Sleep Study

Interpretation
Gina S. de los Reyes, MD, MHPED,
FPCCP, FPSSM
 Outline
 Indications for PSG
 Hook-up, preparation for PSG
 Types of sleep studies
 Diagnostic, titration, split night
 Indices derived from PSG
 Approach to reading sleep study reports
 Polysomnography
 Single most important laboratory
technique used in the diagnosis &
treatment of sleep disorders

 The technique of recording, analyzing, &

interpreting multiple simultaneous
physiologic characteristics during sleep
 Indications
 Excessive daytime sleepiness
 Obstructive sleep apnea
 Breathing difficulties during sleep
 Behavior disturbances during sleep
 Poor sleep quality or Insomnia to exclude
other sleep disorders
Parameters monitored in PSG
 Sleep Parameters
 EEG
 EOG
 EMG

 Cardiopulmonary Parameters
 ECG
 Air Flow
 Effort
 SaO2
SLEEP PARAMETERS

CARDIO-PULMONARY
PARAMETERS
 Input 1(Exploring electrode) Differential Amplifier

Input 2 (Reference electrode)

-

Moving Paper

Amplitude

1 sec
uV
Time

Cycles per second or Hz

 EEG Frequency Bands

 Alpha 8 to 13 Hz
 Beta >13 Hz
 Delta <4 Hz (0.5-2Hz)
 Theta 4 to 7 Hz
Alpha waves-8-13 cps
Beta waves->13 cps
Theta waves -4-7cps
 Sleep spindle K complex

Sleep spindle K complexes

•12-14 cps; -negative sharp wave
immed ffd by a positive
•at least 0.5 sec component
duration; ie. 6-7
distinct waves w/in >0.5sec, maximal over
the half second vertex regions
Delta waves
•0.5 to 2 cps
•75 uV
 Sleep Stages

Stage W
Non- REM
Stage N1
Stage N2
Stage N3
Stage R

*AASM Manual, 2007

STAGE WAKE
•Eyes closed-alpha waves (>50%)
•Eyes open – low voltage mixed frequency
•Relatively high tonic EMG
STAGE N1
•Low voltage, mixed freq activity, 2-7cps range
•amount(<50%), amplitude, freq of alpha
•Decreased tonic EMG
•With SEM; Without REM
K complex Sleep spindle K complex

STAGE N2
•Background of low voltage,
mixed freq activity
•Presence of spindle and/or K-
complex
•Delta waves <20% of epoch
STAGE N3
•Moderate amounts of high amp, slow
wave activity, delta waves occupying
>20% epoch
STAGE REM
•Low voltage, mixed freq activity
•EOG- paroxysmal, relatively sharply
contoured, high-amplitude activity
•EMG- lowest tone in the record
•absence of spindles, K complexes,
& delta
AROUSALS
•Abrupt shift in EEG freq (theta, alpha &/or freq>16hz but not
spindles)
•EEG freq shift duration of >/=3 secs
•Previously asleep for >/= 10secs
Sleep Stage Summary
Hypnogram
REM sleep

Stage N3, Slow

wave sleep
Tonsillar size scoring

Mallampati grading
 EPWORTH SLEEPINESS SCALE

Situation Chance of Dosing (0-3)

Sitting and reading 0 1 2 3

Watching television 0 1 2 3
Sitting inactive in a public place – ex theater 0 1 2 3
or meeting
As a passenger in a car for an hour without a 0 1 2 3
break
Lying down to rest in the afternoon 0 1 2 3
Sitting and talking to someone 0 1 2 3

Sitting quietly after lunch (when you’ve had no 0 1 2 3

alcohol)
In a car, while stopped in traffic 0 1 2 3
TOTAL
SCORE

0 = would never dose 2=moderate chance of dozing

1= slight chance of dozing 3=high chance of dozing ESS>10
SLEEP PARAMETERS

CARDIO-PULMONARY
PARAMETERS
 Apnea
 temporary absence or cessation of
breathing (airflow) during sleep; 10secs
 CENTRAL APNEA – no effort to breathe is
made
 OBSTRUCTIVE APNEA – there is ventilatory
effort but no airflow because the upper airway
is closed
 MIXED APNEA- initially no ventilatory effort
but an obstructive apnea pattern is present
when effort resumes
OBSTRUCTIVE
APNEA
CENTRAL APNEA
MIXED APNEA
HYPOPNEA
1. Decrease in nasal pressure
amplitude >30% from baseline
2. with oxygen desaturation of >3% or
an arousal
3. event >/=10s
RERA
1. Increasing
respiratory effort
or flattening of
nasal pressure
waveform
2. event >/=10s
3. Followed by an
arousal
 Apnea/Hypopnea Index
 Apnea/Hypopnea index – apneas +
hypopneas /total sleep time
 # Apneas +# Hypopneas x 60

