Atlas of

Polysomnography

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FM.indd ii 8/7/2009 3:28:00 PM
 Atlas of
Polysomnography
SECOND EDITION

James D. Geyer, MD
Director, Sleep Program
Associate Professor of Neurology and Sleep Medicine
Alabama Neurology and Sleep Medicine
Tuscaloosa, Alabama

Paul R. Carney, MD
Wilder Professor and Chief
Division of Pediatric Neurology
Director, Comprehensive Pediatric Epilepsy Program
Departments of Pediatrics and Neurology
McKnight Brain Institute
University of Florida College of Medicine
Gainesville, Florida

Troy A. Payne, MD
Medical Director
St Cloud Hospital Sleep Center
St Cloud, Minnesota

FM.indd iii 8/7/2009 3:28:00 PM

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Library of Congress Cataloging-in-Publication Data

Atlas of polysomnography / James D. Geyer, Paul R. Carney, Troy Payne.2nd ed.
p. ; cm.
Rev. ed. of: Atlas of digital polysomnography / James D. Geyer ... [et al.]. c2000.
Includes index.
ISBN-13: 978-1-6054-7228-7
ISBN-10: 1-6054-7228-X
1. Sleep disordersAtlases. 2. PolysomnographyAtlases. I. Geyer, James D. II. Carney, Paul R. III. Payne, Troy.
IV. Atlas of digital polysomnography.
[DNLM: 1. SleepphysiologyAtlases. 2. PolysomnographyAtlases. 3. Sleep DisordersdiagnosisAtlases.
WL 17 A8844 2010]
RC547.A836 2010
616.8498dc22
2009028925

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 To our families
and to the memory of Michael Aldrich

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 Contributors

Monica Henderson, RN, RPSGT Sachin Talathi, PhD

Sleep Health Coordinator J. Crayton Pruitt Family Department of Biomedical
Department of Sleep Medicine Engineering
Alabama Neurology and Sleep Medicine University of Florida McKnight Brain Institute
Tuscaloosa, Alabama Gainesville, Florida

Jennifer Parr, RPSGT Julie Tsikhlakis, RN, BSN

Chief Sleep Technician Sleep Health Coordinator
DCH Sleep Center Department of Sleep Medicine
DCH Health System Alabama Neurology and Sleep Medicine
Northport, Alabama Tuscaloosa, Alabama

Betty Seals, REEGT

Director
DCH Sleep Center
DCH Health System
Tuscaloosa, Alabama

vi

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 Preface to the Second Edition
Sleep medicine continues to evolve rapidly as a subspecialty
with numerous disorders now recognized and an ever-changing
set of diagnostic criteria and protocols. As with any medical
discipline, accurate diagnosis is an essential prerequisite for
a rational approach to management. Polysomnography, the
recording of multiple physiologic functions during sleep, was
developed in the 1970s and is the most important laboratory
test used in sleep medicine. Polysomnography complements
the clinical evaluation and assists with diagnosis and manage-
ment of a variety of sleep disorders.1
Digital amplifiers and computerized signal processing are
now the standard of care and provide many advantages over
older analog amplifiers and paper recording. This is especially
true for the evaluation of brief electroencephalographic (EEG)
transients such as epileptiform sharp waves and spikes and their
differentiation from artifacts and benign EEG waveforms. This
section of the book has been significantly expanded. Digitized
data can also be displayed using a variety of montages depend-
ing on the purpose at hand; for example, the display can be
limited to EEG, electro-oculogram (EOG), and chin electro-
myogram (EMG) during sleep staging and then expanded to
include respiratory and leg movement channels during scoring
of these functions. Filters and sensitivities can be altered during
review to assist with interpretation of the study.
While digital polysomnography provides a number of
advantages as described above, features related to signal acquisi-
tion, display resolution, and printer resolution must be under-
stood by the technologist and the interpreter. For digital signal
acquisition, the analog signal generated by the transducer must
be converted to digitized information. A critical variable is the
rate at which the signal is sampled and digitized. For slowly
varying signals, such as thoracic motion, a sampling rate of
FM.indd vii
20 Hz may be sufficient; for rapidly varying signals, such as
EEG and EMG, the sampling rate must be much higher, usually
250 Hz or more. If the sampling rate is inadequate, waveforms
are distorted and scoring and interpretation may be erroneous.
For example, if the sampling rate for eye movement channels is
too low, the sharp deflection associated with a rapid eye move-
ment may appear as a slower deflection characteristic of a slow
eye movement.
Because of the differences in signal acquisition and display
parameters, not all digital recordings have the same appear-
ance. In addition, although transducers used for the recording
of EEG, EOG, and EMG are largely standardized, EEG and EOG
montages vary among laboratories. Furthermore, transducers
and recording techniques for the assessment of respiration dur-
ing sleep vary widely among sleep laboratories.2 For example,
airflow can be monitored directly with a pneumotachograph,
thermistor, or thermocouple or indirectly with the recordings
of tracheal sound or by the summation of signals from tho-
racic and abdominal inductance recordings. Respiratory effort
can be assessed with respiratory inductance plethysmography,
stretch sensitive transducers (strain gauges), diaphragmatic
EMG, intrathoracic (esophageal) pressure, or nasal pressure.
Scoring of sleep stages has been standardized for many years3
and has recently been updated.4 The new scoring and staging
criteria are discussed in detail in the text and the waveforms are
presented in appropriate chapters.
As a result of these variations, the overall appearance of the
polysomnographic display may be markedly different from one
laboratory to the next. No atlas can provide examples of nor-
mal and abnormal polysomnography using all of the displays
and transducers used in accredited sleep laboratories. For this
atlas, the illustrations were prepared from several sleep centers
vii
8/7/2009 3:28:01 PM
 viii PREFACE TO THE SECOND EDITION

and electrodiagnostic/neurophysiology laboratories in order to 3. Rechtschaffen A, Kales A. A Manual of Standardized Terminology, Tech-
introduce the reader to several of the possible formats. niques, and Scoring System for Sleep Stages of Human Subjects. Los Angeles:
Brain Information Service/Brain Research Institute, 1968.
This atlas is designed to aid the sleep medicine specialist 4. Iber C, Ancoli-Israel S, Chesson A, Quan SF. The AASM Manual for the
and those training in sleep medicine. It also serves as a refer- Scoring of Sleep and Associated Events: Rules, Terminology and Technical Speci-
ence and training tool for technologists. The atlas covers nor- fications. 1st Ed. Westchester, Illinois: American Academy of Sleep Medi-
mal polysomnographic features of wakefulness and the various cine, 2007.
stages of sleep as well as polysomnographic findings character-
istic of sleep-related breathing disorders, sleep-related move-
ments, and parasomnias. In addition, examples of cardiac
arrhythmias, nocturnal seizures, and artifacts are included.
A variety of time scales are used to illustrate their value.

REFERENCES
1. American Academy of Sleep Medicine. International Classification of Sleep
Disorders. 2nd Ed. Diagnostic and coding manual. Westchester, Illinois:
American Academy of Sleep Medicine, 2005.
2. Parisi RA, Santiago TV. Respiration and respiratory function: Technique
of recording and evaluation. In: Chokroverty S, ed. Sleep Disorders Medi-
cine: Basic Sciences, Technical Considerations, and Clinical Aspects. Boston:
Butterworth-Heinemann, 1994:127139.

FM.indd viii 8/7/2009 3:28:01 PM

 Preface to the First Edition
Sleep medicine is a relatively new medical subspecialty that is
rapidly expanding as the prevalence and importance of sleep
disorders have become apparent. As with any medical disci-
pline, accurate diagnosis is an essential prerequisite for a ratio-
nal approach to management. Polysomnography, the recording
of multiple physiologic functions during sleep, was developed
in the 1970s and is the most important laboratory test used
in sleep medicine. Polysomnography complements the clini-
cal evaluation and assists with diagnosis and management of a
wide range of sleep disorders.1
As the array of sleep diagnoses has expanded, the tech-
niques and equipment used for sleep recordings have become
more sophisticated. While sleep studies in the 1970s used ana-
log amplifiers and bulky paper recordings that rarely consisted
of more than eight channels, computer technology of the late
1990s permits recording of dozens of channels using sensitive
noninvasive or minimally invasive transducers, digital ampli-
fiers, electronic displays, and compact data storage on magnetic
or optical media.2
Digital amplifiers and computerized signal processing pro-
vide many advantages over older analog amplifiers and paper
recording. For example, digitized data can be displayed using
a compressed time scale that makes slow rhythms more read-
ily identifiable, such as the regular occurrence of periodic leg
movements at 20- to 30-second intervals. Alternatively, an
expanded time scale can be used that permits easier identifica-
tion of brief electroencephalographic (EEG) transients such as
epileptiform sharp waves and spikes and their differentiation
from artifacts and benign EEG waveforms. Digitized data can
also be displayed using a variety of montages depending on
the purpose at hand; for example, the display can be limited
FM.indd ix
to EEG, electro-oculogram (EOG), and chin electromyogram
(EMG) during sleep staging and then expanded to include
respiratory and leg movement channels during scoring of these
functions. Filters and sensitivities can be altered during review
to assist with interpretation of the study.
In addition to digital polysomnography, several other tech-
nical advances have improved the diagnostic value of sleep
recordings. Polysomnography can be combined with video
recording (video-polysomnography); the simultaneous analy-
sis of behavior and polysomnographic findings assists with the
diagnosis of parasomnias, nocturnal seizures, and other sleep-
related behaviors. To assist with the diagnosis of sleep-related
breathing disorders, intrathoracic pressure can be monitored
with intraesophageal pressure sensors that are easily inserted
and well tolerated. With the availability of 16 to 32 or more
channels for a recording, esophageal pH, end-tidal carbon diox-
ide level, and transcutaneous CO2 monitoring can be included
in selected situations without sacrificing standard channels.
While digital polysomnography provides a number of
advantages as described above, features related to signal acquisi-
tion, display resolution, and printer resolution must be under-
stood by the technologist and the interpreter. For digital signal
acquisition, the analog signal generated by the transducer must
be converted to digitized information. A critical variable is the
rate at which the signal is sampled and digitized. For slowly
varying signals, such as thoracic motion, a sampling rate of 20
Hz may be sufficient; for rapidly varying signals, such as EEG
and EMG, the sampling rate must be much higher, usually 250
Hz or more. If the sampling rate is inadequate, waveforms are
distorted and scoring and interpretation may be erroneous. For
example, if the sampling rate for eye movement channels is too
ix
8/7/2009 3:28:01 PM
 x PREFACE TO THE FIRST EDITION
low, the sharp deflection associated with a rapid eye movement
may appear as a slower deflection characteristic of a slow eye
movement.
Display resolution is based on the characteristics of the
computer, the display monitor, and the software used for data
acquisition and display. The array of pixels in the screen deter-
mines the maximum resolution; for example, a 1024 x 768
display provides lower resolution than a 1600 x 1200 display.
While the lower resolution display may be sufficient for the
assessment of slowly varying signals such as respiration, it may
be inadequate for identification of rapid EEG transients.
Printer resolution is based on the characteristics of the
printer, computer, and software. In some cases, waveforms that
are not adequately displayed on the monitor can be better ana-
lyzed if a high resolution printout is obtained.
Because of the differences in signal acquisition and display
parameters, not all digital recordings have the same appear-
ance. In addition, although transducers used for the recording
of EEG, EOG, and EMG are largely standardized, EEG and EOG
montages vary among laboratories. Furthermore, transducers
and recording techniques for the assessment of respiration dur-
ing sleep vary widely among sleep laboratories.3 For example,
airflow can be monitored directly with a pneumotachograph,
thermistor, or thermocouple or indirectly with the recordings
of tracheal sound or by the summation of signals from thoracic
and abdominal inductance recordings. Respiratory effort can be
assessed with respiratory inductance plethysmography, stretch
sensitive transducers (strain gauges), diaphragmatic EMG,
intrathoracic (esophageal) pressure, or nasal pressure. Further-
more, although scoring of sleep stages has been standardized
for many years,4 no consensus has been reached at this writing
concerning scoring criteria for respiratory events.
As a result of these variations, the overall appearance of the
polysomnographic display may be markedly different from
one laboratory to the next. No atlas can provide examples of
normal and abnormal polysomnography using all of the dis-
plays and transducers used in accredited sleep laboratories. For
this atlas, all of the illustrations were prepared from the sleep
studies performed at the University of Michigan Sleep Disor-
ders Center, or, in a few cases, from the neonatal EEG studies
FM.indd x
performed in the University of Michigan Electrodiagnostic
Laboratory. The studies were recorded using digital equipment
manufactured by the Telefactor Corporation (Conshohocken,
PA). The montages, filter settings, sensitivities, and A-D sam-
pling rates used to generate the displays are specified in the
Technical Introduction.
The illustrations were prepared based on 1600 x 1200
screen displays and were printed with a Hewlett-Packard Laser
Jet printer on 8.5 x 11 inch paper at 600 dot per inch resolu-
tion.
The EEG electrodes were placed according to the Interna-
tional 1020 system.
The EOG electrodes were placed 1 cm superior and lateral
to the right outer canthus and 1 cm inferior and lateral to the
left outer canthus.
One chin EMG electrode was placed on the chin (mental)
and two electrodes were placed under the chin (submental).
The submental electrode placement is generally at the mandi-
ble. Generally, there is a 3-cm distance between electrodes.
The EKG was recorded with one electrode each placed 2 to
3 cm below the left and right clavicles midway between the
shoulder and the neck..
Many of the recordings also include the second EKG chan-
nel recorded from a left leg EMG channel and a left ear elec-
trode.
Airflow was recorded with a single channel nasal/oral ther-
mocouple from Pro-Tech (Woodinville, WA). This thermocou-
ple has sensors for each nostril and another that is located over
the mouth.
Thoracic and abdominal motion were recorded with respi-
ratory effort sensors utilizing piezoelectric crystal sensors from
EPM Systems (Midlothian, VA). These sensors are attached to a
belt that is placed around the patient.
For many of the recordings, an additional system was used
to assess respiratory effort. This system, labeled Backup in the
montages, was also recorded with piezoelectric crystal sensors
from EPM Systems (Midlothian, VA). This backup belt was
placed between the thoracic and the abdominal belts.
Snoring sound was recorded with piezoelectric crystal sen-
sors from EPM Systems (Midlothian, VA). This sensor is placed
8/7/2009 3:28:01 PM

either 2 cm to the left or right of the trachea, midway down the
neck.
Oximetry was recorded with an Ohmeda model 3740 (Lou-
isville, CO). Oximetry was recorded from a finger site.
Many of the illustrations were obtained from studies of
patients who were undergoing a treatment trial of continuous
positive airway pressure (CPAP) or bilevel positive airway pres-
sure (BPAP) and include recordings of mask flow and tidal vol-
ume. The CPAP and BPAP equipment, which generated these
signals, included models manufactured by Respironics, Inc.
and Healthdyne.
This atlas is designed to aid the sleep medicine specialist
and those training in sleep medicine. It also serves as a refer-
ence and training tool for technologists. The atlas covers nor-
mal polysomnographic features of wakefulness and the various
stages of sleep as well as polysomnographic findings character-
istic of sleep-related breathing disorders, sleep-related move-
ments, and parasomnias. In addition, examples of cardiac
arrhythmias, nocturnal seizures, and artifacts are included.
While most of the figures use a 30-second time base, a variety of
shorter and longer time scales are used to illustrate their value.
FM.indd xi
PREFACE TO THE FIRST EDITION xi
REFERENCES
1. American Sleep Disorders Association. International Classification of
Sleep Disorders. Diagnostic and coding manual, Revised. Rochester,
Minnesota: American Sleep Disorders Association, 1997.
2. Gotman J. The use of computers in analysis and display of EEG and
evoked potentials. In: Daly DD, Pedley TA, eds. Current Practice of Clini-
cal Electroencephalography. 2nd Ed. New York: Raven Press, 1990:5183.
3. Parisi RA, Santiago TV. Respiration and respiratory function: Technique
of recording and evaluation. In: Chokroverty S, ed. Sleep Disorders Medi-
cine: Basic Sciences, Technical Considerations, and Clinical Aspects. Boston:
Butterworth-Heinemann, 1994:127139.
4. Rechtschaffen A, Kales A. A Manual of Standardized Terminology, Tech-
niques, and Scoring System for Sleep Stages of Human Subjects. Los Ange-
les: Brain Information Service/ Brain Research Institute, 1968.
8/7/2009 3:28:01 PM
 Acknowledgments to
the Second Edition

As in all projects of this type, thanks must go to the technical
and support staff at each of our sleep centers: the DCH Sleep
Center, the University of Florida, and the St.Cloud Hospital
Sleep Center.
A special thanks goes to Leanne McMillan, Tom Gibbons,
Fran DeStefano, Lisa McAllister, and the other members of the
editorial and production staff at Lippincott Williams & Wilkins
who provided important suggestions and support.
Finally, a special thanks goes to our wives and families for
their unwavering support.

xii

FM.indd xii 8/7/2009 3:28:01 PM

 Acknowledgments to
the First Edition
Ronald Chervin, M.D., and Beth Malow, M.D., were invalu-
able contributors to this project. The other faculty members
of the University of Michigan, Department of Neurology, Clini-
cal Neurophysiology Laboratory, Ivo Drury, M.B B.Ch., Ahmad
Beydoun, M.D., Linda Selwa, M.D., Robert MacDonald, M.D.,
Ph.D., Jaideep Kapur, M.D., Ph.D., Erasmo Passaro, M.D., and
Wassim Nasreddine, M.D., were vital to both the fellowship
program in sleep medicine and the production of this text.
The other members of the fellowship training programs in
sleep medicine and clinical neurophysiology provided support,
ideas, and interesting studies. We, therefore, thank and acknowl-
edge the contributions of Sarah Nath, M.D., L. John Greenfield,
M.D., Ph.D., Kirk Levy, M.D., and Willie Anderson, M.D.
FM.indd xiii
As in all projects of this type, a special thanks must go to
the technical and support staff. In particular, we would like to
thank Ken Morton, RPSGT, sleep laboratory supervisor at the
University of Michigan and Brenda Livingston, clinic coordi-
nator at the University of Michigan Sleep Disorders Center.
A special thanks goes to Anne Sydor, Ph.D., and the other
members of the editorial and production staff at Lippincott
Williams & Wilkins who provided important suggestions and
support.
Finally, a special thanks goes to our families for their unwav-
ering support.
xiii
8/7/2009 3:28:02 PM
 Contents

Contributors vi CHAPTER 5
Preface to the Second Edition vii Limb Movement Disorders 197
Preface to the First Edition ix James D. Geyer, Troy A. Payne,
Acknowledgments to the Second Edition xii and Paul R. Carney
Acknowledgments to the First Edition xiii
CHAPTER 6
CHAPTER 1
Parasomnias 209
Introduction to Sleep and James D. Geyer, Troy A. Payne,
Polysomnography 1 and Paul R. Carney
James D. Geyer, Troy A. Payne,
Sachin Talathi, and Paul R. Carney
CHAPTER 7
CHAPTER 2 Electroencephalographic
Staging 17 Abnormalities 225
James D. Geyer, Troy A. Payne, James D. Geyer, Troy A. Payne,
and Paul R. Carney and Paul R. Carney

CHAPTER 3 CHAPTER 8
Multiple Sleep Latency Test (MSLT)/ Artifacts 251
Maintenance of Wakefulness James D. Geyer, Troy A. Payne,
Test (MWT) 89 and Paul R. Carney
James D. Geyer, Troy A. Payne,
and Paul R. Carney CHAPTER 9

CHAPTER 4
Electrocardiography 261
James D. Geyer, Troy A. Payne,
Breathing Disorders 101 and Paul R. Carney
James D. Geyer, Troy A. Payne,
and Paul R. Carney

xiv

FM.indd xiv 8/7/2009 3:28:02 PM

 CONTENTS xv

CHAPTER 10 APPENDIX A
Calibrations 287 Electrode Placement 313
James D. Geyer, Troy A. Payne, James D. Geyer, Troy A. Payne,
and Paul R. Carney Paul R. Carney, and Julie Tsikhlakis

APPENDIX B
CHAPTER 11
Patient Calibrations for Nighttime
Actigraphy 297 Polysomnography 315
James D. Geyer, Troy A. Payne, James D. Geyer, Troy A. Payne
and Paul R. Carney Paul R. Carney, and Monica Henderson

CHAPTER 12 APPENDIX C
Technical Background 301 Multiple Sleep Latency Test (MSLT) Protocol 317
James D. Geyer, Troy A. Payne, James D. Geyer, Troy A. Payne,
and Paul R. Carney Paul R. Carney, and Betty Seals

APPENDIX D
CHAPTER 13
Maintenance of Wakefulness Test (MWT)
Recording Artifacts and Solving Protocol 321
Technical Problems with James D. Geyer, Troy A. Payne,
Polysomnography Technology 309 and Paul R. Carney
James D. Geyer, Paul R. Carney,
Troy A. Payne, and Jennifer Parr Index 323

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FM.indd xvi 8/7/2009 3:28:02 PM
 CHAPTER
Introduction to Sleep
and Polysomnography
1 James D. Geyer, MD
Troy A. Payne, MD
Sachin Talathi, PhD
Paul R. Carney, MD
OVERVIEW OF SLEEP STAGES AND CYCLES
The monitoring of sleep is complex and requires a distinct
skill set including a detailed knowledge of EEG, respiratory
monitoring, and EKG. Expertise in only one of these areas
does not confer the ability to accurately interpret the poly-
somnogram.
Sleep is not homogeneous and is characterized by sleep
stages based on electroencephalographic (EEG) or electrical
brain wave activity, electrooculographic (EOG) or eye move-
ments, and electromyographic (EMG) or muscle electrical
activity (13). The basic terminology and methods involved
with monitoring each of these types of activity will be discussed
below. Sleep is composed of nonrapid eye movement (NREM)
and rapid eye movement (REM) sleep. NREM sleep is further
divided into stages N1, N2, and N3. Stages N3 and N4 sleep
were recently combined into stage N3 sleep. Stages N1 and N2
are called light sleep and stage N3 is called deep or slow-wave
sleep. There are usually four or five cycles of sleep, each com-
posed of a segment of NREM sleep followed by REM sleep. Peri-
ods of wake may also interrupt sleep during the night. As the
night progresses, the length of REM sleep in each cycle usually
increases. The hypnogram is a convenient method of graphi-
cally displaying the organization of sleep during the night. Each
Chap01.indd 1
stage of sleep is characterized by a level on the vertical axis of
the graph with time of night on the horizontal axis. REM sleep
is often highlighted by a dark bar.
Sleep monitoring was traditionally by polygraph recording
using ink-writing pens which produced tracings on paper. It was
convenient to divide the night into epochs of time that corre-
spond to the length of each paper page. The usual paper speed for
sleep recording is 10 mm per second; a 30-cm page corresponds to
30 seconds. Each segment of time represented by one page is called
an epoch; sleep is staged in epochs. Today most sleep recording
is performed digitally, but the convention of scoring sleep in
30-second epochs or windows is still the standard. If there is a
shift in sleep stage during a given epoch, the stage present for the
majority of the time names the epoch. When the tracings used to
stage sleep are obscured by artifact for more than one half of an
epoch, it is scored as movement time (MT). When an epoch of
what would otherwise be considered MT is surrounded by epochs
of wake, the epoch is also scored as wake. Some sleep centers con-
sider MT to be wake and do not tabulate it separately.
SLEEP ARCHITECTURE DEFINITIONS
The term sleep architecture describes the structure of sleep.
Common terms used in sleep monitoring are listed in
1
8/6/2009 4:01:10 PM
 2 CHAPTER 1
Table 1-1. The total monitoring time or total recording time
(TRT) is also called total bedtime (TBT). This is the time dura-
tion from lights out (start of recording) to lights on (termi-
nation of recording). The total amount of sleep stages N1,
N2, N3, R, and MT is termed the total sleep time (TST). The
time from the first sleep until the final awakening is called
the sleep period time (SPT). SPT encompasses all sleep as well
as periods of wake after sleep onset and before the final awak-
ening. This wake time is termed the WASO (wake after sleep
onset). Therefore, SPT = TST + WASO. The time from the start
of sleep monitoring (or lights out) until the first epoch of
sleep is called the sleep latency. The time from the first epoch
of sleep until the first REM sleep is called the REM latency.
It is useful to determine not only the total minutes of each
sleep stage, but also to characterize the relative proportion of
time spent in each sleep stage. One can characterize stages N1
to N3 and REM as a percentage of total sleep time (%TST).
Another method is to characterize the sleep stages and WASO
as a percentage of the sleep period time (%SPT). Sleep effi-
ciency (in percent) is usually defined as either the TST 100/
SPT or TST 100/TBT.
TABLE 1-1 Sleep Architecture Definitions
Lights outstart of sleep recording
Light onend of sleep recording
TBT (total bedtime)time from lights out to Lights on
TST (total sleep time) = minutes of stages N1, N2, N3, and R
WASO (wake after sleep onset)minutes of wake after first
sleep but before the final awakening
SPT (sleep period time) = TST + WASO
Sleep latencytime from lights out until the first epoch of
sleep
REM latencytime from first epoch of sleep to the first epoch
of REM sleep
Sleep efficiency(TST 100)/ TBT
Stage N1, N2, N3, and R as % TSTpercentage of TST
occupied by each sleep stage
Stage N1, N2, N3, and R, WASO as % SPTpercentage of SPT
occupied by sleep stages and WASO
Arousal index
Chap01.indd 2
The normal range of the percentage of sleep spent in each
sleep stage varies with age (2,3) and is impacted by sleep dis-
orders (Table 1-2). In adults there is a decrease in stage N3
sleep with increasing age, while the amount of REM sleep
remains fairly constant. The amount of stage N1 sleep and
WASO also increases with age. In patients with severe obstruc-
tive sleep apnea (OSA) there is often no stage N3 sleep and a
reduced amount of REM sleep. Chronic insomnia (difficulty
initiating or maintaining sleep) is characterized by a long
sleep latency and increased WASO. The amount of stages N3
and R sleep is commonly decreased as well. The REM latency
is also affected by sleep disorders and medications. A short
REM latency (usually <70 minutes) is noted in some cases of
sleep apnea, depression, narcolepsy, prior REM sleep depriva-
tion, and the withdrawal of REM suppressant medications.
An increased REM latency can be seen with REM suppressants
(ethanol and many antidepressants), an unfamiliar or uncom-
fortable sleep environment, sleep apnea, and any process that
disturbs sleep quality.
INTRODUCTION
TO ELECTROENCEPHALOGRAPHIC
TERMINOLOGY AND MONITORING
EEG activity is characterized by the frequency in cycles per
second or hertz (Hz), amplitude (voltage), and the direction of
major deflection (polarity). The classically described frequency
ranges are delta (<4 Hz), theta (4 to 7 Hz), alpha (8 to 13 Hz),
and beta (>13 Hz). Alpha waves (8 to 13 Hz) are commonly
noted when the patient is in an awake, but relaxed, state with
the eyes closed. They are best recorded over the occiput and are
attenuated when the eyes are open. Bursts of alpha waves also
are seen during brief awakenings from sleepcalled arousals.
Alpha activity can also be seen during REM sleep. Alpha activ-
ity is prominent during drowsy eyes-closed wakefulness. This
activity decreases with the onset of stage N1 sleep. Near the
transition from stage N1 to stage N2 sleep, vertex sharp waves
high-amplitude negative waves (upward deflection on EEG
tracings) with a short durationoccur. They are more promi-
nent in central than in occipital EEG tracings. A sharp wave
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 INTRODUCTION TO SLEEP AND POLYSOMNOGRAPHY 3

TABLE 1-2 Representative Changes in Sleep Architecture

20-Year-Old 60-Year-Old Severe Sleep Apneaa

WASO% SPT 5 15 20
1% SPT 5 5 10
2% SPT 50 55 60
3% SPT 20 5 0
REM% SPT 25 20 10
a
High interpatient variability.

