AP done*****

Technical Notes

Technical notes for digital polysomnography recording in

sleep medicine practice
Manjari Tripathi
Department of Neurology, Associate Professor Neurology, AASM International Fellow 2008, Room number 705,
Neurosciences Centre, AIIMS, Delhi, India

For correspondence: Dr. Manjari Tripathi, E-mail: [email protected]

Ann Indian Acad Neurol 2008;11:00-00******

Introduction was published from UCLA by Allan Rechtschaffen and

Anthony Kales,[3,4] which we had followed till 2007. The
In our country, the standards of digital polysomnography existence of qualitative differences in sleep in newborns
(PSG) recordings vary widely, as is their interpretation. and children was identiÞed; this resulted in publication
Proper recording and interpretation of digital PSG is of a separate manual for this age group in 1971.[5] In
crucial in the appropriate management of patients who 2007, a more comprehensive scoring manual published
undergo this test. This review is aimed to highlight the by the American Academy of Sleep Medicine (AASM)[6]
technical standards for digital PSG recording and scoring established the evolutionary and evidence-based changes
in sleep practice. that are occurring in this dynamic Þeld. The various
methods for evaluating sleep in the clinical laboratory
Historical Background are listed below:
• Overnight PSG
The science of sleep medicine has evolved tremendously • Multiple sleep latency tests (MSLT)
as a result of the development of tools that enable • Maintenance of wakefulness tests (MWT)
us to detect and document the activities of various • Video-PSG
physiological and pathological events that occur in • Extended electroencephalography (EEG) and PSG
the central nervous system accompanied by changes, montage: In suspected seizure disorder
which develop in the cardio respiratory, circulatory and • Ambulatory PSG
autonomic nervous systems during sleep. This Þeld is • Actigraphy
still evolving with tremendous pace in technology and
interpretation. The initial steps towards this were taken The indications for PSG are as follows:
as long back as 1875 when the ability to detect brain • Sleep-related breathing disorders (obstructive
surface electrical activity in animals became available. In sleep apneas, suspected upper-airway resistance
1937, scalp brain recordings during PSG initially focused syndrome, obesity hypoventilation syndrome,
on visually identiÞable patterns of brain activity during patient with neuromuscular disorder and breathing
rapid eye movement (NREM) sleep, brain waveform problems)
patterns such as alpha and delta activities, and on well- • CPAP-Bi-PAP titration
isolated waveforms such as K complexes, spindles, vertex • For assessment of treatment efficacy after CPAP
waves and posterior occipital sharp transients. In 1953, therapy
a landmark description of rapid eye movements (REMs) • After oral appliances or surgery
associated with respiratory and cardiac effects was given • Follow-up PSG if signiÞcant changes in symptoms
by Aserinsky and Kleitman[1] and later annotated as the occur
REM stage of sleep. The Þrst continuous sleep recording • Suspected narcolepsy (overnight PSG followed by
was performed in 1957 by Dement and Kleitman.[2] In MSLT)
as early as 1960, initial efforts for characterizing sleep • Parasomnias: unexplained nocturnal awakenings,
patterns for performing an objective sleep scoring, unusual behavioral events in sleep-like sleep terror,
which could permit inter-rater reliability in scoring, was REM behavior disorder or difference between seizure
started. A consensus meeting in April 1967, led to the and a sleep disorder
formation of a standardized scoring manual; this manual • Periodic limb movements in sleep (PLMS)

