AASM Scoring Manual Version 2.4 Berry Et Al. 2017

The AASM Manual
for the Scoring of Sleep

and Associated Events
RULES, TERMINOLOGY AND TECHNICAL SPECIFICATIONS
VERSION 2.4
Richard B. Berry, MD (Chair); Rita Brooks, MEd, RST, RPSGT; Charlene E. Gamaldo, MD;
Susan M. Harding, MD; Robin M. Lloyd, MD; Stuart F. Quan, MD; Matthew M. Troester, DO;
Bradley V. Vaughn, MD; for the American Academy of Sleep Medicine
American Academy of Sleep Medicine, Darien, IL
All Content © 2017 American Academy of Sleep Medicine AASM | Scoring Manual Version 2.4 1
Copyright © 2017 American Academy of Sleep Medicine, 2510 North Frontage Road, Darien, IL 60561, U.S.A.
Yearly subscriptions to the online manual are available at www.aasmnet.org.
All rights reserved. Unauthorized reproduction or transmission of this manual or any portion thereof in any
form or by any means, mechanical or electronic, is strictly prohibited.
Correspondence regarding copyright permissions should be directed to the American Academy of Sleep
Medicine, 2510 North Frontage Road, Darien, IL 60561, U.S.A. Translations to other languages must be
authorized by the American Academy of Sleep Medicine, U.S.A.
Recommended Citation:
Berry RB, Brooks R, Gamaldo CE, et al.; for the American Academy of Sleep Medicine. The AASM Manual
for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Version 2.4.
Darien, IL: American Academy of Sleep Medicine; 2017.
2 AASM | Scoring Manual Version 2.4 All Content © 2017 American Academy of Sleep Medicine
Table of Contents
Contributors 4
Preface 6
I. User Guide 7
II. Parameters to be Reported for Polysomnography 8
III. Technical and Digital Specifications 12
IV. Sleep Staging Rules

Part 1: Rules for Adults 17
Part 2: Rules for Children 33
Part 3: Rules for Infants 37
V. Arousal Rule 46
VI. Cardiac Rules 47
VII. Movement Rules 49
VIII. Respiratory Rules

Part 1: Rules for Adults 56
Part 2: Rules for Children 62
IX. Home Sleep Apnea Testing (HSAT) Rules for Adults

Part 1: HSAT Utilizing Respiratory Flow and/or Effort Parameters 66
Part 2: HSAT Utilizing Peripheral Arterial Tonometry (PAT) 71
X. Development Process 74
XI. Procedural Notes 75
XII. Glossary of Terms 87
Contributors Karl Doghramji, MD
Thomas Jefferson University, Philadelphia, PA
Ronald D. Chervin, MD, MS
University of Michigan, Ann Arbor, MI
Timothy Roehrs, PhD Meir Kryger, MD

Wayne State University, Detroit, MI University of Manitoba, Winnipeg, MB Canada
Editors Stephen Sheldon, DO, FAAP Clete A. Kushida, MD, PhD, RPSGT
Children’s Memorial Hospital, Chicago, IL Stanford University, Stanford, CA
VERSION 2.4 (2017) Edward J. Stepanski, PhD Beth A. Malow, MD, MS
Richard B. Berry, MD, Chair Rush University Medical Center, Chicago, IL Vanderbilt University, Nashville, TN
Rita Brooks, MEd, RST, RPSGT Arthur S. Walters, MD Michael H. Silber, MBChB
Charlene E. Gamaldo, MD NJ Neuroscience Institute at JFK Medical Center, Mayo Clinic College of Medicine, Rochester, MN
Susan M. Harding, MD Edison, NJ
Michael V. Vitello, PhD
Robin M. Lloyd, MD Merrill S. Wise, MD University of Washington, Seattle, WA
Stuart F. Quan, MD Methodist Healthcare Sleep Disorders Center,
Andrew L. Chesson Jr, MD
Matthew M. Troester, DO Memphis, TN
LSU Health Sciences Center in Shreveport,
Bradley V. Vaughn, MD Andrew L. Chesson Jr, MD Shreveport, LA
Sherene M. Thomas, PhD, Staff LSU Health Sciences Center in Shreveport,
Shreveport, LA GERIATRIC
VERSION 2.0.2–2.3 (2013–2016)
Sonia Ancoli-Israel, PhD, Chair
Richard B. Berry, MD CARDIAC University of California, San Diego, CA
Rita Brooks, MEd, RST, RPSGT Sean M. Caples, DO, Chair
Donald L. Bliwise, PhD
Charlene E. Gamaldo, MD Mayo Clinic College of Medicine, Rochester, MN
Emory University Medical School, Atlanta, GA
Susan M. Harding, MD Virend K. Somers, MD, PhD, Co-Chair
Robin M. Lloyd, MD Susan Redline, MD, MPH
Mayo Clinic College of Medicine, Rochester, MN
Case Western Reserve University, Cleveland, OH
Carole L. Marcus, MBBCh
Michael E. Adams, Research Associate
Bradley V. Vaughn, MD Edward Stepanski, PhD
Holston Valley Medical Center, Kingsport, TN
Rush University Medical Center, Chicago, IL
VERSION 2.0–2.0.1 (2012–2013) William G. Cotts, MD Michael V. Vitiello, PhD
Richard B. Berry, MD Northwestern University, Chicago, IL University of Washington, Seattle, WA
Rita Brooks, MEd, RST, RPSGT Parvin Dorostkar, MD Timothy I. Morgenthaler, MD
Charlene E. Gamaldo, MD Rainbow Babies and Children’s Hospital, Mayo Clinic College of Medicine, Rochester, MN
Susan M. Harding, MD Cleveland, OH
Carole L. Marcus, MBBCh Thomas Kara, MD MOVEMENTS
Bradley V. Vaughn, MD Mayo Clinic College of Medicine, Rochester, MN Arthur S. Walters, MD, Chair
FIRST EDITION (2007–2011) JFK Medical Center, Edison, NJ
Timothy I. Morgenthaler, MD
Conrad Iber, MD Mayo Clinic College of Medicine, Rochester, MN Richard P. Allen, PhD
Sonia Ancoli-Israel, PhD Johns Hopkins University, Baltimore, MD
Carol L. Rosen, MD
Andrew L. Chesson Jr, MD Rainbow Babies and Children’s Hospital, Donald L. Bliwise, PhD
Stuart F. Quan, MD Cleveland, OH Emory University Medical School, Atlanta, GA
Edward J. Stepanski, PhD Sudhansu Chokroverty, MD, FRCP
Rush University Medical Center, Chicago, IL
Consultants NJ Neuroscience Institute at JFK Medical Center,
Edison, NJ
Win K. Shen, MD
Mayo Clinic College of Medicine, Rochester, MN Wayne A. Hening, MD, PhD
VERSION 2.2 (2014–2015) UMDNJ - RW Johnson Medical School, New
Kalyanam Shivkumar, MD
Brunswick, NJ
INFANT SLEEP STAGING David Geffen School of Medicine at UCLA,
Madeleine Grigg-Damberger, MD Los Angeles, CA Clete A. Kushida, MD, PhD, RPSGT
University of New Mexico School of Medicine, Stanford University, Stanford, CA
Conrad Iber, MD
Albuquerque, NM Hennepin County Medical Center and University Gilles Lavigne, DMD, PhD, FRCD
of Minnesota Medical School, Minneapolis, MN Universite de Montreal Sleep Disorder Laboratory,
Mark S. Scher, MD
Case Western Reserve University, Cleveland, OH Sacre Coeur Hospital, Montreal, QC Canada
DIGITAL
Daniel Picchietti, MD
Thomas Penzel, PhD, Chair University of Illinois, Urbana, IL
Task Forces University Hospital, Department of Medicine,
Sonia Ancoli-Israel, PhD
Sleep Laboratory, Marburg, Germany
University of California, San Diego, CA
FIRST EDITION (2007–2011) Max Hirshkowitz, PhD, Co-Chair
Baylor College of Medicine and VAMC, PEDIATRIC
AROUSAL Houston, TX
Madeleine Grigg-Damberger, MD, Chair
Michael H. Bonnet, PhD, Chair Nic Butkov, RPSGT University of New Mexico School of Medicine,
Wright State University, Dayton, OH School of Clinical Polysomnography, Medford, OR Albuquerque, NM
David Gozal, MD, Co-Chair Sonia Ancoli-Israel, PhD
University of Louisville, Louisville, KY University of California, San Diego, CA
Carole L. Marcus, MBBCh Michael H. Bonnet, PhD

University of Pennsylvania, Philadelphia, PA Wright State University, Dayton, OH
Timothy I. Morgenthaler, MD Sudhansu Chokroverty, MD, FRCP

Mayo Clinic College of Medicine, Rochester, MN NJ Neuroscience Institute at JFK Medical Center,
Edison, NJ
Carol L. Rosen, MD
Rainbow Babies and Children’s Hospital, Madeleine Grigg-Damberger, MD
Cleveland, OH University of New Mexico School of Medicine,
Albuquerque, NM
Stephen Sheldon, DO, FAAP
Children’s Memorial Hospital, Chicago, IL Max Hirshkowitz, PhD
Baylor College of Medicine and VAMC,
Stuart F. Quan, MD Houston, TX
Brigham and Women’s Hospital and Harvard
Sheldon Kapen, MD
Medical School, Boston, MA
Wayne State University Medical School and
VAMC, Detroit, MI
RESPIRATORY
Sharon Keenan, PhD, ABSM, RPSGT, REEGT
Richard B. Berry, MD, Chair
The School for Sleep Medicine, Inc., Palo Alto, CA
University of Florida Health Science Center,
Gainsville, FL Meir Kryger, MD
University of Manitoba, Winnipeg, MB Canada
University of Pennsylvania, Philadelphia, PA Thomas Penzel, PhD
University Hospital, Department of Medicine,
Sairam Parthasarathy, MD Sleep Laboratory, Marburg, Germany
SAVAHCS and University of Arizona, Tucson, AZ
Mark Pressman, PhD
Conrad Iber, MD Lankenau and Paoli Hospitals, Wynnewood, PA
Hennepin County Medical Center and University
of Minnesota Medical School, Minneapolis, MN Conrad Iber, MD
Hennepin County Medical Center and University
Reena Mehra, MD, MS of Minnesota Medical School, MN
Case Western Reserve University, Cleveland, OH
Daniel J. Gottlieb, MD
VA Boston Healthcare System and Boston Acknowledgements
University School of Medicine, Boston, MA
The American Academy of Sleep Medicine
Kingman Strohl, MD acknowledges the 2016–2017 Board of Directors
Case Western Reserve University, Cleveland, OH that served over the course of this project and
provided direction and support:
Stuart F. Quan, MD
Brigham and Women’s Hospital and Harvard Ronald Chervin, MD, MS
Medical School, Boston, MA Ilene Rosen, MD
Nathaniel Watson, MD, MS
Sally L. Davidson Ward, MD
Kelly Carden, MD
Children’s Hospital of Los Angeles, Keck School of
Medicine, University of Southern California, Los Douglas Kirsch, MD
Angeles, CA David Kristo, MD
Raman Malhotra, MD
David Gozal, MD
Jennifer Martin, PhD
Corner Children’s Hospital and University of
Chicago, Chicago, IL Eric Olson, MD
Kannan Ramar, MD
Vishesh K. Kapur, MD, MPH
James Rowley, MD
UW Medicine Sleep Center, University of
Washington, Seattle, WA Terri Weaver, PhD, RN
Jerome A. Barrett
Rohit Budhiraja, MD Executive Director
Southern Arizona VA Healthcare System, Southern
Arizona, Tucson, AZ All scoring schematics that provide illustration of
sleep staging, respiratory and movement scoring
Susan Redline, MD, MPH rules were provided by Richard B. Berry, MD.
Brigham and Women’s Hospital, Beth Israel
Deaconess Medical Center and Harvard Medical
School, Boston, MA
VISUAL (SLEEP STAGING)

Michael H. Silber, MBChB, Chair
Mayo Clinic College of Medicine, Rochester, MN
Preface
“We’re moving to this integration of biomedicine, information technology, wireless and mobile now — an
era of digital medicine. Even my stethoscope is now digital. And of course, there’s an app for that.”
— Daniel Kraft, physician-scientist, inventor
The publication of The AASM Manual for the Scoring of Sleep and Associated Events in 2007 was a
landmark event and the culmination of thousands of hours of hard work by many dedicated individuals.
The 2007 manual resulted in standardization of sleep monitoring techniques and scoring, improving
uniformity and reliability in the diagnosis and treatment of sleep disorders across different sleep centers.
Nonetheless, advances in sleep monitoring technology and questions concerning interpretation of the
2007 rules form the basis of an initiative put forth by the AASM Board of Directors to once again
update this critical document in sleep medicine.
At the same time, there has been an explosion of digital information technology and devices that has
shifted publication of nearly all documents away from the printed page. This trend toward a digital
format has been accelerated by the conveniences of publishing online, most notably, accessibility at any
location using smartphones, tablets and computers.
Given the need to update the 2007 Scoring Manual and address a changed digital information landscape,
the Board of Directors of the AASM mandated that the scoring manual be published online with regular
updates as necessary. A Scoring Manual Committee was established to oversee the content and to
make recommendations when content changes are indicated, need for clarification exists, there is new
technology or the literature suggests that updates are needed. The major goals for this initial revision
of the scoring manual included conversion to a Web-based format, standardization of structure and
terminology, inclusion of material covered in the scoring manual FAQs from the AASM website, and
updated figures as necessary. In addition, the committee was tasked with incorporating new rules for
scoring respiratory events that resulted from the work of the Sleep Apnea Definitions Task Force.
In true digital format, the first online version of The AASM Scoring Manual for Sleep and Associated
Events was called Version 2.0. Electronic links quickly take the reader to notes and areas of interest.
The scoring manual is accessible not just on the computer, but also on the flexible viewing styles of
mobile technology. Version 2.0 represented the first step in resolving issues and ambiguities in the
scoring of sleep and associated events. This manual is an incremental work in progress, guided by
feedback from the membership and the Board of Directors, which will continue through annual updates.
It is the hope of the Scoring Manual Committee that the online manual will continue to advance the field
of sleep medicine and improve the quality of care for patients with sleep disorders.
2012–2013 AASM S coring M anual Committee:

Richard B. Berry, MD, Chair
Rita Brooks, MEd, RST, RPSGT
Charlene E. Gamaldo, MD
Susan M. Harding, MD
Bradley V. Vaughn, MD
I. User Guide
Organization of the Manual

The AASM Manual for the Scoring of Sleep and Associated Events is designed to guide users through the technical aspects of
conducting routine polysomnography (PSG) testing as well as the analytic scoring and interpretation of PSG results. The rules
for PSG testing and scoring are divided over seven chapters (II–VIII) of the manual. Chapter II specifies all of the parameters
that should be reported in a routine PSG test. Chapter III details the digital and filter settings that are recommended for routine
PSG recording. Chapters IV–VIII provide additional technical specifications as well as scoring rules for the major categories
of testing: sleep staging, arousal, cardiac, movement, and respiratory. Chapter IX provides technical specifications and scoring
rules for home sleep apnea testing including those utilizing respiratory flow and/or effort and those utilizing peripheral arterial
tonometry (PAT). Chapter X (Development Process) details the process by which the rules were developed. An outline of the
evidence level and decision-making process for each rule may be found in chapter XI (Procedural Notes). Lastly, chapter XII is
a glossary of the terminology used throughout the manual.
While the rules in most chapters apply to patients of all ages, rules for adult and pediatric populations are separated in chapters
IV (Sleep Staging Rules) and VIII (Respiratory Rules) due to critical age-specific differences in testing and scoring.
The rules within each chapter are organized into categories designated by an upper case letter. The rules themselves are num-
bered and may have several components that are identified by lower case letters.
IN EACH SECTION, ALONG WITH THE RULES, YOU WILL NOTICE:

The type of rule:

RECOMMENDED These rules are recommended for the routine scoring of in-laboratory
polysomnography or home sleep apnea testing.

ACCEPTABLE These are rules that may be used as alternatives to the recommended rules at the
discretion of the clinician or investigator.

OPTIONAL These are suggested rules for uncommonly encountered events, events not known to
have physiologic significance or events for which there was no consensus decision.
Scoring may be performed at the discretion of the clinician or investigator.
Notes: If applicable, notes are positioned at the end of a category in order to provide additional information that is
critical for carrying out the rules. Rules are followed by superscripts that signify the corresponding note (ex.N1,N2 ).
Sleep Facility Accreditation

AASM sleep facility accreditation requires compliance with all of the rules, definitions, and notes in this manual. According
to the AASM, rules specified to be recommended, acceptable, or optional are all acceptable methods for scoring. Based
on the discretion of the clinician or investigator, a specific center or laboratory may use the acceptable rule in place of the
recommended rule without any risk to accreditation. Optional rules may be followed in addition to the recommended and
acceptable rules without any risk to accreditation. For further information please contact the accreditation department at the
AASM (accreditation@aasmnet.org).
II. Parameters to be Reported for Polysomnography
Recommended parameters must be reported. Optional parameters may be monitored at the
discretion of the clinician or investigator and if monitored, should be reported.
A. General Parameters
1. Electroencephalogram (EEG) derivations RECOMMENDED
2. Electrooculogram (EOG) derivations RECOMMENDED
3. Chin electromyogram (EMG) RECOMMENDED
4. Leg electromyogram (EMG) RECOMMENDED
5. Airflow signals RECOMMENDED
6. Respiratory effort signals RECOMMENDED
7. Oxygen saturation RECOMMENDED
8. Body position RECOMMENDED
9. Electrocardiogram (ECG) RECOMMENDED
B. Sleep Scoring Data
1. Lights out clock time (hr:min) RECOMMENDED
2. Lights on clock time (hr:min) RECOMMENDED
3. Total sleep time (TST; in min) RECOMMENDED
4. Total recording time (TRT; “lights out” to “lights on” in min) RECOMMENDED
5. Sleep latency (SL; lights out to first epoch of any sleep in min) RECOMMENDED
6. Stage R latency (sleep onset to first epoch of Stage R in min) RECOMMENDED
7. Wake after sleep onset (WASO; TRT − SL − TST, in min) N1 RECOMMENDED
8. Percent sleep efficiency (TST / TRT × 100 ) RECOMMENDED
9. Time in each stage (in min) RECOMMENDED
10. Percent of TST in each stage (time in each stage / TST) × 100 RECOMMENDED
Note 1. Wake after sleep onset includes all wake activity, including time out of bed. Time with the patient
disconnected from the recording equipment should be scored as stage W. Brief episodes of sleep during this
time, if they occur, are not considered significant for the stage scoring summary.
C. Arousal Events
1. Number of arousals RECOMMENDED
2. Arousal index (ArI; number of arousals × 60 / TST) RECOMMENDED
D. Cardiac Events
1. Average heart rate during sleep RECOMMENDED
2. Highest heart rate during sleep RECOMMENDED
3. Highest heart rate during recording RECOMMENDED
4. Occurrence of bradycardia (if observed); report lowest heart rate RECOMMENDED
5. Occurrence of asystole (if observed); report longest pause RECOMMENDED
6. Occurrence of sinus tachycardia during sleep (if observed); report highest heart rate RECOMMENDED
7. Occurrence of narrow complex tachycardia (if observed); report highest heart rate RECOMMENDED
8. Occurrence of wide complex tachycardia (if observed); report highest heart rate RECOMMENDED
9. Occurrence of atrial fibrillation (if observed); report average heart rate RECOMMENDED
10. Occurrence of other arrhythmias (if observed); list arrhythmia RECOMMENDED
E. Movement Events
1. Number of periodic limb movements of sleep (PLMS) RECOMMENDED
2. Number of periodic limb movements of sleep (PLMS) with arousals RECOMMENDED
3. PLMS index (PLMSI; PLMS × 60 / TST) RECOMMENDED
4. PLMS arousal index (PLMSArI; PLMS with arousals × 60 / TST) RECOMMENDED
F. Respiratory Events N1
1. Number of obstructive apneas RECOMMENDED
2. Number of mixed apneas RECOMMENDED
3. Number of central apneas RECOMMENDED
4. Number of hypopneas RECOMMENDED
5. Number of obstructive hypopneas OPTIONAL
6. Number of central hypopneas OPTIONAL
7. Number of apneas + hypopneas RECOMMENDED
8. Apnea index (AI; (# obstructive apneas + # central apneas + # mixed apneas) × 60 / TST) RECOMMENDED
9. Hypopnea index (HI; # hypopneas × 60 / TST) RECOMMENDED
10. Apnea-hypopnea index (AHI; (# apneas + # hypopneas) × 60 / TST) RECOMMENDED
11. O
bstructive apnea-hypopnea index (OAHI; (# obstructive apneas + # mixed apneas + OPTIONAL
# obstructive hypopneas) × 60 / TST)
12. Central apnea-hypopnea index (CAHI; (# central apneas + # central hypopneas) × 60 / TST) OPTIONAL
13. Number of respiratory effort-related arousals (RERAs) OPTIONAL
14. Respiratory effort-related arousal index (RERA index; # of RERAs × 60 / TST) OPTIONAL
15. Respiratory disturbance index (RDI; (# apneas + # hypopneas + # RERAs) × 60 / TST) OPTIONAL
16. Number of oxygen desaturations ≥3% or ≥4% N2 OPTIONAL
17. Oxygen desaturation index ≥3% or ≥4% (ODI; # oxygen desaturations ≥3% or ≥4% × 60 / TST) OPTIONAL
18. Arterial oxygen saturation, mean value RECOMMENDED
19. Minimum oxygen saturation during sleep N3 RECOMMENDED
20. Occurrence of hypoventilation during diagnostic study N4
Adults OPTIONAL
Children RECOMMENDED
21. Occurrence of hypoventilation during PAP titration N4
Adults OPTIONAL
Children OPTIONAL
22. Occurrence of Cheyne-Stokes breathing in adults N5 RECOMMENDED
23. Duration of Cheyne-Stokes breathing (absolute or as a percentage of total sleep time) or the RECOMMENDED
number of Cheyne-Stokes breathing events.
24. Occurrence of periodic breathing in children RECOMMENDED
25. Occurrence of snoring OPTIONAL
Note 1. Using supplemental oxygen may cause an underestimation of respiratory events which should be taken into
consideration by the interpreting physician.
Note 2. The criteria used to score a respiratory event as a hypopnea (either rule 1A or 1B) should be specified in the
PSG report.
Note 3. Percent time spent below a given threshold of oxygen desaturation may be reported at the discretion of the
clinician.
Note 4. If electing to measure the arterial PCO2 or surrogate during sleep in cases where it is optional to do so, the
occurrence/absence of hypoventilation must be included in the PSG report.
Note 5. Reporting the occurrence of Cheyne-Stokes breathing in the PSG report is required only if central apneas
and/or central hypopneas are present.
G. Summary Statements
1. Findings related to sleep diagnoses RECOMMENDED
2. EEG abnormalities RECOMMENDED
3. ECG abnormalities RECOMMENDED
4. Behavioral observations RECOMMENDED
5. Sleep hypnogram OPTIONAL
III. Technical and Digital Specifications
A. Digital Specifications for Routine PSG Recordings N1