TABLE 1-3 Standard Sensitivity and Filter Settings

Sensitivity Low Filter High Filter

EEG 50 V = 1 cm; 100 V = 1 channel width 0.3a 35a
EOG 50 V = 1 cm; 100 V = 1 channel width 0.3 35
EMG 50 V = 1 cm; 100 V = 1 channel width 10 100
EKG 0.1 35
Airflow (thermistor) Variable 0.1 15
Chest Variable 0.1 15
Abdomen Variable 0.1 15
SaO2 (%) 1 Volt = 0100 or 50%100% DC 15
Nasal pressure machine flow Variable DC or AC with low filter 15
setting of 0.01 100 (to see snoring)
a
Note that these filter settings are different from traditional EEG monitoring settings.

is defined as deflection of 70 to 200 milliseconds in duration
(Table 1-3).
Sleep spindles are oscillations of 12 to 14 Hz with a duration
of 0.5 to 1.5 seconds. They are characteristic of stage N2 sleep.
They may persist into stage N3, but usually do not occur in
stage R. The K complex is a high-amplitude, biphasic wave of
at least 0.5-second duration. As classically defined, a K com-
plex consists of an initial sharp, negative voltage (by conven-
tion an upward deflection) followed by a positive-deflection
(down) slow wave. Spindles frequently are superimposed on
K complexes. Sharp waves differ from K complexes in that they
are narrower, not biphasic, and usually of lower amplitude.
As sleep deepens, slow (delta) waves appear. These are
high-amplitude, broad waves. In contrast to the EEG defini-
tion of delta activity as less than 4 Hz, delta slow-wave activ-
ity is defined for sleep staging purposes as waves slower than
2 Hz (longer than 0.5-second duration) with a peak-to-peak
amplitude of greater than 75 mV. The amount of slow-wave
activity as measured in the central EEG derivations is used
to determine if stage N3 is present (1) (see below). Because

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 4 CHAPTER 1
a K complex resembles slow-wave activity, differentiating the
two is sometimes difficult. However, by definition, a K com-
plex should stand out (be distinct) from the low-amplitude,
background EEG activity. Therefore, a continuous series of
high-voltage slow (HVS) waves would not be considered to be
a series of K complexes.
Sawtooth waves are notched-jagged waves of frequency in
the theta range (3 to 7 Hz) that may be present during REM
sleep. Although they are not part of the criteria for scoring REM
sleep, their presence is a clue that REM sleep is present.
EYE MOVEMENT RECORDING
The main purpose of recording eye movements is to identify
REM sleep. EOG (eye movement) electrodes typically are placed
at the outer corners of the eyesat the right outer canthus (ROC)
and the left outer canthus (LOC). In a common approach, two
eye channels are recorded and the eye electrodes are referenced
to the opposite mastoid (ROC-A1 and LOC-A2). However,
some sleep centers use the same mastoid electrode as a reference
(ROC-A1 and LOC-A1). To detect vertical as well as horizontal
eye movements, one electrode is placed slightly above and one
slightly below the eyes (4,5).
Recording of eye movements is possible because a poten-
tial difference exists across the eyeball: front positive (+), back
negative (). Eye movements are detected by EOG recording
of voltage changes. When the eyes move toward an electrode,
a positive voltage is recorded. By standard convention, poly-
graphs are calibrated so that a negative voltage causes an
upward pen deflection (negative polarity up). Thus, eye move-
ment toward an electrode results in a downward deflection
(4,6). Note that movement of the eyes is usually conjugate, with
both eyes moving toward one eye electrode and away from the
other. If the eye channels are calibrated with the same polarity
settings, eye movements produce out-of-phase deflections in the
two eye tracings (e.g., one up and one down). Because ROC is
positioned above the eyes (and LOC below), upward eye move-
ments are toward ROC and away from LOC. Thus, upward eye
movement results in a downward deflection in the ROC tracing
and an upward deflection in the LOC tracing.
Chap01.indd 4
There are two common patterns of eye movements. Slow eye
movements (SEMs), also called slow-rolling eye movements, are
pendular oscillating movements that are seen in drowsy (eyes-
closed) wakefulness and stage N1 sleep. By stage N2 sleep, SEMs
usually have disappeared. REMs are sharper (more narrow deflec-
tions), which are typical of eyes-open wake and REM sleep.
In the two-tracing method of eye movement recording,
large-amplitude EEG activity or artifact reflected in the EOG
tracings usually causes in-phase defections.
ELECTROMYOGRAPHIC RECORDING
Usually, three EMG leads are placed in the mental and submental
areas. The voltage between two of these three is monitored (for
example, EMG1-EMG3). If either of these leads fail, the third
lead can be substituted. The gain of the chin EMG is adjusted so
that some activity is noted during wakefulness. The chin EMG
is an essential element only for identifying stage R sleep. In
stage R, the chin EMG is relatively reducedthe amplitude is
equal to or lower than the lowest EMG amplitude in NREM
sleep. If the chin EMG gain is adjusted high enough to show
some activity in NREM sleep, a drop in activity is often seen
on transition to REM sleep. The chin EMG may also reach the
REM level long before the onset of REMS or an EEG meeting
criteria for stage R. Depending on the gain, a reduction in the
chin EMG amplitude from wakefulness to sleep and often a fur-
ther reduction on transition from stage N1 to N3 may be seen.
However, a reduction in the chin EMG is not required for stages
N2 to N3. The reduction in the EMG amplitude during REM
sleep is a reflection of the generalized skeletal-muscle hypoto-
nia present in this sleep stage. Phasic brief EMG bursts still may
be seen during REM sleep. The combination of REMs, a rela-
tively reduced chin EMG, and a low-voltage mixed-frequency
EEG is consistent with stage R.
SLEEP STAGE CHARACTERISTICS
The basic rules for sleep staging are summarized in Table 1-4.
Note that some characteristics are required (bold) and some
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 INTRODUCTION TO SLEEP AND POLYSOMNOGRAPHY 5

TABLE 1-4 Summary of Sleep Stage Characteristics

Characteristicsa,b
Stage EEG EOG EMG

Wake (eyes open) Low-voltage, high-frequency, Eye blinks, REMs Relatively high
attenuated alpha activity
Wake (eyes closed) Low-voltage, high-frequency Slow-rolling eye movements Relatively high
>50% alpha activity
Stage N1 Low-amplitude mixed- Slow-rolling eye movements May be lower than wake
frequency < 50% alpha
activity NO spindles,
K complexes
Sharp waves near transition
to stage N2
Stage N2 At least one sleep spindle May be lower than wake May be
or K complex <20% lower than wake
Slow-wave activityb
C
Stage N3 (present) >20% slow-wave activity Usually low
C
Stage N4 (prior) >50% slow-wave activity Usually low
Stage R Low-voltage mixed- Episodic REMs Relatively reduced (equal
frequency or lower than the lowest in NREM)
Sawtooth wavesmay
be present
a
Required characteristics in bold.
b
Slow wave activity, frequency <2 Hz; peak to peak amplitude >75 V; >50% means slow wave activity present in more than 50% of the epoch;
REMs, rapid eye movements.
c
Slow waves usually seen in EOG tracings.

are helpful but not required. The typical patterns associated
with each sleep stage are discussed below.
Stage Wake
During eyes-open wake, the EEG is characterized by high-
frequency low-voltage activity. The EOG tracings typically show
REM, and the chin EMG activity is relatively high allowing dif-
ferentiation from Stage R sleep. During eyes-closed drowsy wake,
the EEG is characterized by prominent alpha activity (>50% of
the epoch). Both slow scanning and more rapid irregular eye
movements are usually present. The level of muscle tone is usu-
ally relatively high.
Stage N1
The stage N1 EEG is characterized by low-voltage, mixed-
frequency activity (4 to 7 Hz). Stage N1 is scored when less
than 50% of an epoch contains alpha waves and criteria for
deeper stages of sleep are not met. Slow-rolling eye movements

Chap01.indd 5 8/6/2009 4:01:10 PM

 6 CHAPTER 1
often are present in the eye movement tracings, and the level of
muscle tone (EMG) is equal or diminished compared to that in
the awake state. Some patients do not exhibit prominent alpha
activity, making detection of sleep onset difficult. The ability of a
patient to produce alpha waves can be determined from biocali-
brations at the start of the study. The patient is asked to lie qui-
etly with eyes open and then with the eyes closed. Alpha activity
usually appears with eye closure. When patients do not pro-
duce significant alpha activity, differentiating wakefulness from
stage N1 sleep can be difficult. Several points are helpful. First,
the presence of REMs in the absence of a reduced chin EMG
usually means the patient is still awake. However, SEMs can
be present during drowsy wake and stage N1 sleep. In this case
one must differentiate wake from stage N1 by the EEG. In wake,
the EEG has considerable high-frequency activity. In stage N1,
the EEG has mixed frequency with activity in the 4 to 7 Hz theta
range. Often the easiest method to determine sleep onset in dif-
ficult cases is to find the first epoch of unequivocal sleep (usu-
ally stage N2) and work backward. The examiner can usually be
confident of the point of sleep onset within one or two epochs.
Vertex waves are common in stage N1 sleep and are defined
by a sharp configuration maximal over the central derivations.
Vertex waves should be easily distinguished from the back-
ground activity.
Stage N2
Stage N2 sleep is characterized by the presence of one or more
K complexes or sleep spindles. To qualify as stage N2, an epoch
also must contain less than 20% of slow (delta) wave EEG activity
(<6 seconds of a 30-second epoch). Slow-wave activity is defined
as waves with a frequency less than 2 Hz and a minimum peak-to-
peak amplitude of greater than 75 mV. Stage N2 occupies the great-
est proportion of the TST and accounts for roughly 40% to 50%
of sleep. Stage N2 sleep ends with a sleep stage transition (to stage
W, stage N3, stage R), an arousal, or a major body movement fol-
lowed by SEMs and low-amplitude, mixed-frequency EEG.
Stage N3 (formerly stage N3 and N4)
Stages N3 NREM sleep is called slow-wave, delta, or deep sleep.
Stage N3 is scored when slow-wave activity (frequency < 2 Hz and
Chap01.indd 6
amplitude > 75 mV peak-to-peak) is present for greater than 20%
of the epoch. Spindles may be present in the EEG. Frequently,
the high-voltage EEG activity is transmitted to the eye leads. The
EMG often is lower than during stages N1 and N2 sleep, but this
is variable. In older patients, the slow-wave amplitude is lower
and the total amount of slow-wave sleep is reduced. The ampli-
tude of the slow waves (and amount of slow-wave sleep) is usu-
ally highest in the first sleep cycles. Typically, stage N3 occurs
mostly in the early portions of the night. Several parasomnias
(disorders associated with sleep) occur in stage N3 sleep and,
therefore, can be predicted to occur in the early part of the night.
These include somnambulism (sleep walking) and night terrors.
By contrast, parasomnias occurring in REM sleep (for example,
nightmares) are more common in the early morning hours.
Stage R
Stage R sleep is characterized by a low-voltage, mixed-frequency
EEG, the presence of episodic REMs, and a relatively low-am-
plitude chin EMG. Sawtooth waves also may occur in the EEG.
There usually are three to five episodes of REM sleep during
the night, which tend to increase in length as the night pro-
gresses. The number of eye movements per unit time (REM
density) also increases during the night. Not all epochs of REM
sleep contain REMs. Epochs of sleep otherwise meeting criteria
for stage R and contiguous with epochs of unequivocal stage
R (REMs present) are scored as stage R (see Advanced Staging
Rules). Bursts of alpha waves can occur during REM sleep, but
the frequency is often 1 to 2 Hz slower than during wake.
Stage R is associated with many unique, physiologic changes,
such as widespread skeletal muscle hypotonia and sleep-related
erections. Skeletal muscle hypotonia is a protective mechanism
to prevent the acting out of dreams. In a pathologic state known
as the REM behavior disorder, muscle tone is present, and body
movements and even violent behavior can occur during REM
sleep.
Arousals
Arousal from sleep denotes a transition from a state of sleep to
wakefulness. Frequent arousals can cause daytime sleepiness by
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shortening the total amount of sleep. However, even if arousals
are brief (1 to 5 seconds) with a rapid return to sleep, daytime
sleepiness may result, although the TST is relatively normal (7).
Thus, the restorative function of sleep depends on continuity as
well as duration. Many disorders that are associated with exces-
sive daytime sleepiness also are associated with frequent, brief
arousals. For example, patients with OSA frequently have arousals
coincident with apnea/hypopnea termination. Therefore, deter-
mination of the frequency of arousals has become a standard
part of the analysis of sleep architecture during sleep testing.
Movement arousals were defined in the Rechtschaffen and
Kales (R&K) scoring manual (1) as an increase in EMG that is
accompanied by a change in pattern on any additional chan-
nel. For EEG channels, qualifying changes included a decrease
in amplitude, paroxysmal high-voltage activity, or an increase
in alpha activity. Subsequently, arousals were the object of
considerable research, but the criteria used to define them was
variable. A report from the Atlas Task Force of the American
Academy of Sleep Medicine (formerly the American Sleep Dis-
orders Association or ASDA) has become the standard defini-
tion (8). According to the ASDA Task Force, an arousal should
be scored in NREM sleep when there is an abrupt shift in EEG
frequency, which may include theta, alpha, and/or frequencies
greater than 16 Hz, but not spindles, of 3 seconds or longer
duration. The 3-second duration was chosen for methodologi-
cal reasons; shorter arousals may also have physiologic impor-
tance. To be scored as an arousal, the shift in EEG frequency
must follow at least ten continuous seconds of any stage of
sleep. Arousals in NREM sleep may occur without a concur-
rent increase in the submental EMG amplitude. In REM sleep,
however, the required EEG changes must be accompanied by
a concurrent increase in EMG amplitude for an arousal to be
scored. This extra requirement was added because spontaneous
bursts of alpha rhythm are a fairly common occurrence in REM
(but not NREM) sleep. Note that according to the above recom-
mendations, increases in the chin EMG in the absence of EEG
changes are not considered evidence of arousal in either NREM
or REM sleep. Scoring of arousal during REM does, however,
require a concurrent increase in submental EMG lasting at least
1 second. Similarly, sudden bursts of delta (slow-wave) activity
in the absence of other changes do not qualify as evidence of
Chap01.indd 7
INTRODUCTION TO SLEEP AND POLYSOMNOGRAPHY 7
arousal. Because cortical EEG changes must be present to meet
the above definition, such events are also termed electrocortical
arousals. Note that the above guidelines represent a consensus
on events likely to be of physiologic significance. The commit-
tee recognized that other EEG phenomena, such as delta bursts,
also can represent evidence of arousal in certain contexts.
The frequency of arousals usually is computed as the arousal
index (number of arousals per hour of sleep). Relatively little
data is available to define a normal range for the arousal index.
Normal young adults studied after adaptation nights frequently
have an arousal index of 5 per hour or less. In one study, how-
ever, normal subjects of variable ages had a mean arousal index
of 21 per hour and the arousal index was found to increase with
age (9). However, a respiratory arousal index (RAI) (arous-
als associated with respiratory events) as low as 10 per hour
has been associated with daytime sleepiness in some individu-
als with the upper-airway resistance syndrome (UARS) (10).
While some have argued that patients with this disorder really
represent the mild end of the OSA syndrome, most would
agree with the concept that respiratory arousals of sufficient
frequency can cause daytime sleepiness in the absence of frank
apnea and arterial oxygen desaturation.
ADVANCED SLEEP STAGING RULES
Staging of REM sleep also requires special rules (REM rules) to
define the beginning and end of REM sleep. This is necessary
because REMs are episodic, and the three indicators of stage R
(EEG, EOG, and EMG) may not change to (or from) the REM-
like pattern simultaneously. R&K recommend that any section
of the record that is contiguous with uneqivocal stage R and dis-
plays a relatively low-voltage, mixed-frequency EEG be scored
as stage R regardless of whether REMs are present, providing
the EMG is at the stage R level. To be REM-like, the EEG must
not contain spindles, K complexes, or slow waves.
Atypical Sleep Patterns
Four special cases in which sleep staging is made difficult by
atypical EEG, EOG, and EMG patterns will be briefly mentioned.
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 8 CHAPTER 1
In alpha sleep, prominent alpha activity persists into NREM
sleep. The presence of spindles, K complexes, and slow-wave
activity allows sleep staging despite prominent alpha activ-
ity. Causes of the pattern include pain, psychiatric disorders,
chronic pain syndromes, and any cause of nonrestorative
sleep (11, 12). Patients taking benzodiazepines may have very
prominent pseudo-spindle activity (14 to 16 Hz rather than
the usual 12 to 14 Hz) (13). SEMs are usually absent by the
time stable stage N2 sleep is present. However, patients on
some serotonin reuptake inhibitors (fluoxetine and others)
may have prominent slow and REMs during NREM sleep (14).
While a reduction in the chin EMG is required for staging REM
sleep, patients with the REM sleep behavior disorder may have
high chin activity during what otherwise appears to be REM
sleep (15).
Sleep Staging in Infants and Children
Newborn term infants do not have the well-developed adult
EEG patterns to allow staging according to R&K rules. The fol-
lowing is a brief description of terminology and sleep staging
for the newborn infant according to the state determination of
Anders, Emde, and Parmelee (16). Infant sleep is divided into
active sleep (corresponding to REM sleep), quiet sleep (cor-
responding to NREM sleep), and indeterminant sleep, which
is often a transitional sleep stage. Behavioral observations are
critical. Wakefulness is characterized by crying, quiet eyes open,
and feeding. Sleep is often defined as sustained eye closure.
Newborn infants typically have periods of sleep lasting 3 to
4 hours interrupted by feeding and total sleep in 24 hours is
usually 16 to 18 hours. They have cycles of sleep with a 45- to
60-minute periodicity with about 50% active sleep. In new-
borns, the presence of REM (active sleep) at sleep onset is the
norm. By contrast, the adult sleep cycle is 90 to 100 minutes,
REM occupies about 20% of sleep, and NREM sleep is noted at
sleep onset.
The EEG patterns of newborn infants have been character-
ized as low-voltage irregular (LVI), trac alternant (TA), HVS,
and mixed (M) (Table 1-5). Eye movement monitoring is used
as in adults. An epoch is considered to have high or low EMG if
over one half of the epoch shows the pattern. The characteristics
Chap01.indd 8
of active sleep, quiet sleep, and indeterminant sleep are listed
in Table 1-6. The change from active to quiet sleep is more
likely to manifest indeterminant sleep. Nonnutritive sucking
commonly continues into sleep.
As children mature, more typically adult EEG patterns begin
to appear. Sleep spindles begin to appear at 2 months and are
usually seen after 3 to 4 months of age (17). K complexes usu-
ally begin to appear at 6 months of age and are fully developed
by 2 years of age (18). The point at which sleep staging fol-
lows adult rules is not well defined, but usually is possible after
age 6 months. After about 3 months, the percentage of REM
sleep starts to diminish and the intensity of body movements
during active (REM) sleep begins to decrease. The pattern of
NREM at sleep onset begins to emerge. However, the sleep cycle
period does not reach the adult value of 90 to 100 minutes
until adolescence.
Note that the sleep of premature infants is somewhat differ-
ent from term infants (36 to 40 weeks gestation). In premature
infants, quiet sleep usually shows a pattern of trac discontinu
(19). This differs from TA as there is electrical quiescence (rather
than a reduction in amplitude) between bursts of high-voltage
activity. In addition, delta brushes (fast waves of 10 to 20 Hz) are
superimposed on the delta waves. As the infant matures, delta
brushes disappear and TA pattern replaces trac discontinue.
RESPIRATORY MONITORING
The three major components of respiratory monitoring during
sleep are airflow, respiratory effort, and arterial oxygen satura-
tion (20, 21). Many sleep centers also find using a snore sen-
sor to be useful. For selected cases, exhaled or transcutaneous
PCO2 may also be monitored.
Traditionally, airflow at the nose and mouth was monitored
by thermistors or thermocouples. These devices actually detect
airflow by the change in the device temperature induced by a
flow of air over the sensor. It is common to use a sensor in
or near the nasal inlet and over the mouth (nasal-oral sensor)
to detect both nasal and mouth breathing. While temperature
sensing devices may accurately detect an absence of airflow
(apnea), their signal is not proportional to flow and they have
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 INTRODUCTION TO SLEEP AND POLYSOMNOGRAPHY 9

TABLE 1-5 EEG Patterns Used in Infant Sleep Staging

EEG Pattern
Low-voltage irregular (LVI) Low-voltage (1435 V)a, little variation theta (58 Hz) predominates
Slow activity (15 Hz) also present
Trac alternant (TA) Bursts of high-voltage slow waves (0.53 Hz) with superimposition of rapid low-voltage
sharp waves 24 Hz
In between the high-voltage bursts (alternating with them) is low-voltage mixed-
frequency activity of 4 8 seconds in duration
High-voltage slow (HVS) Continuous moderately rhythmic medium- to high-voltage (50150 V) slow waves
(0.54 Hz)
Mixed (M) High-voltage slow- and low-voltage polyrhythmic activity
Voltage lower than in HVS

V, microvolts.
a

TABLE 1-6 Characteristics of Active and Quiet Sleep

Active Sleep Quiet Sleep Indeterminant

Behavioral Eyes closed Eyes closed Not meeting criteria for active
Facial movements: smiles, No body movements except or quiet sleep
grimaces, frowns startles and phasic jerks
Burst of sucking Sucking may occur
Bodysmall digit or limb
movements
EEG LVI, M, HVS (rarely) HVS, TA, M
EOG REMs No REMs
A few SEMs and a few dysconjugate
movements may occur
EMG Low High
Respiration Irregular Regular
Postsigh pauses may occur

Chap01.indd 9 8/6/2009 4:01:10 PM

 10 CHAPTER 1
a slow response time (22). Therefore, they do not accurately
detect decreases in airflow (hypopnea) or flattening of the air-
flow profile (airflow limitation). Exact measurement of airflow
can be performed by use of a pneumotachograph. This device
can be placed in a mask over the nose and mouth. Airflow is
determined by measuring the pressure drop across a linear resis-
tance (usually a wire screen). However, pneumotachographs are
rarely used in clinical diagnostic studies. Instead, monitoring of
nasal pressure via a small cannula in the nose connected to a
pressure transducer has gained in popularity for monitoring air-
flow (22, 23). The nasal pressure signal is actually proportional
to the square of flow across the nasal inlet (24). Thus, nasal
pressure underestimates airflow at low flow rates and overes-
timates airflow at high flow rates. In the midrange of typical
flow rates during sleep, the nasal pressure signal varies fairly lin-
early with flow. The nasal pressure versus flow relationship can
be completely linearized by taking the square root of the nasal
pressure signal (25). However, in clinical practice, this is rarely
performed. In addition to changes in magnitude, changes in the
shape of the nasal pressure signal can provide useful informa-
tion. A flattened profile usually means that airflow limitation is
present (constant or decreasing flow with an increasing driving
pressure) (22, 23). The unfiltered nasal pressure signal also can
detect snoring if the frequency range of the amplifier is ade-
quate. The only significant disadvantage of nasal pressure mon-
itoring is that mouth breathing often may not be adequately
detected (10% to 15% of patients). This can be easily handled
by monitoring with both nasal pressure and a nasal-oral therm-
istor. An alternative approach to measuring flow is to use respi-
ratory inductance plethysmography. The changes in the sum of
the rib cage and abdomen band signals (RIPsum) can be used
to estimate changes in tidal volume (26, 27). During positive-
pressure titration, an airflow signal from the flow-generating
device is often recorded instead of using thermistors or nasal
pressure. This flow signal originates from a pneumotachograph
or other flow-measuring device inside the flow generator.
In pediatric polysomnography, exhaled CO2 is often mon-
itored. Apnea usually causes an absence of fluctuations in
this signal although small expiratory puffs rich in CO2 can
sometimes be misleading (6, 21). The end-tidal PCO2 (value
at the end of exhalation) is an estimate of arterial PCO2.
Chap01.indd 10
During long periods of hypoventilation that are common in
children with sleep apnea, the end-tidal PCO2 will be elevated
(>45 mm Hg) (21).
Respiratory effort monitoring is necessary to classify respi-
ratory events. A simple method of detecting respiratory effort
is detecting movement of the chest and abdomen. This may
be performed with belts attached to piezoelectric transducers,
impedance monitoring, respiratory-inductance plethysmog-
raphy (RIP), or monitoring of esophageal pressure (reflecting
changes in pleural or intrathoracic pressure). The surface EMG
of the intercostal muscles or diaphragm can also be monitored
to detect respiratory effort. Probably the most sensitive method
for detecting effort is monitoring of changes in esophageal
pressure (reflecting changes in pleural pressure) associated with
inspiratory effort (23). This may be performed with esopha-
geal balloons or small fluid-filled catheters. Piezoelectric bands
detect movement of the chest and abdomen as the bands are
stretched, and the pull on the sensors generates a signal. How-
ever, the signal does not always accurately reflect the amount
of chest/abdomen expansion. In RIP, changes in the induc-
tance of coils in bands around the rib cage (RC) and abdomen
(AB) during respiratory movement are translated into voltage
signals. The inductance of each coil varies with changes in the
area enclosed by the bands. In general, RIP belts are more accu-
rate in estimating the amount of chest/abdominal movement
than piezoelectric belts. The sum of the two signals [RIPsum =
(a RC) + (b AB)] can be calibrated by choosing appropri-
ate constants: a and b. Changes in the RIPsum are estimates of
changes in tidal volume (28). During upper-airway narrowing
or total occlusion, the chest and abdominal bands may move
paradoxically. Of note, a change in body position may alter the
ability of either piezoelectric belts or RIP bands to detect chest/
abdominal movement. Changes in body position may require
adjusting band placement or amplifier sensitivity. In addition,
very obese patients may show little chest/abdominal wall move-
ment despite considerable inspiratory effort. Thus, one must be
cautious about making the diagnosis of central apnea solely on
the basis of surface detection of inspiratory effort.
Arterial oxygen saturation (SaO2) is measured during sleep
studies using pulse oximetry (finger or ear probes). This is often
denoted as SpO2 to specify the method of SaO2 determination.
8/6/2009 4:01:10 PM

A desaturation is defined as a decrease in SaO2 of 4% or more
from baseline. Note that the nadir in SaO2 commonly follows
apnea (hypopnea) termination by approximately 6 to 8 sec-
onds (longer in severe desaturations). This delay is secondary
to circulation time and instrumental delay (the oximeter aver-
ages over several cycles before producing a reading). Various
measures have been applied to assess the severity of desatu-
ration, including computing the number of desaturations, the
average minimum SaO2 of desaturations, the time below 80%,
85%, and 90%, as well as the mean SaO2 and the minimum
saturation during NREM and REM sleep. Oximeters may vary
considerably in the number of desaturations they detect and
their ability to discard movement artifact. Using long averaging
times may dramatically impair the detection of desaturations.
ADULT RESPIRATORY DEFINITIONS
In adults, apnea is defined as absence of airflow at the mouth for
10 seconds or longer (20, 21). If one measures airflow with a very
sensitive device, such as a pneumotachograph, small expiratory
puffs can sometimes be detected during an apparent apnea. In
this case, there is inspiratory apnea. Many sleep centers regard a
severe decrease in airflow (to <10% of baseline) to be an apnea.
An obstructive apnea is cessation of airflow with persistent
inspiratory effort. The cause of apnea is an obstruction in the
upper airway. In central apnea, there is an absence of inspira-
tory effort. A mixed apnea is defined as an apnea with an initial
central portion followed by an obstructive portion. A hypopnea
is a reduction in airflow for 10 seconds or longer (20). The
apnea + hypopnea index (AHI) is the total number of apneas
and hypopneas per hour of sleep. In adults, an AHI of less than
5 is considered normal.
Hypopneas can be further classified as obstructive, central,
or mixed. If the upper airway narrows significantly, airflow can
fall (obstructive hypopnea). Alternatively, airflow can fall from a
decrease in respiratory effort (central hypopnea). Finally, a com-
bination is possible (mixed hypopnea) with both a decrease in
respiratory effort and an increase in upper-airway resistance.
However, unless accurate measures of airflow and esophageal
or supraglottic pressure are obtained, such differentiation is
Chap01.indd 11
INTRODUCTION TO SLEEP AND POLYSOMNOGRAPHY 11
usually not possible. In clinical practice, one usually identifies
an obstructive hypopnea by the presence of airflow vibration
(snoring), chest-abdominal paradox (increased load), or evi-
dence of airflow flattening (airflow limitation) in the nasal
pressure signal. In both examples, the nasal pressure shows a
flattened profile not seen in the thermistor. In the second exam-
ple, there is chest-abdominal paradox during the event. Note the
sudden transition from a flattened nasal pressure profile to a
more rounded profile at event termination. A central hypopnea
is associated with an absence of snoring, a round airflow pro-
file (nasal pressure), and absence of chest-abdominal paradox.
However, in the absence of esophageal pressure monitoring,
a central hypopnea cannot always be classified with certainty.
In addition, obstructive hypopnea may not always be associ-
ated with chest-abdominal paradox. Because of the limitations
in exactly determining the type of hypopnea, most sleep cen-
ters usually report only the total number and frequency of
hypopneas.
The new requirements for an event to be classified as a
hypopnea are as follows. A hypopnea should be scored only if
all of the following criteria are present.
The nasal pressure signal excursions (or those of the alterna-
tive hypopnea sensor) drop by more than 30% of baseline
The event duration is at least 10 seconds
There is more than 4% oxygen desaturation from pre-event
baseline
At least 90% of the events duration must meet the amplitude
reduction of criteria for hypopnea
Alternatively, a hypopnea can also be scored if all of these cri-
teria are present.
The nasal pressure signal excursions (or those of the alterna-
tive hypopnea sensor) drop by more than 50% of baseline
The duration of the event is at least 10 seconds
There is more than 3% oxygen 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 hypopnea
Respiratory events that do not meet criteria for either apnea or
hypopnea can induce arousal from sleep. Such events have been
8/6/2009 4:01:10 PM
 12 CHAPTER 1
called upper-airway resistance events (UARE), after the UARS
(10). An AASM task force recommended that such events be called
respiratory effort-related arousals (RERAs). The recommended
criteria for a RERA is a respiratory event of 10 seconds or longer
followed by an arousal that does not meet criteria for an apnea
or hypopnea, but is associated with a crescendo of inspiratory
effort (esophageal monitoring) or a flattened waveform on nasal
pressure monitoring (27). Typically, following arousal, there is a
sudden drop in esophageal pressure deflections. The exact defi-
nition of hypopnea that one uses will often determine whether
a given event is classified as a hypopnea or a RERA.
One can also detect flow-limitation arousals (FLA) using an
accurate measure of airflow, such as nasal pressure. Such events
are characterized by flow limitation (flattening) over several
breaths followed by an arousal and sudden, but often tempo-
rary, restoration of a normal-round airflow profile. One study
suggested that the number of FLA per hour corresponded closely
to the RERA index identified by esophageal pressure monitoring
(29). Some centers compute a RAI, determined as the arousals
per hour associated with apnea, hypopnea, or RERA/FLA events.
The AHI and respiratory disturbance index (RDI) are often used
as equivalent terms. However, in some sleep centers the RDI
= AHI + RERA index, where the RERA index is the number of
RERAs per hour of sleep, and RERAs are arousals associated with
respiratory events not meeting criteria for apnea or hypopnea.
One can use the AHI to grade the severity of sleep apnea. Stan-
dard levels include normal (<5), mild (5 to <15), moderate (15 to
29), and severe (>30) per hour. Many sleep centers also give sepa-
rate AHI values for NREM and REM sleep and various body posi-
tions. Some patients have a much higher AHI during REM sleep
or in the supine position (REM-related or postural sleep apnea).
Because the AHI does not always express the severity of oxygen
desaturation, one might also grade the severity of desaturation.
For example, it is possible for the overall AHI to be mild, but for
the patient to have quite severe desaturation during REM sleep.
PEDIATRIC RESPIRATORY DEFINITIONS
Periodic breathing is defined as three or more respiratory
pauses of at least 3 seconds in duration separated by less than
Chap01.indd 12
20 seconds of normal respiration. Periodic breathing is seen
primarily in premature infants and mainly during active sleep
(30). Although controversial, some feel that the presence of
periodic breathing for more than 5% of TST or during quiet
sleep in term infants is abnormal. Central apnea in infants is
thought to be abnormal if the event is greater than 20 seconds
in duration or associated with arterial oxygen desaturation or
significant bradycardia (3033).
In children, a cessation of airflow of any duration (usu-
ally two or more respiratory cycles) is considered an apnea
when the event is obstructive (3033), i.e., the 10-second
rule for adults does not apply. Of note, the respiratory rate
in children (20 to 30 per minute) is greater than in adults
(12 to 15 per minute). In fact, 10 seconds in an adult is usu-
ally the time required for two to three respiratory cycles.
Obstructive apnea is very uncommon in normal children.
Therefore, an obstructive AHI greater than 1 is considered
abnormal. In children with OSA, the predominant event
during NREM sleep is obstructive hypoventilation rather
than a discrete apnea or hypopnea. Obstructive hypoventila-
tion is characterized by a long period of upper-airway nar-
rowing with a stable reduction in airflow and an increase in
the end-tidal PCO2. There is usually a mild decrease in the
arterial oxygen desaturation. The rib cage is not completely
calcified in infants and young children. Therefore, some
paradoxical breathing is not necessarily abnormal. However,
worsening paradox during an event would still suggest a par-
tial airway obstruction. Nasal pressure monitoring is being
used more frequently in children and periods of hypoventi-
lation are more easily detected (reduced airflow with a flat-
tened profile). Normative values have been published for the
end-tidal PCO2. One paper suggested that a peak end-tidal
PCO2 greater than 53 mm Hg or end-tidal PCO2 greater than
45 mm Hg for more than 60% of TST should be considered
abnormal (31).
Central apnea in infants was discussed above. The signifi-
cance of central apnea in older children is less certain. Most do
not consider central apneas following sighs (big breaths) to be
abnormal. Some central apnea is probably normal in children,
especially during REM sleep. In one study, up to 30% of normal
children had some central apnea. Central apneas, when longer
8/6/2009 4:01:10 PM

than 20 seconds, or those of any length associated with SaO2
below 90%, are often considered abnormal, although a few
such events have been noted in normal children (34). There-
fore, most would recommend observation alone unless the
events are frequent.
LEG MOVEMENT MONITORING
The EMG of the anterior tibial muscle (anterior lateral aspect
of the calf) of both legs is monitored to detect leg movements
(LMs) (35). Two electrodes are placed on the belly of the upper
portion of the muscle of each leg about 2 to 4 cm apart. A elec-
trode loop is taped in place to provide strain relief. Usually,
each leg is displayed on a separate channel. However, if the
number of recording channels is limited, one can link an elec-
trode on each leg and display both leg EMGs on a single trac-
ing. Recording from both legs is required to accurately assess
the number of movements. During biocalibration, the patient
is asked to dorsiflex and plantarflex the great toe of the right
and then the left leg to determine the adequacy of the elec-
trodes and amplifier settings. The amplitude should be 1 cm
(paper recording) or at least one half of the channel width on
digital recording.
An LM is defined as an increase in the EMG signal of a
least one fourth the amplitude exhibited during biocalibra-
tion that is one-half to 10 seconds in duration (35). Periodic
LMs (PLMs) should be differentiated from bursts of spikelike
phasic activity that occur during REM sleep. To be considered
a PLM, the movement must occur in a group of four or more
movements, each separated by more than 5 seconds and less
than 90 seconds (measured onset to onset). To be scored as
a periodic leg movement in sleep, an LM must be preceded
by at least 10 seconds of sleep. In most sleep centers, LMs
associated with termination of respiratory events are not
counted as PLMs. Some may score and tabulate this type of
LM separately. The PLM index is the number of periodic LMs
divided by the hours of sleep (TST in hours). Rough guide-
lines for the PLM index are more than 5 to less than 25 mild,
25 to less than 50 moderate, and 50 per hour severe (36).
A PLM arousal is an arousal that occurs simultaneously with
Chap01.indd 13
INTRODUCTION TO SLEEP AND POLYSOMNOGRAPHY 13
or following (within 1 to 2 seconds) a PLM. The PLM arousal
index is the number of PLM arousals per hour of sleep.
A PLM arousal index of more than 25 per hour is considered
severe. LMs that occur during wake or after an arousal are
either not counted or tabulated separately. For example, the
PLMW (PLMwake) index is the number of PLMs per hour of
wake. Of note, frequent LMs during wake, especially at sleep
onset, may suggest the presence of the restless legs syndrome.
The latter is a clinical diagnosis made on the basis of patient
symptoms.
POLYSOMNOGRAPHY, BIOCALIBRATIONS,
AND TECHNICAL ISSUES
In addition to the standard physiological parameters moni-
tored in polysomnography, body position (using low-light
video monitoring) and treatment level (CPAP, bilevel pres-
sure) are usually added in comments by the technologists. In
most centers, a video recording is also made on traditional
video tape or digitally as part of the digital recording. It is
standard practice to perform amplifier calibrations at the
start of recording. In traditional paper recording, a calibra-
tion voltage signal (square wave voltage) was applied and the
resulting pen deflections, along with the sensitivity, polarity,
and filter settings on each channel, were documented on the
paper. Similarly, in digital recording, a voltage is applied,
although it is often a sine-wave voltage. The impedance of the
head electrodes is also checked prior to recording. An ideal
impedance is less than 5,000 W although 10,000 W or less
is acceptable. Electrodes with higher impedances should be
changed.
A biocalibration procedure is performed (Table 1-7)
while signals are acquired with the patient connected to the
monitoring equipment (4,5). This procedure permits check-
ing of amplifier settings and integrity of monitoring leads/
transducers. It also provides a record of the patients EEG and
eye movements during wakefulness with eyes closed and open.
A summary of typical commands and their utility is listed in
Table 1-7.
8/6/2009 4:01:10 PM
 14 CHAPTER 1
TABLE 1-7 Biocalibration Procedure
Eyes closed
Eyes open
Look right, look left, look up, look down
Grit teeth
Breathe in, breathe out
Deep breath in, hold breath
Wiggle right toe, left toe
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EEG: alpha EEG activity
EOG: slow eye movements
EEG: attenuation of alpha rhythm
EOG: REMs, blinks
Integrity of eye leads, polarity, amplitude
Eye movements should cause out-of-phase deflections
Chin EMG
Airflow, chest, abdomen movements adequate gain? Tracings in
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24. Monserrat JP, Farr R, Ballester E, et al. Evaluation of nasal prongs for
estimating nasal flow. Am J Respir Crit Care Med 1997;155:211215.
25. Farr R, Rigau J, Montserrat JM, et al. Relevance of linearizing nasal
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26. Tobin M, Cohn MA, Sackner MA. Breathing abnormalities during
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28. Chada TS, Watson H, Birch S, et al. Validation of respiratory inductance
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29. Ayappa I, Norman RG, Krieger AC, et al. Non-invasive detection of
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30. American Thoracic Society. Standards and indication for cardio-
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34. Weese-Mayer DE, Morrow AS, Conway LP, et al. Assessing clinical
significance of apnea exceeding fifteen seconds with event record-
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35. ASDA Task Force. Recording and scoring leg movements. Sleep
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Chap01.indd 16 8/6/2009 4:01:10 PM
 CHAPTER

