 Sleep pattern
according to age
Distribution Sleep stages
Children/young adults
NonREM REM
(75% TST) (25% TST)
Stage N1 5%

Stage N2 45%

Stage N3 25%

Wake < 5% of the night

How much REM sleep at the age of 50 ?
(%sleep)
 TIB= time in bed
(total time recorded)
TIB
SPT=Sleep Period Time
SPT
TST=Total Sleep Time
TST=SPT-WASO***

* * * * * * ********* ** ** * *

WASO (all periods with *)

( “wake after sleep onset” or
intermittent wake)
TST and SPT

In this example: TST=SPT

 Sleep latency (SL)

SL

How long is a normal SL ?

 REM latency time
(“sleep onset latency to REM”)
REM-
latency

How long is a normal REM sleep latency time ?

REM latency according to age

C= control
D=depressed
 CPAP titration night

REM rebound
SEI=Sleep Efficiency Index
SEI=TST/TIB
SEI=Sleep Efficiency Index
SEI=TST/SPT

At which level is SEI reliable ?

Which SEI can be considered as normal ?
 First night effect ?

SEI=71% SEI=78%

Portier F et al AJRCCM 2000, 162: 814-18

Subjective assessment sleep quality at
home vs in the hospital

Portier F et al AJRCCM 2000;162: 814-18

 “First night” effect !

Kingshott R et al Sleep 2000, 23(8): 1109-13

?
 Arousal index
according to age:
– Teenagers: 13.8
– Young adults: 14.7
– Middel aged: 17.8
– Elderly: 27.1
 “Normal” patiente:
AHI<5 and PLMI<5
Boselli M et al, Sleep 1998;21(4): 351-
351-7
Awakenings
 Body position
Positional OSAS (supine)
When is OSAS positional ?
 Positional OSAS
Definition
 50% reduction of AHI in non-supine position

AHIruglig ("sup ine")

2
AHIzijlig ("non sup ine")
Cartwright RD. Sleep 1984;7:110-114.
Cartwright R et al Sleep 1991;14:546-552.

50-60% of OSAS patients positional

 Supine dependent AHI: # apneas & hypopneas supine
Time in supine position

 Non-supine dependent AHI: # apneas & hypopneas non-supine

Time non-supine
 Alternative definition
 Non-supine dependent AHI<5 or 10
 Supine AHI≥10 and non-supine AHI <10
 Duration criterion:
– Theoretical: no formal minimal duration per position
– Practical: at least 15 min

Mador MJ et al Chest 2005;128:2130-2137

(Very) severe OSAS
Extremely severe OSAS
 Trends non-SRBD
Problem of maintaining sleep
Superficial sleep pattern
 Depression/mood disturbance
Increased REM pressure + shift delta sleep
SOREM
Early awakening
 Few REM sleep
(due to treatment with antidepressants)
PLMI= periodic leg movement index
(#PLM x 60/TST)
 PLMD

AantalPLMSx60
PLMI 
TST
AantalPLMmetarousalx60
PLMAI 
TST
Primary ? Secondary ?
Clinical relevance ?
10 to 30% of the population
 Chronic alcohol use ?

 Shorter sleep duration

 Interrupted and fragmented sleep
 ↓ SL, ↓SEI, ↓ SWS, ↑ REM %

Benca RM et al Arch Gen Psychiatry 1992;49(8):651-70

 OSAS in alcohol users

With
Alcohol

Without
 During “Withdrawal”
 3-5 days of altered sleep
-fragmented and short sleep
-episodes of ↑ REM sleep (=REM
sleep rebound)

Mello et al 1970; Johnson et al, 1970; Smith et al,

1971; Allen et al, 1977
 Take home message
Interpretation polysomnography
 A gold mine of information
 Correct scoring mandatory
 Always take into account age
 ‘first night’ effect
 “overinterpretation”
 Interpretation in case of low SEI
 Some ‘alterations’ occur frequently in healthy subjects
 Reliability of AHI in extreme OSAS ?
 AHI polygraphy cannot be compared with the AHI based on PSG
 Comparison of sleep studies: always look how parameters are
defined and measured
 OSAS: underestimation of severity if a patients drinks alcohol at
home