1. Maximum Electrode Impedances: 5 K Ω N2 RECOMMENDED
2. Minimum Digital Resolution: 12 bits per sample RECOMMENDED
3. Sampling Rates
Desirable Minimal
EEG N3,N4 500 Hz 200 Hz RECOMMENDED
EOG N5 500 Hz 200 Hz RECOMMENDED
EMG N6 500 Hz 200 Hz RECOMMENDED
ECG N7 500 Hz 200 Hz RECOMMENDED
Airflow 100 Hz 25 Hz RECOMMENDED
Oximetry, Transcutaneous PCO2 N8 25 Hz 10 Hz RECOMMENDED
Nasal Pressure, End-Tidal PCO2, PAP Device Flow N9 100 Hz 25 Hz RECOMMENDED
Esophageal Pressure 100 Hz 25 Hz RECOMMENDED
Body Position N10 1 Hz 1 Hz RECOMMENDED
Snoring Sounds N11 500 Hz 200 Hz RECOMMENDED
Rib Cage and Abdominal Movements N12 100 Hz 25 Hz RECOMMENDED
4. Routinely Recorded Filter Settings

Low-Frequency High-Frequency
Filter Filter
EEG N4,N13 0.3 Hz 35 Hz RECOMMENDED
EOG N13 0.3 Hz 35 Hz RECOMMENDED
EMG N6 10 Hz 100 Hz RECOMMENDED
ECG N14 0.3 Hz 70 Hz RECOMMENDED
Oronasal Thermal Flow, Thoracoabdominal Belt Signals 0.1 Hz 15 Hz RECOMMENDED
Direct current (DC)

Nasal Pressure 100 Hz RECOMMENDED
or ≤0.03 Hz
PAP Device Flow DC DC RECOMMENDED
Snoring 10 Hz 100 Hz RECOMMENDED
Note 1. In the absence of clear preferences, use similar settings among leads to simplify technical implementation.
Note 2. This applies to measured EEG and EOG electrode impedance. Electrode impedances should be rechecked
during a recording when any pattern that might be artifactual appears.
Note 3. For EEG, 500 Hz sampling rate could improve resolution of spikes in the EEG and better maintain details of
the waveform.
Note 4. For more detailed EEG analysis, sampling rate and high-frequency filter settings may be increased. In these
circumstances, the sampling rate should be at least 3 times the highest frequency of interest.
Note 5. For EOG, using the 500 Hz desirable EEG sampling rate also allows the reflection of the EEG in this lead as
an EEG backup and may better define some artifacts in these leads.
Note 6. This applies to submental and leg EMG. Higher sampling rates better define waveforms; while the waveform
itself is not an issue, a better-defined waveform can help avoid amplitude attenuation as the envelope of the
rapidly oscillating signal is interpreted.
Note 7. For ECG, 500 Hz sampling rate can better define pacemaker spikes and ECG waveforms, however,
pacemaker spikes can be seen at 200 Hz, and the evaluation of cardiac ischemia by ECG waveform is not
a common PSG issue. Higher frequencies may be required for complex waveform analysis and research
applications.
Note 8. For oximetry, 25 Hz sampling is desirable to assist with artifact evaluation.
Note 9. For nasal pressure transducer technology (especially with settings which identify snoring occurring on top of
the airflow waveform), this higher frequency may be of benefit for better definition of vibration and snoring.
Note 10. The body position channel is exempt from the digital resolution standard. However, the recommended
sampling rate of 1 Hz remains in effect.
Note 11. For snoring sound, 500 Hz sampling rate can better define amplitude variation by clearer waveforms with
more accurate amplitude determination as the envelope of the rapidly oscillating signal is interpreted, (as for
EMG). If a preprocessing of snoring results in a continuous sound loudness level or in a sound intensity level,
then a much lower sampling rate is acceptable. That sampling rate is not specified because it depends on the
preprocessing of the sound in order to produce loudness.
Note 12. For rib cage and abdominal movements using inductance plethysmography, cardiogenic oscillations can be
better seen and may result in better artifact assessment at a higher sampling rate.
Note 13. To accommodate older equipment, filter settings in the range of 30–35 Hz may be used to comply with the
recommendations of 35 Hz. This applies most specifically in the context of EEG and EOG high filter settings.
Note 14. For ECG, low-frequency settings and wide bandwidth minimizes distortion in a 12 lead ECG; however in
PSG recording with single-channel modified lead II used for identifying basic heart rates and dysrhythmias,
it may not be as necessary. Advanced cardiac assessment may be more optimal using a low-frequency filter
of 0.3 Hz for slower parts of the cardiac cycle. The channel is susceptible to artifacts at this setting due to
patient movement, perspiration, muscle activity and electrode displacement. Artifact is less likely at these
settings when standard ECG leads are used for cardiac monitoring.
B. PSG Recording Features
1. A
toggle switch permitting visual (on-screen), standard, negative 50 μV DC calibration
signal for all channels to demonstrate polarity, amplitude and time constant settings for each RECOMMENDED
recorded parameter
2. A separate 50/60 Hz filter control for each channel RECOMMENDED
3. The capability of selecting sampling rates for each channel RECOMMENDED
4. A method of measuring actual individual electrode impedance against a reference (the latter RECOMMENDED
may be the sum of all other applied electrodes)
5. The capability of retaining and viewing the data in the exact manner in which it was
recorded by the attending technologist (i.e., retain and display all derivation changes, RECOMMENDED
sensitivity adjustments, filter settings, temporal resolution)
6. T
he capability of retaining and viewing the data in the exact manner it appeared when it was
scored by the scoring technologist (i.e., retain and display all derivation changes, sensitivity RECOMMENDED
adjustments, filter settings, temporal resolution)
7. A filter design for data collection which functionally simulates or replicates conventional
(analog-style) frequency response curves rather than removing all activity and harmonics RECOMMENDED
within the specified bandwidth
8. A
n electrode selector process with the flexibility for choosing and/or changing electrode OPTIONAL
input signal derivations without relying on a common reference electrode
C. Use Systems with the Following PSG Display and Display Manipulation Features
1. T
he display for scoring and review of sleep study data must meet or exceed the following RECOMMENDED
criteria: 15 inch screen size, 1,600 pixels horizontal and 1,050 pixels vertical
2. Histogram with stage, respiratory events, leg movement events, O2 saturation, and arousals, RECOMMENDED
with cursor positioning on histogram and ability to jump to the page
3. Ability to view a screen on a time scale ranging from the entire night to windows as small as RECOMMENDED
5 seconds
4. Recorded video data must be synchronized with PSG data and have an accuracy of at least RECOMMENDED
one video frame per second
5. Page automatic turning and automatic scrolling OPTIONAL
6. Channel-off control key or toggle OPTIONAL
7. Channel-invert control key or toggle OPTIONAL
8. Change order of channel by click and drag OPTIONAL
9. Display setup profiles (including colors) which may be activated at any time OPTIONAL
10. Fast Fourier Transformation or spectral analysis on specifiable interval (omitting segments OPTIONAL
marked as data artifact)
D. Perform the Following Digital Analyses of PSG
1. A
bility to display whether sleep stage scoring was performed visually or computed by the RECOMMENDED
system
2. Ability to turn off and on, as demanded, highlighting of EEG patterns used to make sleep OPTIONAL
stage decisions (for example sleep spindle, K complex, alpha activity)
3. Ability to turn off and on, as demanded, highlighting of patterns identifying respiratory OPTIONAL
events (for example apneas, hypopneas, desaturations)
4. Ability to turn off and on, as demanded, highlighting of patterns identifying identifying the OPTIONAL
movement analysis (for example PLMs)
E. Perform the Following Calibrations to Document Appropriate System Response N1,N2
1. P
erform and document an impedance check of the EEG, EOG and EMG electrodes N3 RECOMMENDED
2. Record a minimum of 30 seconds of EEG with patient awake lying quietly with eyes open N4 RECOMMENDED
3. Record a minimum of 30 seconds of EEG with patient lying quietly with eyes closed N4 RECOMMENDED
4. Ask the patient to look up and down without moving head ( ×5) RECOMMENDED
5. Ask the patient to look left and right without moving head ( ×5) RECOMMENDED
6. Ask the patient to blink ( ×5) RECOMMENDED
7. Ask the patient to grit teeth and/or chew (5 seconds) N5 RECOMMENDED
8. Ask the patient to simulate a snore or hum (5 seconds) N6 RECOMMENDED
9. A
sk the patient to breathe normally and assure that airflow and effort channel signals are RECOMMENDED
synchronized
10. Ask the patient to perform a breath hold (10 seconds) N7 RECOMMENDED
11. A
sk the patient to breathe normally and upon instruction to take a breath in and OPTIONAL
out—check polarity and mark the record IN and OUT accordingly N7
12. Ask the patient to breathe through the nose only (10 seconds) N7 RECOMMENDED
13. Ask the patient to breathe through the mouth only (10 seconds) N7 RECOMMENDED
14. A
sk the patient to take a deep breath and exhale slowly OPTIONAL
(prolonged expiration—10 seconds) N7
15. Ask the patient to flex the left foot/raise toes on left foot (×5) N8 RECOMMENDED
16. Ask the patient to flex the right foot/raise toes on right foot (×5) N8 RECOMMENDED
17. Ask the patient to flex/extend the fingers on the left hand, as appropriate, if upper extremity OPTIONAL
EMG is recorded N8,N9
18. Ask the patient to flex/extend the fingers on the right hand, as appropriate, if upper OPTIONAL
extremity EMG is recorded N8,N9
19. Adjust EKG signal to provide a clear waveform—the R wave should deflect upward N10 OPTIONAL
20. Perform and document a repeat impedance check of the EEG, EOG and EMG electrodes at RECOMMENDED
the end of the PSG recording N11
21. R
epeat physiological calibrations at the end of the PSG recording N11 RECOMMENDED
Note 1. Perform physiological calibrations for all patients to the extent that the patient is able to cooperate and
complete the requested maneuvers.
Note 2. Document all calibrations. Verify that the signal appropriately responds to the requested patient maneuvers.
Repeat calibrations as needed to document a working signal for all recording parameters.
Note 3. Measured EEG, EOG and EMG channel impedances should be 5 K Ω or less and relatively equal. Limb
EMG impedances of 10 K Ω or less are acceptable, but impedances of 5 K Ω or less are preferred. Recheck
impedances during the recording when any pattern that might be artifact appears.
Note 4. Check EEG channels for blocking, 60 Hz, EKG, and sweat or respiratory artifact and make any necessary
adjustments to assure a readable EEG recording.
Note 5. Adjust chin EMG to an adequate sensitivity while patient is awake. In an awake relaxed patient the chin
EMG signal should be visible (at least 1–2 mm amplitude). During chewing or teeth gritting maneuvers the
chin EMG signal should be at least double the size of the baseline signal.
Note 6. Check the integrity of the snore microphone or sensor by asking the patient to simulate a snore and hum.
Adjust as necessary to provide a clear signal with activity. Activity should be negligible with quiet breathing.
Note 7. Adjust all respiratory channels to provide a large clean signal with each respiration. Observe and document
the signal direction during inhalation and exhalation. Airflow and effort and signals should be in phase with
respect to each other. Adjust belt position to attain a readable signal on all airflow and effort channels. Assure
that airflow and effort signals respond appropriately to a 10 second breath hold.
Note 8. Adjust limb EMG signal to reflect a low background; check signal with bilateral limb movements to verify a
noticeable deflection with movement.
Note 9. If recording the flexor digitorum superficialis, the patient should flex the fingers at the base (avoid bending at
the distal two joints). If recording the extensor digitorum communis, the patient should extend their fingers
back without moving their wrist.
Note 10. Compare heart rate (HR) to EKG signal (heart rate is collected from pulse oximetry) to assure HR accuracy.
Note 11. Repeat the impedance check and physiological calibrations after lights on in the morning.
IV. Sleep Staging Rules Part 1: Rules for Adults
A. Technical Specifications for Electroencephalogram (EEG)

1. The recommended EEG derivations are: N1,N2 RECOMMENDED
a. F4-M1
b. C4-M1
c. O2-M1
Backup electrodes should be placed at F3, C3, O1 and M2 to allow display of F3-M2, C3-M2 and O1-M2 if electrodes
malfunction during the study. (see Figure 1A)
2. Acceptable EEG derivations are: N1,N2,N3 ACCEPTABLE
a. Fz-Cz
b. Cz-Oz
c. C4-M1
Backup electrodes should be placed at Fpz, C3, O1, and M2 to allow substitution of Fpz for Fz, C3 for Cz or C4, O1 for
Oz and M2 for M1 if electrodes malfunction during the study. (see Figure 1B)
3. EEG electrode position is determined by the International 10-20 System. (see Figure 1) RECOMMENDED
A. RECOMMENDED B. ACCEPTABLE
Figure 1. Images
illustrating the placement
of electrodes utilized in
the recommended (A) and
acceptable (B) derivations
for electroencephalography
(EEG) during
polysomnography.
The electrode placement
and nomenclature follow
the International 10-20
System. Illustration may
not be to scale.
© 2017 American Academy of Sleep Medicine. All rights reserved.
Note 1. At a minimum, frontal, central, and occipital derivations (3 EEG channels) are required to stage sleep.
Note 2. M1 and M2 refer to the left and right mastoid processes. M1 is the standard reference electrode for recording
EEG. If M1 fails during the recording, backup electrodes should be used and referenced to M2.
Note 3. Fz-Cz is not appropriate for measuring the amplitude of frontal activity for determination of slow wave
activity. When using the acceptable EEG derivations and the acceptable EOG derivations (Figure 2), the
E1-Fpz derivation should be used to measure frontal slow wave amplitude. Used in this way, Fpz will be the
active electrode recording frontal activity and E1 the reference electrode in a referential derivation. When
using the acceptable EEG derivations and the recommended EOG derivations, EEG amplitude to determine
slow wave activity should be measured using the C4-M1 derivation (C3-M2 if either C4 or M1 electrodes
malfunction). When using the recommended EEG derivations and recommended EOG derivations, the
EEG amplitude is measured using the derivation F4-M1.
B. Technical Specifications for Electrooculogram (EOG)

1. The recommended EOG derivations and electrode positions are: N1 (see Figure 2A) RECOMMENDED
a. Derivations: E1-M2 and E2-M2
b. Electrode positions: E1 is placed 1 cm below and 1 cm lateral to the left outer canthus and E2 is placed 1 cm above and
1 cm lateral to the right outer canthus
2. Acceptable EOG derivations and electrode positions are: N2 (see Figure 2B) ACCEPTABLE
a. Derivations: E1-Fpz and E2-Fpz
b. Electrode positions: E1 is placed 1 cm below and 1 cm lateral to the outer canthus of the left eye and E2 is placed 1 cm
below and 1 cm lateral to the outer canthus of the right eye
A. RECOMMENDED
RIGHT LEFT
E2
outer canthus
outer canthus
E1
= 1 cm
B. ACCEPTABLE
RIGHT LEFT
outer canthus outer canthus
Figure 2.
A. Recommended
E2 and B. acceptable
E1
derivations for
electrooculogram
(EOG). Illustration
may not be to scale.
Note 1. When using the recommended EOG derivations, if the M2 reference electrode fails, E1 and E2 should be
referenced to M1.
Note 2. When using the recommended electrode derivations, conjugate eye movements result in out-of-phase
deflections. The acceptable derivations allow determination of the direction of eye movements, i.e. vertical
movements will show in-phase deflections and horizontal eye movements, out-of-phase deflections.
C. Technical Specifications for Electromyogram (EMG)

1. Three electrodes should be placed to record chin EMG: RECOMMENDED
a. One in the midline 1 cm above the inferior edge of the mandible (see ChinZ in Figure 3)
b. One 2 cm below the inferior edge of the mandible and 2 cm to the right of the midline (see Chin2 in Figure 3)
c. One 2 cm below the inferior edge of the mandible and 2 cm to the left of the midline (see Chin1 in Figure 3)
2. The standard chin EMG derivation consists of either of the electrodes below the mandible referred to the electrode
above the mandible. The other inferior electrode is a backup electrode to allow for continued display of EMG activity
if one of the primary electrodes malfunctions. N1 RECOMMENDED
midline
ChinZ
inferior
edge of the
Chin2 Chin1 mandible Figure 3. Placement of electrodes on
the chin for electromyogram (EMG)
= 1 cm recording. Illustration may not be to
= 2 cm
scale.
Note 1. If EMG electrode ChinZ (above the mandible) fails during the recording, it should be replaced, if possible.
Otherwise, reference electrodes Chin2 and Chin1 (below the mandible) to each other.
D. General Scoring of Sleep Stages

1. The following terminology should be used for the stages of sleep in adults: RECOMMENDED
a. Stage W (Wakefulness)
b. Stage N1 (NREM 1)
c. Stage N2 (NREM 2)
d. Stage N3 (NREM 3)
e. Stage R (REM)N1
2. Score epochs using the following parameters: RECOMMENDED

a. Score sleep stages in 30-second, sequential epochs commencing at the start of the study.
b. Assign a stage to each epoch.
c. If two or more stages coexist during a single epoch, assign the stage comprising the greatest portion of the epoch.
d. When three or more segments of an epoch meet criteria for different stages (stage W, N1, N2, N3, R):
i. Score the epoch as sleep if the majority of the epoch meets criteria for stage N1, N2, N3, or R.
ii. Assign the sleep stage that occurs for the majority of sleep within the epoch. (see Figure 4)
3. Score in accordance with the following definitions for EEG frequencies: RECOMMENDED
a. Slow wave activity: frequency of 0.5–2.0 Hz and peak-to-peak amplitude of >75 µV, measured over the frontal regions
b. Delta waves are 0–3.99 Hz
c. Theta waves are 4–7.99 Hz
d. Alpha waves are 8–13 Hz
e. Beta waves are greater than 13 Hz
K complex
alpha LAMF
Figure 4. In this epoch, there is an
F4-M1 initial segment meeting criteria for
stage W (12 seconds), a second
LAMF
C4-M1 segment meeting criteria for stage
N1 (11 seconds) and a final segment
LAMF meeting criteria for stage N2
O2-M1
(7 seconds). The epoch is scored as
LAMF
sleep as the majority of the epoch is
E1-M2 sleep. The epoch is scored as stage
N1 as the majority of sleep is stage N1.
E2-M2 LAMF
The following epoch would be scored
as stage N2 unless there was evidence
Chin EMG of a shift to another sleep stage. (See
subsequent sections in this chapter for
definitions of alpha rhythm, LAMF, and
5 10 15 20 25
K complex.)
12 11 7
Note 1. When referring to scoring, use the term “Stage R,” and when referring to the physiological state, use the term
“REM sleep” (e.g., REM Sleep Behavior Disorder).
E. Scoring Stage W N1,N2,N3,N4,N5

1. Score in accordance with the following definitions: RECOMMENDED
Alpha rhythm (posterior dominant rhythm in adults and older children): An EEG pattern consisting of trains of
sinusoidal 8–13 Hz activity recorded over the occipital region with eye closure and attenuating with eye opening.
Eye blinks: Conjugate vertical eye movements at a frequency of 0.5–2 Hz present in wakefulness with the eyes open or
closed.
Reading eye movements: Trains of conjugate eye movements consisting of a slow phase followed by a rapid phase in the
opposite direction as the individual reads.
Rapid eye movements (REMs): Eye movements recorded in the EOG derivations consisting of conjugate, irregular,
sharply peaked eye movements with an initial deflection usually lasting <500 msec. While rapid eye movements are
characteristic of stage R sleep, they may also be seen in wakefulness with eyes open when individuals visually scan the
environment.
Slow eye movements (SEM): Conjugate, reasonably regular, sinusoidal eye movements with an initial deflection that
usually lasts >500 msec. Slow eye movements may be seen during eyes closed wake and stage N1.
2. Score epochs as stage W when more than 50% of the epoch contains EITHER 2a or 2b or BOTH:
(see Figure 5) RECOMMENDED
a. Alpha rhythm (posterior dominant rhythm) over the occipital region (individuals generating alpha rhythm with eye
closure)
b. Other findings consistent with stage W (all individuals)
i. Eye blinks (0.5 to 2 Hz)
ii. Rapid eye movements associated with normal or high chin muscle tone
iii. Reading eye movements
100 μV
F4-M1
1 sec
C4-M1
O2-M1
E1-M2
E2-M2
Chin EMG
Note 1. Stage W represents the waking state, ranging from full alertness through early stages of drowsiness.
Electrophysiological and psychophysiological markers of drowsiness may be present during stage W and may
persist into stage N1.
Note 2. In stage W, the majority of individuals with eyes closed will demonstrate alpha rhythm (posterior dominant
rhythm). The EEG pattern with eyes open consists of low-amplitude activity (chiefly beta and alpha
frequencies) without the rhythmicity of alpha rhythm. About 10% of individuals do not generate an alpha
rhythm upon eye closure, and a further 10% may generate a limited alpha rhythm. In these individuals, the
occipital EEG activity is similar during eye opening and eye closure.
Note 3. The EOG during wakefulness may demonstrate rapid eye blinks at a frequency of about 0.5–2 Hz. The
earliest sign of drowsiness is the absence of eye blinks. As drowsiness develops, slow eye movements may
develop, even in the presence of continued posterior dominant rhythm. If the eyes are open, voluntary rapid
eye movements or reading eye movements may be seen.
Note 4. The chin EMG during stage W is of variable amplitude but is usually higher than during sleep stages.
Note 5. Time with the patient disconnected from the recording equipment should be scored as stage W. Brief
episodes of sleep during this time, if they occur, are not considered significant for the stage scoring
summary.
F. Scoring Stage N1
Low-amplitude, mixed-frequency (LAMF) EEG activity: Low-amplitude, predominantly 4–7 Hz activity.
Vertex sharp waves (V waves): Sharply contoured waves with duration <0.5 seconds (as measured at the base of the
wave), maximal over the central region and distinguishable from the background activity. They are most often seen
during transition to stage N1 sleep but can occur in either stage N1 or N2 sleep. These waveforms typically first appear
at 4-6 months post-term.
Sleep onset: The start of the first epoch scored as any stage other than stage W. (In most individuals this will usually be the
first epoch of stage N1.)
2. In individuals who generate alpha rhythm, score stage N1 if the alpha rhythm is attenuated and replaced by low-
amplitude, mixed-frequency activity for more than 50% of the epoch. N1,N2,N3 RECOMMENDED
3. In individuals who do not generate alpha rhythm, score stage N1 commencing with the earliest of ANY of the following
phenomena: N1,N2,N3,N4,N5 RECOMMENDED
a. EEG activity in range of 4–7 Hz with slowing of background frequencies by ≥1 Hz from those of stage W
b. Vertex sharp waves
c. Slow eye movements
4. An epoch is scored as stage N1 if the majority of the epoch meets the criteria for stage N1 (EEG showing LAMF EEG
activity) in the absence of evidence for another sleep stage. Subsequent epochs with an EEG showing LAMF EEG
activity are scored as stage N1 until there is evidence for another sleep stage (usually stage W, stage N2 or stage R).
A. Epoch B. Epoch
50 51 52 53 54 60 61 62 63 64
eyes eyes eyes eyes
open closed open closed
F4-M1 F4-M1
C4-M1 C4-M1
O2-M1 no alpha SEM

