Polysomnograpy

Charmain Beatriz A. Atos

Polymonograpy
It is a simultaneous and continuous monitoring of normal and abnormal physiological activity during sleep. Largely regarded as the gold standard for the diagnosis of sleep disorders.

Polysomnography typically records:

brain wave changes (electroencephalogram) eye movements (electrooculogram)

muscle tone (electromyogram)

Respiration electrocardiogram (EKG) leg movements.

This study can evaluate sleeping problems, such as: Breathing that stops during sleep ( apnea ) Trouble falling or staying asleep ( insomnia ) A problem with falling asleep suddenly during the day ( narcolepsy ) Nightmares and sleepwalking Problems with arm or leg movement during sleep

Sleep Apnea
Sleep apnea is defined as a reduction or cessation of breathing during sleep. Sleep apnea usually is a chronic (ongoing) condition that disrupts your sleep. When your breathing pauses or becomes shallow, youll often move out of deep sleep and into light sleep.

As a result, the quality of your sleep is poor, which makes you tired during the day. Sleep apnea is a leading cause of excessive daytime sleepiness.

Sleep Apnea is: Common

Dangerous

Easily recognized
Treatable

Types of sleep apnea

Obstructive Central Mixed

OSA is caused by a blockage of the airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep.

In Central sleep apnea, the airway is not blocked but the brain fails to signal the muscles to breathe

Mixed Apnea, as the name implies, is a combination of the two. With each apnea event, the brain briefly arouses in order for them to resume breathing, but consequently sleep is extremely fragmented and poor quality

Is sleep apnea common?

Sleep apnea is as common as adult diabetes Sleep apnea affects more than twelve million people annually Risk factors include being male, overweight, and over the age of forty However Sleep apnea can strike anyone, any age, even children Still today, due to lack of awareness by the public and healthcare professionals the vast majority remain undiagnosed and therefore untreated, despite the significant consequences of this disorder

Associated Features of Apnea:

Loud snoring Morning headaches Un-refresh sleep Dry mouth upon awakening Chest retraction during sleep (children) Irritability Change in personality Depression Excessive perspiring during sleep Insomnia Frequent nocturnal urination Restless sleep Nocturnal snorting, gasping, choking (may wake self up)

Why get a Sleep Study?

Signs and symptoms poorly predict disease severity Appropriate therapy dependent on severity Failure to treat leads to:
Increased morbidity Motor vehicle crashes

Other causes of daytime sleepiness

How is Sleep Apnea Diagnosed

After an initial visit to a Physician a Polysomnogram may be ordered This requires a nights stay in a Sleep Lab A Polysomnogram is non-invasive, painless and lasts no more than 2 nights typically Every Sleep lab is different some are private, others are part of a hospital

The set-up usually involves a private bedroom and bathroom

Sleep Study Measures:

Air flow in and out of the lungs during breathing Blood oxygen levels Body position Brain waves (EEG) Breathing effort and rate Electrical activity of muscles Eye movement Heart rate

The Test is Performed..

You will be asked to arrive about 2 hours before bedtime. You will sleep in a bed at the center. The test is often done during the night so that your normal sleep patterns can be studied. The health care provider will place electrodes on your chin, scalp, and the outer edge of your eyelids. These must remain in place while you sleep. Signals from the electrodes are recorded while you are awake (with your eyes closed) and during sleep.

Obstructive apnea

Central Apnea

Mixed apnea

Hypopnea
Hypopnea refers to a transient reduction of airflow (often while asleep) that lasts for at least 10 seconds, shallow breathing, or an abnormally low respiratory rate. Hypopnea is less severe than apnea (which is a more complete loss of airflow). It may likewise result in a decreased amount of air movement into the lungs and can cause oxygen levels in the blood to drop. It more commonly is due to partial obstruction of the upper airway.

