RPSGT Pre-Exam

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Terms in this set (...)

Adult Mild RDI
5 to < 15
Adult Moderate RDI
15 to 30
Adult Severe RDI
more than 30
Child Mild RDI
1 to < 5
Child Moderate RDI
5 to < 10
Child Severe RDI
more than 10
Reason for PAP Titration Referral
Diagnosis of OSA during a PSG (polysomnogram)
Adult Minimum CPAP Pressure
4cm H2O
Adult Maximum CPAP Pressure
20cm H2O
Child Minimum CPAP Pressure
4cm H2O
Child Maximum CPAP Pressure
15cm H2O
Increase pressure by minimum of ______ no less than _____minute interval
1cm, 5min
Increase Pressure by minimum of 1cm with CHILDREN when Patient shows______(list)
1 Obstructive Apnea, 1 Hypopnea, 3 RERAs, 1min of Loud snoring
Increase Pressure by a minimum of 1cm with ADULTS when patient shows_____(list)
2 Obstructive Apnea, 3 Hypopnea, 5 RERAs, 3 min of Loud snoring
OPTIMAL RDI with CPAP
Less than 5 per hour
OPTIMAL SpO2 with CPAP
Above 90%
OPTIMAL Position, Sleep Stage, Behavior (list)
Supine Position, REM Sleep, No Spontaneous arousals or awakenings
ADEQUATE RDI with CPAP
10 or more but 75% less than baseline
ADEQUATE CPAP Titration (short answer)
Same Goals as good as optimal but was not recorded in REM sleep in supine position.
GOOD RDI with CPAP
less than 10 or 50% less than baseline if RDI is less than 15
GOOD SpO2 with CPAP
above 90%
GOOD Position, Sleep Stage, Behavior with CPAP
Supine Position, REM Sleep, No Spontaneous arousals or awakenings
Reason to repeat Titration
Does not meet any of the Optimal, Good, or Adequate requirements
When to switch to Bi-PAP (short answer)
When PT is uncomfortable or intolerant of High pressure, When Respiratory Events continue with 15cm
Starting Bi-PAP pressure (child and adult)
IPAP-8cm , EPAP-4cm
Max IPAP for CHILD
20cm
Minimum I/E PAP Difference for CHILD
4cm
Maximum I/E PAP Difference for CHILD
10cm
Max IPAP for ADULT
30cm
Minimum I/E PAP Difference for ADULT
4cm
Maximum I/E PAP Difference for ADULT
10cm
Increase both I/E PAP by a minimum of 1cm if CHILD has
1 Obstructive Apnea within 5 or more mins
Increase both I/E PAP by a minimum of 1cm if ADULT has
2 Obstructive Apnea within 5 or more mins
Reasons to Increase IPAP only in CHILD (list)
1 hypopnea, 3 RERAs, 1min of loud snoring
Reasons to Increase IPAP only in ADULT (list)
3 hypopnea, 5 RERAs, 3 min of loud snoring
Bi-PAP Optimal, Good, Adequate Titration
Same Parameters as CPAP
Supplemental O2 recommended when PT is (short answer)
when SpO2 is less than 88% for 5mins of longer while patient is awake
Location to connect O2 on CPAP Equipment (short answer)
Connect through CPAP Tubing by use of adapter or T connector
Recommended starting rate for O2
1 L/min
rate of O2 increase (short answer)
Increase 1 L/min with 15 min intervals until pt is with in 88%-94% SpO2
reason to lower O2 (short answer)
When CPAP/Bi-PAP pressure in Increased.
