SLEEP SOLUTIONS

13920 North Western Avenue

Edmond, OK 73013
(405) 949-0060 Fax: (405) 949-0412

Patient Name: Moreno, Pedro Patient ID: EDM140499 Date of Study: 5/30/2014

SPLIT-NIGHT POLYSOMNOGRAPHIC INTERPRETATION

Patient Name: Moreno, Pedro Referring Physician: Crain, M.D.,Rachel

Patient ID: EDM140499 Date of Study: 5/30/2014
Date of Birth: 5/29/1959 Scoring Technologist: Jennifer Daggs, RPSGT
Ht(in): 69 Wt(lbs): 285 Acquisition Technologist: Kelli Roberts, RRT

Methods/Technique: The standards of the American Academy of Sleep Medicine were followed. The polysomnogram was attended and
included recording of electroencephalography (EEG: using10/20 electrode configuration , C3 ,C4, F3, F4, O1, O2), electrooculographic
(EOG: E1/M2 & E2/M1), surface electromyography (EMG) of submental musculature and bilateral anterior tibialis muscles, thoracic and
abdominal inductive plethysmography respiratory belt recordings; Nasal transducer and a thermocouple was used to monitor airflow; EKG
and pulse oximetry were used.

SLEEP HISTORY: This is an overnight sleep study performed at the Sleep Solutions Sleep
Disorders Center in Edmond, OK on 5/30/2014. This is a split-night nocturnal polysomnogram
obtained on this 55-year-old patient whose primary sleep complaint is “machine too loud – had it
since 1998”. On review of the sleep questionnaire the patient gives a history of
snoring and witnessed apnea. The patient has significant complaints suggestive of a nocturnal
movement disorder. There is strong evidence to suggest a diagnosis of restless legs syndrome. The
patient has significant complaints of sleep initiation insomnia and has significant complaints of sleep
maintenance insomnia. There is no evidence of cataplexy to suggest a diagnosis of narcolepsy.
There is no evidence of nocturnal heartburn. The patient’s body mass index is 42 with a neck size of
18.5 inches. The patient’s Epworth Sleepiness Scale is 0.

TECHNICAL SUMMARY: The polysomnography began at 10:32:01 PM and the recording

continued until 05:38:31 AM. The total recording time was 425.8 minutes.

DIAGNOSTIC SUMMARY: The diagnostic portion of the study consisted of 203.2 minutes and a
total sleep time of 152.5 minutes giving the patient a sleep efficiency of 75.1%. The sleep onset
latency after lights out was 12 minutes. The patient had 0 REM period(s) during the diagnostic
portion of the study. Sleep architecture revealed there was 33.1% Stage N1, 66.9% Stage N2, 0.0%
Stage N3, and 0.0% Stage R sleep.
SLEEP DISORDERED BREATHING: There was a moderate sleep-related breathing disorder
noted with an overall AHI of 25.2/hour. The maximum duration of the respiratory event was 27
seconds. During NREM sleep the AHI was 25.2/hour. During supine sleep the AHI was 40.5/hour.
While in non-supine positions the AHI was 20.0/hour. Cheyne-Stokes Respirations were not noted.
The baseline SaO2 while awake was 94.3% with desaturations to a nadir of 88%.

LIMB MOVEMENTS AND AROUSALS: Arousals were severely elevated at 68.5/hour. Monitoring of
the anterior tibialis muscles revealed severe periodic limb movements of sleep with severe
associated arousals. There were 1.2 spontaneous arousals per hour. Arousals due to respiratory
events and snoring were 22.0/hour.
 SLEEP SOLUTIONS
13920 North Western Avenue
Edmond, OK 73013
(405) 949-0060 Fax: (405) 949-0412

Patient Name: Moreno, Pedro Patient ID: EDM140499 Date of Study: 5/30/2014

TITRATION SUMMARY: The titration portion of the study consisted of a total recording time of
222.6 minutes with a total sleep time of 202.5 minutes resulting in a sleep efficiency of 91.0%.
Sleep architecture revealed there was 7.7% Stage N1, 69.4% Stage N2, 0.0% Stage N3, and 23.0%
Stage R sleep. The patient had 3 REM period(s) during the titration portion of the study.