2 Staging
James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD

17

Chap02.indd 17 8/6/2009 8:07:01 PM

 18 CHAPTER 2

FIGURE 2-1 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 60-second page.
Clinical: 55-year-old man.
Staging: Stage wake. Biocalibration of eye movements. The patient is instructed to look up and down, left
and right, and to open and close the eyes. The representations of these eye movements insure that the eye
movement is properly recorded and provide a reference for identification of rapid eye movements during
REM sleep and wakefulness.

Chap02.indd 18 8/6/2009 8:07:01 PM

 STAGING 19

FIGURE 2-2 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 60-second page.
Clinical: 55-year-old man.
Staging: Stage wake. Biocalibration of breathing and leg movements. The representations of these activi-
ties insure that they are recorded properly and assist in the identification of breathing and leg move-
ment abnormalities during sleep.

Chap02.indd 19 8/6/2009 8:07:03 PM

 20 CHAPTER 2

* ^
FIGURE 2-3 Polysomnogram: Standard montage; 30-second page.
Clinical: 47-year-old woman.
Staging: Stage wake. Eyes are open. There is a well-modulated posteriorly dominant 9-Hz alpha rhythm
which is attenuated when eyes are open (*) and becomes more prominent with eye closure ().

Chap02.indd 20 8/6/2009 8:07:05 PM

 STAGING 21

FIGURE 2-4 Polysomnogram: CPAP montage; 30-second page.

Clinical: 23-year-old man.
Staging: Stage wake. Wakefulness with eyes open and rapid eye movements. The alpha rhythm attenu-
ates when the eyes are open; a small amount of alpha activity can be seen from the occipital deriva-
tions during the last few seconds of the page.

Chap02.indd 21 8/6/2009 8:07:06 PM

 22 CHAPTER 2

FIGURE 2-5 Polysomnogram: Standard montage; 30-second page.

Clinical: 17-year-old man.
Staging: Stage wake. There is a well-modulated 8-Hz alpha rhythm. The alpha rhythm is most prominent
posteriorly but its scalp topography varies across individuals. In this patient, the alpha rhythm is well
represented in the central derivations.

Chap02.indd 22 8/6/2009 8:07:08 PM

 STAGING 23

FIGURE 2-6 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 29-year-old man.
Staging: Stage wake. Slow eye movements with continued alpha activity indicate that the subject is
drowsy and approaching the transition to stage N1 sleep.

Chap02.indd 23 8/6/2009 8:07:09 PM

 24 CHAPTER 2

* *
FIGURE 2-7 Polysomnogram: Standard montage; 30-second page.
Clinical: 39-year-old woman.
Staging: Stage wake. Although alpha activity is present during the majority of the epoch, intermittent
prominent theta activity (*) is consistent with brief episodes of sleep (microsleep).

Chap02.indd 24 8/6/2009 8:07:11 PM

 STAGING 25

FIGURE 2-8 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 34-year-old man.
Staging: Stage N1 sleep. Transition from wakefulness to stage N1 sleep with slow eye movements.
The alpha rhythm is present during the first 6 seconds, becomes intermittent for the next 11 seconds,
and is fully replaced by theta activity during the final 13 seconds.

Chap02.indd 25 8/6/2009 8:07:12 PM

 26 CHAPTER 2

FIGURE 2-9 Polysomnogram: CPAP montage; 30-second page.

Clinical: 37-year-old man.
Staging: Stage N1 sleep.

Chap02.indd 26 8/6/2009 8:07:14 PM

 STAGING 27

FIGURE 2-10 Polysomnogram: CPAP montage; 30-second page.

Clinical: 37-year-old man.
Staging: Stage N1 sleep with prominent theta activity. There are slow eye movements and a gradual
reduction of EMG activity.

Chap02.indd 27 8/6/2009 8:07:16 PM

 28 CHAPTER 2

*
FIGURE 2-11 Polysomnogram: Standard montage; 30-second page.
Clinical: 29-year-old man.
Staging: Stage N1 sleep with an arousal (*) followed by movement artifact. Several seconds of stage N1
sleep are followed by an awakening. The respiratory and EEG channels are obscured by artifact for sev-
eral seconds. Alpha activity characteristic of wakefulness is present during the final third of the epoch.

Chap02.indd 28 8/6/2009 8:07:17 PM

 STAGING 29

* ^
FIGURE 2-12 Polysomnogram: Standard montage; 30-second page.
Clinical: 5-year-old girl.
Staging: Stage N1 sleep.
EEG: Rhythmic moderate to high amplitude 4- to 5-Hz activity, referred to as hypnagogic hypersyn-
chrony (*), is a prominent feature of drowsy wakefulness and stage N1 sleep between the ages of
6 months and 6 years. It becomes less prominent during late childhood and adolescence. Near the
end of the epoch, a K complex () indicates the transition to stage N2 sleep.

Chap02.indd 29 8/6/2009 8:07:18 PM

 30 CHAPTER 2

* * ^
FIGURE 2-13 Polysomnogram: Standard montage; 30-second page.
Clinical: 55-year-old man.
Staging: Stage N1 sleep. There are positive occipital sharp transients (POSTs) (*) and vertex waves ().
These transients are seen in most persons during stage N1 sleep and occasionally during stage N2 sleep.

Chap02.indd 30 8/6/2009 8:07:19 PM

 STAGING 31

* * *
FIGURE 2-14 Polysomnogram: Standard montage; 7.5-second page.
Clinical: 55-year-old man.
Staging: Stage N1 sleep with several POSTs (*).

Chap02.indd 31 8/6/2009 8:07:20 PM

 32 CHAPTER 2

* ^
FIGURE 2-15 Polysomnogram: Standard montage; 30-second page.
Clinical: 62-year-old man.
Staging: Stage N2 sleep with a K complex (*) and repetitive POSTs ().

Chap02.indd 32 8/6/2009 8:07:20 PM

 STAGING 33

*
FIGURE 2-16 Polysomnogram: Standard montage; 30-second page.
Clinical: 34-year-old man.
Staging: Stage N2 sleep with sleep spindles (*).

Chap02.indd 33 8/6/2009 8:07:21 PM

 34 CHAPTER 2

^ * ^
FIGURE 2-17 Polysomnogram: CPAP montage; 30-second page.
Clinical: 38-year-old woman.
Staging: Stage N2 sleep with K complexes (*) and sleep spindles ().

Chap02.indd 34 8/6/2009 8:07:21 PM

 STAGING 35

* ^
FIGURE 2-18 Polysomnogram: Standard montage; 30-second page.
Clinical: 44-year-old woman.
Staging: Stage N2 sleep with a K complex (*). A vertex wave () is also evident; although they are most
prominent in stage N1 sleep, they can be seen occasionally in stage N2 sleep.

Chap02.indd 35 8/6/2009 8:07:22 PM

 36 CHAPTER 2

^ ** * ^
FIGURE 2-19 Polysomnogram: Standard montage; 60-second page.
Clinical: 57-year-old man.
Staging: Stage N2 sleep with a K complex (*) and vertex waves (). A transient with features intermedi-
ate between a K complex and a vertex wave is evident (**).

Chap02.indd 36 8/6/2009 8:07:23 PM

 STAGING 37

* ^ ^
FIGURE 2-20 Polysomnogram: Standard montage; 60-second page.
Clinical: 44-year-old woman.
Staging: Stage N2 sleep with K complexes (*) and sleep spindles (). The individual waves of the sleep
spindles cannot be distinguished with the 60-second display.

Chap02.indd 37 8/6/2009 8:07:23 PM

 38 CHAPTER 2

* ^
FIGURE 2-21 Polysomnogram: Expanded EEG montage; 30-second page.
Clinical: 24-year-old man.
Staging: Stage N2 sleep with sleep spindles (*) and a vertex wave (). The expanded EEG montage
demonstrates the frontocentral topography of the sleep spindle and the parasagittal topography of
the vertex wave.

Chap02.indd 38 8/6/2009 8:07:24 PM

 STAGING 39

* ^ * * *
FIGURE 2-22 Polysomnogram: Expanded EEG montage; 30-second page.
Clinical: 24-year-old man.
Staging: Stage N2 sleep with frequent sleep spindles (*) and K complexes ().

Chap02.indd 39 8/6/2009 8:07:25 PM

 40 CHAPTER 2

*
FIGURE 2-23 Polysomnogram: EEG channels only; 30-second page.
Clinical: 24-year-old man.
Staging: Stage N2 sleep with sleep spindles and vertex waves. The asymmetric topography of the initial
spindle (*), with greater amplitude in the right temporal derivations than in the left temporal deriva-
tions, is within normal limits.

Chap02.indd 40 8/6/2009 8:07:26 PM

 STAGING 41

*
FIGURE 2-24 Polysomnogram: EEG channels only; 30-second page.
Clinical: 24-year-old man.
Staging: Stage N2 sleep with sleep spindles and K complexes. Some spindles (*) are better represented in
temporal derivations than in other derivations.

Chap02.indd 41 8/6/2009 8:07:26 PM

 42 CHAPTER 2

*
FIGURE 2-25 Polysomnogram: CPAP montage; 30-second page.
Clinical: 67-year-old man.
Staging: Stage N2 sleep with K complexes and sleep spindles. The presence of delta waves (*)
presages the transition to stage N3 sleep.

Chap02.indd 42 8/6/2009 8:07:27 PM

 STAGING 43

* ^
FIGURE 2-26 Polysomnogram: Expanded EEG montage with CO2 monitoring; 30-second page.
Clinical: 68-year-old man with excessive daytime sleepiness and chronic obstructive pulmonary
disease (COPD).
Staging: Stage N2 sleep.
Respiratory: Normal respirations.
EEG: Asymmetric sleep spindles occurring first on the right (*) and then on the left (). Other features of
stage N2 sleep are present including K complexes and POSTs.

Chap02.indd 43 8/6/2009 8:07:28 PM

 44 CHAPTER 2

*
FIGURE 2-27 EEG channels from an expanded EEG montage polysomnogram; 10-second page.
Clinical: 68-year-old man with excessive daytime sleepiness and COPD.
Staging: Stage N2 sleep.
EEG: Asymmetric sleep spindles (*) most prominent over the left hemisphere especially channels Fp1-F3
and F3-C3. POSTs are prominent in the occipital derivations.

Chap02.indd 44 8/6/2009 8:07:29 PM

 STAGING 45

FIGURE 2-28 Polysomnogram: Standard montage; 30-second page.

Clinical: 10-month-old girl.
Staging: Stage N3 sleep. The delta waves characteristic of slow wave sleep are prominent by the end of
the first year of life.

Chap02.indd 45 8/6/2009 8:07:30 PM

 46 CHAPTER 2

FIGURE 2-29 Polysomnogram: Expanded EEG montage; 30-second page.

Clinical: 2-year-old boy.
Staging: Stage N3 sleep.

Chap02.indd 46 8/6/2009 8:07:32 PM

 STAGING 47

FIGURE 2-30 Polysomnogram: Standard montage; 30-second page.

Clinical: 4-year-old boy.
Staging: Stage N3 sleep.

Chap02.indd 47 8/6/2009 8:07:34 PM

 48 CHAPTER 2

FIGURE 2-31 Polysomnogram: Standard montage; 30-second page.

Clinical: 4-year-old boy.
Staging: Stage N3 sleep.

Chap02.indd 48 8/6/2009 8:07:35 PM

 STAGING 49

FIGURE 2-32 Polysomnogram: Standard montage; 30-second page.

Clinical: 6-year-old boy.
Staging: Stage N3 sleep.

Chap02.indd 49 8/6/2009 8:07:37 PM

 50 CHAPTER 2

FIGURE 2-33 Polysomnogram: Standard montage; 30-second page.

Clinical: 8-year-old girl.
Staging: Stage N3 sleep.

Chap02.indd 50 8/6/2009 8:07:39 PM

 STAGING 51

FIGURE 2-34 Polysomnogram: Standard montage; 30-second page.

Clinical: 10-year-old boy.
Staging: Stage N3 sleep.

Chap02.indd 51 8/6/2009 8:07:41 PM

 52 CHAPTER 2

FIGURE 2-35 Polysomnogram: Standard montage; 30-second page.

Clinical: 18-year-old man.
Staging: Stage N3 sleep.

Chap02.indd 52 8/6/2009 8:07:43 PM

 STAGING 53

FIGURE 2-36 Polysomnogram: Standard montage; 30-second page.

Clinical: 18-year-old man.
Staging: Stage N3 sleep.

Chap02.indd 53 8/6/2009 8:07:45 PM

 54 CHAPTER 2

FIGURE 2-37 Polysomnogram: Expanded EEG montage; 30-second page with 1-second lines.
Clinical: 29-year-old man.
Staging: Stage N3 sleep with delta activity. The delta waves are diffusely distributed with greater ampli-
tude in anterior derivations.

Chap02.indd 54 8/6/2009 8:07:47 PM

 STAGING 55

FIGURE 2-38 Polysomnogram: CPAP montage; 30-second page.

Clinical: 35-year-old woman.
Staging: Stage N3 sleep with delta activity. Delta activity originating in prefrontal regions is well repre-
sented in the eye movement channels.

Chap02.indd 55 8/6/2009 8:07:48 PM

 56 CHAPTER 2

FIGURE 2-39 Polysomnogram: CPAP montage; 60-second page.

Clinical: 35-year-old woman.
Staging: Stage N3 sleep with nearly continuous delta activity.

Chap02.indd 56 8/6/2009 8:07:50 PM

 STAGING 57

FIGURE 2-40 Polysomnogram: CPAP montage; 120-second page.

Clinical: 35-year-old woman.
Staging: Stage N3 sleep with delta activity.

Chap02.indd 57 8/6/2009 8:07:52 PM

 58 CHAPTER 2

FIGURE 2-41 Polysomnogram: Standard montage; 30-second page.

Clinical: 48-year-old man.
Staging: Stage N3 sleep with alpha activity during delta sleep, a pattern referred to as alpha-delta sleep.
Unlike alpha activity characteristic of wakefulness, the alpha activity of alpha-delta sleep is diffusely
distributed and does not have a posterior maximum. The clinical significance of this finding is uncertain.

Chap02.indd 58 8/6/2009 8:07:54 PM

 STAGING 59

FIGURE 2-42 Polysomnogram: Standard montage; 60-second page.

Clinical: 48-year-old man.
Staging: Stage N3 sleep with alpha activity during delta sleep.

Chap02.indd 59 8/6/2009 8:07:56 PM

 60 CHAPTER 2

FIGURE 2-43 Polysomnogram: CPAP montage with CO2 monitoring; 30-second page.
Clinical: 57-year-old man.
Staging: Stage N3 sleep with alpha activity during delta sleep. The alpha activity is nearly continuous
during the second half of the epoch.

Chap02.indd 60 8/6/2009 8:07:58 PM

 STAGING 61

*
FIGURE 2-44 Polysomnogram: CPAP montage; 30-second page.
Clinical: 35-year-old woman.
Staging: Stage R sleep. Sawtooth waves (*) characteristic of REM sleep are evident. Epochs of REM
sleep, such as this one, that do not contain rapid eye movements are sometimes referred to as tonic
REM sleep.

Chap02.indd 61 8/6/2009 8:08:00 PM

 62 CHAPTER 2

*
FIGURE 2-45 Polysomnogram: CPAP montage; 60-second page.
Clinical: 35-year-old woman.
Staging: Stage R sleep with sawtooth waves (*).

Chap02.indd 62 8/6/2009 8:08:01 PM

 STAGING 63

FIGURE 2-46 Polysomnogram: CPAP montage; 60-second page.

Clinical: 35-year-old woman.
Staging: Stage R sleep. Several rapid eye movements occur in a cluster accompanied by limb twitches and
irregular respirations. Epochs containing such clusters of rapid eye movements and muscle twitches are
sometimes referred to as phasic REM sleep.

Chap02.indd 63 8/6/2009 8:08:01 PM

 64 CHAPTER 2

FIGURE 2-47 Polysomnogram: Standard montage; 30-second page.

Clinical: 59-year-old man.
Staging: Stage R sleep. There are rapid eye movements, brief bursts of EMG activity, and poorly formed
sawtooth waves.

Chap02.indd 64 8/6/2009 8:08:03 PM

 STAGING 65

*
FIGURE 2-48 Polysomnogram: CPAP montage; 7.5-second page.
Clinical: 64-year-old man.
Staging: Stage R sleep with sawtooth waves (*).

Chap02.indd 65 8/6/2009 8:08:05 PM

 66 CHAPTER 2

^ *
FIGURE 2-49 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 39-year-old woman.
Staging: Stage R sleep with sawtooth waves (*). Although a single K complex () is present, rapid eye movements
were present in preceding and succeeding epochs, indicating that this epoch should be scored as REM sleep.

Chap02.indd 66 8/6/2009 8:08:05 PM

 STAGING 67

*
FIGURE 2-50 Polysomnogram: CPAP montage; 30-second page.
Clinical: 41-year-old man.
Staging: Stage R sleep with alpha activity (*). The amount of posterior dominant alpha activity during
REM sleep varies widely among individuals.

Chap02.indd 67 8/6/2009 8:08:06 PM

 68 CHAPTER 2

FIGURE 2-51 Polysomnogram: Standard montage; 30-second page.

Clinical: 55-year-old man.
Staging: Stage R sleep with a small amount of posteriorly dominant alpha activity, most prominent in
the O2-A1 derivation.

Chap02.indd 68 8/6/2009 8:08:07 PM

 STAGING 69

FIGURE 2-52 Polysomnogram: CPAP montage; 30-second page.

Clinical: 61-year-old man.
Staging: Stage R sleep with phasic eye movements.
EMG: Bursts of EMG activity accompany the eye movements. The amount of EMG activity is probably
above normal.

Chap02.indd 69 8/6/2009 8:08:08 PM

 70 CHAPTER 2

FIGURE 2-53 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 24-year-old man.
Staging: Transition from NREM sleep to REM sleep. During the transition into REM sleep, the EMG tone
decreases to complete muscle atonia about midway through the epoch, followed by the appearance
of rapid eye movements.

Chap02.indd 70 8/6/2009 8:08:10 PM

 STAGING 71

*
FIGURE 2-54 Polysomnogram: Standard montage; 30-second page.
Clinical: 49-year-old man.
Staging: Stage R sleep with sawtooth waves (*).

Chap02.indd 71 8/6/2009 8:08:12 PM

 72 CHAPTER 2

FIGURE 2-55 Polysomnogram: Expanded EEG; 60-second page.

Clinical: 38-year-old man.
Staging: Stage R sleep with representation of rapid eye movements in channels Fp1-F7 and Fp2-F8. The
potentials produced by rapid eye movements are recorded by the lateral frontal electrodes, F7 and
F8. Horizontal rapid eye movements, such as these, are often recorded by lateral frontal or anterior
temporal (T1 and T2) electrodes, while vertical eye movements may be recorded by prefrontal (Fp1
and Fp2) electrodes.

Chap02.indd 72 8/6/2009 8:08:12 PM

 STAGING 73

FIGURE 2-56 Polysomnogram: Standard montage; 30-second page.

Clinical: 49-year-old man.
Staging: Stage R sleep without eye movements.

Chap02.indd 73 8/6/2009 8:08:14 PM

 74 CHAPTER 2

FIGURE 2-57 Polysomnogram: Standard montage; 30-second page.

Clinical: 49-year-old man.
Staging: Stage R sleep with a cluster of rapid eye movements.

Chap02.indd 74 8/6/2009 8:08:16 PM

 STAGING 75

FIGURE 2-58 Polysomnogram: Standard montage; 30-second page.

Clinical: 49-year-old man.
Staging: Stage R sleep with frequent rapid eye movements.

Chap02.indd 75 8/6/2009 8:08:18 PM

 76 CHAPTER 2

* ^
FIGURE 2-59 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 28-year-old man.
Staging: Transition from NREM sleep to REM sleep. There are elements of REM sleep including sawtooth
waves (*) and decreased muscle tone. There are also several sleep spindles (). Features of REM and
NREM sleep are often intermixed for a few seconds or minutes before and after a period of REM sleep.

Chap02.indd 76 8/6/2009 8:08:20 PM

 STAGING 77

FIGURE 2-60 Polysomnogram: Standard montage; 60-second page.

Clinical: 5-week-old girl.
Staging: Stage R sleep with incomplete atonia.
Respiratory: Irregular respirations during REM sleep. Such variations in frequency and amplitude of respi-
rations are normal at this age during REM sleep.

Chap02.indd 77 8/6/2009 8:08:20 PM

 78 CHAPTER 2

FIGURE 2-61 Polysomnogram: CPAP montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 22-year-old woman treated with fluoxetine.
Staging: Stage N3 sleep with alpha activity (alpha-delta sleep).
EOG: Slow eye movements. Slow eye movements are usually confined to drowsy wakefulness and stage
N1 sleep. However, fluoxetine and other antidepressants may cause such eye movements to occur in
all stages of sleep.

Chap02.indd 78 8/6/2009 8:08:22 PM

 STAGING 79

FIGURE 2-62 Polysomnogram: Standard montage; 60-second page.

Clinical: 49-year-old man.
Staging: Awakening with a position change.

Chap02.indd 79 8/6/2009 8:08:24 PM

 80 CHAPTER 2

FIGURE 2-63 Polysomnogram: Standard montage; 30-second page.

Clinical: 55-year-old man.
Staging: Elements of stage N2 sleep, Stage N3 sleep, REM sleep, and an arousal.
Respiratory: Hypopnea with an associated arousal.

Chap02.indd 80 8/6/2009 8:08:26 PM

 STAGING 81

FIGURE 2-64 Neonatal recording: 30-second page.

Clinical: 30-week conceptional age patient.
Respiratory: Normal respirations.
EEG: Trace discontinue with delta brushes. This discontinuous EEG pattern is a normal feature of NREM
sleep (quiet sleep) at this age.

Chap02.indd 81 8/6/2009 8:08:28 PM

 82 CHAPTER 2

FIGURE 2-65 Neonatal recording: 30-second page.

Clinical: 30-week conceptional age patient.
Respiratory: Normal respirations.
EEG: Trace discontinue with delta brushes during NREM sleep.

Chap02.indd 82 8/6/2009 8:08:30 PM

 STAGING 83

FIGURE 2-66 Neonatal recording: 30-second page.

Clinical: 42-week conceptional age patient in NREM sleep.
Respiratory: Partially obscured by artifact.
EEG: Trac alternant with bursts of higher amplitude delta and theta activity separated by periods of
moderate amplitude mixed frequency activity. The trac alternant pattern is a normal feature of
NREM sleep at this age.

Chap02.indd 83 8/6/2009 8:08:32 PM

 84 CHAPTER 2

FIGURE 2-67 Neonatal recording: 30-second page.

Clinical: 30-week conceptional age patient in R sleep (active sleep).
Respiratory: Slightly irregular respirations.
EEG: Continuous mixed frequency background activity. REM sleep is the most common sleep onset pat-
tern in neonates and makes up about 50% of newborn sleep.

Chap02.indd 84 8/6/2009 8:08:34 PM

 STAGING 85

FIGURE 2-68 Infant recording: 15-second page.

Clinical: 4-month-old patient in NREM sleep.
EEG: Symmetric sleep spindles and vertex waves.

Chap02.indd 85 8/6/2009 8:08:36 PM

 86 CHAPTER 2

FIGURE 2-69 Polysomnogram: Standard montage; 60-second page.

Clinical: 49-year-old man with some snoring and excessive daytime sleepiness. Also just recently started
an SSRI for depression and has developed restless sleep. Discontinuation of the SSRI and switching to
another antidepressant dramatically improved the restless sleep and daytime sleepiness.
Staging: Stage N2 sleep.
Eye leads: Slow eye movements on eye channels.
Leg leads: PLMs. The PLM index was 63.7.

Chap02.indd 86 8/6/2009 8:08:37 PM

 STAGING 87

Unremarkable Respirations and Frequent PLMs

Patient:
Account Number:
Medical Records:
Study Number:
Date of Study:
Date of Birth:
Requesting Physician:
Referring Physician:
Indications for Study: Sleep disturbance with hypersomnolence (780.54).
Study Description: Polysomnogram
Equipment: Central, frontal, and occipital EEG, EOG, EKG, submentalis EMG, intercostal EMG, airflow, thoracic motion, abdominal
motion, snore sensor, anterior tibialis EMG, and pulse oximetry were recorded throughout the study. The tracing was recorded in
30-second epochs.
Sleep Study Summary Report:
Record Time: 485.5 minutes; Sleep Time: 423.5 minutes
Analysissee detailed analysis tables
EEG/Sleep Stage
Stage N1 sleep: 15.7% (4%8%) Sleep latency: 43 minutes
Stage N2 sleep: 65.1% (45%63%) R latency: 130.5 minutes
Stage N3 sleep: 0% (4%20%) Sleep efficiency: 87.2%
Stage R sleep: 19.2% (23%31%)
Respiratory
AHI: 1 NR AHI: 0.8 R AHI: 2 Supine AHI: 0.9
RERA Index: 1.3 (9 RERA)
Total Respiratory Events: 7 (7 obstructive)
Arousal Index: 15.2
Minimum Oxygen Saturation: 93%
Snoring: moderate.
EKG: unRarkable.
Limb Movement
PLM Index: 46.5
PLM Arousal Index: 11.5
Impression: Sleep disturbance with hypersomnolence (780.54). Periodic limb movements (327.51).
There is no evidence of a sleep-related breathing disorder. A normal polysomnogram does not exclude the possibility of obstructive
sleep apnea or other sleep disorders. The findings indicate periodic limb movements with associated arousals. Clinical correlation is
advised.
Recommendations: The patient will be scheduled for a follow-up visit.
______________ , MD
The physician reviewed the record in its entirety, including sleep staging, EMG activity, EKG, EEG, respiration, oxygen saturation, body
position, and behavior unless otherwise noted. The interpretation is based on this information in addition to the available clinical history
and physical examination. This is a summary report. Please see the additional tabular report from this study for more detailed analysis.
TR:
DD:
DT:

Chap02.indd 87 8/6/2009 8:08:40 PM

Chap02.indd 88 8/6/2009 8:08:40 PM
 Multiple Sleep Latency
CHAPTER Test (MSLT) / Maintenance
3 of Wakefulness Test (MWT)
James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD

89

Chap03.indd 89 8/6/2009 4:06:41 PM

 90 CHAPTER 3

FIGURE 3-1 Multiple Sleep Latency Test: 30-second page.

Clinical: 32-year-old man with excessive daytime sleepiness.
Staging: Wakefulness. Calibration test.

