Professional Documents
Culture Documents
Learning Objectives
• Learn the basics of sleep staging
• Identify common sources of artifacts
• Identify the impact of medications on sleep staging
• Learn about the special nuances for scoring respiratory
events
American Thoracic Society
Sleep Stages
• AASM scoring manual for sleep was introduced in 2007
Characteristics: Stage N2
• Background LAMF activity
associated with K
complexes and/or sleep
spindles
• Begin scoring N2 if K
complexes are
unassociated with arousals
or sleep spindles are
present during 1st half of
the epoch or during the 2nd
half of the previous epoch
Continuation of Stage N2
Continue to score N2 in epochs with
LAMF without K complexes or sleep
spindles if preceded by an N2 epoch
without an intervening arousal
• Transition to W or
End of Stage N2
another sleep stage
• Arousal followed by
LAMF (stage as N1 if
criteria for R are not
met)
Stage N3
• Characterized by slow
wave activity (0.5-2 Hz
and peak-to-peak
amplitude > 75 uV)
• Stage epoch as N3 if
slow wave activity >
20% of epoch (AASM
recommended)
• Corrected by applying
electrode gel, replacing the
affected electrode or switching
to an alternative derivation
American Thoracic Society
Cardio-ballistic artifact:
• Small “pulse” waves which
occur synchronously with
heartbeat and the
electrocardiogram tracing
Apnea
Defined by:
– Drop in airflow by >
90% on oronasal
thermistor or PAP flow
device
AND
– Duration of decreased
airflow > 10 seconds
Apneas
Definition of Hypopnea
Recommended
– Peak airflow drop > 30%
on nasal pressure/PAP
flow device
– Duration > 10 seconds
– Desaturation > 3% or
arousal
Acceptable
– Peak airflow drop > 30%
– Duration > 10 seconds
– Desaturation > 4%
Scoring Hypopneas
• 3% and 4% desaturation criteria have been found to be equivalent in
predicting adverse outcomes1
A 32 year old obese male presents with loud snoring and non-refreshed
sleep. He denies ever being told of witnessed apnea or waking up gasping.
His ESS is 11. He undergoes overnight polysomnography and the following
respiratory pattern is seen.
A 32 year old obese male presents with loud snoring and non-refreshed
sleep. He denies ever being told of witnessed apnea or waking up gasping.
His ESS is 11. He undergoes overnight polysomnography and the following
respiratory pattern is seen.
Cheyne-Stokes Breathing
• ≥ 3 consecutive central apneas
and/or central hypopneas
separated by a crescendo-
decrescendo change in breathing
amplitude, with a cycle length of >
40 seconds (1)
AND
• Central apnea index ≥ 5/hour
associated with crescendo/
decrescendo breathing over ≥ 2
hours of recording
A. Restless Leg
Syndrome
B. 60 Hz artifact
C. Periodic limb
movements in sleep
D. Sleep-related
seizures
E. Obstructive apneas
A. Restless Leg
Syndrome
B. 60 Hz artifact
C. Periodic limb
movements in sleep
D. Sleep-related
seizures
E. Obstructive apneas
Key Points
• Sleep stages include NREM stages N1, N2, N3, and stage R (REM)
Key Points
• The recommended definition of hypopnea has recently been
shown to increase the prevalence of OSA