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The Sleep

Technician guide
Practical aspects of sleep diagnostic











Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
A.Pre-study patient evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1. Subjective methods: sleep diaries and questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2. Objective methods: Screening devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
B.Use of actigraphy in sleep medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
C.Origin and practical aspects of physiological measurement
in Polygraphy and Polysomnography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
1. EEG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2. EOG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3. Chin EMG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4. Respiratory airow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
5. Snore sensor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
6. ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
7. Respiratory effort. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
8. Position sensor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
9. Limb Movement sensor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
10. Leg EMG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
11. Pulse Oximetry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
12. Pulse Transit Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
13. Video recording . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
14. Types of artefacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
15. Summary of drug effects on Sleep architecture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
D.Practical aspects of AASM guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
1. Key rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
2. Technical and digital specications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3. Visual rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
4. Arousals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
5. Cardiac rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6. Movement rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
7. Respiratory rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Practical aspects of sleep diagnostic 1
The Sleep Technician guide 2













Preface
Sleep is known to be a natural need and is also essential for all species. Nevertheless, it was
not considered as part of the medical curriculum until recently.
Whereas we spend a third of our lives sleeping, which means about 25 years for most of
us, only 30 minutes over the 8 years of teaching at medical school were dedicated to sleep
medicine until 2000. The same applies to allied professions such as nurses, technicians,
physiotherapists etc. who have to take care of patients suffering from sleep disorders. Until
recently, no appropriate information was provided to doctors and allied professions from
pathophysiology to treatments of sleep disorders.
Sleep medicine leads to holistic understanding of related conditions at the crossroads of
many medical specialities such as neurology, respiratory medicine, endocrinology, psychiatry,
occupational medicine, cardiology, ENT, sports medicine, paediatrics. Sleep medicine brings
strong evidence of its relevance.
This evolution of sleep medicine owes a lot to the improvement of sleep technology and skills
from sleep technicians.
Indeed, over the last few years, sleep studies were signicantly simplied by information
technology allowing the gap to be bridged from research to bedside. 15 years ago,
electroencephalograms were just printed. More than 1000 pages (ie, 10 kilos of paper each
night) had to be visually analyzed for sleep interpretation. Today, data is directly recorded
on digital portable polysomnographs or in the software of the sleep lab. Patient's comfort
(which is critical in sleep medicine) and reports have also improved. A better understanding
of circadian rhythms and a better screening of sleep disorders are now achievable. Home
sleep studies (respiratory studies in particular) are now routine tests even if the need to have
multiple electrodes all night long is still a constraint for the patient.
A Sleep Technician guide was necessary and we have to be grateful to Maxime Elbaz (President
of the SFTS) and also to Philips Respironics for being the initiators of the project and making the
technological innovations of sleep recording and analysis accessible and educational.
I hope this guide will lead to new developments in sleep medicine for the patients thanks to a
new wave of sleep technicians working in collaboration with physicians.
Pr Damien Lger
Centre du Sommeil et de la Vigilance
Htel Dieu, Paris APHP
Paris Descartes Faculty.
Practical aspects of sleep diagnostic 3








Preface
Over the last 20 years, sleep studies have quickly evolved. Indeed, the period of analog
recordings has shown the essential role of the sleep technician, especially concerning the
good performance of recordings: ampliers calibration, lters and gains setting and various
set-up congurations.
The advent of digital processing in the 90s launched a new and much more convenient way of
implementing polysomnography, polygraphy and actigraphy.
The role of the sleep technician is to provide the specialist with an accurate recording of the
electrical brain activity recorded over the scalp as well as cardio-respiratory variables.
The sleep technician should be able to pick out different artefacts which can hamper
sleep recording. Very recently, a diploma in sleep and wakefulness technologies allows the
technician to understand and examine what is being recorded, and also, with the help of a
sleep specialist, interpret the data. The technicians task is not only to apply electrodes,
cardio-respiratory sensors and to twiddle on buttons.
Under the auspices of Philips Respironics, it becomes clear of the need for our rst Sleep
Technician guide. This guide provides technical information about polysomnography at the
sleep lab, domiciliary sleep recording and actigraphy.
Sleep screening and diagnostics are illustrated with many pictures showing how to apply
electrodes and sensors.
Actigraphy, which is less known, is described as a very promising technique allowing a better
management of insomnia and circadian rhythm disorders.
This manual summarises also the new scoring rules of the AASM 2007, illustrated with some
concrete examples.
Finally it will help the sleep technician in his everyday practice, enhance knowledge and create
interactions between sleep professionals.
Maxime Elbaz
President of the SFTS
Chief Technologist
Centre du Sommeil et de la Vigilance
Htel-Dieu, Paris
The Sleep Technician guide 4



Preface
Growing awareness by the medical profession of the importance of sleep and its disorders
has led to a plethora of services for which there is a need for a consistent clinical approach.
Sleep medicine is a multi-disciplinary speciality encompassing a broad body of knowledge
and skills with polysomnography (PSG) the most fundamental laboratory technique for
assessment of sleep and its disorders.
The role of the sleep physiologist is to ensure the safe and accurate assessment of patients, to
aid diagnosis and effective titration of therapy.
Formal training in sleep medicine and its technology is not readily available in many countries
and the principal aim of this handbook is to act as a source material for all practitioners
working in this eld.
Anwen Evans
RPSGT, Clinical Specialist Manager
Practical aspects of sleep diagnostic 5







Acknowledgments
First, sincere thanks to Maxime Elbaz and Pr Damien Lger (Htel-Dieu, Paris) who
contributed to the realization of this project.
Thanks to Dr Marie-Franoise Vecchierini (Htel-Dieu, Paris) for reviewing early versions of
this guide.
We would like to acknowledge all hospitals who largely contributed in making this project
possible by opening their doors and allowing us to meet their technicians: Hpital Foch
(Suresnes), Hpital Priv de lOuest Parisien (Trappes), Centre hospitalier de Roubaix,
Centre Antoine Bclre (Clamart).
Many thanks to Pr Escourrou for answering our questions, welcoming us and for supporting
this project.
Thanks to Joyce Black, Pamela Minkley and Emmanuel Billaud for providing us materials and
information.
We are also grateful to Alexander Hoffmann and Pr Ingo Fietze for their work on a German
version of this book.
Thanks to Dr Philippe Grunstein (MD FRCP Consultant Physician, Norfolk and Norwich
University Hospital, Associate Professor of Medicine) and Mrs Jane Taylor, Sleep Co-
ordinator, for their precious help.
This book would not have been possible without the help of Anwen Evans (RPSGT). Many
thanks to her for reviewing early versions of this guide and for providing her helpful and
appreciated inputs.
Finally many thanks to you, our readers. May this guide be of a great support and interest in
your daily practice.
Thanks to all.
The Respironics Team,
Valrie Leroux, Biomedical Intern EAME.
Bernard Favier, Product Manager Sleep Diagnostic and Cardio EAME.
Alexander Hoffmann, PhD, Market Development Manager Sleep Diagnostic and Cardio,
Central Europe.
Emmanuel Billaud, Diagnostic Specialist, France.
The Sleep Technician guide 6

















Introduction
The need for the guideline
Sleep disorders are a signicant public health problem and there is an increasing demand for
sleep studies, due to the high prevalence and growing public awareness of sleep disorders,
especially concerning obstructive sleep apnoea (OSA) [1].
It seems desirable to produce a guide which may help those working in the eld of Sleep
Medicine to provide an efcient and cost effective delivery of service to meet the growing
needs and referrals. This guide aims to provide information about screening tools, actigraphy
and how to correctly perform a sleep study. Included are many tips and illustrations. The last
recommendations of the AASM
1
have been summarised.
This guide is not intended to be construed or to serve as a standard of medical care. Some
approaches or techniques described may differ from centre to centre and should not exclude
other acceptable methods aimed at obtaining the same goals.
For each measurement, you can nd easily the tips symbolized by Tips
and also practical aspects: Good practice
Home sleep studies and polysomnography (PSG)
The diagnosis of OSA and other sleep-related disorders has typically been based on overnight
studies performed in sleep laboratories. The most widely accepted diagnostic test for the
investigation of OSA is polysomnography (PSG), a detailed sleep study. A diagnosis of mild
OSA is conrmed when PSG reveals an AHI
2
greater than 5 events per hour of sleep and an
excessive daytime sleepiness [2]. An AHI of 5 or less is deemed to be within normal limits
and confers a negative diagnosis for OSA [3]. In addition to OSA, PSG allows physicians
to diagnose a variety of other sleep disorders, including central apnoea, periodic limb
movement, chronic obstructive pulmonary disease and narcolepsy [2].
In 1994, the ASDA
3
has classied sleep study systems into four different categories according
to their level of complexity.
1 American Academy of Sleep Medicine
2 Apnoea Hypopnoea Index
3 American Sleep Disorders Association, now the AASM
Practical aspects of sleep diagnostic 7












Table 1: Diagnostic levels of ASDA [2]
Laboratory PSG (involving at least 7 signals: EEG, EOG, Trained personnel able
chin EMG, ECG, Respiratory strength, airow, oxygen to intervene when
saturation, position +/- leg EMG). required
Type 1
Type 2 Home PSG (involving most of the same measures used
in laboratory PSG).
Trained personnel
only required in the
preparation stage of the
study
Type 3 Portable devices measuring at least 4 channels of
information (2 respiratory effort or respiratory effort
and airow, heart rate or ECG, oxygen saturation).
Type 4 Devices measuring 1 or 2 channels of information,
usually oxygen saturation and/or airow.
Devices measuring one to three channels or does not
include airow despite having four channels.
Level 4 systems are screening devices, whereas other systems are diagnostic devices
(cf. gure 1).
Figure 1: Differentiation between screening and diagnostic tests
Respiratory airflow Portable
SpO
2
devices
Respiratory effort (Screening)
Polygraphy
Position
(Diagnostic)
Snore
Polysomnography
+/- ECG
(Diagnostic)
+/- leg EMG
EEG
EOG Sleep parameters
Chin EMG
The Sleep Technician guide 8















Table 2: Advantages and limitations of respiratory polygraphy and polysomnography
Respiratory polygraphy (level 3) Polysomnography (level 1)
Main
advantages
Systems are generally more
straightforward.
Increase accessibility and throughput to
diagnosis.
Lower cost.
Set up and validation time is considerably
less.
Can be used at home in the patients
familiar environment and thus freeing up
a hospital bed for the more complicated
investigations.
Validation studies must be carried out in
sleep laboratories.
Heterogeneity of the systems available.
These systems do not record sleep
physiology and distribution of the sleep
cycle.
The AHI cannot be calculated, instead
RDI is calculated depending on the total
study time and not total sleep time.
A PSG has to be carried out if the
respiratory polygraphy study is negative
or inconclusive.
More susceptible to data loss (e.g sensor
failure), requiring repeat studies [4].
Inability to diagnose other sleep
disorders beyond OSA.
PSG allows for the accurate
physiological measurement and
sleep stage distribution.
Specic clinical endpoints
such as Sleep Onset Latency.
REM latency, sleep efciency,
AHI, Arousal index can be
calculated.
Essential for the accurate
diagnosis of certain sleep
disorders, sleep stage/state
dependent sleep disorders.
Clear directives for the staging
and scoring of sleep and events.
Medico-legal issues.
Time consuming and labour
intensive.
Complex.
Requires specialised technical
skills.
Negative laboratory effects e.g.
rst-night effect.
Location/suitable environment
required for daytime testing.
Invasive laboratory-based data
collection.
Availability.
Limitations
Practical aspects of sleep diagnostic 9




