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Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Basics of Polysomnography (PSG) Testing.

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Presentation on theme: "Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Basics of Polysomnography (PSG) Testing."— Presentation transcript:

1 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Basics of Polysomnography (PSG) Testing

2 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 The following presentation is being provided for informational and educational purposes only. While Compumedics endeavors to ensure the validity and accuracy of the information within, we cannot be held responsible for inaccuracies, opinions or practices that often vary between various experts or are without established acceptable medical standards. Please consult your own medical director for clarification or for policies that are specific to your facility. We welcome your comments, suggestions and corrections. Please your comments to:

3 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Why Perform Sleep Studies? Quantify sleep pattern Determine cause of excess daytime sleepiness Initialize and evaluate treatment Evaluate treatment effectiveness

4 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Types of sleep studies Diagnostic - investigative study to determine if there are identifiable problems with the patients sleep CPAP titration - once a patient is identified as having sleep apnea, another study is performed in which the technician adjusts the CPAP/BiPAP level during the test and decides which mask and type of treatment is best Split Night - combines a diagnostic study and a titration study into one night. The patient is diagnosed during the first half of the night; CPAP/BiPAP applied the second half if required by protocol MSLT - Multiple Sleep Latency Test (nap study) MWT – Maintenance of Wakefulness Test

5 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Diagnostic Sleep Studies – Variables Evaluated Sleep staging Wake, NREM (N1,N2,N3), REM Arousals Respiratory Apneas and hypopneas Upper airway resistance Limb EMG PLMS Restless legs

6 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Polysomnography (PSG) EEG F4-M1, EEG C4-M1, EEG O2-M1, EOG-L(E1), EOG-R(E2), EMG (chin) AIRFLOW, both Thermal and Nasal Pressure THOR EFFORT, ABDO EFFORT SpO2, ECG, LEG(L), LEG(R) SOUND, POSITION CPAP pressure and flow Optional: additional EEG, dB meters, temperature, blood pressure Typical Montage

7 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Typical Polysomnogram

8 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Sleep Architecture Normal? Deficient in REM? Contain supine REM? Deficient in Delta sleep? Fragmented or disrupted by frequent arousals?

9 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Normal Sleep Architecture Entered through NREM Approximately 90 minute cycle including NREM and REM Slow wave dominates first third of night REM sleep dominates last third of night REM sleep: 20-25% total sleep time

10 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Examples - Sleep Hynograms Normal Sleep Architecture No Delta (Restorative) Sleep Severely Fragmented Sleep

11 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Sleep Staging Variables Electroencephalogram (EEG) - acquired by surface electrodes on the scalp at standardized locations (10-20 system) Electrooculogram (EOG) - acquired by surface electrodes placed at the outer canthus of each eye Electromyogram (EMG) - acquired by surface electrodes placed on the chin muscle (sub-mental)

12 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Sleep Staging Channels

13 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 EEG Frequency and amplitude change with sleep stage: Wake: high frequency Stage N1 and REM: low amplitude, mixed frequency Stage N2: spindles, K-complexes Stage N3: delta waves (slow frequency, high amplitude) Standard sleep epoch is 30 seconds (10 mm/sec paper speed)

14 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing / EEG Locations

15 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 EEG Electrode Placement

16 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Sleep Stage Criteria Awake Alpha or faster > 50% of epoch Many eye movements High EMG Stage N1 Alpha or faster < 50 % of epoch Increasing theta activity Slow rolling eyes Vertex waves ALPHA WAVES THETA WAVES VERTEX WAVE

17 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Sleep Staging Criteria Stage N2 Sleep spindles or K-complexes Stage N3 Delta-H > 20% of epoch ( 2 Hz, 75uV)

18 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Sleep Staging Criteria REM Lowest EMG Rapid Eye Movements Saw-tooth EEG Low-amplitude, mixed frequency EEG similar to stage 1

19 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 EOG EOG records voltage changes caused by eye movement EOG changes with sleep stage Wake: random, high amplitude Stage 1: slow rolling REM: very flat with occasional Rapid Eye Movements

20 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 EOG Electrode Placement

21 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 EMG Recorded as the potential between two surface electrodes placed several centimeters apart Typically, the chin (submental) muscle is used because it exhibits large differences during sleep, aiding in the identification of stages Wake - high activity Sleep - lower activity REM sleep - paralysis of skeletal muscles

22 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 EMG Placement Submental (chin) AASM placement = one midline and two under the chin

23 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Wake

24 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Stage N1 Sleep

25 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Stage N2 Sleep

26 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Stage N3 Sleep

27 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Stage REM Sleep

28 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Respiratory variables Respiratory effort (thoracic and abdominal) Airflow (thermistor, thermocouple, nasal pressure, ETCO2) SpO2 Snoring sounds Optional signals ETCO2 tcCO2