TITRATION: CPAP was initiated at 9 cmH2O and then the pressure was titrated to a maximum
pressure setting of 11 cmH20, which appeared to adequately treat the patient’s sleep-related
breathing problem and reduced the AHI to 0/hour. It is noted that the patient did achieve supine,
stage REM sleep at this pressure setting. The patient’s lowest oxygen saturation was 94% with an
average saturation of 96%.

ELECTROCARDIAC MONITORING: Continuous ECG monitoring revealed an average sleeping

heart rate of 69 beats per minute. The lowest heart rate was 60 and the maximum heart rate was
111 during the PSG. No significant cardiac arrhythmia problems were observed.

LIMB MOVEMENTS AND AROUSALS: Arousals were mildly elevated at 8.6/hour. Monitoring of
the anterior tibialis muscles revealed no significant periodic limb movements of sleep. There were
2.1 spontaneous arousals per hour. Arousals due to respiratory events and snoring were 0.6/hour.
 SLEEP SOLUTIONS
13920 North Western Avenue
Edmond, OK 73013
(405) 949-0060 Fax: (405) 949-0412

Patient Name: Moreno, Pedro Patient ID: EDM140499 Date of Study: 5/30/2014

IMPRESSION:
1. Obstructive Sleep Apnea Syndrome (327.23), moderate overall, but severe during supine
sleep with mild O2 desaturations. Indeed, I suspect that this patient’s sleep-related breathing
difficulties may be underestimated due to the lack of stage REM sleep during the baseline
portion of the study.
2. Morbid obesity (278.01).
3. Disorder of initiating and maintaining sleep (327.3).
4. Periodic Limb Movements of Sleep (327.51), severe during the baseline portion of the study.
5. Possible Restless Legs Syndrome (333.94) by history.
These recommendations are based on my review of the sleep study data and sleep questionnaire without having seen or
evaluated the patient. Unless otherwise specified, the referring physician has the ultimate responsibility for choosing and
implementing the appropriate options for the patient.

RECOMMENDATIONS:
1. Consider CPAP at 11 cm H20 using a CPAP machine with the capability of a downloadable
compliance report using an interface of choice and heated humidity.
2. Alternatively, could consider use of an auto-titrating PAP device to obtain more information
with regard to pressure requirements and to help desensitize the patient to this form of
therapy, and could consider an auto-titrating PAP device for permanent use.
3. Weight reduction is encouraged and referral to a registered dietician or comprehensive
weight loss program may be worthwhile.
4. The patient should be counseled with regard to maintaining impeccable sleep hygiene and
often times it is helpful to ask the patient to maintain a sleep log in this regard. Of course,
certain medications can contribute to problems with insomnia. Additionally, referral to a
behavioral sleep medicine specialist may be helpful in the treatment of insomnia.
5. Consider ropinirole or pramipexole for the treatment of Periodic Limb Movement Disorder
and Restless Legs Syndrome if clinically indicated. PLMD/RLS have been associated with
uremia, anti-depressant medications, ferritin < 50mcg/L, neuropathy, hypocalcemia,
hypomagnesemia, rheumatoid arthritis, alcohol and caffeine intake, so it is important to rule
out reversible causes prior to treatment.
6. This patient should be followed closely to assess efficacy of therapy and document resolution
of symptoms.

Electronically signed by Robert M. Gordon, MD

Robert M. Gordon, M.D., F.A.A.S.M.
Board Certified Pulmonary Disease and Sleep Medicine
Diplomat, American Board of Sleep Medicine

Interpreted and signed 3 June 2014 0442

Accredited by the Joint Commission

 SLEEP SOLUTIONS
13920 North Western Avenue
Edmond, OK 73013
(405) 949-0060 Fax: (405) 949-0412

Patient Name: Moreno, Pedro Patient ID: EDM140499 Date of Study: 5/30/2014

Sleep Architecture Summary

Lights Out: 10:32:01 PM Lights On: 05:38:31 AM
Total Record Time: 439.4 min. # REM Episodes: 3
# Awakenings: 25