Sleep disorders diagnosis strategy (example of OSA)
Figure 2: OSA diagnosis strategy established in the RPC
4
2008 [5]
NO
High pre-test
probability of OSA?
Think about another sleep
disorder (PSG +/- MSLT
(Multiple Sleep Latency Test))
Any signs of other
sleep disorders?
Polysomnography
Is the OSA diagnosis
definite?
OSA treatment
Is the OSA
diagnosis definite?
Respiratory
Polygraphy
YES
YES
YES
YES
NO
NO
NO
References
[1] http://www.sign.ac.uk/pdf/sign73.pdf
[2] Hensley, M. J., Hillman, D. R. et al (2005), 'Guidelines for sleep studies in adults' [Internet],
Australasian Sleep Association and Thoracic Society of Australia and New Zealand.
Available from: http://www.sleepaus.on.net/guidelinesforadultsleepstudies.pdf.
[3] Chesson et al. (1997), The indications for polysomnography and related procedures,
Sleep, 20(6), 423-487.
[4] Douglas et al. (2003), Home diagnosis of the obstructive sleep apnea/hypopnea
syndrome, Sleep Med Rev, 7(1), 53-59.
[5] http://www.splf.org/s/IMG/pdf/RPC-SAHOS.pdf
4 Recommandations pour la Pratique Clinique
The Sleep Technician guide 10





A. Pre-study patient evaluation
Subjective tests (questionnaires, sleep diaries) enable a rapid and cost
effective assessment of sleepiness/alertness. Their use should be utilised as part
of a more comprehensive assessment.
Objective tests (overnight pulse oximetry, nasal pressure monitoring) are
simple, non-invasive investigations which can easily be carried out at home.
Their results may conrm suspicions and form part of a clinical decision pathway
regarding the need for and type of further investigations required.
Practical aspects of sleep diagnostic 11





1. Subjective methods: sleep diaries and questionnaires
Sleep diaries
A sleep diary is a record of an individuals sleeping and waking time and is a useful tool in
evaluating the evolution of a sleep disorder and identies sleep problems. Usually kept over
a period of several weeks [1] it is simple and easy to use and is self-reported or can be
recorded by a care-giver.
Information gained provides insight into quality, quantity and sleep/wake schedule, as well as a
record of factors which are known to affect sleep and wakefulness.
It is a useful resource in the diagnosis and treatment of poor sleep hygiene, insufcient sleep
and circadian rhythm sleep disorders. Additionally, the sleep diary is useful in monitoring
efcacy of treatment. This data alone can help people self-diagnose, raising awareness of
factors which may be affecting their ability to obtain good sleep.
Sleep diaries may be used in conjunction with actigraphy and prior to the Multiple Sleep
Latency Test and Maintenance of Wakefulness Test.
Figure 3: Example of a sleep diary
The Sleep Technician guide 12

Questionnaires: some examples
Many sleep questionnaires exist. Here are some examples.
a. The Berlin questionnaire
The Berlin questionnaire is a validated screening tool for the probability of OSA (cf gure 4).
This 10-item scale assesses the risk (high or low) of having sleep apnoea based on the
responses to the questions. It consists of 3 categories:
snoring
somnolence
overweight (BMI
5
>30) and high blood pressure
The Berlin Questionnaire, in English, performed with 62% sensitivity and 43% specicity at
the RDI
6
> 10 level [2].
Figure 4: The Berlin Questionnaire
5 Body Mass Index
6 Respiratory Disturbance Index
Practical aspects of sleep diagnostic 13














b. The Epworth Sleepiness Scale (ESS)
The Epworth Sleepiness Scale (ESS) is a widely used tool, consisting of 8 situations whereby
the patient is asked to rate their likelihood of falling asleep. It is a simple self-reporting
questionnaire, easy and quick to complete.
The individual chooses a score for each situation from a 4 point scale, with 0 being would
never doze and 4 being high chance of dozing. The total score is obtained, providing the
individuals subjective assessment of their level of sleepiness over time.
0 - 9: Average score, normal population.
10 - 24: Sleep specialist advice recommended.
The ESS obtained a relatively low sensitivity (66%) in the identication of an apnoea-
hypopnoea index >5 at the suggested cutoff of 10. The results of the study showed only fair
discriminatory ability of the ESS as a screener for OSA. It is used to assess excessive daytime
sleepiness, and is useful as a serial measurement e.g. after the administration of treatment
(e.g. CPAP) to document improvement of symptoms [3]. However, it is important to note
that subjects with high risk of cardiovascular disease and with moderate-severe OSA may be
minimally symptomatic or asymptomatic [4]. In narcolepsy, the Epworth sleepiness scale has
both a high specicity (100%) and sensitivity (93.5%) when a cut-off ESS score > 10 is used [5].
The Scale should be completed independently by both the patient and their partner as
patients can underestimate the severity of their sleepiness.
Figure 5: The Epworth Sleepiness Scale* [6]
*SLEEP. Volume 14, Issue 6,
540-545. 1991
1990-1997
MW Johns
Used under license
Permission granted by the
Associated Professional Sleep
Societies, LLC.
All rights reserved.
The Sleep Technician guide 14













2. Objective methods: Screening devices
a. Overnight pulse oximetry
The pulse oximeter is widely used in the domiciliary setting and is a useful screening tool,
helping to identify patients with Sleep Disordered Breathing.
An overnight measurement determines the frequency and extent of haemoglobin
desaturation during sleep and provides information regarding the severity of Obstructive
Sleep Apnoea.
Pulse oximetry is a well-established screening tool to determine a patients arterial oxygen
saturation and heart rate. A series of studies looking at the clinical utility, reproducibility and
adequacy of pulse oximetry for the diagnosis of sleep and breathing disorders have shown
that overnight pulse oximetry detects moderate to severe OSA well, but is less useful for
milder cases [7-8].
A sensor is placed usually on a ngertip or an earlobe, or in the case of a neonate, across a
foot, and a light containing both red and infrared wavelengths is passed from one side to the
other [1]. Based upon the ratio of changing absorbance caused by the difference in colour
between oxygen-bound and oxygen unbound blood haemoglobin, a measure of oxygenation
(the per cent of haemoglobin molecules bound with oxygen molecules) can be made.
Pulse oximeters also measure heart rate and brief increases are an indirect marker of
transient arousal from sleep. Reviewing oximeter tracings with the accompanying pulse rate
can indicate sleep fragmentation.
A more detailed overnight study will be required in patients who have a negative or
ambiguous overnight pulse oximetry result but whose symptoms are severe. Moreover, a
normal result cannot eliminate an OSA diagnosis, but it can be useful to prioritise access to
diagnostic studies for patients with a high pretest probability of OSA [9].
Good practice
1. Select a nger which is less prone to movement, on the non-dominant hand and prepare
the site by removing articial nails and nail polish.
2. Position the sensor around the carefully chosen digit with the wire on the upper side of
the hand. The light emitter and receiver should be directly opposite one another over
the nailbed.
The light source must be above the nail (cf gure 6).
Practical aspects of sleep diagnostic 15






Figure 6: Correct Figure 7: An example of pulse oximeter.
probe placement.
CAUTION:
Finger nail polish may reduce light transmission and thereby affect SpO
2
values.
Excessive movement by the patient may interfere with the signal processing of the pulse
oximeter, producing erroneous values. To avoid it, tape the wire at the end of the nger
and around the wrist. Avoid taping over the probe causing constriction and consequent
inaccurate readings.
For overnight pulse oximetry in sleep medicine, it is important that the oximeter is set to the
shortest time interval for measurement 5 seconds or less is regarded as being acceptable
[10].
Limitations (examples)
Often, patients with OSA are distinguished from non-OSA groups by the number of
desaturation events/hour, with a saturation decrease of 4%. Such denitions may lead to
false-negative oximetry results especially in younger and less obese patients who may not
exhibit desaturations despite changes in PaO
2
.
Patients who only desaturate when sleeping in a supine position may not show desaturation
if, on the night of the recording, they avoided sleeping in this position.
Some patients with minimal arterial oxygen desaturation have severe OSA.
Alone, pulse oximetry does not provide information about other causes of excessive
daytime sleepiness such as narcolepsy and periodic limb movement disorder.
Generally overnight pulse oximetry does not allow for easy differentiation of respiratory
events (hypopnoeas, Cheyne-Stokes respiration, obstructive or central apnoeas).
The Sleep Technician guide 16







b. Nasal pressure
Another parameter is nasal airow, provided by a nasal pressure cannula linked to a small
device able to determine the AHI.
It is an objective device designed to supplement other subjective methods such as
questionnaires and diaries. Together, these provide comprehensive screening to assess the
need and prioritisation for polysomnography.
Concerning the RUSleeping RTS, it has a 92% sensitivity and a 77% specicity when compared
to a polysomnography, if a cut-off AHI of 15 is used as the indication of OSA (based upon an
internal study of 25 patients).
Note: For further information about nasal cannula, see part C below.
Figure 8: RUSleeping RTS, a nasal air pressure screening device.
Good practice
The nasal cannula should be placed directly underneath the patients nose, with each of
the two prongs just below each nostril. Put surgical tape 2 cm from the nose to secure the
stability of the cannula during the night.
RUSleeping is a trademark of Respironics, Inc and its afliates.
Practical aspects of sleep diagnostic 17





References
[1] http://en.wikipedia.org/
[2] Ahmadi N, Chung SA, Gibbs A, Shapiro CM, 'The Berlin Questionnaire for sleep apnea in
a sleep clinic population: relationship to polysomnographic measurement of respiratory
disturbance', Sleep Breath 2008 Mar; 12(1):39-45.
[3] Hardinge FM, Pitson DJ, Stradling JR, 'Use of the Epworth Sleepiness Scale to demonstrate
response to treatment with nasal continuous positive airways pressure in patients with
obstructive sleep apnea', Respir Med 1995; 89(9):617-20.
[4] http://www.hkma.org/bhme/10bhme/Shao-guang%20HUANG.pdf
[5] Johns, MW, 'Sensitivity and specicity of the multiple sleep latency test (MSLT), the
maintenance of wakefulness test and the Epworth Sleepiness Scale: failure of the MSLT as
a gold standard', Journal of Sleep Research 2000 Mar; 9(1):5-11.
[6] http://www.cdha.nshealth.ca/
[7] Stradling et al., 'Adequacy of oximetry alone studies for the diagnosis of sleep and
breathing disorders', Jl Ambulatory Monitoring 1989; 2(3):197-201.
[8] Ryan PJ, et al., 'Validation of British Thoracic Society guidelines for the diagnosis of the
sleep apnoea/hypopnoea syndrome: Can polysomnography be avoided?', Thorax 1995; 50:
972-975.
[9] http://www.splf.org/s/IMG/pdf/RPC-SAHOS.pdf
[10] Farre R, Montserrat JM, Ballester E, et al., 'Importance of the pulse oximeter averaging
time when measuring oxygen desaturation in sleep apnea', Sleep 1998; 21:386-390.
The Sleep Technician guide 18





B. Use of actigraphy in sleep
medicine
What is actigraphy?
Actigraphy is a general term for a system that records and analyzes movement. The
recording instruments for actigraphy are small, computerized devices that record and store
data [1].
Actigraphs are generally watch-shaped and worn on the wrist of the non-dominant arm
but they can also be worn on the ankle or on the toes (cf. gure 9).
Figure 9: Examples of actigraphs (Actiwatch 2, Actiwatch Spectrum, Actiwatch Score and
Actiwatch Mini).
A complete actigraphy system includes an actigraph, an interface for transferring data to a
computer, and software for setting recording parameters and analyzing the digital record.
Figure 10: Example of a complete actigraphy system
Actigraphy has become an increasingly important and widespread method for measuring rest/
activity patterns in both clinical and research settings.
Actiwatch is a trademark of Respironics, Inc and its afliates.
Practical aspects of sleep diagnostic 19