Chap03.indd 90 8/6/2009 4:06:42 PM

 MULTIPLE SLEEP LATENCY TEST (MSLT) / MAINTENANCE OF WAKEFULNESS TEST (MWT) 91

FIGURE 3-2 Multiple Sleep Latency Test: 30-second page.

Clinical: 32-year-old man with excessive daytime sleepiness.
Staging: Wakefulness.

Chap03.indd 91 8/6/2009 4:06:44 PM

 92 CHAPTER 3

FIGURE 3-3 Multiple Sleep Latency Test: 30-second page.

Clinical: 32-year-old man with excessive daytime sleepiness.
Staging: Wakefulness with rapid eye movements.

Chap03.indd 92 8/6/2009 4:06:46 PM

 MULTIPLE SLEEP LATENCY TEST (MSLT) / MAINTENANCE OF WAKEFULNESS TEST (MWT) 93

*
FIGURE 3-4 Multiple Sleep Latency Test: 30-second page.
Clinical: 24-year-old woman with excessive daytime sleepiness.
Staging: Stage N1 sleep with slow eye movements and attenuation of the alpha rhythm.
Theta activity (*) is evident in C3-A2 and C4-A1 derivations.

Chap03.indd 93 8/6/2009 4:06:48 PM

 94 CHAPTER 3

FIGURE 3-5 Multiple Sleep Latency Test: 30-second page.

Clinical: 48-year-old man with excessive daytime sleepiness.
Staging: Transition from wakefulness to stage N1 sleep. The patient is awake for the first third of the
epoch, with a prominent alpha rhythm. He then enters stage N1 sleep with attenuation of alpha
activity and the appearance of central theta activity. Slow eye movements are prominent throughout
the epoch.

Chap03.indd 94 8/6/2009 4:06:49 PM

 MULTIPLE SLEEP LATENCY TEST (MSLT) / MAINTENANCE OF WAKEFULNESS TEST (MWT) 95

^
*
FIGURE 3-6 Multiple Sleep Latency Test: 30-second page.
Clinical: 27-year-old man with excessive daytime sleepiness.
Staging: Stage N2 sleep with a K complex (*) and sleep spindles ().

Chap03.indd 95 8/6/2009 4:06:51 PM

 96 CHAPTER 3

FIGURE 3-7 Multiple Sleep Latency Test: 30-second page.

Clinical: 32-year-old man with excessive daytime sleepiness.
Staging: Stage N3 sleep with intermixed alpha activity (alpha-delta sleep).

Chap03.indd 96 8/6/2009 4:06:52 PM

 MULTIPLE SLEEP LATENCY TEST (MSLT) / MAINTENANCE OF WAKEFULNESS TEST (MWT) 97

FIGURE 3-8 Multiple Sleep Latency Test: 30-second page.

Clinical: 32-year-old man with excessive daytime sleepiness.
Staging: Stage N3 sleep with intermixed alpha activity (alpha-delta sleep).

Chap03.indd 97 8/6/2009 4:06:54 PM

 98 CHAPTER 3

FIGURE 3-9 Multiple Sleep Latency Test: 30-second page.

Clinical: 22-year-old man with excessive daytime sleepiness and episodes of cataplexy.
Staging: Stage R sleep with alpha activity posteriorly.

Chap03.indd 98 8/6/2009 4:06:56 PM

 MULTIPLE SLEEP LATENCY TEST (MSLT) / MAINTENANCE OF WAKEFULNESS TEST (MWT) 99

FIGURE 3-10 Multiple Sleep Latency Test: 30-second page.

Clinical: 30-year-old woman with excessive sleepiness.
Staging: Stage R sleep with alpha activity posteriorly.

Chap03.indd 99 8/6/2009 4:06:58 PM

 100 CHAPTER 3

FIGURE 3-11 Multiple Sleep Latency Test: 30-second page.

Clinical: 32-year-old man with excessive daytime sleepiness.
Staging: Sleep onset with transition from wakefulness to stage N1 sleep.

Chap03.indd 100 8/6/2009 4:07:00 PM

 CHAPTER

4 Breathing Disorders
James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD

101

Chap04.indd 101 8/6/2009 4:10:22 PM

 102 CHAPTER 4

FIGURE 4-1 Strip chart: Position chart and pulse oximetry.

Clinical: 46-year-old obese man with severe obstructive sleep apnea.
Pulse oximetry: Frequent oxygen desaturations, which are most prominent during REM sleep. Apneas
occurred repeatedly while the patient was supine and in the right lateral decubitus position.

Chap04.indd 102 8/6/2009 4:10:22 PM

 BREATHING DISORDERS 103

FIGURE 4-2 Strip chart: Pulse oximetry and position.

Pulse oximetry: Obstructive sleep apnea with prolonged oxygen desaturations when supine.
This finding can be seen with hypoventilation or with conditions associated with ventilation-
perfusion mismatch.

Chap04.indd 103 8/6/2009 4:10:24 PM

 104 CHAPTER 4

FIGURE 4-3 Strip chart: Pulse oximetry, position, and CPAP settings.
Pulse oximetry: Severe obstructive sleep apnea. The initial half of the night (labeled CPAP setting 1.0) is
the baseline portion of the recording with no CPAP. CPAP is applied at four different settings, ranging
from 5 cm of water (setting 2.0) to 11 cm of water (setting 5.0). Continued moderate obstructive sleep
apnea is present with CPAP at levels 2.0 and 3.0. Further improvement of the obstructive sleep apnea is
evident at CPAP levels 4.0 and 5.0.

Chap04.indd 104 8/6/2009 4:10:25 PM

 BREATHING DISORDERS 105

FIGURE 4-4 Strip chart: Pulse oximetry, position, and CPAP settings.
Pulse oximetry: Severe obstructive sleep apnea. The initial half of the night (labeled CPAP setting 1.0) is
the baseline portion of the recording with no CPAP. CPAP is applied at three different settings, ranging
from 5 cm of water (setting 2.0) to 9 cm of water (setting 4.0). Continued moderate obstructive sleep
apnea is present with CPAP at levels 2.0 and 3.0. Further improvement of the obstructive sleep apnea is
evident at CPAP level 4.0.

Chap04.indd 105 8/6/2009 4:10:27 PM

 106 CHAPTER 4

FIGURE 4-5 Polysomnogram: Standard montage; 60-second page.

Clinical: 30-year-old woman with retrognathia and suspected obstructive sleep apnea.
Staging: Stage R sleep with an arousal.
Respiratory: Obstructive apnea with paradoxical respirations followed by a snort, arousal, and an oxygen
desaturation.

Chap04.indd 106 8/6/2009 4:10:29 PM

 BREATHING DISORDERS 107

FIGURE 4-6 Polysomnogram: Standard montage; 120-second page.

Clinical: 30-year-old woman with retrognathia and suspected obstructive sleep apnea.
Staging: Stage N2 sleep with frequent arousals.
Respiratory: Repeated obstructive apneas with paradoxical respirations followed by snorts, arousals, and
oxygen desaturations.

Chap04.indd 107 8/6/2009 4:10:30 PM

 108 CHAPTER 4

FIGURE 4-7 Polysomnogram: Standard montage; 120-second page.

Clinical: 46-year-old obese man with suspected obstructive sleep apnea.
Staging: Stage N2 sleep with arousals.
Respiratory: Repeated obstructive apneas with increasing effort followed by arousals and oxygen
desaturations.

Chap04.indd 108 8/6/2009 4:10:32 PM

 BREATHING DISORDERS 109

FIGURE 4-8 Polysomnogram: Standard montage; 60-second page.

Clinical: 30-year-old woman with retrognathia and suspected obstructive sleep apnea.
Staging: Stage N2 sleep and arousals.
Respiratory: Obstructive apnea with decreased chest wall motion followed by an arousal, snoring, and an
oxygen desaturation.

Chap04.indd 109 8/6/2009 4:10:34 PM

 110 CHAPTER 4

FIGURE 4-9 Polysomnogram: Standard montage; 60-second page.

Clinical: 58-year-old obese man with a low-lying soft palate and suspected obstructive sleep apnea.
Staging: Stage R sleep with rapid eye movements.
Respiratory: Prolonged obstructive apnea with increasing effort followed by an oxygen desaturation.
The oxygen desaturation at the beginning of this page is a result of the apnea from the preceding page
of the record.

Chap04.indd 110 8/6/2009 4:10:36 PM

 BREATHING DISORDERS 111

FIGURE 4-10 Polysomnogram: Standard montage; 60-second page.

Clinical: 29-year-old obese woman with a thick neck and suspected obstructive sleep apnea.
Staging: Stage N2 sleep with an arousal.
Respiratory: Obstructive apnea with in-phase respiratory effort in the thoracic and abdominal channels
followed by an arousal, a snort, and an oxygen desaturation.

Chap04.indd 111 8/6/2009 4:10:38 PM

 112 CHAPTER 4

*
FIGURE 4-11 Polysomnogram: Standard montage; 60-second page.
Clinical: 42-year-old man with a low-lying soft palate and suspected obstructive sleep apnea.
Staging: Stage N2 sleep with transition into REM sleep. Although the epoch does not meet scoring
criteria for REM sleep due to the absence of rapid eye movements, the reduction in chin EMG activity
and the occurrence of sawtooth waves (*) are consistent with REM sleep.
Respiratory: Obstructive apnea with decreased but in-phase respiratory effort followed by an arousal
and an oxygen desaturation.

Chap04.indd 112 8/6/2009 4:10:40 PM

 BREATHING DISORDERS 113

*
FIGURE 4-12 Polysomnogram: Standard montage; 60-second page.
Clinical: 42-year-old man with a low-lying soft palate and suspected obstructive sleep apnea.
Staging: Stage R sleep with rapid eye movements and arousals.
Respiratory: Obstructive apnea with increasing respiratory effort followed by an arousal.
EEG: Sawtooth waves (*) in REM sleep.

Chap04.indd 113 8/6/2009 4:10:41 PM

 114 CHAPTER 4

FIGURE 4-13 Polysomnogram: Standard montage; 120-second page.

Clinical: 42-year-old man with a low-lying soft palate and suspected obstructive sleep apnea.
Staging: Stage R sleep with rapid eye movements and arousals.
Respiratory: Obstructive apneas with increasing respiratory effort followed by arousals, snorts, and oxy-
gen desaturations.
EEG: Sawtooth waves in REM sleep.

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 BREATHING DISORDERS 115

FIGURE 4-14 Polysomnogram: Standard montage; 30-second page.

Clinical: 12-year-old with large tonsils and suspected obstructive sleep apnea.
Staging: Stage R sleep with rapid eye movements and bursts of leg EMG activity.
Respiratory: Obstructive apnea with decreased but in-phase respiratory effort followed by an arousal.

Chap04.indd 115 8/6/2009 4:10:43 PM

 116 CHAPTER 4

*
FIGURE 4-15 Polysomnogram: Standard montage; 120-second page.
Clinical: 12-year-old with large tonsils and suspected obstructive sleep apnea.
Staging: Stage R sleep with rapid eye movements.
Respiratory: Prolonged obstructive apnea with decreased but in-phase respiratory effort followed by an
arousal and an oxygen desaturation. There is also a brief post-arousal central apnea (*). The oxygen desatu-
ration at the beginning of this page was caused by an apnea from the preceding page of the record.

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 BREATHING DISORDERS 117

FIGURE 4-16 Polysomnogram: Standard montage; 60-second page.

Clinical: 29-year-old moderately obese woman with excessive daytime sleepiness and suspected obstruc-
tive sleep apnea.
Staging: Stage N2 sleep with arousals.
Respiratory: Mixed apnea followed by an arousal and an oxygen desaturation. The oxygen desaturation
at the beginning of this page is a result of an apnea from the preceding page of the record.

Chap04.indd 117 8/6/2009 4:10:46 PM

 118 CHAPTER 4

FIGURE 4-17 Polysomnogram: Standard montage; 120-second page.

Clinical: 22-year-old obese man with marked retrognathia.
Staging: Stage N3 sleep with arousals.
Respiratory: Mixed apnea with in-phase respiratory effort at the beginning and end of the apnea fol-
lowed by an arousal and an oxygen desaturation. The oxygen desaturation at the beginning of this
page is a result of an apnea from the preceding page of the record.

Chap04.indd 118 8/6/2009 4:10:48 PM

 BREATHING DISORDERS 119

FIGURE 4-18 Polysomnogram: Standard montage; 120-second page.

Clinical: 42-year-old woman with multiple sclerosis, restless legs syndrome, and suspected
obstructive sleep apnea.
Staging: Stage N1 sleep with arousals.
Respiratory: Repeated mixed apneas with arousals and minimal oxygen desaturations.

Chap04.indd 119 8/6/2009 4:10:50 PM

 120 CHAPTER 4

FIGURE 4-19 Polysomnogram: Standard montage; 60-second page.

Clinical: 52-year-old man with snoring and excessive daytime sleepiness.
Staging: Stage N1 sleep with arousals.
Respiratory: Mixed apnea with increasing effort and paradoxical respirations followed by a snort, an
arousal, an oxygen desaturation, and snoring. The oxygen desaturation on this page was caused by an
apnea from the preceding page of the record.

Chap04.indd 120 8/6/2009 4:10:52 PM

 BREATHING DISORDERS 121

FIGURE 4-20 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 44-year-old woman with snoring and excessive daytime sleepiness.
Staging: Stage N1 sleep with arousals.
Respiratory: Mixed apnea with an initial portion without respiratory effort followed by two obstructed
breaths. Respiratory effort, as measured by the esophageal pressure monitor (Pes), increases with the
second obstructed breath and then decreases after the arousal and resumption of breathing. There is
minimal oxygen desaturation from 94% to 91%.

Chap04.indd 121 8/6/2009 4:10:54 PM

 122 CHAPTER 4

* ^
FIGURE 4-21 Polysomnogram: Standard montage; 60-second page.
Clinical: 77-year-old thin man with severe polyneuropathy and excessive daytime sleepiness.
Staging: Stage N2 sleep with an arousal.
Respiratory: Hypopnea (onset at *) with decreased airflow and respiratory effort followed by an arousal ().

Chap04.indd 122 8/6/2009 4:10:56 PM

 BREATHING DISORDERS 123

*
FIGURE 4-22 Polysomnogram: Standard montage; 60-second page.
Clinical: 64-year-old obese woman with cognitive impairment.
Staging: Stage R sleep with rapid eye movements.
Respiratory: Hypopnea with minimal airflow and decreased respiratory motion followed by an arousal
and an oxygen desaturation. The oxygen desaturation at the beginning of this page was caused by an
apnea from the preceding page of the record.
EEG: Sawtooth waves (*) and alpha activity during REM sleep.

Chap04.indd 123 8/6/2009 4:10:56 PM

 124 CHAPTER 4

FIGURE 4-23 Polysomnogram: Standard montage; 120-second page.

Clinical: 41-year-old woman with excessive daytime sleepiness and intractable headaches.
Staging: Stage N2 sleep.
Respiratory: Repeated hypopneas with paradoxical respirations followed by arousals and oxygen
desaturations.
EEG: Alpha intrusion into stage N2 sleep. Respiratory artifact from the A1 electrode is apparent in chan-
nels 2, 5, and 7.

Chap04.indd 124 8/6/2009 4:10:57 PM

 BREATHING DISORDERS 125

FIGURE 4-24 Polysomnogram: Standard montage; 120-second page.

Clinical: 41-year-old woman with excessive daytime sleepiness and intractable headaches.
Staging: Stage R sleep with an arousal.
Respiratory: Prolonged hypopnea with minimal airflow and paradoxical respiratory effort followed by
a snort, an arousal, and an oxygen desaturation from 93% to 71%.

Chap04.indd 125 8/6/2009 4:10:59 PM

 126 CHAPTER 4

FIGURE 4-25 Polysomnogram: CPAP montage; 60-second page.

Clinical: 57-year-old man with excessive daytime sleepiness.
Staging: Stage R sleep.
Respiratory: Decreased airflow and respiratory effort without an arousal or oxygen desaturation occur-
ring during phasic REM sleep. Reductions in ventilation accompanying phasic REM sleep, which often
resemble hypopneas, are common in normal individuals.

Chap04.indd 126 8/6/2009 4:11:01 PM

 BREATHING DISORDERS 127

FIGURE 4-26 Polysomnogram: Standard montage with intrathoracic pressure (Pes) monitoring; 60-second page.
Clinical: 37-year-old man with fatigue.
Staging: Stage N3 sleep with an arousal.
Respiratory: Increasing respiratory effort best appreciated in the Pes channel, is apparent in several
breaths preceding the arousal. There is only minimal oxygen desaturation associated with this event.

Chap04.indd 127 8/6/2009 4:11:03 PM

 128 CHAPTER 4

FIGURE 4-27 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 60-second page.
Clinical: 29-year-old woman with excessive daytime sleepiness.
Staging: Stage N2 sleep with alpha intrusion.
Respiratory: Hypopnea with an associated oxygen desaturation from 94% to 88%. The change in the
respiratory effort is most clearly seen with the intrathoracic pressure (Pes) monitor.

Chap04.indd 128 8/6/2009 4:11:05 PM

 BREATHING DISORDERS 129

FIGURE 4-28 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 60-second page.
Clinical: 29-year-old woman with excessive daytime sleepiness.
Staging: Stage N3 sleep with an arousal.
Respiratory: Hypopnea followed by an arousal then a post-arousal central apnea. Intrathoracic pres-
sure monitoring shows increasing effort during the hypopnea and no effort during the post-arousal
central apnea.

Chap04.indd 129 8/6/2009 4:11:07 PM

 130 CHAPTER 4

FIGURE 4-29 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 60-second page.
Clinical: 36-year-old man with suspected upper-airway resistance syndrome.
Staging: Stage N3 sleep.
Respiratory: Decreased airflow with a high baseline intrathoracic pressure and a gradual increase in
intrathoracic pressure. There is no arousal or oxygen desaturation with this event.

Chap04.indd 130 8/6/2009 4:11:09 PM

 BREATHING DISORDERS 131

FIGURE 4-30 Polysomnogram: Standard montage; 60-second page.

Clinical: 49-year-old man with unrefreshing sleep.
Staging: Stage N1 sleep.
Respiratory: Decreased airflow and respiratory effort. There is no arousal or oxygen desaturation. Such
events are thought to be of little clinical significance.

Chap04.indd 131 8/6/2009 4:11:11 PM

 132 CHAPTER 4

* ^
FIGURE 4-31 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 26-year-old man with excessive daytime sleepiness and several motor vehicle accidents.
Staging: Stage N2 sleep with an arousal.
Respiratory: There is a high baseline negative intrathoracic pressure with a progressive increase in intratho-
racic pressure from 20 (*) to 29 () cm of water.

Chap04.indd 132 8/6/2009 4:11:13 PM

 BREATHING DISORDERS 133

FIGURE 4-32 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 60-second page.
Clinical: 31-year-old woman with excessive fatigue and chronic headaches.
Staging: Stage N2 sleep.
Respiratory: Snoring with a persistently elevated negative intrathoracic pressure at 22 cm of water.
There is no associated hypopnea, arousal, or oxygen desaturation.

Chap04.indd 133 8/6/2009 4:11:14 PM

 134 CHAPTER 4

* ^
FIGURE 4-33 Polysomnogram: Standard montage with intrathoracic pressure (Pes) monitoring; 60-second page.
Clinical: 49-year-old man with suspected upper-airway resistance syndrome.
Staging: Stage N2 sleep with an arousal.
Respiratory: Negative intrathoracic pressure increases gradually over several breaths from 12 (*) to 19
() cm of water. There is a subsequent arousal but no oxygen desaturation. These events, sometimes
referred to as upper-airway resistance events, are characteristic of the upper-airway resistance syndrome.

Chap04.indd 134 8/6/2009 4:11:15 PM

 BREATHING DISORDERS 135

* ^
FIGURE 4-34 Polysomnogram: Standard montage with intrathoracic pressure (Pes) monitoring; 120-second page.
Clinical: 49-year-old man with upper-airway resistance syndrome.
Staging: Stage N2 sleep with an arousal.
Respiratory: Negative intrathoracic pressure increases gradually from 12 (*) to 19 () cm of water.
There is a subsequent arousal but no oxygen desaturation.

Chap04.indd 135 8/6/2009 4:11:16 PM

 136 CHAPTER 4

FIGURE 4-35 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 60-second page.
Clinical: 17-year-old woman with mild retrognathia, excessive daytime sleepiness associated with
recent weight gain.
Staging: Stage N3 sleep with alpha intrusion and an arousal.
Respiratory: Negative intrathoracic pressure increases gradually over several breaths followed by an
arousal but no oxygen desaturation. Snoring is minimal. The increased respiratory effort preceding
the arousal would be more difficult to appreciate without the Pes monitoring.

Chap04.indd 136 8/6/2009 4:11:17 PM

 BREATHING DISORDERS 137

*
FIGURE 4-36 Polysomnogram: Standard montage; 60-second page.
Clinical: 39-year-old man with snoring, unrefreshing sleep, and headaches.
Staging: Stage N2 sleep with an arousal.
Respiratory: Snoring increases in amplitude for several breaths and then is followed by an arousal (*). The
increase in snoring is inferential evidence of increased respiratory effort, which is difficult to detect in
the thoracic and abdominal channels.

Chap04.indd 137 8/6/2009 4:11:19 PM

 138 CHAPTER 4

FIGURE 4-37 Polysomnogram: Standard montage; 30-second page.

Clinical: 24-year-old man with snoring and hypertension.
Staging: Stage N1 sleep.
Respiratory: Snoring increases in amplitude over several breaths accompanied by subtle evidence of
increased respiratory effort in the thoracic and abdominal channels.

Chap04.indd 138 8/6/2009 4:11:20 PM

 BREATHING DISORDERS 139

FIGURE 4-38 Polysomnogram: Standard montage; 60-second page.

Clinical: 24-year-old man with snoring and hypertension.
Staging: Stage N2 sleep.
Respiratory: Snoring increases over several breaths without a subsequent arousal. Blocking of the intrathoracic
pressure signal does not allow quantitation of inspiratory force.

Chap04.indd 139 8/6/2009 4:11:22 PM

 140 CHAPTER 4

FIGURE 4-39 Polysomnogram: Standard montage; 30-second page.

Clinical: 39-year-old man with loud snoring and excessive daytime sleepiness.
Staging: Stage N2 sleep.
Respiratory: Snoring with otherwise normal respirations.

Chap04.indd 140 8/6/2009 4:11:24 PM

 BREATHING DISORDERS 141

FIGURE 4-40 Polysomnogram: Standard montage; 30-second page.

Clinical: 47-year-old woman with fatigue and snoring.
Staging: Stage N3 sleep.
Respiratory: Snoring with otherwise normal respirations.

Chap04.indd 141 8/6/2009 4:11:26 PM

 142 CHAPTER 4

FIGURE 4-41 Polysomnogram: Standard montage; 30-second page.

Clinical: 45-year-old man with snoring and hypertension.
Staging: Stage N3 sleep.
Respiratory: Normal respirations except for pronounced snoring.

Chap04.indd 142 8/6/2009 4:11:27 PM

 BREATHING DISORDERS 143

FIGURE 4-42 Polysomnogram: Standard montage; 60-second page.

Clinical: 45-year-old man with snoring and hypertension.
Staging: Stage N3 sleep.
Respiratory: Normal respirations except for loud snoring.

Chap04.indd 143 8/6/2009 4:11:29 PM

 144 CHAPTER 4

FIGURE 4-43 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 54-year-old man with excessive daytime sleepiness and congestive heart failure.
Staging: Stage N2 sleep with an arousal.
Respiratory: Central apnea with no effort on intrathoracic pressure monitoring followed by a snort
and an arousal. These central apneas resolved with CPAP treatment.

Chap04.indd 144 8/6/2009 4:11:31 PM

 BREATHING DISORDERS 145

*
FIGURE 4-44 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 33-year-old man with witnessed episodes of apnea.
Staging: Stage N2 sleep with an arousal (*).
Respiratory: Central apnea with no effort on intrathoracic pressure monitoring.

Chap04.indd 145 8/6/2009 4:11:33 PM

 146 CHAPTER 4

FIGURE 4-45 Polysomnogram: Periodic limb movements montage; 30-second page.

Clinical: 41-year-old man with frequent nocturnal movements.
Staging: Transition from wake to stage N1 sleep.
Respiratory: Sleep onset central apnea. Brief central apneas that occur in the transition from wakeful-
ness to sleep are common in normal persons.

Chap04.indd 146 8/6/2009 4:11:33 PM

 BREATHING DISORDERS 147

FIGURE 4-46 Polysomnogram: Standard montage; 120-second page.

Clinical: 46-year-old woman with excessive daytime sleepiness.
Staging: Stage R sleep.
Respiratory: Central apnea with no associated arousal or oxygen desaturation. Brief central apneas are
common during REM sleep in normal individuals.

Chap04.indd 147 8/6/2009 4:11:35 PM

 148 CHAPTER 4

FIGURE 4-47 Polysomnogram: Expanded EEG montage with CO2 monitoring; 30-second page.
Clinical: 39-year-old man with hypertension and several motor vehicle accidents which related to
sleepiness.
Staging: Stage R sleep.
Respiratory: Central apnea followed by an oxygen desaturation and tachycardia.

Chap04.indd 148 8/6/2009 4:11:37 PM

 BREATHING DISORDERS 149

FIGURE 4-48 Polysomnogram: Standard montage; 60-second page.

Clinical: 51-year-old man with snoring and witnessed apneas.
Staging: Stage R sleep.
Respiratory: Central apnea during phasic REM sleep without associated arousal or oxygen
desaturation. Brief central apneas are common during REM sleep in normal individuals.

Chap04.indd 149 8/6/2009 4:11:39 PM

 150 CHAPTER 4

FIGURE 4-49 Polysomnogram: Standard montage; 60-second page.

Clinical: 5-week-old infant girl with frequent witnessed apneas.
Staging: Stage R sleep with an arousal.
Respiratory: Central apnea followed by an arousal.

Chap04.indd 150 8/6/2009 4:11:41 PM

 BREATHING DISORDERS 151

FIGURE 4-50 Polysomnogram: Standard montage with CO2 monitoring; 60-second page.
Clinical: 52-year-old obese man with witnessed apneas.
Staging: Stage N2 sleep with arousals.
Respiratory: Central apnea. The capnogram indicates that CO2 is highest with the first breath following
the apnea and then rapidly returns to normal (60 to 41 torr).

Chap04.indd 151 8/6/2009 4:11:43 PM

 152 CHAPTER 4

FIGURE 4-51 Polysomnogram: CPAP montage; 60-second page.

Clinical: 55-year-old man with snoring and frequent pauses in breathing.
Staging: Stage N2 sleep.
Respiratory: Periodic breathing with two normal breaths followed by a central apnea. The central
apneas are followed by oxygen desaturations from 95% to 88%.

Chap04.indd 152 8/6/2009 4:11:45 PM

 BREATHING DISORDERS 153

FIGURE 4-52 Polysomnogram: CPAP montage; 60-second page.

Clinical: 55-year-old man with snoring and frequent pauses in breathing.
Staging: Stage N2 sleep.
Respiratory: Periodic breathing consisting of two normal breaths with snoring followed by a cen-
tral apnea. The central apneas are followed by oxygen desaturations from 95% to 88%.

Chap04.indd 153 8/6/2009 4:11:47 PM

 154 CHAPTER 4

* ^
FIGURE 4-53 Polysomnogram: CPAP montage; 60-second page.
Clinical: 59-year-old man with congestive heart failure and excessive daytime sleepiness.
Staging: Stage N2 sleep with an arousal.
Respiratory: Central apnea and Cheyne-Stokes respirations with an EEG arousal (*) occurring at the
onset of breathing and movement () occurring at the apex of the respiratory cycle.

Chap04.indd 154 8/6/2009 4:11:48 PM

 BREATHING DISORDERS 155

*
FIGURE 4-54 Polysomnogram: Standard montage; 120-second page.
Clinical: 67-year-old man with frequent witnessed apneas.
Staging: Stage N2 sleep with an arousal.
Respiratory: Central apnea and Cheyne-Stokes respirations with an EEG arousal (*) and movement occur-
ring at the apex of the respirations. This pattern in which the arousal does not accompany resumption of
breathing, but instead, occurs at the apex of the respiratory cycle, differs from the pattern usually seen
with obstructive apnea in which the arousal coincides with the resumption of breathing.

Chap04.indd 155 8/6/2009 4:11:49 PM

 156 CHAPTER 4

FIGURE 4-55 Polysomnogram: CPAP montage; 120-second page.

Clinical: 64-year-old woman with a recent myocardial infarction and excessive daytime sleepiness.
Staging: Stage R sleep.
Respiratory: Cyclic variation in respiratory effort and airflow without arousals or oxygen desaturations.
Patients with Cheyne-Stokes respirations and central apneas in NREM sleep may show this pattern in
REM sleep and wakefulness.

Chap04.indd 156 8/6/2009 4:11:50 PM

 BREATHING DISORDERS 157

FIGURE 4-56 Polysomnogram: Standard montage; 30-second page.

Clinical: 44-year-old man with recent weight gain and excessive daytime sleepiness.
Staging: Stage N1 sleep.
Respiratory: Post-arousal central apnea.

Chap04.indd 157 8/6/2009 4:11:52 PM

 158 CHAPTER 4

FIGURE 4-57 Polysomnogram: Standard montage; 60-second page.

Clinical: 44-year-old man with recent weight gain and excessive daytime sleepiness.
Staging: Stage R with an arousal.
Respiratory: Obstructive apnea followed by an arousal and then a post-arousal central apnea. The
oxygen desaturation at the beginning of this page is a result of an apnea from the preceding
page of the record.

Chap04.indd 158 8/6/2009 4:11:54 PM

 BREATHING DISORDERS 159

FIGURE 4-58 Polysomnogram: Standard montage; 60-second page.

Clinical: 57-year-old man with disturbed, poor quality sleep.
Staging: Stage N2 sleep followed by an arousal.
Respiratory: Post-arousal central apnea.

Chap04.indd 159 8/6/2009 4:11:56 PM

 160 CHAPTER 4

FIGURE 4-59 Polysomnogram: Expanded EEG montage; 30-second page.

Clinical: 22-year-old man with possible nocturnal seizures.
Staging: Stage N2 sleep.
Respiratory: Normal respirations.

Chap04.indd 160 8/6/2009 4:11:57 PM

 BREATHING DISORDERS 161

FIGURE 4-60 Polysomnogram: CPAP montage with CO2 monitoring; 30-second page.
Clinical: 48-year-old obese man with witnessed apneas.
Staging: Stage N3 sleep.
Respiratory: Normal respirations.

Chap04.indd 161 8/6/2009 4:11:59 PM

 162 CHAPTER 4

FIGURE 4-61 Polysomnogram: CPAP montage; 30-second page.

Clinical: 65-year-old man with obstructive sleep apnea.
Staging: Stage N1 sleep.
Respiratory: Hypopnea with increasing snoring followed by an arousal and a mild oxygen desatura-
tion. The oxygen desaturation at the beginning of this page is a result of an apnea from the pre-
ceding page of the record. Nasal CPAP was set at 7 cm of water for this portion of the recording.
Hypopneas were eliminated at higher levels of CPAP.

Chap04.indd 162 8/6/2009 4:12:01 PM

 BREATHING DISORDERS 163

FIGURE 4-62 Polysomnogram: CPAP montage; 30-second page.

