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Polysomnography: An Overview

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DOI: 10.1007/978-1-4939-1185-1_4

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 Polysomnography: An Overview
S.R. Pandi-Perumal, D. Warren Spence,
and Ahmed S. BaHammam
The Stages of Sleep
Sleep in humans can be broadly divided into
non-rapid-eye-movement (NREM) and rapid-
eye-movement (REM) sleep. NREM sleep is fur-
ther divided into three stages: These range from
the lightest sleep in stage N1 to the deepest level
of sleep in stage N3 (referred to as slow-wave
sleep or SWS). REM sleep alternates with NREM
sleep about every 90 min. Overnight sleep record-
ing (e.g., 6–8 h) usually has 4–6 cycles of REM
and NREM sleep. Sleep displays an ultradian
rhythm (rhythm with ~90-min periodicity), in
which alternations of NREM and REM sleep
successively occur. This cyclic sequence of
NREM and REM sleep is a highly characteristic
feature of human sleep. The number and depth of
sleep cycles which occur during the night, along
S.R. Pandi-Perumal, M.Sc. (*)
Department of Population Health, Center for
Healthful Behavior Change (CHBC), 227 East 30th
Street (between 2nd and 3rd Ave), Floor # 6 - 632D,
New York, NY 10016, USA
e-mail: pandiperumal2014@gmail.com;
pandi.perumal@nyumc.org
D.W. Spence, M.A., M.A.
652 Dufferin Street, Toronto, ON, Canada M6K 2M6
e-mail: dwspence@fastmail.fm
A.S. BaHammam, M.D., F.A.C.P.
University Sleep Disorders Center, King Khalid
University Hospital, King Saud University,
Riyadh, Saudi Arabia
e-mail: ashammam2@gmail.com
J.F. Pagel and S.R. Pandi-Perumal (eds.), Primary Care Sleep Medicine: A Practical Guide,
DOI 10.1007/978-1-4939-1185-1_4, © Springer Science+Business Media New York 2014
4
with the body’s reactions to the changes in these
cycles, are clinically useful for identifying the
nature of a patient’s sleep problems.
Stage W
The state of active wakefulness, with eyes open,
is characterized by low-voltage (10 − 30 μV)
mixed-frequency EEG profile. This contrasts
with the features of quiet wakefulness, a state in
which the eyes are closed, and during which
alpha activity begins to appear in the parieto-
occipital area. The presence of alpha activity in
50 % or more of this epoch is often noted. Stage
W is characterized by relatively high tonic EMG
activity. The EOG channel shows a voluntary eye
movements with rapid deflections and numerous
eye blinks (Fig. 4.1).
Stage N1
Stage N1 is characterized by low-voltage, mixed-
frequency EEG activity, with the highest amplitude
in the 2–7 Hz range. More than 50 % of each epoch
is characterized by theta activity (4–7 Hz). Sharp
vertex waves may occur; their amplitude can reach
a value of about 200 μV (a vertex sharp wave is a
sharp negative deflection (upward) followed by a
positive deflection (downward) lasting for <0.5 s
(seen in the frontal/central regions; during the first
half of the stage)). Stage N1 is also associated with
a cessation of blinking and an absence of saccadic
29
30 S.R. Pandi-Perumal et al.

Fig. 4.1 30-s Epoch consisting of the parameters of staging sleep (EEG, EOG, and chin EMG) showing stage W
(wakefulness)

Fig. 4.2 30-s Epoch consisting of the parameters of staging sleep (EEG, EOG, and chin EMG) showing stage N1
(NREM 1)

eye movements. Additionally, slow-rolling eye lower. To be classified as stage N1, the epoch must
movements (SEMs; slow and oscillating eye move- contain alpha activity as well as a mixed-frequency
ments) begin to appear. Compared to stage W, the EEG profile, with the alpha activity accounting for
EMG activity level of stage N1 is considerably less than 50 % of the epoch (Fig. 4.2).