O2-M1 no alpha SEM
E1-M2 E1-M2
REM
REM
E2-M2 E2-M2
Chin EMG Chin EMG
W W W N1 N2 W W N1 N1 N2
Stage Stage
5. When an arousal interrupts stage N2 sleep, score subsequent segments of the recording as stage N1 if the EEG exhibits
low-amplitude, mixed-frequency activity without one or more K complexes and/or sleep spindles until there is evidence
for another stage of sleep (see G. Scoring Stage N2). RECOMMENDED
6. When an arousal interrupts stage R sleep and is followed by a low-amplitude, mixed-frequency EEG without posterior
dominant rhythm AND with slow eye movements, score the segments of the record containing the eye movements as
stage N1 even if the chin EMG activity remains low (at the stage R level). Continue to score stage N1 until there is
evidence for another stage of sleep, usually stage N2 (see G.2) or stage R (see I.2 and I.3). RECOMMENDED
Note 1. Vertex sharp waves may be present but are not required for scoring stage N1.
Note 2. The EOG will often show slow eye movements in stage N1, but these are not required for scoring.
Note 3. During stage N1, the chin EMG amplitude is variable, but often lower than in stage W.
Note 4. As slow eye movements often commence before attenuation of alpha rhythm, sleep latency may be slightly
shorter for some individuals who do not generate alpha rhythm compared to those who do.
Note 5. Theta frequency (4–7 Hz) waveforms that are of pathological origin (such as those resulting from neurological
impairment, encephalopathy or epilepsy) should not be considered toward the determination of Stage N1
sleep. In a person with a slow background EEG in the awake state, further non-pathological slowing of the
background activity of >1 Hz from that seen in the wake state would be considered evidence of Stage N1 sleep.
G. Scoring Stage N2
K complex: A well-delineated, negative, sharp wave immediately followed by a positive component standing out from
the background EEG, with total duration ≥0.5 seconds, usually maximal in amplitude when recorded using frontal
derivations. For an arousal to be associated with a K complex, the arousal must either be concurrent with the K complex
or commence no more than 1 second after termination of the K complex. (see V. Arousal Rule)
Sleep spindle: A train of distinct sinusoidal waves with frequency 11–16 Hz (most commonly 12–14 Hz) with a duration
≥0.5 seconds, usually maximal in amplitude in the central derivations.
2. Begin scoring stage N2 (in absence of criteria for N3) if EITHER OR BOTH of the following occur during the first half
of that epoch or the last half of the previous epoch: N1,N2,N3 RECOMMENDED
a. One or more K complexes unassociated with arousals
b. One or more sleep spindles
3. Score a given epoch as stage N2 if the majority of the epoch meets criteria for stage N2. If the waveforms in rule
G.2.a or G.2.b are followed by an arousal in the same or subsequent epoch (see Figure 7), the segment of the recording
preceding the arousal is considered stage N2 (see rule G.6.b). N1,N4 RECOMMENDED
A. Epoch B. Epoch C. Epoch

50 51 52 53 60 61 62 63 70 71 72 73
K complex K complex K complex K with K complex K complex K complex
arousal
arousal arousal
F4-M1 F4-M1 F4-M1
C4-M1 C4-M1 C4-M1
O2-M1 O2-M1 O2-M1
E1-M2 E1-M2 E1-M2
E2-M2 E2-M2 E2-M2
Chin EMG Chin EMG Chin EMG
N2 N2 N1 N2 N2 N2 N1 N2 N2 N1 N1 N2
Stage Stage Stage
4. Continue to score epochs with low-amplitude, mixed-frequency EEG activity without K complexes or sleep spindles
as stage N2 if they are preceded by epochs containing EITHER of the following and there is no intervening
arousal: RECOMMENDED
a. K complexes unassociated with arousals
b. Sleep spindles
5. Epochs following an epoch of stage N3 that do not meet criteria for stage N3 are scored as stage N2 if there is no
intervening arousal and the epoch does not meet criteria for stage W or stage R. (see Figure 8) RECOMMENDED
Epoch 200 Epoch 201
100 μV
F4-M1
1 sec
C4-M1
O2-M1
E1-M2
E2-M2
Chin EMG
30 sec
Stage N3 Stage N2
6. End scoring stage N2 sleep when ONE of the following events occurs: N5,N6 RECOMMENDED
a. Transition to stage W
b. An arousal followed by low-amplitude, mixed-frequency EEG (change to stage N1 until a K complex unassociated with an
arousal or a sleep spindle occurs) (see Figure 7). This assumes that the epoch does not meet criteria for stage R (rule I.3)
(see Figure 11C).
c. A major body movement followed by slow eye movements and low-amplitude, mixed-frequency EEG without non-arousal
associated K complexes or sleep spindles (score the epoch following the major body movement as stage N1; score the
epoch as stage N2 if there are no slow eye movements; the epoch containing the body movement is scored using the major
body movement rules under section J) (see Figure 9)
d. Transition to stage N3
e. Transition to stage R
A. Epoch B. Epoch
50 51 52 53 60 61 62 63
K complex major body K complex major body
movement movement
F4-M1 F4-M1
no no
alpha alpha
C4-M1 C4-M1
O2-M1 O2-M1
SEM
E1-M2 E1-M2
E2-M2 E2-M2
Chin EMG Chin EMG
N2 N2 N2 N2 N2 N1 N1 N2
Stage Stage
Note 1. An epoch of stage N2 meeting criteria in rule G.2 is termed definite stage N2. If there is a conflict between a
stage N2 and stage R scoring rule, the stage R rule takes precedence (see I.4).
Note 2. Continue to score stage N1 for epochs with arousal-associated K complexes unless they contain sleep
spindles or K complexes not associated with arousals.
Note 3. For the purposes of scoring N2 sleep, arousals are defined according to the arousal rule in chapter V. (V.A.1).
Note 4. For scoring epochs with a mixture of K complexes and/or sleep spindles and REMs, see rule I.7.
Note 5. The EOG usually shows no eye movement activity during stage N2 sleep, but slow eye movements may
persist in some individuals.
Note 6. In stage N2, the chin EMG is of variable amplitude, but is usually lower than in stage W, and may be as low
as in stage R sleep.
H. Scoring Stage N3 N1
1. Score in accordance with the following definition: N2,N3 RECOMMENDED
Slow wave activity: Waves of frequency 0.5 Hz–2 Hz and peak-to-peak amplitude >75 μV, measured over the frontal
regions referenced to the contralateral ear or mastoid (F4-M1, F3-M2).
2. Score stage N3 when ≥20% of an epoch consists of slow wave activity, irrespective of age. N4,N5,N6 RECOMMENDED
Note 1. Stage N3 represents slow wave sleep and replaces the Rechtschatten and Kales nomenclature of stage 3 and
stage 4 sleep.
Note 2. K complexes would be considered slow waves if they meet the definition of slow wave activity.
Note 3. Pathological wave forms that meet the slow wave activity criteria, such as those generated by metabolic
encephalopathies, epileptic, or epileptiform activity, are not counted as slow wave activity of sleep. Similarly,
waveforms produced by artifact or those of non-cerebral origin should not be included in the scoring of slow
waves.
Note 4. Sleep spindles may persist in stage N3 sleep.
Note 5. Eye movements are not typically seen during stage N3 sleep.
Note 6. In stage N3, the chin EMG is of variable amplitude, often lower than in stage N2 sleep and sometimes as low
as in stage R sleep.
I. Scoring Stage R
environment.
Low chin EMG tone: Baseline EMG activity in the chin derivation no higher than in any other sleep stage and usually at
the lowest level of the entire recording.
Sawtooth waves: An EEG pattern consisting of trains of sharply contoured or triangular, often serrated, 2–6 Hz
waves maximal in amplitude over the central head regions and often, but not always, preceding a burst of rapid eye
movements.
Transient muscle activity: Short irregular bursts of EMG activity usually with duration <0.25 seconds superimposed
on low EMG tone. The activity may be seen in the chin or anterior tibial EMG derivations, as well as in EEG or EOG
deviations, the latter indicating activity of cranial nerve innervated muscles (facial and scalp muscles). The activity is
often maximal when associated with rapid eye movements.
2. Score stage R sleep in epochs with ALL of the following phenomena (definite stage R): N1,N2,N3,N4,N5,N6 RECOMMENDED
a. Low-amplitude, mixed-frequency (LAMF) EEG activity without K complexes or sleep spindles

b. Low chin EMG tone for the majority of the epoch and concurrent with REMs
c. REMs at any position within the epoch
3. Score segments of sleep preceding and contiguous with an epoch of definite stage R (as defined in I.2), in the
absence of rapid eye movements, as stage R if ALL of the following are present: (see Figures 10, 11 and 12) RECOMMENDED
a. The EEG shows low-amplitude, mixed-frequency activity without K complexes or sleep spindles N4
b. The chin EMG tone is low (at the stage R level)
c. There is no intervening arousal (see Figure 11C)
d. Slow eye movements following an arousal or stage W are absent N5

50 51 52 53 60 61 62 63 70 71 72 73
LAMF LAMF LAMF LAMF LAMF LAMF
F4-M1 F4-M1 F4-M1
C4-M1 C4-M1 C4-M1

alpha alpha alpha
O2-M1 O2-M1 O2-M1
E1-M2 E1-M2 E1-M2

SEM SEM REM SEM SEM REM SEMs REM
E2-M2 E2-M2 E2-M2
W W R R W N1 R R W R R R
Stage Stage Stage

50 51 52 53 60 61 62 63 64 70 71 72 73
K complex K complex K complex K complex
LAMF LAMF LAMF
F4-M1 F4-M1 F4-M1
arousal
C4-M1 C4-M1 C4-M1
O2-M1 O2-M1 O2-M1

REM REM
E1-M2 E1-M2 E1-M2
E2-M2 E2-M2 E2-M2
N2 R R R N2 N2 R R R N2 R R R
Stage Stage Stage

50 51 52 53 60 61 62 63 70 71 72 73
K complex K complex sleep K complex
LAMF LAMF
spindle
F4-M1 F4-M1 F4-M1
sleep
spindle
C4-M1 C4-M1 C4-M1
O2-M1 O2-M1 O2-M1

REM REM REM
E1-M2 E1-M2 E1-M2
E2-M2 E2-M2 E2-M2
N2 N2 R R N2 N2 N2 R N2 N2 R R
Stage Stage Stage
4. If the majority of an epoch contains a segment of the recording meeting criteria for stage R (I.2, I.3, I.5), the
epoch is scored as stage R. Stage R rules take precedence over stage N2 rules. (see Figure 11, epoch 62 and
Figure 12, epoch 72) RECOMMENDED
5. Continue to score segments of sleep that follow one or more epochs of definite stage R (as defined in I.2), in the
absence of rapid eye movements, as stage R if ALL of the following are present: (see Figures 13–17) RECOMMENDED
a. The EEG shows LAMF EEG activity without K complexes or sleep spindles
b. The chin EMG tone is low (at the stage R level) for the majority of the epoch
c. There is no intervening arousal
A. Epoch B. Epoch
50 51 52 53 60 61 62 63
K complex K complex
LAMF LAMF
F4-M1 F4-M1
C4-M1 C4-M1
O2-M1 O2-M1
REM REM
E1-M2 E1-M2
E2-M2 E2-M2
Chin EMG Chin EMG
R R R N2 R R N1 N2
Stage Stage
A. Epoch B. Epoch
50 51 52 53 60 61 62 63
K complex K complex
arousal arousal
F4-M1 F4-M1
C4-M1 C4-M1
O2-M1 O2-M1
E1-M2 E1-M2
REM REM
E2-M2 E2-M2
SEM
Chin EMG Chin EMG
R R N1 N2 R R R N2
Stage Stage
A. Epoch B. Epoch
50 51 52 53 60 61 62 63
no no
alpha alpha
F4-M1 F4-M1
major body major body
movement movement
C4-M1 C4-M1
O2-M1 O2-M1
REM REM SEM
E1-M2 E1-M2
E2-M2 E2-M2
Chin EMG Chin EMG
R R R R R N1 N1 N1
Stage Stage
A. Epoch B. Epoch
50 51 52 53 60 61 62 63
K complex K complex
F4-M1 F4-M1
C4-M1 C4-M1
O2-M1 O2-M1
REM REM
E1-M2 E1-M2
E2-M2 E2-M2
Chin EMG Chin EMG
R R N2 N2 R R R N2
Stage Stage
A. Epoch B. Epoch C. Epoch D. Epoch

50 51 52 53 60 61 62 63 70 71 72 73 80 81 82 83
K complex K complex K complex K complex K complex
F4-M1
C4-M1
O2-M1
REM REM Stage R R
REM N2
REM
E1-M2
REM REM REM REM
E2-M2
Chin EMG
R R R R R R R R R N1 N2 R R N2 R R
Stage Stage Stage Stage
6. End scoring stage R sleep when ONE OR MORE of the following occur: RECOMMENDED
a. There is a transition to stage W or N3
b. An increase in chin EMG tone above the level of stage R is seen for the majority of the epoch and criteria for stage N1 are
met (see Figure 13, epoch 62)
c. An arousal occurs followed by low-amplitude, mixed-frequency EEG and slow eye movements (Score the epoch as stage
N1; if there are no slow eye movements and chin EMG tone remains low, continue to score as stage R) (see Figure 14)
d. A major body movement followed by slow eye movements and low-amplitude, mixed-frequency EEG without non-arousal
associated K complexes or sleep spindles (Score the epoch following the major body movement as stage N1; if no slow
eye movements are present and the EMG tone remains low, continue to score as stage R; the epoch containing the body
movement is scored using the criteria under heading J) (see Figure 15)
e. One or more non-arousal associated K complexes or sleep spindles are present in the first half of the epoch in the absence
of rapid eye movements, even if chin EMG tone remains low (Score the epoch as stage N2) (see Figure 16)
7. Score segments of the record with low chin EMG activity and a mixture of REMs and sleep spindles and/or
K complexes as follows: N1,N2,N3,N4,N5,N6 RECOMMENDED
a. Segments between two K complexes, two sleep spindles, or a K complex and sleep spindle without intervening REMs are
considered to be stage N2.
b. Segments of the record containing REMs without K complexes or sleep spindles and chin tone at the REM level are
considered to be stage R.
c. If the majority of an epoch contains a segment considered to be stage N2, it is scored as stage N2. If the majority of an
epoch contains a segment considered to be stage R, it is scored as stage R. (see Figure 17)
Note 1. Epochs defined by rule I.2 are called epochs of definite stage R.
Note 2. Low-amplitude, mixed-frequency activity in stage R resembles that seen in stage N1. In some individuals,
a greater amount of alpha activity can be seen in stage R than in stage N1. The alpha frequency in stage R
often is 1–2 Hz slower than during wakefulness.
Note 3. Sawtooth waves or transient muscle activity are strongly supportive of the presence of stage R sleep and may
be helpful when the stage is in doubt, however, they are not required for scoring stage R.
Note 4. For scoring epochs with low chin EMG tone and a mixture of REMs and K complexes or sleep spindles see
I.7.
Note 5. Slow eye movements can occur during stage R but slow eye movements following an arousal in combination
with an EEG showing LAMF activity suggests a transition to stage N1 even if the chin tone remains low.
Note 6. Segments of the record with low chin EMG activity and a mixture of REM and sleep spindles and/or
K complexes usually occur during the first REM period of the night.
J. Scoring Epochs with Major Body Movements

1. Score in accordance with the following definition: RECOMMENDED
Major body movement: Movement and muscle artifact obscuring the EEG for more than half an epoch to the extent that
the sleep stage cannot be determined.
2. If alpha rhythm is present for part of the epoch (even <15 seconds duration), score as stage W. RECOMMENDED
3. If no alpha rhythm is discernible, but an epoch scoreable as stage W either precedes or follows the epoch with a major
body movement, score as stage W. RECOMMENDED
4. Otherwise, score the epoch as the same stage as the epoch that follows it. RECOMMENDED
IV. Sleep Staging Rules Part 2: Rules for Children
A. Ages for Which Pediatric Sleep Staging Rules Apply

1. Pediatric sleep staging rules can be used to score sleep and wakefulness in children 2 months post-term or
older. N1,N2 RECOMMENDED
Note 1. For infants less than 2 months post-term, refer to IV. Sleep Staging Rules Part 3: Rules for Infants.
Note 2. There is no precise upper age boundary for pediatric sleep staging rules; refer to discussion in the
Pediatric Task Force review paper.1
Reference
1. Grigg-Damberger M, Gozal D, Marcus CL, et al. The visual scoring of sleep and arousal in infants and children. J Clin
Sleep Med. 2007;3(2):201–240.
B. Technical Specifications
1. See IV. Sleep Staging Rules Part 1: Rules for Adults and III. Technical and Digital Specifications for technical
considerations other than those in the note below. N1 RECOMMENDED
Note 1. Adult electrode derivations for EEG, EOG and chin EMG are acceptable for recording sleep except that the
distance between the chin EMG electrodes often needs to be reduced from 2 cm to 1 cm and the distance
from the eyes in EOG electrodes often need to be reduced from 1 cm to 0.5 cm in children and infants with
small head size.
C. General Scoring of Sleep Stages

1. The following terminology should be used when scoring sleep in children 2 months post-term or older: RECOMMENDED
b. Stage N1 (NREM 1)
c. Stage N2 (NREM 2)
d. Stage N3 (NREM 3)
e. Stage N (NREM)
f. Stage R (REM)
Not all sleep waveforms are well developed by 2 months post-term, therefore, the following possible scenarios may
apply: N1,N2,N3,N4,N5
2. If all epochs of NREM sleep contain no recognizable sleep spindles, K complexes or high-amplitude 0.5–2 Hz slow
wave activity, score all epochs as stage N (NREM). RECOMMENDED
3. If some epochs of NREM sleep contain sleep spindles or K complexes, score those as stage N2 (NREM 2). If in the
remaining NREM epochs, there is no slow wave activity comprising more than 20% of the duration of epochs, score as
stage N (NREM). RECOMMENDED
4. If some epochs of NREM sleep contain greater than 20% slow wave activity, score these as stage N3 (NREM 3). If in
the remaining NREM epochs, there are no K complexes or spindles then score as stage N (NREM). RECOMMENDED
5. If NREM is sufficiently developed that some epochs contain sleep spindles or K complexes and other epochs contain
sufficient amounts of slow wave activity, then score NREM sleep in this infant as either stage N1, N2 or N3 as in an
older child or adult. RECOMMENDED
Note 1. Sleep spindles may be seen by age 6 weeks – 3 months post-term and are present in all normal infants by age
2–3 months post-term. At this age the spindles are asynchronous between the hemispheres but become more
synchronous over the first year of life.
Note 2. K complexes are usually present by age 3–6 months post-term.
Note 3. EEG activity of 0.5–2 Hz with a typical amplitude of 100–400 μV in the frontal regions may first appear by
2 months of age and is usually present by age 4–5 months post-term. The criteria for slow wave activity are
the same as for adults (amplitude >75 μV of 0.5–2 Hz ).
Note 4. NREM sleep can be scored as stage N1, N2 or N3 in most infants by age 5–6 months post-term and
occasionally in infants as young as 4 months post-term.
Note 5. In infants younger than 6 months post-term, non-EEG parameters are helpful in distinguishing NREM sleep
from REM sleep. In REM sleep these parameters include the presence of irregular respiration, loss of chin
muscle tone, transient muscle activity (muscle twitches), and rapid eye movements. In NREM sleep, they
consist of regular respiration, absence of eye movements, and preserved chin muscle tone.
D. Scoring Stage W
1. Score in accordance with the following definitions: N1,N2,N3 RECOMMENDED
Eye blinks: Conjugate vertical eye movements at a frequency of 0.5–2 Hz present in wakefulness with eyes open or closed.
Reading eye movements: Trains of conjugate eye movements consisting of a slow phase followed by a rapid phase in the
opposite direction as the child reads or visually scans the environment.
environment.
Posterior dominant rhythm (PDR): The dominant reactive EEG rhythm over the occipital regions in relaxed wakefulness
with eyes closed which is slower in infants and young children and attenuates with eye opening or attention. Frequency
is 3.5–4.5 Hz when first seen in infants 3–4 months post-term, 5–6 Hz by 5–6 months, and 7.5–9.5 Hz by 3 years of age
and amplitude is usually >50 μV. In older children and adults, posterior dominant rhythm is often referred to as alpha
rhythm. N1,N2 (see Table 1)
Table 1. Initial age of waveform appearance.
Waveform Age of Initial Appearance
Sleep spindles 6 weeks – 3 months post-term
K complexes 3–6 months post-term
Slow wave activity 2–5 months post-term
Posterior dominant rhythm
Frequency of 3.5–4.5 Hz 3–4 months post-term
Frequency of 5–6 Hz 5–6 months post-term
Frequency of 7.5–9.5 Hz 3 years
Mean frequency of 9 Hz 9 years
Mean frequency of 10 Hz 15 years
Vertex sharp waves 4–6 months post-term
Hypnagogic hypersynchrony (HH) 3–6 months post-term
2. Score epochs as stage W when more than 50% of the epoch contains EITHER or BOTH: RECOMMENDED
a. Age-appropriate posterior dominant rhythm over the occipital region (individuals generating alpha rhythm with eye
closure)
b. Other findings consistent with stage W (all individuals)
i. Eye blinks (0.5–2 Hz)
ii. Rapid eye movements associated with normal or high chin muscle tone
iii. Reading eye movements
Note 1. The PDR in infants and children typically contains intermixed slower EEG rhythms including:
a. Posterior slow waves of youth (PSW) which are intermittent runs of bilateral but often asymmetric 2.5–4.5
Hz slow waves superimposed, riding upon, or fused with the PDR, are usually <120% of PDR voltage,
block with eye opening and disappear with drowsiness and sleep. PSW are uncommon in children <2 years
of age, have a maximal incidence between ages 8–14 years, and are uncommon after age 21 years.
b. R
andom or semi-rhythmic occipital slowing: <100 μV, 2.5–4.5 Hz rhythmic or arrhythmic activity lasting
<3 seconds; a normal finding in EEGs of children ages 1–15 years, especially prominent in ages 5–7 years;
the amount of intermixed slowing decreases and its frequency increases with increasing age.
Note 2. Spontaneous eye closure in infants signals drowsiness.
Note 3. The highest amplitude and sharpest component of reading eye movements in children is usually surface-
negative in the occipital derivations, typically lasting 150–250 msec, and having amplitudes up to 65 μV.
E. Scoring Stage N1
Low-amplitude, mixed-frequency (LAMF) activity: Low amplitude, predominantly 4–7 Hz activity.
at 4–6 months post-term.
Sleep onset: The start of the first epoch scored as any stage other than stage W. (In most subjects this will usually be the
Hypnagogic hypersynchrony (HH): Paroxysmal bursts or runs of diffuse, high-amplitude, sinusoidal, 75–350 μV,
3–4.5 Hz waves which begin abruptly, are usually widely distributed but often are maximal over the central, frontal, or
frontocentral scalp regions. These waveforms can occur in stage N1 and N2.
2. In individuals who generate a posterior dominant rhythm (PDR), score stage N1 if the PDR is attenuated or replaced
by low-amplitude, mixed-frequency activity for more than 50% of the epoch. N1,N2,N3,N4 RECOMMENDED
3. In individuals who do not generate a posterior dominant rhythm, score stage N1 commencing with the earliest of ANY
of the following phenomena: N5 RECOMMENDED
a. Activity in the range of 4–7 Hz with slowing of background frequencies by ≥1–2 Hz from those of stage W
b. Slow eye movements
c. Vertex sharp waves
d. Hypnagogic hypersynchrony
e. Diffuse or occipital-predominant, high-amplitude, rhythmic 3–5 Hz activity
Note 1. In most individuals sleep onset will be the first epoch of stage N1, but in infants younger than 2 months post-
term, this is often stage R.
Note 2. Drowsiness in infants up to 6–8 months of age is characterized by the gradual appearance of diffuse, high-
amplitude (often 75–200 μV) 3–5 Hz activity which is typically of higher amplitude, more diffuse, and 1–2
Hz slower than the waking EEG background activity.
Note 3. Drowsiness in children 8 months to 3 years is characterized by either diffuse runs or bursts of rhythmic or
semi-rhythmic bisynchronous 75–200 μV, 3–4 Hz activity often maximal over the occipital regions and/or
higher amplitude (>200 μV) 4–6 Hz theta activity maximal over the frontocentral or central regions.
Note 4. Sleep onset from 3 years on is often characterized by a 1–2 Hz slowing of the PDR frequency and/or the PDR
often becomes diffusely distributed then is gradually replaced by relatively low-voltage, mixed-frequency
EEG activity.
Note 5. Hypnagogic hypersynchrony is a distinctive EEG pattern of drowsiness and stage N1 that often disappears
with deeper stages of NREM sleep. HH is seen in approximately 30% of infants at 3 months post-term, 95%
of all normal children ages 6–8 months, and is less prevalent after age 4–5 years; it is seen in only 10% of
healthy children by age 11 and is rarely seen after age 12 years.
F. Scoring Stage N2
1. Same as the adult rules found under the adult sleep staging rules heading G. N1,N2,N3 RECOMMENDED
Note 1. Sleep spindles are usually are first seen in infants 4–6 weeks post-term as brief bursts of low-amplitude, less-
sinusoidal 12–14 Hz activity maximal over the vertex region, are usually well-developed and are present in
all normal infants 8–9 weeks.
Note 2. Eighty percent of children <13 years of age have two independent scalp locations and frequency ranges for
sleep spindles: 10.0–12.75 Hz over the frontal and 12.5–14.75 Hz maximal over the central or centroparietal
region.
Note 3. K complexes are usually present 5–6 months post-term and are maximal over the pre-frontal and frontal
regions, as they are in adults.
G. Scoring Stage N3
1. Same as the adult rules found under the adult sleep staging rules heading H. N1 RECOMMENDED
Note 1. Slow wave activity in pediatric populations is often of high amplitude (100–400 μV), 0.5–2.0 Hz activity,
maximal over the recommended derivations in the frontal scalp regions and first appears as early as 2
months, more often 3–4.5 months post-term.
H. Scoring Stage R
1. Same as the adult rules found under the adult sleep staging rules heading I. N1 RECOMMENDED
Note 1. The continuous, low-amplitude, mixed-frequency EEG activity of stage R in infants and children resembles
adults although the dominant frequencies increase with age: approximately 3 Hz activity at 7 weeks post-
term, 4–5 Hz activity with bursts of sawtooth waves at 5 months, 4–6 Hz at 9 months, and prolonged runs
or bursts of notched 5–7 Hz theta activity at 1–5 years of age may populate the background activity. By 5–10
years of age, the low-amplitude, mixed-frequency activity in stage R is similar to that of adults.
IV. Sleep Staging Rules Part 3: Rules for Infants
A. Ages for Which Infant Sleep Staging Rules Apply