DIAGNOSTIC TREATMENT ENTIRE NIGHT

Time %TST Time %TST Time %TST
Time In Bed (TIB): (min)
203.2 (min)
222.6 (min)
425.8
Total Sleep Time (TST): 152.5 100 202.5 100 355 100
Total Stage N1: 50.5 33.1 15.5 7.7 66 18.6
Total Stage N2: 102 66.9 140.5 69.4 242.5 68.3
Total Stage N3: 0 0.0 0 0.0 0 0.0
Total Stage R: 0 0.0 46.5 23.0 46.5 13.1
Total Wake Time 50.7 20.1 71
WASO: 50.7 18.6 59.0
Wake Time During SPT: 33.5 8.0 41.5
Latency to Sleep Onset: 12 9 12
Latency to REM Sleep: N/A 11 211
Sleep Efficiency: 75.1 % 91.0 % 83.4 %
Sleep Maintenance: 82.0 % 96.2 % 89.5 %
* Sleep Efficiency is time asleep as a % of time in bed. Sleep Maintenance is time asleep as a % of sleep period time.
Positional Summary
DIAGNOSTIC TREATMENT ENTIRE NIGHT
Time %TST Time %TST Time %TST
(min) (min) (min)
Left: 35.5 23.3 % 0 0.0 % 35.5 10.0 %
Right: 78.5 51.5 % 0 0.0 % 78.5 22.1 %
Supine: 38.5 25.2 % 202.5 100.0 % 241 67.9 %
Prone: 0 0.0 % 0 0.0 % 0 0.0 %
* Positional times are given for TST.
Arousal Summary
DIAGNOSTIC TREATMENT ENTIRE NIGHT
Arousal Caused By: Number Index Number Index Number Index
Respiratory Events: 56 22.0 2 0.6 58 9.8
LM: 115 45.2 20 5.9 135 22.8
Spontaneous: 3 1.2 7 2.1 10 1.7
Total: 174 68.5 29 8.6 203 34.3
 SLEEP SOLUTIONS
13920 North Western Avenue
Edmond, OK 73013
(405) 949-0060 Fax: (405) 949-0412

Patient Name: Moreno, Pedro Patient ID: EDM140499 Date of Study: 5/30/2014

Respiratory Events Summary

DIAGNOSTIC Number of Respiratory Events – Position & Sleep
Stage
NREM REM
TOTAL
Non-supine Supine Non-Supine Supine
Obstructive Apnea: 0 0 0 0 0
Mixed Apnea: 0 0 0 0 0
Central Apnea: 0 0 0 0 0
All Apneas: 0 0 0 0 0
Hypopneas: 38 26 0 0 64
Apneas + Hypopneas: 38 26 0 0 64
A/H INDEX: 20 40.5 0 0 25.2

By Sleep Stage By Position

NREM REM Non- Supine TOTAL
Supine
Sleep Time (Min.): 152.5 0 114 38.5 152.5
Obstructive Apnea: 0 0 0 0 0
Mixed Apnea: 0 0 0 0 0
Central Apnea: 0 0 0 0 0
All Apneas: 0 0 0 0 0
Hypopneas: 64 0 38 26 64
Apneas + Hypopneas: 64 0 38 26 64
Apnea Index: 0.0 0.0 0.0 0.0 0.0
Hypopnea Index: 25.2 0.0 20.0 40.5 25.2
A/H INDEX: 25.2 0.0 20.0 40.5 25.2
* RDI denotes the average number of all respiratory events (Apnea+Hypop+RERA) per hour of sleep.
 SLEEP SOLUTIONS
13920 North Western Avenue
Edmond, OK 73013
(405) 949-0060 Fax: (405) 949-0412

Patient Name: Moreno, Pedro Patient ID: EDM140499 Date of Study: 5/30/2014

TREATMENT Number of Respiratory Events – Position & Sleep

Stage
NREM REM
TOTAL
Non-supine Supine Non-Supine Supine
Obstructive Apnea: 0 0 0 0 0
Mixed Apnea: 0 0 0 0 0
Central Apnea: 0 0 0 0 0
All Apneas: 0 0 0 0 0
Hypopneas: 0 8 0 5 13
Apneas + Hypopnea: 0 8 0 5 13
A/H INDEX*: 0 3.1 0 6.5 3.9

By Sleep Stage By Position

NREM REM Non- Supine TOTAL
Supine
Sleep Time (Min.): 156 46.5 0 202.5 202.5
Obstructive Apnea: 0 0 0 0 0
Mixed Apnea: 0 0 0 0 0
Central Apnea: 0 0 0 0 0
All Apneas: 0 0 0 0 0
Hypopneas: 8 5 0 13 13
Apneas + Hypopneas: 8 5 0 13 13
Apnea Index: 0.0 0.0 0.0 0.0 0.0
Hypopnea Index: 3.1 6.5 0.0 3.9 3.9
A/H INDEX: 3.1 6.5 0.0 3.9 3.9
* RDI denotes the average number of all respiratory events (Apnea+Hypop+RERA) per hour of sleep.

