1. Understanding and Applying the Updated AASM Scoring Rules
Marietta B. Bibbs, BA, RPSGT
Morton Plant Mease Healthcare
Clearwater, FL
Presented at FOCUS 2013-Nashville, TN

2. Conflict of Interest Disclosures Speaker: Marietta B. Bibbs
1. I do not have any potential conflicts of interest to disclose, OR
2. I wish to disclose the following potential conflicts of interest: x
Type of Potential Conflict
Details of Potential Conflict
Grant/Research Support
Cephalon & UCB
Consultant
Grass Technologies
Speakers’ Bureaus
Financial support
Other x
3. The material presented in this lecture has no relationship with any of these potential conflicts, OR
4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:
© 2010 American Association of Sleep Technologists

3. Objectives Discuss goals of the AASM Scoring Manual development.
Describe the significance of changing the scoring rules four years ago.
Review and critique current AASM scoring rules.
Outline changes and discuss implementation of the AASM scoring rules revisions.

4. AASM Scoring Rules1 GOALS
AASM Scoring Rules Updated R & K Rules3 and Implemented Changes in:
Implemented 4 years ago to:
Standardize comprehensive PSG recording, scoring, analysis and reporting.
Incorporate age and disease effects on sleep.
Simplify the rules for easier implementation.
Improve interscorer reliability.
Utilize evidence-based or consensus recommendations for rule development.
Simplify rules for REM onset and termination.
Define major body movements and redefine movement time.
Digital analysis
Technical Specifications
Visual Rules
Arousal Rules
Movement Rules
Respiratory Rules

5. Justifications for Revision of R & K Scoring Rules3
No revision in the scoring rules since 1963.
Rules did not apply to digital recording techniques (paper based ).
Rules were based on research rather than clinical studies.
Clarification of amplifer settings for recording parameters was
needed.
Rules did not incorporate scoring for arousals, respiratory events,
limb movements, ECG and age effects.

6. Justifications for Revision of R & K Scoring Rules3
The stage assigned to an epoch was dependent on the score of
previous epoch.
Sleep stage changes were not assigned during the time of actual
occurrence.
Scoring accuracy was compromised in the presence of excessive sleep
fragmentation.
Boundary rules were difficult to follow in REM sleep.

7. Justifications for Revision of R & K Scoring Rules3
Difficult to determine sleep latency in non-alpha producers.
Criteria for slow wave sleep was subjective.
Single EEG derivation limited display of maximal deflection of certain
waveforms.

8. Justifications for Revision of AASM Scoring Rules
Need to address many of the “Frequently Asked Questions”, which are addressed and clarified in the AASM Scoring Rule Revision – Version 2.
Need to address areas of controversy:
Permitting alternative bipolar EEG derivations that result in (cancellation effects) decreasing the amplitude in the frontal EEG recording channels.
Recommending EOG derivations that do not display eye movement direction and is less likely to show eye movements that are low in amplitude.
Combining Sleep stages 3 and 4 into N3, especially in pediatric patients.

9. Controversial Areas in AASM Scoring Rules1 that Needed to be Addressed
Allowing two different rules (definitions) for hypopnea scoring.
Disallowing scoring of apnea and hypopnea in Stage W.
Permitting scoring of respiratory events in adolescents >13 using adult scoring criteria.
Lack of sufficient evidence for visual scoring rules to warrant recommendations as a standard when only 3 of 29 rules are evidence-based and the rest based on consensus.