4 Polysomnography: An Overview
Fig. 4.3 30-s Epoch consisting of the parameters of staging sleep (EEG, EOG, and chin EMG) showing stage N2
(NREM 2)
Stage N2
The first appearance of stage N2 is often consid-
ered the real onset of sleep. Stage N2 is charac-
terized by wave patterns, an absence of slow
waves, and episodic occurrences of K-complexes
and one or more trains of sleep spindles. Stage
N2 is characterized by high tonic submental
EMG levels, and hence an absence of body move-
ments (Fig. 4.3).
Sleep Spindles and K-Complexes
The K-complex (KC), which represents a major
EEG sign of resting sleep in humans, is formed
by a cycle of the slow cortical oscillation fol-
lowed by a brief sequence of spindles generated
in the thalamus. The KC generally lasts for at
least 1 s and appears in scalp EEG recordings as
a sequence of three waves (positive–negative–
positive). These complexes (KCs) can appear
spontaneously without an apparent cause, but can
be provoked by sensory, especially acoustic,
31
stimuli. The amplitude of the negative compo-
nent (often referred to as the N550) is at least
5–10 times as large as the positive components
which precede and follow it.
Sleep spindles are short synchronized waves
in the 10–16 Hz range, but are often separated
into two subtypes, i.e., slow waves (11–13 Hz),
which tend to be distributed anteriorly in the
brain, and fast waves (13–15 Hz), which are usu-
ally found in posterior regions. Sleep spindles
occur in 12–14 Hz frequency range. Barbiturate
anesthesia induces powerful spindle activities
(slow spindles; frequency range 9–12 Hz) that
represent a good model of stage N2.
Both sleep spindles and K-complexes (KCs)
are characteristic features of NREM sleep.
Stage N3
The term “slow wave,” “delta wave,” or “deep
sleep,” which occurs during stage N3, is used
to indicate the deepest stages of NREM sleep.
As NREM sleep progresses, the brain becomes
32
Fig. 4.4 30-s Epoch consisting of the parameters of staging sleep (EEG, EOG, and chin EMG) showing stage N3
(NREM 3)
less responsive to external stimuli, and it becomes
increasingly difficult to awaken an individual
from this stage of sleep. In stage N3 20–50 % of
the epoch of the EEG record contains waves
(measured over frontal regions) which are in the
0.5–2 Hz range and which have peak-to-peak
amplitudes greater than 75 μV. Sleep spindles
may also occur during this stage. The “slow-wave
activity” (SWA) that characterizes these two
stages is the result of mass synchronization of
underlying cortical activity (Fig. 4.4).
Stage R
Stage R is one of the most interesting of the sleep
stages, and is characterized by fast, rapid eye
movements, thus giving this stage its name. Stage
R is associated with low voltage and mixed
frequencies (similar to stage 1) of EEG, along with
a sawtooth wave pattern. During stage R, EMG
activity reaches its lowest level and additionally
episodic REMs begin to occur. The frequency of
REMs per hour of REM sleep is designated as
REM density, which is a reflection of REM sleep
S.R. Pandi-Perumal et al.
intensity. REM sleep is prominent in the last third
of the night and most dreaming occurs during
REM sleep. A shortened rapid eye movement-
onset latency (REMOL) is thought to represent a
biological marker of primary depression (Fig. 4.5).
Phasic and Tonic REM
There are both phasic (episodic) and tonic (per-
sistent) components to stage R. When the phasic
or tonic components occur the EEG tracing is
similar to that of stage N1, as noted above.
Additionally, a generalized atonia of muscles
occurs in stage R. An important exception to this
is that the muscles of the diaphragm and extra-
ocular muscles remain tonic.
Overview of Polysomnography
Polysomnography (PSG) uses a number of physi-
ological monitoring techniques to provide an
overall assessment of a patient’s quality and
quantity of sleep. The term polysomnography is
4 Polysomnography: An Overview
Fig. 4.5 30-s Epoch consisting of the parameters of staging sleep (EEG, EOG, and chin EMG) showing stage R (REM)
Fig. 4.6 Illustrates the location of the various electrodes
used for monitoring sleep. This includes the electroen-
cephalography (EEG; brainwave activity), electrooculo-
gram (EOG; for horizontal and vertical eye movement),
electromyogram (EMG; usually chin or mentalis and/or
submentalis for recording the muscle tone). Other param-
derived from the Greek root poly meaning
“many,” the Latin noun somnus meaning “sleep,”
and the Greek verb graphein meaning “to write.”