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• Insomnias (If suspected to have sleep apnea or to attach electrodes to the patient. At the conclusion
PLMS, the cause is uncertain or failure of adequate of the study, adhesive remover is used to dissolve the
behavioral and pharmacological treatment) adhesive on the patients’ skin. Care should be taken to
• MSLT will be required in suspected narcolepsy and prevent the use of the adhesive to attach the EOG around
unexplained daytime drowsiness the eyes. Due to the high ßammability of collodion and
• MWT should be performed to detect response to acetone, they should be used with caution, especially
continuous positive airway pressure (CPAP) therapy in those patients who require supplemental oxygen.
or medication Patients with parasomnias or seizures may be at risk
• A split study is performed when a previous scoring for injury related to movements during sleep. The
has been performed on the patients’s sleep or if integrity of PSG equipment’s electrical isolation should
the clinician is reasonably certain that the patient be certiÞed by engineering or biomedical personnel
could have severe OSA, and the Þrst 2 h of sleep can qualiÞed to make such assessment. Institution-speciÞc
document the sleep pattern with at least 20 apneas policies, protective measures and guidelines describing
per hour. However, in many patients, REM may personnel responsibilities and appropriate responses in
not occur during this time; hence, providing a false such situations should be developed.
impression of the severity of hypoxia.
Assessment of test quality
Setting
With respect to sleep-related respiratory disturbances,
It is mandatory that all persons involved in the recording PSG should either conÞrm or eliminate a diagnosis.
of sleep use the most scientiÞc and secure mechanisms. Reporting should be performed following a standard
Maintaining a laboratory involves tremendous format; automated scoring should be strongly discouraged
responsibility and having standard operating procedures because of the false over or under scoring. All recordings
(SOPs) manual, and technician’s familiarity and continuous should be manually scored. Documentation of Þndings
attendance with the procedure is very important. suggested therapeutic intervention, and/or other
clinical decisions resulting from PSG should be noted
The recording room should be sound proof, comfortable, in the patients’ chart. Each laboratory should devise and
have soothing soft colors on the wall; there should be a implement indicators of quality assurance with respect
facility for video with lights switched off and an infrared to equipment calibration and maintenance, patient
video camera. The technician should be able to see from preparation and monitoring, scoring methodology, and
his station the patient’s video and monitor continuously. inter-rater scoring issues.
Intervention is required if the physiological signals
are missed due to problems with instrumentation or Monitoring
become obscured due to artifacts. The technician should
also intervene if an acute change in the physiological Patients should have been previously examined by
status occurs and communicate these changes to the the physician in the clinic, explained and consented
appropriate medical personnel on call. There should be for the procedure. They should be requested to avoid
an attached toilet in the room for the patients’ comfort. stimulants before the procedure. Ideally, two weeks
The patient should be made to feel as comfortable as prior to the procedure, the medication should be tapered
possible. The patient should be encouraged to bring and stopped. If MSLT is being performed, it should be
along objects associated with sleep and all measures to in the morning after the PSG. The Epworth sleep scale
help prevent the Þrst night effect. should be recorded and a detailed history of the patients
complaints and habitual sleep pattern be recorded. The
Contraindications reason and indication for performing the study should
be clearly documented. A complete physical examination
There are no absolute contraindications to PSG when the such as height, weight, BMI, perioral characteristics of
indications are clearly established. However, risk-beneÞt the patient should be documented. The type of mask to
ratios should be assessed if medically unstable inpatients be selected during the CPAP titration will depend not
are to be transferred from the clinical setting to a sleep only on the patient’s preferences and affordability but
laboratory for overnight PSG; all resuscitative equipment also on his breathing patterns and predominant sleep
should be made available in the room. postures.

Precautions/Complications Calibration

Skin irritation may occur as a result of the adhesive used Calibration should be performed both at the beginning

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and the end of the study under the following categories. Alternative acceptable derivations are:
Physiological/biological calibration has to be performed a. Fz-Cz
as follows: ask the patient to keep the eyes open, look b. Cz-Oz
straight ahead for 30 s, close the eyes, look straight ahead c. C4-M1
for 30 s, look to the left and right, repeat up and down,
hold head still, blink eyes slowly five times, grit teeth, Backup electrodes should be placed at Fpz, C3, O1, and
clench jaw or smile, inhale and exhale, hold breath for M2 to enable substitution of Fpz for Fz, C3 for Cz or C4,
10 s, flex right foot, flex left foot, flex right hand, flex left O1 for O2 and M2 for M1 if electrodes malfunction during
hand, turn the patient to either side to check on the body the study.
position sensors. Mechanical calibration should also be
performed [Figure 1]. 2) EOG: The recommended EOG derivations are:
a. E 1 -M 2 (E 1 is placed 1 cm below the left outer
The patient variables to be monitored during PSG as canthus)
recommended by AASM guidelines, 2007, are listed b. E 2-M 2 (E 2 is placed 1 cm above the right outer
below. canthus)

Recording parameters Alternative acceptable derivations are:

1) EEG derivations a. E1-FPz (E1 is placed 1 cm below and 1 cm lateral to
2) Electro-oculogram (EOG) derivations the outer of the left eye)
3) Chin electromyography (EMG) b. E2-Fpz (E2 is placed 1 cm below and 1 cm lateral to
4) Leg EMG derivations the canthus of the right eye)
5) Airflow parameters
6) Effort parameters 3) EMG: Three electrodes should be placed to record
7) Oxygen saturation chin EMG:
8) Body position A. One in the midline 1 cm above the inferior edge of
9) Electrocardiography (ECG) the mandible
B. One 2 cm below the inferior edge of the mandible
1) EEG: EEG electrode position is determined by and 2 cm to the right of the midline
international 10–20 System. [7] A minimum of three C. One 2 cm below the inferior edge of the mandible
EEG derivations are recommended to sample the and 2 cm to the left of the midline
activity from the frontal (F), central (C) and occipital
regions (O). The standard chin EMG derivation consists of either
of the electrodes below the mandible referred to the
The recommended derivations are: electrode above the mandible. The other inferior
a. F4-M1 electrode is a backup electrode to permit continuous
b. C4-M1 display of EMG activity if one of the primary electrodes
c. O2-M1 malfunctions [Figure 2].

Backup electrodes should be placed at F 3, C 3, O 1 4) Scoring of leg movements: Surface electrodes should
referenced to M2 to allow display of F3-M2, C3-M2 and be placed longitudinally and symmetrically around
O1-M2 if electrodes malfunction during the study. the middle of the muscle so that they are 2–3 cm apart

Figure 1: Calibration 30-s epoch Figure 2: Electrode placement {(EEG 10 × 20), CHIN, EOG}

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[Figure 3]. Both legs can be used for monitoring the 2) Lights on clock time (h: min)
movements, especially if alternate leg muscle activation 3) Total sleep time (TST; min)
is suspected (ALMA). The upper limbs may also be 4) Total recording time (“lights out” to “lights on” in
sampled, especially if they are the ones involved in severe min)
PLMS or RBD. 5) Sleep latency (SL; lights out to the first epoch of any
sleep in min)
5) Airflow parameters: The current guidelines recommend 6) Stage R latency (sleep onset to the first epoch of
the use of a thermal sensor, which is placed in the stage R in min)
patient’s nostril to detect the apnea; the nasal pressure 7) Wake after sleep onset (WASO; stage W during A4,
transducer is used for identifying hypopnea. Ideally, both minus A5, in min)
the sensor and transducer should be used. 8) Percent sleep efficiency (A3/A4) ×100
9) Time in each stage (min)
6) Effort parameters: Respiratory inductance 10) Percentage of TST in each stage (A9 values/A3)
plethysmography (RIP belts), individual chest and ×100
abdominal belts with peizo electrodes may be used for
detecting respiratory effort. Esophageal manometry is B. Arousal events
difficult to perform and is uncomfortable for the patient 1) The number of arousals
who already has a difficulty in sleeping. 2) The arousal index (ArI; B1×60/TST)

7) Oxygen saturation: Pulse oximetry with a maximum C. Respiratory events

acceptable signal averaging time of 3 s should be used 1) Number of obstructive apneas
for detection of blood oxygen. 2) Number of mixed apneas
3) Number of central apneas
8) Body position: Body position sensors may be 4) Number of hypopneas
unreliable, and a video film of the patient should be 5) Number of apneas + hypopneas
acquired to confirm the position when there is any 6) Apnea index (AI; (C1+C2+C3)×60/TST)
suspicion. 7) Hyponea index (AHI; C4×60/TST)
8) Apnea+ Hypopneas index (AHI; C5×60/TST)
9) ECG: A single modified electrocardiograph 9) Respiratory effort-related arousals (RERAS), total
Lead II, which uses torso electrode placement, is number
recommended. 10) Respiratory effort-related arousals index,
(C9×60/TST)
Sleep Scoring 11) Oxygen desaturations ≥3% or ≥4% - total number
12) Oxygen desaturations index ≥3% or ≥4 %(DI;
Data to be recorded in the study is as given below. All C11×60/TST) [9–12 are optional]
the following steps are recommended. 13) Continuous oxygen saturation, mean value
14) Minimum oxygen saturation during sleep
A. Sleep scoring data 15) Occurrence of hypoventilation (yes/no)
1) Lights out clock time (h: min) 16) Occurrence of Cheyne Stokes breathing (yes/no)

D. Cardiac events
The average heart rate (HR) during sleep, highest HR
during sleep and also the entire recording should be
noted. Occurrence of the following arrythmias should
be noted with the duration of pause. Bradycardia- note
the lowest HR , asystole – report the longest pause, sinus
tachycardia- report the highest rate, narrow complex
tachycardia- report the highest rate, wide complex
tachycardia- report the highest rate and the occurrence
of atrial fibrillation.