Table 3 : Advantages and limitations of actigraphy
Main
advantages
Relatively low cost of the devices and scoring software;
Accessibility;
Non-invasive procedure;
Recordings may be carried out in the home over a period of time
(usually, between 1 and 3 weeks, often longer);
24hour activities may be recorded;
Useful in uncooperative patients when laboratory tests are not possible;
Longitudinal studies (e.g during therapeutic regime);
Various software applications;
Clinical utility (various sleep disorders);
Differentiate normal and disturbed sleep-wake patterns.
Limitations Do not diagnose Obstructive Sleep Apnoea;
Do not clarify the cause of Insomnia;
Do not discriminate types of movements;
Do not allow to identify sleep stages;
Overestimation of sleep during periods of quiescence;
Cannot be used if the patient suffers from a motor disorder (Parkinson)
or pathologies with abnormal movements;
Lack of standard procedures for scoring.
How it works?
With each subject movement an accelerometer generates a variable voltage that is digitally
processed and sampled. The data is later read to a computer where it can be analysed.
An actigraph records physical activity over time in 'counts'. The denition of these counts
can differ from one actigraph to another. In the Actiwatch, the data logged is the sum of the
captured counts from the individual 1-second intervals making up the epoch period.
Example for a 2-second epoch Period Highest count
1 sec 5
1 sec 10
Total Count 15
The scores (total counts) are plotted on an Actogram epoch
by epoch. The Actogram below has 16 epochs, however only
12 epochs contain activity.
The Sleep Technician guide 20




Estimating sleep and wake depends on the sensitivity level of the algorithm. Using the medium
sensitivity on the Actiwatch, for 1-minute epoch data, a total score of 40 will be enough to
designate the epoch as being Awake.
Actigraphy analysis provides sleep-wake schedule variability, sleep quantity and quality
statistics, and daytime rest-activity patterns for weeks at a time (cf. gures 12, 13). The long-
term data collected from the home environment by actigraphy also provides sleep efciency,
total sleep time and sleep start and end times not available from any other methods.
Figure 11: Example of a sleep analysis from actigraphy results
Figure 12: Actigraphy results (from ActiWatch):
Regular sleep pattern :
Practical aspects of sleep diagnostic 21







An insomniac :
A shift worker :
Note: Aqua: rest periods / Black: activity periods.
Use in sleep medicine
Actigraphy is useful for assessing sleep-wake patterns and disturbed sleep over a period of
time. It is used to clinically evaluate insomnia [2], circadian rhythm sleep disorders, excessive
sleepiness, sleep disturbances associated with periodic limb movement disorder (leg
actigraphs can be used). It is especially useful when self-reporting is not an option, as with
patients who cannot accurately or reliably self-report sleep information.
Some actigraphs can also record body temperature or light. Actigraphy plays an important
role by providing a complementary objective record of rest-wake activity over days or
weeks. Moreover, the actigraphy device is easily incorporated into the patients lifestyle
with a minimum of interaction. By combining the results of subjective diaries with objective
actigraphy data, a more complete picture of the patients rest/activity patterns over time and
sleep history is obtained.
The Sleep Technician guide 22











Validity of actigraphic measures
General conclusions are presented here but the reader is encouraged to go to the reviews
for further information.
For systems that have been assessed, studies have shown that actigraphy is indicated for
delineating sleep patterns, and to document treatment responses in normal infants and
children (in whom traditional sleep monitoring by polysomnography can be difcult to
perform and/or interpret), and in special paediatric populations [3].
Actigraphy can be used as a reliable indicator of sleep in young infants [4].
Moreover, actigraphy, when added to simplied polygraphy, may assist in the diagnosis of OSA
[5].
Clinicians should use subjective data as an adjunct to actigraphic data when evaluating total
sleep time and sleep efciency. This may be especially important in patients with disorders of
excessive somnolence (e.g. the obstructive sleep apnoea syndrome, upper airway resistance
syndrome, periodic limb movement disorder and narcolepsy) [6].
Subjective data appear to be less sensitive than actigraphy for documenting sleep
fragmentation, particularly in patients with insomnia [7].
References
[1] Butkov N., Lee-Chiong T., 'Fundamentals of Sleep Technology', Lippincott Williams &
Wilkins, 2007.
[2] Sadeh A, Hauri PJ, Kripke DF, et al., 'The role of actigraphy in the evaluation of sleep
disorders', Sleep 1995; 18(4):288-302.
[3] American Sleep Disorders Association, 'Practice parameters for the use of actigraphy in
the clinical assessment of sleep disorders', Sleep 1995 May; 18(4):285-7.
[4] So, K., Buckley, P., Adamson, TM., Horne, RS. 'Actigraphy correctly predicts
sleep behavior in infants who are younger than six months, when compared with
polysomnography', Pediatr Res Oct 2005; 58(4):761-765.
[5] Elbaz M. et al., 'Utility of actigraphy in the diagnosis of OSA', Sleep 2002 ;25(5):527-31.
[6] Kushida et al., 'Comparison of actigraphic, polysomnographic, and subjective assessment
of sleep parameters in sleep-disordered patients', Sleep Medicine 2001; 2:389-396.
[7] Chambers MJ., 'Actigraphy and insomnia: a closer look.Part I.', Sleep 1994; 17(5):405-408.
Practical aspects of sleep diagnostic 23









C.Origin and practical
aspects of physiological
measurement in Polygraphy and
Polysomnography
Polysomnography (PSG) is the most important laboratory technique for
assessment of sleep and its disorders. PSG records multiple physiological
characteristics simultaneously during sleep.
Applying the electrodes and sensors is the most important part of the sleep
study to ensure quality data.
Tips
It is essential to be well prepared; have your equipment and materials prepared and close
to hand.
Table 4: Basic supplies to perform a polysomnograph
General EEG, ECG and EMG EEG ECG Leg EMG
Non latex
gloves
Scissors
Medical tape
Impedance
meter
(optional)
Scalp, facial electrodes
Alcohol wipes (Kodan
spray)
Abrasive skin
preparation (NuPrep)
Cotton buds
EEG conductive paste
(Ten20)
Gauze 4x4 squares
Medical tape
Elastic net bandage
(optional)
EEG marker
pencil
Tape measure
EC2 paste
Disposable
ECG
electrodes
Snap pads
Gold cup
electrodes
(extra long
leads 72)
Kodan is a trademark of Schlke & Mayr. NuPrep and Ten20 are trademarks of D.O. Weaver & Co. EC2 is a
trademark of Grass Product Group.
The Sleep Technician guide 24


Always proceed in a consistent order when performing these tests. This will result in
greater efciency and speed up the process.
For example, to perform a polysomnograph, below is a suggested sequence:
Reassure the patient and explain what each sensor measures.
Biocalibration
Biocalibrations are a series of exercises performed prior to initiating a study, to verify correct
intput derivations and signal quality [1]. It is important to record them to facilitate scoring
and interpretation.
Practical aspects of sleep diagnostic 25



















Table 5: Biocalibration
Test Instructions Duration of
biocalibration
Quality signal
EEG Relax with the eyes
open and then with
eyes closed.
Move the eyes left
and right, then up
and down.
Blink the eyes.
Grit your teeth.
Relax.
Breathe in and
At least 30
seconds each
Several times
during 30
seconds period
5-10 seconds
15 seconds
Alpha waves are typically prominent in
the occipital channels with eyes closed.
Prominent deections and opposite
signals.
EMG amplitude must increase.
Be sure the EMG tracing shows an
adequate amount of baseline muscle
tone (at least 0.5 cm in amplitude).
With normal breathing, the airow
EOG
Chin EMG
Respira-
tory out through your 15 seconds channels should show a clean sine
channels mouth.
Breathe in and out
through your nose.
Hold your breath.
Count aloud to ve.
Change your body
position: Left, Right,
Supine, Prone.
Flex your left toe/leg.
Flex your right toe/leg.
5 seconds
5-10 seconds
each
wave. All the airow and respiratory
effort channels should be in phase.
During the breath hold, the
respiratory channels should show a
at line.
High degree of deection.
Take a moment to verify that the
polarity of the ECG signal is not
reversed.
All positions are indicated correctly.
Burst of activity in the recording for
each leg.
With normal breathing, the signal
should be a at line above 90% SpO
2
.
Snore
sensor
ECG
Position
sensor
Leg EMG
Oximetry
Note: Yawning, swallowing and chewing may also increase muscle tone in the chin region.
The Sleep Technician guide 26








1. EEG
Sleep is divided into two states: NREM and REM, dened by a combination of parameters
including electroencephalography (EEG), electro-oculography (EOG) and electromyography
(EMG).
NREM is divided into three stages (N1, N2 and N3) [AASM 2007].
To identify these different states and stages, including wakefulness, electrodes are placed on
the scalp in a symmetrical pattern. The electrodes measure very small voltages caused by
synchronized activity in very large numbers of synapses in the brains outer layers (cerebral
cortex). Electroencephalogram (EEG) data is represented by waveforms classied according
to their amplitude and frequency.
Amplitude refers to the vertical height of the wave, measured in microvolts.
Frequency refers to the number of waves in a 1 second span, measured as cycles per second
or Hertz (Hz).
A time constant is the time required for the current or voltage to rise or fall two-thirds of
its amplitude.
Filters are used to pass certain frequencies and attenuate others.
High-pass lter: a lter that passes frequencies above a certain value and attenuates
frequencies below that value.
Low-pass lter: a lter that passes frequencies below a certain value and attenuates
frequencies above that value.
Figure 13: EEG brain wave patterns during sleep [2]
Practical aspects of sleep diagnostic 27







Alpha waves have a frequency of 8-13 Hz and are the predominant brain waves during relaxed
wakefulness, best seen over the Occipital region and the Occipital leads (O1-M2 or O2-M1
leads).
Theta waves have a frequency of 4-7 Hz and are the predominant brain waves of stage N1.
Spindles have a frequency of 12-14 Hz with a duration of at least 0.5 seconds and along with
K-complexes are seen in N2 sleep and are usually maximal over the Central region (C4-M1,
C3-M2).
Delta waves have a slow frequency of 0.5-2 Hz and an amplitude >75 V. These dominate
in N3 sleep and are maximal over Frontal regions (F1-M2 or F2-M1). K complexes are also
maximal over the Frontal region.
The Central EEG location (C3-M2, C4-M1) is used to record the majority of brain waves, to
distinguish between the various sleep stages and are considered to be the main scoring leads.
M1 and M2 (left and right mastoid processes) are silent electrodes used as references.
See the International 10-20 electrode placement system for site locations [3]:
The letters F, T, C, P and O stand for Frontal, Temporal, Central, Parietal and Occipital
respectively. A "z" (zero) refers to an electrode placed on the midline. Even numbers (2, 4,
6, 8) refer to electrode positions on the right hemisphere, whereas odd numbers (1, 3, 5, 7)
refer to those on the left hemisphere.
Two anatomical landmarks are used for the essential positioning of the EEG electrodes:
rst, the nasion which is the point between the forehead and the nose; second, the inion
which is the lowest point of the skull from the back of the head and is normally indicated by a
prominent bump.
Usually: 3 electrodes + 2 references (mastoid processes) + 1 ground (in the middle of the forehead).
The Sleep Technician guide 28

Good practice
1) Place a tubular elastic net bandage around the patients neck. It will be useful to secure all
the EEG electrodes (optional).

2) If necessary, wipe off any excess of hair gel or spray with a piece of gauze moistened in
alcohol (Kodan Spray).
3) Patients skin preparation for electrode application (also available for EOG, ECG
and EMG)
Prepare each site by rst lightly abrading the area where the electrode will be placed. Use
a small dot of NuPrep
7
(abrasive skin preparation gel) and a piece of gauze. Abrasion is
important to decrease the skins resistance and ensure quality signals.