TST in minutes
 0-5/hr = Normal
 5-15/hr = Mild
 15-30/hr = Moderate

 >30/hr = Severe
 Types of Sleep Studies
 Diagnostic – investigative study to determine if
there are identifiable problems with the patient’s
sleep
 CPAP Titration – once the patient is identified
as having sleep apnea, another study is
performed in which the technician adjusts the
CPAP level during the test
 Split Night- combines a diagnostic study & a
CPAP titration study into one night.
Positive Airway Pressure

IV.41
Positive Airway Pressure

IV.42
 Indices derived from PSG
Sleep Related Indices
 Time in Bed (TIB)

 Total recording time (TRB)

 Total sleep time (TST)

 Sleep Efficiency >90%

 Sleep Latency <20 mins

 REM latency 90-120 mins
 Wake after Sleep Onset (WASO) <20 mins
 Sleep Period Time (SPT)
 Indices derived from PSG
Distribution of Sleep:
Stages of Sleep Percentage of TST
N1 5% (3-8%)
N2 50% (45-55%)
N3 20% (15-20%)
REM (R) 25% (20-25%)
 Indices derived from PSG
Arousals
 Total arousal index

 Respiratory arousal index

 Periodic limb movement (PLM) Arousal

Index <15/hr
 Respiratory Effort Related Arousals
(RERA)
 Indices derived from PSG
Abnormal activity during the study
 Periodic Limb movements index (PLMI)

 Bruxism

 ECG
 Indices derived from PSG
Respiratory Indices
 Apnea Hypopnea index (AHI)

 RERA index

 Respiratory Disturbance Index (RDI)

 Oxygen saturation indices

 Apnea/Hypopnea Index
 Apnea/Hypopnea index – apneas +
hypopneas /total sleep time
 # Apneas +# Hypopneas x 60

TST in minutes
 0-5/hr = Normal
 5-15/hr = Mild
 15-30/hr = Moderate

 >30/hr = Severe
 Factors affecting interpretation
 Sleep Quantity & Quality – decreased
sleep quantity & poor sleep efficiency will
overestimate AHI
 Absent REM sleep – underestimate AHI
since apneas & hypopneas tend to be
worse in REM sleep when respiratory
muscles are more hypotonic
 Factors affecting interpretation
 Position –apneas & hypopneas tend to be
worse in supine position due to the base of
tongue & soft palate falling back more
easily when supine
 Case 1
 50/M with HPN, DM
 excessive daytime sleepiness with snoring
& witnessed apneas during sleep
 BMI 35.5 ESS 18
 Nose: no septal deviation; normal
turbinates
 Soft palate low, tonsils: Grade 3;
 Mallampati score: 4
Total sleep 463.5 min %Stage N3 13.5%
time
Time in bed 508.0 min %REM 22.2%
Sleep 91.2% Arousal 45.4/hTST
Efficiency Index
Lowest satn 79% PLMI 2.8/h
NREM AHI 70.4/hr REM AHI 81.6/hr
AHI 72.9/hr
 Question 1
 What is the severity of OSA?
A. Mild
B. Moderate
C. Severe
D. Very severe
 Apnea/Hypopnea Index
 Apnea/Hypopnea index – apneas +
hypopneas /total sleep time
 # Apneas +# Hypopneas x 60

TST in minutes
 0-5/hr = Normal
 5-15/hr = Mild
 15-30/hr = Moderate

 >30/hr = Severe 72.9/hr

 Case 2
 32/M with no previous medical problems
 excessive daytime sleepiness with snoring
& witnessed apneas during sleep
 BMI 27.5 ESS 14
 Nose: hypertrophic inferior turbinates;
 Soft palate low, tonsils: Grade 1;
 Mallampati score:3
Total sleep 429 min %Stage N3 5.0%
time
Time in bed 475 min %REM 17.0%
Sleep 90.3% Arousal 11.3/hr
Efficiency Index
Lowest satn 88% PLMI 3.1/h
NREM AHI 4.1/hr REM AHI 46.8/hr
AHI 13.8/hr
L
P
PL
 Question 2
 What is your impression?
A. Position dependent OSA
B. REM dependent OSA
C. Severe OSA
D. Primary snoring
 Case 3
 55/F with HPN, CAD, dyslipidemic, s/p Coronary
bypass surgery.
 Loud snoring, choking episodes during sleep,
falls asleep while driving
 BMI 38.5, neck circumference = 42.5 cm, ESS of
16/24.
 Nose: normal turbinates
 Soft palate low, tonsils: Grade 2;
 Mallampati score: 4
 Question 3
 What type of sleep study will you request?
A. Unattended portable sleep
monitoring
B. CPAP titration study
C. Split night study
D. Multiple Sleep Latency test
Portable sleep monitoring

