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Pediatric Scoring Review

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Presentation on theme: "Pediatric Scoring Review"— Presentation transcript:

1 Pediatric Scoring Review
Cindy Nichols, PhD, FAASM, CBSM Munson Sleep Disorders Center Traverse City, MI

2 I do not have any potential conflicts of interest to disclose.

3 Objectives Describe the context for the AASM Scoring Manual
Describe pediatric PSG scoring rules and recent updates Compare and contrast adult and pediatric scoring

4 Opening Comments Pediatric PSGs often have more artifact that adult PSGs, and are more susceptible to GIGO. Excluding artifact from real data is one of the most important tasks of the scoring technologist. PSG scoring rules artificially dichotomize developmental and other aspects of sleep scoring, but this is not a rationale for breaking the rules.

5 Scoring tech thought this was “pop artifact”; acquiring tech made no observational comment

6 Same with PS = 10mm/sec

7 Introduction Pediatrics are defined as children age 2 months post term (vs. neonates). There is no precise upper age boundary for pediatric visual (staging) rules; age 18 is conventional. Criteria for respiratory events can be used for children <18 years, but an individual sleep specialist can choose to score children >13 years using adult respiratory criteria.

8 The AASM manual is our friend
Prior to using this manual, there was no certainty that events were scored similarly between sleep centers. This lack of inter-center consistency in scoring led to a reimbursement crisis, with the potential that sleep studies would not be paid for by Medicare or other third party payers The AASM responded by inviting experts in all aspects of PSG who volunteered thousands of hours to review the literature and establish new scoring rules. The AASM provided administrative and clerical support for this effort. AASM sets the rules for scoring the events that lead to reimbursement. There is no ethical option for technologists other than using the rule book. Although the 2007 manual is a clear improvement from the previous piecemeal approach to scoring, it is intended to be a document that will continue to be revised. A revised manual is currently in progress. Iber C et al. American Academy of Sleep Medicine (AASM), 2007.

9 Terminology of Sleep Stages in Children
Similar to adults for stages W, N1, N2, N3, and R. An added category of N (NREM) is used for infants 6 months post-term and younger.

10 Electrode Placement and Sensitivities
Electrode placement for chin EMG can be reduced from 1 cm to 0.5 cm in children with small head size, at the discretion of the technologist. Begin with EEG sensitivity (vertical scaling) of 7 µV/mm but it is permissible to reduce this to 10 or 15 µV/mm. This will result in some difficulty viewing spindles and other low voltage fast frequencies (LVFF), so scoring and review should be performed with portions of the recording at 7 µV/mm to accurately recognize these frequencies.

11 Scoring W In some children age 2 months – 6 months, and in children with developmental delays, NREM sleep may contain no spindles, K-complexes, or high amplitude Hz slow wave activity. Score these epochs as N. For the purpose of scoring W and NREM sleep in children, the term “dominant posterior rhythm” (DPR) replaces the term “alpha rhythm”. DPR gradually increases in frequency until it meets criteria for alpha. DPR is usually slightly asymmetrical (higher on the R)

12 More About Dominant Posterior Rhythm (DPR)
This is defined as the dominant reactive EEG rhythm over the occipital regions in relaxed wakefulness with eyes closed (evolves into “adult alpha”). DPR is reactive, attenuating with eye opening or attention. DPR amplitude is usually >50 μV. DPR is slower in infants and younger children. DPR first develops by age 3-4 months post-term; frequency is Hz in infants 3-4 months, 5-6 Hz by 5-6 months, and Hz by age 3 in most.