Good practice
1) Place a tubular elastic net bandage around the patients neck. It will be useful to secure
all the EEG electrodes (optional).
2) If necessary, wipe off any excess of hair gel or spray with a piece of gauze moistened in
alcohol (Kodan Spray).
3) Patients skin preparation for electrode application (also available for EOG,
ECG and EMG)
Prepare each site by rst lightly abrading the area where the electrode will be placed. Use
a small dot of NuPrep
7
(abrasive skin preparation gel) and a piece of gauze. Abrasion is
important to decrease the skins resistance and ensure quality signals.
7 Ref. 8052: EEG Electrode Prep (NuPrep)
Practical aspects of sleep diagnostic 29










Wipe off the abrasive cream, which is non conductive, with a piece of gauze moistened in
alcohol (Kodan Spray):
4) Electrode application
Fill the electrode cup
8
with a conductive paste Ten20
9
(you can also use the electrode
cream EC2) and apply rmly to the prepared site. The thick electrolyte adheres the
electrode to the skin surface. Further adhesion can be gained by applying a small dot of
EC2 onto a gauze swab which is then placed over the electrode.
Gold cup electrode EC2
Ten20 (or EC2)
Apply the lled cup on the appropriate site, and follow this by placing the swab (as
described above) on top.
8 Ref. 1020971: EEG/ EMG/ EOG Leads 48 (1.20 m)
Ref. 1016339: EEG/ EMG/ EOG Leads 72 (1.80 m) (recommended for leg EMG)
Ref. 1020972: EEG/ EMG/ EOG Leads 96 (2.40 m)
Ref. 1020970: EEG/ EMG/ EOG Leads 120 (3 m)
9 Ref. 8051 : EEG Electrode Cream (Ten20)
The Sleep Technician guide 30



Place all EEG electrodes by using the same skin preparation techniques outlined above.
The ground electrode should be secured with surgical tape.
Finally, connect the wires to the diagnostic device, according to the chosen leads.
Note: A1 and A2 are left and right mastoid references.
Practical aspects of sleep diagnostic 31
Tips
Placement of the Mastoid/reference electrodes:
The reference electrodes M1 and M2 are placed over the mastoid process. To decrease
artifacts, the electrodes should be placed over the attest and most bony area.
Placement of the ground electrode:
The exact location of the ground electrode is not critical, but try to avoid areas with deep
creases or wrinkles. A at area, just below the hairline works well.
Site preparation:
Clean a small section only (no larger than your electrode).
Managing the electrode leads:
Attach all electrodes with the trailing wires pointing in a common direction e.g to the top
or back of the head. After attaching the electrodes to the face and scalp, gather all the
wires together into a ponytail, making sure that no wire is pulled too tight.
Bundle the wires together and use pieces of tape or Velcro strips every 4 6 inches to
secure and reduce tangling.







-
Tips
Placement of the Mastoid/reference electrodes:
The reference electrodes M1 and M2 are placed over the mastoid process. To decrease
artefacts, the electrodes should be placed over the attest and most bony area.
Placement of the ground electrode:
The exact location of the ground electrode is not critical, but try to avoid areas with deep
creases or wrinkles. A at area, just below the hairline works well.
Site preparation:
Clean a small section only (no larger than your electrode).
Managing the electrode leads:
Attach all electrodes with the trailing wires pointing in a common direction e.g to the
top or back of the head. After attaching the electrodes to the face and scalp, gather all
the wires together into a ponytail, making sure that no wire is pulled too tight.
Bundle the wires together and use pieces of tape or Velcro strips every 4-6 inches to
secure and reduce tangling.
The Sleep Technician guide 32


2. EOG
The Electro-oculography (EOG) picks up eye activity, based on recording the electropotential
difference between the cornea and the retina (the cornea has a positive voltage output, while
the retina has a negative polarity).
There are two reasons for recording EOG. The rst is to record rapid eye movement of REM
sleep and the second to assess sleep onset which is associated with rolling eye movements.
Figure 14: EOG principle [4].
Two electrodes may be placed (the ground electrode is the one used for EEG). The
recommended derivations are E1-M2, E2-M1, but others are possible (please refer to the
AASM Guidelines).
Ground
EOG_R
(E2)
EOG_L
(E1)
E1 is placed 1 cm below the left outer canthus
E2 is placed 1 cm above the right outercanthus
Practical aspects of sleep diagnostic 33



Good practice
1) Patients skin preparation for electrode application
Place the two EOG electrodes using the same skin preparation techniques described for
EEG.
For each site: light abrasion with NuPrep (the area around the eyes is very sensitive) and
cleaning with Kodan spray.
2) Electrode application
Fill each electrode cup with Ten20. Apply the electrodes to the prepared sites, secure
with tape and trail the wire toward the others.
Finally, connect the two wires (Right and Left EOG) to the diagnostic device.
The Sleep Technician guide 34

Tips
Avoid placing the EOG electrodes directly over the temples, otherwise you will record
ECG activity.
Examples of quality signals, when the patient looks left, then right:
Practical aspects of sleep diagnostic 35




3. Chin EMG
The Electromyography (EMG) records chin muscle tone at the mentalis and submentalis
muscles.
Chin EMG is a mandatory recording parameter for staging sleep (REM vs. NREM) and is
essential to determine onset of REM. Muscle tone decreases during sleep with maximal
decrease occuring during REM.
Recorded simultaneously, EEG, EOG and chin EMG provide the basis for classifying the
different states and stages of sleep.
Figure 15: Characteristic EEG, EOG and EMG patterns for wakefulness, REM sleep and
NREM sleep. Each of the nine patterns was made over a period of about three seconds [5].
Once again, many derivations are possible In the example below, two leads are placed.
According to the AASM guidelines, three leads should be placed: 2 for recording and the
third as back up lead in case one fails. The ground is the same as the one used for EEG (in the
middle of the forehead).
EMG_C
Ground
One chin lead should be placed 2 cm to the left of the
center point.
Another chin lead is placed 2 cm to the right.
Both are placed 1 cm above the jaw line.
The Sleep Technician guide 36

Good practice
1) Patients skin preparation for electrode application
Place the two EMG electrodes using the same skin preparation techniques described for
EEG.
For each site: abrasion with NuPrep (begin by shaving the patient if necessary) and cleaning
with Kodan spray.
2) Electrode application
Apply the electrode cream (Ten20 or EC2) lled cup to the appropriate site, and secure
the electrode with tape.

Finally, connect the two wires to the headbox.
Note: You can choose either or + for chin EMG electrodes.




Good practice
1) Patients skin preparation for electrode application
Place the two EMG electrodes using the same skin preparation techniques described for
EEG.
For each site: abrasion with NuPrep (begin by shaving the patient if necessary) and cleaning
with Kodan spray.
2) Electrode application
Apply the electrode cream (Ten20 or EC2) lled cup to the appropriate site, and secure
the electrode with tape.
Finally, connect the two wires to the headbox.
Note: You can choose either or + for chin EMG electrodes.
Practical aspects of sleep diagnostic 37
Tips
Chin EMG tracings should display amplitudes of at least 0.5cm during relaxed wakefulness to
allow for the visible reduction in amplitude during the onset of REM sleep physiology.
Example of chin EMG quality signal, when the patient grits his/her teeth:




Tips
Chin EMG tracings should display amplitudes of at least 0.5cm during relaxed wakefulness
to allow for the visible reduction in amplitude during the onset of REM sleep physiology.
Example of chin EMG quality signal, when the patient grits his/her teeth:
ONCE YOU HAVE ATTACHED ALL THE SENSORS:
Similar to managing the face and scalp electrodes, it is also necessary to effectively manage
the body electrodes and sensors linking them to a unique point of attachment (e.g. on the
patients shoulder). You can use a spiral bound jacket.
The wires may be threaded up through the patients night clothes, making sure that they
are not pulled tight and sufcient slack to allow for movement. As previously, bundle them
together, securing with tape or Velcro strips every 10-15 cm.
The Sleep Technician guide 38
















4. Respiratory airow
The recognition of sleep disordered breathing requires the recording of both airow and
respiratory effort.
Thermal sensors (thermistors, thermocouples) are commonly used to record airow. The
non-quantitative signals are based on the variation between the temperature of inhaled and
exhaled air.
1. Thermal ow devices
When using the thermistor or thermocouple, a sensor is placed above the upper lip and
usually uses three wires to sense temperature changes. A wire is positioned in front of
each nare and the third one is positioned in front of the mouth. Exhaled air, warmed by the
body, heats the sensor. Inhaled air, drawn from the environment, cools the sensor. These
temperature changes are then converted to a signal that denotes airow uctuations and is
recorded as airow on the polysomnogram.
Oronasal thermal sensors are recommended to score apnoeas (see the AASM
recommendations), and they are useful, when used with a pressure sensing device, to detect
airow from the mouth.
Figure 16: Thermistors
10
(Adult, Paediatric and Neonatal)
Limitations:
Some potential problems may arise when using these devices. Environmental conditions
can adversely affect the accuracy of the readings e.g when the temperature differentiation
is minimal, a warm room, or a room that has an oscillating fan or a fan directed toward the
patient. Interpretation of the signals may be difcult and results inaccurate. If a thermal-based
sensor is used with a positive pressure device, the air owing through the mask may become
so diluted that it becomes useless or difcult to interpret.
Moreover, recording snoring or ow limitations with these devices is also difcult.
10 Ref. P1274 : Airow Thermistor Large Adult 1.5 mm
Ref. P1336: Airow Thermistor Pediatric
Ref. P1337: Airow Thermistor Neonatal
Practical aspects of sleep diagnostic 39

Good practice
The thermal sensor should be placed directly underneath the patients nose, with each of
the two prongs just below each nostril. The small mouthpiece that extends down should be
placed in front of the closed mouth, so it can detect airow when the mouth is open.
Secure the sensor in place by looping the wires around the ears and bring them together
under the chin by sliding the connector that holds the thermal sensor in place.
Additional tape can be used to fasten the wires to the cheeks to prevent the sensor from
becoming dislodged.








Good practice
The thermal sensor should be placed directly underneath the patients nose, with each of
the two prongs just below each nostril. The small mouthpiece that extends down should
be placed in front of the closed mouth, so it can detect airow when the mouth is open.
Secure the sensor in place by looping the wires around the ears and bring them together
under the chin by sliding the connector that holds the thermal sensor in place.
Additional tape can be used to fasten the wires to the cheeks to prevent the sensor from
becoming dislodged.
The Sleep Technician guide 40
Tips
The small mouthpiece that extends down should be placed in front of the closed mouth,
so it can detect airow when the mouth is open.

OK

It is recommended to tape it as described below (see pressure sensing devices).






Tips
The small mouthpiece that extends down should be placed in front of the closed
mouth, so it can detect airow when the mouth is open.
OK
It is recommended to tape it as described below (see pressure sensing devices).
Example of quality signal:
Normal breathing appears as a series of fairly equal sinusoidal waveforms.
If we only look at the temperature ow signal we may miss important diagnostic information.
Indeed, the pressure sensor is extremely accurate and very sensitive to changes in the
airow.
Thats why the sensor recommended to identify hypopnoeas is a nasal air pressure
device.
Practical aspects of sleep diagnostic 41



Good practice
The cannula
11
placement is quite the same as described above for the thermal sensor.
Put surgical tape 2 cm from the nose to ensure cannula stability during the night.

Example of quality signal:
Example of apnoea detection (red lines):



2. Pressure sensing device
This pressure sensing device uses a nasal cannula connected to a very sensitive pressure
transducer and produces a qualitative signal quite comparable to the pneumotachograph
(most accurate quantitative way of measuring airow but unrealistic to use in a clinical
setting).
The oral/nasal prongs may be used to monitor oral breathing. The tip of the oral cannula
should be trimmed to lie where the upper and lower lips meet.
Good practice
The cannula
11
placement is quite the same as described above for the thermal sensor.
Put surgical tape 2 cm from the nose to ensure cannula stability during the night.
Example of quality signal:
Example of apnoea detection (red lines):
11 Ref. P1301: Pro-Flow, Adult, 10 per pk
Ref. P1302: Pro-Flow, Pediatric, 10 per pk
Ref. P1303: Pro-Flow, Pediatric Small, 10 per pk
The Sleep Technician guide 42
Tips
Always check polarity of nasal pressure sensors:
List of common issues when using a cannula:
Common Issues Possible Explanations Possible Solutions
Loss of inspiratory
or expiratory ow
or a complete loss
of the signal
Prongs are coming out of the
nares
Secure the cannula with tape
Prongs are too long, they may
lie against the nasal membrane
Prongs may be trimmed
The patient has severe
rhinorhea, the mucus can cause
a complete blockage of the
lumen of the nasal cannula
Change the cannula
The batteries of the pressure
transducer may be dead
Make sure the batteries are
fresh or change them
The signal is poor
or seems chaotic
The lter settings for the AC
amplier may be incorrect
Highest acceptable setting =
0.05 Hz, time constant= 3s.
If the correct lter settings are
not available, a DC amplier
may need to be used
Note: AC means Alternating Current and DC means Direct Current.