E. Movement events
The number of PLMS should be noted; PLMS with
arousals (PLMSAr), PLMS index (PLMSI; PLMS × 60/
TST) and PLMS arousal index (PLMSIArl; PLMSAr ×
Figure 3: EMG tibialis anterior 60/TST) should also be noted.

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The summary of the report should have the following 7) A Þlter design for data collection, which functionally
headings: simulates or replicates conventional (analog style)
Findings related to sleep diagnosis frequency response curves rather than removing
EEG abnormalities all activity and harmonics within the specified
ECG abnormalities bandwidth.
Behavioral observations
Hypnogram (optional) Rules for PSG Display and Display Manipulation
1) Resolution of digital screen and video card should
Digital SpeciÞcations for Routine PSG Recording be at least 1600 × 1200 for display and scoring of raw
Maximum Electrode Impedances 5 KΩ PSG data
Minimum Digital Resolution 12 bits per sample 2) Histogram with stage, respiratory events, leg
movement events, O2 saturation and arousals, with
Sampling Rates Desirable Minimal cursor positioning on histogram and ability to jump
EEG 500 Hz 200 Hz to the page of selection.
EOG 500 Hz 200 Hz 3) Ability to view a screen on a scale ranging from the
EMG 500 Hz 200 Hz entire night to windows as small as 5 s.
ECG 500 Hz 200 Hz 4) Recorded video data should be synchronized with
Airßow 100 Hz 25 Hz PSG data and have an accuracy of at least one video
Oximetry 25 Hz 10 Hz frame per second.
Nasal pressure 100 Hz 25 Hz 5) Automatic page turning and scrolling, channel-off
Esophageal pressure 100 Hz 25 Hz control key or toggle, channel invert control key
Body position 1 Hz 1 Hz or toggle, ability to change the order of channel by
Snoring sounds 500 Hz 200 Hz click and drag, display setup proÞles along with
Rib cage and colors that may be activated at any time, Fast Fourier
abdominal moments 100 Hz 25 Hz Transformation or spectral analysis on speciÞable
intervals is optional.
Routinely Low High
Recorded Frequency Frequency
Whether sleep stage scoring was performed should be
Filter Settings Filter Filter
identiÞed for all systems. The capability to turn off and
EEG 0.3 Hz 35 Hz
on, as demanded, highlighting for patterns identifying
EOG 0.3 Hz 35 Hz
sleep stage decisions (for example, sleep spindle
EMG 10 Hz 100 Hz
complex, alpha and delta), patterns identifying the
ECG 0.3 Hz 70 Hz
respiratory analysis (for example, apneas, hyponeas and
Respiration 0.1 Hz 15 Hz
desaturations), patterns identifying movement analysis
Snoring 10 Hz 100 Hz
(for example, PLMs) and automatic calculation of the
time in the highlighted area are optional.
The digital recording system must include the
following features:
1) A toggle switch-permitting visual (onscreen) standard Scoring of sleep stages
negative 50-µv DC calibration signal for all channels
to demonstrate polarity, amplitude and time constant A. Stages of sleep
settings for each recorded parameters. 1) The following terminologies are recommended for
2) A separate 50/60 Hz Þlter control for each the stages of sleep:
3) The capability of selecting sampling rates for each a. Stage W (Wakefulness)
channel b. Stage N1 (NREM 1)
4) A method of measuring actual individual electrode c. Stage N2 (NREM 2)
impedance against a reference (the latter may be the d. Stage N3 (NREM 3 and 4 in R and K,
sum of all other applied electrodes) respectively)
5) The capability of retaining and viewing the data in e. Stage R (REM)
the same manner in which it was recorded by the
attending technologist (i.e., retain and display all B. Scoring sleep by epochs
derivation changes, sensitivity adjustments, Þlter Score sleep stages in 30 s sequential epochs commencing
settings and temporal resolution) from the beginning of the study, and assign a stage to
6) The capability of retrieving and viewing the data in each epoch. If 2 or more stages coexist during a single
the same manner as it appeared when it was scored epoch, assign to the stage comprising the largest portion
by the scoring technologist. of the epoch.