PSG is therefore a term that indicates the multi-
factorial nature of the physiological assessment
which occurs in sleep studies (Fig. 4.6).
33
eters that are usually monitored includes airflow (nasal
and/or oral), electrocardiography, pulse oximetry, respira-
tory effort (thoracic/abdominal), snore microphone
(sound recording to measure snoring), along with continu-
ous video monitoring of various body positions during
overnight sleep recordings
For an overnight test to be regarded as a full
PSG study, a patient’s sleep activity must be
recorded with the resulting profile of sleep stages
being presented appropriately and based on stan-
dard criteria. PSG is distinguished from portable
sleep studies by the addition of several types of
34
electrophysiological monitoring: these parameters
include EEG, EOG, and submental EMG, all of
which are used to determine the sleep stage of the
patient. Additionally PSG monitors the ventila-
tion and respiratory effort, airflow, muscle
activity in extremities, motor-activity movement,
arterial oxygen saturation, and electrocardiogram
(ECG). Other parameters may be measured based
on individual patient symptoms, including such
things as, but not limited to esophageal reflux
measurements, nocturnal penile tumescence
(NPT), end-tidal or transcutaneous CO2, continu-
ous blood pressure, body positions, and pulse
transit time (Tables 4.1 and 4.2).
Parameters to Be Monitored During
Overnight Polysomnography
EEG Recording
Electroencephalography (EEG) is the recording
of electrical activity along the scalp. EEG record-
ings summate extracellular field potentials from
large pyramidal neurons in the cerebral cortex.
The EEG measures voltage fluctuations resulting
from ionic current flows within the neurons of the
brain. The EEG trace records potential differ-
ences between two electrodes. In clinical labora-
tory settings, the EEG signals provide valuable
information for understanding brain functioning
and any underlying neurological disturbance.
Thus, the study of the brain’s neuronal function
and neurophysiological properties, which is made
possible by EEG signal analysis. This plays a vital
role in detection, diagnosis, treatment, and man-
agement of brain disorders and brain diseases.
Dramatic changes in neocortical electroenceph-
alogram (EEG) rhythms are also associated with the
sleep/waking cycle of mammals, including humans.
For purposes of analysis the EEG is divided into
broad-frequency bands by visual inspection.
A number of features of the EEG profile permit
inferences about the state or the “levels” of sleep.
EEG phenomena including sleep spindles and
slow waves, such as delta waves, typify non-rapid-
eye-movement (NREM) sleep in mammals.
For the purpose of EEG recording, the PSG
references the left and right centrocephalic leads
S.R. Pandi-Perumal et al.
Table 4.1 Placement of electrodes
EEG
The 10/20 system or the International 10/20 system is an
internationally recognized method for describing the
location of scalp electrodes.
The system is based on the relationship between the
location of an electrode and the underlying area of
cerebral cortex. The numbers “10” and “20” refer to the
fact that the distances between adjacent electrodes are
either 10 or 20 % of the total front-back or right-left
distance of the skull.
Each electrode site has a letter to identify the lobe and a
number to identify the hemisphere location.
No central lobe exists; the letter “C” is used for the
purpose of identification only.
The “z” (zero) refers to an electrode placed on the
midline.
While the odd numbers refer to electrode positions on the
left hemisphere, the even numbers refer to electrode
positions on the right hemisphere.
Four anatomical landmarks are used for the essential
positioning of the electrodes: first, the nasion which is the
point between the forehead and the nose; second, the inion
which is the lowest point of the skull from the back of the
head and is normally indicated by a prominent bump; and
third, the preauricular points anterior to the ear.
