Ebook Atlas of polysomnography (2/E): Part 2

Part 1 book “Atlas of polysomnography” has contents: Limb movement disorders, parasomnias, electroencephalographic abnormalities, artifacts, electrocardiography, calibrations, actigraphy, technical background, recording artifacts and solving technical problems with polysomnography technology.

CHAPTER 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 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 Chap05.indd 198 8/6/2009 4:13:50 PM 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 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 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 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 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 APPENDIX B Patient Calibrations for Nighttime Polysomnography James D Geyer, MD Troy A Payne, MD Paul R Carney, MD Monica Henderson, RN, RPSGT Patient calibrations are performed before the start of each test to verify that all the channels being recorded are working properly The patient should be instructed to these simple exercises As these are done, the commands should be clearly documented on the recording If a piece of equipment is malfunctioning, it should be repaired prior to the start of the test Occasionally, a patient may be so sleepy that he or she is unable to stay awake during the pretrials; when these situations occur, the technician should document that the patient is unable to complete the pretrials and use better judgment as to what pieces of equipment need to be repaired 1.1 Ask the patient to relax with his or her eyes open and stare straight ahead for 30 seconds 1.2 With eyes open, move your eyes to the L, R, L, R, U, D, U, D 1.3 Ask the patient to close his or her eyes for 30 seconds 1.4 With eyes closed, move your eyes to the L, R, L, R, U, D, U, D 1.5 Ask the patient to open his or her eyes and then to blink three times 1.6 Ask the patient to smile, or grit his or her teeth, or make a chewing motion 1.7 Ask the patient to point the toes on his or her left foot only, toward the end of the bed 1.8 Ask the patient to point the toes on his or her right foot only, toward the end of the bed 1.9 Ask the patient breathe through his or her nose only for 30 seconds 1.10 Ask the patient to breathe through his or her mouth only for 30 seconds 1.11 Ask the patient to hold his or her breath for 10 seconds 1.12 If a snore sensor is being used, ask the patient to make three snoring noises 1.13 Abbreviations 1.13.1 L = left 1.13.2 R = right 1.13.3 U = up 1.13.4 D = down 315 Appendix B.indd 315 8/6/2009 5:10:36 PM Appendix B.indd 316 8/6/2009 5:10:37 PM APPENDIX C Multiple Sleep Latency Test (MSLT) Protocol 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 the patient’s arising in the morning, should be completed 1.3 The patient’s arising time should be noted on the night summary sheet, which is completed by the night technologist near the end of the overnight polysomnogram or CPAP retitration 1.4 After completion of the polysomnogram, airflow, respiratory monitoring devices, chest respiration belts, oximeter probe, and limb EMG electrodes should be removed as well as any loose scalp or facial electrodes 1.5 The technologist conducting the MSLT is responsible for replacing necessary electrodes as well as measuring impedances on those left attached 1.6 The daytime technologist conducting the MSLT upon arriving should introduce his/her self, explain the day’s 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 should be obtained 1.9 REM suppressant medications and stimulant medications, including Provigil/Nuvigil and traditional 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 amphetamine-based medications, should be withdrawn weeks prior to the study if possible Sleep logs may be obtained for the one week before the MSLT to