Tips
Always check polarity of nasal pressure sensors:
List of common issues when using a cannula:
Common Issues Possible Explanations Possible Solutions
Loss of inspiratory
or expiratory ow
or a complete loss
of the signal
Prongs are coming out of the
nares
Secure the cannula with tape
Prongs are too long, they may
lie against the nasal membrane
Prongs may be trimmed
The patient has severe
rhinorhea, the mucus can cause
a complete blockage of the
lumen of the nasal cannula
Change the cannula
The batteries of the pressure
transducer may be dead
Make sure the batteries are
fresh or change them
The signal is poor
or seems chaotic
The lter settings for the AC
amplier may be incorrect
Highest acceptable setting =
0.05 Hz, time constant= 3s.
If the correct lter settings are
not available, a DC amplier
may need to be used
Note: AC means Alternating Current and DC means Direct Current.
Practical aspects of sleep diagnostic 43




Frequently asked questions
Can I use an oxygen cannula instead of a nasal pressure airow cannula?
Yes, but
A nasal pressure cannula is much more sensitive than a simple 02 cannula, especially in terms
of detection of snoring. Moreover, it is better to use a nasal pressure cannula with a lter.
This lter will protect the sensor against humidity.
Examples of signals when in both cases the patient is snoring:
Can both end-tidal CO
2
and the nasal pressure airow system be used at the
same time?
Since both end-tidal CO
2
and the nasal pressure airow system use a nasal cannula, it would
be necessary to use a dual lumen cannula. These are commercially available.
The Sleep Technician guide 44


When all the sensors are placed on the patients head, you can use the elastic net
bandage to secure them (optional). Cut it and possibly do a knot at the top of the head.
Practical aspects of sleep diagnostic 45

Secure the snore microphone to the patients neck, lateral to the larynx, to obtain the
maximum signal output (the Pro Tech logo should be facing away from the patient).
The lead wire should be looped and securely taped in place to provide additional strain relief
in the event of the patient pulling on the wire.
Example of quality signal when the patient is snoring:


5. Snore sensor
Snoring is the low frequency sound produced by vibrations of the upper airway during sleep.
Habitual heavy snoring is the most commonly reported symptom of Upper Airways
Resistance Syndrome (UARS) and Obstructive Sleep Apnoea and Hypopnoea Syndrome
(OSAHS).
1.Microphone
A microphone can simply record the sounds produced when the patient is snoring.
Figure 17: Snore microphone Pro-tech
12
-
Good practice
Secure the snore microphone to the patients neck, lateral to the larynx, to obtain the
maximum signal output (the Pro-Tech logo should be facing away from the patient).
The lead wire should be looped and securely taped in place to provide additional strain
relief in the event of the patient pulling on the wire.
Example of quality signal when the patient is snoring:
12 Ref. P1716: Snore microphone
The Sleep Technician guide 46


Locate the sensor onto the neck in an area that gives maximum signal on the recording
device. The sensor and lead wire should be carefully secured in position using surgical tape.
Many placements are possible on the throat, but avoid placing the sensor directly over the
carotid artery, otherwise you will record ECG and pulse sounds may obscure the airow
sounds you wish to record.
Connect the sensor to the diagnostic device.

Tips
To locate the best position, place 2 ngers on the patients throat and ask him/her to hum.
The sensor should be placed and secured over the area with the strongest vibration.




2.Piezo snoring sensor
A piezo snoring sensor allows you to record snoring vibrations from the side of the neck by
converting these vibrations into different voltages.
Figure 18: Piezo snore sensor Pro-Tech
13
Piezo
Good practice
Locate the sensor onto the neck in an area that gives maximum signal on the recording
device. The sensor and lead wire should be carefully secured in position using surgical tape.
Many placements are possible on the throat, but avoid placing the sensor directly over the
carotid artery, otherwise you will record ECG and pulse sounds may obscure the airow
sounds you wish to record.
Connect the sensor to the diagnostic device.
Tips
To locate the best position, place 2 ngers on the patients throat and ask him/her to hum.
The sensor should be placed and secured over the area with the strongest vibration.
13 Ref. P1696: Piezo snore
Practical aspects of sleep diagnostic 47








3.From nasal pressure cannula
When the signal from airow sensor cannula is unltered, snoring is superimposed on the
airow waveform signal.
As the frequency of snoring (10-70 Hz) is higher than the airows frequency (0.05 Hz-5 Hz),
snoring can be obtained by ltering the input airow waveform.
The PTAF Lite
14
is a small pressure-sensing transducer having two different outputs.
The ltered output signal consists of the nasal pressure airow waveform without the
superimposed snoring. When snoring with ow limitation occurs with the ltered signal, a
attening of the waveform is observed.
14 Ref. P1304 : PTAF Lite for Alice 5
The Sleep Technician guide 48






6. ECG
The Electrocardiography (ECG) is the record of the electrical potential changes in the cells
created by hearts activity via skin electrodes.
Recording the electrical activity of the heart in order to:
measure the heart rate evolution and notice any signs of cardiac arrhythmias which may be
linked to sleep disorders;
conrm some sleep events such as arousals;
measure the Pulse Time Transit.
To show changes that may occur in the signal, electrodes have to cross the heart. Thats why
leads may be placed in all three positions or in RA (right arm) and LA (left arm) or RA and LL
(left leg). The left leg electrode must be placed below the level of the heart.
One lead is placed approximately 35 cm below the right clavicle.
Another lead is placed four intercostals spaces up on the left rib cage or at the level of the
seventh rib.
ECG
RA
LL
ECG
RA
LL RL
Note: The ground electrode is the one used for EEG. Nevertheless, if EEG is not included in the
sleep study (e.g. for a respiratory polygraphy), RL (Right Leg) using torso electrode placement is
recommended to place the ground electrode. Do not use 2 ground electrodes!
Practical aspects of sleep diagnostic 49

Good practice
1) Patients skin preparation for electrode application
Place the two ECG electrodes using the same skin preparation techniques described for
EEG.
For each site:
For each site: abrasion with NuPrep (begin by shaving the patient if necessary) and cleaning
with Kodan spray.
2) Electrode application
Snap the electrode to the lead before applying to the patients skin.
Peel off the backing from the electrode and apply each of the adhesive electrodes
15
gel side
down on to the prepared sites. Secure them with tape if necessary.
Feed the wires through the patients night clothes and bundle with the other sensors.

Connect the wires
16
to the diagnostic device.













Good practice
1) Patients skin preparation for electrode application
Place the two ECG electrodes using the same skin preparation techniques described for
EEG.
For each site: abrasion with NuPrep (begin by shaving the patient if necessary) and cleaning
with Kodan spray.
2) Electrode application
Snap the electrode to the lead before applying to the patients skin.
Peel off the backing from the electrode and apply each of the adhesive electrodes
15
gel side
down on to the prepared sites. Secure them with tape if necessary.
Feed the wires through the patients night clothes and bundle with the other sensors.
Connect the wires
16
to the diagnostic device.
Example of quality signal:
15 Ref. 1016360 : adult ECG electrodes (3M Red Dot)
Ref. 1016361 : infant ECG electrodes
16 Ref. 1016362 : ECG Lead Set 4 Wire, 72
The Sleep Technician guide 50







7. Respiratory effort
Breathing, and breathing events, can be assessed by measuring chest and abdominal wall
movement. The essential task is to demonstrate respiratory effort to distinguish between an
obstructive apnoea (respiratory effort) or central apnoea (lack of effort).
There are a variety of methods currently used in PSG to evaluate respiratory effort.
1. Oesophageal manometry
It is one of the most accurate methods of measuring respiratory effort. Oesophageal
pressure (Pes) is measured by inserting a pressure catheter through the nasal cavity and into
the oesophageal tract, remaining there throughout the sleep study. Rhythmic uctuations in
thoracic pressure in the absence of signicant nasal and oral airow are the best proof of the
presence of obstructive apnoea.
End-tidal or transcutaneous CO
2
monitoring, or pulse oximetry, may reveal obstructive
hypoventilation, but these methods miss many respiratory eventrelated arousals that are
detected by Pes [6]. In clinical practice however the procedure is not used routinely as the
procedure is invasive and very uncomfortable for most patients and the catheter is difcult to
place.
Another measure of respiratory effort can be obtained by measuring changes in chest and
abdominal volume, known as plethysmography.
Practical aspects of sleep diagnostic 51








2. Elastometric (Piezo-electric) Plethysmography
In Elastometric plethysmography an elastic belt is fastened around the chest or abdomen
which will exhibit a change in tension as the chest or abdomen expands or contracts. This
change in tension is easily measured and converted to a voltage by a piezo-electric sensor.
This sensor is a crystal that directly generates a voltage when compressed or stretched.
Figure 19: Piezo belts Pro-Tech
17
Thoracic belt
Abdominal belt
Advantages:
This method is quite simple and inexpensive.
Limitations:
This method is subject to trapping artefact. It is fairly easy to imagine how a portion of
elastic belt may become trapped as a person turns from one side to another, resulting in
variable tension along the belt circumference. Thus this method can both signicantly under
and/or overestimate the actual degree of chest or abdominal movement. Additionally, the
piezo crystal is only located on a very small section of the belt. So when the patient is lying
on the top of the piezo crystal, the effort signal can be dampened or not detected. This may
produce erroneous readings or unexplained changes in polarity resulting in false paradoxical
breathing events being recorded.
17 Ref. P1586 : CT2 Adult Alice 5
Ref . P1587 : CT2 Paediatric Alice 5
The Sleep Technician guide 52

Good practice
The thoracic belt is placed around the breast for men (near the nipple line) or around the
upper breast for women.
The abdominal belt is placed around the abdomen (belly button). The piezo crystal is
near the connection and should be placed on the front side of the patient. To avoid any
movements of the sensor, secure the belts with tape.
The belts should be tight enough around the patient to achieve optimal readings based
on subtle thoracic and abdominal movements, but not too tight to restrict the patients
breathing. When applying the belts, it is important that they do not get twisted, as this can
limit the belts ability to monitor subtle changes in effort.

Example of quality signal:
Tips
Ask the patient to fold their arms to assess whether the thoracic belt is tight enough.




Good practice
The thoracic belt is placed around the breast for men (near the nipple line) or around the
upper breast for women.
The abdominal belt is placed around the abdomen (belly button). The piezo crystal is
near the connection and should be placed on the front side of the patient. To avoid any
movements of the sensor, secure the belts with tape.
The belts should be tight enough around the patient to achieve optimal readings based
on subtle thoracic and abdominal movements, but not too tight to restrict the patients
breathing. When applying the belts, it is important that they do not get twisted, as this can
limit the belts ability to monitor subtle changes in effort.
Example of quality signal:
Tips
Ask the patient to fold their arms to assess whether the thoracic belt is tight enough.
Practical aspects of sleep diagnostic 53








3. Respiratory Inductance Plethysmography (zRIP)
Calibrated inductance plethysmography can quantitatively estimate chest and abdominal
movement [7].
zRIP relies on the principle that a current applied through a loop of wire generates a
magnetic eld normal for that orientation of the loop. Any change in the area enclosed by
the loop creates an opposing current within the loop directly proportional to the change in
the area. With a zRIP system, a zigzagging coiled wire is sewn into an elastic belt. This belt
can be worn around the chest or abdomen. An alternating current is passed through the belt,
generating a magnetic eld. Breathing changes the shape of the magnetic eld generated by
the belt, inducing an opposing current that can be measured.
Advantages:
The signal produced is linear and is a fairly accurate representation of the change in cross-
sectional area. In addition, RIP does not rely on belt tension and is not affected by belt
trapping.
Be careful:
There are conditions that can decrease the accuracy of a zRIP device. If the belts are placed
too tight, causing the actual cross-sectional change of the chest or abdomen to be restricted,
it will not reect the patients true breathing efforts. If the belts are placed too loosely, the
belts will have a tendency to move and may overlap one another.
Another consideration is belt placement. For example, if a zRIP effort belt is placed around the
hips, there will be little to no change in the cross-sectional area during diaphragmatic excursions.
The Sleep Technician guide 54
Cover 80% of the patients circumference, the other 20% allows for belt stretching.