13 Dominant Posterior Rhythm (DPR) is not all “pseudo-alpha”
DPR typically contains intermixed slower EEG rhythms including posterior slow waves of youth (PSW) which are: intermittent runs of bilateral but often asymmetric Hz slow waves superimposed, riding upon, or fused with the DPR (looks a little like “alpha-delta”; can be mistaken for low frequency artifact or N3) usually >120% of DPR voltage usually blocked with eye opening and disappear with drowsiness and sleep uncommon in children <2 years, have maximal incidence in age 8-14, and are uncommon after age 21

14 Other Waves Seen Mixed In With DPR
DPR typically contains intermixed slower EEG rhythms including: Posterior slow waves of youth (PSW) Random or semi-rhythmic occipital slowing is <100 μV, Hz rhythmic or arrhythmic activity lasting <3 seconds. is a normal finding in EEGs of children 1-15 years, especially prominent in age 5-7. With increasing age, the amount of intermixed slowing decreases and its frequency increases.

15 A Few More Wake Rhythms Mu 8-10 Hz
Resembles alpha but does not block with eye opening Blocks contralaterally with movement, intent to move, or tactile stimulation of an extremity More common in females Lambda Sharp, fairly rhythmic waves with negative deflection Often present unilaterally Usually seen in well-lighted room if child is looking at a patterned design

16 Sens 7uv/mm HFF 70Hz LFF 1.0 Hz PS 30mm/sec
MU Sens 7uv/mm HFF 70Hz LFF 1.0 Hz PS 30mm/sec

17 Same with sens 15uv/mm

18 Same with PS 10mm/sec and only central and occipital channels

19 Lambda Sens 5uv/mm HFF 70Hz notch off LFF 1.0Hz PS 30mm/sec

20 Same sample with central and occipital only, same settings

21 Same sample at 10mm/sec

22 Scoring W Score epochs as W when more than 50% of the epoch has either reactive alpha or age-appropriate DPR over the occipital region. If there is no discernable reactive alpha or no age-appropriate DPR, score W if any of the following are present: eye blinks at a frequency of Hz reading eye movements irregular conjugate REMs associated with normal or high chin muscle tone

23 Scoring W It is important to differentiate occipital sharp waves occurring in stage W from K-complexes which are characteristic of stage N2. Occipital sharp waves typically occur msec after an eye blink or eye movement. Occipital sharp waves are typically single monophasic or biphasic <200 V sharp waves over the occipital derivation and usually last msec. The initial component is surface-positive, the next is negative and has a steep ascending wave front, and the final descending phase of the second component is less steep.

24 Eye Movements in W Spontaneous eye closure in children, particularly infants, typically signals drowsiness. (Zoom video in on eyes while scoring!) The highest amplitude and sharpest component of reading eye movements in children is usually surface-negative in the occipital derivations, typically lasts msec, and has amplitude up to 65 μV.

25 Scoring N1 In children who generate DPR, score N1 if the posterior rhythm is attenuated or replaced by low amplitude mixed frequency activity for more than 50% of the epoch. In children who do not generate a DPR (often seen with psychoactive medications), score N1 commencing with the earliest of any of the following phenomena: 4-7 Hz activity with slowing of background frequencies by >1-2 Hz from stage W slow eye movements vertex sharp waves or rhythmic anterior theta activity hypnagogic hypersynchrony 3-5 Hz diffuse or rhythmic occipital predominant high amplitude rhythm

26 Drowsiness in W-N1 Drowsiness in infants up to 6-8 months is characterized by the gradual appearance of diffuse high amplitude ( μV) 3-5 Hz activity which is typically of higher amplitude, more diffuse, and 1-2 Hz slower than the waking EEG background activity. Drowsiness in children 8 months-3 years is characterized by either diffuse runs or bursts of rhythmic or semi-rhythmic bisynchronous 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.

27 Drowsiness in W-N1 Sleep onset from 3 years on is often characterized by a 1-2 Hz slowing of the DPR frequency and/or the DPR rhythm becomes diffusely distributed then is gradually replaced by relatively low voltage mixed frequency EEG activity. In most children sleep onset will be the first epoch of stage N1 but in infants younger than 3 months post-term, this is often stage R. Rhythmic anterior theta activity is commonly seen in adolescents and young adults when drowsy, and may first appear at age 5 years.