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Stage W is defined by the presence of an alpha rhythm:

these are trains of sinusoidal 8–13 Hz activity over the
occipital regions and are best seen with eyes closed
and attenuated with eye opening. Eye blinks appear as
conjugate eye movements consisting of 0.5–2 Hz present
in wakefulness with eyes open or closed.

Reading eye movements may be seen as trains of conjugate

eye movements consisting of a phase followed by a rapid
phase in the opposite directions as the subjects read. REM
that may also be seen are conjugate, irregular and sharply
peaked eye movements. They may be seen in the awake
state when the patient scans the environment. Figure 5: Stage N1: SEMs are seen with gradual drop out of alpha,
10-s epoch
Rules
Score epochs as stage W when more than 50% of the amplitude, mixed frequency activity for more than
alpha rhythm is over the occipital region. 50% of the epoch.
B. In subjects who do not generate alpha rhythm, score
Score epochs without visually discernable alpha stage N1 commencing with the earliest of any of the
rhythm as stage W if any of the following are present following phenomena.
[Figure 4]: 1) Activity in the range of 4–7 Hz with slowing of
1) Eye blinks at a frequency of 0.5–2 Hz background frequencies by ≥1 Hz from those of
2) Reading eye movements stage W.
3) Irregular conjugate REMs associated with normal or 2) Vertex sharp waves.
high chin muscle tone 3) Slow eye movements (SEM).

Stage N1 is defined by the presence of slow eye movements Stage N2: Is defined by the appearance of K complexes,
(SEM) Conjugate, reasonably regular and sinusoidal eye which are well-delineated negative sharp waves
movements with an initial deflection usually lasting immediately followed by a positive component standing
>500 ms [Figure 5]. The EEG is low amplitude, mixed out from the background EEG, with total duration ≥0.5
frequency activity, predominantly of 4–7 Hz. Presence s, usually maximal in amplitude when recorded using
of vertex sharp waves (V waves): are sharply contoured frontal derivations. For an arousal to be associated with a
waves with duration <0.5 s seen mostly over the central K complex, it should commence no more than 1 s after the
region and are distinguishable from the background termination of the K complex. Sleep Spindle are present
activity. Sleep onset is defined as the beginning of the first in N2; these are trains of distinct waves with frequency
epoch scored as any other than stage W (In most subjects, pattern of 11–16 Hz (most commonly 12–14 Hz) with
this will usually be the first epoch of stage N1). a duration ≥0.5 s, usually maximal in amplitude in the
central derivations [Figure 6].
Rules
A. In subjects who generate alpha rhythm, score stage Rules
N1 if alpha rhythm is attenuated and replaced by low A. The following rule defines that the beginning of the

Figure 4: Stage W: note the eye movements with high chin tone, Figure 6: Stage N2: K complexes and sleep spindles seen, 30-s
30-s epoch epoch

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period of stage N2 Sleep: Stage R is defined by REMs; these are conjugate,