There are three anatomically defined main measures:
1. Nasion to inion via Cz = 100 %
Use percentages of this measure to place Fpz, Cz,
and Pz.
2. Left ear-channel opening to right ear-channel opening
via Cz = 100 %
Use percentages of this measure to place T7, C3, Cz,
C4, and T8.
3. Nasion to inion via ear-channel opening = 100 %
Use percentages of this measure to place Fp1/2, F7/8,
T7/8, P7/8, and O1/2.
The remaining electrode positions F3/4 and P3/4 are
placed equidistantly to their adjacent neighbors.
EOG
The electrodes are usually placed 1 cm above the outer
canthus (outside corner of the eye) of the right eye, while
the left EOG electrode is attached 1 cm below the outer
canthus of the left eye. Both are referenced to the
contralateral mastoid site (M1, M2).
EMG
(a) The chin EMG electrode is placed on the mentalis
and submentalis muscle
(b) The leg EMG electrode is placed on the anterior
tibialis muscle, 2–4 cm apart vertically. To locate the
anterior tibialis muscle, palpate the shin as the
patient repetitively points and flexes the foot or the
toes. The optimal electrode placement area is below
the knee, anywhere from midpoint of the shinbone to
the outer area of the upper shin.
(continued)
4 Polysomnography: An Overview
Table 4.1 (continued)
The EMG records the electrical activity of the muscles
on the chin as the face twitches, the teeth grinds or when
the muscles relax during REM sleep. Electrodes are also
placed on the limb, such as leg and/or arm, to monitor
excessive amount of movements during sleep.
EKG
EKG records the electrical activity of the heart, such as
the rate and the rhythm.
• Electrodes are placed just beneath the right clavicle
(collar bone) and at the midclavicular line on the left
(slightly lower than the right) and the fifth intercostal
space.
Table 4.2 Parameters that can be monitored in a sleep
study
During polysomnographic testing, the technologist will
measure and record the following parameters:
• Brainwave activity will be recorded and measured
using the electroencephalogram (EEG)
• Muscle activity such as face twitches, teeth grinding,
and leg movements will be recorded using the
electromyogram (EMG); this testing also helps in
determining the presence of REM-stage sleep.
• Eye movements are recorded using the
electrooculogram (EOG); these movements are
important for determining the different sleep stages,
particularly REM-stage sleep.
• The heart rate and rhythm are recorded using the
electrocardiogram (EKG or ECG).
• The Nasal and oral airflow are recorded with the
airflow sensor.
• The patient’s thoracoabdominal movements (thoracic
and abdominal) are recorded to gauge the respiratory
effort.
• Snoring activity is recorded using the snore
microphone.
• The oxygen content of the blood is measured using
the technique of pulse oximetry: this is a bandage-
like oximeter probe which is placed on the finger
(finger probe).
• A body position sensor is also used during overnight
recording procedure.
Optional parameters that can be monitored in a sleep
study include the following:
• Ventilation and respiratory effort.
• Gas exchange by oximetry, transcutaneous
monitoring, or end tidal gas analysis.
• Extremity muscle activity, motor activity movement.
• Extended EEG monitoring (extended or full montage).
• Gastroesophageal reflux disease (GERD).
• Continuous blood pressure monitoring.
(continued)
35
Table 4.2 (continued)
• Continuous video monitoring of body positions.
– Core body temperature (cBT).
– Incident light intensity.
– Pressure and pH at various esophageal levels.
– Nocturnal penile tumescence (NPT).
Note: All these signals are recorded either digitally or by
paper recordings running at 15 mm/s. All signals are
stored for further analysis
(C3, C4), the left and right occipital leads (O1,
O2), and the left and right frontal leads (F3, F4)
to electrodes on the opposite right and left mas-
toid processes (M2, M1). These electrodes are
chosen to capture the slow waves (best repre-
sented frontally), spindles (best seen in central
derivation), and the posterior dominant or alpha
rhythm (best seen occipitally). Thus, these elec-
trodes help to identify a patient’s sleep stage eas-
ily. Although the EOG and EMG provide useful
ancillary information, the EEG signal is of pri-
mary importance (taking precedence) in inter-
preting polysomnographic studies.