assess the patient’s 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 continuously monitored visually by technicians to insure that no napping occurs The first nap begins 1.5 to hours after the ending of the patient’s nighttime sleep study and every 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 Appendix C.indd 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 interruptions 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 minutes: Presleep questionnaire, asking the patient for his subjective opinion of his sleepiness 1.21.7 minutes: Patient hooked up 1.21.8 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 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 minutes (in other words, add at least minutes Appendix C.indd 318 1.25 1.26 1.27 1.28 from the first page of scorable REM) The maximum nap time in this scenario could be as long as 40 minutes 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) The absence of sleep on a nap opportunity is recorded as a sleep latency of 20 minutes 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 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 electrodes more than 10,000W are replaced and rechecked 1.28.4 Patient is placed in bed at naptime and equipment 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 MULTIPLE SLEEP LATENCY TEST (MSLT) PROTOCOL 1.29 Knock and enter the patient’s 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, post test machine calibrations and turn off polygraph or exit computer 1.30.2 Gently remove all sensors from patient Take care to avoid irritation of patient’s skin 1.30.3 Carefully soak each electrode site with warm water until the electrode lifts away from the patient’s skin 1.30.4 Assure that all paste residue has been removed by using a wet washcloth on the skin and a finetoothed 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 electrodes 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 integrity 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 1.33 1.34 1.35 1.36 319 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 Scoring: 1.33.1 Sleep stage scoring should be based on the AASM scoring guidelines The sleep latency is determined 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 latencies are based on “Guidelines for the multiple sleep latency test (MSLT): a standard measure of sleepiness,” (1986) by Carskadon et al 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 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) Reference Standards of Practice Committee of the AASM Practice parameters 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 APPENDIX D Maintenance of Wakefulness Test (MWT) Protocol James D Geyer, MD Troy A Payne, MD Paul R Carney, MD 1.1 The MWT may be conducted at the sleep laboratory following 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 1.2–1.4 1.2 The night postsleep questionnaire, immediately following the patient’s arising in the morning, may be completed 1.3 The patient’s arising time may be noted on the night summary sheet, which is completed by the night technologist 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 day’s 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 traditional stimulant based medications, may be withdrawn 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 minimal 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 hours after the patient’s 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 hours 1.18 The room may be dark with a light source positioned slightly behind the patient’s 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 feet laterally removed from the patient’s 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 (including going to the restroom if needed) 1.19.6 minutes: Presleep questionnaire, asking the patient for his subjective opinion of his sleepiness 