1) Begin scoring stage N2 (in absence of criteria for irregular and sharply peaked eye movements with initial
N3) if one or both of the following occur during defection usually lasting <500 ms. Low Chin EMG Tone
the first half of this epoch or the last half of the is the hallmark of this stage; the baseline EMG activity
pervious epoch. in chin derivation is not higher than in any sleep stage
a) One or more K complexes unassociated with and is usually at the lowest level of the entire recording.
arousals. Saw tooth waves are seen; these are trains of sharply
b) One or more trains of sleep spindles. contoured or triangular, often serrated [Figure 8] waves
of 2–6 Hz with maximal amplitude over the central head
B. The following rule defines the continuation of the regions and often, but not always, is preceded by a burst
period of stage N2 Sleep. of REMs.
1) Continue to score epochs with low amplitude, mixed
frequency EEG activity without K complex or sleep Transient muscle activity: Short irregular bursts of EMG
spindles as stage N2 if they are preceded by (a) K activity usually of duration <0.25 s superimposed on low
complexes unassociated with arousals or (b) sleep EMG tone can be seen. The activity may be seen in the
spindles chin or anterior tibial EMG derivations as well as EEG or
2) End stage N2 sleep when either of the following EOG derivations, the latter indicating activity of cranial
events occurs: nerve innervated muscles. The activity is maximal in
a. Transition to stage W association with the REMs.
b. An arousal (change to stage N1 until a K complex
unassociated with an arousal or a sleep spindle Rules
occurs) A. Score stage R sleep for epochs with all the following
c. A major body movement followed by SEM with phenomena:
low amplitude mixed frequency EEG without a. Low amplitude, mixed frequency EEG
nonarousal-associated K complexes or sleep b. Low Chin EMG tone
spindles (score the epoch following the major c. REMs
movements as stage N1; score the epoch as stage
N2 if there are no SEMs) B. The following rule defines the continuation of a period
d. Transition to stage N3 state R sleep:
e. Transition to stage R Continue to score R, even in the absence of REMs, for
epochs following one or more epochs of stage R as
Stage N3: is defined by slow wave activity, which defined above, if EEG continues to show low amplitude,
are waves of frequency 0.5–2 Hz with a peak-to-peak mixed frequency activity without K complexes or sleep
amplitude >75 µv, as measured over the frontal regions spindles and the chin EMG tone remains low.
[Figure 7].
C. The following rule defines the end of a period stage
Rule R sleep:
Score stage N3 when 20% or more of an epoch consists
of slow wave activity irrespective of age. Spindles may Stop scoring stage R sleep when one or more of the
persist in N3; alpha intrusions and alpha delta may also following occur:
be seen, and eye movements are typically absent.

Figure 8: Stage R: Note saw tooth waves with REMS; further, note that
Figure 7: Stage N3: Delta slow waves are seen, 30-s epoch the criteria are fulfilled for obstructive hypopnea 30-s epoch

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There is a transition to stage W or N3

a. An increase in chin EMG tone above the level of stage
R is seen and criteria for stage N1 are fulfilled
b. An arousal occurs followed by low amplitude, mixed
frequency EEG and SEM (score as stage N1; if no
SEMs and chin EMG tone remains, continue to score
as stage R)
c. A major body movement followed by SEMs and low
amplitude mixed frequency EEG without nonarousal-
associated K complexes or sleep spindles (score the
epoch following body movement as stage N1; if no
SEMs are seen and EMG tone remains low, continue
to score as stage R) Figure 9: Major body movement occupying more than half of the epoch
d. If one or more nonarousal-associated K complexes and obscuring the basal rhythm 30-s epoch
or sleep spindles are present in the first half of the
epoch in the absence of REMs, even if chin EMG tone scorable as stage W either precedes or follows the
remains low, score as stage N2. epoch with a major body movement, score as stage
W.
D. Score epochs at the transition between stages N2 and c. Otherwise, score the epoch as the one that follows
R as follows: it.
1) In between epochs of definite stages N2 and R, score
an epoch with a distinct drop in chin EMG in the first Arousal rule: Score an arousal during any sleep stage if
half of the epoch to the level seen in stage R as stage there is an abrupt shift in EEG frequency in any range
R if all the following criteria are fulfilled, even in the (but not spindles); this shift should last for 3 s with at
absence of REMs least 10 s of stable sleep preceding the change. Scoring
a) Presence of non-arousal associated K complexes of an arousal during REM requires an increase in chin
or sleep spindles EMG lasting for at least 1 s [Figure 10].
b) Absence of rapid eye movements.
Scoring PLMS: The duration of a significant leg movement
2) In between epochs of definite stages N2 and R, score should be between 0.5–10 s. The maximum increase in the
an epoch with a distinct drop in chin EMG in the first amplitude should be 8 µV in the EMG voltage above the
half of the epoch to the level seen in stage R as stage resting EMG. A PLM series should have at least 4 LMs in
N2 if all of the following criteria are fulfilled. a series. The minimum duration between these should
a) Absence of nonarousal-associated K complexes be 5 ms, and the maximum duration, 90 ms. If both legs
b) Absence of or sleep spindles. move and the separation between them is less than 5 s
then they are scored as one movement.
3) In between epochs of definite stage N2 with minimal
chin EMG tone and definite stage R without further Scoring Apneas: The amplitude criteria for scoring an
drop in chin EMG tone, score epochs as stage R apnea are at least a 90% drop or more in the thermal
if all of the following criteria are fulfilled, even in sensor excursion, lasting for at least 10 s. It should
the absence of REMs that there is a) Absence of
nonarousal-associated K complexes b) Absence of
sleep spindles.