10. Hypopnea Scoring Rules: Why Use Two Rules?
Recommended Rule: >30% drop from baseline on the nasal pressure channel with a >4% desaturation from pre-event baseline during at least 90% of event duration. 1
Alternative Rule: >50% drop from baseline on the nasal pressure channel with a >3% desaturation from pre-event baseline during at least 90% of event duration. 1
Improve interscorer reliability:
The 4% desaturation rule correlates well with :
High blood pressure
Decreased cognition
Motor vehicles accidents related to sleepiness
Why is this important?
Variablity in scoring can significantly affect diagnosis
IRR is affeced by:
Event duration
Degree of amplitude reduction
Oxygen desaturation level
Presence and duration of arousal accompanying the event.
Improve interscorer reliability:
IRR improves when scoring hypopneas in adults when scoring with a >50% reduction in airflow and a >3% desaturaiton.
Evidence shows that more subtle reductions in airflow are more difficult top achieve good inerscorer agreement.
Recommendations after publication of the manual:
Alternative rule be used in epidemiological and outcome studies
Physicians may select either rule for clinical purposes
In clinical research, both rules could be used for comparison purposes.
Recommended rule was chosen for CMS reimbursement purposes, but the alternative definition is preferred by most clinicians.

11. The Revised AASM Scoring Rules
Accredited sleep centers are required to comply with all the rules, notes and definitions in the manual.
Accredited sleep centers may use the recommended, acceptable, or optional rule for scoring without risk to accreditation.
Rules used in the center are left to the discretion of the physician or investigator.
Released on October 1, 2012 as version 2.0.
In digital format for easier updates.
The scoring manual is copyrighted and may not be reproduced or transmitted in any form (mechanical or electronic).

12. The Scoring Section of the Manual Includes Seven Chapters
Report parameters to be used in accredited sleep centers (Chapter II)*
Digital and filter specifications (Chapter III)
Technical Specifications and scoring rules (Chapters IV-VIII):
Visual
Arousal
Cardiac
Movement
Respiratory
All report parameters are recommended with exception of a few of the
Respiratory events and summary statements.

13. Informational Chapters
Rules Development -Chapter IX
Procedural Notes – Chapter X
Glossary of Terms – chapter XI

14. Age Specific Chapters
The visual rules and respiratory rules are separated into Pediatric and Adult rules in order to address age-specific differences in both recording procedures and scoring procedures in these patient groups.

15. Report Parameters

16. REPORT PARAMETERS General Parameters Sleep Scoring Data
EEG derivations - Recommended
EOG derivations - Recommended
Chin EMG derivations – Recommended
Leg EMG derivations – Recommended
Airflow signals used – Recommended
Respiratory effort signals – Recommended
Oxygen saturation – Recommended
Body Position – Recommended
Electrocardiogram –Recommended (added)
Sleep Scoring Data
EEG derivations - Recommended
EOG derivations - Recommended
Chin EMG derivations – Recommended
Leg EMG derivations – Recommended
Airflow signals used – Recommended
Respiratory effort signals – Recommended
Oxygen saturation – Recommended
Body Position – Recommended
Electrocardiogram –Recommended (added)

17. REPORT PARAMETERS Sleep Scoring Data (continued)
Stage R latency: - sleep onset to first epoch of Stage R in min
Wake after sleep onset: (WASO;TRT-SL-TST, in min)*
Percent sleep efficiency (TST / TRT × 100 )
Time in each stage (min)
Percent of TST in each stage (time in each stage / TST) × 100
*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.2

18. REPORT PARAMETERS Arousals Events Number of arousals - Ar (count)
Arousal Index - ArI (Ar/sleep hour) Ar X 60 / TST]
Movement Events
Number of periodic limb movements of sleep - PLMS (count)
Number of periodic limb movement of sleep with arousal - PLMSAr (count)
Periodic limb movement of sleep index – PLMSI (ratio) [PLMSX60/TST]
Periodic limb movement of sleep with arousal index - PLMSArI (ratio) [PLMSArX60/TST]

19. Cardiac Events Average heart rate during sleep
REPORT PARAMETERS
Cardiac Events
Average heart rate during sleep
Highest heart rate during sleep
Highest Heart rate during recording
Occurrence of arrhythmia:
Bradycardia (yes/no) [list lowest rate]
Asystole (yes/no) [list longest pause]
Sinus tachycardia (yes/no) [list highest rate]
Narrow complex tachycardia (yes/no) [list highest rate]
Wide complex tachycardia (yes/no) [list highest rate]
Atrial fibrillation (yes/no)
Other arrhythmias if present (yes/no) [list type]