1.19.7 minutes: Patient hooked up 1.19.8 minutes: Patient calibration, instructing the patient to sit in a comfortable chair with the head supported such that the neck is not uncomfortably 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 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 cumulative 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 parameters 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 Abdominal effort channel, cardioballistic artifact, 252 Airflow decreased flow-limitation arousals (FLA), 12 hypopneas, 11–12 obstructive apnea, 11 respiratory effort-related arousals (RERAs), 12 upper-airway resistance events (UARE), 12 obstructive sleep apnea, 167 respiratory monitoring, 8, 10 Alpha-delta sleep alpha activity, 58, 78, 96–97 delta activity, 58 Alpha waves alpha-delta sleep, 58, 78 arousals, frequency range, hypopnea, 143 NREM sleep, stage N1 sleep, 5–6, 25, 28, 93–94 stage N2 sleep, 124, 128 stage N3 sleep, 58–60, 96–97 stage R sleep, 6, 67–68, 98–99 stage wake, 5, 20–24 Amplifier common mode rejection ratio (CMRR), 301 differential amplifier, 301 filter, 302 Antidepressants, eye movements, 78 Apnea central apnea, 10–12 (see also Central apnea) EKG abnormalities, 263–268, 270–279 (see also Electrocardiography (EKG)) mixed apnea, 11 (see also Mixed apnea) obstructive sleep apnea (OSA), 2, 102–105 (see also Obstructive sleep apnea (OSA)) Arousal alpha waves, central apnea arousal, 150 post-arousal central apnea, 157, 159 stage R sleep, 150 decreased airflow flow-limitation arousals (FLA), 12 respiratory effort-related arousals (RERAs), 12 delta waves, 7, 214–215 hypopnea, 166 mixed apnea, 119, 158 theta waves, wakefulness, 6–7 Arteriovenous malformation, 240 Artifacts cardioballistic artifact, 252–253 chest patting, 256 face rubbing, 258 laptop computer, 257 swallow artifact, 255 sweat artifact, 259 unilateral rapid eye movements, 254 Artificial eye, unilateral REMs, 254 Atrial fibrillation, 268, 269 Atrioventricular block first-degree, 279 third-degree, 274 Awakening, position change, 79, 86 B Baby (see Infant; Neonate) Bigeminy, 265, 280 Biocalibration breathing, 19 eye movements, 18 leg movements, 13, 19 procedure, 14t Bradycardia central apnea, 12 obstructive sleep apnea, 270, 275–276 Brain tumors, EEG abnormalities, 227–229, 238–239 Breach rhythm, arteriovenous malformation, 240 Breathing disorders cardiac events, 195t central apneas Cheyne-Stokes respiration, 154–156 expanded EEG montage with CO2 monitoring, 148 intrathoracic pressure monitoring, 144–145 oxygen desaturation, 147, 187 periodic breathing, 152–153 323 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, 128–129 nasal pressure signal excursion, 185 RIP recording, 181 scoring, 183–184 snoring, 162 standard montage, 122–125 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, 104–105, 163–170 fatigue and fibromyalgia, 186 hypoventilation, 103 in-phase respiratory effort, 111–112, 115–116 oxygen desaturation, 108, 110 PAP titration, 177–179 paradoxical respiration, 106–107 phasic REM sleep, 180 pulse oximetry, 102–105 respiratory effort and airflow, 167 Index.indd 324 RIP recording, 181–182, 182 sample report, 189–190 sawtooth waves, 113–114 snoring, 137–143 CPAP level, 165 intrathoracic pressure monitoring, 133 upper-airway resistance syndrome intrathoracic pressure (Pes) monitoring, 130, 134–135 Bruxism, 210–211 C Calibrations breath hold, 289 calibration sequence, 295 closed eyes, 293 eye movements, 294 foot flex, 291 grit teeth, 290 machine calibrations, 288 open eyes, 292 Carbon dioxide monitoring, 161 central apnea, 148, 151 chest patting, 256 epilepsy, 235 staging, 43, 60 Cardioballistic artifact, 252–253 Central apnea Cheyne-Stokes respiration, 154–156 expanded EEG montage with CO2 monitoring, 148 intrathoracic pressure monitoring, 144–145 oxygen desaturation, 147, 187 periodic