Split -Night studies (list/ short answer)
more than 3 hours of Titration time, Should not be performed on children (<12yo), pressure increase with minimum of 2cm with interval of 5 min or more
TST: Total Sleep Time
Time in minutes and/or # of epochs of Sleep (not including WASO, Arousals, and TNR)
TRT: Total Recording Time
Time in mins Lights out - Lights on
Sleep Latency
Time from Lights out to the first epoch of sleep
Stage R Latency
Time from Sleep onset to the first epoch of REM
WASO: Wake After Sleep Onset
Time(mins) the patient is wake after AFTER sleep onset. including time not connected/recorded. WASO= TRT-SL-TST
Sleep Efficiency Percent
TST/TRT x 100
Time in each stage
# of epochs and mins
Percent of TST in each stage
Time in stage(n1,n2,n3,R)/TST x 100
Arousal Index
#of arousals x 60 / TST
Heart Rate
Average BPM, Highest during sleep, Highest during TRT
Bradycardia
If reported; Lowest BPM during TRT
Types of Tachycardia
-Sinus tachycardia
-Narrow complex tachycardia
-Wide complex tachycardia
Atrial Fibrillation
Report average BPM
Arrhythmias
List types of arrhythmias
Movement events
- # PLMS and PLMS with arousal
- PLMS and PLMArI index ( # of events x 60 / TST)
Asystole
Pauses for 3 seconds or longer between heart beats
Respiratory Events
# of; Apneas (Ob,C,M), Hypopneas (Ob,C), RERAs
Apnea Index
AI; (# obstructive apneas + # central apneas + # mixed apneas) × 60 / TST)
Hypopnea Index
HI; (# hypopneas × 60 / TST)
Obstructive apnea-hypopnea index (no centrals)
OAHI; (# obstructive apneas + # mixed apneas + # obstructive hypopneas) × 60 / TST)
Central apnea-hypopnea index (only centrals)
CAHI; (# central apneas + # central hypopneas) × 60 / TST)
RERA Index
# of RERAs x 60 / TST
Respiratory Disturbance index
RDI; (# apneas + # hypopneas + # RERAs) × 60 / TST)
Oxygen Desaturation index
# oxygen desaturations ≥3% or ≥4% × 60 / TST)
Oxygen saturation
Mean value and Minimum during sleep
Types of breathing patterns
- Hypoventilation with or without CPAP
- Cheyne-Stokes breathing (duration, or # of events)
- Periodic breathing (children only)
- Snoring
Narcolepsy
Inability to maintain wakefulness/alertness during major waking episodes of the day, occurring daily for at least 3 months
MSLT score of <5mins
Parasomnia
Abnormal movements/behavior right before, during, after sleep, or during transition into or out of sleep.
Hypersomnia
Increased sleepiness during the day and prolonged nocturnal sleep. PT will have intentional/non-intentional naps)
MSLT score of 5-10 mins
Hypnagogic Jerk
simple Parasomnia;
Sudden, brief jerks of the whole body or on or more segments at sleep onset (sense of falling)
Bruxism
simple Parasomnia;
quick jerks or grinding movements in the muscles of mastication
Periodic limb movements of sleep (PLMS)
simple Parasomnia;
repetitive movements occurring ever 5-90 seconds primarily during N-REM sleep. Does not mean Person has RLS
Disorders of arousals
N-REM complex Parasomnia;
Sleepwalking, confusional arousal, sleep terrors mixture of NREM and wake states.
Sleep Related Eating Disorder (SRED)
N-REM complex parasomnia; mixture of NREM and wake states, person will consume anything with partial or no memory of the event.
Sleep Paralysis
REM complex Parasomnia; Persistance REM sleep-related atonia into wakefulness.
Nightmare Disorder
REM complex Parasomnia; Distressing dreams that have an emotional carryover into wakefulness. can end abruptly with a sudden jerk or yell
REM sleep behavior disorder (RBD)
REM complex Parasomnia; complex movements or behaviors during REM sleep when the PT should have complete atonia.
Primary Insomnia
difficulty/inability to sleep/stay asleep lasting at least 1 month, ^ in beta/alpha waves, lethargic, ^N1 and decrease N2and N3
Acute insomnia
Short term; caused by stress, emotional/physical discomfort, environmental factors, medications, interference of normal sleep schedule
Chronic insomnia: Psychological
Self perpetuating anxiety about the inability to sleep
Chronic Insomnia: Sleep-state Misperception
Has normal sleep but PTs reports reduced or no sleep
Chronic Insomnia: Sedative Dependent
PT develops a tolerance to a sedative an is unable to sleep without medication.
Chronic Insomnia: Fatal Familial Insomnia
Fatal neurological disorder in which PT's difficulty in falling asleep progress to inability. absent slow wave sleep
Time Spent in each stage by percent
N1 2-5%
N2 45-50%
N3 20%
REM 25%
Stage W: EOG
REM, SEM, Eye blinks, and Reading movements
Stage W: EEG (eyes Closed)
Alpha Rhythm(posterior dominant rhythm) 8-13hz
Stage W: EMG
Amplitudes varies but will be highest of any other stage
Stage W: Notes
a. time not connected is W.

b. 10% of people dont have Alpha with eyes closed.
Stage N1: EOG
Slow Eye Movement (SEM) not required
Stage N1: EEG
Low Amplitude Mixed Frequency (4-7hz), V-Waves, No Spindles,K-complex, delta waves, alpha, sawtoothwaves.