Major Body Movements

Definition of Major body movement: Movement and

muscle artifact that obscure the EEG for more than half
an epoch to the extent that the sleep stage cannot be
determined [Figure 9]

Rules: Score a epoch with a major body movement as

follows:
a. If alpha rhythm is present for part of the epoch (even
Figure 10: Arousal in REM note the increase in chin tone, which is
<15 s duration), score stage W essential for scoring an REM arousal associated is a period of mixed
b. If no alpha rhythm is discernable, but an epoch apnea 60-s epoch

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be labeled as obstructive if the efforts (respiratory however, sleep apnea and acute withdrawal from REM
and abdominal continue) are seen; it should be called suppressing medications can also cause this.
central if none of these excursions are seen, and mixed
[Figure 10], if this effort is resumed toward the end of MWT: It tests the patient’s ability to remain awake and
the period of apnea. the instruction provided to the patient is to stay awake
in a comfortable sitting position in a dark room for five
Scoring Hypopnea: The duration of hypopnea should 20-min trials. The normal sleep latency should be 11 min.
be at least 10 s. The drop in the amplitude of the nasal The test may be helpful in specific pharmacological trials
transducer is >30%, with a 4% drop in saturation and also in monitoring efficacy to treatment.
[Figure 8] or >50%, with a 3% drop in the saturation.
The continuous 24- or 36-h ambulatory PSG provides
Scoring respiratory effort-related arousals: The duration information on the number, duration, times and types
of change should be more than 10 s seen mainly as a of daytime sleep episodes, as well as documenting
flattening or deformed nasal pressure signal accompanied nighttime sleep disruptions. In addition, this long PSG
by an arousal from sleep which does not fulfill the criteria recording may identify the dissociated REM sleep-
of apnea or hypopnea [Figure 11]. inhibitory process characterizing cataplexy by showing
the elimination of chin and muscle twitches that are
Hypoventilation should be suspected if there is a typical of REM sleep.
>10 mmHg increase in PaCO2 by either end tidal or
transcutaneous CO2 measures. Cheyne stokes pattern Actigraphy: It is reliable and valid for detecting sleep
should be scored if there are at least 3 consecutive in healthy populations but less reliable for assessing
cycles of cyclical crescendo and decrescendo change in disturbed sleep. It is a useful adjunct to the routine
breathing that lasts for 10 min continuously, with 5 or evaluation of insomnia, sleep state misperception,
more apneas or hypopneas per hour. circadian rhythm disorders and excessive sleepiness,
and it helps in the diagnosis of PLMS and restless legs
MSLT: Each laboratory should have a set protocol for syndrome. It is also useful in specific populations affected
both MSLT and MWT, although MSLT is performed with dementia, such as children or older adults.
more often. MSLT comprises 5 naps performed at least
2 h after the end of the PSG. It should be performed in a The rules differ slightly in children, the description of
comfortable, soundproof, dark bedroom, while wearing which is beyond the preview of this report. The author
street clothes. The patient is instructed to fall asleep; recommends reading of the 2007 AASM manual for the
he should be requested to avoid smoking or caffeine same.
between naps, and he can read a book in between
naps. Each nap time is approximately 20 min with 2 h Since reading and interpreting sleep studies involves
between each nap. It records the latency for each nap eyeballing, reading more and more studies will enhance
(time between light-out and sleep onset); the mean sleep the visual pattern recognition memory and register
latency can then be calculated. Latency below 5 min is the findings, hence increasing the scorer’s confidence,
abnormal and suggestive of severe sleepiness, 5–10 min is which is strongly recommended. Subjective evaluation
moderate and 10–15 min is mild sleepiness. The presence of the procedure by the patient should be performed for
of two or more sleep onset REMs (SOREMS- REM onset quality control and also for knowing the efficacy of the
within 15 min of sleeping) is suggestive of narcolepsy; CPAP therapy.