20. REPORT PARAMETERS Respiratory Events Optional Parameters
Number of obstructive apneas
Number of mixed apneas
Number of central apneas
Number of hypopneas
Number of obstructive hypopneas (optional) (added)
Number of central hypopneas (optional) (added)
Number of apneas + hypopneas
Apnea index (AI; (# obstructive apneas + # central apneas + # mixed apneas) × 60 / TST)
Hypopnea index (HI; # hypopneas × 60 / TST)
Apnea + Hypopnea index (AHI; # of apneas and hypopneas × 60 / TST)
Optional Parameters
Obstructive apnea hypopnea index (OAHI; (# obstructive apneas + # mixed apneas + # obstructive hypopneas) × 60 / TST) *
Central apnea hypopnea index (CAHI; (# central apneas + # central hypopneas) × 60 / TST) *
Respiratory effort-related arousals (RERAs, total number)
Respiratory effort-related arousal index (RERA index; # of RERAs × 60 / TST)
Respiratory disturbance index index (RDI; AHI + RERA index)*
Oxygen desaturations ≥3% total number**
Oxygen desaturation index ≥3% (ODI; # oxygen desaturations ≥3% × 60 / TST)N1 **
*added **removed or >4%

21. REPORT PARAMETERS Respiratory Events Important Notes:
Arterial oxygen saturation, mean value *
Minimum oxygen saturation during sleep
Occurrence of hypoventilation during diagnostic study *
Adults (optional) *
Children *
Occurrence of hypoventilation during PAP titration (in adults and children) (optional)*
Occurrence of Cheyne-Stokes breathing in adults
Duration of Cheyne-Stokes breathing (absolute or as a percentage of total sleep time) or
the number of Cheyne-Stokes breathing events.
Occurrence of periodic breathing in children
Occurrence of snoring
*added
Important Notes:
If measuring 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.2
Reporting the occurrence of Cheyne-Stokes breathing in the PSG report is required only if central apneas are present. 2

22. Digital Specifications
Filter Settings
No change in recommended filter settings for EEG, EOG, EMG, ECG, Respiration and Snoring.
Expanded respiration to specify filter settings relate to thermal flow and respiratory effort belts.
Added filter settings for Nasal Pressure and PAP device flow.
Electrode impedances remain at a maximum recommendation of 5 KΩ.
Minimum digital resolution remains the same at 12 bits per sample.
No change to sampling rates for all recording parameters (EEG, EOG, EMG, ECG, airflow, oximetry, nasal pressure , esophageal pressure, body position, snoring or respiratory effort).
YANG
Added digital specifications for Transcutaneous PCO2, End-Tidal PCO2, esophageal pressure and PFlow.
All digitial specifications and filter settings are recommended. No alternatives or options provided.
Notes are more comprehensive in explaining the filter settings and digitial specifications.

23. Recommended Sampling Rates
Parameter
Desirable
Minimal
EEG
500 Hz
200 Hz
EOG
EMG
ECG
AIRFLOW
100 Hz
25 Hz
Parameter
Desirable
Minimal
SaO2, TcPO2
25 Hz
10 Hz
Nasal Pressure, End-Tidal PCO2, PFlow
100 Hz
Esophageal Pressure
Body Position
1 Hz
Snoring
500 Hz
200 Hz
Respiratory Effort

24. Filter Settings Low Frequency High Frequency EEG 0.3 Hz 35 Hz
EOG Hz 35 Hz
EMG 10 Hz Hz
ECG Hz 70 Hz
Flow and Effort 0.1 Hz 15 Hz
Snoring 10 Hz Hz
Nasal Pressure DC or 0.03 Hz Hz
Pflow DC DC
The rule: filter settings should simulate or replicate conventional analog filter frequency response curves.
Older equipment high frequency filter settings can be Hz

25. Digital Analysis of PSG
PSG Recording Features, PSG Display and Display Manipulation and Digital Analysis of PSG
PSG Recording Features
No changes noted in this section of the manual.
All are Recommended with exception of a electrode selector panel which would allow changing electrode derivations without using a common reference.
PSG Display and Display Manipulation
Virtually unchanged with the same recommendations and optional features
Clarified information regarding display resolution for scoring and reviewing data. Screen must meet or exceed 15 inch screen size, 1600 pixels horizontal and 1050 pixels vertical.
Digital Analysis of PSG
Requirements for PSG recording systems unchanged with the same recommended features and optional features.