Stage N1: EMG
Varies but is usually lower amplitude than Stage W
Vertex Sharp Waves (V-Waves)
<.5 seconds, distinguishable form background activity, can persists in n2 sleep. Are NOT required to score N1
Stage N1: Beginning in PTs with Posterior Dominate Rhythm
When Posterior Dominate Rhythm(alpha) attenuates and is replaced my LAMF
Stage N1: Beginning PT's without Posterior dominant rhythm
When Posterior Dominate Rhythm(alpha) attenuates and is replaced my LAMF
Stage N1: Appears
After any epoch with LAMF, no evidence of another sleep stage AND AFTER an arousal or major body movement..
Stage N1: Ends
When Evidence of any other sleep stage apears
Stage N1: Arousal during N2
All epochs after the arousal are N1 until evidence of another sleep stage appear.
Stage N1: Arousal during REM
All epochs after the arousal are N1 ONLY if LAMF AND SEM are present
Stage N2: EEG
K complex and Sleep Spindle, LAMF in the background
K Complex
Sharp negative wave preceding a slow positive wave lasting longer than 0.5 seconds
Sleep Spindle
A short burst of rhythmic activity 11-16hz lasting longer than 0.5 seconds
Stage N2: EMG
low amplitude, lower than awake and N1.
Stage N2: EOG
Commonly there is no movement
Stage N2: Onset
a. The Epoch with a K complex or Sleep spindle in the first half
OR
b. if K complex or sleep spindle occurs in the second half then the next epoch will be the first for N2
Stage N2: Continues
Even with no spindles or K complexes and LAMF is present UNLESS evidence for REM appears without an interrupting Arousal, N1 or N3
Stage N2: Transition into N1
After an arousal and LAMF is present and/or SEM.
Stage N2: Transition into N3
When an Epoch is 20% or more Slow Wave Sleep (Delta)
Stage N2: Transition into REM
If there is Evidence for REM all preceding epochs WITHOUT K complexes or spindles in the second half but contain LAMF are REM

Possible drop in EMG tone (not required)
Stage N3: EEG
contains Slow wave (Delta) activity, possible to contain k-complex or sleep spindles in first epoch of N3
Delta Waves
>75microvolts lasting more than 0.5 seconds and a frequency of 0.5-2hz
Stage N3: EMG
Lower Amplitude than N1 or N2 may be equal to REM
Stage N3: EOG
Usually no activity
Stage N3: Begins
When 20% or more of an epoch is Slow wave sleep. Sleep spindles may persist
Stage N3: Ends
After an arousal or major body movement and/or a shift into LAMF in the EEG
Stage REM: EEG
LAMF with Saw Tooth Theta waves. Sleep Spindles and K complexes are ABSENT.
Saw Tooth Theta Waves
Trains of Sharply contoured or triangular waves at 2-6hz
Stage REM: EMG
Muscle tone is at it lowest but Transient Muscle Activity may occur
Transient Muscle Activity
Short Irregular burst of EMG acitivty <0.25seconds. may be associated with Eye Movements
Stage REM: EOG
Irregular, sharply peaked movements lasting <500msec
Stage REM: Begins
The epoch with Rapid Eye Movement and Low EMG amplitude often preceded by LAMF, Sawtooth Theta waves
Stage REM: Onset
The First Epoch (and all others after it) with LAMF and WITHOUT K complexes/Sleep Spindles or an arousal that precede a Rapid Eye Movement with low EMG Amplitude.
Stage REM: Continues
All Epochs after REM onset that have LAMF and low EMG amplitude. Epochs without REM that are after an Epoch with REM are still stage R if no K complexes/Spindles are present.
Stage REM: Ends
On the Epoch with:
K complex
Spindle
increase in EMG Amplitude
Delta waves
SEM after an arousal or major body movement in the first half of the epoch.
Stage REM: Major Body Movements with no Alpha
If a Major body movement occurs during stage R with out alpha waves in the EEG and is followed by LAMF and low EMG amplitude the epoch is still Stage R.
Major Body Movemetns
Movement or Muscle artifact that obscures the EEG for more than half of an epoch (sleep stage cannot be determined)
Scoring Epochs with Major Body Movements as awake
If alpha waves are present during
or
the Epoch directly before or after are scored as W
Scoring Epochs with Major Body Movements as sleep
If the Epochs before and after are Stages of sleep and no Alpha is present during, Then the MBM is scored the same as the epoch after it.