Clinical: 42-year-old woman with obstructive sleep apnea.
Staging: Stage N1 sleep with an arousal.
Respiratory: Obstructive apnea followed by a snort and an arousal. The oxygen desaturation at the
beginning of this page was caused by an apnea from the preceding page of the record. Nasal CPAP
was set at 7 cm of water for this portion of the recording. Obstructive apneas were eliminated with
higher levels of CPAP.

Chap04.indd 163 8/6/2009 4:12:03 PM

 164 CHAPTER 4

FIGURE 4-63 Polysomnogram: CPAP montage; 60-second page.

Clinical: 53-year-old man with obstructive sleep apnea.
Staging: Stage N1 sleep with arousals.
Respiratory: Two hypopneas are followed by snorts, arousals, and oxygen desaturations. Hypopneas
resolved at higher levels of CPAP. The oxygen desaturation at the beginning of this page was caused
by an apnea from the preceding page of the record.

Chap04.indd 164 8/6/2009 4:12:04 PM

 BREATHING DISORDERS 165

FIGURE 4-64 Polysomnogram: CPAP montage; 30-second page.

Clinical: 28-year-old man with obstructive sleep apnea.
Staging: Stage N2 sleep.
Respiratory: Snoring with no associated hypopneas or apneas with CPAP at 5 cm of water. The snor-
ing resolved with higher levels of CPAP.

Chap04.indd 165 8/6/2009 4:12:06 PM

 166 CHAPTER 4

*
FIGURE 4-65 Polysomnogram: CPAP montage; 60-second page.
Clinical: 28-year-old man with obstructive sleep apnea.
Staging: Stage R sleep with an arousal.
Respiratory: Hypopnea followed by an arousal and movement. The beginning of the hypopnea is
marked (*).

Chap04.indd 166 8/6/2009 4:12:08 PM

 BREATHING DISORDERS 167

FIGURE 4-66 Polysomnogram: CPAP montage; 60-second page.

Clinical: 35-year-old man with obstructive sleep apnea.
Staging: Stage R sleep.
Respiratory: Decreased respiratory effort and airflow without an arousal or an oxygen desaturation during
phasic REM sleep. Brief reductions in ventilation often accompany phasic REM sleep in normal persons

Chap04.indd 167 8/6/2009 4:12:09 PM

 168 CHAPTER 4

* ^
FIGURE 4-67 Polysomnogram: CPAP montage; 120-second page.
Clinical: 49-year-old morbidly obese man with obstructive sleep apnea and poorly controlled
hypertension.
Staging: Stage R sleep.
Respiratory: Prolonged obstructive apnea (*) followed by an arousal, a snort, right leg movement, and
a brief post-arousal central apnea ().

Chap04.indd 168 8/6/2009 4:12:11 PM

 BREATHING DISORDERS 169

FIGURE 4-68 Polysomnogram: CPAP montage; 60-second page.

Clinical: 53-year-old thin woman with obstructive sleep apnea.
Staging: Stage R sleep with frequent rapid eye movements.
Respiratory: Central apnea with no associated arousal or oxygen desaturation.

Chap04.indd 169 8/6/2009 4:12:11 PM

 170 CHAPTER 4

FIGURE 4-69 Polysomnogram: CPAP montage; 60-second page.

Clinical: 58-year-old man with obstructive sleep apnea.
Staging: Stage N2 sleep.
Respiratory: Normal respirations with CPAP at 11 cm of water.

Chap04.indd 170 8/6/2009 4:12:13 PM

 BREATHING DISORDERS 171

FIGURE 4-70 Strip chart: Pulse oximetry, CPAP settings, position, and sleep staging.
Six CPAP settings were used during the study. The first three settings (5 cm, 7 cm, 9 cm) were inad-
equate and apneas continued to occur (*). At the fourth CPAP setting (11 cm), apneas became much
less frequent and there was marked REM sleep rebound (increased amounts of REM sleep).

Chap04.indd 171 8/6/2009 4:12:15 PM

 172 CHAPTER 4

FIGURE 4-71 Polysomnogram: CPAP montage; 60-second page.

Clinical: 61-year-old man with obstructive sleep apnea and continued excessive daytime sleepiness
despite nasal CPAP.
Staging: Stage N2 sleep.
Respiratory: CPAP mask leak seen as a sharp dip below the baseline at the end of breaths on the mask
flow channel.

Chap04.indd 172 8/6/2009 4:12:17 PM

 BREATHING DISORDERS 173

FIGURE 4-72 Polysomnogram: CPAP montage; 30-second page.

Clinical: 27-year-old man with obstructive sleep apnea.
Staging: Stage N1 sleep.
Respiratory: CPAP mask leak seen as a sharp dip below the baseline at the end of breaths on the mask
flow channel. Lip quiver recorded in the snore channel coincides with the mask leak.

Chap04.indd 173 8/6/2009 4:12:19 PM

 174 CHAPTER 4

FIGURE 4-73 Polysomnogram: CPAP montage; 30-second page.

Clinical: 27-year-old man with obstructive sleep apnea.
Staging: Stage N2 sleep.
Respiratory: CPAP mask leak with lip quiver recorded in the snore channel and associated with oral
air flow, which coincides with the mask leak.

Chap04.indd 174 8/6/2009 4:12:20 PM

 BREATHING DISORDERS 175

FIGURE 4-74 Strip chart: Pulse oximetry, CPAP settings, and position.
Obstructive sleep apnea with severe oxygen desaturations during REM sleep. The initial half of the
night (labeled CPAP setting 1.0) is the baseline portion of the recording with no CPAP. When
CPAP is applied, at six different settings, ranging from 5 cm of water (setting 2.0) to 15 cm of
water (setting 7.0), apneas and associated hypoxemia were almost completely eliminated.

Chap04.indd 175 8/6/2009 4:12:22 PM

 176 CHAPTER 4

*
FIGURE 4-75 Strip chart: Pulse oximetry, CPAP settings, position, and sleep staging.
Prolonged oxygen desaturation during REM sleep (*) in a patient with obesity hypoventilation
syndrome. There are also frequent oxygen desaturations caused by obstructive sleep apnea.

Chap04.indd 176 8/6/2009 4:12:24 PM

 BREATHING DISORDERS 177

FIGURE 4-76 Strip chart: Pulse oximetry, PAP settings, position, and sleep staging.
PAP titration in a patient with obstructive sleep apnea.

Chap04.indd 177 8/6/2009 4:12:24 PM

 178 CHAPTER 4

FIGURE 4-77 Strip chart: Pulse oximetry, PAP settings, position, and sleep staging.
PAP titration in a patient with obstructive sleep apnea.

Chap04.indd 178 8/6/2009 4:12:25 PM

 BREATHING DISORDERS 179

FIGURE 4-78 Strip chart: Pulse oximetry, PAP settings, position, and sleep staging.
PAP titration in a patient with obstructive sleep apnea with marked
improvement in sleep depth and respirations.

Chap04.indd 179 8/6/2009 4:12:26 PM

 180 CHAPTER 4

LOC
ROC
Chin
F3
F4
C3
C4
O1
O2
EKG
LAT
RAT
Snorer
Nasal Pressure
Airflow
Chest
Abd
Intercostal EMG
SaO2

FIGURE 4-79 Polysomnogram: CPAP montage; 60-second page.

Clinical: 37-year-old man with obstructive sleep apnea.
Staging: Stage R.
Respiratory: Apnea primarily during phasic REM sleep.

Chap04.indd 180 8/6/2009 4:12:27 PM

 BREATHING DISORDERS 181

FIGURE 4-80 Polysomnogram: Polysomnogram montage; 120-second page.

Clinical: 39-year-old man with witnessed apneas and a recent myocardial infarction.
Staging: Stage N2 sleep.
Respiratory: Apneas and hypopneas are seen in this recording made with respiratory inductance
plethysmography (RIP) recording.
Obstructive apneaThere is a drop in the peak thermal sensor excursion by 90% of the baseline. The event
lasts at least 10 seconds. At least 90% of the events duration meets the amplitude reduction criteria for
apnea. There is continued or increased effort throughout the entire period of absent airflow (From The AASM
Manual for Scoring Sleep, 2007).

Chap04.indd 181 8/6/2009 4:12:28 PM

 182 CHAPTER 4

FIGURE 4-81 Polysomnogram: Polysomnogram montage; 150-second page.

Clinical: 53-year-old female with bad dreams, most in the last half of the night, usually of being smothered or
held down. Snoring.
Staging: Stage R.
Respiratory: Obstructive apneas are seen in this recording made with RIP recording. The patient screamed
Help, Help. She then said I had a terrible dream and sat up in bed on video monitoring.

Chap04.indd 182 8/6/2009 4:12:30 PM

 BREATHING DISORDERS 183

FIGURE 4-82 Polysomnogram: Polysomnogram montage; 30-second page.

Clinical: 41-year-old man with loud snoring, night sweats, and morning headaches.
Staging: Stage N1 sleep.
Respiratory: The hypopnea is scored by the alternative method.

Chap04.indd 183 8/6/2009 4:12:31 PM

 184 CHAPTER 4

FIGURE 4-83 Polysomnogram: Polysomnogram montage; 60-second page.

Clinical: 41-year-old man with loud snoring, night sweats, and morning headaches.
Staging: Stage N2 sleep.
Respiratory: The hypopnea is scored by the standard method.

Chap04.indd 184 8/6/2009 4:12:32 PM

 BREATHING DISORDERS 185

FIGURE 4-84 Polysomnogram: Polysomnogram montage; 120-second page.

Clinical: 52-year-old man with loud snoring and nocturnal reflux.
Staging: Stage N2 sleep.
Respiratory:
RERAThere is a sequence of breaths lasting at least 10 seconds characterized by increasing respiratory effort or flattening
of the nasal pressure waveform leading to an arousal from sleep when the sequence of breaths does not meet criteria for
an apnea or hypopnea (From The AASM Manual for Scoring Sleep, 2007). In this example, there is no 4% desaturation and
therefore, it cannot be a hypopnea.
HypopneaThe nasal pressure signal excursion drops by 30% of baseline. The duration of this drop occurs for a period lasting at
least 10 seconds. There is a 4% desaturation from pre-event baseline. At least 90% of the events duration meets the amplitude
reduction criteria (From The AASM Manual for Scoring Sleep, 2007).

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 186 CHAPTER 4

FIGURE 4-85 Polysomnogram: Polysomnogram montage; 30-second page.

Clinical: 56-year-old woman with fatigue and reported fibromyalgia.
Staging: Stage R.
Respiratory: Obstructive apnea.

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 BREATHING DISORDERS 187

FIGURE 4-86 Polysomnogram: Polysomnogram montage; 120-second page.

Clinical: 68-year-old man with poor sleep and heart failure.
Staging: Stage N2 sleep with arousals.
Respiratory: Periodic central apneas with oxygen desaturations.

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 188 CHAPTER 4

FIGURE 4-87 Polysomnogram: Polysomnogram montage; 60-second page.

Clinical: 8-year-old boy with poor sleep and heart failure.
Staging: Stage N3.
Respiratory: ETCO2 monitoring.

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 BREATHING DISORDERS 189

Sample Report: Obstructive Sleep Apnea

Patient:
Account Number:
Medical Records:
Study Number:
Date of Study:
Date of Birth:
Requesting Physician:
Referring Physician:
Indications for Study: Sleep disturbance with hypersomnolence (780.54).
Study Description: Polysomnogram
Equipment: Central, frontal, and occipital EEG, EOG, EKG, submentalis EMG, intercostal EMG, airflow, thoracic motion, abdominal
motion, snore sensor, anterior tibialis EMG, and pulse oximetry were recorded throughout the study. The tracing was recorded in
30-second epochs.
Sleep Study Summary Report:
Record time: 485.5 minutes; sleep time: 423.5 minutes
Analysissee detailed analysis tables
EEG/Sleep stage
Stage N1 sleep: 15.7% (4%8%) Sleep latency: 43 minutes
Stage N2 sleep: 65.1% (45%63%) REM latency: 130.5 minutes
Stage N3 sleep: 0% (4%20%) Sleep efficiency: 87.2%
Stage R sleep: 19.2% (23%31%)
Respiratory
AHI: 9.1 NREM AHI: 4.6 REM AHI: 28 Supine AHI: 9.1
RERA index: 9.8 (69 RERA)
Total respiratory events: 64 (63 obstructive)
Arousal index: 19.7
Minimum oxygen saturation: 90%
Snoring: loud.
EKG: PVCs.
Limb movement
PLM index: 0
PLM arousal index: 0.8
Impression: Obstructive sleep apnea (327.23).

The findings indicate obstructive sleep apnea consisting apneas and hypopneas with associated arousals and oxygen desaturations which was
most prominent during REM sleep. Obstructive sleep apnea may be related to other medical conditions. Clinical correlation is advised.
Recommendations: The patient will be scheduled for a follow-up visit along with a CPAP titration.
______________________ , M.D.
The physician reviewed the record in its entirety, including sleep staging, EMG activity, EKG, EEG, respiration, oxygen saturation, body
position, and behavior unless otherwise noted. The interpretation is based on this information in addition to the available clinical history
and physical examination. This is a summary report. Please see the additional tabular report from this study for more detailed analysis.
TR:
DD:
DT:

Chap04.indd 189 8/6/2009 4:12:43 PM

 190 CHAPTER 4

Sample Report: Severe Obstructive Sleep Apnea

Patient:
Account Number:
Medical Records:
Study Number:
Date of Study:
Date of Birth:
Requesting Physician:
Referring Physician:
Indications for Study: Sleep disturbance with hypersomnolence (780.54) and witnessed apneas.
Study Description: Polysomnogram
Equipment: Central, frontal, and occipital EEG, EOG, EKG, submentalis EMG, intercostal EMG, airflow, thoracic motion, abdominal
motion, snore sensor, anterior tibialis EMG, and pulse oximetry were recorded throughout the study. The tracing was recorded in
30-second epochs.
Sleep Study Summary Report:
Record time: 393.5 minutes; sleep time: 355.5 minutes
Analysissee detailed analysis tables
EEG/Sleep stage
Stage N1 sleep: 11% (2%9%) Sleep latency: 25 minutes
Stage N2 sleep: 78.9% (50%64%) REM latency: 264.5 minutes
Stage N3 sleep: 0% (7%18%) Sleep efficiency: 90.3%
Stage R sleep: 10.1% (20%27%)
Respiratory
AHI: 35.6 NREM AHI: 32.1 REM AHI: 66.7 Supine AHI: 35.6
RERA index: 0 (0 RERA)
Total respiratory events: 211 (211 obstructive)
Arousal index: 35.3
Minimum oxygen saturation: 80%
Snoring: moderate.
EKG: unremarkable.
Limb movement
PLM index: 0.7
PLM arousal index: 0.8
Impression: Obstructive sleep apnea (327.23).
The findings indicate severe obstructive sleep apnea consisting of apneas and hypopneas with associated arousals and oxygen
desaturations. Obstructive sleep apnea may be related to other medical conditions. Clinical correlation is advised.
Recommendations: The patient will be scheduled for a follow-up visit along with a CPAP titration.
____________________ , M.D.
The physician reviewed the record in its entirety, including sleep staging, EMG activity, EKG, EEG, respiration, oxygen saturation, body
position, and behavior unless otherwise noted. The interpretation is based on this information in addition to the available clinical history
and physical examination. This is a summary report. Please see the additional tabular report from this study for more detailed analysis.
TR:
DD:
DT:

Chap04.indd 190 8/6/2009 4:12:43 PM

 BREATHING DISORDERS 191

Sample Report: Long Form

Diagnostic Polysomnographic Report

Patient: Date:
DOB: PSG Study #:
Age: Referring Physician: Physician:
Sex: Account #:
PSG Tech: Medical Record #:
Scored by:

Sleep Architecture Summary

Lights Out: 11:12:54 PM Lights On: 05:46:24 AM

Total Record Time: 413.0 minutes # REM Episodes: 1
a
# of Awakenings : 5

Time (minutes) % of TST % of SPT

Time in Bed (TIB): 393.5
Total Sleep Time (TST): 355.5 100% 96.5%
Total Stage N1: 39 11.0% 10.6%
Total Stage N2: 280.5 78.9% 76.1%
Total Stage N3: 0 0% 0.0%
Total Stage R: 36 10.1% 9.8%
Total Movement Time: 0 0.0%
Total Wake Time: 38
WASO: 13.0
Wake Time During SPT: 13.0 3.5%
Latency to Sleep Onset: 25
Latency to Persistent Sleep: 25
Latency to Stage N2: 29.5
Latency to REM Sleep: 264.5
Latency to Persistent Sleep: 25
Sleep Efficiency: 90.3%
Sleep Maintenance: 96.5%
a
Sleep efficiency is time asleep as a percentage of time in bed. Sleep Maintenance is time asleep as a percentage of sleep period time. Awakenings are
defined as 30 seconds or more.

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 192 CHAPTER 4

Positional Summary Arousal Summary

Time (minutes)a %TST Arousal Caused By: Number Index

Left: 0 0.0% Respiratory Events: 173 29.2

Right: 0 0.0% Snore: 0 0.0
Supine: 355.5 100.0% LM: 5 0.8
Prone: 0 0.0% Spontaneous: 31 5.2
a
Positional times are given for TST. Bruxism: 0 0.0
Other: 0 0.0
Total: 209 35.3

Respiratory Events Summary

Oxygen Saturation Summary

Wake NREM REM Total Record

Total O2 Desaturations: 13 108 28 149
O2 Desaturation Index: 20.5 20.3 46.7 22.7
Average O2 Saturation (%) 96.4 94.8 92.9 94.8
Min O2 Saturation (%) 88 86 80 80
Max O2 Saturation (%) 99 99 98 99
Time @ 90%100% (minutes) 36.7 315.2 28.6 380.5
Time @ 80%89% (minutes) 1.3 4.1 7.4 12.8
Time @ 70%79% (minutes) 0.0 0.0 0.0 0.0
Time @ 60%69% (minutes) 0.0 0.0 0.0 0.0
Time @ 50%59% (minutes) 0.0 0.0 0.0 0.0
Time 88% (minutes) 0.6 1.8 4.9 7.3

SaO2 < 90% for 3.3% of the total sleep time.

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 BREATHING DISORDERS 193

Oximetry Histogram

SaO2 Histogram
30
%
20
T
i
m 10
e
0
50 60 70 80 90 100
% O2

Respiratory Event Durations

Average Maximum
(seconds) (seconds)
Apnea (NREM): 15.2 21.5
Hypopnea (NREM): 17.7 31.9
RERA (NREM): 0 0
Apnea (REM): 13.0 20.6
Hypopnea (REM): 14.4 28.0
RERA (REM): 0 0

Number of Respiratory EventsPosition and Sleep Stage

NREM REM
Non-supine Supine Non-supine Supine TOTAL

Obstructive Apnea: 0 33 0 21 54
Mixed Apnea: 0 0 0 0 0
Central Apnea: 0 0 0 0 0
All Apneas: 0 33 0 21 54
Hypopneas: 0 138 0 19 157
Apneas + Hypopneas: 0 171 0 40 211
RERA: 0 0 0 0 0
A/H INDEX: 0 32.1 0 66.7 35.6
RDI: 0 32.1 0 66.7 35.6

Chap04.indd 193 8/6/2009 4:12:43 PM

 194 CHAPTER 4

By Sleep Stage By Position

NREM REM Non-supine Supine TOTAL

Sleep Time (minutes): 319.5 36 0 355.5 355.5

Obstructive Apnea: 33 21 0 54 54
Mixed Apnea: 0 0 0 0 0
Central Apnea: 0 0 0 0 0
All Apneas: 33 21 0 54 54
Hypopneas: 138 19 0 157 157
Apneas + Hypopneas: 171 40 0 211 211
RERA: 0 0 0 0 0
Apnea Index: 6.2 35 0 9.1 9.1
Hypopnea Index: 25.9 31.7 0 26.5 26.5
A/H INDEX: 32.1 66.7 0 35.6 35.6
a
RDI : 32.1 66.7 0 35.6 35.6
a
RDI denotes the average number of all respiratory events (Apnea + Hypopnea + RERA) per hour of sleep.

Positional RDI

Left: 0
Right: 0
Prone: 0
Supine: 35.6

Other Respiratory Patterns

Yes No
Cheyne Stokes:
Hypoventilation:

Hypopnea rule used: Alternative

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 BREATHING DISORDERS 195

Limb Movements Summary

Number Indexa
LM Arousals: 5 0.8
Isolated Limb Movements: 2 0.3
Periodic Limb Movements: 4 0.7
TOTAL Limb Movements: 6 1.0
a
Index is number per hour of sleep.

Heart Rate Summary

Wake NREM REM TOTAL

Average Heart Rate (bpm) 69 69 70 69

Minimum Heart Rate (bpm) 58 55 55 55
Maximum Heart Rate (bpm) 91 91 90 91

Cardiac Events:

Occurrence of the following arrhythmias was observed:

BPM
Bradycardia: N/A Lowest heart rate observed: 55
Asystole: N/A Longest pause observed:
Sinus Tachycardia During Sleep: N/A
Narrow Complex Tachycardia: N/A Highest heart rate observed: 91
Wide Complex Tachycardia: N/A
Atrial Fibrillation: N/A
Other Arrhythmias Observed:

Technologist Comment Section

Highest heart rate: 91 bpm, during wake time. Lowest heart rate: 55 bpm. No pauses observed.

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Chap04.indd 196 8/6/2009 4:12:44 PM
 CHAPTER

5 Limb Movement Disorders

James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD

197

Chap05.indd 197 8/6/2009 4:13:49 PM

 198 CHAPTER 5

FIGURE 5-1 Polysomnogram: Standard montage; 60-second page.

Clinical: 58-year-old woman with a low back injury and frequent nocturnal leg movements.
Staging: Stage N1 sleep.
EMG: Unilateral (left) periodic leg movements.

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 LIMB MOVEMENT DISORDERS 199

FIGURE 5-2 Polysomnogram: Standard montage; 120-second page.

Clinical: 40-year-old woman with restless legs syndrome and a right lumbar radiculopathy.
Staging: Stage N3 sleep.
EMG: Unilateral (right) periodic leg movements.

Chap05.indd 199 8/6/2009 4:13:52 PM

 200 CHAPTER 5

FIGURE 5-3 Polysomnogram: Standard montage; 120-second page.

Clinical: 62-year-old man with excessive daytime sleepiness and a history of kicking his wife at night.
Staging: Stage N2 sleep with K complexes. The K complexes accompany some but not all of the periodic
limb movements.
Respiratory: Snoring with otherwise normal respirations.
EMG: Bilateral periodic leg movements starting slightly earlier on the left side.

Chap05.indd 200 8/6/2009 4:13:53 PM

 LIMB MOVEMENT DISORDERS 201

FIGURE 5-4 Polysomnogram: CPAP and PLM montage; 30-second page.

Clinical: 68-year-old man with obstructive sleep apnea and peripheral neuropathy.
Staging: Stage N2 sleep.
Respiratory: Normal respirations.
EMG: Right periodic leg movements and fragmentary myoclonus in both right and left leg channels.

Chap05.indd 201 8/6/2009 4:13:55 PM

 202 CHAPTER 5

FIGURE 5-5 Polysomnogram: Standard montage; 30-second page.

Clinical: 64-year-old man with excessive daytime sleepiness and frequent nocturnal leg movements.
Staging: Stage N2 sleep.
Respiratory: Effort increases with the arousal.
EMG: Bilateral periodic leg movements with an associated arousal.

Chap05.indd 202 8/6/2009 4:13:57 PM

 LIMB MOVEMENT DISORDERS 203

FIGURE 5-6 Polysomnogram: CPAP montage; 120-second page.

Clinical: 39-year-old man with obstructive sleep apnea.
Staging: Stage N2 sleep.
Respiratory: Normal respirations while using CPAP.
EMG: Asymmetric periodic leg movements. The compressed time base facilitates identification of the
periodicity of the movements.

Chap05.indd 203 8/6/2009 4:13:59 PM

 204 CHAPTER 5

FIGURE 5-7 Polysomnogram: Expanded EEG montage; 60-second page.

Clinical: 44-year-old woman with excessive daytime sleepiness and low back pain.
Staging: Stage N2 sleep.
Respiratory: Normal respirations.
EMG: Periodic leg movements with associated tachycardia. The compressed time base facilitates identification
of the periodicity of the movements.
EKG: A transient increase in the heart rate accompanies the periodic leg movements, despite no definite EEG
evidence of an arousal.

Chap05.indd 204 8/6/2009 4:14:01 PM

 LIMB MOVEMENT DISORDERS 205

FIGURE 5-8 Polysomnogram: Expanded EEG montage; 30-second page.

Clinical: 44-year-old woman with excessive daytime sleepiness and low back pain.
Staging: Stage N2 sleep.
Respiratory: Normal respirations.
EMG: Periodic leg movements associated with tachycardia.
EKG: A transient increase in the heart rate accompanies the periodic leg movements, despite no definite
EEG evidence of an arousal.

Chap05.indd 205 8/6/2009 4:14:03 PM

 206 CHAPTER 5

FIGURE 5-9 Polysomnogram: Expanded EEG montage; 30-second page.

Clinical: 58-year-old man with excessive daytime sleepiness.
Staging: Stage N2 sleep.
Respiratory: Normal respirations.
EMG: Periodic leg movements with arousals and tachycardia.
EKG: A transient increase in the heart rate occurs with the arousal and periodic leg movement.

Chap05.indd 206 8/6/2009 4:14:05 PM

 LIMB MOVEMENT DISORDERS 207

FIGURE 5-10 Polysomnogram: Standard montage; 30-second page.

Clinical: 32-year-old woman with restless legs syndrome.
Staging: Stage wake.
Respiratory: Normal respirations.
EMG: Frequent leg movements during wakefulness are typical of restless legs syndrome.

Chap05.indd 207 8/6/2009 4:14:08 PM

Chap05.indd 208 8/6/2009 4:14:10 PM
 CHAPTER

6 Parasomnias
James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD

209

Chap06.indd 209 8/6/2009 4:15:14 PM

 210 CHAPTER 6

FIGURE 6-1 Polysomnogram: Expanded EEG montage; 30-second page.

Clinical: 41-year-old man with witnessed apneas and tooth grinding.
Staging: Stage N1 sleep.
Respiratory: Normal respirations.
Behavior: Bruxism. Bursts of EMG activity occur at a rate of about 1/second in the EEG, chin EMG, and
EOG channels.

Chap06.indd 210 8/6/2009 4:15:14 PM

 PARASOMNIAS 211

FIGURE 6-2 Polysomnogram: Standard montage; 60-second page.

Clinical: 26-year-old woman with excessive daytime sleepiness, tooth grinding, and morning headache.
Staging: Probable stage N1 sleep but difficult to stage because of artifact.
Respiratory: Normal respirations.
Behavior: Bruxism. Rhythmic bursts of EMG activity occur about every 4 seconds.

Chap06.indd 211 8/6/2009 4:15:16 PM

 212 CHAPTER 6

*
FIGURE 6-3 Polysomnogram: Standard montage; 30-second page.
Clinical: 47-year-old woman with excessive daytime sleepiness.
Staging: Stage N1 sleep.
Respiratory: Normal respirations.
Behavior: Movements of the left leg (*) occur rhythmically at a rate of about 1/second, characteristic of
rhythmic movement disorder. Movement artifact is evident in the thoracic and abdominal channels.

Chap06.indd 212 8/6/2009 4:15:18 PM

 PARASOMNIAS 213

* * * *
FIGURE 6-4 Polysomnogram: Standard montage; 120-second page.
Clinical: 47-year-old woman with excessive daytime sleepiness.
Staging: Stage wake.
Respiratory: Normal respirations.
Behavior: Movements of the left leg (*) occur rhythmically at a rate of about 1/second, with a brief
period of quiescence between the runs of movement. This pattern is characteristic of rhythmic
movement disorder. Movement artifact is evident in the thoracic and abdominal channels.

Chap06.indd 213 8/6/2009 4:15:19 PM

 214 CHAPTER 6

*
FIGURE 6-5 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 7-year-old boy with nocturnal episodes of inconsolable fear.
Staging: Stage N3 sleep with an arousal.
Respiratory: Normal respirations.
EEG: Arousal (*) with delta activity associated with screaming and inconsolable fear, characteristic of
sleep terrors. The EEG following the arousal consists of a mixture of delta and faster frequencies. This
EEG pattern commonly accompanies arousals from slow-wave sleep in children with arousal disorders.

Chap06.indd 214 8/6/2009 4:15:20 PM

 PARASOMNIAS 215

*
FIGURE 6-6 Polysomnogram: Expanded EEG montage; 30-second page.
Clinical: 38-year-old woman with sleep talking.
Staging: Stage N3 sleep.
Respiratory: Normal respirations.
EEG: Spontaneous arousal (*) from stage N3 sleep associated with sleep talking. The EEG following the
arousal consists of a mixture of theta and delta frequencies.

Chap06.indd 215 8/6/2009 4:15:21 PM

 216 CHAPTER 6

*
FIGURE 6-7 Polysomnogram: Expanded EEG montage; 30-second page.
Clinical: 51-year-old man with frequent nocturnal arousals.
Staging: Stage N2 sleep.
Respiratory: Normal respirations.
EEG: An arousal (*) is followed a few seconds later by a full awakening and sleep talking. Sleep talking
can occur with arousals from any stage of sleep.

Chap06.indd 216 8/6/2009 4:15:21 PM

 PARASOMNIAS 217

*
FIGURE 6-8 Polysomnogram: Expanded EEG montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 53-year-old man with confusional arousals.
Staging: Stage N3 sleep.
Respiratory: Normal respirations.
EEG: Following the arousal (*), the EEG shows continued delta activity intermixed with faster frequen-
cies, associated with moving and crying. The observed behavior was typical of a confusional arousal.
In the 5 to 6 seconds preceding the arousal, the EEG shows delta activity that is more rhythmic and
synchronous than the delta activity that usually occurs in slow-wave sleep. Rhythmic, synchronous
delta activity sometimes precedes or accompanies arousals from slow-wave sleep in patients with
arousal disorders.

Chap06.indd 217 8/6/2009 4:15:22 PM

 218 CHAPTER 6

FIGURE 6-9 Polysomnogram: RLS montage; 30-second page.

Clinical: 45-year-old with excessive daytime sleepiness.
Staging: Stage R sleep.
Respiratory: Normal respirations with occasional snoring.
EMG: Increased phasic EMG activity is most prominent in the LAT1-LAT2 derivation. Chin EMG activ-
ity is tonically increased. Increased phasic and tonic EMG activity during REM sleep is characteristic of
patients with REM sleep behavior disorder.

Chap06.indd 218 8/6/2009 4:15:24 PM

 PARASOMNIAS 219

FIGURE 6-10 Polysomnogram: Standard montage; 30-second page.

Clinical: 63-year-old man with excessive daytime sleepiness and mild parkinsonism.
Staging: Stage R sleep with bursts of rapid eye movements.
Respiratory: Mildly irregular breathing accompanying the bursts of rapid eye movements.
EMG: Phasic EMG activity which is most prominent in the right leg. The amount of activity is excessive
for an adult. Epochs of REM sleep with excessive phasic EMG activity are common in patients with REM
sleep behavior disorder.