1. Infant sleep staging rules should be used to score sleep and wakefulness in infants 0–2 months post-term (37–48 weeks
conceptional age). N1,N2,N3,N4 RECOMMENDED
Note 1. Conceptional age (CA) is gestational age (GA) at birth plus the number of weeks postpartum. GA is the
time elapsed between the first day of the mother’s last menstrual period and the day of delivery expressed in
completed weeks. If the pregnancy was achieved using assisted reproductive technology, GA is calculated by
adding 2 weeks to the CA. Chronological age (or postnatal or legal age) is the time elapsed since birth (can be
expressed in days, months, or years).
Note 2. At birth, an infant is classified as one of the following: premature (<37 weeks gestation); full-term (37–42
weeks); or post-term (born after 42 weeks). A neonate is a child during the first 28 days after birth; an infant
is a child age 1 to 12 months.1
Note 3. Knowing an infant’s CA is crucial for interpreting the normalcy, immaturity or abnormality of an EEG or
PSG because the brain and the EEG continue to develop and mature at a similar rate independent of whether
the infant is in utero or post-delivery.
Note 4. For premature infants (<37 weeks CA) refer to discussion in the Pediatric and Infant Scoring Task Force
review paper.2
References
1. Engle WA; American Academy of Pediatrics Committee on Fetus and Newborn. Age terminology during the perinatal
period. Pediatrics. 2004;114(5):1362–1364.
2. Grigg-Damberger M, Gozal D, Marcus CL, et al. The visual scoring of sleep and arousal in infants and children. J Clin
Sleep Med. 2007;3(2):201–240.
1. See IV. Sleep Staging Rules Part 1: Rules for Adults and III. Technical and Digital Specifications for technical
considerations other than those below. RECOMMENDED
2. Adult electrode derivations for EEG, EOG and chin EMG are acceptable when recording sleep except that the distance
between the chin EMG electrodes often needs to be reduced from 2 cm to 1 cm and the distance from the eyes in EOG
electrodes often need to be reduced from 1 to 0.5 cm because of small infant head sizes. RECOMMENDED
3. Since sleep spindles are often asynchronous in children until 2 years of age, and may be more prominent in the midline
central (C3-Cz, C4-Cz) and central derivations (C3-M2, C4-M1), simultaneous display of the recommended and
backup electrodes and Cz (midline central) may be considered (e.g. montage to consider: F4-M1, C4-M1, O2-M1, F3-
M2, C3-M2, O1-M2, C4-Cz, C3-Cz). N1 OPTIONAL
4. Since behavioral patterns are extremely useful, synchronized video and audio recording is highly desirable. OPTIONAL
Note 1. Since rudimentary sleep spindles first appear at 43 to 48 weeks CA at the midline central (Cz, vertex) region
and are often asynchronous, simultaneous display of left, right and midline central EEG channels may be
considered (e.g., C3-Cz, Cz-C4). In infants this age, sleep spindles are often low voltage 12–14 Hz, not the
wider range of 11–16 Hz seen at later ages.
C. General Scoring of Sleep Stages

1. The following terminology should be used when scoring sleep in infants 0–2 months post-term
(37–48 weeks CA): N1,N2 RECOMMENDED
b. Stage N (NREM)
c. Stage R (REM)
d. Stage T (Transitional)
2. Score epochs using the following rules: RECOMMENDED

a. Score sleep stages in 30-second, sequential epochs commencing at the start of the study
b. Assign a stage to each epoch
c. If two or more stages coexist, assign the stage comprising the greatest portion of the epoch
d. If two or more PSG characteristics are discordant for stage R or stage N sleep, score the epoch as stage T (Transitional)
sleep
e. Score sleep onset as the first epoch of sleepN3
3. Sleep and wakefulness in infants 38 to 48 weeks CA are scored based on behavioral observation; regularity or
irregularity of respiration; and EEG, EOG, and chin EMG patterns defined in Tables 1–6. RECOMMENDED
4. Score sleep based on behavioral characteristics as defined in Table 1. N4 RECOMMENDED
Table 1. Behavioral characteristics of sleep stages.
Stage Behavioral Characteristics
Wake Calm or active with eyes open, scanning eye movements; Brief eye closure can occur with crying
N Eyes closed, few movements, sucking can occur
R Eyes closed, REM seen under closed eyelids, squirming, sucking, grimacing, small movements of the face or limbs
5. Score sleep based on the respiration characteristics as defined in Table 2. N5,N6 RECOMMENDED
Table 2. Respiration characteristics of sleep stages.
Stage Respiration Characteristics
Wake Irregular, rapid, and shallow
N Regular
R Irregular, some central pauses (may or may not meet criteria for apnea)
6. Score sleep based on the EEG characteristics as defined in Table 3. (see also Figure 1) RECOMMENDED
Table 3. EEG characteristics of sleep stages. N7,N8
Patterns EEG Characteristics Stage(s)
Discontinuous
This EEG pattern in full-term infants is generally only seen in stage N sleep. It is
characterized by at least 3 alternating runs of bilaterally symmetrical synchronous high
Trace alternant (TA) N9,N10 voltage (50–150 µV) bursts of 1–3 Hz delta activity lasting 5–6 seconds (range 3–8 N
seconds) alternating with periods of lower amplitude (25–50 µV) 4–7 Hz theta activity
(range 4–12 seconds).
Continuous
Continuous low voltage mixed-frequency activity with delta and predominantly theta
Low voltage irregular (LVI) R, Wake
activity.
High voltage slow (HVS) N11 Continuous synchronous symmetrical predominantly high voltage 1–3 Hz delta activity. N, rarely R
Both high voltage slow and low voltage polyrhythmic components; these are intermingled Wake, R,
Mixed (M)
with little periodicity. The amplitude is lower than seen in the HVS pattern. rarely N
Waveforms of interest
12 to 14 Hz, asynchronous, most prominent in midline central (CZ) and central derivations.
Sleep spindles N12,N13 N
Occur only in stage N sleep.
7. Score sleep in accordance with the following definitions and based on the EOG characteristics as defined in
Table 4. RECOMMENDED
Eye blinks: Conjugate vertical eye movements at a frequency of 0.5–2 Hz present in wakefulness with eyes open or closed.
Scanning eye movements: Trains of conjugate eye movements with eyes open consisting of a slow phase followed by a
rapid phase in the opposite direction as the infant visually scans the environment or follows objects. N14
environment.
Table 4. EOG characteristics of sleep stages.
Stage EOG Characteristics
Wake Eye blinks, REMs, scanning eye movements; transient eye closures may be seen in wakefulness especially when the infant is crying
N Eyes closed, not moving
R Eyes closed with REMs
8. Score sleep in accordance with the following definitions and based on the chin EMG patterns as defined in
Table 5. RECOMMENDED
Table 5. Chin EMG patterns of sleep stages.
Stage Chin EMG Patterns
Wake Present, movement artifact
N Present; could be lower than wake
R Low, TMA may occur
Table 6 provides a summary of Tables 1 to 5.
Table 6. Summary of state characteristics. N15
Stage Behavioral Respiration EEG EOG Chin EMG
Eyes open, crying, REMs, blinks, scan-

Wake Irregular LVI or M Present
feeding ning eye movements
Reduced movement
relative to wake
TA, HVS, sleep Eyes closed with no
N (Eyes closed, Regular Present or low
spindles, or M EMs
periodic sucking,
occasional startle)
REMs or
Eyes closed LVI or M Low, TMA may
R Irregular Eyes closed with no
Small movements (rarely HVS) occur
EMs N16
LVI = low voltage irregular, M = mixed, TA = trace alternant, HVS = high voltage slow, REMs = rapid eye movements.
Note 1. If NREM is sufficiently developed so that some epochs contain sleep spindles or K complexes and other
epochs contain sufficient amounts of slow wave activity, then score NREM sleep in this infant as either stage
N1, N2 or N3 as in IV. Sleep Staging Rules Part 2: Rules for Children, C.5.
Note 2. Stage N is analogous to the previously used terminology of “quiet sleep,” stage R is analogous to the
previously used terminology of “active sleep,” and stage T is analogous to the previously used terminology of
“indeterminate sleep.”
Note 3. Up until 2 to 3 months post-term, the first epoch of sleep in infants is often stage R.
Note 4. The transition to sleep in an infant is characterized by relative immobility, absence of focused attention,
and intermittent eye closure. If an infant’s eyes are closed for more than 3 minutes, the infant is considered
asleep. Theta and delta activity, especially over the frontal derivations, may increase in amplitude in
transitions between W and sleep onset.
Note 5. Regularity or irregularity of respiration during sleep is the most reliable PSG characteristic in differentiating
stage N and stage R sleep, respectively.
Note 6. Periodic breathing is common during stage R sleep and may rarely occur during stage N sleep in normal
infants.
Note 7. The EEG patterns of transitional sleep may contain any of the EEG characteristics outlined in Table 3.
Note 8. Pathological EEG waveforms, such as those from spike and slow wave, projected rhythms or those generated
due to underlying pathology, should not be included in defining stage or state as noted in Table 3.
Note 9. It is permissible to look at preceding and following epochs to identify the trace alternant (TA) pattern.
Note 10. Trace alternant (TA) first appears at 37 weeks conceptional age (CA), is the predominant EEG pattern in
stage N sleep at 40 weeks CA and unlikely to be seen after 44 weeks CA. After 42 weeks CA, interburst
intervals (IBIs) of TA last only 1–2 seconds and the IBI is of higher amplitude. TA after 44 weeks CA is
replaced by high voltage slow (HVS) activity.
Note 11. High voltage slow (HVS) activity is the more mature EEG pattern of stage N sleep at term. It is characterized
by continuous synchronous symmetrical 100–150 µV 1–3 Hz delta activity which often has an occipital or
central predominance.
Note 12. Since rudimentary sleep spindles first appear at 43 to 48 weeks CA at the midline central (Cz, vertex) region
and are often asynchronous, simultaneous display of left, right and midline central EEG channels may be
considered (e.g., C3-Cz, Cz-C4). In infants this age, sleep spindles are often low voltage 12–14 Hz, not the
wider range of 11–16 Hz seen at later ages.
Note 13. Since sleep spindles are often asynchronous in children until 2 years of age, simultaneous display of the
recommended and backup electrodes may be considered (e.g. montage to consider: F3-M2, F4-M1, C3-M2,
C4-M1, O1-M2, O2-M1, C3-Cz, Cz-C4).
Note 14. Scanning eye movements can be seen as early as 2 weeks post-term.
Note 15. Stage T (Transitional) is scored when 3 NREM and 2 REM or 2 NREM and 3 REM characteristics are
present.
Note 16. In epoch(s) contiguous and following an epoch of definite stage R (e.g. containing REMs).
D. Scoring Stage W
1. Score epochs as stage W if either a, b, or c is present for the majority of the epoch: N1,N2 (Figure 2) RECOMMENDED
a. Eyes are wide open (for the majority of the epoch)

b. Vocalization (whimpering, crying, etc.) or actively feeding
c. All of the following are met:
i. Eyes are open intermittently
ii. REMs or scanning eye movements
iii. Sustained chin EMG tone with bursts of muscle activity
iv. Irregular respiration
v. EEG: LVI or M N3
Figure 2. A 30 second tracing of stage W in an infant. EEG: mixed frequency pattern; EOG: REMs present; Chin EMG: present
(high); Respiration: irregular; Behavior: eyes open, moving head. The thermal sensor is an oronasal flow sensor.
Note 1. Wake is most reliably scored by behavioral observations, because many of the distinctive EEG features of
wakefulness are not seen until after 2 months post-term.
Note 2. W (Wakefulness) is characterized by an EEG background of continuous, symmetrical, irregular, low-to-
medium amplitude mixed frequencies which may include: a) irregular theta and delta activity (to 100 µV)
maximal in O1, O2; b) diffuse irregular alpha and beta activity (to 30 µV); c) rhythmic theta activity
(to 50 µV), often maximal in C3, Cz, C4; or d) artifacts from body movements, and eye movements.
Note 3. This may have superimposed frequent movement artifacts.
E. Scoring Stage N (NREM)

1. Score stage N if four or more of the following are present, including regular respiration, for the majority of the
epoch:N1,N2 (Figures 3 and 4) RECOMMENDED
a. Eyes closed with no eye movements
b. Chin EMG tone present
c. Regular respiration (post sigh respiratory pauses may occur)
d. Trace alternant (TA), high voltage slow (HVS), or sleep spindles present
e. Reduced movement relative to wake
Figure 3. A 30 second tracing of stage N sleep in an infant. EEG: Trace alternant; EOG: no REMs; Chin EMG: present;
Respiration: regular; Behavior: eyes closed, no movements. The thermal sensor is an oronasal flow sensor.
Figure 4. A 30 second tracing of stage N sleep in an infant. EEG: HVS; EOG: no eye movements; Chin EMG: present;
Respiration: regular; Behavior: eyes closed, no movements. The thermal sensor is an oronasal flow sensor.
Note 1. Chin EMG in stage N is variable; it is generally lower than Wake and higher than in stage R. That is, if chin
EMG activity is present (higher than stage R) this is evidence for stage N (Table 5). However, stage N can still be
scored with low EMG tone provided at least four other criteria for stage N including regular respiration are met.
Note 2. Regularity or irregularity of respiration during sleep is the most reliable PSG characteristic in differentiating
stage N and stage R sleep, respectively.
F. Scoring Stage R
1. Score stage R sleep (definite R) in epochs with 4 or more of the following criteria present, including irregular
respiration AND rapid eye movement: N1 (Figure 5) RECOMMENDED
a. Low chin EMG (for the majority of the epoch) N2
b. Eyes closed with at least one rapid eye movement (concurrent with low chin tone)
c. Irregular respiration
d. Mouthing, sucking, twitches or brief head movements
e. EEG exhibits a continuous pattern without sleep spindles N3
2. Score segments of sleep contiguous with and following an epoch of definite R (as defined in F.1) in the absence of rapid
eye movements, as stage R if ALL of the following are present: RECOMMENDED
a. The EEG shows low or medium amplitude mixed frequency activity without trace alternant or sleep spindles
b. The chin muscle tone is low for the majority of the epoch
c. There is no intervening arousal (see chapter V. Arousal Rule, same rule as for children and adults)
Figure 5. A 30 second tracing of stage R sleep in an infant. EEG: LVI; EOG: REMs; Chin EMG: low; Respiration: irregular;
Behavior: eye movements noted with small movements of mouth. The thermal sensor is an oronasal flow sensor.
Note 1. In infants, the first epoch of sleep is most commonly stage R. Given the difficulty in determining sleep onset,
an epoch of definite stage R is required to begin scoring this sleep stage.
Note 2. Epochs of stage R sleep containing periods without atonia (sustained activity or transient muscle activity in
the chin EMG) are not uncommon in infants. Bursts of muscle activity during stage R often occur associated
with movements. The intervening chin EMG activity between movements is usually low.
Note 3. Continuous EEG pattern includes low voltage irregular (LVI), high voltage slow (HVS), and mixed (M)
(Table 3).
G. Scoring Stage T
1. Score an epoch as stage N, stage R or stage W if only one PSG characteristic is discordant for the sleep
state. N1,N2 RECOMMENDED
2. Score an epoch as stage T (transitional) if it contains either 3 NREM and 2 REM characteristics or 2 NREM and
3 REM characteristics. (Table 6, Figure 6) RECOMMENDED
Figure 6. A 30 second tracing of Transitional (T) sleep in an infant. EEG: LVI; EOG: no REMs; Chin EMG: absent (low);
Respiration: irregular; Behavioral: no movements, eye closed. Three characteristics of stage R (LVI, Chin EMG absent, irregular
respiration) and two characteristics of NREM (no movement, no REMs) are seen in this epoch. This assumes that the epoch was
not immediately preceded by an epoch of definite R. The thermal sensor is an oronasal flow sensor.
Note 1. Transitional (T) or indeterminate sleep is common in infants because of discordant features (contains
physiological markers of more than one sleep state).
Note 2. The terminology Transitional (T) sleep is favored over indeterminate sleep as the sleep stage most often
occurs in transitions from stage W to stage R sleep, before awakening and at sleep onset.
H. Reference
The following reference applies to content throughout chapter IV. Sleep Staging Rules Part 3: Rules for Infants.
nders T, Emde R, Parmelee A. A Manual of Standardized Terminology, Techniques and Criteria for Scoring of States of
1. A
Sleep and Wakefulness in Newborn Infants. Los Angeles, CA: UCLA Brain Information Service/BRI Publications Office,
NINDS Neurological Information Network; 1971.
V. Arousal Rule
A. Scoring Arousals
1. Score arousal during sleep stages N1, N2, N3, or R if there is an abrupt shift of EEG frequency including alpha, theta
and/or frequencies greater than 16 Hz (but not spindles) that lasts at least 3 seconds, with at least 10 seconds of stable
sleep preceding the change. Scoring of arousal during REM requires a concurrent increase in submental EMG lasting
at least 1 second.N1,N2,N3,N4,N5 RECOMMENDED
Note 1. Arousal scoring should incorporate information from the frontal, central, and occipital derivations.
Note 2. Arousal scoring can be improved by the use of additional information in the recording such as respiratory
events and/or additional EEG channels. Scoring of arousals, however, cannot be based on this additional
information alone and such information does not modify any of the arousal scoring rules.
Note 3. Arousals meeting all scoring criteria but occurring during an awake epoch in the recorded time between
“lights out” and “lights on” should be scored and used for computation of the arousal index.
Note 4. The 10 seconds of stable sleep required prior to scoring an arousal may begin in the preceding epoch,
including a preceding epoch that is scored as stage W.
Note 5 An arousal may still be scored if it immediately precedes a transition to stage W. That is, both the arousal
and transition to wake are scored.
VI. Cardiac Rules
A. Technical Specifications
1. Use a single modified electrocardiograph Lead II and torso electrode placement. N1,N2,N3,N4 (see Figure 1) RECOMMENDED
Figure 1.
Diagram of Lead
II placement
on torso during
cardiac recording.
Illustration may not
be to scale.
Note 1. Additional leads may be placed if clinically indicated at the discretion of the practitioner.
Note 2. Increasing the image size on the display may improve detection of arrhythmias.
Note 3. While classically Lead II is derived from electrodes placed on the right arm and left leg, the electrodes may
be placed on the torso aligned in parallel to the right shoulder and left hip.
Note 4. Standard ECG electrode applications are superior to EEG electrodes in minimizing artifact.
VI. Cardiac Rules
B. Scoring Cardiac Events N1,N2