Age to apply Pediatric sleep staging
Children 2 months post-term or older
Pediatric Stage N:
Any Epoch with no recognizable k complexes, spindles, or slow wave activity are scored as Stage NREM(N)
Pediatric Stage W: EEG Eyes closed
Posterior Dominant Rhythm(PDR) is present in the occipital region (Frequency varies according to age)
Pediatric Stage W: EOG
SEM, REM, Eye blinks, Reading movements
Pediatric Stage N1: EEG
LAMF (mostly 4-7hz activity)
Vertex sharp waves(V-waves)
Pediatric Stage N1: EOG
SEM
Pediatric Stage N1: Beginning in PT's WITH PDR
If PDR is slowed or replaced with LAMF
Pediatric Stage N1: Beginning in Pt's WITHOUT PDR
a. activity in the range of 4-7hz, slowing of background frequency by > or equal to 1-2hz
b. SEM
c. Vertex Sharp Waves
d. Hypnagogic Hypersynchrony
e. High amplitude, rhythmic 3-5hz activity
Pediatric Stage N2
Same as Adults
Pediactric Stage N3
Same as Adults
Pediatric Stage REM
Same as Adults
Infant Stage Transitional (Stage T)
When two or more Sleep stage characteristics contradict each other the epoch is scored as Stage T
Infant Stage W: Bahavioral Characteristics
Reduced movement (relative to wake), eyes closed, periodic sucking, occasional startle
Infant Stage W: Respiration Characteristics
Irregular, rapid, shallow
Infant Stage W: EEG Characteristics
Low voltage irregular(LVI), Mixed (M)
Infant Stage W: EOG characteristics
Blinking, REM, Scanning movements, brief evey closures (longer than blink)
Infant Stage W: EMG
Present, Movement artifacts
Infant Stage N: Behavioral characteristics
Reduced movement (relative to wake), eyes closed, periodic sucking, occasional startle.
Infant Stage N: Respiration
Regular
Infant Stage N: EEG
Trace Alternate (TA), High Voltage Slow(HVS), Sleep spindles or Mixed (M)
Infant Stage N: EOG
Eyes closed, no movements
Infant Stage N: EMG
Present or Low (relative to wake)
Infant Stage R: Behavioral
Eyes closed, small movements
Infant Stage R: Respiratory
Irregular
Infant Stage R: EEG
Low voltage irregular (LVI) or Mixed (M)
infant Stage R: EOG
REMS or No eye movements (only after Definite REM)
Infant Stage R: EMG
low, Transient Muscle activity(TMA) may occur
Infant EEG Characteristics: Trace Alternate (TA)
At least 3 alternating runs of bilateral Symmetrical synchronous High voltage, 1-3hz delta activity that last 5-6sec, ALTERNATING WITH lower amplitude 4-7hz theta activity lasting 4-12 secs
Infant EEG Characteristics: Low Voltage irregular (LVI)
Continuous LAMF WITH Delta and Predominately Theta activity.
Infant EEG Characteristics: High Voltage Slow (HVS)
Continuous Symmetrical High voltage 1-3hz delta activity
Infant EEG Characteristics: Mixed (M)
Both high voltage and low voltage happening non-periodically, Lower voltage than HVS
Infant EEG Characteristics:
Sleep Spindles
12-14hz activity prominently in the central region, ONLY in Stage N sleep.
Progesterone
Hormone that causes drowsiness especially in the first trimester of pregnancy
Pregnancy effect on sleep
Total Sleep time decreases, Shortness of breath, Insomnia, Sleep apnea.
Cardiac Output
The amount of blood that is pumped through the ventricles in one minute
Stroke volume
Amount of blood EJECTED by the ventricle in one contraction
Vascular resistance
The amount of resistance that must be overcome to push blood through the circulatory system
Systemic circulation
The flow of Oxygenated blood away from the heart and Deoxygenated blood back to the heart.
Systemic Vascular Resistance
The amount of resistance in systemic circulation
Pulmonary Circulation
The flow of Deoxygenated blood away from the heart To the lungs and oxygenated blood back to the heart.
Pulmonary vascular resistance
The amount of resistance in the pulmonary circulation
Cardiac Index
A measure of Cardiac performance in relation to the size of the individual.

measures in L/min/squared meter
Excessive Fragmentary myoclonus
at least 5 twitching movements that occur every minute for 20 mins during NREM sleep
Hypnagogic foot tremor
HFT: A minimum of 4 HFT burst are needed to make a train. frequency of the burst range from .3hz- 4.0hz
Rhythmic movement disorder
Involuntary, repetitive movements that range between .5hz-2.0hz. 4 movements are required to mark a single cluster of movements.
Periodic Leg Movements in Sleep: Single event
PLMS: Duration range from .5-10 seconds, increase of z8uv, the end begins when there is at least .5 seconds of EMG tone that is no more than 2uv higher than resting EMG amplitude.
