About the Atlas of Clinical Polysomnography

Nic Butkov, RPSGT   •   2nd Edition

About the Atlas

The original Atlas of Clinical Polysomnography was introduced in 1996 at the Association of Professional Sleep Societies (APSS) conference in Washington D.C. Since that time, the Atlas has been used extensively by physicians and technologists for board examination preparation, as well as for general training and education by sleep centers, sleep schools, colleges, and universities worldwide.

The 2010 edition of the Atlas has been expanded to include an in-depth overview of polysomnography including instrumentation, electrode and sensor application, sleep stage and event scoring, abnormal sleep record interpretation, positive airway pressure titration, and other relevant topics. By including this information, the new edition effectively serves as a technical manual, as well as an Atlas.

Because of the many changes that have occurred within the field of sleep medicine in recent years, the author has made efforts to provide the reader with a sense of historical perspective, by summarizing both traditional and revised methodology and scoring rules. These are balanced with practical commentary, emphasizing clinical judgment and common sense.


Table of Contents:

Introduction

  • Historical Perspective Professional Organizations
  • Developments in Recording Technology
  • The AASM Scoring Manual

Polysomnography: An Overview

  • Signal Sources
  • Signal Processing
  • Signal Derivations
  • Back-up Derivations
  • Signal Polarity Signal Pathway
  • Signal Measurements
  • Amplifier Gain and Sensitivity
  • Low and High Frequency Filters
  • 50/60 Hz Filters
  • Digital Filters
  • Filter Selection
  • AC and DC Amplifiers
  • Analog to Digital Conversion
  • Signal Multiplexing
  • Signal Display
  • System Referencing
  • Other Digital Recording System Options
  • Equipment Calibration
  • Time Constants
  • Ancillary Equipment Calibration
  • Baseline Adjustments
  • Time Axis Alignment
  • Essential Components of a Polysomnography Recording System

Electrode Application

  • Head Measurements for EEG Electrode Application
  • Head Measurements for Applying Frontal EEG Leads
  • Applying EEG Electrodes
  • Applying Scalp Electrodes with EEG Paste
  • Applying the Occipital EEG Electrodes
  • Applying the Mastoid Electrodes
  • Applying the System Reference Electrode
  • Applying Facial Electrodes
  • Applying EOG Electrodes
  • Applying Chin EMG Electrodes
  • Preliminary Impedance Check
  • Applying ECG Electrodes
  • Applying Leg EMG Electrodes
  • Applying Respiratory Transducers
  • Applying the Oximeter Probe
  • Final Impedance Check
  • Bio-Calibrations
  • Recording Maintenance
  • Patient Safety

Polysomnogram Scoring and Interpretation

  • Overview
  • Sleep Stage Scoring
  • Evaluating the Microstructure of Sleep
  • Event Scoring
  • Sleep Stage Pattern Recognition
  • Establishing a Proper Workspace for Sleep Stage Scoring
  • Sleep Stage Definitions
  • AASM Scoring Revision Commentary
  • Practical Tips for Scoring Sleep Stages
  • Scoring Arousals
  • Sleep Stage Changes with Arousals
  • Atypical Arousals and Other Forms of Activation
  • Common Arousal and Movement Definitions
  • Practical Tips for Scoring Arousals
  • Alpha-Sleep

Clinical Record Samples

  • Grid Paper Measurements
  • Evaluating the Bio-Calibration Routine
  • Wake EEG Patterns
  • Micro-Sleep
  • Sleep Onset
  • NREM Sleep
  • REM Sleep