1. Score sinus tachycardia during sleep for a sustained sinus heart rate of greater than 90 beats per minute for adults.
N3,N4 RECOMMENDED
2. Score bradycardia during sleep for a sustained heart rate of less than 40/minute for ages 6 years through
adult. N4 RECOMMENDED
3. Score asystole for cardiac pauses greater than 3 seconds for ages 6 years through adult. RECOMMENDED
4. Score wide complex tachycardia for a rhythm lasting a minimum of 3 consecutive beats at a rate greater than 100 per
minute with QRS duration of greater than or equal to 120 msec. RECOMMENDED
5. Score narrow complex tachycardia for a rhythm lasting a minimum of 3 consecutive beats at a rate of greater than 100
per minute with QRS duration of less than 120 msec. RECOMMENDED
6. Score atrial fibrillation if there are irregularly irregular QRS complexes associated with replacement of consistent
P waves by rapid oscillations that vary in size, shape, and timing. RECOMMENDED
Note 1. Significant arrhythmias such as heart block should be reported if the quality of the single lead is sufficient for
accurate scoring.
Note 2. Ectopic beats should be reported if felt to be clinically significant.
Note 3. Sinus rates vary according to age in children, with faster rates in young children as compared to adults. For
typical sinus rates in children, refer to the Cardiac Task Force review paper.1
Note 4. Sustained sinus bradycardia or tachycardia is defined by more than 30 seconds of a stable rhythm to
distinguish it from transient responses, associated sleep disordered breathing events or arousals.
Reference
aples SM, Rosen CL, Shen WK, et al. The scoring of cardiac events during sleep. J Clin Sleep Med. 2007;3(2):147–154.
1. C
VII. Movement Rules
A. Technical SpecificationsN1
1. For monitoring leg movements (LMs), surface electrodes should be placed longitudinally and symmetrically in the
middle of the anterior tibialis muscle so that they are 2–3 cm apart or 1/3 of the length of the anterior tibialis muscle,
whichever is shorter. Both legs should be monitored for the presence of the leg movements. Separate channels for
each leg are strongly preferred. Combining electrodes from the 2 legs to give 1 recorded channel may suffice for some
clinical settings, although it should be recognized that this strategy may reduce the number of detected LMs.
Figure 1. Placement
of electrodes on the
anterior tibialis muscle
for monitoring leg
movements. Illustration
may not be to scale.
2. For monitoring leg movements, use of 60 Hz (notch) filters should be avoided. Impedances need to be less than
10,000 Ω. Less than 5,000 Ω is preferred but may be difficult to obtain. RECOMMENDED
3. Movements of the upper limbs may be sampled using a similar method as for legs if clinically indicated.
(see Figures 2 and 3) OPTIONAL
Figure 2. Placement of
electrodes on the flexor
digitorum superficialis
for detecting transient
muscle activity in REM
sleep. Illustration may
not be to scale.
VII. Movement Rules
Figure 3. Placement
extensor digitorum
communis for
detecting transient
muscle activity in REM
sleep. Illustration may
not be to scale.
4. For detecting bruxism, in addition to the recommended placement of chin EMG electrodes as noted in the adult
sleep staging rules chapter (IV.C), additional masseter electrodes may be placed if clinically indicated.N2
(see Figure 4) OPTIONAL
Figure 4. Placement
masseter muscle for
detecting bruxism.
Illustration may not be
to scale.
5. For detecting transient muscle activity in REM sleep, use one of the following EMG recordings:N3 OPTIONAL
a. Flexor digitorum superficialis (see Figure 2)

b. Extensor digitorum communis (see Figure 3)
6. For diagnosis of RBD, time-synchronized, audio-equipped video PSG is essential to document complex motor
behaviors and vocalizations during REM sleep. A diagnosis of RBD is based on demonstration of such episodes or a
characteristic clinical history of dream enactment in addition to polysomnographic evidence of REM sleep without
atonia. RECOMMENDED
7. For monitoring rhythmic movement disorder (RMD), bipolar surface electrodes should be placed to record electrical
activity of the large muscle groups involved.N3 (see Figure 5) OPTIONAL
8. For diagnosis of RMD, time-synchronized video PSG is necessary to accurately characterize the disorder, in addition
to polysomnographic criteria. RECOMMENDED
VII. Movement Rules
Figure 5. Placement of
electrodes on the neck
paraspinal muscles for
monitoring rhythmic
movement disorder.
Illustration may not be
to scale.
Note 1. For accurate electrode placement, the patient should be asked to activate the muscle so that the muscle can be
more readily felt. The following are the actions to activate various muscles:
• Anterior tibialis: patient should raise foot toward their head or flex their foot up
• Flexor digitorm superficialis: patient should bend only at the base of their fingers (avoid bending at the
distal two joints)
• Extensor digitorum communis: patient should extend their fingers back without moving their wrist
• Masseter: patient should bite down
Note 2. If two electrodes are used (see Figure 4), they should be 2–3 cm apart. A single masseter electrode may be
used using a chin EMG electrode as the reference.
Note 3. Surface electrodes should be placed 2–3 cm apart.
B. Scoring Periodic Limb Movements in Sleep (PLMS)

1. The following define a significant leg movement (LM) event: N1 RECOMMENDED
a. The minimum duration of a LM event is 0.5 seconds.
b. The maximum duration of a LM event is 10 seconds.
c. The minimum amplitude of a LM event is an 8 μV increase in EMG voltage above resting EMG (duration of at least 0.5
seconds).
d. The timing of the onset of a LM event is defined as the point at which there is an 8 μV increase in EMG voltage above
resting EMG.
e. The timing of the ending of a LM event is defined as the start of a period lasting at least 0.5 seconds during which the
EMG does not exceed 2 μV above resting EMG.
2. The following define a PLM series: N2 RECOMMENDED

a. The minimum number of consecutive LM events needed to define a PLM series is 4 LMs.
b. The period length between LMs (defined as the time between onsets of consecutive LMs) to include them as part of a PLM
series is 5 to 90 seconds.
c. Leg movements on 2 different legs separated by less than 5 seconds between movement onsets are counted as a single leg
movement. The period length to the next LM following this group of LMs is measured from the onset of the first LM to
the onset of the next. (see Figure 6)
VII. Movement Rules
Period Length
Figure 6. The first two LMs are counted as one
4 sec leg movement since the time from onset to onset
of the LMs in the left anterior tibial EMG channel
(LAT) and right anterior tibial EMG channel (RAT)
LAT is less than 5 seconds. The period length to the
next LM is measured from the onset of the first
RAT LM in the group considered to be a single LM.
3. An arousal and a limb movement that occur in a PLM series should be considered associated with each other if they
occur simultaneously, overlap, or when there is <0.5 seconds between the end of one event and the onset of the other
event regardless of which is first. (see Figure 7) RECOMMENDED
Epoch Epoch
50 51 52 53
PLM arousal PLM arousal PLM arousal PLM arousal
F4-M1 F4-M1
C4-M1 C4-M1
O2-M1 O2-M1
E1-M2 E1-M2
E2-M2 E2-M2
Chin EMG Chin EMG

PLMS PLMS PLMS PLMS
RAT RAT
LAT LAT
0 30 60 0 30 60
Epoch
54
PLM arousal PLM arousal
F4-M1
C4-M1
O2-M1
E1-M2
E2-M2
Chin EMG
PLMS
PLMS
RAT
LAT
0 15 30
0.5 sec 0.5 sec
Figure 7. An arousal and LM occurring in a PLM series are considered to be associated if they occur simultaneously (epochs
50 and 51), overlap (epochs 52 and 53) or if the time from the end of one event to the start of the next is less than 0.5 seconds,
regardless which event comes first (epoch 54).
4. An LM should not be scored if it occurs during a period from 0.5 seconds preceding an apnea, hypopnea, or RERA to
0.5 seconds following the event. RECOMMENDED
5. When a period of wake <90 seconds separates a series of LMs, this does not prevent LMs preceding the period of wake
from being included with the subsequent LMs as part of a PLM series. (see Figure 8) RECOMMENDED
VII. Movement Rules
30 sec
55 sec
1 2 3 4
LAT Figure 8. Five LMs are depicted.
The fourth occurs in an epoch of wake
RAT
and cannot be counted as a PLM in
sleep. However, the other 4 LMs would
be included in the same PLM series.
Stage N2 Stage N2 Stage W Stage N1
Note 1. Rule 1.c. defines a significant leg movement event by an absolute increase of 8 μV above resting baseline for
the anterior tibialis EMG. This requires a stable resting EMG for the relaxed anterior tibialis whose absolute
signal should be no greater than +10 μV between negative and positive deflection (±5 μV) or +5 μV for
rectified signals.
Note 2. When periodic limb movements occur with an interval of less than 10 seconds and each is associated with
a ≥ 3 second change in the EEG/chin EMG meeting criteria for an arousal, only the first EEG/chin EMG
change should be scored as an arousal (assuming it is preceded by at least 10 seconds of sleep). Both limb
movements may be scored, assuming the onsets are separated by 5 seconds or more, but only one PLM
associated with an arousal (and only one arousal) would be scored.
C. Scoring Alternating Leg Muscle Activation (ALMA)

1. The following define ALMA: N1,N2,N3 OPTIONAL
a. The minimum number of discrete and alternating EMG bursts of leg muscle activity events needed to score an ALMA
series is 4 ALMAs.
b. The minimum frequency of the alternating EMG bursts in ALMA is 0.5 Hz.
c. The maximum frequency of the alternating EMG bursts in ALMA is 3.0 Hz.
Note 1. ALMAs alternate between legs.

Note 2. The usual range for duration of ALMA is 100–500 msec.
Note 3. ALMA may simply be a benign movement phenomenon associated with characteristic EMG patterns as there
have been no reported clinical consequences.
D. Scoring Hypnagogic Foot Tremor (HFT)

1. The following define HFT: N1,N2 OPTIONAL
a. The minimum number of EMG bursts needed to make a train of bursts in a HFT series is 4 HFT bursts.
b. The minimum frequency of the EMG bursts in a HFT is 0.3 Hz.
c. The maximum frequency of the EMG bursts in a HFT is 4.0 Hz.
Note 1. The usual range for duration of hypnagogic foot tremor is 250–1,000 msec.
Note 2. HFT may simply be a benign movement phenomenon associated with characteristic EMG patterns as there
have been no reported clinical consequences.
VII. Movement Rules
E. Scoring Excessive Fragmentary Myoclonus (EFM)

1. The following define EFM: N1,N2,N3 OPTIONAL
a. The usual maximum EMG burst duration seen in fragmentary myoclonus is 150 msec.
b. At least 20 minutes of NREM sleep with EFM must be recorded.
c. At least 5 EMG potentials per minute must be recorded.
Note 1. EFM may be a benign movement phenomenon associated with a characteristic EMG pattern as there have
been no reported clinical consequences.
Note 2. In many cases no visible movements are present. Gross, jerk-like movements across the joint spaces are not
observed. When minor movement across a joint space is present, the movement resembles the small twitch-
like movements of the fingers, toes, and the corner of the mouth intermittently seen in REM sleep in normal
individuals.
Note 3. In some cases when visible movement is present, the EMG burst duration may be >150 msec.
F. Scoring Bruxism
1. The following define bruxism: N1,N2 RECOMMENDED
a. Bruxism may consist of brief (phasic) or sustained (tonic) elevations of chin EMG activity that are at least twice the
amplitude of background EMG.
b. Brief elevations of chin or masseter EMG activity are scored as bruxism if they are 0.25–2 seconds in duration and if at
least 3 such elevations occur in a regular sequence.
c. Sustained elevations of chin or masseter EMG activity are scored as bruxism if the duration is more than 2 seconds.
d. A period of at least 3 seconds of stable background chin EMG must occur before a new episode of bruxism can be scored.
e. Bruxism can be scored reliably by audio in combination with polysomnography by a minimum of 2 audible tooth grinding
episodes/night of polysomnography in the absence of epilepsy.
Note 1. In sleep, jaw contraction frequently occurs. This contraction can take 2 forms: a) sustained (tonic) jaw
clenching contractions or b) a series of repetitive brief (phasic) muscle contractions termed rhythmic
masticatory muscle activity (RMMA).
Note 2. Characteristic changes in masseter EMG are often more prominent than changes in the chin EMG.
G. Scoring PSG Features of REM Sleep Behavior Disorder (RBD)

Sustained muscle activity (tonic activity) in REM sleep: An epoch of REM sleep with at least 50% of the duration of the
epoch having a chin EMG amplitude greater than the minimum amplitude demonstrated in NREM sleep.
Excessive transient muscle activity (phasic activity) in REM sleep: In a 30-second epoch of REM sleep divided into
10 sequential 3-second mini-epochs, at least 5 (50%) of the mini-epochs contain bursts of transient muscle activity. In
RBD, excessive transient muscle activity bursts are 0.1–5.0 seconds in duration and at least 4 times as high in amplitude
as the background EMG activity.
2. The polysomnographic characteristics of RBD are characterized by EITHER or BOTH of the following
features: N1,N2,N3 RECOMMENDED
a. Sustained muscle activity in REM sleep in the chin EMG
b. Excessive transient muscle activity during REM in the chin or limb EMG
VII. Movement Rules
Note 1. Transient muscle activity and occasional accompanying visible twitching of small muscle groups are a
normal phenomenon seen in REM sleep (see IV.I.1). When larger muscle groups are involved, this activity is
not associated with large, overt muscular activity acting across large joints. When smaller muscle groups are
involved, the movement often involves the distal muscles of the hands and face or the corners of the mouth.
Transient muscle activity may be excessive in RBD.
Note 2. The sustained muscle activity or the excessive transient muscle activity observed in REM sleep may be
interrupted by superimposed (usually dream-enacting) behaviors of RBD.
Note 3. In normal individuals there is an atonia seen in REM sleep in the chin and anterior tibialis EMG. In this
state the baseline amplitude of the EMG signal decreases markedly. This atonia of REM sleep is lost to a
considerable extent in RBD, with variable frequency, and as a result, the EMG baseline amplitude is often
higher. In this situation, the EMG can be said to be in a tonic rather than atonic state.
H. Scoring the PSG Features of Rhythmic Movement Disorder

1. The following define the polysomnographic characteristics of rhythmic movement disorder: RECOMMENDED
a. The minimum frequency for scoring rhythmic movements is 0.5 Hz.
b. The maximum frequency for scoring rhythmic movements is 2.0 Hz.
c. The minimum number of individual movements required to make a cluster of rhythmic movements is 4 movements.
d. The minimum amplitude of an individual rhythmic burst is 2 times the background EMG activity.
VIII. Respiratory Rules Part 1: Rules for Adults
A. Technical Specifications
1. For identification of an apnea during a diagnostic study, use an oronasal thermal airflow sensor to monitor
airflow. N1 RECOMMENDED
2. For identification of an apnea during a diagnostic study when the oronasal thermal airflow sensor is not functioning or
the signal is not reliable, use one of the following (alternative apnea sensors): N2
a. nasal pressure transducer (with or without square root transformation) RECOMMENDED
b. Respiratory inductance plethysmography sum (RIPsum) (calibrated or uncalibrated) RECOMMENDED
c. Respiratory inductance plethysmography flow (RIPflow) (calibrated or uncalibrated) RECOMMENDED
d. PVDFsum ACCEPTABLE
3. For identification of a hypopnea during a diagnostic study, use a nasal pressure transducer (with or without square
root transformation of the signal) to monitor airflow. N3 RECOMMENDED
4. For identification of a hypopnea during a diagnostic study when the nasal pressure transducer is not functioning or the
signal is not reliable, use one of the following (alternative hypopnea sensors): N2
a. oronasal thermal airflow RECOMMENDED
b. RIPsum (calibrated or uncalibrated) RECOMMENDED
c. RIPflow (calibrated or uncalibrated) RECOMMENDED
d. dual thoracoabdominal RIP belts (calibrated or uncalibrated) RECOMMENDED
e. PVDFsum ACCEPTABLE
5. During positive airway pressure (PAP) titration, use the PAP device flow signal to identify apneas or
hypopneas. RECOMMENDED
6. For monitoring respiratory effort, use one of the following:

a. esophageal manometry RECOMMENDED
b. dual thoracoabdominal RIP belts (calibrated or uncalibrated) RECOMMENDED
c. dual thoracoabdominal PVDF belts ACCEPTABLE
7. For monitoring oxygen saturation, use pulse oximetry with a maximum acceptable signal averaging time of ≤3 seconds
at a heart rate of 80 beats per minute. RECOMMENDED
8. For monitoring snoring, use an acoustic sensor (e.g. microphone), piezoelectric sensor or nasal pressure
transducer. N4 RECOMMENDED
9. For detection of hypoventilation during a diagnostic study, use arterial PCO2, transcutaneous PCO2 or end-tidal
PCO2. N5,N6 RECOMMENDED
10. For detection of hypoventilation during PAP titration, use arterial PCO2, or use transcutaneous
Note 1. Thermal sensors include thermistors, thermocouples, or polyvinylidene fluoride (PVDF) airflow sensors.
Note 2. The RIPsum is the sum of the signals from thoracic and abdominal RIP sensors (belts) and excursions in the
signal are an estimate of tidal volume. The RIPflow is the time derivative of the RIPsum and excursions in
the signal are an estimate of airflow. The PVDFsum is the sum of signals from thoracic and abdominal PVDF
sensors (belts). Recording of RIPsum, RIPflow, or PVDFsum is optional.
Note 3. Using the nasal pressure signal without square root transformation for scoring hypopneas will result in a
slightly higher hypopnea index than scoring using a square root transformation of the signal. This difference
is not clinically significant in most patients.
Note 4. Monitoring snoring is optional as noted in Parameters to be Reported (II.F).
Note 5. Monitoring hypoventilation is optional as noted in Parameters to be Reported (II.F).
Note 6. a. Clinical judgment is essential when assessing the accuracy of end-tidal PCO2 and transcutaneous PCO2
readings. The values should not be assumed to be accurate surrogates of the arterial PCO2 when the values
do not fit the clinical picture.
b. T
he transcutaneous PCO2 sensor should be calibrated with a reference gas according to the manufacturer’s
recommendations and when the accuracy of the reading is doubtful. Of note, the value of the
transcutaneous PCO2 typically lags behind changes in the arterial PCO2 by two minutes or more.
c. The end-tidal PCO2 often malfunctions or provides falsely low values in patients who have marked nasal
obstruction, profuse nasal secretions, are obligate mouth breathers, or who are receiving supplemental
oxygen It is crucial to obtain a plateau in the end-tidal waveform for the signal to be considered valid.
B. Measuring Event Duration

1. For scoring either an apnea or a hypopnea, the event duration is measured from the nadir preceding the first breath
that is clearly reduced to the beginning of the first breath that approximates the baseline breathing amplitude. (see red
bracket, Figures 1 and 2) RECOMMENDED
2. For apnea duration, the oronasal thermal sensor signal (diagnostic study) or PAP device flow signal (PAP titration
study) should be used to determine the event duration. For hypopnea event duration, the nasal pressure signal
(diagnostic study) or PAP device flow signal (PAP titration study) should be utilized. When the diagnostic study
sensors fail or are inaccurate, alternative sensors may be used (see Technical Specifications for adults A.2 and
A.4). RECOMMENDED
3. When baseline breathing amplitude cannot be easily determined (and when underlying breathing variability is large),
events can also be terminated when either there is a clear and sustained increase in breathing amplitude, or in the case
where a desaturation has occurred, there is event-associated resaturation of at least 2%. RECOMMENDED
Epoch
50 51
Nasal
Pressure
Thermal
Sensor
Inductance
Pleth Sum
Figure 1. A respiratory
event that should be
scored as an apnea. The
SpO2
red bracket indicates the
full duration of the apnea
10 sec event.
Epoch
50 51
Nasal
Pressure
Thermal
Sensor
Inductance
Pleth Sum Figure 2. A respiratory
event that should
be scored as a
hypopnea. The red
SpO2
bracket indicates the
10 sec full duration of the
hypopnea event.
C. Scoring of Apneas
1. Score a respiratory event as an apnea when BOTH of the following criteria are met: N1,N2,N3,N4 (see Figure 1) RECOMMENDED
a. There is a drop in the peak signal excursion by ≥90% of pre-event baseline using an oronasal thermal sensor (diagnostic
study), PAP device flow (titration study) or an alternative apnea sensor (diagnostic study).
b. The duration of the ≥90% drop in sensor signal is ≥10 seconds.
2. Score an apnea as obstructive if it meets apnea criteria and is associated with continued or increased inspiratory effort
throughout the entire period of absent airflow. RECOMMENDED
3. Score an apnea as central if it meets apnea criteria and is associated with absent inspiratory effort throughout the
entire period of absent airflow. RECOMMENDED
4. Score an apnea as mixed if it meets apnea criteria and is associated with absent inspiratory effort in the initial portion
of the event, followed by resumption of inspiratory effort in the second portion of the event. N5 RECOMMENDED
Note 1. Identification of an apnea does not require a minimum desaturation criterion.

Note 2. If a portion of a respiratory event that would otherwise meet criteria for a hypopnea meets criteria for apnea,
the entire event should be scored as an apnea.
Note 3. If the apnea or hypopnea event begins or ends during an epoch that is scored as sleep, then the corresponding
respiratory event can be scored and included in the computation of the apnea-hypopnea index (AHI). This
situation usually occurs when an individual has a high AHI with events occurring so frequently that sleep is
severely disrupted and epochs may end up being scored as wake even though <15 seconds of sleep is present
during the epoch containing that portion of the respiratory event. However, if the apnea or hypopnea occurs
entirely during an epoch scored as wake, it should not be scored or counted towards the apnea-hypopnea
index because of the difficulty of defining a denominator in this situation. If these occurrences are a
prominent feature of the polysomnogram and/or interfere with sleep onset, their presence should be
mentioned in the narrative summary of the study.
Note 4. For alternative apnea sensors see Technical Specifications for adults (A.2).
Note 5. There is not sufficient evidence to support a specific duration of the central and obstructive components of a
mixed apnea; thus, specific durations of these components are not recommended.
D. Scoring of Hypopneas
Scoring hypopneas as central or obstructive events is optional as noted in Parameters to be Reported (II.F).
1A. Score a respiratory event as a hypopnea if ALL of the following criteria are met: N1,N2,N3 (see Figure 2) RECOMMENDED
a. The peak signal excursions drop by ≥30% of pre-event baseline using nasal pressure (diagnostic study), PAP device flow
(titration study), or an alternative hypopnea sensor (diagnostic study).
b. The duration of the ≥30% drop in signal excursion is ≥10 seconds.
c. There is a ≥3% oxygen desaturation from pre-event baseline or the event is associated with an arousal.
1B. Score a respiratory event as a hypopnea if ALL of the following criteria are met: N1,N2,N3 ACCEPTABLE
(titration study), or an alternative hypopnea sensor (diagnostic study).
c. There is a ≥4% oxygen desaturation from pre-event baseline.
2. If electing to score obstructive hypopneas, score a hypopnea as obstructive if ANY of the following criteria are
met: RECOMMENDED
a. There is snoring during the event.
b. There is increased inspiratory flattening of the nasal pressure or PAP device flow signal compared to baseline breathing.
c. There is an associated thoracoabdominal paradox that occurs during the event but not during pre-event breathing.
3. If electing to score central hypopneas, score a hypopnea as central if NONE of the following criteria are
met: RECOMMENDED
Note 1. The criteria used to score a respiratory event as a hypopnea (either rule 1A or 1B) should be specified in the
PSG report. It is the responsibility of the individual practitioner to confirm and follow the criteria that should
be used for reporting to the patient’s payer in order to be reimbursed and qualify the patient for therapy.
Note 2. For alternative hypopnea sensors see Technical Specifications for adults (A.4).
Note 3. Supplemental oxygen may blunt desaturation. There are currently no scoring guidelines for when a patient
is on supplemental oxygen and no desaturation is noted. If the diagnostic study is performed while the
individual is on supplemental oxygen, its presence should be mentioned in the narrative summary of
the study.
E. Scoring Respiratory Effort-Related Arousal

Scoring respiratory effort-related arousals is optional as noted in Parameters to be Reported (II.F).
1. If electing to score respiratory effort-related arousals, score a respiratory event as a respiratory effort-related arousal
(RERA) if there is a sequence of breaths lasting ≥10 seconds characterized by increasing respiratory effort or by
flattening of the inspiratory portion of the nasal pressure (diagnostic study) or PAP device flow (titration study)
waveform leading to arousal from sleep when the sequence of breaths does not meet criteria for an apnea or hypopnea.
Epoch
50 51
Arousal
Nasal
Pressure
Thermal
Sensor
Inductance Figure 3. A respiratory