PLMS Series
at least 4 LM events are needed to become a series, LM events with in the SAME series can be 5-90 seconds apart. LM events on different legs that happen within 5seconds of each other count as a SINGLE movement
PLMS and Arousals
Arousals and LMs that occur in a PLM series should be considered associated with each other if both happen simultaneously, overlap, or is there is <.5secs between the two events.
Temporal Lobe Epilepsy
Seizures that occur primarily in the temporal lobe
lennox-gestaut syndrome
non specific Severe Seizures during childhood usually in PTs younger than 8years old, Mental Retardation, slow (less than 2.5hz) spike wave like pattern on the EEG
Landau-kleffner
Deterioration of the language part of the brain. contains multifocal spikes and spike wave discharges.
Generalized Anxiety Disorder
Increase in Stage 1 Non-REM sleep. Difficulty falling asleep, decreased REM sleep
Hypothalamus
Responsible for production of hormones that regulate sleep, hunger, thirst, sex drive, and release of other hormones. Creates homeostasis and controls autonomic functions
hypocampus
center for memory, emotion, and autonomic nervous system
Mamillary bodies
Important in Recollective memory
Posterior pituitary gland
produces antidiuretic hormone that promps kidneys to absorb more water from the blood
Hypsarrhythmia
In the Periods between seizures, EEG shows Irregular and disorganized activity in the EEG. no distinguishable pattern, often seen in Infantile Spams
Hematocrit
Measure of the percentage of red blood cells in 100ml of blood
Alcohol Intoxication
- While intoxicated Decrease sleep latency, PT has increase N3 and reduced REM.

- After being intoxicated Reduced N3 and Increased REM
Alcohol Withdrawal
Insomnia, Disturbed sleep, ^REM, vDelta
Amphetamines Intoxication
Total sleep is reduced, Deep sleep Reduced, increase sleep latency, Increase EMG activity
Amphetamines withdrawl
Increased TST, increase deep sleep, excessive daytime sleepiness (EDS)
Cocaine Intoxication
PT May only sleep for short, disrupted periods
Cocaine withdrawal
Sleep is prolonged
Opioids: Acute Vs Chronic
-Acute: Increase in sleepiness with reduced stage R

- Chronic: increase tolerance = Insomnia, reduced TST
Opioid Withdrawal
prolonged sleep
sedative/hypnotic intoxication
Initial Increase in sleepiness, decrease of REM and increase sleep-spindle activities
Sedative/Hypnotic Chronic use and withdrawal
- chronic use: increase tolerance PT will have insomnia

-Withdrawal: insomnia, REM rebound, anxiety, tremors and ataxia
antiarrhythmics
Disruption of sleep, increase sleepiness
Antihistamines
Increased daytime sleepiness and prolonged sleep.
Beta Blockers
disruptive sleep, prevents melatonin secretion
Bronchodilators
Disruption of sleep, twitching, cramping
Corticosteroids
Decrease sleep time, daytime fatigue
Diuretics
May lower potassium causing cramps, increase urinary output.
Nicotine
Reduced sleep duration and vivid dreams
Selective serotonin reuptake inhibitors (SSRIs)
EDS, and sleep disruption
Thyroid hormone
Disrupts sleep, heart palpatations, tremors, nervousness
History and Physical: Sleep Disorders
obstructive/central apnea, narcolepsy, circadian rhythm disorders, RLS, PLMS, parasomnia, insomnia
History and physical: Respiratory Disorders
COPD, Cystic Fibrosis, restrictive lung disease, and asthma
History and physical: Neuromuscular Disease
MS, ALS, myasthenia gravis, poliomyelitis, myotonic dystophy.
History and physical:
Spinal cord injury
Bilateral Diaphragmatic paralysis
Morning/Evening Questionnaires
19 questions about time preferences. determines when PT is most awake
Morning Questionnair
given after a PSG to determine if Varribles of the sleep lab effected sleep performance.
Bed-partner Questionnair
Given to PT's Bed-Partner(roommate). Gives insight to PT's behavior while in sleep that PT may not be aware of.
Pre Sleep Questionnair
Helps determine if the previous 24hrs were normal for the PT prior to PSG. Technologist may ask additonal questions.
Sleep diaries
Has two components:
Evening- mood assesment, Medications taken, time of Lights out.
Morning- Approximate sleep onset, #of arousals, 1-5 mood scale
Stanford Sleepiness scale
Assessment for EDS, 1-7 sleepiness scale used to describe different parts of the day. 4-7 correlates with EDS
Epworth Sleepiness Scale
Determines how likely PT will Fall asleep in a given scenario, 0-3 scale. Score of 9or< is high index for sleep.