26. Visual Rules for Adults

27. Technical Specifications for EEG Derivations
No change in recommendations
Acceptable
FZ-CZ
CZ-OZ
C4-M1
Recommended
F4-M1
C4-M1
O2-M1
Backup
F3-M2
C3-M2
O1-M2
Backup
FPZ, C3, O1, M2
For    
FZ CZ/C4 O2 M1
The International System is used to determine electrode placement.

28. Special Considerations
The manual notes that the Fz-Cz derivation used in the acceptable montage is not appropriate for scoring Stage N3 due to the fact that this derivation produces cancellation effects when N3 slow wave activity or K-complexes are of similar amplitude over the frontal and central regions.
If the recommended EEG derivations are used, slow wave activity should be measured from F4-M1. The C4-M1 derivation can also be used to measure slow wave activity when using the recommended EOG derivations and the acceptable EEG derivations, but this does not resolve the problem with the frontal derivations.
If the acceptable EEG and EOG montage derivations are used, the E1-FPz derivation is recommended since FPz would become the active electrode.

29. EOG Technical Specifications
No Change
Recommended Derivations and placements:
E1-M2 and E2-M2
E1 (active electrode) is placed 1 cm below the left outer canthus
E2 (active electrode) is placed 1 cm above the right outer canthus
Conjugate eye movements preserve the angular relationship between the right and left eyes. When one moves both eyes left and then right, a conjugate movement is made. Up and down movements and combinations of vertical and lateral movements are also conjugate eye movements. 
 1 cm 
 1 cm
Right = E2
Left = E1
The recommended derivation does not display eye movement direction and is less likely to show eye movements that are low in amplitude; however, artifacts are more easily seen.

30. EOG Technical Specifications
No Change
Acceptable EOG Derivations and placements:
E1-Fpz & E2 – Fpz
E1 placed 1 cm below and 1 cm lateral to the left outer canthus, and E2 placed 1 cm below and 1 cm lateral to the right outer canthus
1 cm
 1 cm
 1 cm
 1 cm  
Left = E1
Right = E2
The acceptable placement shows the direction of eye movements. Moving the eyes to the left and right (horizontal) will result in out-of-phase deflections, and moving the eyes up and down (vertical) will produce in-phase deflections.

31. Recommended vs Alternative EOG Derivation
RECOMMENDED EOG
ACCEPTABLE EOG
E1-M E2 (1 cm above)
E2-M ↑ ↓
E1 (1 cm below)
E1-FPz
E2-FPz
E2 E1
Does not show direction of eye movements
Does show direction of eye movements
Can miss low amplitude eye movements
Shows all eye movements
Easy to distinguish artifacts and EEG
Less easy to distinguish artifacts

32. EMG Technical Specifications
Three recording electrodes recommended:
One electrode at midline: 1 cm above the inferior edge of the mandible
Two electrodes placed 2 cm below the inferior edge of the mandible with one electrode 2 cm right and the other placed 2 cm left of the midline.
Derivation: Reference one inferior electrode to the midline electrode and use second electrode as backup.
No Change   

33. Sleep Stage Scoring No Change to Stage Terminology
Score in 30-second epochs and assign a sleep stage to each epoch.
If two or more sleep stages appear in one epoch, assign the score to the stage comprising the majority of the epoch.
Stage W (Wakefulness) Stage N1 (NREM 1)
Stage N2 (NREM 2)
Stage N3 (NREM 3)
Stage R (REM)
Notable that manual does not show any examples of sleep stages under the descriptions