Pleth Sum event that should be
scored as a respiratory
effort-related arousal
SpO2 (RERA). The red
bracket indicates the
10 sec full duration of the
RERA event.
F. Scoring Hypoventilation
Monitoring hypoventilation is optional as noted in Parameters to be Reported (II.F).
1. If electing to score hypoventilation, score hypoventilation during sleep if EITHER of the below occur: N1,N2 RECOMMENDED
a. There is an increase in the arterial PCO2 (or surrogate) to a value >55 mmHg for ≥10 minutes.
b. There is ≥10 mmHg increase in arterial PCO2 (or surrogate) during sleep (in comparison to an awake supine value) to a
value exceeding 50 mmHg for ≥10 minutes.
Note 1. See Technical Specifications for adults (A.9 and A.10) for information on surrogate signals for monitoring
hypoventilation.
Note 2. Use the following conversion factor in order to change the units of the pressures listed from mmHg to kPa:
1 mmHg = 0.133 kPA.
G. Scoring Cheyne-Stokes Breathing

1. Score a respiratory event as Cheyne-Stokes breathing if BOTH of the following are met: N1,N2 (see Figure 4) RECOMMENDED
a. There are episodes of ≥3 consecutive central apneas and/or central hypopneas separated by a crescendo and decrescendo
change in breathing amplitude with a cycle length of ≥40 seconds.
b. There are ≥5 central apneas and/or central hypopneas per hour of sleep associated with the crescendo/decrescendo
breathing pattern recorded over ≥2 hours of monitoring.
Minutes
1 2 3 4 5 6 7 8 9 10
Nasal
Pressure
Thermal
Sensor
Inductance
Pleth Sum
SpO2
20 sec
Note 1. Cycle length is the time from the beginning of a central apnea to the end of the next crescendo-decrescendo
respiratory phase (start of the next apnea).
Note 2. Central apneas that occur within a run of Cheyne-Stokes breathing should be scored as individual apneas as
well.
VIII. Respiratory Rules Part 2: Rules for Children
A. Ages for Which Pediatric Respiratory Scoring Rules Apply

1. Criteria for respiratory events during sleep for infants and children can be used for children <18 years, but an
individual sleep specialist can choose to score children ≥13 years using adult criteria. N1 RECOMMENDED
Note 1. Several studies suggest that the apnea-hypopnea index (AHI) will be higher in adolescent patients when
using pediatric compared to the adult rules presented in the 2007 version of the AASM scoring manual. As
adult hypopnea rule 1A and pediatric hypopnea rules are similar, there may now be less difference in the
AHI when using adult versus pediatric rules.
1. For identification of an apnea during a diagnostic study, use an oronasal thermal airflow sensor to monitor
airflow.N1 RECOMMENDED
2. For identification of an apnea during a diagnostic study when the oronasal thermal airflow sensor is not functioning or
the signal is not reliable, use one of the following (alternative apnea sensors): N2
a. nasal pressure transducer (with or without square root transformation) RECOMMENDED
b. Respiratory inductance plethysmography sum (RIPsum) (calibrated or uncalibrated) RECOMMENDED
c. Respiratory inductance plethysmography flow (RIPflow) (calibrated or uncalibrated) RECOMMENDED
d. end-tidal PCO2 ACCEPTABLE
3. For identification of a hypopnea during a diagnostic study, use a nasal pressure transducer (with or without square
root transformation of the signal) to monitor airflow. N3 RECOMMENDED
4. For identification of a hypopnea during a diagnostic study when the nasal pressure transducer is not functioning or the
signal is not reliable, use one of the following to monitor airflow (alternative hypopnea sensors): N2
a. oronasal thermal airflow RECOMMENDED
b. RIPsum (calibrated or uncalibrated) RECOMMENDED
c. RIPflow (calibrated or uncalibrated) RECOMMENDED
d. dual thoracoabdominal RIP belts (calibrated or uncalibrated) RECOMMENDED
5. During positive airway pressure (PAP) titration, use the PAP device flow signal to identify apneas or
hypopneas. RECOMMENDED
6. For monitoring respiratory effort, use one of the following:

a. esophageal manometry RECOMMENDED
b. dual thoracoabdominal RIP belts (calibrated or uncalibrated) RECOMMENDED
7. For monitoring oxygen saturation, use pulse oximetry with a maximum acceptable signal averaging time of ≤3 seconds
at a heart rate of 80 beats per minute. RECOMMENDED
transducer. N4 RECOMMENDED
9. For detection of hypoventilation during a diagnostic study, use arterial PCO2, transcutaneous PCO2 or end-tidal
10. For detection of hypoventilation during PAP titration, use arterial PCO2, or use transcutaneous
PCO2.N5,N6 RECOMMENDED
the signal are an estimate of airflow. Recording of RIPsum or RIPflow is optional.
Note 3. Using the nasal pressure signal without square root transformation for scoring hypopneas will result in a
slightly higher hypopnea index than scoring using a square root transformation of the signal. This difference
is not clinically significant in most patients.
Note 4. Monitoring snoring is optional, as noted in Parameters to be Reported (II.F).
Note 5. Monitoring hypoventilation during diagnostic study is recommended, as noted in Parameters to be Reported
(II.F). Monitoring hypoventilation during PAP titration is optional, as noted in Parameters to be Reported
(II.F)
Note 6. a. Clinical judgment is essential when assessing the accuracy of end-tidal PCO2 and transcutaneous PCO2
readings. The values should not be assumed to be accurate surrogates of the arterial PCO2 when the values
do not fit the clinical picture.
b. T
he transcutaneous PCO2 sensor should be calibrated with a reference gas according to the manufacturer’s
recommendations and when the accuracy of the reading is doubtful. Of note, the value of the
transcutaneous PCO2 typically lags behind changes in the arterial PCO2 by two minutes or more.
c. The end-tidal PCO2 often malfunctions or provides falsely low values in patients who have marked nasal
obstruction, profuse nasal secretions, are obligate mouth breathers, or who are receiving supplemental
oxygen It is crucial to obtain a plateau in the end-tidal waveform for the signal to be considered valid.
C. Measuring Event Duration

1. Same as Measuring Event Duration in adults (B.1–3)N1,N2 RECOMMENDED
Note 1. For alternative apnea sensors see Technical Specifications for children (B.2).
Note 2. For alternative hypopnea sensors see Technical Specifications for children (B.4).
D. Scoring of Apneas
1. Score a respiratory event as an apnea when ALL of the following criteria are met: N1,N2,N3,N4,N5,N6 RECOMMENDED
a. There is a drop in the peak signal excursion by ≥90% of pre-event baseline using an oronasal thermal sensor (diagnostic
study), PAP device flow (titration study), or an alternative apnea sensor (diagnostic study).
b. The duration of the ≥90% drop in sensor signal lasts at least the minimum duration as specified by obstructive, mixed, or
central apnea duration criteria.
c. The event meets respiratory effort criteria for obstructive, central or mixed apnea.
2. Score an apnea as obstructive if it meets apnea criteria for at least the duration of 2 breaths during baseline breathing
AND is associated with the presence of respiratory effort throughout the entire period of absent airflow. RECOMMENDED
3. Score an apnea as central if it meets apnea criteria, is associated with absent inspiratory effort throughout the entire
duration of the event AND at least one of the following is met: RECOMMENDED
a. The event lasts ≥20 seconds.
b. The event lasts at least the duration of two breaths during baseline breathing and is associated with an arousal or a ≥3%
arterial oxygen desaturation.
c. The event lasts at least the duration of two breaths during baseline breathing and is associated with a decrease in heart rate
to less than 50 beats per minute for at least 5 seconds or less than 60 beats per minute for 15 seconds (infants under 1 year
of age only).
4. Score an apnea as mixed if it meets apnea criteria for at least the duration of 2 breaths during baseline breathing AND
is associated with absent respiratory effort during one portion of the event AND the presence of inspiratory effort in
another portion, regardless of which portion comes first. RECOMMENDED

Note 2. If a portion of a respiratory event that would otherwise meet criteria for a hypopnea meets criteria for apnea
(including 2 breath minimum), the entire event should be scored as an apnea.
Note 3. If the apnea or hypopnea event begins or ends during an epoch that is scored as sleep, then the corresponding
respiratory event can be scored and included in the computation of the apnea-hypopnea index (AHI). This
situation usually occurs when an individual has a high AHI with events occurring so frequently that sleep
is severely disrupted and epochs may end up being scored as wake even though <15 seconds of sleep is
present during the epochs containing that portion of the respiratory event. However, if the apnea or hypopnea
occurs entirely during an epoch scored as wake, it should not be scored or counted towards the AHI because
of the difficulty of defining a denominator in this situation. If these occurrences are a prominent feature of
the polysomnogram and/or interfere with sleep onset, their presence should be mentioned in the narrative
summary of the study.
Note 4. For alternative apnea sensors see Technical Specifications for children (B.2).
Note 6. While not a requirement for reporting, it is valuable to describe any airway protective maneuvers, such
as persistent mouth opening/mouth breathing, neck hyperextension and avoidance of sleep in the supine
position, as these can be supplemental evidence of obstructive sleep apnea.
E. Scoring of Hypopneas
Scoring hypopneas as central or obstructive events is optional as noted in Parameters to be Reported (II.F).
1. Score a respiratory event as a hypopnea if ALL of the following criteria are met: N1,N2,N3 RECOMMENDED
(titration study) or an alternative hypopnea sensor (diagnostic study).
b. The duration of the ≥30% drop in signal excursion lasts for ≥2 breaths.
c. There is a ≥3% oxygen desaturation from pre-event baseline or the event is associated with an arousal.
2. If electing to score obstructive hypopneas, score a hypopnea as obstructive if ANY of the following criteria are
met: RECOMMENDED
3. If electing to score central hypopneas, score a hypopnea as central if NONE of the following criteria are
met: RECOMMENDED
Note 1. For alternative hypopnea sensors see Technical Specifications for children (B.4).
Note 2. Supplemental oxygen may blunt desaturation. There are currently no scoring guidelines for when a
patient is on supplemental oxygen and no desaturation is noted. If the diagnostic study is performed while
the individual is on supplemental oxygen, its presence should be mentioned in the narrative summary
of the study.
Note 3. While not a requirement for reporting, it is valuable to describe any airway protective maneuvers, such
as persistent mouth opening/mouth breathing, neck hyperextension and avoidance of sleep in the supine
position, as these can be supplemental evidence of obstructive sleep apnea.
F. Scoring Respiratory Effort-Related Arousal

Scoring respiratory effort-related arousals is optional as noted in Parameters to be Reported (II.F).
1. If electing to score respiratory effort-related arousals, score a respiratory event as a RERA if there is a sequence of
breaths lasting ≥2 breaths (or the duration of two breaths during baseline breathing) that do not meet criteria for an
apnea or hypopnea and lead to an arousal from sleep. The breathing sequence can be characterized when one or more
of the following is present: RECOMMENDED
a. Increasing respiratory effort
b. Flattening of the inspiratory portion of the nasal pressure (diagnostic study) or PAP device flow (titration study) waveform
c. Snoring
d. An elevation in the end-tidal PCO2 above pre-event baseline
G. Scoring of Hypoventilation
Monitoring hypoventilation in children is recommended during a diagnostic study and optional during a PAP titration study.
1. Score as hypoventilation during sleep when >25% of the total sleep time as measured by either the arterial PCO2 or
surrogate is spent with a PCO2 >50 mmHg. N1,N2 RECOMMENDED
Note 1. See Technical Specifications for children (B.9 and B.10) for information on surrogate signals for monitoring
hypoventilation.
Note 2. Use the following conversion factor in order to change the units of the pressures listed from mmHg to kPa:
1 mmHg = 0.133 kPA.
H. Scoring of Periodic Breathing

1. Score a respiratory event as periodic breathing if there are ≥3 episodes of central pauses in respiration (absent airflow
and inspiratory effort) lasting >3 seconds separated by ≤20 seconds of normal breathing. N1 RECOMMENDED
Note 1. Central apneas that occur within a run of periodic breathing should be scored as individual apneas as well.
Part 1: HSAT Utilizing Respiratory Flow and/or Effort Parameters
A. General Parameters to be Reported N1
1. Type of device RECOMMENDED
2. Type of airflow sensor(s) N2 RECOMMENDED
3. Type of respiratory effort sensor(s) (single or dual) RECOMMENDED
5. Heart rate (ECG or derived from oximeter) RECOMMENDED
6. Body position OPTIONAL
7. Sleep/wake or monitoring time (method of determination) N3 OPTIONAL
8. Snoring (acoustic or piezo-electric sensor or signal derived from nasal pressure sensor) OPTIONAL
Note 1. For alternative measures see Part 2: HSAT Utilizing Peripheral Arterial Tonometry (PAT).
Note 2. Tidal volume sensors (i.e. RIPsum) can also be used.
Note 3. Sleep should be determined using EEG, EOG, and chin (submental) EMG recording. The method used to
determine monitoring time (MT) should be specified in the report.
B. Recording Data to be Reported
1. Recording start time (hr:min) RECOMMENDED
2. Recording end time (hr:min) RECOMMENDED
3. Total recording time (TRT) min (including wake and artifact) RECOMMENDED
4. Monitoring time (MT) N1 in min (time used to calculate respiratory event index) N2 RECOMMENDED
5. Total sleep time (TST) in min (if recorded) N3 OPTIONAL
6. Heart rate (average, highest, lowest) RECOMMENDED
7. Number of respiratory events (RE) RECOMMENDED
7a. Number of apneas RECOMMENDED
IX. Home Sleep Apnea Testing (HSAT) Rules for Adults Part 1: HSAT Utilizing Respiratory Flow and/or Effort Parameters
7b. Number of hypopneas RECOMMENDED
7c. Number of obstructive, central, and mixed apneas OPTIONAL
8. R
espiratory event index (REI) based on monitoring time (MT) = RECOMMENDED
(# respiratory events × 60) / MT in min
9. A
pnea-hypopnea index (AHI) = ((# apneas + # hypopneas) × 60) / TST in min RECOMMENDED
(only if sleep is recorded) N3
10. REI or AHI in the supine and non-supine positions OPTIONAL
11. Central apnea index (CAI) = (# central apneas × 60) / MT in min OPTIONAL
12. A measure of oxygen saturation (one of these three parameters) N4 RECOMMENDED
12a. Oxygen desaturation index (ODI) ≥3 or ≥4% = (# oxygen desaturations ≥3% or ≥4% × 60) /
MT in min [Specify measure of desaturation ≥3 or ≥4%] N5
12b. Arterial oxygen saturation, mean value, maximum value, and minimum value
12c. Arterial oxygen saturation % of time at or below 88% or other thresholds
13. Occurrence of snoring (if recorded) OPTIONAL
Note 1. Monitoring time (MT) = Total recording time minus periods of artifact and time the patient was awake as
determined by actigraphy, body position sensor, respiratory pattern, or patient diary. The method used to
determine MT should be stated. For reimbursement purposes, individual practitioners may need to indicate
in their HSAT report that monitoring time (MT) is being used in place of total recording time (TRT).
Note 2. Respiratory event index (REI) = Total number of respiratory events scored × 60 divided by monitoring time
(MT). For reimbursement purposes, individual practitioners may need to indicate in their HSAT report that
REI is a surrogate for AHI.
Note 3. This assumes monitoring EEG, EOG, and submental chin EMG.
Note 4. Reporting all three parameters may provide important information for the clinician.
Note 5. ODI should report the same desaturation as used for scoring hypopneas. For example, if hypopnea is scored
based on a ≥3% desaturation, the ODI should be the number of ≥3% desaturations × 60 divided by MT.
C. Summary Statements
1. Date of test/date of interpretation RECOMMENDED
2. Technical adequacy of study (defined by sleep center policy and procedure) RECOMMENDED
2a. Document repeat study for technical failures RECOMMENDED
2b. Limitations of study RECOMMENDED
3. Interpretation of REI (based on MT) or AHI (if sleep is recorded) RECOMMENDED
4. Occurrence of snoring RECOMMENDED
5. Interpretation RECOMMENDED
5a. Study supports diagnosis of OSA or not RECOMMENDED
5b. Statement of diagnostic severity (if applicable) RECOMMENDED
5c. If study is non-diagnostic, recommend in-laboratory PSG (if clinically indicated) RECOMMENDED
6. Printed name and signature of interpreting physician (verifying review of raw data) RECOMMENDED
7. Recommendation for management that meets AASM Clinical Practice Guidelines and RECOMMENDED
Practice Parameters
8. Chain of custody (if applicable) OPTIONAL
D. Technical and Digital Specifications: HSAT Equipment Recording Features
1. FDA approval of device RECOMMENDED
2. Unique identifier for each unit RECOMMENDED
3. Must meet minimum definition for CPT codes 95800, 95801 or 95806 N1 RECOMMENDED
4. Ability to record oximetry RECOMMENDED
5. Ability to record a measure of heart rate RECOMMENDED
6. Ability to display raw data for review, manual scoring or editing of automated scoring N2 RECOMMENDED
7. Ability to calculate a respiratory event index (REI) based on monitoring time (MT) as a RECOMMENDED
surrogate for the apnea-hypopnea index (AHI) determined by PSG
8. Ability to determine chain of custody OPTIONAL
Note 1. 95800—Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis
(e.g. by airflow or peripheral arterial tone), and sleep time
95801—Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis
(e.g. by airflow or peripheral arterial tone)
95806—Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory airflow
and respiratory effort (e.g. thoracoabdominal movement)
Note 2. Raw tracings must be viewable in detail with the ability to edit events.
E. HSAT Respiratory Events Rules: Technical Specifications

1. For identification of respiratory events (RE) based on respiratory airflow during a home sleep apnea test (HSAT)
diagnostic study, use at least one of the following sensors: N1
a. oronasal thermal airflow sensor N2 RECOMMENDED
b. nasal pressure transducer (with or without square root transformation) N3,N4 RECOMMENDED
c. alternative sensors include: N5
i. respiratory inductance plethysmography sum (RIPsum) or flow (RIPflow) RECOMMENDED
ii. PVDFsum ACCEPTABLE
2. For monitoring respiratory effort,N6 use one of the following technologies:

a. single or dual thoracoabdominal RIP belts N5 RECOMMENDED
b. single or dual thoracoabdominal PVDF belts N5 ACCEPTABLE
c. single or dual thoracoabdominal piezo beltsN5 ACCEPTABLE
d. single or dual pneumatic beltsN5 ACCEPTABLE
3. For monitoring oxygen saturation, use pulse oximetry. N7 RECOMMENDED
transducer. OPTIONAL
Note 1. At least one airflow sensor is required. Ideally both an oronasal thermal sensor and a nasal pressure
transducer should be used to record airflow. An alternative sensor (as listed above) may be a substituted for
an oronasal thermal sensor.
If used without simultaneous nasal pressure monitoring, some thermal sensors may be less sensitive for
detection of hypopneas.
Note 3. Using the nasal pressure signal without square root transformation for scoring sleep-related respiratory
events (SRE) will result in a slightly higher hypopnea index than scoring using a square root transformation
of the signal. This difference is not clinically significant in most patients.
Note 4. If the nasal pressure signal is used without simultaneous recording of oronasal thermal sensor signal, some
hypopneas may be classified as apneas.
the signal are an estimate of airflow. The PVDFsum is the sum of signals from thoracic and abdominal PVDF
sensors (belts).
Note 6. Only CPT code 95806 requires respiratory effort monitoring. If respiratory effort monitoring is performed
one of these technologies should be used. The use of two belts is preferred; however, one respiratory
monitoring belt is acceptable.
Note 7. The recording device should meet the same requirements for oximetry as the in-laboratory PSG.
F. HSAT Respiratory Events Rules: Scoring Apnea Utilizing Respiratory Flow and/or Effort
Sensors
1. Score a respiratory event as an apnea when BOTH of the following criteria are met: N1,N2,N3,N4 RECOMMENDED
a. There is a drop in the peak signal excursion by ≥90% of pre-event baseline using a recommended or alternative airflow
sensor.
b. The duration of the ≥90% drop in sensor signal is ≥10 seconds.
2. Score an apnea as obstructive if it meets apnea criteria and is associated with continued or increased inspiratory effort
throughout the entire period of absent airflow. RECOMMENDED
3. Score an apnea as central if it meets apnea criteria and is associated with absent inspiratory effort throughout the
entire period of absent airflow. RECOMMENDED
4. Score an apnea as mixed if it meets apnea criteria and is associated with absent inspiratory effort in the initial portion
of the event, followed by resumption of inspiratory effort in the second portion of the event. RECOMMENDED

Note 2. If a portion of a respiratory event that would otherwise meet criteria for a hypopnea meets criteria for apnea,
the entire event should be scored as an apnea.
Note 4. Some devices may not differentiate between different types of apneas.
G. H
SAT Respiratory Events Rules: Scoring Hypopnea Utilizing Respiratory Flow and/or Effort
Sensors N1
1A. I f sleep is NOT recorded, score a respiratory event as a hypopnea if ALL of the following criteria are
met: N1 RECOMMENDED
a. The peak signal excursions drop by ≥30% of pre-event baseline using a recommended or alternative airflow sensor.
1B. I f sleep is NOT recorded, score a respiratory event as a hypopnea if ALL of the following criteria are
met: N1 ACCEPTABLE
2A. If sleep IS recorded, score a respiratory event as a hypopnea if ALL of the following criteria are met: N1,N2 RECOMMENDED
c. There is a ≥3% oxygen desaturation from pre-event baseline or the event is associated with an arousal. N2
2B. If sleep IS recorded, score a respiratory event as a hypopnea if ALL of the following criteria are met: N1,N2 ACCEPTABLE
Note 1. The criteria used to score a respiratory event as a hypopnea should be specified in the report.
Note 2. Scoring a hypopnea based on arousals is only possible if sleep is recorded.
H. References
The following references apply to content throughout chapter IX. Home Sleep Apnea Testing (HSAT) Rules for Adults
Part 1: HSAT Utilizing Respiratory Flow and/or Effort Parameters.
1. C
ollop NA, Anderson WM, Boehlecke B, et al.; for the Portable Monitoring Task Force of the American Academy of Sleep
Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in
adult patients. J Clin Sleep Med. 2007;3(7):737–747.
2. C
ollop NA, Tracy SL, Kapur V, et al. Obstructive sleep apnea devices for out-of-center (OOC) testing: technology
evaluation. J Clin Sleep Med. 2011;7(5):531–548.
Part 2: HSAT Utilizing Peripheral Arterial Tonometry (PAT )
A. General Parameters to be Reported
1. Type of device RECOMMENDED
2. Sleep/wake and REM time estimates (derived from actigraphy) RECOMMENDED
3. Airflow/effort surrogate (peripheral arterial tone) signals RECOMMENDED
5. Heart rate RECOMMENDED
6. Occurrence of snoring (if recorded) OPTIONAL
7. Body position (if recorded) OPTIONAL
B. Recording Data to be Reported
1. Recording start time (hr:min) RECOMMENDED
2. Recording end time (hr:min) RECOMMENDED
3. Duration of recording (hr:min) (total recording time, TRT) RECOMMENDED
4. Estimated sleep time (in min) RECOMMENDED
4a. Estimated % REM, deep sleep, light sleep OPTIONAL
5. Heart rate (average, highest, lowest) RECOMMENDED
6. Number of sleep-related respiratory events (RE) RECOMMENDED
7. Oxygen desaturation index (ODI) ≥4% = (# oxygen desaturations ≥4% × 60) / MT in min RECOMMENDED
C. Summary Statements
1. Date of test/Date of interpretation RECOMMENDED
2. Technical adequacy of study (defined by sleep center policy and procedure) RECOMMENDED
2a. Document repeat study for technical failures RECOMMENDED
IX. Home Sleep Apnea Testing (HSAT) Rules for Adults Part 2: HSAT Utilizing Peripheral Arterial Tonometry (PAT)
2b. Limitations of study RECOMMENDED
3. Interpretation of estimated sleep time RECOMMENDED
4. Occurrence of snoring OPTIONAL
5. Interpretation RECOMMENDED
5a. Study supports diagnosis of OSA or not RECOMMENDED
5b. Statement of diagnostic severity (if applicable) RECOMMENDED
5c. If study is non-diagnostic, recommend in-laboratory PSG (if clinically indicated) RECOMMENDED
6. Printed name and signature of interpreting physician (verifying review of raw data) RECOMMENDED
7. Recommendation for management that meets AASM Clinical Practice Guidelines and RECOMMENDED
Practice Parameters
8. Chain of custody (if applicable) OPTIONAL
D. Technical and Digital Specifications: HSAT Equipment Recording Features
1. FDA approval of device RECOMMENDED
2. Unique identifier for each unit RECOMMENDED
3. Must meet minimum definition for CPT codes 95800 or 95801 N1 RECOMMENDED
4. Ability to record oximetry RECOMMENDED
5. Ability to record a measure of heart rate RECOMMENDED
6. Ability to display raw data for review, manual scoring or editing of automated scoring N2 RECOMMENDED
7. Ability to calculate REI (a surrogate apnea-hypopnea index (AHI)) N3 that is analogous to RECOMMENDED
apnea-hypopnea index (AHI) used for in-laboratory PSG
8. Ability to determine chain of custody OPTIONAL
Note 1. 95800—Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis
(e.g. by airflow or peripheral arterial tone), and sleep time
95801—Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis
(e.g. by airflow or peripheral arterial tone)
Note 2. Raw tracings must be viewable in detail with the ability to edit events.
Note 3. Surrogate AHI is based on estimated sleep time derived from actigraphy rather than EEG measurement of
total sleep time (TST).
IX. Home Sleep Apnea Testing (HSAT) Rules for Adults Part 2: HSAT Utilizing Peripheral Arterial Tonometry (PAT)
E. HSAT Respiratory Event Rules: Technical Specifications