Sleep-Wake Activity Inventory
Nine Statements that the PT will score with 1-9 scale. (1-always present, 9 never present). score of <50 mean sleepiness
Fatigue Severity Scale
9 descriptions relating to fatigue, PT will score on 1-7. above 35 suggest high Fatigue
Berlin Questionnair
Determines risk of OSA or Progress after treament with PAP device. total of 14 questions in three categories: snoring, Fatigue, hypertension. High risk is positive in 2 or more category.
Pittsburgh sleep quality index
19 questions which make up 7 sections that create a global score. This questionnaire help asses the PTs sleep quality after 1 month.
STOP-BANG
Obstructive Sleep Apnea screening tool. 8 yes or no questions which every "yes" answer is 1 point. less than 3 is low risk for OSA
Bioelectric Signal
Generated by the PT's Tissue and motion and recored by surface electrodes
Transduced Signals
Generated by sensors that convert action into electrical signals.
Standard Time Scale
1cm/sec
Frequency
Waves/cycles per second
Amplitude
Vertical height of the wave Determined by voltage
Standard Voltage setting
50 microvolts/cm (50 microvolts of signal produce a standard waveform that is 1cm high).
Sensitivity Setting
Adjust the visual height of the wave without changing the Time constant or Voltage
Filters
Used to Isolate Bandwidths and reduce outside interference.
Low-Frequency Filters
Used to eliminate signals below the normal bandwidth
High-Frequency filters
Used to eliminate signals above Normal bandwidth
60 Hz notch
Used to remove Signals in 50-60hz range without affecting other frequencies
Band-pass filters
only record signals within a particular range
Sample Rate: EEG
Desirable: 500 hz Minimal: 200 hz
Sample Rate: EOG
Desirable: 500 hz Minimal: 200 hz
Sample Rate: EMG
Desirable: 500 hz Minimal: 200 hz
Sample Rate: ECG
Desirable: 500 hz Minimal: 200 hz
Sample Rate: Airflow
Desirable: 100 hz Minimal: 25hz
Sample Rate: Oximetry
Desirable:25 hz minimal: 10hz
Sample Rate: Nasal Pressure, EtCO2, PAP
Desirable: 100 hz Minimal: 25 hz
Sample Rate: Body position
1hz
Sample Rate: Snore sounds
D: 500hz M:200hz
Sample Rate: Chest/abdominal movements
D: 100 hz M: 25 hz
EEG Filters
L: 0.3 hz H: 35 hz
EOG Filters
L: 0.3 hz H: 35 hz
EMG Filters
L: 10hz H: 100hz
ECG Filters
L: 0.3hz H: 70hz
Flow and Respiratory effort Filters
L: 0.1hz H: 15hz
snore Filters
L: 10hz H: 100hz
Respiratory Event Duration
measure from the lowest point before the first wave of an event to the beginning of the first wave of normal breath.
Devices to measure Apnea Duration
Oralnasal thermal sensor or PAP device Flow signal
Devices used to measure Hypopnea Duration
Nasal Pressure or PAP device Flow
Adult Apnea: General parameters
z90% decrease in baseline wave size for z10sec

SpO2 Desaturation is not necessary
Adult Apnea: Obstructive
Meets criteria for Apnea and is associated with continued inspiratory effort during event
Adult Apnea: Central
Meets criteria for Apnea and is associated with ABSENT inspiratory effort
Adult Apnea: Mixed
Meets criteria for apnea and is associated with absent inspiratory effort followed by resumption of effort.
Adult Hypopnea: General parameters
z30% decrease is wave size lasting z10sec with z3% or z4% desaturation or if the event is associated with an arousal (note wether you are using 3% or 4%)
Adult Hypopnea: Obstructive
If Criteria for Hypopnea is met and ANY of the following occur:
snoring during the event
flattening of the flow signal
paradoxical movement in the thoracoabdminal channels during the event
Adult Hypopnea: Central
Criteria for hypopnea is met and NONE of the Obstructive criteria are present..
Adult Respiratory Effort-Related Arousal (RERA)
Must result in an arousal and is characterized by increased respiratory effort or flattening of inspiratory portion of nasal pressure or pap flow. DOES NOT meet criteria for Apnea or Hypopnea.
