Lily Y.

Lao, MD
Joseph Hope G. Cal, MD
Teresita Celestina S. Fuentes, MD
Emeraldee L. Garcia, RPSGT
Nanette G. Deyro, RPSGT

provide both didactic and laboratory

training for interested personnel on
the basics of polysomnographic
technology
recognize
the
basics
of
polysomnographic
monitoring,
including EEG, respiration, body
movements, and how to score a
sleep study

Sleep Medicine Workshop

6th Biennial Symposium: Understanding Pulmonary DiseasesTrends and

Evidences

Reversible
behavioral state of
perceptual disengagement from and
unresponsiveness to the environment
Complex amalgam of physiological
and behavioral processes

Carskadon and Dement

Non-rapid eye movement

75-80% of sleep time in adult humans
Stage I NREM
2-5% of sleep time; lightest stage of sleep
alpha rhythm < 50% in an epoch
theta rhythm & beta waves appear
EMG activity slightly

Stage II NREM
45-55% of sleep time; intermediate sleep
begins after 10-12 minutes of Stage I NREM
sleep spindles, K complexes, delta waves <
20%
lasts 30-60 mins

Stage III NREM

15-20% of sleep time; deep sleep
delta waves 20% of the epoch

Rapid Eye Movement

20-25% of sleep time
1st REM noted 60-90mins after onset of
NREM sleep
EEG fast rhythms and delta waves
sawtooth appearance

Tonic Stage
desynchronized EEG, hypotonia & atonia of
major muscle groups

Phasic Stage
characterized by rapid eye moments in all
directions
phasic swings in BP, HR, RR
frequently occur in early morning hours
Chokroverty 2000

Four or five 90-minute cycles of sequential

stages recur during the night
REM stage episodes increase in duration
Slow-wave sleep disappears beyond the
second cycle
Infants: large REM sleep up to 2 years
Old: stage 3 diminishes or disappears,
sleep fragmentation
REM : total sleep 25%
Nocturnal sleep fluctuates between 5-9 hrs

The single most important laboratory

technique for assessment of sleep
and its disorders

Method of identifying and evaluating

sleep-state and several physiologic
variable during sleep
ATS 1989

A multi-parametric test that is used to

study/record
in
detail
all
the
biophysiological changes that occur in
the human body when the person is
asleep

It monitors the multiple physiological characteristics

simultaneously during sleep at night.
It allows assessment of sleep stages and wakefulness,
respiration,

cardio-circulatory

functions

and

body

movements.
It monitors physiological or pathological events in
sleep.

Serious excessive daytime sleepiness with

no known medical cause and not relieved by
2 weeks of significant increase of time in bed
Snoring
with interrupted
periodic limb movements

breathing

Nocturnal seizures

Hauri et al. Sleep Disorders, 1992

or

Electroencephalogra
m (EEG)
Electrooculogram
(EOG)
Chin
electromyogram
(EMG)
Electrocardiogram
(ECG)

Oximetry
Leg electromyogram
(EMG)
Body position
Snoring sensors
Continuous audio/video
monitoring & behavior
observation

Nasal and/or oral

AASM Practice Parameters for Indications for Polysomnography 2005
airflow

International 10/20 System

4 anatomical landmarks
Nasion
Inion
Right pre-auricular point
Left pre-auricular point

Cleansing of site
Collodion or EEG electrode paste

Record eye
movement activity
Vicinity of right and
left outer canthus

Several varieties of eye movements

are
recorded
and
may
assist/facilitate in sleep staging
Waking eye movement (WEMs)
Slow eye movements (SEMs)
Rapid eye movements (REMs)

Mental-submental
derivation
Electrode placed
directly over chin,
referenced to
electrode placed 2-3
cm off midline,
slightly below
jawbone

Single-channel ECG
Electrodes over
right clavicle and
lower left thorax

Anterior tibialis
muscles of each leg
Less precise than
scalp and facial
derivations

Respiratory tracings
represent indirect,
qualitative
measures of
respiratory airflow
and effort
Thermal airflow
sensors
Nasal cannula
pressure transducers

Pulse oximeter connected to

polysomnograph
Periodically check readings with a
regular pulse oximeter

Monitored by placing a microphone

on the patients neck

AASM 2007

(Apnea 10 sec. & 5/hr of sleep)

Central Apnea
cessation of airflow with no respiratory
effort

Obstructive sleep Apnea

cessation of airflow through the nose or
mouth with persistence of diaphragmatic &
intercostal muscle activities

Mixed Apnea
initial cessation of airflow with no
respiratory effort followed by periods of
upper airway OSA
ATS, 1989

Cessation of airflow, usually for more

than 10 seconds
With abdominal and/or thoracic effort
Usually terminated by an arousal
and/or associated with a
desaturation

Cessation of airflow, usually for more

than 10 seconds
Without abdominal and/or thoracic
effort
May be terminated by an arousal
and/or associated with a desaturation
Very different type syndrome than
OSA; chemo-receptor irregularities

Cessation of airflow >10 s (in adults) with

respiratory effort
Contains both central and obstructive
components, with each component lasting
at least one normal respiratory cycle
Typically leads to a desaturation and an
arousal
Is really just a type of obstructive event
with the same consequences

Reduced airflow, usually for more than

10 seconds
Many labs require at least a 50%
reduction in flow; however, more and
more labs do not require a specific %
reduction, but look at the SaO2 and
EEG to affect the decision
May be terminated by an arousal
and/or associated with a desaturation

Repetitive (at least 4) episodes of muscle

contraction (0.5-5 s duration), typically
separated by 20-40 seconds, but not more
than 90 seconds (120 seconds in some
laboratories)
Arousals sometimes associated with the
movements
Positive diagnosis if > 5 per hour of sleep
Movements may be determined to be not
clinically significant if not associated with
arousals

Apnea index (AI): number of apneas per hour

of TST
Hypopnea index (HI): number of hypopneas
per hour of TST
Apnea/hypopnea index (AHI): number of
combined apneas and hypopneas per hour of
TST
Periodic limb movement index (PLMI):
number of periodic limb movements in sleep per
hour of TST
Isolated limb movements index: number of
non-periodic limb movements per hour of TST

Spontaneous arousal index: number of

arousals that occur which are not associated
with any other clinical event
Arousal index (AI): number of all arousals per
hour of TST
Periodic limb movement arousal index
(PLMAI): number of periodic limb movements
associated with arousal in sleep per hour of TST
Mean Heart rate: the average heart rate
during the PSG evaluation which can also be
reported by sleep state, REM, non-REM, and
wake.

Supplemental oxygen therapy should be instituted

upon receipt of a physician order under specific
circumstances :
the patient is currently under treatment of a physician and
supplemental oxygen therapy is prescribed
the patient is undergoing a PSG study for titration of nasal PAP
therapy & is still experiencing desaturation, per facility
protocol, after reaching optimal PAP level to eliminate
respiratory events & arousals & no signs of CO2 retention are
present
the patient is unable to tolerate nasal PAP therapy & is
experiencing significant desaturation with respiratory events

In patients with chronic obstructive

pulmonary disease, adding supplemental
oxygen may lead to
an increase in PaCO2 and
changes in hypoxic drive, which impairs the drive
to breathe

Fire hazard is increased with the use of

oxygen in the sleep disorders facility
Power outage can lead to inability to use the
oxygen concentrator and adequate back up
should be in place

Laugh and the

world laughs with
you,
snore and you
Anthony Burgess
sleep alone.
English novelist, critic

Thank You