1. For identification of respiratory events (RE) based on peripheral arterial tone during a home sleep apnea test (HSAT)
diagnostic study, use peripheral arterial tone, oxygen desaturation and changes in heart rate derived from
oximetry. N1 ACCEPTABLE
2. For monitoring oxygen saturation, use pulse oximetry. RECOMMENDED
Note 1. The algorithm used by the device must meet current AASM accreditation standards.
F. References
The following references apply to content throughout chapter IX. Home Sleep Apnea Testing (HSAT) Rules for Adults
Part 2: HSAT Utilizing Peripheral Arterial Tonometry (PAT).
1. C
ollop NA, Anderson WM, Boehlecke B, et al.; for the Portable Monitoring Task Force of the American Academy of Sleep
Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in
adult patients. J Clin Sleep Med. 2007;3(7):737–747.
2. C
ollop NA, Tracy SL, Kapur V, et al. Obstructive sleep apnea devices for out-of-center (OOC) testing: technology
evaluation. J Clin Sleep Med. 2011;7(5):531–548.
X. Development Process
Development of Version 2.0 and Future Updates

The principal participants in the development of Version 2.0 included: a) the scoring manual committee of 5 clinicians with a range
of expertise, 1 technologist and 1 board liaison appointed by the AASM Board of Directors, b) the 13 members of the Sleep Apnea
Definitions (SAD) Task Force appointed by the AASM Board of Directors and c) the science and research, graphics, communications,
and information technology staff of the AASM. The SAD Task Force consisted of 9 of the original 13 individuals who authored the
evidence review 1 used to develop the 2007 respiratory scoring rules and 4 additional respiratory scoring experts. After a review of the
literature, the task force developed recommendations on the sensors and rules to be used for scoring respiratory events, which were
subsequently approved by the AASM Board of Directors. More information on the methods used and the evidence examined by the
SAD task force may be found in the review paper 2 published in the Journal of Clinical Sleep Medicine.
For the most part, the content of the chapters on parameters to be reported, technical and digital specifications, visual rules (now sleep
staging rules), arousal rules, cardiac rules and movement rules remains largely unchanged from the 2007 version. The 2007 manual
should be consulted for the development process of these chapters.3 The Scoring Manual Committee, two members of which also
served on the SAD Task Force, drafted rules for a new respiratory chapter based on the recommendations in the SAD Task Force re-
view paper.2 Headings and formatting throughout the manual were edited for clarity and consistency. Critical terminology was made
up-to-date and consistent. The use of certain definitions in the manual was made into a rule to emphasize their importance. Scoring
manual FAQs from the AASM website were incorporated as notes in the appropriate sections of the manual. Already existing notes in
the manual were examined for relevance and clarity. New figures were designed for the sleep staging rules chapter that better illustrate
the rules for scoring sleep stages. Upon completion of the edits, all rules, figures and notes were re-edited and re-voted on until there
was consensus agreement among the committee. The AASM Board of Directors approved Version 2.0 of the scoring manual in July
2012. The Scoring Manual Committee was then tasked to continuously review and update the manual in order to further clarify existing
rules and notes or to recommend revisions based on new clinical evidence or advances in technology. The AASM Board of Directors
reviews and approves all revisions before a new version of the manual is published.
All scoring manual committee members completed AASM conflict of interest statements. Scoring manual committee members did
not have any level 1 conflicts of interest with any medical device that might be affected by the development of any recommendation.
Summary and Future Editions

According to the tenets of evidence-based medicine, clinical decision making should be guided by the best evidence from the research
field, the expertise of the clinician, and the expectations and values of the patient. The American Academy of Sleep Medicine (AASM)
is committed to utilizing evidence-based medicine in the updating of The AASM Manual for the Scoring of Sleep and Associated
Events. Systematic literature searches are conducted to collect all available evidence. Clinician content experts provide guidance and
feedback on drafts of potential rules. Sleep technologists and other sleep center staff contribute not only to expert opinion, but in com-
municating the priorities of the patient. Finally, the online format of the manual makes it particularly amendable to new evidence in the
literature and feedback from users and beneficiaries alike.
References
edline S, Budhiraja R, Kapur V, et al. The scoring of respiratory events in sleep: reliability and validity. J Clin Sleep Med.
1. R
2007;3(2):169–200.
2. B
erry RB, Budhiraja R, Gottlieb DJ, et al. Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual
for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American
Academy of Sleep Medicine. J Clin Sleep Med. 2012;8(5):597–619.
3. I ber C, Ancoli-Israel S, Chesson A, Quan SF; for the American Academy of Sleep Medicine. The AASM Manual for
the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. 1st ed. Westchester, IL:
American Academy of Sleep Medicine; 2007.
XI. Procedural Notes
Levels of Evidence

STANDARD Recommendation based on level 1 evidence or overwhelming level 2 evidence.

GUIDELINE Recommendation based on level 2 evidence or a consensus of level 3 evidence.

CONSENSUS Recommendation with less evidence than guideline for which agreement was reached in a standardized
consensus process based on available information.

ADJUDICATION Recommendation from the steering committee based on all available information. Adjudication was only
performed a) when there was insufficient evidence and no consensus agreement or b) in conjunction with
task force leaders on issues regarding minor clarifications and additions to rules.
Parameters. No evidence. Adopted and modified from previous AASM practice

A.1–9 CONSENSUS
parameter. Consensus of Task Force with approval by Steering Committee.
Sleep scoring data. No evidence. Adopted and modified from previous AASM
B.1–10 CONSENSUS
practice parameter. Consensus of Task Force with approval by Steering Committee.
Arousal events. No evidence. Adopted and modified from previous AASM practice
C.1–2 parameter and compliant with rules of Arousal Task Force. Consensus of Task Force CONSENSUS
with approval by Steering Committee.
Cardiac events. No evidence. Compliant with rules of Cardiac Task Force. Consensus
D.1–10 CONSENSUS
of Cardiac Task Force with approval by Steering Committee.
Movement events. No evidence. Compliant with rules of Movements Task Force.

E.1–4 CONSENSUS
Consensus of Movements Task Force with approval by Steering Committee.
Respiratory events. No evidence. Adopted and modified from previous AASM

practice parameter and compliant with rules of Respiratory Task Force. Consensus of
F.1–25 CONSENSUS
Respiratory Task Force with approval by Steering Committee. Version 2.0 additions
and approval from Scoring Manual Committee (SMC).*
Summary statements. No evidence. Adopted and modified from previous AASM

G.1–5 practice parameter. Consensus of Movements Task Force with approval by Steering CONSENSUS
Committee.
Sampling frequency and filter specifications for routine PSG recordings. No

evidence. Non-systematic review on ECG sampling rates and commonly applied
A.1–4 CONSENSUS
principles in practice. Consensus of Digital Task Force with approval by Steering
Committee.
Digital PSG recording systems features. No evidence. Consensus of Digital Task

B.1–8 CONSENSUS
Force with approval by Steering Committee.
PSG display and display manipulation. No evidence. Consensus of Digital Task Force
C.1–10 CONSENSUS
with approval by Steering Committee.
Digital analysis of PSG. No evidence. Consensus of Digital Task Force with approval
D.1–4 CONSENSUS
by Steering Committee.
Calibrations to document appropriate system response. No evidence. Consensus

E.1–21 agreement of Scoring Manual Editorial Board and approved by the AASM Board of CONSENSUS
Directors.
IV. Sleep Staging Rules Part 1: Rules For Adults
Recommended EEG derivation. Level 4 evidence. Consensus agreement by Visual

A.1 CONSENSUS
Task Force approved by Steering Committee.
Alternative EEG derivation. Level 4 evidence. Consensus agreement by Visual Task

A.2 CONSENSUS
Force approved by Steering Committee.
Ten-twenty application map. No evidence. Consensus vote was not felt necessary,
A.3 ADJUDICATION
Steering Committee approved as a standardized and universally accepted procedure.
Recommended EOG derivation. Level 4 evidence. Consensus agreement by Visual

B.1 CONSENSUS
Alternative EOG derivation. Level 4 evidence. Consensus agreement by Visual Task

B.2 CONSENSUS
EMG derivation. No evidence. Consensus agreement with clarification of specific CONSENSUS
C.1–2 distances and back-up electrode requested by industry and technical review panel and and
provided by Visual Task Force chair with Steering Committee approval. ADJUDICATION
Sleep stage terminology. No evidence. Consensus agreement by Visual Task Force

D.1 CONSENSUS
approved by Steering Committee.
Epoch scoring parameters. No evidence. Consensus agreement by Visual Task Force

D.2.a–b,d CONSENSUS
Assignment of epoch with multiple stages. No evidence. Clarification was provided

D.2.c ADJUDICATION
by agreement of Visual Task Force chair and Steering Committee.
Limited evidence. Consensus agreement of Scoring Manual Committee and approved

D.3 CONSENSUS
by the AASM Board of Directors.
Stage W definitions. Very limited level 3 and 4 evidence. Consensus agreement by

E.1 CONSENSUS
Visual Task Force approved by Steering Committee.
Presence of alpha. Inconsistent level 1 and level 2 evidence for reliability and level
E.2 3 evidence for validity. Consensus agreement by Visual Task Force approved by CONSENSUS
Steering Committee.
Stage N1 definitions. Limited evidence. Consensus agreement by Visual Task Force

F.1 CONSENSUS
Stage N1 based on replacement of alpha. Inconsistent level 1 and 2 evidence for

F.2 reliability and level 3 evidence for validity. Consensus agreement by Visual Task CONSENSUS
Stage N1 based on frequency slowing, vertex waves, and slow eye movements.
F.3 Limited evidence. Consensus agreement of Visual Task Force approved by Steering CONSENSUS
Committee.

F.4 CONSENSUS

F.5 CONSENSUS

F.6 CONSENSUS
Stage N2 definitions. Limited level 3 and 4 evidence. Consensus agreement of Visual

G.1 CONSENSUS
Stage N2 based on K complexes and spindles. Consistent level 1 and 2 evidence.

G.2 STANDARD
Decision by Steering Committee and consensus agreement of Visual Task Force.

G.3 CONSENSUS
Stage N2 continuation. Limited evidence. Consensus agreement of Visual Task Force

G.4 CONSENSUS

G.5 CONSENSUS
Stage N2 ending. Limited evidence, inferred from other rules. Consensus agreement
G.6 CONSENSUS
of Visual Task Force approved by Steering Committee.
Stage N3 definition. Consistent levels 3 and 4 evidence. Consensus agreement of

H.1 CONSENSUS
Visual Task Force approved by Steering Committee.
Stage N3 rule. Consistent level 1 and 2 evidence. Decision by Steering Committee

H.2 STANDARD
and consensus agreement of Visual Task Force.
Stage R definitions. Limited evidence. Consensus agreement of Visual Task Force

I.1 CONSENSUS
Stage R based on rapid eye movements, low EMG and EEG. Consistent level 1 and 2
I.2 evidence. Decision by Steering Committee and consensus agreement of Visual Task STANDARD
Force.

I.3 CONSENSUS

I.4 CONSENSUS
Continuation of Stage R. Limited evidence. Consensus agreement of Visual Task

I.5 CONSENSUS
Stage R ending. Inferred from other rules. Limited evidence. Consensus agreement
I.6 CONSENSUS
of Visual Task Force approved by Steering Committee.

I.7 CONSENSUS
Major body movement definition. No evidence. Consensus agreement of Visual Task

J.1 CONSENSUS
Major body movement rules. No evidence. Consensus agreement of Visual Task

J.2–4 CONSENSUS
Ages. Limited evidence. Consensus agreement of Pediatric Task Force approved by

A.1 CONSENSUS
Steering Committee.
Technical considerations. Adult rules accepted by Pediatric Task Force with pediatric
B.1 CONSENSUS
caveats provided in notes.
Terminology. No evidence. Consensus agreement of Pediatric Task Force approved

C.1 CONSENSUS
Scoring sleep stages. Limited evidence. Consensus agreement of Pediatric Task Force
C.2–5 CONSENSUS
Stage W definitions. Limited evidence. Consensus agreement of Pediatric Task Force

D.1 CONSENSUS
Stage W rules. Limited evidence. Consensus agreement of Pediatric Task Force

D.2 CONSENSUS
Stage N1 definitions. Limited evidence. Consensus agreement of Pediatric Task Force

E.1 CONSENSUS
Stage N1 rules. Limited evidence. Consensus agreement of Pediatric Task Force

E.2–3 CONSENSUS
F.1 Stage N2 rules. Adult rules accepted by Pediatric Task Force. CONSENSUS
G.1 Stage N3. Adult rules accepted by Pediatric Task Force. CONSENSUS
H.1 Stage R. Adult rules accepted by Pediatric Task Force. CONSENSUS
Ages. Consensus agreement of Scoring Manual Editorial Board and approved by the
A.1 CONSENSUS
AASM Board of Directors.
B.1 Technical considerations. Adult rules accepted by Scoring Manual Editorial Board. CONSENSUS
Recommended technical considerations. Consensus agreement of Scoring Manual

B.2 CONSENSUS
Editorial Board and approved by the AASM Board of Directors.
Optional technical considerations. Consensus agreement of Scoring Manual Editorial

B.3–4 CONSENSUS
Board and approved by the AASM Board of Directors.
Terminology. Consensus agreement of Scoring Manual Editorial Board and approved

C.1 CONSENSUS
Scoring sleep stages. Consensus agreement of Scoring Manual Editorial Board and
C.2–6 CONSENSUS
approved by the AASM Board of Directors.
EOG characteristics definitions. Consensus agreement of Scoring Manual Editorial

C.7 CONSENSUS
Chin EMG patterns definitions. Consensus agreement of Scoring Manual Editorial

C.8 CONSENSUS
Stage W rules. Consensus agreement of Scoring Manual Editorial Board and

D.1.a–c CONSENSUS
Stage N rules. Consensus agreement of Scoring Manual Editorial Board and

E.1.a–e CONSENSUS
Stage R rules. Consensus agreement of Scoring Manual Editorial Board and

F.1–2 CONSENSUS
Stage T rules. Consensus agreement of Scoring Manual Editorial Board and

G.1–2 CONSENSUS
V. Arousal Rule
Arousal Rule. Duration and EEG change. Level 1 and 2 evidence. Decision by
A.1 STANDARD
Steering Committee and consensus of Arousal Task Force.
Arousal Rule. Specification for duration of EMG increase was requested by

A.1 technical/industry and recommended by task force chair. This decision was then ADJUDICATION
adjudicated by Steering Committee.
VI. Cardiac Rules
Single lead. No evidence. Consensus agreement by Cardiac Task Force approved by

A.1 CONSENSUS
Steering Committee.
Tachycardia. Level 3 and 4 evidence. Consensus agreement by Cardiac Task Force

B.1 CONSENSUS
Bradycardia. Level 3 and 4 evidence. Consensus agreement by Cardiac Task Force

B.2 CONSENSUS
Asystole. Limited evidence. Consensus agreement by Cardiac Task Force approved

B.3 CONSENSUS
Wide complex tachycardia. Limited evidence. Consensus of Cardiac Task Force and
B.4 CONSENSUS
Narrow complex tachycardia. Limited evidence. Consensus of Cardiac Task Force

B.5 CONSENSUS
and approved by Steering Committee.
Atrial fibrillation. American Heart Association consensus modified by consensus of

B.6 CONSENSUS
Cardiac Task Force and approved by Steering Committee.
VII. Movement Rules
Recommended electrode placement for monitoring leg movements. Consensus

A.1 agreement of Scoring Manual Editorial Board and approved by the AASM Board of CONSENSUS
Directors.
Recommended parameters for monitoring leg movements. Consensus agreement of

A.2 CONSENSUS
Scoring Manual Editorial Board and approved by the AASM Board of Directors.
Optional sampling of upper limbs. Consensus agreement of Scoring Manual Editorial

A.3 CONSENSUS
Optional masseter electrodes. Consensus agreement of Scoring Manual Editorial

A.4 CONSENSUS
Optional EMG recordings for detecting transient muscle activity in REM sleep.
A.5 Consensus agreement of Scoring Manual Editorial Board and approved by the CONSENSUS
Recommended video PSG for diagnosis of RBD. Consensus agreement of Scoring

A.6 CONSENSUS
Manual Editorial Board and approved by the AASM Board of Directors.
Optional electrode placement for monitoring RMD. Consensus agreement of Scoring

A.7 CONSENSUS
Recommended video PSG for diagnosis of RMD. Consensus agreement of Scoring

A.8 CONSENSUS
Leg movements. Evidence level 5. Consensus agreement by Movements Task Force,

B.1.a CONSENSUS
Leg movements. Evidence level 5. Rule states 10 seconds instead of the previous 5
B.1.b second rule based on consensus agreement by Movements Task Force; approved by CONSENSUS
Steering Committee.
Leg movements. Evidence level 5. Consensus agreement by Movements Task Force,

B.1.c–e CONSENSUS
PLM series. Evidence level 5. Consensus agreement by Movements Task Force,

B.2.a CONSENSUS
PLM series. Evidence level 5 based on ICSD Consensus. Consensus agreement by

B.2.b–c CONSENSUS
Movements Task Force, approved by Steering Committee.
Arousal and limb movement that occur in a PLM series. Consensus agreement of
B.3 CONSENSUS
Leg movements preceding a respiratory event. Consensus agreement of Scoring

B.4 CONSENSUS
Wake that separates a series of leg movements. Consensus agreement of Scoring

B.5 CONSENSUS
The minimum duration of the muscle bursts for ALMA was removed due to concerns
C.1 by the technical panel and Movements Task Force leader and adjudication by CONSENSUS
Steering Committee.
Alternating Leg Muscle Activation (ALMA). Evidence level 4 based on ICSD

C.1.a–c Consensus. Consensus agreement by Movements Task Force; approved by Steering CONSENSUS
Committee.
Hypnagogic Foot Tremor (HFT). Evidence level 2 Consensus agreement by

D.1.a–c GUIDELINE
Movements Task Force; approved by Steering Committee
Excessive Fragmentary Myoclonus (EFM). Evidence level 4. Consensus agreement

E.1.a–c CONSENSUS
by Movements Task Force, approved by Steering Committee.
Bruxism phasic bursts. Evidence level 5. Consensus agreement by Movements Task

F.1.a–b CONSENSUS
Force, approved by Steering Committee.
Bruxism tonic bursts. Evidence level 5. Consensus agreement by Movements Task

F.1.a,c CONSENSUS
Bruxism amplitude of individual burst. No evidence. Consensus agreement by

F.1.a Movements Task Force plus adjudication by Steering Committee based on technical ADJUDICATION
panel input and discussions of the Movements Task Force.
Bruxism episodes. Evidence level 5. Consensus agreement by Movements Task

F.1.d CONSENSUS
Bruxism scoring. Evidence level 2 and evidence level 5. Consensus agreement by

F.1.e STANDARD
Definitions for REM Sleep Behavior Disorder. REM sleep without atonia and
G.1 duration of bursts of transient muscle activity. Evidence level 3. Consensus CONSENSUS
agreement by Movements Task Force, approved by Steering Committee.
Definitions for REM Sleep Behavior Disorder. Amplitude criterion and 3 second
G.1 sequences of transient muscle activity. Evidence level 3. Recommended by task force ADJUDICATION
chair and approved by Steering Committee.
Rule for REM Sleep Behavior Disorder. Evidence level 3. Consensus agreement by
G.2.a–b CONSENSUS
Rhythmic Movement Disorder (RMD) frequency. Evidence level 4. Consensus

H.1.a–b CONSENSUS
agreement by Movements Task Force, approved by Steering Committee.
Rhythmic Movement Disorder (RMD). No evidence. Consensus agreement by

H.1.c–d CONSENSUS
Movements Task Force approved by Steering Committee.
VIII. Respiratory Rules Part 1: Rules For Adults
Recommended airflow sensor for apnea detection. Consensus agreement by

A.1 CONSENSUS
Respiratory Task Force approved by Scoring Manual Committee (SMC).
Alternative airflow sensors for apnea detection. Consensus agreement by Respiratory

A.2.a–c CONSENSUS
Task Force approved by SMC.
PVDFsum alternative and acceptable for apnea detection. No agreement by

A.2.d Respiratory Task Force, adjudicated by AASM Board of Directors, approved by ADJUDICATION
SMC.
Recommended airflow sensor for detection of a hypopnea. Consensus agreement by

A.3 CONSENSUS
Respiratory Task Force approved by SMC.
Alternative airflow sensors for hypopnea detection. Consensus agreement by

A.4.a–d CONSENSUS
PVDFsum alternative and acceptable for hypopnea detection. No agreement by

A.4.e Respiratory Task Force, adjudicated by AASM Board of Directors, approved by ADJUDICATION
SMC.
Airflow sensor for apnea and hypopnea detection during PAP titration. Consensus
A.5 CONSENSUS
agreement by Respiratory Task Force approved by SMC.
Sensors for monitoring respiratory effort. Consensus agreement by Respiratory Task

A.6.a–b CONSENSUS
Force approved by SMC.
Thoracoabdominal PVDF belts acceptable for monitoring respiratory effort. No

A.6.c agreement by Respiratory Task Force, adjudicated by AASM Board of Directors, ADJUDICATION
approved by SMC.
Preferred sensor for detection of blood oxygen. Use of pulse oximetry and pulse
A.7 oximetry averaging times. Consensus agreement by Respiratory Task Force, CONSENSUS
approved by SMC.
Preferred sensors for monitoring snoring. Consensus agreement by Respiratory Task

A.8 CONSENSUS
Force, approved by SMC.
Preferred sensors for detecting hypoventilation during diagnostic study. Consensus

A.9 CONSENSUS
agreement by Respiratory Task Force, approved by SMC.
Preferred sensors for detecting hypoventilation during a PAP titration study.