34. Stage W Previous recommendations are the same.
Added Slow eye movements (SEM) defined as “conjugate, reasonably regular, sinusoidal eye movements with an initial deflection usually lasting >500 msec.”
SEMs may be due to electrophysiological and physiological indications of drowsiness during Stage W that may continue into Stage N1.
YANG
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35. SEMS in Stage W

36. Stage N1 No change in definitions or rules Definitions still include:
Slow eye movements
Low amplitude, mixed frequency EEG
Vertex sharp waves
Sleep onset defined as the first epoch scored as any stage of sleep.
Rules are the same

37. Stage N1

38. Stage N2 No change in definitions
No change in starting or continuing stage N2
No change in ending stage N2
No change related to major body movements occurring in N2

39. Stage N2

40. Stage N2

41. Stage N3 No change in Definitions or Rules.
One note added explaining that K complexes are considered to be slow waves if they meet the definition of slow wave activity.

42. Stage N3

43. Stage N3
Using the Acceptable Montage

44. Stage R No change in definitions
Scoring still includes presence of rapid eye movements, low chin EMG, sawtooth waves, and transient muscle activity, low amplitude, mixed frequency.
No change in rules for continuation of Stage R:
Low amplitude, mixed frequency EEG without presence of K complexes or spindles
Low chin tone through the majority of the epoch

45. Stage R

46. Stage R
Stage R using the acceptable montage derivations

47. Ending Stage R Rules are the same for ending Stage R End Stage R if:
There is transition to Stage W or N3;
The chin EMG increases above the Stage R level;
Criteria for Stage N1 are met;
An arousal occurs and is followed by low amplitude, mixed frequency EEG and slow eye movements (transition to Stage N1);
If a REM EEG remains following an arousal, chin tone remains low, and there are no slow eye movements following arousal, keep in stage R.

48. End of Stage R
End of Stage R due to arousal followed by low amplitude, mixed frequency EEG and slow eye movements

49. Scoring Transition Between Stage N2 and Stage R
No change in transition scoring rules between Stage N2 and Stage R.
Between definite Stage N2 and definite Stage R, when there is a drop in the chin EMG in the first half of the next epoch to the Stage R level, score the epoch as Stage R even if there are no REMS if all the following epochs meet the Stage R criteria (absence of non-arousal K complex and absence of sleep spindles).
Between epochs of definite stage N2 and definite Stage R, when there is a drop in the chin EMG in the first half of the epoch to stage R level, score the epoch as Stage N2 if there is presence of non-arousal associated K complexes or spindles and if there is absence of rapid eye movements.

50. Scoring Transition Between Stage N2 and Stage R
No change in transition scoring rules between Stage N2 and Stage R.
Between epochs of definite stage N2 with minimal chin EMG tone and definite stage R without further drop in chin EMG tone, score epochs as stage R even in the absence of rapid eye movements, if there is absence of non-arousal associated K complexes and absence of sleep spindles.
There are no specific rules related to transitions between stage N1 and stage R. Begin Stage R only when rapid eye movements are seen in association with low muscle tone and the typical REM EEG.

51. Transition epoch between N2 and Stage R

52. Scoring Major Body Movements
No change in scoring criteria:
Definition: Major body movement is an epoch in which movement and muscle artifact obscures the EEG for more than half the epoch to the extent that the sleep stage cannot be determined.
If alpha is present in the epoch, even if it is less than 15 seconds, the epoch should be scored as Stage W.
If no alpha rhythm is seen in the epoch, but the preceding or succeeding epoch can be scored as stage W, then the major body movement epoch should be scored as stage W.
If the epoch cannot be scored as stage W, then it should be scored the same as the epoch that follows the major body movement.