Adult HYPOventilation
Increase in arterial PCO2 to a value of >55mmHg for z10mins
OR
z10mmHg increase during sleep compaired to awake lasting z10min
Cheyne-Stokes Breathing
Episodes of z3 consecutive central apneas/hyponeas separated by a crescendo-decrescendo change in breathing amplitude lasting z40seconds
AND
z5 central apnea/hypopneas per hour of sleep recorded over z2hours
Ages to use Pediatric Respiratory Scoring rules
Anyone younger than 18. Children z13yr may use adult rules
Children Apena: General Parameters
Drop is signal size by z90% for at least the minimum duration specified by obstructive/central/mixed criteria
Children Apnea: Obstructive
Meets Criteria for apnea and last the same duration as 2 breaths during baseline AND is associated with respiratory effort during absent airflow.
Children Apnea: Central
Meets apnea criteria with absent Inspiratory effort AND one of the follow is present:
-event last z20sec
-even lasts duration of two normal breaths with z3% desat or and arousal
-two breath duration with decrease is heart rate (50BMP for 5sec or 60BPM for 15sec)
Children Apnea: Mixed
meets criteria for apnea for duration of 2 normal breaths and is associated with no effort and effort.
Children Hypopnea: General parameters
Decrease is signal height by z30% for 2 breath duration with z3% desaturation or associated with an arousal
Children Hypopnea: Obstructive
Criteria for hypopnea is met and is any of the following occur:
-snoring during the event
-inspiratory flattening on nasal pressure or papflow
-thoracoabdominal paradox occurs during the event
Children Hypopnea: Central
Hypopnea Criteria is met and NONE of the Obstructive hypopnea criteria is met.
Children RERAs
When a sequence of breaths lasting z2 normal breath duration that result in an arousal and are characterized by one of the following:
-snoring
-increase respiratory effort
-flattening of inspiratory part of the Pressure/PAP signal
-increase in PCO2 above baseline
Children Hypoventilation
When >25% of TST contains a PCO2 of >50mmHg
Children Periodic Breathing
z3 episodes of central pauses in respiration lasting >3sec that are separated by 20 or less seconds of normal breathing.
MSLT
Multiple Sleep Latency Test: used to measure tendency to fall asleep. May diagnose Narcolepsy and Hypersomnia.
MLST Montage
Required Optional: all other leads
- EEG
- EOG
- ECG
-cEMG
MSLT Procedure: When to start
1.5 - 3hrs after a PSG
MSLT Procedure: Naps
MSLT consists of 5 nap periods separated by breaks that are 2 hours long
MSLT Procedure: PT preparation
- PT should keep a 2 week sleep diary
- Stimulants or sleep altering medications should be discontinued 2 weeks prior
- PT must put on casual clothes
MSLT Procedure: Before each nap
- PT uses bathroom if needed
- no smoking 30 mins before
-no exercise 15 mins before
- Biocalibrations
MSLT Procedure: During the nap
- PT attempts to fall asleep with lights out while lying in bed
- If no sleep is recorded Nap ends after 20 mins (SL is 20mins)
- If PT sleeps study ends 15 mins after sleep onset
MSLT Procedures: After each nap
- PT gets out of bed
- Lights are on
- Monitor PT to prevent sleeping during the break
MSLT Procedure: Ends
After 5th nap is concluded
May end after 4 naps if no REM is recorded in any NAP.
MSLT Diagnosis
Sleep latency averaging 5mins or less means and had at least 2 Sleep Onset REM Periods, then the PT is Narcoleptic.
MWT
Maintenance of wakefulness test; Measures PT's ability to stay awake
MWT Procedure: Trials
MWT consists of 4 trials lasting 40 mins each with 2 hour intervals
MWT Procedure: Begins
1.5 to 3 hrs after PT's normal wakeup time
MWT Procedure: Before each trial
- PT uses bathroom if needed
- Biocalibrations
- PT is seated up right facing away from a dim light source
MWT Procedure: During and End of trial
- PT must stay awake for 40mins
- If patient falls asleep, Wake PT and end trial *IF z3 Epochs of N1 or 1 epoch of any other sleep stage occur
MWT Diagnosis
Sleep Latency less than 8mins is considered abnormal
plethysmograph
A device use to measure changes in volume within an organ or the whole body
PAP compliance data
Data that is transmitted by the PAP device to the doctor or insurance companies so that PAP use can be tracked.
Chronotherapy
Treatment of an illness or a disease that takes into account the body's natural rhythm and cycles.
Insufflation
act of blowing somthing (gas, powder, vapor) into the body
paradoxical insomina
Sleep State Misperception, PT is getting more sleep than they think.
pulmonary hypertention
Increase pressure for oxygenated blood leaving the lungs towards the heart and into the body.
epileptiform discharge
An uncommon EEG pattern that is distinguishable from background EEG and is periodic/almost periodic and associated with PT's with epilepsy
Normal Sleep Latency/Efficiency
<30mins , 80% efficiency
Normal REM Latency
60-120 mins
Holter Monitor
A portable device that continuously monitors the heart
Gain vs Sensitivity
Increasing Gain is when amplitude is added to the input signal from a power source thus creating a higher output signal from an amplifier.