Chap06.indd 219 8/6/2009 4:15:25 PM

 220 CHAPTER 6

FIGURE 6-11 Polysomnogram: CPAP montage; 30-second page.

Clinical: 42-year-old man with a history of poliomyelitis.
Staging: Stage R sleep with rapid eye movements.
Respiratory: Normal breathing.
EMG: Excessive phasic EMG activity which is most prominent in the left leg. The amount of activity is
excessive for an adult. Epochs of REM sleep with excessive phasic EMG activity are common in patients
with REM sleep behavior disorder.

Chap06.indd 220 8/6/2009 4:15:27 PM

 PARASOMNIAS 221

FIGURE 6-12 Polysomnogram: Standard montage; 30-second page.

Clinical: 62-year-old man with a history of fighting behavior in his sleep.
Staging: Stage R sleep with rapid eye movements.
Respiratory: Normal respirations.
EMG: Markedly increased chin EMG tone during REM sleep. Tonic increases in chin EMG activity, with or
without excess phasic EMG activity in the limbs, are common during epochs of REM sleep in patients
with REM sleep behavior disorder.

Chap06.indd 221 8/6/2009 4:15:29 PM

 222 CHAPTER 6

FIGURE 6-13 Polysomnogram: Standard montage; 30-second page.

Clinical: 62-year-old man with a history of fighting behavior in his sleep.
Staging: Stage R sleep with rapid eye movements.
Respiratory: Normal respirations.
EMG: Transiently increased chin EMG tone with leg movements and talking during REM sleep.
The behaviors and polysomnographic features are typical of REM sleep behavior disorder.

Chap06.indd 222 8/6/2009 4:15:31 PM

 PARASOMNIAS 223

FIGURE 6-14 Polysomnogram: Standard montage; 30-second page.

Clinical: 62-year-old man with a history of fighting in his sleep.
Staging: Stage R sleep with rapid eye movements.
Respiratory: Normal respirations.
EMG: Markedly increased chin EMG tone and leg movements during REM sleep. During this REM period,
the patient talked, screamed, and made punching and thrashing movements. The behaviors and
polysomnographic features are typical of REM sleep behavior disorder.

Chap06.indd 223 8/6/2009 4:15:33 PM

 224 CHAPTER 6

FIGURE 6-15 Polysomnogram: Standard montage; 120-second page.

Clinical: 57-year-old man with a history of Post-traumatic stess disorder (PTSD) and frequent nightmares.
The patient awoke with reports of a nightmare about drowning. This was associated with recurrent
hypopneas. He stated that this was a common dream. This resolved after effective treatment of the
obstructive sleep apnea.
Staging: Stage R sleep with rapid eye movements with an arousal.
Respiratory: Hypopnea. The obstructive sleep apnea was isolated to REM sleep in this patient.

Chap06.indd 224 8/6/2009 4:15:35 PM

 CHAPTER Electroencephalographic
7 Abnormalities
James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD

225

Chap07.indd 225 8/6/2009 4:16:26 PM

 226 CHAPTER 7

*
FIGURE 7-1 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 29-year-old woman with complex partial seizures, snoring, and excessive daytime sleepiness.
Staging: Stage N2 sleep.
Respiratory: Snoring with normal respirations.
EEG: Subtle right hemispheric sharp waves (*) during stage N2 sleep with sleep spindles, K complexes,
and POSTs.

Chap07.indd 226 8/6/2009 4:16:26 PM

 ELECTROENCEPHALOGRAPHIC ABNORMALITIES 227

*
FIGURE 7-2 Polysomnogram: Standard montage; 30-second page.
Clinical: 44-year-old man with a right frontal glioma, epilepsy, and excessive daytime sleepiness.
Staging: Stage R sleep.
Respiratory: Normal respirations.
EEG: Right hemispheric sharp and slow waves most prominent in the C4 electrode (*). The sharp wave
can also be seen in the O2-avg derivation.

Chap07.indd 227 8/6/2009 4:16:27 PM

 228 CHAPTER 7

FIGURE 7-3 Polysomnogram: Standard montage; 60-second page.

Clinical: 44-year-old man with a right frontal glioma, epilepsy, and excessive daytime sleepiness.
Staging: Stage R sleep.
Respiratory: Normal respirations.
EEG: Right hemispheric (electrode C4) sharp and slow waves. When compared to the previous figure with
a 30-second time base, the abnormality is more difficult to identify because of time compression.

Chap07.indd 228 8/6/2009 4:16:28 PM

 ELECTROENCEPHALOGRAPHIC ABNORMALITIES 229

*
FIGURE 7-4 Polysomnogram: Standard montage; 120-second page.
Clinical: 44-year-old man with a right frontal glioma, epilepsy, and excessive daytime sleepiness.
Staging: Stage R sleep.
Respiratory: Normal respirations.
EEG: Right hemispheric (electrode C4) sharp and slow waves (*). When compared to the previous two
figures, the abnormality is almost impossible to identify because of time compression.

Chap07.indd 229 8/6/2009 4:16:30 PM

 230 CHAPTER 7

*
FIGURE 7-5 Polysomnogram: Expanded montage; 30-second page.
Clinical: 4-year-old with symptomatic generalized epilepsy and witnessed apneas.
Staging: Stage N2 sleep.
Respiratory: Normal respirations.
EEG: Right frontal sharp and slow waves maximal at electrodes F4 and C4 (*). The expanded EEG mon-
tage permits localization of the discharge.

Chap07.indd 230 8/6/2009 4:16:31 PM

 ELECTROENCEPHALOGRAPHIC ABNORMALITIES 231

*
FIGURE 7-6 Polysomnogram: Expanded EEG montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 28-year-old with frontal epilepsy and episodes of apnea and snoring.
Staging: Stage N1 sleep.
Respiratory: Normal respirations.
EEG: A left frontal spike and wave is maximal at electrode Fp1 (*). It is not seen in the standard sleep staging
channels (C3-A2, C4-A1, O1-A2, O2-A1) but has a subtle representation in the LOC (left eye) channel.

Chap07.indd 231 8/6/2009 4:16:32 PM

 232 CHAPTER 7

*
FIGURE 7-7 Polysomnogram: Expanded EEG montage; 60-second page.
Clinical: 18-month-old boy with seizures and apnea.
Staging: Stage N2 sleep. This page is difficult to stage because of seizure activity.
Respiratory: Increased respiratory effort at the onset of seizure activity.
EEG: Onset (*) of a focal seizure with medium amplitude rhythmic sharp waves maximal in channels
F7-T3 and C3-P3. As commonly occurs with focal seizures, the frequency of the ictal activity gradually
decreases and the amplitude gradually increases.

Chap07.indd 232 8/6/2009 4:16:32 PM

 ELECTROENCEPHALOGRAPHIC ABNORMALITIES 233

*
FIGURE 7-8 Polysomnogram: Expanded EEG montage; 120-second page.
Clinical: 18-month-old boy with seizures and apnea.
Staging: Stage N2 sleep. This page is difficult to stage because of seizure activity.
Respiratory: Increased respiratory effort at the onset of seizure activity.
EEG: Onset (*) of a focal seizure with medium amplitude rhythmic sharp waves maximal in channels
F7-T3 and C3-P3. The evolution of ictal activity is readily apparent with the compressed time base.

Chap07.indd 233 8/6/2009 4:16:33 PM

 234 CHAPTER 7

FIGURE 7-9 Polysomnogram: Expanded EEG montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 18-year-old patient with primary generalized epilepsy and excessive daytime sleepiness.
Staging: Stage N1 sleep.
Respiratory: Normal respirations.
EEG: Generalized, high amplitude spike, and wave discharges are recorded in all EEG channels and in the
EOG channels. The very high amplitudes are cut off in the display.

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 ELECTROENCEPHALOGRAPHIC ABNORMALITIES 235

FIGURE 7-10 Polysomnogram: Standard montage with CO2 monitoring; 30-second page.
Clinical: 7-year-old boy with symptomatic generalized epilepsy and episodes of apnea.
Staging: Stage N3 sleep. Staging is difficult with such severe EEG abnormalities.
Respiratory: Normal respirations.
EEG: Multifocal independent spike and wave discharges and generalized spike and wave discharges.

Chap07.indd 235 8/6/2009 4:16:37 PM

 236 CHAPTER 7

*
FIGURE 7-11 Polysomnogram: CPAP montage; 30-second page.
Clinical: 17-year-old man with epilepsy and obstructive sleep apnea.
Staging: Unable to accurately stage because of generalized spike and wave discharges during this
generalized tonic-clonic seizure and subsequent postictal slowing.
Respiratory: Ictal and postictal obstructive apnea associated with an arousal and an oxygen desaturation.
EEG: Generalized spike and wave discharges. At the end of the seizure (*), there is generalized delta
activity during the postictal phase.
Artifact: The tidal volume channel has artifact caused by the mask being pulled from the patients face
during postictal confusion.

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 ELECTROENCEPHALOGRAPHIC ABNORMALITIES 237

FIGURE 7-12 Polysomnogram: Expanded EEG montage; 30-second page.

Clinical: 15-month-old patient with Turner syndrome and infantile spasms.
Staging: Stage N1 sleep. Staging is difficult because of the severely abnormal EEG.
Respiratory: Normal respirations.
EEG: Hypsarrhythmia, generalized spike and wave discharges, slow spike and wave discharges, and a
slow and asynchronous background.

Chap07.indd 237 8/6/2009 4:16:40 PM

 238 CHAPTER 7

FIGURE 7-13 Polysomnogram: Standard montage; 30-second page.

Clinical: 48-year-old patient with a right frontal glioma and loud snoring.
Staging: Stage N1 sleep with an arousal.
Respiratory: Apnea followed by a snore and an arousal.
EEG: Asymmetric delta activity, greater on the right, during the arousal. Although the tumor is in the
right frontal region, the pathologic delta activity is present over the entire right hemisphere and can
also be seen in the LOC channel.

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 ELECTROENCEPHALOGRAPHIC ABNORMALITIES 239

FIGURE 7-14 Polysomnogram: Standard montage; 60-second page.

Clinical: 48-year-old patient with a right frontal glioma and loud snoring.
Staging: Stage N1 sleep with an arousal.
Respiratory: Apnea followed by a snore and an arousal.
EEG: Asymmetric delta activity, greater on the right, during the arousal. Although the tumor is in the
right frontal region, the pathologic delta activity is present over the entire right hemisphere and can
also be seen in the LOC channel.

Chap07.indd 239 8/6/2009 4:16:44 PM

 240 CHAPTER 7

FIGURE 7-15 Polysomnogram: Expanded EEG montage; 30-second page.

Clinical: 49-year-old woman status post left frontotemporal arteriovenous malformation resection with
excessive daytime sleepiness and disrupted sleep.
Staging: Stage N2 sleep.
Respiratory: Normal respirations.
EEG: Left hemisphere breach rhythm with higher amplitude and higher frequency EEG activity especially
over the frontotemporal regions.

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 ELECTROENCEPHALOGRAPHIC ABNORMALITIES 241

FIGURE 7-16 EEG; 10-second page.

Clinical: 8-year-old boy with episodes of staring.
Staging: Stage wake.
EEG: Generalized 3 Hz spike and wave discharges.

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 242 CHAPTER 7

FIGURE 7-17 EEG; 10-second page.

Clinical: 7-year-old boy with a nocturnal seizure. Benign rolandic epilepsy.
EEG: Centrotemporal spikes are present on an otherwise unremarkable background.

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 ELECTROENCEPHALOGRAPHIC ABNORMALITIES 243

FIGURE 7-18 EEG; 10-second page.

Clinical 3-year-old boy with myoclonic seizures and developmental delay. Dravet syndrome or severe
myoclonic epilepsy of infancy.
EEG: Spike and wave and polyspike and wave discharges with background slowing.

Chap07.indd 243 8/6/2009 4:16:52 PM

 244 CHAPTER 7

FIGURE 7-19 EEG; 10-second page.

Clinical: Neonate with encephalopathy and myoclonus. Early myoclonic encephalopathy.
EEG: Generalized slowing with intervening periods of suppression of the background rhythms.

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 ELECTROENCEPHALOGRAPHIC ABNORMALITIES 245

FIGURE 7-20 EEG; 10-second page.

Clinical: Partial seizure activity occurring in a patient with an intracranial mass. Epilepsia partialis
continua (EPC).
EEG: Prolonged seizure activity with an approximately 5 Hz spike and wave and rhythmic theta activity
morphology.

Chap07.indd 245 8/6/2009 4:16:55 PM

 246 CHAPTER 7

FIGURE 7-21 EEG; 10-second page.

Clinical: Infant with infantile spasms.
EEG: Generalized arrhythmic slowing and a hypsarrhythmia pattern with intermittent suppression of the
background rhythms.

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 ELECTROENCEPHALOGRAPHIC ABNORMALITIES 247

FIGURE 7-22 EEG; 10-second page.

Clinical: 14-year-old boy with morning myoclonus and generalized seizures. Juvenile myoclonic
epilepsy (JME).
Stage: Stage wake.
EEG: Spike and wave and polyspike and wave discharges superimposed on an otherwise unremarkable
background activity.

Chap07.indd 247 8/6/2009 4:16:59 PM

 248 CHAPTER 7

FIGURE 7-23 EEG; 10-second page.

Clinical: Lennox-Gastaut syndrome. Lennox-Gastaut syndrome is characterized by a combination of
clinical seizures, including myoclonic, atonic, atypical absence, tonic axial, and generalized tonic-clonic
seizures.
EEG: The EEG typically shows a generalized spike and wave pattern. The EEG reveals a slow spike wave
complex with a frequency of 1 to 2.5 Hz, multifocal spikes, and generalized paroxysmal fast activity
(GPFA).

Chap07.indd 248 8/6/2009 4:17:01 PM

 ELECTROENCEPHALOGRAPHIC ABNORMALITIES 249

FIGURE 7-24 EEG; 10-second page.

Clinical: Neonate with seizures.
EEG: Seizure activity with centrally predominant rhythmic activity.

Chap07.indd 249 8/6/2009 4:17:02 PM

 250 CHAPTER 7

FIGURE 7-25 EEG; 10-second page.

Clinical: 10-year-old girl with partial status epilepticus.
EEG: EPC with left frontally predominant spike activity.

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 CHAPTER

8 Artifacts
James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD

251

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 252 CHAPTER 8

*
FIGURE 8-1 Polysomnogram: Standard montage; 60-second page.
Clinical: 47-year-old man with witnessed apneas.
Staging: Stage N1 sleep with an arousal.
Respiratory: Mixed apnea followed by an arousal. The oxygen desaturation on this page is a result of the
apnea on the preceding page of the record.
Artifact: Cardioballistic artifact in the abdominal effort channel (*).

Chap08.indd 252 8/6/2009 4:18:10 PM

 ARTIFACTS 253

FIGURE 8-2 Polysomnogram: CPAP montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 43-year-old woman with upper-airway resistance syndrome.
Staging: Stage N1 sleep.
Respiratory: Normal respirations.
Artifact: Cardioballistic artifact in the intrathoracic pressure channel (*).

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 254 CHAPTER 8

FIGURE 8-3 Polysomnogram: Standard montage; 30-second page.

Clinical: 42-year-old man with an artificial eye and excessive daytime sleepiness.
Staging: Stage R sleep.
Respiratory: Normal respirations.
EOG: Unilateral rapid eye movements.

Chap08.indd 254 8/6/2009 4:18:13 PM

 ARTIFACTS 255

FIGURE 8-4 Polysomnogram: Standard montage with intrathoracic pressure monitoring; 30-second page.
Clinical: 33-year-old woman with snoring and excessive daytime sleepiness.
Staging: Stage N1 sleep.
Respiratory: Normal respirations.
Artifact: Swallow artifact in the intrathoracic pressure monitor.

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 256 CHAPTER 8

FIGURE 8-5 Polysomnogram: Standard montage with expanded EEG and CO2 monitoring; 60-second page.
Clinical: 4-month-old patient with apneic episodes.
Staging: Difficult to stage because of artifact.
Artifact: Apparent diffuse rhythmic delta activity caused by patting the babys chest. The rhythmic
activity is also evident in the thoracic channel.

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 ARTIFACTS 257

FIGURE 8-6 Polysomnogram: Standard montage with expanded EEG; 60-second page.
Clinical: 57-year-old man with excessive daytime sleepiness.
Staging: Difficult to stage because of severe 60 Hz artifact.
Artifact: Severe 60 Hz artifact caused by a laptop computer.

Chap08.indd 257 8/6/2009 4:18:19 PM

 258 CHAPTER 8

FIGURE 8-7 Polysomnogram: Standard montage; 30-second page.

Clinical: 32-year-old man with loud snoring and excessive daytime sleepiness.
Staging: Stage wake.
Artifact: Rhythmic face rubbing artifact.

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 ARTIFACTS 259

* ^
FIGURE 8-8 Polysomnogram: Standard montage; 30-second page.
Clinical: 47-year-old obese man with loud snoring and witnessed apneas.
Staging: Stage wake.
Respiratory: Normal respirations.
Artifact: Sweat artifact resulting in a wandering baseline with blocking in the O1-avg (*) and EOG
() channels.

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Chap08.indd 260 8/6/2009 4:18:23 PM
 CHAPTER

9 Electrocardiography
James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD

261

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 262 CHAPTER 9

*
FIGURE 9-1 Polysomnogram: CPAP montage; 30-second page.
Clinical: 56-year-old man with snoring and excessive daytime sleepiness.
Staging: Stage N2 sleep.
Respiratory: Intermittent snoring.
EKG: Frequent premature ventricular complexes (PVCs) with couplets (*).

Chap09.indd 262 8/6/2009 4:19:08 PM

 ELECTROCARDIOGRAPHY 263

* *
FIGURE 9-2 Polysomnogram: Standard montage; 30-second page.
Clinical: 48-year-old woman with intermittent snoring and witnessed apneas.
Staging: Stage N1 sleep.
Respiratory: Normal respirations.
EKG: Narrow premature complexes (*) without definite P waves.

Chap09.indd 263 8/6/2009 4:19:09 PM

 264 CHAPTER 9

*
FIGURE 9-3 Polysomnogram: Standard montage; 10-second page.
Clinical: 48-year-old woman with intermittent snoring and witnessed apneas.
Staging: Stage N1 sleep.
Respiratory: Normal respirations.
EKG: Narrow premature complexes (*) without definite P waves.

Chap09.indd 264 8/6/2009 4:19:10 PM

 ELECTROCARDIOGRAPHY 265

FIGURE 9-4 Polysomnogram: Standard montage; 30-second page.

Clinical: 27-year-old man with obstructive sleep apnea.
Staging: Stage N2 sleep.
Respiratory: Apnea followed by an arousal, snoring, and an oxygen desaturation.
EKG: Ventricular bigeminy.

Chap09.indd 265 8/6/2009 4:19:10 PM

 266 CHAPTER 9

FIGURE 9-5 Polysomnogram: CPAP montage; 30-second page.

Clinical: 31-year-old man with obstructive sleep apnea.
Staging: Stage N2 sleep.
Respiratory: Normal respirations.
EKG: Ventricular trigeminy.

Chap09.indd 266 8/6/2009 4:19:12 PM

 ELECTROCARDIOGRAPHY 267

FIGURE 9-6 Polysomnogram: CPAP montage; 30-second page.

Clinical: 71-year-old man with obstructive sleep apnea.
Staging: Stage N2 sleep.
Respiratory: Normal respirations.
EKG: Ventricular quintigeminy.

Chap09.indd 267 8/6/2009 4:19:14 PM

 268 CHAPTER 9

FIGURE 9-7 Polysomnogram: CPAP montage; 60-second page.

Clinical: 69-year-old man with obstructive sleep apnea and atrial fibrillation.
Staging: Stage N2 sleep.
Respiratory: Mild variations in respiratory effort.
EKG: Atrial fibrillation.

Chap09.indd 268 8/6/2009 4:19:16 PM

 ELECTROCARDIOGRAPHY 269

FIGURE 9-8 Polysomnogram: Standard montage; 30-second page.

Clinical: 52-year-old man with excessive daytime sleepiness and intermittent atrial fibrillation.
Staging: Stage R sleep.
EKG: Atrial fibrillation.

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 270 CHAPTER 9

FIGURE 9-9 Polysomnogram: Standard montage; 30-second page.

Clinical: 40-year-old woman with obstructive sleep apnea.
Staging: Stage R sleep with an arousal.
Respiratory: Apnea followed by an arousal and an oxygen desaturation. The oxygen desaturation on this page
was caused by an apnea from the preceding page of the record.
EKG: Bradycardia with the apnea. There is a 3-second asystole at the end of the apnea.

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 ELECTROCARDIOGRAPHY 271

*
FIGURE 9-10 Polysomnogram: Standard montage; 60-second page.
Clinical: 50-year-old man with obstructive sleep apnea and hypertension.
Staging: Stage R sleep with arousals.
Respiratory: Mixed apneas followed by arousals.
EKG: Wide complex tachycardia with a rate of more than 160 beats/minute accompanies the second arousal (*).

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 272 CHAPTER 9

*
FIGURE 9-11 Polysomnogram: Standard montage; 30-second page.
Clinical: 50-year-old man with obstructive sleep apnea and hypertension.
Staging: Stage R sleep with an arousal.
Respiratory: Mixed apnea followed by an arousal.
EKG: Wide complex tachycardia with a rate of more than 160 beats/minute accompanies the arousal (*).

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 ELECTROCARDIOGRAPHY 273

FIGURE 9-12 Polysomnogram: Standard montage; 30-second page.

Clinical: 58-year-old man with obstructive sleep apnea.
Staging: Stage R sleep with an arousal.
Respiratory: Mixed apnea followed by an arousal.
EKG: Ventricular tachycardia.

Chap09.indd 273 8/6/2009 4:19:23 PM

 274 CHAPTER 9

FIGURE 9-13 Polysomnogram: Standard montage; 30-second page.

Clinical: 69-year-old man with excessive daytime sleepiness and third-degree AV block.
Staging: Stage N2 sleep.
Respiratory: Normal respirations.
EKG: Third-degree AV block. Pacemaker spikes precede several of the QRS complexes and can also be seen in the
backup respiratory channel.

Chap09.indd 274 8/6/2009 4:19:25 PM

 ELECTROCARDIOGRAPHY 275

FIGURE 9-14 Polysomnogram: Standard montage; 60-second page.

Clinical: 40-year-old man with obstructive sleep apnea.
Staging: Stage R sleep with arousals.
Respiratory: Repeated apneas followed by arousals. The pulse oximetry channel is contaminated by artifact.
EKG: Bradycardia accompanies the apnea. Tachycardia occurs with the arousal.

Chap09.indd 275 8/6/2009 4:19:26 PM

 276 CHAPTER 9

FIGURE 9-15 Polysomnogram: CPAP montage; 30-second page.

Clinical: 59-year-old man with obstructive sleep apnea.
Staging: Stage R sleep with an arousal.
Respiratory: Apnea with paradoxical respirations followed by an arousal and an oxygen desaturation.
EKG: Bradycardia accompanies the apnea, while tachycardia occurs with the arousal. Occasional PVCs are evident.

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 ELECTROCARDIOGRAPHY 277

FIGURE 9-16 Polysomnogram: Standard montage; 30-second page.

Clinical: 71-year-old man with obstructive sleep apnea and hypertension.
Staging: Stage N2 sleep with an arousal.
Respiratory: Mixed apnea associated with an arousal and an oxygen desaturation from 93% to 87%.
EKG: Sinus arrhythmia.

Chap09.indd 277 8/6/2009 4:19:30 PM

 278 CHAPTER 9

FIGURE 9-17 Polysomnogram: Standard montage; 30-second page.

Clinical: 38-year-old obese woman with obstructive sleep apnea.
Staging: Stage N2 sleep with an arousal.
Respiratory: Repeated apneas with associated arousals, snorts, and oxygen desaturations.
EKG: Sinus arrhythmia and first-degree AV block.

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 ELECTROCARDIOGRAPHY 279

FIGURE 9-18 Polysomnogram: Standard montage; 10-second page.

Clinical: 38-year-old obese woman with obstructive sleep apnea.
Staging: Stage N2 sleep with an arousal.
Respiratory: Repeated apneas with associated arousals, snorts, and oxygen desaturations.
EKG: Sinus arrhythmia and first-degree AV block.

Chap09.indd 279 8/6/2009 4:19:34 PM

 280 CHAPTER 9

FIGURE 9-19 Polysomnogram: Standard montage; 30-second page.

Clinical: 46-year-old man with excessive daytime sleepiness.
Staging: Stage R sleep.
Respiratory: Variable respiratory effort characteristic of phasic REM sleep.
EKG: Bigeminy occurring in conjunction with phasic REM sleep.

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 ELECTROCARDIOGRAPHY 281

FIGURE 9-20 Polysomnogram: Standard montage; 60-second page.

Clinical: 49-year-old woman with snoring and excessive daytime sleepiness.
Staging: Stage N2 sleep.
Respiratory: Normal respirations.
EKG: Supraventricular tachycardia.

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 282 CHAPTER 9

FIGURE 9-21 Polysomnogram: Standard montage; 30-second page.

Clinical: 55-year-old woman with snoring and excessive daytime sleepiness.
Staging: Stage wake.
Respiratory: Normal respirations.
EKG: EKG artifact not ventricular tachycardia.

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 ELECTROCARDIOGRAPHY 283

FIGURE 9-22 Polysomnogram: Standard montage; 30-second page.

Clinical: 35-year-old man with excessive daytime sleepiness.
Staging: Stage N2 sleep.
Respiratory: The changes in the nasal pressure waveform suggest a respiratory event related arousal.
EKG: The EKG is bad resulting in a waveform suggestive of ventricular tachycardia.

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 284 CHAPTER 9

FIGURE 9-23 Polysomnogram: Standard montage; 30-second page.

Clinical: 58-year-old woman with heart failure and apneas.
Staging: Stage N1 sleep.
Respiratory: Central apnea.
EKG: Supraventricular tachycardia.

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 ELECTROCARDIOGRAPHY 285

FIGURE 9-24 Polysomnogram: Standard montage; 30-second page.

Clinical: 47-year-old man with COPD, snoring, and excessive daytime sleepiness.
Staging: Stage N2 sleep.
Respiratory: Hypopnea. The oxygen desaturation is secondary to the hypopnea from the preceding page.
EKG: Narrow complex tachycardia.

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 286 CHAPTER 9

FIGURE 9-25 Polysomnogram: Standard montage; 30-second page.

Clinical: 62-year-old man with snoring and fatigue.
Staging: Stage N2 sleep.
Respiratory: Hypopnea.
Snoring: There is artifact from snoring in the chin EMG and in the EEG channels.
EKG: Ventricular tachycardia.

Chap09.indd 286 8/6/2009 4:19:45 PM

 CHAPTER

10 Calibrations
James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD

287

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 288 CHAPTER 10

FIGURE 10-1 Machine calibrations.

Chap10.indd 288 8/6/2009 4:24:00 PM

 CALIBRATIONS 289

FIGURE 10-2 Breath hold.

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 290 CHAPTER 10

FIGURE 10-3 Grit teeth.

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 CALIBRATIONS 291

FIGURE 10-4 Foot flex.

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 292 CHAPTER 10

FIGURE 10-5 Eyes open.

Chap10.indd 292 8/6/2009 4:24:06 PM

 CALIBRATIONS 293

FIGURE 10-6 Eyes closed.

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 294 CHAPTER 10

FIGURE 10-7 Eye movements.

Chap10.indd 294 8/6/2009 4:24:08 PM

 CALIBRATIONS 295

FIGURE 10-8 Calibration sequence at 120-second page.

Chap10.indd 295 8/6/2009 4:24:10 PM

Chap10.indd 296 8/6/2009 4:24:12 PM
 CHAPTER

11 Actigraphy
James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD

297

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 298 CHAPTER 11

FIGURE 11-1 Actigraphy in a normal subject.

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 ACTIGRAPHY 299

FIGURE 11-2 Actigraphy in a patient with insomnia.