EOG Recording
Two EOG recording channels are used to monitor
both horizontal and vertical eye movements.
Electrodes are placed at the right and left outer can-
thi of the horizontal eye axis. The right outer can-
thus electrode (ROC) is attached about 1 cm above
and out from the outer canthus of the right eye. The
left outer canthus electrode (LOC) is attached
about 1 cm below and out from the outer canthus of
the left eye. These electrodes pick up the inherent
voltage within the eye; the cornea has a positive
charge and the retina has a negative charge.
Evaluation of the eye movements is necessary for
two reasons: The first reason is that documentation
of REM sleep is needed; the second is that an
assessment of sleep onset, which is associated with
slow-rolling eye movements (SEM), is needed.
EMG Recording
Submental EMG activity is used to determine the
level of muscle tone, which significantly decreases
36
Fig. 4.7 Typical PSG with the raw data showing in the upper part (30-s epoch) the parameters of staging sleep (EOG,
EEG, and chin EMG) and the lower part (5-min epoch) showing the respiratory channel with obstructive events
during REM sleep. EMG channel recordings are
necessary for determining both sleep-onset latency
(SOL), REM sleep-onset latency (REMOL), and
REM occurrence. A single channel is considered
sufficient for this purpose: electrodes are placed
under the chin, in the submental region.
One EMG channel (usually chin or mentalis
and/or submentalis) is used to record atonia dur-
ing REM sleep or lack of atonia in patients with
REM-related parasomnias. To assess bruxism,
the EMG electrodes can be placed over the mas-
seter. The EMG recording from other muscle
groups is assessed for other sleep disorders. Leg
EMG channel also provides information regard-
ing patient movements. For example, the anterior
tibialis EMG is helpful for assessing periodic
limb movements in sleep (PLMS) and the inter-
costal EMG is used adjunctively for determining
the effort during respiratory events.
Electrocardiography
A single electrocardiography (ECG or EKG)
channel is often sufficient during PSG recording.
Typically, two self-stick EKG electrodes are
S.R. Pandi-Perumal et al.
often used: one in the rostral sternum area and the
other at a lateral chest location.
The purpose of recording EKG activity is two-
fold. First, it permits the monitoring of heart
function during overnight sleep recording. For
example, EKG can assess the severity of some
cardiorespiratory dysfunctions, such as in sleep
apnea. Secondly, it helps to identify the cardiac
artifact on the EEG channels. However it may be
less of a problem for routine sleep patients than
for PSG performed on an epilepsy patient.
Respiratory Movement
Respiratory monitoring during sleep is an effec-
tive way to diagnose sleep disorders that are
caused by partial or complete cessation of breath-
ing during sleep (Figs. 4.7, 4.8, 4.9, 4.10, and
4.11). For monitoring airflow, piezoelectric respi-
ratory transducer or thermistor can be used. The
piezoelectric respiratory effort belt should be
placed around the torso of the subject.
Piezoelectric respiratory belt transducer mea-
sures changes in thoracic and abdominal circum-
ference during respiration. These measurements
4 Polysomnography: An Overview 37

Fig. 4.8 Excerpts from an overnight polysomnogram (PSG) tracing showing an example of hypopnea events

Fig. 4.9 Excerpts from an overnight polysomnogram (PSG) tracing showing an example of obstructive apnea
38 S.R. Pandi-Perumal et al.

Fig. 4.10 Excerpts from an overnight polysomnogram (PSG) tracing showing an example of mixed apnea

Fig. 4.11 Excerpts from an overnight polysomnogram (PSG) tracing showing an example of central apnea
4 Polysomnography: An Overview
can indicate inhalation, expiration, and breathing
strength and can be used to derive breathing rate.