breathing, 152–153 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 Chest patting artifact, 256 Cheyne-Stokes respiration, central apnea, 154–156 Chin electromyography bruxism, 210 fighting behavior, 221–223 hypopnea, 286 obstructive sleep apnea, 112 sleep patterns, sleep stage characteristics movement arousals, stage N1 sleep, stage R sleep, stage wake, snoring, 218 stage R sleep identification, Common mode rejection ratio (CMRR), 301 Computer, laptop, artifact from, 257 Confusional arousal, 217 Continuous positive airway pressure (CPAP) montage, 161, 304t–305t central apnea, 144, 152–154, 156 complications and responses, 311 hypopnea, 162, 164 maintenance of wakefulness test (MWT), 321 multiple sleep latency test (MSLT) protocol, 317, 318 obesity hypoventilation syndrome, 176 obstructive sleep apnea oxygen desaturation, 175 postictal confusion, 236 pulse oximetry, 104–105 stage N1 sleep, 163–164, 173–174 stage N2 sleep, 165, 172, 201, 203, 266–268 stage R sleep, 166–170, 276 premature ventricular complexes (PVCs), 262 REM sleep, 126 staging stage N1 sleep, 26–27 stage N2 sleep, 34, 42 stage N3 sleep, 55–57, 60 stage N3/N4 sleep, 78 stage R sleep, 61–63, 65, 67, 69 stage wake, 21 upper-airway resistance syndrome, 253 8/7/2009 1:20:58 PM INDEX D Decreased airflow (see Airflow) Delta brushes, NREM sleep, 81–82 Delta waves arousals, 7, 214–215 chest patting, 256 frequency range, infants and children, seizure, 236 slow-wave activity, stage N1, 238, 239 stage N2 sleep, 6, 42 stage N3 sleep alpha activity, 58–60 characteristics, CPAP montage, 54–57 expanded EEG montage, 54, 217 multiple sleep latency test, 96 slow wave sleep, 45 sweat artifact, 310 tracé alternant pattern, 83 trace discontinuity, 81–82 Differential amplifier, 301 Digital polysomnography artifacts, 309–310 (see also Artifacts) electrocardiography (see Electrocardiography (EKG)) electroencephalography, 1–4 (see also Electroencephalography (EEG)) electromyography (EMG), electrooculography (EOG), limb movements (see Limb movements) nasal and oral airflow, (see also Airflow) respiratory effect (see Respiratory effect) snore sensors, staging, 4–7, 5t (see also Staging) E Electrocardiography (EKG) atrial fibrillation, 268–269 bigeminy, 280 bradycardia, 270, 275–276 first-degree AV block, 278–279 Index.indd 325 premature ventricular complexes (PVCs), 262–264 sinus arrhythmia, 277–279 stage wake, 282 tachycardia, 271–273, 281, 283–286 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, 227–231, 234–236 glioma, 227–229, 238–239 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, 232–233, 243, 249 Turner syndrome, 237 sawtooth waves, 113–114, 123 stage wake, 241 Electromyography (EMG), chin EMG bruxism, 210 fighting behavior, 221–223 hypopnea, 286 RLS montage, 218 vibration artifact, 309 frequent leg movement, 207 periodic leg movement asymmetric, 203 bilateral, 200, 202 tachycardia, 204–206 unilateral, 198–199 Electrooculography (EOG), Epilepsy benign rolandic epilepsy, 242 CO2 monitoring, 235 325 epilepsia partialis continua (EPC), 245 frontal, 231 intrathoracic pressure monitoring, 234 obstructive apnea, 236 partial status epilepticus, 250 Eye movements, 4–6, 13, 18, 294 F Face rubbing artifact, 258 Filters 60 Hz notch filter, 302 CPAP trial, 304t–305t high frequency filter, 302 intrathoracic pressure monitoring, 305t–306t low frequency filter, 302 multiple sleep latency test, 304t parasomnias, 306t–307t phase shift, 302 REM sleep behavior disorder, 307t–308t settings, 3t First-degree atrioventricular block, 279 Focal seizures, 232, 233 Fragmentary myoclonus, 201 Frontal epilepsy, 231 G Glioma stage N1 sleep, 238–239 stage R sleep, 227–229 H Heart rate (see Electrocardiography (EKG)) High frequency filter, 302 Hypnagogic hypersynchrony, 29 Hypopnea, 122–126 arousal and movement, 166 CPAP level, 164 nasal pressure signal