53. Epoch is scored as N2 since N2 follows the epoch
Major Body Movement
Epoch is scored as N2 since N2 follows the epoch

54. Visual Rules for Children

55. No change in age description No change in terminology for staging
Rules can be used to score sleep and wake in children 2 months post-term
No change in terminology for staging
Technical specifications remain the same as adult
Notes related to the need to reduce the distance for EOG and chin EMG electrodes in children and infants with small heads

56. Change in notes related to when sleep spindles may be seen in children and added a description of how spindles occur during this age.
“ Sleep spindles may be seen by age 4-6 weeks 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.2”

57. Pediatric Scoring Rules Scenarios are Unchanged
If all epochs of NREM sleep contain no recognizable sleep spindles, K complexes or high-amplitude Hz slow wave activity, score all epochs of NREM sleep as stage N (NREM). 2
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). 2
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). 2
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. 2

58. Definitions for scoring Stage W are unchanged and include:
STAGE W in Pediatrics
Definitions for scoring Stage W are unchanged and include:
Alpha Rhythm
Eye Blinks
Reading Eye Movements
Rapid Eye Movements
Dominant Posterior Rhythm
The term "posterior dominant rhythm" replaces the term "alpha rhythm" when scoring wakefulness and NREM stages in children.
Epochs are scored as stage W when more than 50% of the epoch has either reactive alpha or age-appropriate posterior dominant rhythm over the occipital region.
Epochs with no discernible reactive alpha or no age-appropriate posterior dominant rhythm should be scored as stage W if ANY of the following are present:
Eye blinks at a frequency of Hz
Reading eye movements
Irregular, conjugate rapid eye movements associated with normal or high chin muscle tone

59. Stage N1 in Pediatrics
Definitions for scoring Stage W are unchanged and include:
Slow eye movements
Low-amplitude, mixed-frequency activity
Vertex sharp waves
Sleep onset
Rhythmic anterior theta activity
Hypnagogic hypersynchrony
If posterior dominant rhythm is present and attenuated or replaced by low-amplitude, mixed-frequency activity >50% of the epoch , score the epoch as stage N1.
If the posterior dominant rhythm, is not present score stage N1 when any of the following occur:
Activity in the range of 4-7 Hz with slowing of background frequencies by ≥1-2 Hz from those of stage W
Slow eye movements
Vertex sharp waves
Rhythmic anterior theta activity
Hypnagogic hypersynchrony
Diffuse or occipital-predominant, high-amplitude, rhythmic 3-5 Hz activity2

60. STAGE N2 and stage n3 in Pediatrics
Score stages N2 and N3 in children utilizing the same rules as adults

61. Score stage R in children utilizing the same rules as adults
Stage R in pediatrics
Score stage R in children utilizing the same rules as adults
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.2

62. No changes in arousal scoring
Arousal Rules
No changes in arousal scoring
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.2
The new rules include an additional note for clarification of arousal scoring during Stage W.
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 index2

63. CARDIAC RULES No change in scoring cardiac events
No change in technical specifications or lead placements
No change in scoring cardiac events
sinus tachycardia
bradycardia
asystole
wide complex tachycardia narrow complex tachycardia
atrial fibrillation
One note added to address sustained sinus braydcardia or tachycardia:
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. 2

64. Movement Rules

65. Periodic Limb Movements
No change in the definition, duration, amplitude, onset or ending, or PLM series.
A significant leg movement has a minimum duration of 0.5 seconds with a maximum duration of 10 seconds and a minimum 8V increase in voltage amplitude above resting EMG.
The onset of a LM is the point where there is an 8V voltage increase in amplitude above the resting EMG.
The LM event ends at the point when at least 0.5 seconds of the EMG does not exceed 2V above resting EMG.2
PLM Series
Four consecutive LM events define a PLM series.
The minimum time between onsets of consecutive LMS to include them as part of a PLM series is 5 seconds.
The maximum time between onsets of consecutive LMs to include them as part of a PLM series is 90 sec.
Leg movements on 2 different legs separated by less than 5 seconds between movement onsets are counted as a single leg movement.2