Frequency

A second PSG study may be indicated under the

following conditions. If the first study is technically
inadequate due to equipment failure; if the subject could
not sleep or slept for an insufficient amount of time due to
first night effect to allow a clinical diagnosis; if initiation
of therapy or confirmation of the efficacy of prescribed
therapy is needed.

Infection control

Figure 11: RERAs/UARS: multiple arousals in 2-m epoch; this did not Practitioners should exercise universal precautions
fulfill the 30% or 50% drop criteria 2-m epoch and precautions for the prevention of the spread of

Annals of Indian Academy of Neurology - April-June 2008

CMYK137
138 Tripathi: polysomnography recording in sleep medicine practice

infections. Nondisposable items for patients’ use (e.g., Conclusion

pneumotachometers, face masks, electrodes) should
undergo cleaning and sterilization procedures as The sleep neurologist and the technologist who is the
recommended by the manufacturer. If sterilization most important person responsible for obtaining a
is not feasible, high-level disinfection is warranted. good recording should take into account the safety and
The syringe and ßat-tipped needle used for injecting well-being of patient Þrst, should be trained and skilled,
transduction gel into the EEG, EOG and EMG ensuring a high quality recording, be able to detect and
electrodes should be discarded after use. With respect correct artifacts (not covered in this review), record all
to body-position sensors, inductance and impedance abnormal events and be alert for the possibility of the
pneumography, abdominal or thoracic strain gauges patient attempting to get out of bed, detect and initiate
or piezoelectric belts, no specialized precautions are management of medical emergencies and be well
generally required. Gas sterilization may be employed versed with the functioning of CPAP, BiPAP and other
if the sensors or belts become contaminated with body ventilatory devices.
ßuids. Some thermistors are equipped with disposable
sensors. If nondisposable sensors are used, they should This technical report states all recommended rules with
be cleaned and subjected to high-level disinfection optional or alternative rules being speciÞcally mentioned
after use. as well.

Portable PSG: The American sleep disorders association References

has divided portable monitoring into four types. Type
I: Attended polysomnography, Type II- Unattended 1. Aserinsky E, Kleitman N. Regularly occurring periods of eye
polysomnography, Type III- ModiÞed portable sleep motility and concomitant phenomena during sleep. Science
1953:118:273-4.
apnea testing (min 4 channels), Type IV- Continuous 2. Dement WC, Kleitman N. cyclic variations in EEG During
single or dual bioparameter recording. The problems sleep and their relation to eye movements body and dreaming.
with the portable recordings are the artifacts and loss Electrorncephalogr Clin Neurophysiol 1957;9:673-90.
of data. 3. Rechtschaffen A, Kales A. A manual of standardized terminology,
techniques and scoring system for sleep stages of human subjects.
US Department of Heath Education, and Welfare Public Health
Pitfalls of PSG: There is no standardized protocol Service-NIH/NIND; 1968.
used in all laboratories in the country as yet; it is 4. Anders T, Emde R, Parmelee A, editors. A manual of standardized
labor intensive, time consuming and expensive. A terminology, TECHNIQUES and criteria for scoring states of sleep
and wakefulness in newborn infants. UCLA Brain Information
single night’s PSG may miss the diagnosis of mild Service. NINDS Neurological Information Network; 1971
OSAS, PLMS, parasomnias and nocturnal seizures 5. Fitch F. Bernstein SJ, Aguliar MS, et al. The RAND/UCLA
and other episodic event. PSG data and patient’s Appropriateness Method User’s Manual. Santa Monica, CA:
clinical history may not be concordant; PSG may be RAND Corporation; 2001.
6. The AASM Manual for the scoring of sleep and associated events.
confounded by the first night effect; and the standard Rules, terminology and technical speciÞcations. 2007
PSG does not measure PaCO 2 and thus may miss 7. Nayak DS, Sajeesh P. Technical standards for digital
hypoventilation. electroencephalogram recording in epilepsy practice. Ann Indian
Acad Neurol 2007;10:121-7
Exchange of clinical PSG: Portability of the record is
Received: 29-04-2008, Revised: 15-06-2008, Accepted: 16-06-08
crucial and it should be possible to perform the same
Source of Support: Nil, Conflict of Interest: Nil
with the current digital systems available.

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Annals of Indian Academy of Neurology - April-June 2008

138 CMYK