A.10 CONSENSUS
Consensus agreement by Respiratory Task Force, approved by SMC.
Identification of breaths beginning and ending events. Consensus agreement by

B.1 CONSENSUS
Respiratory Task Force, approved by SMC.
Sensors used to measure duration of apneas and hypopneas. Consensus agreement by

B.2 CONSENSUS
Identification of beginning and end of events with large variability. Consensus

B.3 CONSENSUS
Apnea amplitude criterion and duration of event criterion. Consensus agreement by

C.1.a–b CONSENSUS
Scoring criteria for obstructive apneas. Consensus agreement by Respiratory Task

C.2 CONSENSUS
Scoring criteria for central apneas. Consensus agreement by Respiratory Task Force,
C.3 CONSENSUS
approved by SMC.
Scoring criteria for mixed apneas. Consensus agreement by Respiratory Task Force,
C.4 CONSENSUS
approved by SMC.
D.1A.a–c Hypopnea amplitude, duration and minimum oxygen desaturation criterion. CONSENSUS
D.1B.a–c Consensus agreement by SMC.
Scoring criteria for obstructive hypopneas. Consensus agreement by Respiratory

D.2.a–c CONSENSUS
Task Force, approved by SMC.
Scoring criteria for central hypopneas. Consensus agreement by Respiratory Task

D.3.a–c CONSENSUS
Scoring criteria for respiratory effort-related arousals. Consensus agreement by

E.1 CONSENSUS
Scoring criteria for hypoventilation. Consensus agreement by Respiratory Task

F.1.a–b CONSENSUS
Scoring criteria for Cheyne-Stokes breathing. Consensus agreement by Respiratory

G.1.a–b CONSENSUS
Ages for which pediatric respiratory scoring rules apply. Consensus agreement by
A.1 CONSENSUS
Recommended airflow sensor for apnea detection. Consensus agreement by

B.1 CONSENSUS
Alternative airflow sensors for apnea detection. Consensus agreement by Respiratory

B.2.a–c CONSENSUS
End-tidal PCO2 acceptable for apnea detection. Consensus agreement by Respiratory

B.2.d CONSENSUS
Recommended airflow sensor for detection of a hypopnea. Consensus agreement by

B.3 CONSENSUS
Alternative airflow sensors for hypopnea detection. Consensus agreement by

B.4.a–d CONSENSUS
Airflow sensor for apnea and hypopnea detection during PAP titration. Consensus
B.5 CONSENSUS
agreement by Respiratory Task Force approved by SMC.
Sensors for monitoring respiratory effort. Consensus agreement by Respiratory Task

B.6.a–b CONSENSUS
Force approved by SMC.
Preferred sensor for detection of blood oxygen. Use of pulse oximetry and pulse
B.7 oximetry averaging times. Consensus agreement by Respiratory Task Force, CONSENSUS
approved by SMC.
Preferred sensors for monitoring snoring. Consensus agreement by Respiratory Task

B.8 CONSENSUS
Preferred sensors for detecting hypoventilation during diagnostic study. Consensus

B.9 CONSENSUS
Preferred sensors for detecting hypoventilation during a PAP titration study.

B.10 CONSENSUS
Measuring event duration same as adults. Consensus agreement by Respiratory Task

C.1 CONSENSUS
Apnea amplitude criterion, duration of event and respiratory effort criterion.

D.1.a–c CONSENSUS
Scoring criteria for obstructive apneas. Consensus agreement by Respiratory Task

D.2 CONSENSUS
Scoring criteria for central apneas. Consensus agreement by Respiratory Task Force,
D.3.a–c CONSENSUS
approved by SMC.
Scoring criteria for mixed apneas. Consensus agreement by Respiratory Task Force,
D.4 CONSENSUS
approved by SMC.
Hypopnea amplitude, duration and minimum oxygen desaturation criterion.

E.1.a–c CONSENSUS
Scoring criteria for obstructive hypopneas. Consensus agreement by Respiratory

E.2.a–c CONSENSUS
Scoring criteria for central hypopneas. Consensus agreement by Respiratory Task

E.3.a–c CONSENSUS
Scoring criteria for respiratory effort-related arousals. Consensus agreement by

F.1.a–d CONSENSUS
Scoring criteria for hypoventilation. Consensus agreement by Respiratory Task

G.1 CONSENSUS
Scoring criteria for periodic breathing. Consensus agreement by Respiratory Task

H.1 CONSENSUS

Part 1: HSAT Utilizing Respiratory Flow and/or Effort Parameters
Parameters. Consensus agreement of Scoring Manual Editorial Board and approved

A.1–8 CONSENSUS
Recording Data. Consensus agreement of Scoring Manual Editorial Board and

B.1–13 CONSENSUS
Summary Statements. Consensus agreement of Scoring Manual Editorial Board and

C.1–8 CONSENSUS
Recording Data. Adopted and modified from previous AASM practice parameters.
D.1–8 Consensus agreement of Scoring Manual Editorial Board and approved by the CONSENSUS
Recommended airflow sensors for respiratory event detection. Consensus agreement

E.1.a–b CONSENSUS
of Scoring Manual Editorial Board and approved by the AASM Board of Directors.
Alternative Recommended airflow sensor for respiratory event detection. Consensus

E.1.c.i agreement of Scoring Manual Editorial Board and approved by the AASM Board of CONSENSUS
Directors.
Alternative Acceptable airflow sensor for respiratory event detection. Consensus

E.1.c.ii agreement of Scoring Manual Editorial Board and approved by the AASM Board of CONSENSUS
Directors.
Recommended sensors for monitoring respiratory effort. Consensus agreement of

E.2.a CONSENSUS
Acceptable thoracoabdominal belts for monitoring respiratory effort. Consensus

E.2.b–c agreement of Scoring Manual Editorial Board and approved by the AASM Board of CONSENSUS
Directors.
Acceptable thoracoabdominal belts for monitoring respiratory effort. No agreement

E.2.d ADJUDICATION
by Scoring Manual Editorial Board, adjudicated by the AASM Board of Directors.
Recommended sensor for monitoring oxygen saturation. Consensus agreement of

E.3 CONSENSUS
Optional sensors for monitoring snoring. Consensus agreement of Scoring Manual

E.4 CONSENSUS
HSAT apnea amplitude criterion and duration of event criterion. Consensus

F.1.a–b agreement of Scoring Manual Editorial Board and approved by the AASM Board of CONSENSUS
Directors.
HSAT scoring criteria for obstructive apneas. Consensus agreement of Scoring

F.2 CONSENSUS
HSAT scoring criteria for central apneas. Consensus agreement of Scoring Manual
F.3 CONSENSUS
HSAT scoring criteria for mixed apneas. Consensus agreement of Scoring Manual
F.4 CONSENSUS
HSAT hypopnea amplitude, duration and minimum oxygen desaturation criterion if

G.1A.a–c
sleep is NOT recorded. Consensus agreement of Scoring Manual Editorial Board and CONSENSUS
G.1B.a–c
HSAT hypopnea amplitude, duration and minimum oxygen desaturation criterion

G.2A.a–c
if sleep IS recorded. Consensus agreement of Scoring Manual Editorial Board and CONSENSUS
G.2B.a–c

Part 2: HSAT Utilizing Peripheral Arterial Tonometry (PAT)
Parameters. Consensus agreement of Scoring Manual Editorial Board and approved

A.1–7 CONSENSUS
Recording Data. Consensus agreement of Scoring Manual Editorial Board and

B.1–7 CONSENSUS
Summary Statements. Consensus agreement of Scoring Manual Editorial Board and

C.1–8 CONSENSUS
Recording Data. Adopted and modified from previous AASM practice parameters.
D.1–8 Consensus agreement of Scoring Manual Editorial Board and approved by the CONSENSUS
Acceptable sensors for respiratory event detection. Consensus agreement of Scoring

E.1 CONSENSUS
Recommended sensor for monitoring oxygen saturation. Consensus agreement of

E.2 CONSENSUS
*In 2015, the name of the Scoring Manual Committee (SMC) was changed to the Scoring Manual Editorial Board.
XII. Glossary of Terms
Alpha rhythm (posterior dominant rhythm in adults and older children): An EEG pattern consisting of trains of
sinusoidal 8–13 Hz activity recorded over the occipital region with eye closure and attenuating with eye opening.
Apnea: Cessation of airflow (≥90% decrease in apnea sensor excursions compared to baseline) of a minimum duration as
defined by adult (VIII.C.1) and pediatric rules (VIII.D.1). Apneas are classified as obstructive, mixed, or central based
on the pattern of respiratory effort.
Asystole: An interruption of cardiac rhythm lasting more than 3 seconds.
Atrial fibrillation: Irregularly irregular QRS complexes associated with replacement of consistent P waves by rapid
oscillations that vary in size, shape and timing.
Beta rhythm: An EEG rhythm consisting of 13–30 Hz activity.
Bradycardia (during sleep): A sustained (>30 seconds) heart rate less than 40 beats per minute for ages 6 years through
adulthood.
Bruxism: Grinding or clenching of the teeth during sleep that is often associated with arousal. (Scoring rule VII.E.1)
Central hypopnea: A specified reduction in airflow lasting at least 10 seconds in adults or the equivalent of 2 breaths in
children during which there is no evidence of snoring, increased inspiratory flattening of the nasal pressure or PAP
device flow signal compared to baseline breathing, or associated thoracoabdominal paradox.
Cheyne-Stokes breathing: A breathing rhythm with a specified crescendo and decrescendo change in breathing amplitude
separating central apneas or hypopneas. (Scoring rule for adults VIII.G.1)
Chronological age: The time elapsed since birth expressed in either days, months, or years; also referred to as postnatal or
legal age.
Conceptional age (CA): Gestational age (GA) at birth plus the number of weeks postpartum.
Delta frequency: An EEG rhythm consisting of 0–4 Hz activity. (See definition of slow wave activity.)
Derivation: The recorded voltage difference between two electrodes (e.g. EEG, EOG, chin EMG derivations).
Excessive fragmentary myoclonus: Limb EMG activity of a specified frequency and duration often unassociated with
visible movement. This polysomnographic finding is not thought to have physiological significance.
Excessive transient muscle activity (phasic activity) in REM sleep: In a 30-second epoch of REM sleep divided into
10 sequential 3-second mini-epochs, at least 5 (50%) of the mini-epochs contain bursts of transient muscle activity.
Excessive transient muscle activity bursts are 0.1–5.0 seconds in duration and at least 4 times as high in amplitude as the
background EMG activity.
Eye blinks: Conjugate vertical eye movements at a frequency of 0.5–2 Hz present in wakefulness with the eyes open or
closed.
Gestational age (GA): The time elapsed between the first day of the mother’s last menstrual period and the day of delivery
expressed in completed weeks. If the pregnancy was achieved using assisted reproductive technology, GA is calculated
by adding 2 weeks to the conceptional age.
High voltage slow (HVS): Continuous synchronous symmetrical predominantly high voltage 1–3 Hz delta activity.
Hypnagogic foot tremor: Trains of EMG activity of the lower limb with a specified frequency; not a defined disorder.
Hypnagogic hypersynchrony (HH): Paroxysmal bursts or runs of diffuse, high-amplitude, sinusoidal, 75–350 μV, 3–4.5
Hz waves which begin abruptly, are usually widely distributed but often are maximal over the central, frontal, or
frontocentral scalp regions. These waveforms can occur in stage N1 and N2.
Hypnogram: A graphical representation of sleep stages which occur throughout the night.
Hypopnea: A reduction in airflow with the minimum amplitude and duration as specified in the hypopnea rules for adults
(VIII.D.1A and 1B) and children (VIII.E.1). The reduction in airflow must be accompanied by a ≥3% desaturation or an
arousal (VIII.D.1A and VIII.E.1) or a ≥4% desaturation (VIII.D.1B).
Hypoventilation: A specified period of increased PCO2 of >50 mmHg in children or >55 mmHg in adults, or a rise of
PCO2 during sleep of ≥10 mmHg that exceeds 50 mmHg for a specified period of time in adults.
K complex: A well-delineated, negative, sharp wave immediately followed by a positive component standing out from
the background EEG, with total duration ≥0.5 seconds, usually maximal in amplitude when recorded using frontal
derivations. For an arousal to be associated with a K complex, the arousal must either be concurrent with the K complex
or commence no more than 1 second after termination of the K complex. (see V. Arousal Rule).
Low-amplitude, mixed-frequency (LAMF) activity: Low amplitude, predominantly 4–7 Hz activity.

Low voltage irregular (LVI): Continuous low voltage mixed-frequency activity with delta and predominantly theta
activity.
Major body movement: Movement and muscle artifact obscuring the EEG for more than half an epoch to the extent that
the sleep stage cannot be determined.
Monitoring time (MT): Total recording time minus periods of artifact and time the patient was awake as determined by
actigraphy, body position sensor, respiratory pattern, or patient diary.
Narrow complex tachycardia: A cardiac rhythm lasting a minimum of 3 consecutive beats with QRS duration of <120
msec and a rate of >100 per minute.
Nasal pressure transducer: A pressure transducer that measures the pressure (relative to atmospheric pressure) inside the
nasal orifice using a nasal cannula. The pressure difference across the nasal inlet during breathing is proportional to
the magnitude of airflow squared. A square root transformation of the nasal pressure signal is proportional to airflow.
The inspiratory waveform of the nasal pressure signal exhibits a flattened pattern during airflow limitation provided the
signal from the transducer is recorded as a DC signal or as an AC signal with an appropriate low filter setting.
Oxygen desaturation index (ODI): The number of oxygen desaturations × 60 divided by the monitoring time (for HSAT)
or total sleep time (for in-laboratory PSG).
Periodic breathing: >3 episodes of central apnea lasting >3 seconds separated by no more than 20 seconds of normal
breathing in children.
Periodic limb movements of sleep: Movements of the limbs during sleep occurring with a specified frequency, duration,
and amplitude.
Peripheral arterial tone: A measure of pulsatile volume changes at the finger tip that reflects changes in sympathetic tone.
Peripheral arterial tonometry (PAT): A technique allowing noninvasive moment-to-moment measurement of
sympathetic tone using finger plethysmography (measurement of pulsatile volume changes in the finger tip that reflects
changes in sympathetic tone). Increases in sympathetic tone result in peripheral arterial constriction and reduced blood
flow to the digit. The reduced volume at the finger is detected by the probe. The combination of a decrease in PAT signal
(sympathetic tone increase following respiratory events), a fall in SaO2 (oximetry), and an increase in heart rate is used
to detect respiratory events.
Positive airway pressure (PAP) flow: An airflow signal derived from a pressure transducer built in to the PAP device.
Posterior dominant rhythm (PDR): The dominant reactive EEG rhythm over the occipital regions in relaxed wakefulness
with eyes closed which is slower in infants and young children and attenuates with eye opening or attention. Frequency
is 3.5–4.5 Hz when first seen in infants 3–4 months post-term, 5–6 Hz by 5–6 months, and 7.5–9.5 Hz by 3 years of age
and amplitude is usually >50 μV. In older children and adults, posterior dominant rhythm is often referred to as alpha
rhythm.
Posterior slow waves of youth (PSW): Intermittent runs of bilateral but often asymmetric 2.5–4.5 Hz slow waves
superimposed, riding upon, or fused with the PDR, are usually <120% of PDR voltage, block with eye opening and
disappear with drowsiness and sleep. PSW are uncommon in children <2 years of age, have a maximal incidence
between ages 8–14 years, and are uncommon after age 21 years.
PVDF sensor: Polyvinylidene fluoride (PVDF) film is a fluoropolymer substance that reacts to changes in temperature
when used as a thermal airflow sensor and to impedance changes when used as an effort sensor.
PVDFsum: PVDFsum is the electrical sum of signals recorded from the thoracic and abdominal PVDF sensors.
environment.
Reading eye movements: Eye movements recorded in the EOG derivations consisting of trains of conjugate eye
movements characterized by an initial slow phase followed by a rapid phase in the opposite direction as the individual
reads.
REM Sleep Behavior Disorder: A parasomnia characterized by abnormal behaviors emerging from REM sleep and EMG
abnormalities during REM sleep (REM sleep without atonia).
Respiratory effort-related arousal: A sequence of breaths characterized by increasing respiratory effort (esophageal
manometry); inspiratory flattening in the nasal pressure or PAP device flow channel; or an increase in end-tidal PCO2
(children) leading to an arousal from sleep. Respiratory effort-related arousals do not meet criteria for hypopnea and
have a minimum duration of ≥10 seconds in adults or the duration of at least two breaths in children.
Respiratory event index (REI): Total number of respiratory events scored × 60 divided by monitoring time (MT).
Respiratory inductance plethysmography (RIP): A technology that uses alternating current in belts surrounding the
thorax and abdomen to generate a signal based on changes in the inductance of belts during breathing. The band
inductance depends on the cross-sectional area encircled by the band.
Rhythmic Movement Disorder: Repetitive, stereotyped and rhythmic motor behaviors that occur predominantly during
drowsiness or sleep and involve large muscle groups.
RIPflow: RIPflow is the time derivative of the RIPsum signal; excursions in the signal are an estimate of airflow.
RIPsum: RIPsum is the electrical sum of the signals from the thoracic and abdominal RIP sensors; excursions in the signal
are an estimate of tidal volume.
Sawtooth waves: An EEG pattern consisting of trains of sharply contoured or triangular, often serrated, 2–6 Hz
waves maximal in amplitude over the central head regions and often, but not always, preceding a burst of rapid eye
movements.
Scanning eye movements: Trains of conjugate eye movements with eyes open consisting of a slow phase followed by a
rapid phase in the opposite direction as the infant visually scans the environment or follows objects.
Sleep onset: The start of the first epoch scored as any stage other than stage W. (In most subjects this will usually be the
Sleep spindle: A train of distinct waves with frequency 11–16 Hz (most commonly 12–14 Hz) with a duration ≥0.5 seconds,
usually maximal in amplitude over the central regions.
Slow wave activity: Waves of frequency 0.5–2 Hz and peak-to-peak amplitude >75 μV, measured over the frontal regions
referenced to the contralateral ear or mastoid (F4-M1, F3-M2).
Sustained muscle activity (tonic activity) in REM sleep: An epoch of REM sleep with at least 50% of the duration of the
epoch having a chin EMG amplitude greater than the minimum amplitude demonstrated in NREM sleep.
Tachycardia or sinus tachycardia (during sleep): A sustained (>30 seconds) sinus heart rate >90 beats per minute for
adults.
Thermal sensor: A thermally sensitive device that detects changes in nasal and/or oral airflow based on changes in
temperature; thermal sensors include thermistors, thermocouples, or polyvinylidene fluoride (PVDF) airflow sensors.
Theta rhythm: An EEG rhythm consisting of 4–7 Hz activity.
Trace alternant (TA): Generally only seen in stage N sleep; characterized by at least 3 alternating runs of bilaterally
synchronous high voltage (50–150 µV) bursts of 1–3 Hz delta activity lasting 5–6 seconds (range 3–8 seconds)
alternating with period of lower amplitude (25–50 µV) 4–7 Hz theta activity (range 4–12 seconds).
at 4–6 months post-term.
Wide complex tachycardia: A cardiac rhythm lasting a minimum of 3 consecutive beats with QRS duration ≥120 msec
and a rate of >100 per minute.

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The AASM Manual

for the Scoring of Sleep

American Academy of Sleep Medicine, Darien, IL

Yearly subscriptions to the online manual are available at www.aasmnet.org.

II. Parameters to be Reported for Polysomnography 8

III. Technical and Digital Specifications 12

IV. Sleep Staging Rules

VI. Cardiac Rules 47

VII. Movement Rules 49

VIII. Respiratory Rules

IX. Home Sleep Apnea Testing (HSAT) Rules for Adults

XI. Procedural Notes 75

XII. Glossary of Terms 87

Timothy Roehrs, PhD Meir Kryger, MD

Carole L. Marcus, MBBCh Michael H. Bonnet, PhD

Timothy I. Morgenthaler, MD Sudhansu Chokroverty, MD, FRCP

VISUAL (SLEEP STAGING)

— Daniel Kraft, physician-scientist, inventor

2012–2013 AASM S coring M anual Committee:

Organization of the Manual

IN EACH SECTION, ALONG WITH THE RULES, YOU WILL NOTICE:

Sleep Facility Accreditation

1. Electroencephalogram (EEG) derivations RECOMMENDED

2. Electrooculogram (EOG) derivations RECOMMENDED

3. Chin electromyogram (EMG) RECOMMENDED

4. Leg electromyogram (EMG) RECOMMENDED

5. Airflow signals RECOMMENDED

6. Respiratory effort signals RECOMMENDED

7. Oxygen saturation RECOMMENDED

8. Body position RECOMMENDED

9. Electrocardiogram (ECG) RECOMMENDED

B. Sleep Scoring Data

1. Lights out clock time (hr:min) RECOMMENDED

2. Lights on clock time (hr:min) RECOMMENDED

3. Total sleep time (TST; in min) RECOMMENDED

6. Stage R latency (sleep onset to first epoch of Stage R in min) RECOMMENDED

7. Wake after sleep onset (WASO; TRT − SL − TST, in min) N1 RECOMMENDED

8. Percent sleep efficiency (TST / TRT × 100 ) RECOMMENDED

9. Time in each stage (in min) RECOMMENDED

1. Number of arousals RECOMMENDED

2. Arousal index (ArI; number of arousals × 60 / TST) RECOMMENDED

1. Average heart rate during sleep RECOMMENDED

2. Highest heart rate during sleep RECOMMENDED

3. Highest heart rate during recording RECOMMENDED

4. Occurrence of bradycardia (if observed); report lowest heart rate RECOMMENDED

5. Occurrence of asystole (if observed); report longest pause RECOMMENDED

10. Occurrence of other arrhythmias (if observed); list arrhythmia RECOMMENDED

1. Number of periodic limb movements of sleep (PLMS) RECOMMENDED

2. Number of periodic limb movements of sleep (PLMS) with arousals RECOMMENDED

3. PLMS index (PLMSI; PLMS × 60 / TST) RECOMMENDED

4. PLMS arousal index (PLMSArI; PLMS with arousals × 60 / TST) RECOMMENDED

1. Number of obstructive apneas RECOMMENDED

2. Number of mixed apneas RECOMMENDED

3. Number of central apneas RECOMMENDED

4. Number of hypopneas RECOMMENDED

5. Number of obstructive hypopneas OPTIONAL

6. Number of central hypopneas OPTIONAL

7. Number of apneas + hypopneas RECOMMENDED

9. Hypopnea index (HI; # hypopneas × 60 / TST) RECOMMENDED

10. Apnea-hypopnea index (AHI; (# apneas + # hypopneas) × 60 / TST) RECOMMENDED