Respiratory inductance plethysmography (RIP)
bands are used for the recording of thorax and
abdominal movement. The thoracic band is fixed
under the armpits and above the nipple line
(for thoracic movement), and the abdominal
band is fixed just above the hips at the navel level
(for abdominal movement). These bands need to
be securely fastened and sufficiently firm to
expand and contract with the patient’s breathing,
yet loose enough for comfort. In this position both
diaphragm and chest breathing can be captured.
Oro-Nasal Thermal Sensor
(the Oral/Nasal Thermocouple)
There is a difference between the thermocouple
and the thermistor. Thermocouples generate a
small voltage that is directly proportional to tem-
perature while a thermistor is a resistor with a
nonlinear resistance vs. temperature characteris-
tic. The oral/nasal thermocouple will be used to
monitor the patient’s airflow. The oro-nasal ther-
mal sensor is placed in the nares for nasal flow
measurement, and over the mouth for oral flow
measurement. The thermistor should be mounted
between the nostrils and upper lip of the subject.
There are three prongs on the thermocouple. The
side with two prongs should point up, one prong
slightly into each nostril. The prong on the bot-
tom of the thermocouple should be bent around
so that the tip is positioned directly in front of,
but not in, the subject’s mouth. The thermistor
can be taped in place and the wires can be run
over the ears and over the back of the head. Two
other pieces of medical tape can be placed over
the wires on the face to further hold the thermis-
tor in place and to keep the leads from dangling
around on the face.
Pulse Oximetry
The technique of pulse oximetry is used for the
detection of blood oxygen saturation. The oxygen
desaturation (SpO2) obtained through overnight
39
pulse oximetry is an important parameter for the
evaluation of respiratory disturbances during
sleep, especially for diagnosing obstructive sleep
apnea (OSAS). The pulse oximetry sensor is
placed on the finger. Alternative sites include the
toe or the ear lobe; however the sensor tends to
dislodge more easily from these sites during sleep.
The pulse oximeters can be set in different sam-
pling rates (longer the interval, lower the accu-
racy). Patients with OSA might experience a
regular fluctuation of O2; in such cases, a shorter
interval (e.g., 3 s) offers better sensitivity.
The 10–20 Electrode Placement
System
The placement of EEG electrodes on the scalp
usually follows a standard arrangement known as
the 10–20 system. This system was devised by the
International Federation of Societies for Electro-
encephalography and Clinical Neurophysiology.
The 10–20 system or the International 10–20
system is an internationally recognized method
for describing and localizing the application of
scalp electrodes in the context of an EEG test or
experiment. This method was developed to ensure
standardized reproducibility so that a subject’s
studies could be compared over time and subjects
could be compared to each other. This system is
based on the relationship between the location of
an electrode and the underlying area of cerebral
cortex. The “10” and “20” refer to the fact that the
actual distances between adjacent electrodes are
either 10 or 20 % of the total front-back or right-
left distance of the skull. Additional EEG chan-
nels can be used, particularly in patients with
epilepsy (i.e., a full 10–20 montage).
Diagnostic Value
of Polysomnography
Obstructive sleep apnea syndrome (OSAS) is a
common disorder in middle-aged and elderly
obese men, in which the muscles of the soft pal-
ate in the back of the throat relax and close off the
airway during sleep. OSAS may cause the person
40
to snore loudly and gasp for air at night. It may
also cause the person to be excessively drowsy
and likely to fall asleep during the day.
Untreated OSAS can result in serious morbid-
ity and may increase mortality. OSAS can also
affect children, often as a result of swollen
adenoids or tonsils. Several lines of evidence
suggest that children with OSAS are at risk for
developing neurocognitive deficits, such as poor
learning, behavioral problems, and attention-
deficit/hyperactivity disorder (ADHD).
Nocturnal, laboratory-based polysomnogra-
phy (PSG) is the most commonly used test in the
diagnosis of obstructive sleep apnea syndrome
(OSAS). It is often considered the criterion stan-
dard for diagnosing the presence of OSAS and its
severity, and for evaluating various other sleep
disorders that can exist with or without OSAS.