excursion, 185 scoring, 183–184 snoring, 162 8/7/2009 1:20:58 PM 326 INDEX I Ictal activity, 232–233, 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, 144–145 epilepsy, 234 filters, 305t–306t hypopnea, 128–129 montages, 305t–306t negative intrathoracic pressure, 132–136 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, 134–135 K K complexes, 3–4, (see also Sleep spindles) children, stage N2 sleep CPAP montage, 34, 42 expanded EEG montage, 39–41, 43 standard montage, 37, 200, 226 L Laptop computer, artifact, 257 Left frontal spike and wave, 231 Limb movement disorders, 198–207 Limb movements, 195t periodic (see Periodic limb movement) Lip quiver, CPAP mask leak, 173, 174 Low frequency filter, 302 Index.indd 326 M Maintenance of wakefulness test (MWT) calibration test, 90–91 protocol, 321–322 rapid eye movements, 92 wakefulness to stage transition in, 94, 100 Mask leak, CPAP, 172–174 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, 304t–305t for intrathoracic pressure monitoring, 305t–306t for multiple sleep latency test, 304t for parasomnias, 306t–307t for REM sleep behavior disorder, 307t–308t for seizures, 306t–307t for standard polysomnogram, 303t Movement time (MT), Multiple sleep latency test (MSLT) protocol, 317–319 stage N1 sleep slow eye movements, 93 wakefulness to stage transition in, 94, 100 stage N2 sleep, 95 stage N3 sleep, 96, 96–97 stage R sleep, 98–99 wakefulness calibration test, 90–91 rapid eye movements, 92 Muscle movements monitoring (see Electromyography (EMG)) REM sleep, Myoclonus, fragmentary, 201 N Nasal and oral airflow, Negative intrathoracic pressure, 132–136 Neonate (see also Infant) myoclonic encephalopathy, 244 REM sleep, 84 seizures, 249 Nocturnal seizures, 160, 242 Non-rapid eye movement (NREM) sleep alpha activity, characteristics, Cheyne-Stokes respirations, 156 chin EMG, desaturation, 11 infants and children, intrathoracic pressure monitoring, 70, 76 movement arousals, periodic breathing, 12 symmetric sleep spindles and vertex waves, 85 trace discontinuity, 81–83 types, 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, 104–105 stage N1 sleep, 163–164, 173–174 stage N2 sleep, 165, 172, 201, 203, 266–268 stage R sleep, 166–170, 276 hypoventilation, 103 in-phase respiratory effort, 111–116 oxygen desaturation, 110 paradoxical respiration, 106–107 respiratory effort and airflow, 167 RIP recording, 181–182 sample report, 189–190 8/7/2009 1:20:58 PM INDEX Oxygen desaturation central apnea periodic breathing, 12 stage N2 sleep, 152–153, 187 stage R sleep, 147–149 hypopnea, 11 stage N2 sleep, 124, 128 stage R sleep, 123, 125 intrathoracic pressure monitoring, 130, 136 mixed apnea stage N1 sleep, 119–121, 252 stage N2 sleep, 117, 277–279 stage N3 sleep, 118 obesity hypoventilation syndrome, 176 obstructive sleep apnea CPAP montage, 236 periodic breathing, 12 pulse oximetry, 102–103, 175 stage N1 sleep, 162–164 stage N2 sleep, 107–109, 111–112, 265 stage R sleep, 106, 110, 114–116, 158, 167, 270, 276 respiratory effort, 126–127 P Parasomnias stage N1 sleep bruxism, 210–211 rhythmic movement disorder, 212 stage N2 sleep, 216 stage N3 sleep, 214–215, 217 stage R sleep, 218–224 stage wake, 213 Periodic breathing central apnea, 12–13 obstructive apnea, 12 Periodic limb movements asymmetric, 203 bilateral, 200, 202 central apnea, 146 restless legs syndrome, 207 stage N2 sleep, 200 tachycardia, 204–206 unilateral, 198–199 Index.indd 327 Pes monitoring hypopnea, 128 in mixed apnea, 121 respiratory effort, 127 upper-airway resistance syndrome, 134–135 Phase shift, 302 Phasic REM sleep, 63, 126 (see also Rapid eye movement (REM) sleep) bigeminy, 280 central apnea, 149 obstructive sleep apnea, 167, 180 Polarity, EEG, 2, 301–302 Polysomnography artifacts blink artifact, 310 cardioballistic artifact, 310 EEG channel, 309 electrode pop, 309–310 humidifier