Type III Type IV

 Limitations of Portable Monitoring
 Inability to assess sleep architecture
 REM sleep and/or supine related OSA
undetected
 Arousals, RERA’s not detected
 Potential misdiagnosis if comorbid conditions
present (ie. COPD, CHF, hypoventilation)
 AHI underestimated
 In-lab PSG: AHI = apneas + hypopneas
/hours of sleep
 PM : • AHI = apneas + hypopneas
/hours recording time
Sleep Medicine Clinics 2011; 6: 261-385
 The “Split Night” Challenge

 You need to monitor the severity of apnea in the

first half of the night to determine if criteria are
met
 You will have a limited amount of time to titrate
the patient
 AASM Split Night Rules

 An AHI of at least 40 is documented during a

minimum of 2 hours of diagnostic PSG.

 considered at an AHI of 20 to 40, based on

clinical judgment (e.g., if there are also repetitive
long obstructions & major desaturations).

 at AHI values below 40, determination of CPAP

pressure requirements, based on split-night
studies, may be less accurate than in full-night
calibrations.
 Case 3 cont…
 A split night study was done
Diagnostic Titration
TST 144.0 450.0
REM mins 15.0 140.0
SWS duration 53.5 21.5
Sleep Efficiency 62.3 90.3
RDI (avg # / hr TST) 81.6 3.4
Minimum SpO2 during 50% 70%
sleep (%)
 Therapy distribution
IPAP EPAP Total Sleep Sleep REM Min. Pos 1 S Snore Resp
Level Level Duration Duration (%) (%) SpO2 (% Dur) (% Total (A
(cmH2O) (cmH2O) (min) (min) (%) SPT) +H+
RERA)
4 4 23.8 0.0 0.0 0.0 90 100.0 9.7 0
5 5 19.4 5.0 25.7 0.0 90 100.0 26.2 62.0
7 7 30.0 15.8 63.2 0.0 70.0 100.0 26.2 53.1
8 8 15.0 15.0 100.0 100.0 72.0 100.0 18.5 58.2
9 9 20.0 20.0 100 100.0 70.0 100.0 0.0 45.5
10 10 180.0 180 98.8 50.0 94.0 100.0 0.0 0.2
11 11 150.0 137.5 91.6 47.2 94.0 100.0 0.0 0.6
Night Hypnogram

L
P
PL
 Question 4
 What is your pressure recommendation?

A. CPAP at 7 cm of water
B. CPAP at 8 cm of water
C. CPAP at 9 cm of water
D. CPAP at 10 cm of water
 Titration guidelines
 The pressure of CPAP or BPAP selected for patient
use following the titration study should reflect control
of the patient's obstructive respiration by:
 a low (preferably < 5 per hour) respiratory
disturbance index (RDI) at the selected pressure,
 a minimum sea level SpO2 above 90% at the
pressure
 and with a leak within acceptable parameters at
the pressure
 Titration guidelines
 Optimal titration
 reduces RDI < 5 for at least a 15-min duration
and
 should include supine REM sleep at the
selected pressure
 not continually interrupted by spontaneous
arousals or awakenings
 titration duration should be > 3 hr
 Question 5
 When will the patient need a follow-up
PSG?
A. change in weight by 10%
B. recurrence of symptoms
C. intolerance of CPAP therapy
D. All of the above
 Follow-up PSG is indicated for

 After substantial weight loss (e.g., 10% of

body weight) to ascertain whether CPAP is still
needed at the previously titrated pressure

 After substantial weight gain (e.g., 10% of

body weight) has occurred in patients previously
treated with CPAP successfully, who are again
symptomatic despite the continued use of
CPAP, to ascertain whether pressure
adjustments are needed

SLEEP, Vol. 28, No. 4, 2005

 Follow-up PSG is indicated for

 When clinical response is insufficient or

when symptoms return despite a good initial
response to treatment with CPAP.

 Follow-up polysomnography is NOT

routinely indicated in patients treated with
CPAP whose symptoms continue to be resolved
with CPAP treatment.

SLEEP, Vol. 28, No. 4, 2005

 Key Points
 PSG is the gold standard in the diagnosis of
obstructive sleep apnea & other sleep disorders
 Report must be interpreted in the proper context
of patient’s clinical scenario
 When looking at a report examine the quantity
and quality of sleep, REM sleep, and position
that may affect interpretation
 Optimal titration is reached when RDI<5, oxygen
saturation >90% & include supine REM.
THANK YOU!!!