29 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Airflow Used for detecting respiratory events Apnea: no airflow Hypopnea: reduced airflow How is airflow commonly measured? Temperature changes: thermistor/thermocouple – used for apnea detection In/ex pressure changes: nasal cannula – used for hypopnea detection ETCO2 – most often used in pediatrics

30 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Respiratory Effort Used for classifying respiratory events e.g. Apnea: no airflow but effort indicates obstruction Inductive plethysmography bands – AASM Piezo-electric bands EMG: diaphragm/intercostal Esophageal pressure

31 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Other Respiratory Variables Gases: SpO2 – Blood oxygen level (%) by oximetry tcCO2 – Transcutaneous CO2 etCO2 – End Tidal CO2 Arterial CO2 – blood analysis

32 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Other Variables Typically Recorded ECG Leg movement: EMG (AASM), piezoelectric Video Body position CPAP flow and pressure (DC input)

33 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Respiratory Events Apneas Obstructive Central Mixed Hypopneas Respiratory Event Related Arousals - RERA Respiratory event does not meet the criteria for event types above Causes a disruption of the sleep architecture (arousal)

34 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Obstructive Apnea Cessation of airflow for more than 10 seconds With abdominal and/or thoracic effort Usually terminated by an arousal and/or associated with a desaturation

35 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Example - Obstructive Apnea

36 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Central Apnea Cessation of airflow, usually for more than 10 seconds Without abdominal and/or thoracic effort May be terminated by an arousal and/or associated with a desaturation Very different type syndrome than OSA; chemo- receptor irregularities

37 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Example - Central Apnea

38 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Mixed Apnea Cessation of airflow >10 s (in adults) with respiratory effort Contains both central and obstructive components, with each component lasting at least one normal respiratory cycle Typically leads to a desaturation and an arousal Is really just a type of obstructive event with the same consequences

39 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Example - Mixed Apnea

40 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Hypopnea Nasal Pressure signal amplitude drop by 30% Duration of at least 10 seconds 4 % desaturation 90% of event meets amplitude reduction criteria

41 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Hypopnea - Alternative Nasal Pressure signal amplitude drop by 50% Duration of at least 10 seconds 3 % desaturation or an associated arousal 90% of event meets amplitude reduction criteria

42 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Example - Hypopnea

43 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 PLMS Repetitive (at least 4) episodes of muscle contraction ( s duration) Minimum amplitude increase of 8 uV above baseline Separated by > 5 seconds, but not more than 90 seconds Arousals sometimes associated with the movements Positive diagnosis if more than 5 per hour of sleep Movements may be clinically significant only if associated with arousals

44 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Example - PLMS

45 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Arousals Abrupt shift of EEG frequency Lasts at least 3 seconds At least 10 seconds of prior stable sleep During REM requires concurrent increase in chin EMG lasting at least one second

46 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Example – REM Arousal

47 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 ECG Normal sinus rhythm? Bradycardia or Tachycardia? Frequent atrial/ventricular arrhythmias? Run of 5 or more ventricular arrhythmias?

48 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 ECG – AASM Reporting Average heart rate during sleep Highest HR during recording/sleep Bradycardia < 40 bpm (lowest observed) Sinus Tachycardia > 90 bpm (highest observed) Narrow Complex Tachycardia (highest observed) Wide complex Tachycardia (highest observed) Asystole, longest pause Atrial fibrillation List other arrhythmias

49 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Basic Steps to Analyze a Study Using Compumedics Software 1. Automatic Analysis –Sleep Staging –Arousal Scoring –Respiratory Scoring –PLM Scoring 2. Manual Editing –Validate Sleep Staging –Event Editing: Respiratory, PLM, and ECG –Arousal Classification and editing 3. Reporting 4. Archiving

50 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Sleep architecture What was the sleep efficiency? What was the percent of each stage of sleep? What was the sleep onset time? What was the REM onset time?

51 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Respiratory Events Which events were most common? Were there any obstructive events? What was the AHI (Apnea/Hypopnea Index)? What was the RDI (Respiratory Disturbance Index) Apnea + Hypopnea + RERA per hour of sleep What was the nadir and baseline SpO2? Was any snoring recorded?

52 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Leg Movements Were they periodic? What was the index (number per hour of sleep) Did they cause arousals?

53 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Arousals How many per hour? Related to events?? Respiratory events Leg movements Esophageal reflux Seizures Unknown (spontaneous)

54 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 CPAP/BiPAP Effective? Best pressure? Best mask? Tolerance?

55 Copyright Compumedics Ltd. Basics of Polysomnography (PSG) Testing /09 Generate report Write results summary Save Print Print raw data examples Add doctors summary File and send to referring doctors Reporting Sleep Studies


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