Tips
Cover 80% of the patients circumference, the other 20% allows for belt stretching.
Note: Mathematical summing of the chest and abdominal signals is particularly useful as a
screen for paradoxical breathing. The more out of phase the signals are becoming, the smaller the
sum channel will be.
Figure A
Chest
Abdomen
Sum
Chest
Abdomen
Sum
Chest
Abdomen
Sum
Complete addition summing
Phase shift and decrease in sum
Exact paradox (phase and amplitude)
Figure B
Figure C
Figure D
Figure A shows normal breathing.
Figure B demonstrates what
occurs during phase shifting,
which is causing the sum channel
to show alterations in the
waveform.
Figure C and D demonstrate
what occurs with a patient who
is having paradoxical breathing
at night, causing the sum
channel to be at.
Practical aspects of sleep diagnostic 55

8. Position sensor
Some obstructive apnoeas are position-dependent. When conducting and reporting on a PSG
or CPAP titration study, it is important to know whether the patient has slept in all positions
to accurately gauge the true severity and appropriate titration.
Thanks to a gravity switch, the body position sensor provides a signal that is directly
proportional to the patient's sleeping position (supine, prone, left, right or upright).
Body position sensor is placed on the thoracic belt.
Figure 20: Body position sensor Pro-Tech
18
Note: A position sensor is included into the Alice PDx device.
Example of quality signal:
Note: 'Do' means 'Dos' (Supine position).
18 Ref. P1694 : Body position sensor Alice 5
The Sleep Technician guide 56



Good practice
1. Select an appropriately sized strap, usually the large PLM strap for the foot and the small
PLM strap for the wrist. Carefully place the PLM Sensor element into the sensor pocket of
the strap assembly. Secure into place by closing the Velcro ap.
2. Place the strap assembly around the patient's ankle or wrist. Straps should be slightly snug,
but not to the point of patient discomfort.
3. Run the lead wires up the patients legs or arms to the recorder. Tape the wire leads to
provide strain relief to the sensors. Tape may also be used further up the patients legs or
arms to prevent the wires from being pulled on.
Figure 21: Limb movement sensor Pro Tech
19
Example of signal obtained with periodic limb movements:






9. Limb Movement sensor
The limb movement sensor is useful to diagnose PLMS (Periodic Limb Movements in Sleep),
leg movement associated with a respiratory event and limb activity associated with nocturnal
seizures.
This sensor is placed on the wrist or ankle and produces a signal that is directly proportional
to the hand or leg movement. Usually a piezo element converts every movement to a small
analogue voltage that provides an indication of that movement.
It is NOT the recording of the muscle activity (EMG).
-
Good practice
1. Select an appropriately sized strap, usually the large PLM strap for the foot and the small
PLM strap for the wrist. Carefully place the PLM Sensor element into the sensor pocket
of the strap assembly. Secure into place by closing the Velcro ap.
2. Place the strap assembly around the patient's ankle or wrist. Straps should be slightly
snug, but not to the point of patient discomfort.
3. Run the lead wires up the patients legs or arms to the recorder. Tape the wire leads to
provide strain relief to the sensors. Tape may also be used further up the patients legs
or arms to prevent the wires from being pulled on.
Figure 21: Limb movement sensor Pro-Tech
19
Example of signal obtained with periodic limb movements:
19 Ref. P1697 : Piezo PLM
Practical aspects of sleep diagnostic 57







Good practice
1) Patients skin preparation for electrode application
Place the EMG electrodes using the same skin preparation techniques described for EEG.
For each leg, abrasion with NuPrep (begin by shaving the patient if necessary) and cleaning
with Kodan spray (alcohol).
2) Electrode application
Fill the electrode cups with Ten20.


10. Leg EMG
The monitoring of the Anterior Tibialis muscle is needed to diagnose PLMS (Periodic Limb
Movements in Sleep). History alone is not sufcient to determine whether PLMs in sleep are
present [8, 9]. Leaving off the leg EMG electrodes would mean missing at least some cases of
other important sleep-related diagnoses [10].
Movement activity from both legs should be monitored during a PSG. Two electrodes should
be placed on the lower half of each leg. The anterior tibialis muscle runs along side the tibia
bone, on the outside of the shin.
Note: The ground electrode is the one used for EEG. Nevertheless, if leg EMG is recorded alone, RL
using torso electrode placement is recommended to place the ground (see ECG).
EMG_L EMG_R
Good practice
1) Patients skin preparation for electrode application
Place the EMG electrodes using the same skin preparation techniques described for EEG.
For each leg, abrasion with NuPrep (begin by shaving the patient if necessary) and cleaning
with Kodan spray (alcohol).
2) Electrode application
Fill the electrode cups with Ten20.
The Sleep Technician guide 58
Tips
To locate the anterior tibialis muscle: ask the
patient to ex the foot back and forth to see the
muscle move.
You may align the electrodes so that they
are inline with each other vertically. Placing
electrodes in this manner will help eliminate
ECG artefact. The distance between the two
electrodes should be approximatively between 2
and 5 cm.
Once located, apply the two electrodes and secure them with tape. Be careful that the two
tapes do not touch each other to avoid any electrical connection between the two leads.
A stress loop should be used after both electrodes are attached to decrease the likelihood
of them being pulled off during the study.
To manage the long leg leads, thread them up through the patients night clothes, securing
to the leg and thigh with tape at 10 15 cm intervals.












-
Tips
To locate the anterior tibialis muscle: ask the
patient to ex the foot back and forth to see the
muscle move.
You may align the electrodes so that they are inline
with each other vertically. Placing electrodes in
this manner will help eliminate ECG artefact. The
distance between the two electrodes should be
approximatively between 2 and 5 cm.
Once located, apply the two electrodes and secure them with tape. Be careful that the
two tapes do not touch each other to avoid any electrical connection between the two
leads.
A stress loop should be used after both electrodes are attached to decrease the likelihood
of them being pulled off during the study.
To manage the long leg leads, thread them up through the patients night clothes, securing
to the leg and thigh with tape at 10-15 cm intervals.
Example of quality signal (when the patient is asked to move his feet):
Practical aspects of sleep diagnostic 59


Good practice
Select a nger which is less prone to movement, on the non dominant hand and prepare the
site by removing articial nails and nail polish.
Position the sensor around the carefully chosen digit with the wire on the upper side of
the hand. The light emitter and receiver should be directly opposite one another over the
nailbed.
Excessive movement by the patient may interfere
with the signal processing of the pulse oximeter,
producing erroneous values. To avoid this, use
tape to secure the wire at the end of the nger,
around the wrist. Avoid taping over the probe
itself as this may cause constriction and
consequent inaccurate readings.
Alternative sites may be the toe or ear lobe.
Connect the wire to the diagnostic device.












11. Pulse Oximetry
Pulse oximetry is described in chapter A.2.
Pulse oximetry records both pulse and oxygen saturation.
In PSG, some hypopnoeas are dened by desaturations, and oximetry is useful to measure the
Pulse Transit Time (see below).
-
Good practice
Select a nger which is less prone to movement, on the non-dominant hand and prepare
the site by removing articial nails and nail polish.
Position the sensor around the carefully chosen digit with the wire on the upper side of
the hand. The light emitter and receiver should be directly opposite one another over the
nailbed.
Excessive movement by the patient may
interfere with the signal processing of the pulse
oximeter, producing erroneous values. To avoid
this, use tape to secure the wire at the end of
the nger, around the wrist. Avoid taping over
the probe itself as this may cause constriction
and consequent inaccurate readings.
Alternative sites may be the toe or ear lobe.
Connect the wire to the diagnostic device.
The Sleep Technician guide 60








12. Pulse Transit Time
Pulse Transit Time (PTT) is not a measure but a calculation. It refers to the time it takes a
pulse wave to travel between two arterial sites. In other words, PTT is the time between the
heartbeat and the arrival of the blood pressure wave to peripheral site such as the nger.
Study data has shown that PTT can provide a non-invasive estimate of inspiratory effort and
a measure of arousals that can be used to document obstructive sleep apnoea/hypopnoea
syndrome, central sleep apnoea, RERAs (Respiratory Effort Related Arousal) and response to
treatment.
Calculating PTT involves the use of an ECG for the recognition of the R wave and oximetric
photoplethysmography (e.g. pulse oximeter) to assess the arrival of the pulse wave in the
periphery.
PTT is calculated as the interval between the ECG R wave and the subsequent arrival of the
pulse wave at the nger (usually the point on the pulse waveform that is 50 percent of the
height of the maximum value).
An acute rise in blood pressure causes vascular tone to increase causing the arterial wall
to stiffen, the pressure wave to travel faster and the PTT to decrease. When arterial blood
pressure falls, vascular tone decreases, which increases PTT value. Thus, PTT is inversely
proportional to blood pressure.
Figure 22: Calculation of PTT when OSA occurs
PTT was validated as an indirect way of assessing repiratory efforts during sleep [11, 12]. As it
is non-invasive, it seems to be really useful in paediatrics [13].
Practical aspects of sleep diagnostic 61




Limitations:
The major drawback of PTT measurement is a lack of respiratory sampling. This is due
to the fact that only one value is available per pulse wave. Under certain conditions, the peak
may be missed because the minimal value of Pes does not happen concurrently with a QRS
complex. As a result, a given maximum PTT value may or may not correspond to the lowest
point of the Pes [14].
A second drawback of PTT is that a reliable assessment of PTT is not possible in patients with
cardiac arrhythmias. Extra systole produces acute variations in PTT despite the absence
of a respiratory event or microarousal.
13. Video recording
Video and audio recording is useful to:
observe the patients behaviour during the sleep study
evaluate parasomnias, nocturnal seizures and other motor events in sleep
monitor snoring or vocalization during sleep
Watemberg et al. [15] demonstrated that adding video recording to routine EEGs increases
diagnostic yield of routine EEGs in children with frequent paroxysmal events.
Figure 23: Infrared projector and video camera
The Sleep Technician guide 62










14. Types of artefacts
Regardless of how well the electrodes and sensors have been applied, over time and with
movement, slippage or some degree of artefact can be expected to occur during a sleep
study. These artefacts may originate from the patients body, instrumentation or the
environment.
Technicians need to be able to recognise artefacts, their cause and how or if they can clear up
the signal, to avoid any misinterpretation and ensure a quality study. The interpretation of a
PSG can be considered as a pattern recognition exercise.
Tips
The troubleshooting enquiry should begin with checking all impedances, which should be
within the recommended values.
Next, methodically check the pathway, starting with the patient and follow the path of
the signal to the recording device.
If the artefact is generalised (involving most channels), the likely source is the ground
electrode.
If the artefact is localised (limited number of channels), ask the question Which channels
have this artefact in common, and what is common to the channels involved?
If the artefact is isolated to a single channel, the source of the problem is easily identied
and usually rectied by reapplying the specic electrode.
The artefact may have a common factor e.g reference electrode M1 or M2.
Often, artefacts originate from the side of the head or face on which the patient is lying,
causing direct pressure on the electrode.
Practical aspects of sleep diagnostic 63















Sources Artefacts Causes Recognition Correction
(if required)
Environ-
mental
50/60 Hz Poor electrode
connection, high
impedance, broken
wire or unplugged
lead. Aggravated
by electrical
equipment,
telephones, pager
systems etc.
Often shows
as a uniform
monorhythmic signal/
banding.
See example below.
Use of a
patient-ground
connection
Low and relatively
equal impedance
levels among the
electrodes
In the leg EMG
channels: use of a
50/60 Hz Notch
lter
In the EEG or
EOG channels:
no lter, but
causes should
be identied and
corrected.
The Sleep Technician guide 64



















