condensation, 310 loose belt, 310 loose electrode, 309 misplaced thermocouple artifact, 310 muscle (EMG) artifact, 309 rectus spike artifact, 310–311 sixty-hertz artifact, 311 swallow artifact, 310 sweat artifact, 310 vibration, 309 electrode placement, 313–314 patient calibrations, 315 signal processing common mode rejection ratio (CMRR), 301 differential amplifier, 301 filters, 302 polarity, 301–302 variables, 301 Positive occipital sharp transients (POSTs), 30 Post-arousal central apnea stage N1 sleep, 157 stage N2 sleep, 159 stage N3 sleep, 129 stage R sleep, 116, 158, 168 327 Posterior dominant alpha activity, 67 Premature ventricular complexes (PVCs), 262–264, 276 Pulse oximetry, 171, 175–179 R Rapid eye movement (REM) sleep, alpha activity, 67 behavior disorder, 307t–308t central apnea, 12, 147, 149, 156 characteristics stage N3 sleep, stage R sleep, stage wake, Cheyne-Stokes respiration, 156 chin EMG, CPAP montage, 63 settings, 171 desaturation, 11 eye movement recording, fighting behavior, 221–223 hypopnea, 80, 224 incomplete atonia, 77 intrathoracic pressure monitoring, 18, 70, 76 latency, 2, 2t leg movements, 13 movement arousal, neonate, 84 obesity hypoventilation syndrome, 176 obstructive sleep apnea, 102, 112, 175, 180 parkinsonism, 219 phasic and tonic EMG activity, 218 poliomyelitis, 220 sawtooth waves, 4, 61, 63, 113–114, 123 staging infants and children, sleep patterns, Respiratory effort (see also Breathing disorders) adult, 11, 12 atrial fibrillation, 268 bilateral periodic leg movements, 202 hypopnea, 122, 125, 128 8/7/2009 1:20:59 PM 328 INDEX Respiratory effort (Continued) intrathoracic pressure (Pes) monitoring, 127, 136 loud snoring and nocturnal reflux, 185 mixed apnea, 118, 121 monitoring, 8–10 myocardial infarction, 156 obstructive apnea, 111–116, 167 phasic REM sleep, 126, 280 seizure activity, 232–233 snoring, 137–138 unrefreshing sleep, 131 Restless legs syndrome, 13, 119, 199, 207 Rhythmic movement disorder, 212, 213 Right frontal sharp and slow waves, 230 Right hemispheric sharp waves, 226–229 S Sawtooth waves, REM sleep frequency range, stage R sleep CPAP montage, 61–63, 65 standard montage, 66, 71, 113–114, 123 Seizures (see also Epilepsy) complex partial, EEG, 226 focal seizure, EEG, 232, 233 Lennox-Gastaut syndrome, 248 montage for, 306t–307t myoclonic seizure, 243 neonate, 249 nocturnal, 160 Sharp waves medium amplitude, 232, 233 right frontal, 230 right hemispheric, 226 Signal processing common mode rejection ratio (CMRR), 301 differential amplifier, 301 filters, 302 polarity, 301–302 Sinus arrhythmia, 277–279 Sleep actigraphy, 298–299 Index.indd 328 architecture, 1–2, 2t, 191t cycles, respiratory monitoring airflow, 8, 10 arterial oxygen saturation (SaO2), 10–11 respiratory effort, 10 staging, arousal, 6–7 atypical patterns, 7–8 children, infants, 8, 9t stage awake, stage N1, 5–6 stage N2, stage N3, stage R, Sleep apnea, obstructive (see Obstructive sleep apnea (OSA)) Sleep montages (see Montages) Sleep onset central apnea, 146 Sleep spindles characteristics, children, infants, 8, 85 NREM sleep, 76, 85 REM sleep, 76 stage N2 sleep, 6, 33–34, 37–44, 95, 226 Sleep talking, 215, 216 Sleep terrors, 214 Slow waves stage N2 sleep, 230 stage N3 NREM sleep, stage R sleep, 227–229 Snoring, 137–143 CPAP level, 165 hypopnea, 162 tachycardia, 281–282 Stage N1 sleep central apnea, 146, 157 hypopnea, 162, 163, 183 limb movement disorders, 198 mixed apnea, 119–121 multiple sleep latency test (MSLT) slow eye movements, 93 wakefulness to stage transition in, 94, 100 obstructive apnea, 163, 173 parasomnias bruxism, 210–211 rhythmic movement disorder, 212 snoring, 138 staging, 25–31, 78 theta waves, 6, 25, 27, 93–94 wakefulness, 6, 25, 28 Stage N2 sleep alpha waves, 124, 128 central apnea, 144–145, 151–155, 159, 187 delta waves, 6, 42 hypopnea, 122, 124, 128, 184–185 k