Polysomnography is indicated for confirming
the presence of OSAS if it has been suspected on
clinical grounds and when any of the following
are present:
• Disruptive snoring
• Engagement in a safety-critical occupation
• Epworth Sleepiness Scale score of >10 (ESS)
• Excessive daytime sleepiness (EDS)
• Failed lifestyle modifications for symptom
relief; examples include:
– Good sleep hygiene
– Reduction of alcohol consumption, espe-
cially before bedtime
– Sleeping in lateral body position
– Weight loss
• Witnessed apnea events, choking, or gasping
during sleep
To identify sleep apnea, the results of the PSG
are reviewed for the frequency of apneic events
(instances when breathing stopped for 10 s or
longer) and the frequency of hypopnea (instances
when breathing was partially blocked for 10 s or
longer).
Results from PSG testing are evaluated using
the Apnea-Hypopnea Index (AHI). The AHI is a
count of the number of apneas and hypopneas per
hour of sleep, and is the key measure used for
case identification, for quantifying disease
severity, and for defining disease prevalence in
normal and clinical populations.
S.R. Pandi-Perumal et al.
Abnormal results are usually indicated by an
AHI score of 5 or higher. Abnormal results are
charted to show degrees of sleep apnea:
Apnea type AHI score
No apnea or normal <5
Mild 5–15
Moderate >15–30
Severe >30
The use of a continuous positive airway
pressure (CPAP) machine may be recommended
as therapy for patients who have been diagnosed
with OSAS. This machine provides a constant air
supply to the patient’s nose and/or mouth while
he or she sleeps. A follow-up PSG may be recom-
mended to determine the proper calibrations for
use of the CPAP machine.
Polysomnography Can Also
Be Used to Diagnose a Variety
of Other Sleep Disorders
In addition to identifying OSAS, PSG is used to
help diagnose and evaluate a number of sleep
disorders:
Other sleep-related breathing disorders such as
hypoventilation syndromes and Cheyne-
Stokes respiration
Narcolepsy (extreme drowsiness and “irresistible
sleep attacks” during the day)
Sleep-related seizure disorders
REM sleep behavior disorder (RBD; acting out
dreams while asleep)
Chronic insomnia (difficulty falling asleep or
remaining asleep)
Summary
Polysomnography (PSG) testing provides a mul-
tifactorial methodology for diagnosing both the
nature and causes of a broad range of sleep disor-
ders. The comprehensiveness of PSG often
allows precise inferences to be made about the
sources of sleep disruption. Some sleep difficul-
ties are traceable to respiratory or neurological
4 Polysomnography: An Overview
conditions. The PSG report can also be an impor-
tant diagnostic tool for more complex health
issues which have a personal or a social basis.
This is particularly the case with the growing
prevalence of shift work, transmeridian jet travel,
and “24/7 shift schedules” of contemporary
lifestyles. Certain psychiatric problems may first
present as a difficulty with sleeping. Inasmuch as
many health problems can cause a loss of sleep,
PSG testing can thus offer insights into these
health issues, and can additionally be useful in
formulating a treatment plan. When administered
on multiple occasions PSG testing can provide a
highly quantified record for measuring a patient’s
response to therapy.
There is also a growing amount of evidence
that sleep disorders have important consequences
for overall health. The US National Heart, Lung,
and Blood Institute for instance has warned that,
if left untreated, sleep disorders can increase the
risk for heart disease, high blood pressure, hyper-
tension, stroke, and congestive heart failure.
Related respiratory conditions such as OSAS
have been associated with a high risk of automo-
bile accidents and injury in the workplace.
Frequent sleep disruptions have also been related
to poor academic performance in children.
Sleep disturbances constitute therefore a sig-
nificant public health concern. In this regard,
PSG is a critical tool for diagnosing sleep disor-
ders and for providing the basis of a comprehen-
sive treatment strategy. The mastery of this
technique is therefore essential for all health pro-
fessionals who are involved in the diagnosis,
treatment, and management of sleep disorders.
Fig. 4.12 Hypnogram of normal sleep indicating sleep stages
41
Glossary of Sleep Parameters
Arousal Index The number of arousals per hour
of sleep.