Sources Artefacts Causes Recognition Correction
(if required)
Electrodes/
Electrode
1. Direct pressure More pronounced 1. Change the pa-
instrumen-
pops
against one of the and abrupt than tients position.
tation
Artefacts
in the
respiratory
channels
Oximetry
Artefacts
specic
to digital
recording
systems
eye electrodes, ag-
gravated by body
movement, associ-
ated with patients
breathing.
2. A broken lead.
3. Faulty electrodes.
4. Poor connec-
tion or insufcient
electrolyte paste.
Own limitations
of each sensor.
Possible
causes include:
displacement,
effect of
temperature,
signal distortion
due to body
movements.
Improper probe
attachment
Probe displacement
Poor perfusion
Motion artefact
Imprecise
calibrations
Faulty oximeter/
computer
interface
System specic
artefacts
1. when no con-
nection is made
with the patient
2. when intermit-
tent signal loss
occurs
3. or generated by
the system refer-
ence electrode
sweat artefacts. May
have a signal blocking
appearance. Usu-
ally limited to one
electrode. Often
synchronous with
respiration.
Cross-examine all
available respiratory
channels.
Erroneous SpO
2
values.
1. Recording of non-
physiological signals
that resemble the
EEG
2. Generation of
a at line (can be
misinterpreted as an
asystole in the ECG
channel)
2. Change the
broken lead.
3. Check the con-
nection is secured.
4. Check the elec-
trode contact and
rell the cup with
conductive paste.
Unavoidable, but
be aware of the
specic properties
of these devices.
Consider changing
the lter settings.
Reapply the probe
if it is displaced.
Use a different
digit/site.
Unavoidable.
Practical aspects of sleep diagnostic 65


































Sources Artefacts Causes Recognition Correction
(if required)
Irrelevant Sweating Perspiration Chaotic, random Cool the room
physiologi- slow-oscillating wave
with a fan or air
cal signals patterns with exces-
conditioning
sive baseline swaying,
Can be prevented
producing very slow-
frequency waves, of-
ten synchronous with
respiration. It may
look like delta waves,
by paying
attention to
the quality of
the electrode
application
and might result in
overscoring of NREM
stage 3 (N3).
Muscle Localised muscle Similar to 50/60 Hz Allow time for the
activity next to an patient to relax,
electrode you will often nd
that the artefact
cleans up without
the need for inter-
vention.
ECG
Increases in pro- ECG appears in the In some cases, a
portion to the EEG, EOG or EMG small amount of
distance between channels. ECG artefact is un-
the exploring avoidable, particu-
and reference larly when studying
electrode. obese patients.
More promi- Avoid soft, fatty
nently when the tissue when apply-
electrode place- ing the reference
ment follows the EEG electrodes.
electrical axis of Attach the elec-
the heart, which trode higher up
may be horizon- on to a more bony
tally deviated in foundation.
morbidly obese In the EMG
individuals. channels (rare):
Occurs when it indicates poor
the electrode is electrode place-
placed over the ment, or unequal
scalp arteries. electrode imped-
ances.
The Sleep Technician guide 66

































Sources Artefacts Causes Recognition Correction
(if required)
Irrelevant Movement
Body movement.
Mixture of arte- Unavoidable but
physiologi-
Head movements
facts (e.g. muscle, minimised by
cal signals
associated with
electrode popping). practicing proper
respiration often
result in artifact
Often shown as a
squaring off or block-
ing of the upper and
electrode applica-
tion techniques +
use of strategies
on the EEG,
lower point of the for preventing pa-
obscuring true
waveform. tients from pulling
cerebral activity. the leads.
Eye move- 1. Direct pressure Atypical (usually 1. Consider chang-
ment on eye electrodes. increased density of) ing the patients
2. Medication (e.g. eye movements. Can position. Deciding
SSRIs). be misinterpreted as whether to change
3. Prosthetic eye. REM sleep. Staging an electrode and
4. Eye disease af- REM becomes dif- possibly waking the
fecting the retina cult in the absence patient requires
or muscle. of (or unilateral) eye careful judgement!
movement.
Skull de- E.g. fractures, Higher frequencies, Unavoidable.
fects damage caused by delta slowing
cranial surgery or
irradiation.
Chewing/ In the case of High muscle activity Unavoidable.
bruxism Bruxism, should recorded in the chin
not be considered EMG. Bruxism is
as artifact, but a characterized by a
true physiological series of tooth grind-
signal of interest. ing that is often as-
sociated with arousal
and rhythmic EMG
artefacts.
For further information, please refer to:
[1] Butkov N., Lee-Chiong T., 'Fundamentals of Sleep Technology', Lippincott Williams & Wilkins,
2007.
[16] Butkov N., 'Atlas of Clinical Polysomnography (vol II)'. Medford, OR, Synapse Media, 1996.
Practical aspects of sleep diagnostic 67




EXAMPLES OF COMMON ARTEFACTS
Example 1: 50/60 Hz artefact in the EOG and EEG channels.
AFTER CORRECTION:
Example 2: Muscle artefacts in the EOG and EEG channels [16].
In this example, the source of the artefact is the reference (M2) electrode, shared by both
channels. Note that the chin EMG also shows a relatively high level of muscle activity; this is
not considered as an artefact, because the chin EMG is specicially intended for recording
muscle activity in the chin region, which is normally elevated during wakefulness and NREM
sleep.
The Sleep Technician guide 68
Example 3: ECG artefacts in the
EOG and EEG channels [16].
Example 4: Electrode popping artefact in the chin EMG channel [16].
Example 5: Sleep bruxism [16].
Practical aspects of sleep diagnostic 69


15. Summary of drug effects on Sleep
architecture
Substance SL TST REM Spindles WASO 1 & 2 SWS OSA PLMS
Barbiturates !
!
!
!
!
!
n
n
n
!
!
!
!
!
!
!
!
!
n
n
!
!
!
n
n
!
n
n
n
n
n
!
!
n
!
n
n
Benzodiazepine
'Z'- Drugs
MAO's
SSRI's
Antihistamines
Melatonin
Alcohol
Amphetamines
Glossary
SL: Sleep Latency
TST: Total Sleep Time
REM: Rapid-Eye Movements sleep
WASO: Wake time After Sleep Onset
SWS: Slow Wave Sleep
OSA: Obstructive Sleep Apnoea
PLMS: Periodic Limb Movements of Sleep
Z-drugs: nonbenzodiazepine drugs with effects similar to benzodiazepines which are used in
the treatment of insomnia.
MAOs: MonoAmine Oxidase (antidepressant)
SSRIs: Selective Serotonin Reuptake Inhibitors (antidepressant)
References
[1] Butkov N., Lee-Chiong T., 'Fundamentals of Sleep Technology', Lippincott Williams &
Wilkins, 2007.
[2] http://www.aolhealth.com/sleep-disorders/learn-about-it/sleep-mechanics
[3] http://www.bem./book/13/13x/1302ax.htm
[4] http://ee.ucd.ie/~smeredith/EOG_index.html
The Sleep Technician guide 70












[5] http://science.education.nih.gov/supplements/nih3/sleep/guide/info-sleep.htm
[6] Guilleminault C, Pelayo R, Leger D, Clerk A, Bocian RCZ, 'Recognition of sleep-
disordered breathing in children', Pediatrics 1996; 98:871-82.
[7] Cantineau JP, Escourrou P, Sartene R, et al., 'Accuracy of respiration inductive
plethysmography during wakefulness and sleep in patients with obstructive sleep apnea',
Chest 1992; 102:1145 -1151.
[8] Picchietti DL, England SJ, Walters AS, Willis K, Verrico T, 'Periodic limb movement
disorder and restless legs syndrome in children with attention-decit hyperactivity
disorder', J Child Neurol 1998; 13:588 -594.
[9] Picchietti DL, Underwood DJ, Farris WA, Walters AS, Shah MM, Dahl RE, Trubnick
LJ, Bertocci MA, Wagner M, Hening WA, 'Further studies on periodic limb movement
disorder and restless legs syndrome in children with attention-decit hyperactivity
disorder', Mov Disord 1999; 14:1000 -1007.
[10] Walters AS, 'Restless legs syndrome, PLMs in sleep and other sleep related movement
disorders', In: Jankovic J and Tolosa E, editors. Parkinson's disease and movement
disorders, 3rd edition. Baltimore, MD: Williams & Wilkins, 1998, p. 601 -621.
[11] Pitson DJ, Stradling JR, 'Value of beat-to-beat blood pressure changes, detected by pulse
transit time, in the management of the obstructive sleep apnoea/hypopnoea syndrome',
Eur Respir J 1998 ; 12:685-92.
[12] Argod J, Ppin J-L, Smith RP, Lvy P, 'Comparison of esophageal pressure with pulse
transit time as a measure of respiratory effort for scoring obstructive nonapneic
respiratory events', Am J Respir Crit Care Med 2000; 162:87-93.
[13] Katz ES, Lutz J, Black C, Marcus CL, 'Pulse transit time as a measure of arousal and
respiratory effort in children with sleep-disordered breathing', Pediatr Res 2003; 53:580-
8.
[14] Tamisier, R., Pepin, JL, Levy, 'Pulse Transit Time', Physiology and sleep laboratory,
University Hospital, Grenoble, France.
[15] Watemberg et al., 'Adding video recording increases the diagnostic yield of routine EEGs
in children with frequent paroxysmal events', Epilepsia 2005; 46(5):716-719.
[16] Butkov N., 'Atlas of Clinical Polysomnography' (vol II), Medford, OR, Synapse Media,
1996.
Practical aspects of sleep diagnostic 71










D. Practical aspects of AASM
guidelines
In 2007, the American Academy of Sleep Medicine published new standardized
scoring rules for sleep: "The AASM Manual for the Scoring of Sleep and
Associated Events: Rules, Terminology, and Technical Specications" [1]. This
completes a three-year project to update standardized sleep scoring.
Why?
AASMs goal was to create a manual that reected current knowledge and that would provide
more comprehensive standardized specications and scoring rules for characterizing natural
sleep as commonly performed in polysomnography.
Current R&K (Rechtschaffen and Kales) scoring rules were developed in 1968 [2] and left too
much room for variability between scorers.
The principal participants in the scoring manual development process included a supervising
steering committee, 8 task forces leaders, 8-12 task force members and the administrative
staff of the AASM.
This manual intended to better reect current scientic evidence and expertise in the eld of
sleep (cf table 6).
Table 6: Some changes in technology available now vs. 1968 (R&K).
1968 (R&K) Nowadays
Analog recordings Digital recordings
4 channels recorded 16 channels recorded or more!
Avaibility of new transducers and synchronised video as standard features
Notes:
For new systems purchased the society recommends systems that are capable of AASM standards,
from a technical perspective (sampling rates) and from a scoring perspective. Any replacement
equipment purchased after July 1, 2008 must be in full compliance with all technical requirements.
For new sleep lab accreditation, staff must have basic knowledge of AASM scoring rules.
You must notice in the sleep report which rules (R&K or AASM) were used.
The Sleep Technician guide 72
Recommended
Alternative
Optional






1. Key rules
Rules fall into one of three descriptions:
These rules are recommended for the routine scoring of PSG.
These are rules that may be used as alternatives to the recommended
rules at the discretion of the clinician or investigator.
These are suggested rules for uncommonly encountered events, events
not known to have physiologic signicance or events for which there
was no consensus decision. Scoring may be performed at the discretion
of the clinician or investigator.
2. Technical and digital speci cations
Digital specications for routine PSG recordings
Maximum Electrode Impedance 5k for EEG and EOG.
Minimum Digital Resolution 12 bits per sample.
Electrode impedances should be rechecked during a recording when artefact suggests high
impedance.
Sampling rate and lter settings for digital signals must be appropriate for signal content (cf
tables).
Practical aspects of sleep diagnostic 73