complexes, 34, 37, 39–43, 200, 226 limb movement disorders, 200–206 mixed apnea, 117 multiple sleep latency test (MSLT), 95 myocardial infarction, 181 negative intrathoracic pressure, 132 nocturnal seizures, 160 obstructive sleep apnea, 107–109, 111–112, 170, 172, 174 parasomnias, 216 snoring, 133, 137, 139–140, 165 staging, 32–44, 80 upper-airway resistance syndrome, 134–135 Stage N3 sleep alpha waves, 58–60, 96–97 arousal, 127, 129 delta waves, 6, 45, 54–60, 96, 217 limb movement disorders, 199 mixed apnea, 118 multiple sleep latency test (MSLT), 96, 96–97 parasomnias, 214–215, 217 snoring, 141–143 staging, 45–60, 80 theta waves, 215 upper-airway resistance syndrome, 130 8/7/2009 1:20:59 PM INDEX Staging awake state, 18–24, 79, 86 continuous mixed frequency background activity, 84 delta brushes, 81–83 stage N1 sleep, 25–31, 78 stage N2 sleep, 32–44, 80 stage N3 sleep, 45–60, 80 stage R sleep, 61–77, 80 symmetric sleep spindles and vertex waves, 85 Swallow artifact, 255 Sweat artifact, 259 T Tachycardia central apnea, 148, 283 hypopnea, 285–286 mixed apnea, 271–273 nasal pressure waveform, 283 obstructive sleep apnea, 275–276 periodic leg movements, 204–206 snoring, 281–282 Teeth grinding, 290, 315 Theta waves frequency range, movement arousals, REM sleep, seizure activity, 245 stage N1 sleep, 6, 25, 27, 93–94 stage N3 sleep, 215 stage wake, 23 tracé alternant pattern, 83 Third-degree atrioventricular block, 274 Tonic REM sleep, 61 Tracé alternant pattern delta and theta activity, 83 infants, Tumors, brain, EEG abnormalities, 227–229, 238–239 Turner syndrome, 237 Index.indd 329 U Upper-airway resistance syndrome arousal, stage N1 sleep, 253 stage N2 sleep, 134–135 stage N3 sleep, 130 V Ventricular bigeminy, 265 Ventricular quintigeminy, 267 Ventricular tachycardia central apnea, 284 hypopnea, 286 mixed apnea, 273 nasal pressure waveform, 283 Ventricular trigeminy, 266 Vertex waves infant, 85 stage N1 sleep, stage N2 sleep, 35–36, 38, 40 staging, 30–31 W Wakefulness (see also Maintenance of wakefulness test (MWT) ) alpha activity, alpha-delta sleep, 58 arousals, 6–7 biocalibration, 13, 18 calibration test, 90 central apnea, 146, 156 Cheyne-Stokes respirations, 156 claustrophobia, 311 electromyographic recording, infants and children, open eyes and rapid eye movements, 21 rapid eye movements, 92 restless legs syndrome, 207 slow eye movements, 78 stage N1 sleep, 6, 25, 28 329 Waves alpha alpha-delta sleep, 58, 78 arousals, frequency range, hypopnea, 143 NREM sleep, stage N1, 5–6, 25, 28, 93–94 stage N2 sleep, 124, 128 stage N3 sleep, 58–60, 96–97 stage R sleep, 6, 67–68, 98–99 stage wake, 5, 20–24 delta arousals, 7, 214–215 chest patting, 256 frequency range, infants and children, seizure, 236 slow-wave activity, stage N1, 238, 239 stage N2 sleep, 6, 42 stage N3 sleep, 6, 45, 54–60, 96, 217 sweat artifact, 310 tracé alternant pattern, 83 trace discontinuity, 81–82 sawtooth frequency, REM sleep, 76, 112 stage R sleep, 6, 61–62, 64–66, 71, 113–114, 123 theta frequency range, movement arousals, REM sleep, seizure activity, 245 stage N1 sleep, 6, 25, 27, 93–94 stage N3 sleep, 215 stage wake, 23 tracé alternant pattern, 83 Wide complex tachycardia, 271–272 8/7/2009 1:20:59 PM ... patient Chap06.indd 22 4 8/6 /20 09 4:15:35 PM CHAPTER Electroencephalographic Abnormalities James D Geyer, MD Troy A Payne, MD Paul R Carney, MD 22 5 Chap07.indd 22 5 8/6 /20 09 4:16 :26 PM 22 6 CHAPTER * FIGURE... typical of REM sleep behavior disorder Chap06.indd 22 2 8/6 /20 09 4:15:31 PM PARASOMNIAS 22 3 FIGURE 6-14 Polysomnogram: Standard montage; 30-second page Clinical: 62- year-old man with a history of “fighting... epochs of REM sleep in patients with REM sleep behavior disorder Chap06.indd 22 1 8/6 /20 09 4:15 :29 PM 22 2 CHAPTER FIGURE 6-13 Polysomnogram: Standard montage; 30-second page Clinical: 62- year-old