67. Other Movements Alternating Limb Movements Hypnagogic Foot Tremor
No change in definition or rules related to:
Alternating Limb Movements
Hypnagogic Foot Tremor
Excessive Fragmentary Myoclonus
Bruxism

68. Scoring Features of REM Sleep Behavior Disorder
Scoring feature of Rhythmic Movement Disorder
No Change in Definitions: Includes:
Sustained (tonic) muscle activity in REM Sleep
Excessive transient muscle activity (phasic activity) in REM sleep
No change in definitions, mininum or maximum frequencies or amplitudes
The polysomnographic characteristics of RBD are characterized by EITHER or BOTH of the following features:
a. Sustained muscle activity in REM sleep in the chin EMG.
b. Excessive transient muscle activity during REM in the chin or limb EMG.2

69. Excessive transient muscle activity (phasic) during REM sleep in the limb EMG

70. Respiratory Rules for Adults

71. More Alternative Sensors Options
Technical Considerations
More Alternative Sensors Options
To score an apnea during a diagnostic study, an oronasal thermal airflow sensor should be used to monitor airflow.
In the event that the oronasal thermal airflow sensor is not functioning or the signal is not reliable during a diagnostic study, use one of the alternative apnea sensors: 2
a. nasal pressure transducer (with or without square root transformation)
b. RIPsum (calibrated or uncalibrated)
c. RIPflow (calibrated or uncalibrated)
d. PVDFsum 2 (acceptable)
To score hypopnea during a diagnostic study, a nasal pressure transducer (with or without square root transformation of the signal) should be used to monitor airflow.
If the nasal pressure transducer is not functioning or the signal is not reliable for identification of a hypopnea during a diagnostic study . use one of the following (alternative hypopnea sensors): 2
a. oronasal thermal airflow
b. RIPsum (calibrated or uncalibrated)
c. RIPflow (calibrated or uncalibrated)
d. dual thoracoabdominal RIP belts (calibrated or uncalibrated)
e. PVDFsum 2
polyvinylidene fluoride

72. Technical Considerations
No change in event duration rules
Apnea or hypopnea event 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.
Terminate events when there is clear and sustained increase in breathing amplitude or where a desaturation has occurred, there is event resaturation of at least 2%.
Added a rule for scoring event duration:
The PAP device flow signal output should be used to identify apnea and hypopnea during positive airway pressure (PAP) titration.
For monitoring respiratory effort, use one of the following:
a. esophageal manometry
b. dual thoracoabdominal RIP belts (calibrated or uncalibrated)
c. dual thoracoabdominal PVDF belts (acceptable)
Oxygen saturation should be monitored with pulse oximetry with a maximum acceptable signal averaging time of ≤3 seconds at a heart rate of 80 beats per minute.
The monitoring of snoring g is optional. If snoring is monitored, use an acoustic sensor (e.g. microphone), piezoelectric sensor or nasal pressure transducer.
Detection of hypoventilation during a diagnostic study is accomplished by using arterial PCO2, transcutaneous PCO2 or end-tidal PCO2.
During PAP titration, detection of hypoventilation is accomplished by using arterial PCO2, or transcutaneous PCO2.
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.2

73. Beginning of first breath Approximating baseline
Nadir preceding
1st reduced breath
Beginning of first breath
Approximating baseline
Beginning of event is nadir preceding the first breath of event
End of event is beginning of first breath that approximates baseline (not defined).

74. Scoring of Apneas
No change in apnea scoring as far as event duraion, amplitude reduction or event classification.
Removed 90% of event duration must meet amplitude reduction criteria.
Significant clarification notes have been added:
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
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.2