Many labs require at least a 50% reduction in flow; however, more and more labs do not require a specific % reduction, but look at the SaO2 and EEG to affect the decision

PLMS (Periodic Limb Movement Syndrome) is a sleep disorder where the patient moves limbs involuntarily during sleep, and has symptoms or problems related to the movement. Repetitive (at least 4) episodes of muscle contraction (0.5-5 s duration), typically separated by 20-40 seconds, but not more than 90 seconds (120 seconds in some laboratories) Arousals sometimes associated with the movements

Central

Obstructive

Hypopnea

Airflow

Absent

Absent

Present but decrease

Thoraco

Absent

Present

Present

Abdominal

Absent

Present

Present

Monitoring Electrodes & Sensors

Cup Electrode Surface electrode

Headbox

Clip or Snap Electrodes

Best used for recording signals from the body (EKG, EMG, EOG)

Patient Preparation

EEG Electrode placement

Patient Preparation
Snore Sensors & Microphones

Detects tracheal sounds.

Designed to pick up the frequency range of snoring

The piezoelectric sensor does not need any power supply Attached with a tape on the subject. Placed on the patients throat, just off center

Pulse Oximeter
Provides percentage of how much hemoglobin in the patients blood is saturated by oxygen Normal range is 94 98%

Respiratory Bands Placed on patients chest and abdomen Records respiratory effort

Body Position Sensors

Detects the patients body position Typically placed on the Thoracic (chest) belt Displayed on the study as:
Supine Prone Left Right Upright

Chin EMG Detects muscle tone of chin and jaw

Muscle tone in this area is:
Slightly lower during sleep than during relaxed wakefulness Markedly reduced during REM sleep as compared to NREM sleep

Airflow Sensors
Thermistor or thermocouple detects changes in temperature Detects airflow A small sensor extends down to detect oral flow A transducer is placed in the thermistor Detects changes in pressure Second method insures accuracy

EKG Leads
Two lead recording typical Some EKG arrhythmias are noted with two lead. Two lead recording typical

Leg EMG Leads

Two leads used on each leg 2 cm apart Tibialis Anterior Muscle Foot & leg movements detected PLMS & Restless Leg Syndrome are detected

Electro-oculogram (EOG)
E1: Left Eye Left Outer Canthus 1 cm out & 1 cm down from the outside corner of the eye E2: Right Eye Right Outer Canthus

1 cm out & 1 cm up from the outside corner of the eye

CO2
CO2: Carbon Monoxide Monitors
End Tidal CO2 (Cannula)
Frequently lose signal secondary to oral breathing which is common in children and condensation in the line AKA ETCO2

Transcutaneous CO2
Sensor on body (forehead)
More accurate May cause burns O2: Carbon Monoxide Monitors

Types of Sleep Studies

Diagnostic Overnight Sleep Study Two Night Sleep Study Split Night Study Multiple Sleep Latency Test Maintenance of Wakefulness Test Portable Monitoring

Diagnostic Overnight Sleep Study

General monitoring of sleep and a variety of body functions during sleep, including breathing patterns along with oxygen levels in the blood, heart rhythms, and limb movements

Two Night Sleep Study

General monitoring and diagnostic evaluation is conducted on the first night. If Sleep Apnea is discovered, the patient returns for a second night to determine the necessary CPAP pressure required to alleviate apnea.

Two Night Sleep Study

Split Night Sleep Study

Split-night PSG is conducted when moderate or severe sleep apnea has been discovered or strongly suspected during the first part of the night's study. The second half of the night is used to determine the necessary CPAP pressure required to alleviate apnea.

Multiple Sleep Latency Test (MSLT)

is a nap study. It is used to see how quickly you fall asleep in quiet situations during the day. The MSLT is the standard way to measure your level of daytime sleepiness. Excessive sleepiness is when you are sleepy at a time and place when you should be awake and alert

The study is based on the idea that you should fall asleep in a shorter amount of time as your feeling of sleepiness increases. The MSLT charts your brain waves and heartbeat and records your eye and chin movements. The study also measures how quickly and how often you enter the rapid-eye-movement (REM) stage of sleep. Results of the nap study are routinely used to detect sleep disorders.

Maintenance of Wakefulness Test (MWT)

Conducted along with a polysomnogram to determine your level of daytime sleepiness after treatment for narcolepsy or sleep apnea. Generally used for commercial drivers, pilots and people who work around heavy equipment to ascertain ability to perform their job safely. Normally provided immediately after an overnight study

 Patient remains wired with most of the wires from the polysomnogram performed the previous night. A series of four naps are taken at two-hour intervals. Each nap requires the patient to sit in a chair for 40 minutes and try to remain awake. The test is usually done by late afternoon, or 5:00pm, and there is little or no discomfort for the patient.