Polysomnographic Features of Sleep Disordered Breathing

  • Introduction
  • Factors that Complicate Sleep Disordered Breathing Evaluation
  • Basic Respiratory Event Scoring Definitions
  • AASM Scoring Manual Recommendations for Respiratory Event Scoring
  • A Closer Look at Respiratory Event Scoring
  • Obstructive apnea
  • Central apnea
  • Arousals with central apnea
  • Mixed apnea
  • Hypopnea
  • Differentiating Central and Obstructive Hypopneas
  • Cheyne-Stoke Respiration
  • Sleep Related Hypoventilation
  • Upper Airway Resistance Syndrome
  • Respiratory Effort-Related Arousals
  • Commentary on the Scoring of Respiratory Effort-Related Arousals
  • Paradoxical Respiratory Effort
  • Overlapping Pathologies
  • Sleep-Onset Central Apnea
  • Opioid-Induced Central Apnea
  • CPAP-Induced Central Apnea
  • Clinical Versus Industry-Based Event Definitions
  • Commonly Used Respiratory Transducers
  • AASM Specifications for Using Respiratory Transducers
  • Recognizing Artifacts in Respiratory Channel Tracings
  • Automated Event Scoring and Tabulation
  • Scoring Sleep Stages and Arousals in Patients with SDB
  • Home Sleep Testing
  • Practical Tips for SDB Scoring and Interpretation

Continuous and Bi-Level Positive Airway Pressure Titration

  • Overview
  • The PAP Circuit
  • Continuous Positive Airway Pressure Titration (CPAP)
  • Introducing Patients to CPAP Mask Selection
  • CPAP Titration Determining Optimal CPAP Levels
  • Monitoring for Mask Leaks
  • Mouth Breathing with CPAP
  • Pressure Relief Technology
  • Heated Humidification
  • Pressure Ramping
  • The Effects of Rebound Sleep
  • CPAP and Central Apneas
  • CPAP and Congestive Heart Failure
  • Split-Night CPAP Protocols
  • Bi-level Positive Airway Pressure Titration (Bi-level PAP)
  • Bi-level PAP Titration
  • Bi-level S/T Mode
  • Pressure Control Mode
  • Timed Mode
  • Auto-Titrating PAP
  • Average Volume-Assured Pressure Support
  • Adaptive Servo-Ventilation
  • ASV Titration
  • ASV and Complex Sleep Apnea
  • Supplemental Oxygen
  • Side Effects Associated with PAP Use
  • Role of the PAP Equipment Provider
  • PAP Download Reports and Compliance Data
  • Summary

Movement Disorders and Other Selected PSG Findings.

  • Periodic Limb Movements in Sleep
  • Association of PLMS and Restless Legs Syndrome
  • Evolution of PLMS Scoring Criteria
  • AASM Recommendations for Scoring PLMS
  • Commentary Regarding the AASM Scoring Criteria for PLMS
  • Practical Considerations Regarding PLMS Scoring
  • Sleep Related Bruxism
  • AASM Recommendations for Scoring Bruxism
  • Commentary Regarding the Scoring of Bruxism
  • REM Sleep Behavior Disorder
  • AASM Recommendation for Scoring Characteristic Features of RBD
  • Practical Considerations for Evaluating PSG Features of RBD
  • Epileptiform Activity in the EEG
  • Delta Hypersynchrony
  • Drug Effects on Sleep
  • Disorganized Sleep/Wake EEG
  • Cardiac Dysrhythmias
  • AASM Recommendations for Scoring Cardiac Events

The Multiple Sleep Latency Test

  • The MSLT Protocol
  • MSLT Recording Montage
  • Preparations for the Naps
  • Ending the Naps
  • MSLT Scoring and Interpretation
  • Practical Considerations for Performing the MSLT
  • The Maintenance of Wakefulness Test

Recording Artifacts

  • Artifact Recognition
  • Artifact Prevention
  • Artifact Correction
  • System Referencing
  • Multiple Channel Recordings
  • Signal Display Replication
  • The Use of Filters
  • 50/60 Artifact
  • Muscle Artifact
  • ECG Artifact
  • Slow Frequency Artifacts
  • Movement Artifacts
  • Artifacts in the Respiratory Channels
  • Oximetry Channel Artifacts
  • Artifacts Specific to Digital PSG Recording Systems
  • Miscellaneous Artifacts

Notes from the Author