Table 7: Sampling rates from the AASM manual
Sampling rates Desirable Minimal
EEG 500 Hz
500 Hz
500 Hz
500 Hz
100 Hz
100 Hz
25 Hz
100 Hz
1 Hz
500 Hz
100 Hz
200 Hz
200 Hz
200 Hz
200 Hz
25 Hz
25 Hz
10 Hz
25 Hz
1 Hz
200 Hz
25 Hz
EOG
EMG
ECG
Airow
Nasal Pressure
Oximetry
Esophageal Pressure
Body position
Snoring sounds
Respiratory efforts
Table 8: Filter settings from the AASM manual
Routinely recorded Filter
Settings
Low Frequency
Filter
High Frequency
Filter
EEG 0.3 Hz
0.3 Hz
10 Hz
0.3 Hz
0.1 Hz
10 Hz
35 Hz
35 Hz
100 Hz
70 Hz
15 Hz
100 Hz
EOG
EMG
ECG
Respiration
Snoring
Digital PSG recording features and rules for PSG display (examples)
Separate 50/60 Hz lter control for each channel.
Recorded video data must be synchronized with the PSG data and have an accuracy of at
least one video frame per second.
The Sleep Technician guide 74







3. Visual rules
The rules and specications in the visual scoring of sleep retain much of the framework of
R&K, based on the accumulated validity and reliability of this scoring system, with some new
denitions and rule modications as well as with new rules for paediatric visual scoring.
EEG
What changes?
Addition of F3 and F4 (frontal) to standard EEG derivations
Renaming of reference sites A1 and A2 (ear lobe) to M1 and M2 (mastoid)
EEG electrode position is determined by International 10-20 System.
Recommended
derivations
a.F4-M1
b.C4-M1
c.O2-M1
+ backup electrodes (if electrodes
malfunction during the study):
d.F3-M2
e.C3-M2
f.O1-M2
Alternative
derivations
a.Fz-Cz
b.Cz-Oz
c.C4-M1
+ backup electrodes (if electrodes
malfunction during the study):
d.Fpz-C3
e.C3-O1
f.C3-M2
Note: A minimum of 3 EEG derivations are required.
Practical aspects of sleep diagnostic 75


EOG
What changes?
LOC & ROC sites are named E1 and E2.
Recommended
derivations
E1-M2 (E1 is placed 1 cm below
the left outer canthus)
E2-M2 (E2 is placed 1 cm above
the right outer canthus)


1 cm
E2
E1
Left Right
1 cm
Do not show direction of eye
movements
Can miss low amplitude
movements
Easy to distinguish artifacts
and EEG
Alternative
derivations
E1-Fpz (E1 is placed 1 cm below
and 1 cm lateral to the left outer
canthus)
E2-Fpz (E2 is placed 1 cm below
and 1 cm lateral to the right outer
canthus)

Left Right
E2
1 cm
E1
1 cm
Show direction of eye
movements
Show all eye movements
Less easy to distinguish
artefacts and EEG
Note: M1 and M2 refer to the left and right mastoid processes.
The Sleep Technician guide 76





Chin EMG
What changes?
The electrode placement for chin EMG is now clearly dened, which was not in the
previous R&K manual.
1) Three electrodes should be placed to record chin EMG:
a. One in the midline 1 cm above the inferior edge of the mandible
b. One 2 cm below the inferior edge of the mandible and 2 cm to the right of the midline
c. One 2 cm below the inferior edge of the mandible and 2 cm to the left of the midline
2) The standard chin EMG derivation consists of either of the electrodes below the mandible
referred to the electrode above the mandible. The other inferior electrode is a backup
electrode to allow for continued display of EMG activity if one of the primary electrodes
malfunctions.
Figure 24: Electrode placement for chin EMG
1cm
Backup electrode
( or )
2cm
Practical aspects of sleep diagnostic 77










Scoring of sleep stages
What changes?
Stages 1,2 and 3 are renamed N1,N2 and N3.
N stands for Non-REM.
Stage N3 represents slow wave sleep and replaces the R&K nomenclature of stage 3 and stage 4 sleep.
REM is renamed stage R.
Movement Time (MT) has been eliminated.
3- minute rule for stage 2 is eliminated.
Frontal leads are recommended for scoring slow wave (N3) sleep.
Each stage now includes more detailed denitions and rules as well as procedural notes
(gures are included in the manual to give some examples of the rules).
The biggest impact will be noticed in the scoring of N2. N2 sleep can be scored as soon
as one or more K-complexes unassociated with arousal or one or more trains of sleep
spindle occur in the rst half of the epoch or the last half of the previous epoch.
Major body movements are now either scored as stage W (if more than 15 seconds of
alpha is present for any part of the epoch or if an epoch of stage W precedes or follows
the movement) or scored as the same stage as the following epoch.
Scoring by Epochs
Score sleep stages in 30 second sequential epochs
Assign a stage to each epoch
If 2 or more stages coexist during a single epoch, assign the stage comprising the greatest
portion of the epoch.
Staging of sleep/wake as follows:
Stage W (Wakefulness)
Low Frequency Filter
Subjects who generate
alpha rhythm
when > 50 % of the epoch has alpha rhythm over the occipital
region
if any of the following are present:
Eye blinks at a frequency of 0.5-2 Hz
Reading eye movements
Irregular conjugate rapid eye movements associated with normal
or high chin muscle tone
Subjects who do not
generate alpha rhythm
(10% of subjects)
The Sleep Technician guide 78












Stage N1 (NREM1)
Score epochs as stage N1:
Subjects who generate
alpha rhythm
If alpha rhythm is replaced low amplitude, mixed frequency
activity for >50 % of the epoch
With the earliest of any of the following phenomena:
Activity of 4-7 Hz with slowing by 1 Hz from W
Vertex sharp waves
Slow eye movements
Subjects who do not
generate alpha rhythm
Stage N2 (NREM2)
START scoring N2 Either a K complex without arousal or a spindle is present
in the rst half of the epoch or the last half of the previous
epoch
CONTINUE scoring N2 Appearance of sleep spindles and/or non-arousal complexes
and < 20 % of the epoch may contain high frontal voltage
(> 75 V and 0.5-2 Hz) activity. Sleep spindles and K
complexes each must last 0.5 second.
STOP scoring N2 Transition to stage W, N3 or R
An arousal:
A major body movement followed by SEM (slow eye
movements):
Practical aspects of sleep diagnostic 79






















activity.
Stage R (REM)
Low amplitude, mixed frequency EEG
+ Low chin EMG tone
+ Rapid eye movements
START scoring R
CONTINUE scoring R
Stage N3 (NREM3)
Score stage N3 when 20 % of an epoch consists of high voltage (> 75 V) and 0.5-2 Hz
STOP scoring R
Low amplitude, mixed frequency EEG
+ Low chin EMG tone
Transition to stage W or N3
An increase in chin EMG tone (N1):
One or more K complexes or sleep spindles in the rst half
of the epoch without rapid eye movements (N2):
An arousal followed by slow eye movements:
The Sleep Technician guide 80








Stage R (REM) suite
STOP scoring R A major body movement followed by slow eye movements:
Rules for children (2 months post-term or older)
What changes?
Dominant posterior rhythm (DPR) replaces the terms alpha rhythm.
For further information about children, please refer to the AASM manual.
4. Arousals
No signicant changes
Score arousal during sleep stages N1, N2, N3 or R if there is an abrupt shift of EEG frequency
including alpha, theta, and/or frequencies greater than 16 Hz (but not spindles) that lasts
at least 3 seconds, with at least 10 seconds of stable sleep preceding the change. Scoring
of arousal during REM requires a concurrent increase in submental EMG lasting at least 1
second.
Practical aspects of sleep diagnostic 81






5. Cardiac rules
A single modied lead II is recommended (cf gure 25).
While classically placed on the right arm and left leg, the electrodes may be placed on the
torso, aligned in parallel to the right shoulder and left hip.
Figure 25: Classic and modied lead II
Classic lead II
Modified lead II
from AASM rules
Scoring rules
Specications are given regarding denitions of sinus tachycardia, bradycardia, asystole, wide
and narrow complex tachycardia, and atrial brillation.
Examples:
Score sinus tachycardia for sustained heart rate greater than 90 beats per minute for adults.
Score sinus bradycardia for sustained heart rate of less than 40 beats for ages 6 through
adult.
Score asystole for pauses greater than 3 seconds for ages 6 through adult.
The Sleep Technician guide 82



6. Movement rules
Minimum duration of a leg movement (LM) is 0.5 second, maximum duration is 10 seconds.
Minimum amplitude is an 8 V-increase in EMG voltage above resting EMG.
Periodic limb movements (PLM) series is dened by a minimum of 4 LMs, minimum period
length between LMs to include them as part of a PLM series is 5 seconds, maximum length is
90 seconds.
Leg movements on 2 different legs separated by less than 5 seconds between movements are
counted as a single leg movement.
Scoring criteria for Alternating Leg Muscle Activation (ALMA), Hypnagogic Foot Tremor
(HFT), Excessive Fragmentary Myoclonus (EFM), bruxism and REM Behavior Disorder (RBD)
were also included.
Practical aspects of sleep diagnostic 83





7. Respiratory rules
What changes?
Clear recommendations about the sensors to use for detection of airow, respiratory
effort and blood oxygen.
Clear recommended and alternative apnoea, hypopnoea, and Cheyne-Stokes denitions
as well as a denition for the optional RERA events are established for both the adult
and paediatric population.
Technical considerations
Detection Recommended sensor Alternative sensor
Apnoea Oronasal thermal sensor Nasal air pressure transducer
Nasal air pressure transducer Uncalibrated or calibrated
inductance plethysmography
or an oronasal thermal
sensor
Oesophageal manometry
or calibrated/ uncalibrated
inductance plethysmography
Diaphragmatic/ intercostal
EMG
Pulse oximetry (with a
maximum acceptable signal
averaging time of 3 seconds)
Hypopnoea
Respiratory effort
Blood oxygen
The Sleep Technician guide 84



Event duration rules
For scoring either an apnoea or a hypopnoea, the event duration is measured from the nadir
preceding the rst breath that is clearly reduced to the beginning of the rst breath that
approximates the baseline breathing amplitude (see horizontal brackets, gure).
Figure 26: Scoring an apnoea (a) and a hypopnoea (b) [1]
a: b:
Scoring of apnoeas
Apnoeas are scored when:
there is a drop in peak thermal sensor excursion by 90% of baseline
the duration of the event lasts at least 10 seconds and at least 90% of the events duration
meets amplitude reduction criteria for apnea.
Classify apnoeas as:
Obstructive, if effort continues throughout.
Central, if effort is absent throughout.
Mixed, if effort is absent initially but resumes in second portion of event.
Practical aspects of sleep diagnostic 85




Hypopnoea rules
Score a hypopnoea if all of the following criteria are met.
Recommended
rules
the nasal pressure signal excursions drop by 30% of baseline
the duration of this drop is at least 10 seconds
there is a 4% desaturation from pre-event baseline
at least 90% of the events duration must meet the amplitude reduction
of criteria for hypopnoea
Alternative
rules
the nasal pressure signal excursions drop by 50% of baseline
the duration of this drop is at least 10 seconds
there is a 3% desaturation from pre-event baseline or the event is
associated with arousal
at least 90% of the events duration must meet the amplitude reduction
of criteria for hypopnoea
Note: Respiratory effort-related arousal and hypoventilation rules are considered as optional.
Cheyne Stokes breathing rule
Score Cheyne Stokes breathing if there are at least 3 consecutive cycles of cyclical crescendo
and decrescendo change in breathing amplitude (gure) and at least 1 of the following:
5 or more central apnoeas or hypopnoeas per hour of sleep
The cyclic crescendo and decrescendo change has duration of at least 10 consecutive
minutes.
Figure 27: Cheyne Stokes breathing [1]
The Sleep Technician guide 86


References
[1] Iber C, Ancoli-Israel S, Chesson AL, Quan SF, 'The AASM Manual for the Scoring of Sleep
and Associated Events: Rules, Terminology, and Technical Specications', Westchester, Ill:
American Academy of Sleep Medicine; 2007.
[2] Rechtschaffen A, Kales A, eds, 'A Manual of Standardized Terminology, Techniques, and
Scoring System for Sleep Stages of Human Subjects', US Department of Health, Education,
and Welfare Public Health Service --NIH/NIND; 1968.
Practical aspects of sleep diagnostic 87
Notes




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