Respiratory Event Durations

DIAGNOSTIC TREATMENT
Average (sec) Maximum Average (sec) Maximum
(sec) (sec)
Apnea (NREM): 0 0 0 0
Hypopnea (NREM): 16.5 26.6 15.7 18.9
Apnea (REM): 0 0 0 0
Hypopnea (REM): 0 0 16.2 18.3
 SLEEP SOLUTIONS
13920 North Western Avenue
Edmond, OK 73013
(405) 949-0060 Fax: (405) 949-0412

Patient Name: Moreno, Pedro Patient ID: EDM140499 Date of Study: 5/30/2014

Oxygen Saturation Summary

DIAGNOSTIC Oxygen Saturation
Total
Wake NREM REM
Record
Total O2 Desaturations: 0 15 0 15
O2 Desaturation Index: 0 5.9 0 4.4
Min O2 Saturation (%) 90 88 N/A 88
Max O2 Saturation (%) 98 96 N/A 98
Average O2 Saturation (%) 94.3 93.6 N/A 93.4
Time @ 90% - 100% (min.) 46.8 152.3 0.0 199.1
Time @ 80% - 89% (min.) 0.0 0.2 0.0 0.2
Time @ 70% - 79% (min.) 0.0 0.0 0.0 0.0
Time @ 60% - 69% (min.) 0.0 0.0 0.0 0.0
Time @ 50% - 59% (min.) 0.0 0.0 0.0 0.0
Time ≤ 88% (min.) 0.0 0.0 0.0 0.0

TREATMENT Oxygen Saturation

Total
Wake NREM REM
Record
Total O2 Desaturations: 0 0 1 1
O2 Desaturation Index: 0 0 1.3 0.3
Min O2 Saturation (%) 93 94 92 92
Max O2 Saturation (%) 97 97 96 97
Average O2 Saturation (%) 95.3 95.2 94.6 94.5
Time @ 90% - 100% (min.) 12.0 156 46.5 214.5
Time @ 80% - 89% (min.) 0.0 0.0 0.0 0.0
Time @ 70% - 79% (min.) 0.0 0.0 0.0 0.0
Time @ 60% - 69% (min.) 0.0 0.0 0.0 0.0
Time @ 50% - 59% (min.) 0.0 0.0 0.0 0.0
Time ≤ 88% (min.) 0.0 0.0 0.0 0.0

Limb Movement Summary

DIAGNOSTIC TREATMENT ENTIRE NIGHT
Number Index Number Index Number Index
PLM Arousals: 115 45.2 20 5.9 135 22.8
Periodic Limb Movements: 169 66.5 33 9.8 202 34.1
TOTAL Limb Movements: 169 66.5 33 9.8 202 34.1
* Index is number per hour of sleep.
Heart Rate Summary
Wake NREM REM TOTAL
Average Heart Rate (BPM) 73 69 70 69
Minimum Heart Rate (BPM) 60 60 60 60
Maximum Heart Rate (BPM) 108 111 84 111
 SLEEP SOLUTIONS
13920 North Western Avenue
Edmond, OK 73013
(405) 949-0060 Fax: (405) 949-0412

Patient Name: Moreno, Pedro Patient ID: EDM140499 Date of Study: 5/30/2014

TREATMENT Breakdown Table

Treatment SLEEP TIME [min.) APNEAS RDI Avg
Arous
Level RERA SaO2 SaO2 AH
HYP # AHI al
NREM REM Total OBS MIX CEN Total # NREM REM Total Min % Avg % Dur.
Index
(sec.)
9.0 23.4 11 34.4 0 0 0 0 9 0 15.7 12.8 21.8 15.7 34.9 92 94 15.9
10.0 63.1 17.1 80.2 0 0 0 0 4 0 3.0 2.9 3.5 3.0 3.7 94 95 16.0
11.0 69.5 18.4 87.9 0 0 0 0 0 0 0 0 0 0 2.7 94 95.5 0
 SLEEP SOLUTIONS
13920 North Western Avenue
Edmond, OK 73013
(405) 949-0060 Fax: (405) 949-0412

Patient Name: Moreno, Pedro Patient ID: EDM140499 Date of Study: 5/30/2014

Hypnograms