28 Terms Related to Scoring N1
Slow eye movement: conjugate, reasonably regular, sinusoidal eye movements with an initial deflection which usually lasts >50 msec Vertex sharp waves: sharply contoured waves with duration <0.5 sec maximal over the central region and distinguishable from the background activity; can be seen in bursts or runs Rhythmic anterior theta activity: runs of 5-7 Hz rhythmic theta activity maximal over the frontal or frontocentral regions

29 Terms Related to Scoring N1 (continued)
Hypnagogic hypersynchrony: paroxysmal bursts or runs of diffuse high amplitude sinusoidal μV, Hz waves which begin abruptly, are usually widely distributed but often maximal over the central, frontal, or frontocentral scalp regions and alternate with LVMF activity (always score N1 if you see this) becomes less prevalent after age 4-5 years and is rarely seen after age 12 years

30 Scoring N2 Same as adult rules Developmental notes
Spindles are usually first seen at age 4-6 weeks and are usually well-developed by age 8-9 weeks. Spindles are more prominent in frontal placement up to age 13, then become more prominent in central placements. K complexes typically develop at 5-6 months post-term and are maximal over the pre-frontal and frontal regions (like adults).

31 Scoring N3 Same as adult rules Developmental notes
Slow wave activity first appears as early as 2 months, more often about months post-term. Amplitude of slow waves is typically μV. The decrease in voltage with increasing age is ascribed to increasing skull bone density.

32 Scoring R Same as adult rules Developmental notes
The LVMF dominant frequencies tend to increase with age and resemble adult LVMF activity by age 5-10.

33 Scoring Arousals Same as adult rule

34 Scoring Cardiac Events
Same as adult except for definition of sinus rates. There is a paucity of heart rate data on children during sleep. Bradycardia for age 6 years and older is defined as a sustained HR <40 bpm. In children under age 6, sinus bradycardia can be defined as 2 SD below the mean heart rate during sleep. It is suggested that sinus tachycardia in children is defined as 2 SD above the mean heart rate during sleep.

35 Scoring Cardiac Events
age SD (brady) SD above (tachy)

36 Scoring Movements Same as adult rules

37 Monitoring Devices for Respiration in Children
Best sensor for detection of apnea is oronasal thermal sensor (same as adults). Best sensor for detection of hypopnea (and alternate sensor for apnea) is a nasal air pressure transducer without square root transformation of the signal. Acceptable sensors for detection of respiratory effort are esophageal manometry, or calibrated or uncalibrated inductance plethysmography (same as adults). IC EMG is no longer recommended. Acceptable methods for assessing alveolar hypoventilation are either transcutaneous (TC) or end-tidal (ET)PCO2 monitoring.

38 Monitoring Devices for Respiration in Children
Alternative sensors are to be used when the signal from the recommended sensor is not reliable. The alternative signal to detect apnea is a nasal air pressure transducer. Alternative signals for identification of apnea are end-tidal PCO2 and summed calibrated inductance plethysmography. Alternative sensor for detection of airflow for identification of hypopnea is an oronasal thermal sensor.

39 Monitoring Devices for Respiration in Children
End-tidal PCO2 often malfunctions or provides falsely low values in patients who have marked nasal obstruction profuse nasal secretions are obligate mouth breathers are receiving supplemental oxygen It is crucial to obtain a plateau in the end-tidal waveform for the signal to be considered valid. Transcutaneous PCO2 monitoring provides only a semi-quantitative index of trends in alveolar ventilation, and varies unpredictably from the PaCO2 (typically lower, and lagging after the event).

40 Apnea Rules: Obstructive
Must meet all of the following: event lasts for at least 2 missed breaths (or the duration of 2 breaths as determined by baseline breathing pattern) event is associated with a >90% fall in the signal amplitude for >90% of the entire respiratory event compared to the pre-event baseline amplitude (same as adults but without the “9 second rule”) event is associated with continued or increased inspiratory effort throughout the entire period of decreased airflow (same as adults) duration of the apnea is measured from the end of the last normal breath to the beginning of the first breath that achieves the pre-event baseline inspiratory excursion (same as adults)