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Chap11.indd 300 8/6/2009 4:30:21 PM
 CHAPTER

12 Technical Background
James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD

INTRODUCTION management of sleep disorders. In addition to these channels,

the other variables listed above are used to identify specific
Polysomnography is the recording of multiple physiologic sleep-related disorders.
functions during sleep. Standard polysomnography usually
includes the following variables.
SIGNAL PROCESSING
Electroencephalogram (EEG)
Electrooculogram (EOG) Differential amplifier: A differential amplifier amplifies the
Electrocardiogram (EKG) difference between two input signals. Any potentials shared
Electromyography (EMG) between the two signals are removed leaving only the differ-
Pulse oximetry ence between the signals.
Airflow (nasal and oral) Common mode rejection ratio (CMRR): This ratio refers to
Respiratory effort (thoracic and abdominal) the ability of an amplifier to reject in-phase potentials and amplify
Limb movements out-of-phase potentials. The CMRR is measured by connecting
Snore sensors both input channels of an amplifier to the same signal source.
Special studies may include the following. Ideally, the output would be zero (CMRR would be infinity).
Good amplifiers have a CMRR between 1,000 and 10,000.
Expanded EEG Polarity: Standard EEG polarity convention is as follows.
Esophageal manometry
If input 1 is negative compared to input 2, an upward signal
CO2 monitoring
is displayed.
CPAP/BiPAP
If input 1 is positive compared to input 2, a downward
Esophageal pH
signal is displayed.
The EEG, EMG, and EOG data are used to identify the sleep If input 2 is negative compared to input 1, a downward
stage. Accurate sleep staging is necessary for the diagnosis and signal is displayed.
301

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 302 CHAPTER 12
If input 2 is positive compared to input 1, an upward signal
is displayed.
Filters
Filters allow the technologist and polysomnographer an
opportunity to attenuate artifacts.
Low frequency filter: Ideally, the low frequency filter attenu-
ates all frequencies below the cutoff frequency of the filter
and allows all frequencies above the cutoff frequency to pass
unchanged. In reality, the cutoff does not occur at a distinct
single frequency but over a range of frequencies with a vari-
able attenuation. For EEG, the cutoff frequency is defined as
the frequency at which the output is reduced by 30%. In digital
recording, little filtering is performed prior to digitization. Sub-
sequent digital filtering can be performed as needed.
High frequency filter: Ideally, the high frequency filter atten-
uates all frequencies above the cutoff frequency of the filter
and allows all frequencies below the cutoff frequency to pass
unchanged. In reality, the cutoff does not occur at a distinct
single frequency but over a range of frequencies with a vari-
able attenuation. For EEG, the cutoff frequency is defined as
the frequency at which the output is reduced by 30%. In digital
recording, little filtering is performed prior to digitization. Sub-
sequent digital filtering can be performed as needed.
60 Hz notch filter: Ideally, the 60 Hz notch frequency filter
removes 60 Hz noise from electrical sources without affect-
ing other frequencies. In reality, the 60 Hz filter attenuates
a range of frequencies around 60 Hz. When 60 Hz noise is
Chap12.indd 302
attenuated, all EEG activity in that range is also attenuated.
Given these and other problems associated with the use of
the 60 Hz notch filter, it should be used only when absolutely
necessary.
Phase shift: Shift of a waveform either earlier or later in time
caused by filtering.
The low frequency filter may cause a significant phase shift.
Increasing the low frequency filter attenuates the signal and
shifts it to the left or earlier in time. This may have a signifi-
cant effect on the interpretation of epileptiform discharges in
expanded EEG studies.
The phase shift secondary to the high frequency filter and the
60 Hz notch filter has a minimal effect on the signals recorded
during polysomnography. The phase shift caused by decreasing
the high frequency filter is to the right or later in time.
SLEEP MONTAGES
Abbreviations used:
EKG = electrocardiogram
hff = high frequency filter in Hz
LAT and RAT = left and right anterior tibialis surface EMG
LEOG and REOG = left and right electrooculogram
lff = low frequency filter in Hz
N/O airflow = nasal/oral airflow
Pes = intrathoracic (esophageal) pressure monitor
SaO2 = pulse oximetry
sens = sensitivity in microvolts/millimeter
8/6/2009 4:31:09 PM
 TECHNICAL BACKGROUND 303

Montage for Standard Polysomnogram

Channel Amplifier Settings Filter Settings

1. LEOG sens = 100 lff = 0.3 hff = 15
2. REOG sens = 100 lff = 0.3 hff = 15
3. Chin-EMG sens = 50 lff = 10 hff = 70
4. F3-A2 sens = 100 lff = 0.3 hff = 35
5. F4-A1 sens = 100 lff = 0.3 hff = 35
6. C3-A2 sens = 100 lff = 0.3 hff = 35
7. C4-A1 sens = 100 lff = 0.3 hff = 35
8. O1-A2 sens = 100 lff = 0.3 hff = 35
9. O2-A1 sens = 100 lff = 0.3 hff = 35
10. LAT-EMG sens = 200 lff = 10 hff = 70
11. RAT-EMG sens = 200 lff = 10 hff = 70
12. EKG sens = 1,000 lff = 1 hff = 15
13. LAT-A1 sens = 1,000 lff = 1 hff = 15
14. Snore1-Snore2 sens = 1,000 lff = 10 hff = 70
15. Nasal pressure
16. N/O airflow sens = 100 lff = 0.1 hff = 15
17. Thoracic motion sens = 500 lff = 0.1 hff = 15
18. Abdominal motion sens = 500 lff = 0.1 hff = 15
19. Backup motion sens = 500 lff = 0.1 hff = 15
20. Intercostal EMG sens = 200 lff = 10 hff = 70
21. SaO2 sens = 2 DC

Chap12.indd 303 8/6/2009 4:31:09 PM

 304 CHAPTER 12

Montage for Multiple Sleep Latency Test

Channel Amplifier Settings Filter Settings

1. LEOG sens = 100 lff = 0.3 hff = 15
2. REOG sens = 100 lff = 0.3 hff = 15
3. Chin-EMG sens = 50 lff = 10 hff = 70
4. F3-A2 sens = 100 lff = 0.3 hff = 35
5. F4-A1 sens = 100 lff = 0.3 hff = 35
6. C3-A2 sens = 100 lff = 0.3 hff = 35
7. C4-A1 sens = 100 lff = 0.3 hff = 35
8. O1-A2 sens = 100 lff = 0.3 hff = 35
9. O2-A1 sens = 100 lff = 0.3 hff = 35
10. LAT-EMG sens = 200 lff = 10 hff = 70
11. RAT-EMG sens = 200 lff = 10 hff = 70
12. EKG sens = 1,000 lff = 1 hff = 15

Montage for CPAP Trial

Channel Amplifier Settings Filter Settings

1. LEOG sens = 100 lff = 0.3 hff = 15
2. REOG sens = 100 lff = 0.3 hff = 15
3. Chin-EMG sens = 50 lff = 10 hff = 70
4. F3-A2 sens = 100 lff = 0.3 hff = 35
5. F4-A1 sens = 100 lff = 0.3 hff = 35
6. C3-A2 sens = 100 lff = 0.3 hff = 35
7. C4-A1 sens = 100 lff = 0.3 hff = 35
8. O1-A2 sens = 100 lff = 0.3 hff = 35
9. O2-A1 sens = 100 lff = 0.3 hff = 35
10. LAT-EMG sens = 200 lff = 10 hff = 70
11. RAT-EMG sens = 200 lff = 10 hff = 70
12. EKG sens = 1,000 lff = 1 hff = 15
13. LAT-A1 sens = 1,000 lff = 1 hff = 15
(continued )

Chap12.indd 304 8/6/2009 4:31:09 PM

 TECHNICAL BACKGROUND 305

Montage for CPAP Trial (continued )

Channel Amplifier Settings Filter Settings

14. Snore1-Snore2 sens = 1,000 lff = 10 hff = 70
15. Mask flow sens = 2 lff = 50%
16. Tidal volume sens = 2 lff = 50%
17. Oral airflow sens = 100 lff = 0.1 hff = 15
18. Thoracic motion sens = 500 lff = 0.1 hff = 15
19. Abdominal motion sens = 500 lff = 0.1 hff = 15
20. Backup motion sens = 500 lff = 0.1 hff = 15
21. SaO2 sens = 2 DC

Montage for Polysomnogram with Intrathoracic Pressure Monitoring

Channel Amplifier Settings Filter Settings

1. LEOG sens = 100 lff = 0.3 hff = 15
2. REOG sens = 100 lff = 0.3 hff = 15
3. Chin-EMG sens = 50 lff = 10 hff = 70
4. F3-A2 sens = 100 lff = 0.3 hff = 35
5. F4-A1 sens = 100 lff = 0.3 hff = 35
6. C3-A2 sens = 100 lff = 0.3 hff = 35
7. C4-A1 sens = 100 lff = 0.3 hff = 35
8. O1-A2 sens = 100 lff = 0.3 hff = 35
9. O2-A1 sens = 100 lff = 0.3 hff = 35
10. LAT-EMG sens = 200 lff = 10 hff = 70
11. RAT-EMG sens = 200 lff = 10 hff = 70
12. EKG sens = 1,000 lff = 1 hff = 15
13. LAT-A1 sens = 1,000 lff = 1 hff = 15
14. Snore1-Snore2 sens = 1,000 lff = 10 hff = 70
15. Nasal pressure
16. N/O airflow sens = 100 lff = 0.1 hff = 15
17. Thoracic motion sens = 500 lff = 0.1 hff = 15
(continued )

Chap12.indd 305 8/6/2009 4:31:09 PM

 306 CHAPTER 12

Montage for Polysomnogram with Intrathoracic Pressure Monitoring (continued )

Channel Amplifier Settings Filter Settings

18. Abdominal motion sens = 500 lff = 0.1 hff = 15
19. Backup motion sens = 500 lff = 0.1 hff = 15
20. Intercostal EMG sens = 200 lff = 10 hff = 70
21. SaO2 sens = 2 DC
22. Pes sens = 2 lff = 50%

Montage for Suspected Parasomnias or Seizures

Channel Amplifier Settings Filter Settings

1. Fp1-F7 sens = 100 lff = 0.3 hff = 35
2. F7-T3 sens = 100 lff = 0.3 hff = 35
3. T3-T5 sens = 100 lff = 0.3 hff = 35
4. T5-O1 sens = 100 lff = 0.3 hff = 35
5. Fp1-F3 sens = 100 lff = 0.3 hff = 35
6. F3-C3 sens = 100 lff = 0.3 hff = 35
7. C3-P3 sens = 100 lff = 0.3 hff = 35
8. P3-O1 sens = 100 lff = 0.3 hff = 35
9. Fp2-F4 sens = 100 lff = 0.3 hff = 35
10. F4-C4 sens = 100 lff = 0.3 hff = 35
11. C4-P4 sens = 100 lff = 0.3 hff = 35
12. P4-O2 sens = 100 lff = 0.3 hff = 35
13. Fp2-F8 sens = 100 lff = 0.3 hff = 35
14. F8-T4 sens = 100 lff = 0.3 hff = 35
15. T4-T6 sens = 100 lff = 0.3 hff = 35
16. T6-O2 sens = 100 lff = 0.3 hff = 35
17. LEOG sens = 100 lff = 0.3 hff = 15
18. REOG sens = 100 lff = 0.3 hff = 15
19. Chin-EMG sens = 50 lff = 10 hff = 70
20. F3-A2 sens = 100 lff = 0.3 hff = 35
21. F4-A1 sens = 100 lff = 0.3 hff = 35
(continued )

Chap12.indd 306 8/6/2009 4:31:09 PM

 TECHNICAL BACKGROUND 307

Montage for Suspected Parasomnias or Seizures (continued )

Channel Amplifier Settings Filter Settings

22. C3-A2 sens = 100 lff = 0.3 hff = 35
23. C4-A1 sens = 100 lff = 0.3 hff = 35
24. O1-A2 sens = 100 lff = 0.3 hff = 35
25. O2-A1 sens = 100 lff = 0.3 hff = 35
26. LAT-EMG sens = 200 lff = 10 hff = 70
27. RAT-EMG sens = 200 lff = 10 hff = 70
28. EKG sens = 1,000 lff = 1 hff = 15
29. LAT-A1 sens = 1,000 lff = 1 hff = 15
30. Snore1-Snore2 sens = 1,000 lff = 10 hff = 70
31. Nasal pressure
32. N/O airflow sens = 100 lff = 0.1 hff = 15
33. Thoracic motion sens = 500 lff = 0.1 hff = 15
34. Abdominal motion sens = 500 lff = 0.1 hff = 15
35. Backup motion sens = 500 lff = 0.1 hff = 15
36. Intercostal EMG sens = 200 lff = 10 hff = 70
37. SaO2 sens = 2 DC

Montage for Suspected REM Sleep Behavior Disorder

Channel Amplifier Settings Filter Settings

1. Fp1-F7 sens = 100 lff = 0.3 hff = 35
2. F7-T3 sens = 100 lff = 0.3 hff = 35
3. T3-T5 sens = 100 lff = 0.3 hff = 35
4. T5-O1 sens = 100 lff = 0.3 hff = 35
5. Fp1-F3 sens = 100 lff = 0.3 hff = 35
6. F3-C3 sens = 100 lff = 0.3 hff = 35
7. C3-P3 sens = 100 lff = 0.3 hff = 35
8. P3-O1 sens = 100 lff = 0.3 hff = 35
9. Fp2-F4 sens = 100 lff = 0.3 hff = 35
10. F4-C4 sens = 100 lff = 0.3 hff = 35
(continued )

Chap12.indd 307 8/6/2009 4:31:09 PM

 308 CHAPTER 12

Montage for Suspected REM Sleep Behavior Disorder (continued )

Channel Amplifier Settings Filter Settings

11. C4-P4 sens = 100 lff = 0.3 hff = 35
12. P4-O2 sens = 100 lff = 0.3 hff = 35
13. Fp2-F8 sens = 100 lff = 0.3 hff = 35
14. F8-T4 sens = 100 lff = 0.3 hff = 35
15. T4-T6 sens = 100 lff = 0.3 hff = 35
16. T6-O2 sens = 100 lff = 0.3 hff = 35
17. LAT1-EMG sens = 200 lff = 10 hff = 70
18. RAT1-EMG sens = 200 lff = 10 hff = 70
19. LED-EMG sens = 200 lff = 10
20. RED-EMG sens = 200 lff = 10 hff = 70
21. LEOG sens = 100 lff = 0.3 hff = 15
22. REOG sens = 100 lff = 0.3 hff = 15
23. Chin-EMG sens = 50 lff = 10 hff = 70
24. F3-A2 sens = 100 lff = 0.3 hff = 35
25. F4-A1 sens = 100 lff = 0.3 hff = 35
26. C3-A2 sens = 100 lff = 0.3 hff = 35
27. C4-A1 sens = 100 lff = 0.3 hff = 35
28. O1-A2 sens = 100 lff = 0.3 hff = 35
29. O2-A1 sens = 100 lff = 0.3 hff = 35
30. LAT-EMG sens = 200 lff = 10 hff = 70
31. RAT-EMG sens = 200 lff = 10 hff = 70
32. EKG sens = 1,000 lff = 1 hff = 15
33. LAT-A1 sens = 1,000 lff = 1 hff = 15
34. Snore1-Snore2 sens = 1,000 lff = 10 hff = 70
35. Nasal pressure
36. N/O airflow sens = 100 lff = 0.1 hff = 15
37. Thoracic motion sens = 500 lff = 0.1 hff = 15
38. Abdominal motion sens = 500 lff = 0.1 hff = 15
39. Backup motion sens = 500 lff = 0.1 hff = 15
40. Intercostal EMG sens = 200 lff = 10 hff = 70
41. SaO2 sens = 2 DC

Chap12.indd 308 8/6/2009 4:31:09 PM

 Recording Artifacts and
CHAPTER Solving Technical Problems
13 with Polysomnography
Technology
James D. Geyer, MD Paul R. Carney, MD
Troy A. Payne, MD Jennifer Parr, RPSGT

ARTIFACTS IN POLYSOMNOGRAPHY The artifact in the EEG channels should be time locked to the
RECORDINGS EKG.
Method for reducing or eliminating the artifact: Re-reference
Loose Electrode the EEG channels to A1 + A2.

Description: High-frequency noise superimposed on high-am-

plitude slow activity with possible superimposed electrode pops.
Method for reducing or eliminating the artifact: Reprep and
repaste the electrode to decrease the impedance.
Muscle (EMG) Artifact
Description: Obscuration of the background EEG and occasion-
ally EOG by myogenic (muscle) artifact.
Method for reducing or eliminating the artifact: Ask the
patient to relax; opening the jaw slightly can dramatically
reduced EMG artifact. Re-referencing electrodes can also
decrease artifact.
EKG in the EEG Channel Artifact
Description: A representation of the EKG in the EEG chan-
nels secondary to volume conduction of the EKG waveform.
Vibration Artifact
Description: The vibration caused by leg movements or snoring
can result in high-frequency artifacts in other channels. One
can see a manifestation of the snore registering in the chin
EMG channel.
Method for reducing or eliminating the artifact: This artifact is
very difficult to reduce but should be recognized as a normal
physiologic occurrence.
Electrode Pop Artifact
Description: Very sharp, spikelike deflection originating from
a mechanically or electrically unstable electrode. The deflec-
tions should have no electrical field and should be isolated
to a single electrode. The deflection may, however, be seen in
multiple channels if that electrode is used as a component of
a channel.

309

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 310 CHAPTER 13
Method for reducing or eliminating the artifact: Reprep and
repaste the electrode to decrease the impedance.
Cardioballistic Artifact
Description: A pulse wave may be seen in the chest belt or
abdominal belt that has only a slight delay behind the EKG
channel. A representation of the pulse wave may be seen in
airflow channels, nasal pressure monitors, and in esophageal
pressure-monitoring channels.
Method for reducing or eliminating the artifact: This artifact is
very difficult to reduce but should be recognized as a normal
physiologic occurrence.
Blink Artifact
Description: An electric dipole is created by the eye, with the cor-
nea being electropositive and the retina being electronegative.
Eyelid movement also creates an electrical potential. Eye and
eyelid movement create a frontally (with variable amplitude
and field depending upon the direction of gaze) predominate
slow wave.
Method for reducing or eliminating the artifact: This artifact is
very difficult to reduce but should be recognized as a normal
physiologic occurrence.
Sweat Artifact
Description: Slow delta frequency rolling or swaying deflections
are superimposed on the background EEG. One can see the
sweat artifact most prominently in the O1-A2 channel.
Method for reducing or eliminating the artifact: Decrease the
room temperature by lowering the air-conditioner temperature
or by turning on a fan. Use of filtering to decrease the artifact
can result in alteration of physiologic waveforms.
Loose Belt Artifact
Description: Effort channels begin to flatten without any evident
movement despite continued respiratory effort because the
Chap13.indd 310
belt is no longer tight enough or in the appropriate location to
accurately reflect movement.
Method for reducing or eliminating the artifact: Tighten the
loose belt.
Swallow Artifact
Description: The glossokinetic potential occurs because the tip
of the tongue is more electrically negative than the base of the
tongue. Movement of the tongue may result in a slow wave,
predominantly in the temporal regions. One can see the swal-
low occurring during the arousals.
Method for reducing or eliminating the artifact: This artifact is
very difficult to reduce but should be recognized as a normal
physiologic occurrence.
Misplaced Thermocouple Artifact
Description: The airflow-sensing thermocouple can move from
its proper position. When the thermocouple moves, it may no
longer be able to monitor changes in temperature between
inhalation and exhalation.
Method for reducing or eliminating the artifact: Place thermo-
couple in proper position.
Humidifier Condensation or Drainage in the
Continuous Positive Air Pressure Tubing
Description: In the airflow channels, there may be an M-shaped
waveform with each breath as the water moves backward and
forward in the tubing.
Method for reducing or eliminating the artifact: Drain water
from the tubing.
Rectus Spike Artifact
Description: The electric potential created by the rectus eye mus-
cles can create a small spikelike discharge in the frontal and
frontotemporal EEG derivations.
8/6/2009 4:31:49 PM
 RECORDING ARTIFACTS AND SOLVING TECHNICAL PROBLEMS WITH POLYSOMNOGRAPHY TECHNOLOGY
Method for reducing or eliminating the artifact: This artifact is
very difficult to reduce but should be recognized as a normal
physiologic occurrence.
Sixty-Hertz Artifact
Description: Lighting, electrical wiring, and machinery can pro-
duce electrical artifact, which occurs at approximately 60 Hz.
This may be superimposed on baseline EEG, EKG, EOG, and
EMG waveforms.
Method for reducing or eliminating the artifact: Reprep or reat-
tach electrodes. Check ground lines. Turn off lighting and any
unnecessary electrical equipment.
CONTINUOUS POSITIVE AIR PRESSURE
COMPLICATIONS AND POTENTIAL
RESPONSES
Nasal drainagetreat with nasal saline spray, nasal steroid
spray, or over-the-counter nasal decongestant sprays.
Chap13.indd 311
311
Nasal congestionincrease heated humidity, nasal spine
saline spray, nasal steroid spray, and when occurring on an
infrequent basis, over-the-counter nasal decongestant sprays.
Poor seal/mask leaktighten headgear, refit mask, try a new
style of mask.
Sore noseloosen headgear, if no improvement try a new
mask style, topical antibiotic ointment.
Nasal drynessincrease heated humidification, nasal saline
spray.
Nosebleedsincrease heated humidification, nasal saline
spray.
Allergy to mask materialchange to a hypoallergenic mask.
Patient reports that pressure is too high, but study shows that
setting is correctchange to C-flex produced by Respironics.
Difficulty exhalinguse lowest possible CPAP setting, change
to a bilevel pressure system, change to C-flex by Respironics.
Claustrophobiaeducate patients on the possibility of
claustrophobia and that it will likely improve over time,
select mask for patient comfort, meditation, CPAP adjust-
ment periods during wakefulness, sedative medications, or
anxiolytic medications at bedtime if necessary.
Air swallowing (aerophagia) and gaschin strap, bilevel pres-
sure, educate patients on the possibility that this may occur.
8/6/2009 4:31:49 PM
Chap13.indd 312 8/6/2009 4:31:49 PM
 APPENDIX
Electrode Placement
A James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD
Julie Tsikhlakis, RN, BSN
1.1. All material should be assembled on a tray and positioned
for easy access during hookup.
1.2. The patients head is measured and electrode placement
sites are plotted according to the International 10/20
system of electrode placement. The nasion is the inden-
tation above the bridge of the nose, below the forehead.
The inion is the small bony protrusion at the back of the
head. The preauricular points are the small indentations
in the front of the ears.
1.2.1. The first measurement is made by applying the
tape measure across the top of the head measur-
ing the distance from the nasion to the inion.
A mark is made of the top of the head.
1.2.2. Calculate 10% of the distance between the nasion and
the inion and make a mark 10% above the nasion.
1.2.3. Look down the bridge of the patients nose and
center the 10% mark in line with the nose. This
location is called FPz.
1.2.4. Make a mark 10% above the inion.
1.2.5. Measure the patients head across from left to right
preauricular points, holding the measuring tape
directly through the center mark at the top of the
head. The midpoint between the two preauricular
points is identified as Cz.
Appendix A.indd 313
1.2.6. Calculate 10% of the distance between the two
preauricular points and make a mark 10% above
the left preauricular point. Then locate the 30%
mark by measuring half the distance between the
10% mark above the preauricular points and the
center mark at the top of the head (Cz). Repeat
the same procedure on the opposite side of the
head.
1.2.7. At this time, you should have a 10% mark above
the nasion, a 10% mark above the inion, and 10%
marks above each preauricular point. Holding the
tape through these four landmarks, measure the
circumference of the patients head.
1.2.8. Calculate 5% of the head circumference and make
a mark 5% to the left and 5% to the right of the
FPz on the patients forehead. These locations
are designated Fp1 and Fp2. This spacing should
be 10% of the total head circumference.
1.2.9. Center the 10% mark above the inion by calculat-
ing one-half the head circumference and vertically
intersecting that 10% mark. This location is called
Oz. Then measure 5% over to the left and 5% over
to the right. These locations are designated O1
and O2.
313
8/6/2009 5:10:10 PM
 314 APPENDIX A
1.2.10. To locate C3, measure the distance between Fp1
and O1 holding the tape through the 30% mark
above the left preauricular point. Calculating half of
that distance, intersect the 30% mark. This intersect
site is the placement for electrode C3.
1.2.11. To locate electrodes site C4, repeat the same pro-
cedure on the right side of the head, measuring
from Fp2 to O2, holding the tape through the
30% mark above the right preauricular point.
1.3. Gloves should be worn.
1.4. Examine the condition of the electrodes.
1.4.1. Check for frayed or loose connections.
1.5. Electrode application
1.5.1. The electrodes cups are filled with conductive gel
which serves as an interface between the patient
and the electrode providing a pathway for the
electrical signals.
1.5.2. Surface electrodes are applied by using electrode
paste. Electrode paste is a thick substance which
holds electrodes in place and is easily removed
after the study. The paste should be squeezed from
the tube onto the gauze pad for each electrode.
Press the electrode into the paste to obtain a cap
full leaving the remainder on the gauze to cover
the entire electrode. Press this on the patients
scalp with the gauze over the electrode. Too much
paste can cause the electrode to shift during the
study.
1.6. Facial electrodes are applied using infant pellet
electrodes.
Appendix A.indd 314
1.7. Respiratory sensors include nasal/oral thermocouple
and piezocrystal respiratory effort bands. The leads from
these devices are plugged directly into the electrode jack
box. The thermocouple should be placed directly in the
path of the patients oral and nasal outflow tracts. They
should be secured in place with tape.
1.8. The pressure transducer should be applied in a fashion
similar to nasal cannula oxygen in order to monitor nasal
pressure. Exact sensor location should be obtained from
the transducer package instructions.
1.9. Leg EMG electrodes are placed in close proximity of the
ridge of the anterior tibialis muscle. The leads are taped
to the patients leg and routed through the patients bed-
clothes. They are then plugged into the jack box.
1.10. Oximetry is used for measuring and recording blood oxy-
gen saturation levels. A probe is attached to the patients
finger. It is then plugged into the appropriate socket.
1.11. Intercostal EMG electrodes (if used) are placed in the
area over the respiratory muscles. They should be placed
in close proximity to each other.
1.12. The snoring sensor should be placed to the side of the
larynx.
1.13. Electrode leads should be plugged into the electrode jack
box in the appropriate pen sockets. The jack box should
be placed in the jack box holder.
1.14. Impedances should be checked. If unable to achieve read-
ings below 30 kW without overscrubbing the electrode
sites, try to balance the impedances between the two loca-
tions. This will help minimize artifact caused by voltage
imbalances between two similar electrode locations.
8/6/2009 5:10:10 PM
 Patient Calibrations
APPENDIX for Nighttime
Polysomnography
B James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD
Monica Henderson, RN, RPSGT

1. Patient calibrations are performed before the start of each 1.6. Ask the patient to smile, or grit his or her teeth, or make
test to verify that all the channels being recorded are work- a chewing motion.
ing properly. The patient should be instructed to do these 1.7. Ask the patient to point the toes on his or her left foot
simple exercises. As these are done, the commands should only, toward the end of the bed.
be clearly documented on the recording. If a piece of equip- 1.8. Ask the patient to point the toes on his or her right foot
ment is malfunctioning, it should be repaired prior to the only, toward the end of the bed.
start of the test. Occasionally, a patient may be so sleepy 1.9. Ask the patient breathe through his or her nose only for
that he or she is unable to stay awake during the pretrials; 30 seconds.
when these situations occur, the technician should docu- 1.10. Ask the patient to breathe through his or her mouth
ment that the patient is unable to complete the pretrials and only for 30 seconds.
use better judgment as to what pieces of equipment need to 1.11. Ask the patient to hold his or her breath for 10 seconds.
be repaired. 1.12. If a snore sensor is being used, ask the patient to make
1.1. Ask the patient to relax with his or her eyes open and three snoring noises.
stare straight ahead for 30 seconds. 1.13. Abbreviations
1.2. With eyes open, move your eyes to the L, R, L, R, U, D, 1.13.1. L = left
U, D. 1.13.2. R = right
1.3. Ask the patient to close his or her eyes for 30 seconds. 1.13.3. U = up
1.4. With eyes closed, move your eyes to the L, R, L, R, U, D, 1.13.4. D = down
U, D.
1.5. Ask the patient to open his or her eyes and then to blink
three times.

315

Appendix B.indd 315 8/6/2009 5:10:36 PM

Appendix B.indd 316 8/6/2009 5:10:37 PM
 APPENDIX
Multiple Sleep Latency
Test (MSLT) Protocol
C James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD
Betty Seals, REEGT
1.1. The MSLT should be conducted at the sleep laboratory
following the polysomnogram or CPAP retitration.
1.2. The night postsleep questionnaire, immediately following 1.10.
the patients arising in the morning, should be completed.
1.3. The patients arising time should be noted on the night 1.11.
summary sheet, which is completed by the night tech-
nologist near the end of the overnight polysomnogram 1.12.
or CPAP retitration. 1.13.
1.4. After completion of the polysomnogram, airflow, respi-
ratory monitoring devices, chest respiration belts, oxime-
ter probe, and limb EMG electrodes should be removed 1.14.
as well as any loose scalp or facial electrodes.
1.5. The technologist conducting the MSLT is responsible 1.15.
for replacing necessary electrodes as well as measuring
impedances on those left attached.
1.6. The daytime technologist conducting the MSLT upon 1.16.
arriving should introduce his/her self, explain the days
itinerary and other necessary information, and answer
any appropriate questions the patient may have. 1.17.
1.7. Patients may freshen up and attend to minimum daily
personal routines.
1.8. A urine drug screen should be obtained.
1.9. REM suppressant medications and stimulant medi-
cations, including Provigil/Nuvigil and traditional
Appendix C.indd 317
amphetamine-based medications, should be withdrawn
2 weeks prior to the study if possible.
Sleep logs may be obtained for the one week before the
MSLT to assess the patients recent sleep-wake schedule.
After arising in the morning, the patient should toilet,
dress in street clothes, and eat breakfast.
The MSLT procedure is explained to the patient.
Between naps the patient should be out of bed and con-
tinuously monitored visually by technicians to insure
that no napping occurs.
The first nap begins 1.5 to 3 hours after the ending of the
patients nighttime sleep study and every 2 hours afterward.
Perform five nap opportunities at 2-hour intervals.
A shorter four nap test may be performed if at least two
sleep onset REM periods have occurred.
Patients are not allowed to remain in bed or sleep
between naps. They are not allowed to consume caffeine
during the day.
MSLT Montage
1.17.1. LEOG-A2
1.17.2. REOG-Al
1.17.3. Submental EMG
1.17.4. C3-A2
1.17.5. C4-Al
317
8/6/2009 5:11:14 PM
 318 APPENDIX C
1.17.6. Ol-A2
1.17.7. O2-Al
1.17.8. EKG
1.18. Perform machine and patient calibrations prior to
nap #1.
1.19. A quiet and dark room, conducive to sleep and with
minimal interruptions, should be used. Any noise inter-
ruptions especially those producing arousals or delayed
sleep should be documented.
1.20. No caffeine should be ingested on the day of the test.
1.21. MSLT Instruction Summary
1.21.1. Prior to testing:
1.21.2. Time procedure
1.21.3. 30 minutes: Suspend tobacco smoking
1.21.4. 15 minutes: Subdue physical activity
1.21.5. 10 minutes: Patient prepares for bed and gets
into bed
1.21.6. 6 minutes: Presleep questionnaire, asking the
patient for his subjective opinion of his sleepiness
1.21.7. 4 minutes: Patient hooked up
1.21.8. 2 minutes: Patient calibration, instructing the
patient to get into a comfortable position for
falling asleep, to lie still with eyes closed, and to
try to fall asleep (relax and please lie still, keep
your eyes closed, and let yourself fall asleep). If
the patient uses CPAP, the patient should use the
CPAP during the naps.
1.21.9. 30 seconds: 60 cycle check and good-night phrase
1.21.10. 0 second: Lights out and begin test
1.22. Duration of nap
1.23. End nap after: Condition
1.23.1. 20 minutes: No scorable epochs of sleep
1.23.2. 15 minutes: First scorable epoch of sleep (even if
not until the second epoch of 19th minute)
1.23.3. 20 minutes after first epoch of sleep if first REM
epoch occurs in second epoch of last anticipated
minute before end of nap.
1.24. If the patient has not had a scorable epoch of REM until
the last 4.5 minutes of the nap, the test should be run
another 5 minutes (in other words, add at least 5 minutes
Appendix C.indd 318
from the first page of scorable REM). The maximum
nap time in this scenario could be as long as 40 minutes.
1.25. Sleep onset is defined as
1.25.1. the first page of the first epoch of sleep (whether
stage N1 or a combination of sleep stages).
1.26. The absence of sleep on a nap opportunity is recorded as
a sleep latency of 20 minutes.
1.27. In order to assess the occurrence of REM sleep, the test
continues for 15 minutes after the first recorded epoch
of sleep. The duration of 15 minutes is determined by
clock time and is not determined by a sleep time of
15 minutes. REM latency is the time of the first epoch
of sleep to the beginning of the first epoch of REM
sleep regardless of the intervening stages of sleep or
wakefulness.
1.28. Patient calibration is conducted in the same way as the
nighttime polysomnogram, with the exception of leg
movement and respiratory documentation.
1.28.1. A 50-mV standard calibration is performed for all
recording channels.
1.28.2. The electrodes are visually inspected for good
adherence and any loose electrodes are replaced.
1.28.3. An impedance check is performed and any elec-
trodes more than 10,000W are replaced and
rechecked.
1.28.4. Patient is placed in bed at naptime and equip-
ment plugged in.
1.28.5. Technologist starts polygraph or computer and
makes adjustments in tracing. When tracing is
acceptable, technologist performs the following
patient biocalibrations:
1.28.5.1. Eyes open for 30 seconds
1.28.5.2. Eyes closed for 30 seconds
1.28.5.3. Moving eyes only, look right
1.28.5.4. Moving eyes only, look left
1.28.5.5. Moving eyes only, look up
1.28.5.6. Moving eyes only, look down
1.28.5.7. Blink several times
1.28.5.8. Swallow
1.28.5.9. Grit teeth
8/6/2009 5:11:14 PM