75. Scoring Apneas Notes Added
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.

76. Absent Airflow
10 Seconds
Paradoxical motion
Obstructive Apnea

77. Thermal
Pressure
Snore
SpO2
RIP Sum
RIP RC
RIP ABD
10 Seconds

78. Pressure
10 seconds
Snore
SpO2
RIP Sum
RIP RC
RIP ABD

79. Thermal
Pressure
10 seconds
Snore
SpO2
RIP Sum
RIP RC
RIP ABD

80. Sleep onset Central Apnea
Absent Airflow
10 Seconds
Absent Effort
Sleep onset Central Apnea

81. Thermal
Pressure
Snore
10 seconds
SpO2
RIP Sum
RIP RC
RIP ABD

82. 10 Seconds
Central
Obstructive
Mixed Apnea

83. Hypopnea Scoring Most significant changes in the scoring rules.
Recommended rule changed.
No acceptable rule is noted.
Removed the 90% of event duration must meet amplitude reduction criteria.
Added definitions for scoring obstructive and central hypopnea.
Noted that it is optional to score hypopneas as central or obstructive.

84. Hypopnea Scoring Recommended Rule:2
Score a respiratory event as a hypopnea if ALL of the following criteria are met:
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.

85. Definition of Obstructive & Central Hypopnea
Score a hypopnea as central if NONE of the following criteria are met:
a. Snoring during the event
b. Increased inspiratory flattening of the nasal pressure or PAP device flow signal compared to baseline breathing
c. Associated thoracoabdominal paradox occurs during the event but not during pre-event breathing.
Score a hypopnea as obstructive if ANY of the following criteria are met:
a. Snoring during the event
b. Increased inspiratory flattening of the nasal pressure or PAP device flow signal compared to baseline breathing
c. Associated thoracoabdominal paradox occurs during the event but not during pre-event breathing.

86. Hypopnea Reduced Airflow Snoring Desaturation >= 4% Phase Shift
10 Seconds
Phase Shift
Hypopnea

87. Thermal
Pressure
10 seconds
Snore
SpO2
RIP Sum
RIP RC
RIP ABD

88. Scoring Respiratory Effort Related Arousal
No change in rules for scoring respiratory effort-related arousal (RERA) except adding the technical specifications for recording devices used during diagnostic and PAP studies.

89. Scoring Hypoventilation
Language clarified for scoring hypoventilation during sleep:
Score a respiratory event as hypoventilation during sleep if EITHER of the below occur:
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.2

90. Scoring Cheyne Stokes Breathing
Rule has been updated and language changed:
Score a respiratory event as Cheyne-Stokes breathing if BOTH of the following are met:
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.
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.2

91. Cheyne Stokes Breathing
Crescendo- Decrescendo pattern
10 Seconds
Cheyne Stokes Breathing

92. RESPIRATORY RULES IN CHILDREN
Rules expanded to Include:
Ages for which Pediatric Scoring Rules Apply.
Technical Specifications
Measuring Event Duration
Scoring of Apneas
Scoring of Hypopneas
Scoring Respiratory Effort-Related Arousal
Scoring Hypoventilation
Scoring of Periodic Breathing

93. RESPIRATORY RULES IN CHILDREN
Technical Specifications:
Same as adult
Event Duration:
Applicable Age:
Rules can be used for children <18 years, but an individual sleep specialist can choose to score children ≥13 years using adult criteria.

94. RESPIRATORY RULES IN CHILDREN
Hypopnea Rules:
Same as adult scoring using the recommended rule and adding drop in signal excursion lasts for ≥2 breaths.
Event Duration:
Same as adult
Apnea Rules
No change in event duration, amplitude missed breaths or event definitions (central, mixed or obstructive).

95. RESPIRATORY RULES IN CHILDREN
No significant change in rules for scoring Respiratory Effort-Related Arousal, Hypoventilation and Periodic Breathing in children.

96. References
1. Iber C, Ancoli-Israel S, Chesson A, and 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, Illinois: American Academy of Sleep Medicine, 2007.
2. Berry RB, Brooks R, Gamaldo CE, Harding SM, Marcus CL, Vaughn BV and Tangredi MM for the American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, Version Darien, Illinois: American Academy of Sleep Medicine, 2012.
3. Rechtschaffen A, Kales A, eds. A manual of standardized terminology, techniques and scoring system for sleep stages of human subjects. Los Angeles, CA: BI/BR, 1968.