41 Apnea Rules: Mixed Must meet all of the following criteria:
event lasts for at least 2 missed breaths (or the duration of 2 breaths as determined by baseline breathing pattern) event is associated with a >90% fall in the signal amplitude for >90% of the entire respiratory event compared to the pre-event baseline amplitude (same as adults except for the 9 second rule) event is associated with absent inspiratory effort in the initial portion of the event, followed by resumption of inspiratory effort before the end of the event (same as adults)

42 Apnea Rules: Central Event is associated with absent inspiratory effort throughout the entire duration of the event and one of the following criteria is met: event lasts 20 seconds or longer event lasts at least 2 missed breaths (or the duration of 2 breaths as determined by baseline breathing pattern) and is associated with an arousal, an awakening or a >3% desaturation.

43 Pediatric Hypopnea Rules
Score a respiratory event as hypopnea if it meets all of the following criteria: event is associated with a >50% fall (adult is 30%) in the amplitude of the nasal pressure or alternative signal compared to the pre-event baseline excursion event lasts at least 2 missed breaths (or the duration of 2 breaths as determined by baseline breathing pattern) from the end of the last normal breathing amplitude fall in the nasal pressure signal amplitude must last for >90% of the entire respiratory event compared to the signal amplitude preceding the event (same as adult) event is associated with an arousal, awakening, or >3% desaturation (adult is 4%)

44 Pediatric RERA Rules for Use with the Nasal Pressure Sensor
All of the following must be met: Event is associated with arousal discernible fall in the amplitude of signal but less than 50% in comparison to the baseline level flattening of the waveform event is accompanied by snoring, noisy breathing, elevation in the end-tidal PCO2 or transcutaneous PCO2, or visual evidence of increased work of breathing duration is at least two breath cycles (or the duration of 2 breaths as determined by baseline breathing pattern)

45 Comments on Hypopneas and RERAS
Intolerance and malfunction of the nasal pressure sensor occurs more commonly in infants and children than in adults. When this occurs, hypopneas may be scored using a thermal sensor if the signal quality is adequate, following the same criteria used for scoring hypopneas with a nasal pressure sensor. RERA in children cannot be scored without adequate nasal pressure or esophageal pressure signal. Classification of hypopnea as obstructive, central, or mixed should not be performed without a quantitative assessment of ventilatory effort (esophageal manometry or calibrated respiratory inductance plethysmography) more on this …. Use of a derived signal is promising technology but not yet acceptable for scoring of respiratory events.

46 Change begins with a first step…
Dr. Cindy

47 Proposed Definition for Central Hypopnea
Central hypopnea:  50-90% reduction in oronasal airflow for at least 10 seconds,  associated with 50-90% in-phase reduction of thoracoabdominal movement, followed by oxygen desaturation of at least 3% (4% in adults).  The event should not be scored as central in the presence of snoring or increase in submental EMG activity. 

48 Follow-up – will using this proposed rule jeopardize our accreditation status?
Per Dr. Rosenberg (AASM): “Given the ambiguity of the scoring rules you will not be penalized on accreditation for specifying scoring criteria for central hypopnea.” This response needs to be used in context – it does not mean that you can simply invent a rule; it must be supported by the evidence

49 Hypoventilation and Periodic Breathing Rules
Score hypoventilation when >25% of the TST (include only the time in which CO2 measure is valid!) as measured by either the transcutaneous PCO2 and/or end-tidal CO2 sensor(s) is spent with a CO2 >50 mmHg. Score periodic breathing if there are >3 episodes of central apnea lasting >3 seconds separated by no more than 20 seconds of normal breathing.

50 This is the Last Slide An understanding of the ontogeny of sleep is critical to expert pediatric sleep scoring. Be on the lookout for interesting EEG waveforms in children. Capture examples and share with your colleagues. Identification of artifact by the acquiring tech is critical to accurate scoring. Review your AASM 2007 manual and the articles in the accompanying JCSM issue at least once per year and keep these references at your work station. Check the AASM Scoring FAQs at least 4 times per year for scoring updates.


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