1.29. Knock and enter the patients room, disconnect jack box
from head of bed, and get patient out of bed. Inform
them that they must stay out of bed and awake until the
start of the next nap at approximate (time).
1.30. End of study:
1.30.1. At the end of the last nap, do post test machine
calibrations and turn off polygraph or exit com-
puter.
1.30.2. Gently remove all sensors from patient. Take care
to avoid irritation of patients skin.
1.30.3. Carefully soak each electrode site with warm
water until the electrode lifts away from the
patients skin.
1.30.4. Assure that all paste residue has been removed
by using a wet washcloth on the skin and a fine-
toothed comb after all electrodes have been
removed.
1.30.5. When patient is ready to leave, ask him or her if he
or she has a follow-up appointment. If not, take
him or her to the front desk to schedule a follow-up
and then discharge him or her from the lab.
1.31. After the polysomnogram:
1.31.1. Carefully sort wires and group them together by
lengths and application sites.
1.31.2. Remove any remaining tape and wash elec-
trodes with soap and water, rinse and allow to
soak in disinfectant solution for a minimum
of 10 minutes. Rinse well and allow to dry.
Inspect wires at this time to insure their integ-
rity. Return any equipment and all cleaned
and disinfected wires to their storage area for
future use.
1.32. General cleanup checklist:
1.32.1. Discard all used tape, collars, gauze, etc.
1.32.2. Return patient preparation box to appropriate
area.
1.32.3. Stock patient preparation box as needed.
Appendix C.indd 319
MULTIPLE SLEEP LATENCY TEST (MSLT) PROTOCOL 319
1.32.4. If CPAP and/or oxygen equipment was used,
remove and empty humidifier, connecting tubing,
nasal cannula, and any other equipment and
place in designated dirty equipment area for
cleaning and disinfecting.
1.32.5. Discard disposable equipment such as the nasal
cannula or disposable oximeter probe.
1.32.6. Remove any lint from CPAP equipment filter.
1.32.7. Leave patient suites in clean and orderly
condition.
1.33. Scoring:
1.33.1. Sleep stage scoring should be based on the AASM
scoring guidelines. The sleep latency is deter-
mined from lights out to the first scored epoch
of any stage of sleep. REM latency is scored from
sleep onset to the first epoch of REM. MSLT laten-
cies are based on Guidelines for the multiple
sleep latency test (MSLT): a standard measure of
sleepiness, (1986) by Carskadon et al.
1.34. Amplifier calibration is done at the beginning of the MSLT
and at the end of the day. An all-channel calibration is
done and also an individual amplifier calibration.
1.35. MSLT Report
1.35.1. Should include the start and end times of each
nap or nap opportunity.
1.35.2. Latency from lights out to the first epoch of
sleep.
1.35.3. Mean sleep latency (arithmetic mean of all naps
or nap opportunities).
1.35.4. Number of sleep-onset REM periods (defined
as greater than 15 seconds of REM sleep in a
30-second epoch).
1.36. Reference
Standards of Practice Committee of the AASM. Practice param-
eters for clinical use of the multiple sleep latency test and the
maintenance of wakefulness test. Sleep 28(1):2005.
8/6/2009 5:11:14 PM
Appendix C.indd 320 8/6/2009 5:11:14 PM
 Maintenance of
APPENDIX Wakefulness Test (MWT)
Protocol
D James D. Geyer, MD
Troy A. Payne, MD
Paul R. Carney, MD

1.1. The MWT may be conducted at the sleep laboratory fol-
lowing the polysomnogram or CPAP retitration (based
on the clinical considerations as decided by the sleep
specialist). If the patient does have a sleep study on the
night before the MWT please see 1.21.4.
1.2. The night postsleep questionnaire, immediately following
the patients arising in the morning, may be completed.
1.3. The patients arising time may be noted on the night
summary sheet, which is completed by the night tech-
nologist near the end of the overnight polysomnogram
or CPAP retitration.
1.4. Respiratory monitoring devices and tibialis electrodes
may be removed from the patient as well as any loose
scalp or facial electrodes.
1.5. The technologist conducting the MWT is responsible
for replacing necessary electrodes as well as measuring
impedances on those left attached.
1.6. The daytime technologist conducting the MWT upon
arriving may introduce his/her self, explain the days
itinerary and other necessary information, and answer
any appropriate questions the patient may have.
1.7. Patients may freshen up and attend to minimum daily
personal routines.
1.8. A urine drug screen may be obtained.
1.9. Stimulant medications, including modafanil and tradi-
tional stimulant based medications, may be withdrawn
2 weeks prior to the study if possible unless the study is
being performed to assess the effectiveness of treatment.
1.10. MWT Montage
1.10.1. LEOG-A2
1.10.2. REOG-Al
1.10.3. Submental EMG
1.10.4. C3-A2
1.10.5. C4-Al
1.10.6. Ol-A2
1.10.7. O2-Al
1.10.8. EKG
1.11. Perform machine and patient calibrations prior to nap
#1.
1.12. A quiet and dark room, conducive to sleep and with min-
imal interruptions, may be used. Any noise interruptions
especially those producing arousals or delayed sleep may
be documented.
1.13. No caffeine may be ingested on the day of the test.
1.14. The use of medications and tobacco may be decided on
an individual basis by the sleep specialist.
1.15. The first trial may begin 1.5 to 3 hours after the patients
usual wake-up time.

321

Appendix D.indd 321 8/6/2009 5:13:18 PM

 322 APPENDIX D
1.16. Four 40-minute trials may be run.
1.17. Trials may be run every 2 hours.
1.18. The room may be dark with a light source positioned
slightly behind the patients head, just out of vision. The
light source may deliver an illumination of 0.10 to 0.13
lux at the corneal level (a 7.5 watt night light can be used,
placed one foot off the floor and 3 feet laterally removed
from the patients head).
1.19. MWT instruction summary
1.19.1. Prior to testing:
1.19.2. Time Procedure
1.19.3. 30 minutes: Suspend tobacco smoking
1.19.4. 15 minutes: Subdue physical activity
1.19.5. 10 minutes: Patient prepares for the test (includ-
ing going to the restroom if needed)
1.19.6. 6 minutes: Presleep questionnaire, asking the
patient for his subjective opinion of his sleepi-
ness
1.19.7. 4 minutes: Patient hooked up
1.19.8. 2 minutes: Patient calibration, instructing the
patient to sit in a comfortable chair with the
head supported such that the neck is not uncom-
fortably flexed or extended and to stay awake as
long as possible (relax and please sit still, and
stay awake as long as possible looking straight
ahead but not at the light).
1.19.9. 30 seconds: 60 cycle check and start phrase
1.19.10. 0 second: Begin test
1.20. End a trial after 40 minutes if no sleep is recorded, after
unequivocal sleep (three consecutive epochs of stage N1
sleep), or one epoch of any other stage of sleep.
1.20.1. 40 minutes: No scorable epochs of sleep
Appendix D.indd 322
1.21. Sleep onset is defined as
1.21.1. the first page of the first epoch of sleep (whether
stage N1 or a combination of sleep stages). Sleep
is defined as greater than 15 seconds of cumula-
tive sleep in a 30-second epoch.
1.22. Patient calibration is conducted in the same way as the
night time polysomnogram with the exception of leg
movement and respiratory documentation.
1.23. Amplifier calibration is done at the beginning of the
MWT and at the end of the day. An all channel calibration
is done and also an individual amplifier calibration.
1.24. Clinicians might recommend that patients with a mean
sleep latency on MWT avoid driving or engaging in other
potentially dangerous activities.
1.25. MWT Report
1.25.1. The following data may be noted
1.25.1.1. Start and stop times for each trial.
1.25.1.2. Sleep latency.
1.25.1.3. Total sleep time.
1.25.1.4. Stages of sleep achieved for each trial.
1.25.1.5. Mean sleep latency (the arithmetic
mean of the four trials).
1.26. Reference
Standards of Practice Committee of the AASM. Practice param-
eters for clinical use of the multiple sleep latency test and the
maintenance of wakefulness test. Sleep 28(1):2005.
8/6/2009 5:13:18 PM
 Index

Page numbers in italics denote figures; those followed by a t denote tables.

A Antidepressants, eye movements, 78 unilateral rapid eye movements, 254

Abdominal effort channel, cardioballistic Apnea Artificial eye, unilateral REMs, 254
artifact, 252 central apnea, 1012 (see also Central Atrial fibrillation, 268, 269
Airflow apnea) Atrioventricular block
decreased EKG abnormalities, 263268, 270279 first-degree, 279
flow-limitation arousals (FLA), 12 (see also Electrocardiography (EKG)) third-degree, 274
hypopneas, 1112 mixed apnea, 11 (see also Mixed apnea) Awakening, position change, 79, 86
obstructive apnea, 11 obstructive sleep apnea (OSA), 2, 102105
respiratory effort-related arousals (see also Obstructive sleep apnea B
(RERAs), 12 (OSA)) Baby (see Infant; Neonate)
upper-airway resistance events Arousal Bigeminy, 265, 280
(UARE), 12 alpha waves, 7 Biocalibration
obstructive sleep apnea, 167 central apnea breathing, 19
respiratory monitoring, 8, 10 arousal, 150 eye movements, 18
Alpha-delta sleep post-arousal central apnea, 157, 159 leg movements, 13, 19
alpha activity, 58, 78, 9697 stage R sleep, 150 procedure, 14t
delta activity, 58 decreased airflow Bradycardia
Alpha waves flow-limitation arousals (FLA), 12 central apnea, 12
alpha-delta sleep, 58, 78 respiratory effort-related arousals obstructive sleep apnea, 270, 275276
arousals, 7 (RERAs), 12 Brain tumors, EEG abnormalities, 227229,
frequency range, 2 delta waves, 7, 214215 238239
hypopnea, 143 hypopnea, 166 Breach rhythm, arteriovenous malformation,
NREM sleep, 8 mixed apnea, 119, 158 240
stage N1 sleep, 56, 25, 28, 9394 theta waves, 7 Breathing disorders
stage N2 sleep, 124, 128 wakefulness, 67 cardiac events, 195t
stage N3 sleep, 5860, 9697 Arteriovenous malformation, 240 central apneas
stage R sleep, 6, 6768, 9899 Artifacts Cheyne-Stokes respiration, 154156
stage wake, 5, 2024 cardioballistic artifact, 252253 expanded EEG montage with CO2
Amplifier chest patting, 256 monitoring, 148
common mode rejection ratio (CMRR), face rubbing, 258 intrathoracic pressure monitoring,
301 laptop computer, 257 144145
differential amplifier, 301 swallow artifact, 255 oxygen desaturation, 147, 187
filter, 302 sweat artifact, 259 periodic breathing, 152153

323

Index.indd 323 8/7/2009 1:20:58 PM

 324 INDEX
Breathing disorders (Continued)
periodic limb movements montage, 146
post-arousal central apnea., 157, 159
REM sleep, 149
stage R sleep and arousal, 150
standard montage with CO2
monitoring, 151
ETCO2 monitoring, 188
heart rate, 195t
hypopnea
arousal and movement, 166
CPAP level, 126, 164
intrathoracic pressure (Pes) monitoring,
128129
nasal pressure signal excursion, 185
RIP recording, 181
scoring, 183184
snoring, 162
standard montage, 122125
intrathoracic pressure (Pes) monitoring,
127, 132
mixed apnea
arousal, 158
arousals and minimal oxygen
desaturation, 119
in-phase respiratory effort, 118
oxygen desaturation, 117
paradoxical respiration, 120
respiratory effort, 121
nocturnal seizures, 160
obstructive sleep apnea
arousals, 108
chest wall motion, 109
CPAP level, 104105, 163170
fatigue and fibromyalgia, 186
hypoventilation, 103
in-phase respiratory effort, 111112,
115116
oxygen desaturation, 108, 110
PAP titration, 177179
paradoxical respiration, 106107
phasic REM sleep, 180
pulse oximetry, 102105
respiratory effort and airflow, 167
Index.indd 324
RIP recording, 181182, 182 Chin electromyography
sample report, 189190 bruxism, 210
sawtooth waves, 113114 fighting behavior, 221223
snoring, 137143 hypopnea, 286
CPAP level, 165 obstructive sleep apnea, 112
intrathoracic pressure monitoring, 133 sleep patterns, 8
upper-airway resistance syndrome sleep stage characteristics
intrathoracic pressure (Pes) monitoring, movement arousals, 7
130, 134135 stage N1 sleep, 6
Bruxism, 210211 stage R sleep, 6
stage wake, 5
C snoring, 218
Calibrations stage R sleep identification, 4
breath hold, 289 Common mode rejection ratio (CMRR), 301
calibration sequence, 295 Computer, laptop, artifact from, 257
closed eyes, 293 Confusional arousal, 217
eye movements, 294 Continuous positive airway pressure (CPAP)
foot flex, 291 montage, 161, 304t305t
grit teeth, 290 central apnea, 144, 152154, 156
machine calibrations, 288 complications and responses, 311
open eyes, 292 hypopnea, 162, 164
Carbon dioxide monitoring, 161 maintenance of wakefulness test (MWT), 321
central apnea, 148, 151 multiple sleep latency test (MSLT)
chest patting, 256 protocol, 317, 318
epilepsy, 235 obesity hypoventilation syndrome, 176
staging, 43, 60 obstructive sleep apnea
Cardioballistic artifact, 252253 oxygen desaturation, 175
Central apnea postictal confusion, 236
Cheyne-Stokes respiration, 154156 pulse oximetry, 104105
expanded EEG montage with CO2 stage N1 sleep, 163164, 173174
monitoring, 148 stage N2 sleep, 165, 172, 201, 203,
intrathoracic pressure monitoring, 266268
144145 stage R sleep, 166170, 276
oxygen desaturation, 147, 187 premature ventricular complexes (PVCs),
periodic breathing, 152153 262
periodic limb movements montage, 146 REM sleep, 126
post-arousal central apnea., 157, 159 staging
REM sleep, 149 stage N1 sleep, 2627
stage R sleep and arousal, 150 stage N2 sleep, 34, 42
standard montage with CO2 monitoring, stage N3 sleep, 5557, 60
151 stage N3/N4 sleep, 78
Chest patting artifact, 256 stage R sleep, 6163, 65, 67, 69
Cheyne-Stokes respiration, central apnea, stage wake, 21
154156 upper-airway resistance syndrome, 253
8/7/2009 1:20:58 PM
 INDEX 325

D premature ventricular complexes (PVCs), epilepsia partialis continua

Decreased airflow (see Airflow)
Delta brushes, NREM sleep, 8182
Delta waves
arousals, 7, 214215
chest patting, 256
frequency range, 2
infants and children, 8
seizure, 236
slow-wave activity, 3
stage N1, 238, 239
stage N2 sleep, 6, 42
stage N3 sleep
alpha activity, 5860
characteristics, 6
CPAP montage, 5457
expanded EEG montage, 54, 217
multiple sleep latency test, 96
slow wave sleep, 45
sweat artifact, 310
trac alternant pattern, 83
trace discontinuity, 8182
Differential amplifier, 301
Digital polysomnography
artifacts, 309310 (see also Artifacts)
electrocardiography (see Electrocardiogra-
phy (EKG))
electroencephalography, 14 (see also
Electroencephalography (EEG))
electromyography (EMG), 4
electrooculography (EOG), 1
limb movements (see Limb movements)
nasal and oral airflow, 8 (see also Airflow)
respiratory effect (see Respiratory
effect)
snore sensors, 8
staging, 47, 5t (see also Staging)
E tachycardia, 204206
Electrocardiography (EKG)
atrial fibrillation, 268269
bigeminy, 280
bradycardia, 270, 275276
first-degree AV block, 278279
262264
sinus arrhythmia, 277279
stage wake, 282
tachycardia, 271273, 281, 283286
third-degree AV block, 274
ventricular bigeminy, 265
ventricular quintigeminy, 267
ventricular trigeminy, 266
Electroencephalography (EEG)
abnormalities
arteriovenous malformation, 240
benign rolandic epilepsy, 242
complex partial seizure, 226
epilepsy, 227231, 234236
glioma, 227229, 238239
infantile spasms, 237, 246
juvenile myoclonic epilepsy
(JME), 247
Lennox-Gastaut syndrome, 248
nocturnal seizure, 242
partial seizure activity, 245
partial status epilepticus, 250
seizures, 232233, 243, 249
Turner syndrome, 237
sawtooth waves, 113114, 123
stage wake, 241
Electromyography (EMG), 4
chin EMG
bruxism, 210
fighting behavior, 221223
hypopnea, 286
RLS montage, 218
vibration artifact, 309
frequent leg movement, 207
periodic leg movement
asymmetric, 203
bilateral, 200, 202
unilateral, 198199
Electrooculography (EOG), 1
Epilepsy
benign rolandic epilepsy, 242
CO2 monitoring, 235
(EPC), 245
frontal, 231
intrathoracic pressure monitoring, 234
obstructive apnea, 236
partial status epilepticus, 250
Eye movements, 46, 13, 18, 294
F
Face rubbing artifact, 258
Filters
60 Hz notch filter, 302
CPAP trial, 304t305t
high frequency filter, 302
intrathoracic pressure monitoring,
305t306t
low frequency filter, 302
multiple sleep latency test, 304t
parasomnias, 306t307t
phase shift, 302
REM sleep behavior disorder,
307t308t
settings, 3t
First-degree atrioventricular block, 279
Focal seizures, 232, 233
Fragmentary myoclonus, 201
Frontal epilepsy, 231
G
Glioma
stage N1 sleep, 238239
stage R sleep, 227229
H
Heart rate (see Electrocardiography
(EKG))
High frequency filter, 302
Hypnagogic hypersynchrony, 29
Hypopnea, 122126
arousal and movement, 166
CPAP level, 164
nasal pressure signal excursion, 185
scoring, 183184
snoring, 162

Index.indd 325 8/7/2009 1:20:58 PM

 326 INDEX
I M
Ictal activity, 232233, 236
Infant (see also Neonate)
chest patting, 256
NREM sleep, 85
periodic breathing, 12
sleep staging, 8, 9t
Infantile spasms, 237, 246
Intrathoracic pressure (Pes) monitoring,
127, 132
central apnea, 144145
epilepsy, 234
filters, 305t306t
hypopnea, 128129
montages, 305t306t
negative intrathoracic pressure,
132136
non-rapid eye movement (NREM) sleep,
70, 76
oxygen desaturation, 130, 136
rapid eye movement (REM) sleep, 18, 70,
76
respiratory effort, 127, 136
snoring, 133
upper-airway resistance syndrome, 130,
134135
K Multiple sleep latency test (MSLT)
K complexes, 34, 6 (see also Sleep
spindles)
children, 8
stage N2 sleep
CPAP montage, 34, 42
expanded EEG montage, 3941, 43
standard montage, 37, 200, 226
L wakefulness
Laptop computer, artifact, 257
Left frontal spike and wave, 231
Limb movement disorders, 198207
Limb movements, 195t
periodic (see Periodic limb movement)
Lip quiver, CPAP mask leak, 173, 174
Low frequency filter, 302
Index.indd 326
Maintenance of wakefulness test (MWT)
calibration test, 9091
protocol, 321322
rapid eye movements, 92
wakefulness to stage 1 transition in,
94, 100
Mask leak, CPAP, 172174
Mixed apnea
arousal, 158
arousals and minimal oxygen
desaturation, 119
in-phase respiratory effort, 118
oxygen desaturation, 117
paradoxical respiration, 120
respiratory effort, 121
Montages
for CPAP trial, 304t305t
for intrathoracic pressure monitoring,
305t306t
for multiple sleep latency test, 304t
for parasomnias, 306t307t
for REM sleep behavior disorder,
307t308t
for seizures, 306t307t
for standard polysomnogram, 303t
Movement time (MT), 1
protocol, 317319
stage N1 sleep
slow eye movements, 93
wakefulness to stage 1 transition in,
94, 100
stage N2 sleep, 95
stage N3 sleep, 96, 9697
stage R sleep, 9899
calibration test, 9091
rapid eye movements, 92
Muscle movements
monitoring (see Electromyography
(EMG))
REM sleep, 4
Myoclonus, fragmentary, 201
N
Nasal and oral airflow, 8
Negative intrathoracic pressure, 132136
Neonate (see also Infant)
myoclonic encephalopathy, 244
REM sleep, 84
seizures, 249
Nocturnal seizures, 160, 242
Non-rapid eye movement (NREM) sleep
alpha activity, 8
characteristics, 6
Cheyne-Stokes respirations, 156
chin EMG, 4
desaturation, 11
infants and children, 8
intrathoracic pressure monitoring,
70, 76
movement arousals, 7
periodic breathing, 12
symmetric sleep spindles and
vertex waves, 85
trace discontinuity, 8183
types, 1
O
Obesity hypoventilation syndrome, 176
Obstructive sleep apnea (OSA), 186
arousals and oxygen desaturations, 108
chest wall motion, 109
CPAP montage
oxygen desaturation, 175
postictal confusion, 236
pulse oximetry, 104105
stage N1 sleep, 163164, 173174
stage N2 sleep, 165, 172, 201, 203,
266268
stage R sleep, 166170, 276
hypoventilation, 103
in-phase respiratory effort, 111116
oxygen desaturation, 110
paradoxical respiration, 106107
respiratory effort and airflow, 167
RIP recording, 181182
sample report, 189190
8/7/2009 1:20:58 PM
 INDEX 327

Oxygen desaturation Pes monitoring Posterior dominant alpha activity, 67

central apnea hypopnea, 128 Premature ventricular complexes (PVCs),
periodic breathing, 12 in mixed apnea, 121 262264, 276
stage N2 sleep, 152153, 187 respiratory effort, 127 Pulse oximetry, 171, 175179
stage R sleep, 147149 upper-airway resistance syndrome,
hypopnea, 11 134135 R
stage N2 sleep, 124, 128 Phase shift, 302 Rapid eye movement (REM) sleep, 1
stage R sleep, 123, 125 Phasic REM sleep, 63, 126 (see also Rapid eye alpha activity, 67
intrathoracic pressure monitoring, 130, 136 movement (REM) sleep) behavior disorder, 307t308t
mixed apnea bigeminy, 280 central apnea, 12, 147, 149, 156
stage N1 sleep, 119121, 252 central apnea, 149 characteristics
stage N2 sleep, 117, 277279 obstructive sleep apnea, 167, 180 stage N3 sleep, 6
stage N3 sleep, 118 Polarity, EEG, 2, 301302 stage R sleep, 6
obesity hypoventilation syndrome, 176 Polysomnography stage wake, 5
obstructive sleep apnea artifacts Cheyne-Stokes respiration, 156
CPAP montage, 236 blink artifact, 310 chin EMG, 4
periodic breathing, 12 cardioballistic artifact, 310 CPAP
pulse oximetry, 102103, 175 EEG channel, 309 montage, 63
stage N1 sleep, 162164 electrode pop, 309310 settings, 171
stage N2 sleep, 107109, 111112, 265 humidifier condensation, 310 desaturation, 11
stage R sleep, 106, 110, 114116, 158, loose belt, 310 eye movement recording, 4
167, 270, 276 loose electrode, 309 fighting behavior, 221223
respiratory effort, 126127 misplaced thermocouple artifact, 310 hypopnea, 80, 224
muscle (EMG) artifact, 309 incomplete atonia, 77
P rectus spike artifact, 310311 intrathoracic pressure monitoring, 18, 70, 76
Parasomnias sixty-hertz artifact, 311 latency, 2, 2t
stage N1 sleep swallow artifact, 310 leg movements, 13
bruxism, 210211 sweat artifact, 310 movement arousal, 7
rhythmic movement disorder, 212 vibration, 309 neonate, 84
stage N2 sleep, 216 electrode placement, 313314 obesity hypoventilation syndrome, 176
stage N3 sleep, 214215, 217 patient calibrations, 315 obstructive sleep apnea, 102, 112, 175, 180
stage R sleep, 218224 signal processing parkinsonism, 219
stage wake, 213 common mode rejection ratio (CMRR), phasic and tonic EMG activity, 218
Periodic breathing 301 poliomyelitis, 220
central apnea, 1213 differential amplifier, 301 sawtooth waves, 4, 61, 63, 113114, 123
obstructive apnea, 12 filters, 302 staging
Periodic limb movements polarity, 301302 infants and children, 8
asymmetric, 203 variables, 301 sleep patterns, 8
bilateral, 200, 202 Positive occipital sharp transients (POSTs), 30 Respiratory effort (see also Breathing
central apnea, 146 Post-arousal central apnea disorders)
restless legs syndrome, 207 stage N1 sleep, 157 adult, 11, 12
stage N2 sleep, 200 stage N2 sleep, 159 atrial fibrillation, 268
tachycardia, 204206 stage N3 sleep, 129 bilateral periodic leg movements, 202
unilateral, 198199 stage R sleep, 116, 158, 168 hypopnea, 122, 125, 128

Index.indd 327 8/7/2009 1:20:59 PM

 328 INDEX

Respiratory effort (Continued) architecture, 12, 2t, 191t multiple sleep latency test (MSLT)
intrathoracic pressure (Pes) monitoring, cycles, 1 slow eye movements, 93
127, 136 respiratory monitoring wakefulness to stage 1 transition in,
loud snoring and nocturnal reflux, 185 airflow, 8, 10 94, 100
mixed apnea, 118, 121 arterial oxygen saturation (SaO2), obstructive apnea, 163, 173
monitoring, 810 1011 parasomnias
myocardial infarction, 156 respiratory effort, 10 bruxism, 210211
obstructive apnea, 111116, 167 staging, 1 rhythmic movement disorder, 212
phasic REM sleep, 126, 280 arousal, 67 snoring, 138
seizure activity, 232233 atypical patterns, 78 staging, 2531, 78
snoring, 137138 children, 8 theta waves, 6, 25, 27, 9394
unrefreshing sleep, 131 infants, 8, 9t wakefulness, 6, 25, 28
Restless legs syndrome, 13, 119, 199, 207 stage awake, 5 Stage N2 sleep
Rhythmic movement disorder, 212, 213 stage N1, 56 alpha waves, 124, 128
Right frontal sharp and slow waves, 230 stage N2, 6 central apnea, 144145, 151155, 159, 187
Right hemispheric sharp waves, 226229 stage N3, 6 delta waves, 6, 42
stage R, 6 hypopnea, 122, 124, 128, 184185
S Sleep apnea, obstructive (see Obstructive k complexes, 34, 37, 3943, 200, 226
Sawtooth waves, REM sleep sleep apnea (OSA)) limb movement disorders, 200206
frequency range, 4 Sleep montages (see Montages) mixed apnea, 117
stage R sleep Sleep onset central apnea, 146 multiple sleep latency test (MSLT), 95
CPAP montage, 6163, 65 Sleep spindles myocardial infarction, 181
standard montage, 66, 71, 113114, 123 characteristics, 3 negative intrathoracic pressure, 132
Seizures (see also Epilepsy) children, 8 nocturnal seizures, 160
complex partial, EEG, 226 infants, 8, 85 obstructive sleep apnea, 107109, 111112,
focal seizure, EEG, 232, 233 NREM sleep, 76, 85 170, 172, 174
Lennox-Gastaut syndrome, 248 REM sleep, 76 parasomnias, 216
montage for, 306t307t stage N2 sleep, 6, 3334, 3744, snoring, 133, 137, 139140, 165
myoclonic seizure, 243 95, 226 staging, 3244, 80
neonate, 249 Sleep talking, 215, 216 upper-airway resistance syndrome,
nocturnal, 160 Sleep terrors, 214 134135
Sharp waves Slow waves Stage N3 sleep
medium amplitude, 232, 233 stage N2 sleep, 230 alpha waves, 5860, 9697
right frontal, 230 stage N3 NREM sleep, 6 arousal, 127, 129
right hemispheric, 226 stage R sleep, 227229 delta waves, 6, 45, 5460, 96, 217
Signal processing Snoring, 137143 limb movement disorders, 199
common mode rejection ratio (CMRR), CPAP level, 165 mixed apnea, 118
301 hypopnea, 162 multiple sleep latency test (MSLT), 96,
differential amplifier, 301 tachycardia, 281282 9697
filters, 302 Stage N1 sleep parasomnias, 214215, 217
polarity, 301302 central apnea, 146, 157 snoring, 141143
Sinus arrhythmia, 277279 hypopnea, 162, 163, 183 staging, 4560, 80
Sleep limb movement disorders, 198 theta waves, 215
actigraphy, 298299 mixed apnea, 119121 upper-airway resistance syndrome, 130

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 INDEX 329

Staging U Waves
awake state, 1824, 79, 86 Upper-airway resistance syndrome alpha
continuous mixed frequency background arousal, 7 alpha-delta sleep, 58, 78
activity, 84 stage N1 sleep, 253 arousals, 7
delta brushes, 8183 stage N2 sleep, 134135 frequency range, 2
stage N1 sleep, 2531, 78 stage N3 sleep, 130 hypopnea, 143
stage N2 sleep, 3244, 80 NREM sleep, 8
stage N3 sleep, 4560, 80 V stage N1, 56, 25, 28, 9394
stage R sleep, 6177, 80 Ventricular bigeminy, 265 stage N2 sleep, 124, 128
symmetric sleep spindles and vertex Ventricular quintigeminy, 267 stage N3 sleep, 5860, 9697
waves, 85 Ventricular tachycardia stage R sleep, 6, 6768, 9899
Swallow artifact, 255 central apnea, 284 stage wake, 5, 2024
Sweat artifact, 259 hypopnea, 286 delta
mixed apnea, 273 arousals, 7, 214215
T nasal pressure waveform, 283 chest patting, 256
Tachycardia Ventricular trigeminy, 266 frequency range, 2
central apnea, 148, 283 Vertex waves infants and children, 8
hypopnea, 285286 infant, 85 seizure, 236
mixed apnea, 271273 stage N1 sleep, 6 slow-wave activity, 3
nasal pressure waveform, 283 stage N2 sleep, 3536, 38, 40 stage N1, 238, 239
obstructive sleep apnea, 275276 staging, 3031 stage N2 sleep, 6, 42
periodic leg movements, 204206 stage N3 sleep, 6, 45, 5460, 96, 217
snoring, 281282 W sweat artifact, 310
Teeth grinding, 290, 315 Wakefulness (see also Maintenance of trac alternant pattern, 83
Theta waves wakefulness test (MWT) ) trace discontinuity, 8182
frequency range, 2 alpha activity, 2 sawtooth
movement arousals, 7 alpha-delta sleep, 58 frequency, 4
REM sleep, 4 arousals, 67 REM sleep, 76, 112
seizure activity, 245 biocalibration, 13, 18 stage R sleep, 6, 6162, 6466, 71,
stage N1 sleep, 6, 25, 27, 9394 calibration test, 90 113114, 123
stage N3 sleep, 215 central apnea, 146, 156 theta
stage wake, 23 Cheyne-Stokes respirations, 156 frequency range, 2
trac alternant pattern, 83 claustrophobia, 311 movement arousals, 7
Third-degree atrioventricular block, 274 electromyographic recording, 4 REM sleep, 4
Tonic REM sleep, 61 infants and children, 8 seizure activity, 245
Trac alternant pattern open eyes and rapid eye stage N1 sleep, 6, 25, 27, 9394
delta and theta activity, 83 movements, 21 stage N3 sleep, 215
infants, 8 rapid eye movements, 92 stage wake, 23
Tumors, brain, EEG abnormalities, 227229, restless legs syndrome, 207 trac alternant pattern, 83
238239 slow eye movements, 78 Wide complex tachycardia,
Turner syndrome, 237 stage N1 sleep, 6, 25, 28 271272

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