Artifact According to the glossary of the
International Federation of Clinical Neuro-
physiology (IFCN), the term artifact is
described as “any potential difference due to
an extracerebral source, recorded in EEG trac-
ings” and also includes more generally “any
modification of the EEG caused by extrace-
rebral factors such as alterations of the media
surrounding the brain, instrumental distortion
or malfunction, and operational errors.”
Electrodes (channels) Sensors normally made
of Ag/AgCl that are used to record electro-
encephalogram.
Electroencephalography (EEG) Brain activity
obtained as recorded signals from the scalp
using electrodes. EEG is the measurement and
recording of the gross electrical activity of the
brain. During EEG recordings, electrodes are
typically placed across multiple scalp regions.
The electrodes are connected to amplifiers
and filters that detect, magnify, and record the
electrical activity of the brain.
Epoch 30-s Period of recording time.
Hypnogram A hypnogram is a graph that repre-
sents the stages of sleep as a function of time
(Fig. 4.12).
Number of REM episodes The number of
REM episodes that appear during sleep period
time. If REM sleep continues with interrup-
tions by wake or other sleep stages, such REM
episodes are considered to be a single REM
42
episode when the interruption is less than
15 min.
Number of stage shifts The number of occa-
sions of sleep stages shifting from one to
another.
Polysomnography (PSG) Measurement and
recording of EEG activity, typically coupled
with measurement and recording of cardiore-
spiratory activity and eye movements, during
sleep.
REM density REM density is a function that
expresses the frequency of eye movements per
unit of time during stage REM.
REM sleep-onset latency (REMOL) The
interval between the first epoch of sleep and
the appearance of the first REM sleep episode
in a recording.
Sleep architecture Sleep is not a homogeneous
state of unconsciousness, but it is characterized
by an internal structure, called “sleep archi-
tecture,” described by different sleep stages
(stage W, stage N1, stage N2, stage N3, and
stage R) and transitions among them. It rep-
resents the cyclical pattern of sleep as it shifts
between the different sleep stages, including
non-rapid-eye-movement (NREM) and rapid-
eye-movement (REM) sleep. It allows us to
produce a picture of what sleep looks like
over the course of a night, taking into account
various depths of sleep as well as arousals to
wakefulness. Sleep architecture can be repre-
sented by a graph called a hypnogram.
Sleep cycle The first sleep cycle is the period
from sleep onset to the end of the first REM
sleep episode. Later sleep cycles are defined
as the periods from the end of an REM sleep
episode to the end of the subsequent REM
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sleep episode. Sleep distributed in a cyclic
pattern across the night. One complete sleep
cycle includes an episode of NREM sleep
followed by an episode of REM sleep. In a
healthy individual, a typical night of sleep
consists of 4–6 sleep cycles of 90–110 min.
There is a great deal of interindividual
variability among people, and duration of
sleep cycles, but the overall pattern is gener-
ally consistent in the same individual from
night to night.
Sleep efficiency (SE) The ratio of total sleep
time to time in bed, i.e., TST/TIB × 100.
Sleep homeostasis A sleep deficit elicits a com-
pensatory increase in the intensity and dura-
tion of sleep, while excessive sleep reduces
sleep propensity. This basic principle of sleep
regulation is known as “sleep homeostasis.”
Sleep latency Time from lights out to the first
epoch of sleep.
Sleep-onset latency (SOL) The duration of time
from “lights out” to the first epoch of sleep.
Sleep period time (SPT) The duration of time
from sleep onset (SO) to final awakening.
Time spent in each of the sleep stages based
on total recording time (TRT).
Time in bed (TIB) The duration of time from
“light off” to final awakening.
Total recording time (TRT) The duration of
time from the start to the end of a recording.
Total sleep time (TST) The amount of actual
sleep time during recording.
Wake time after sleep onset (WASO) Inter-
mittent awakening, the amount of time during
the night spent in the awake state after being
fallen asleep, i.e., the total time spent awake
during sleep period time (SPT).