Sensitivity Increases the pen deflection without changed the input/output signal or the time constant (visual size of the wave)
Pickwickian syndrome
A.K.A. Obesity Hypoventilation Syndrome, PT is unable to breath rapidly enough or deep enough resulting in low oxygen and high CO2.
Stridor
A harsh Vibrating noise during breathing due to obstruction in the windpipe or lungs
Oral Appliance for OSA
Designed to relieve upper airway obstruction
Oral Appliance: appropriate candidates
- Mild to moderate OSA
- Treatment beyond behavior modification (weightloss, abstinence from alcohol, etc.)
- PT's the prefer an oral appliance rather than a PAP device
- Non-adherence with PAP therapy or non-responsivness to therepay
Oral appliance Advantage
Easier to use, more portable, quiet, require no power source
Oral Appliance Contraindication
-If PT requires rapid initiation of treatment for severe symptomatic OSA, Active Cardiovascular comorbidities.
- PT with prolonged low SaO2
- PT with Dental conditions that would prevent appliance retention in the mouth.
Types of Oral Appliances
- Mandibular Advancement splints
- Tongue retaining device
Mandibular Advancement Splints
Most common oral appliance, Enlarge airway by re positioning anatomical features.
Tongue Retaining device
uses suction to move tongue to enlarge air way.
Esophageal pH Monitoring
Used on PTs with symptoms suggestive of GERD.
Complex Sleep Apnea
During a CPAP titration if Increasing the pressure eliminates Obstructive apnea but Central apneas begin to apear.
Complex sleep apnea treatment
Best choice is switching to ASV mode and if not possible to then use BPAP WITH a backup rate.
Pneumothorax
When lungs collapse due to negative pressure. Air between the lungs and the chest wall
Pnuemothorax causes
Lung damage by COPD, Cystic fibrosis or Pneumonia
Mallampati score
Scoring system to predict difficult intubation. Looks at size of the tongue and how wide the mouth can open.
Air Hunger
Respiratory distress, labored breathing or dyspnea. Feeling of suffocating
ALMA
Alternating Leg Muscle Activation: A single episode is at least four muscle activations that alternate between the legs .5-3hz
strain gauge
Mercury filled device thats used to measure Respiratory effort
Impedance Pneumography
A device that measure respiratory effort by measuring difference between two electrodes placed onto the chest.
Intercostal EMG
alternative to measure effort /OSA
An alternative sensor for detection of effort is:
Diaphragmatic/intercostal EMG
What is an oronasal thermal sensor?
the sensor to detect absence of airflow for identification of an apnea.
The sensor for detection of respiratory effort is:
Either esophageal manometry or calibrated or uncalibrated inductance plethysmography.
SA Node fires
Atrial Depolarization
Sino-Atrial Node
-The dominant pacemaker of the heart
-Sends an electrical impulse at regular intervals through the atria that causes them to depolarize and contract (p-wave)
Transmission time across the atria through AV node
P P-R interval
Atrio-Ventricular Node
-When the electrical impulse reaches the the AV node it is slowed, creating a pause, this pause allows the ventricles to have enough time to full up with blood (represented by the flat line following the p-wave)
Bundle of HIS and Bundle Branches
-After being slowed by the AV node, the electrical impulse rapidly moves through the Bundle of HIS and then splits
-The impulse then travels down the left and right bundle branches to the terminal ends of Purkinje Fibers and causes the ventricular myocardium to depolarize and contract
-Represented by the QRS complex
Ventricular Depolarization
QRS
Repolarization
After a contraction, the heart muscle cells need time to return to their original state in order to initiate a new contraction, this time required to complete this action is the repolarization phase, represented by the ST segment and the T wave
Evaluating A rhythm
1. Is the rhythm regular?
2. Rate?
3. What are atria doing?
4.What are ventricles doing? QRS.
5.Relationship between atria and ventricles
Normal Sinus rhythm
1. PR Interval 0.12-0.20 seconds
2. QRS Complex 0.04-0.10 seconds
3. QT Interval 0.36-0.44 seconds
4. A heart rate of 60-90 beats per minute
5. P waves Uniform and upright in appearance
Arrhythmia
An abnormal cardiac cycle conduction pattern
Causes of arrhythmias
-Damage to tissues of the conduction system
-Replacement of the conduction tissue
-Abnormal levels of electrolytes involved in conduction
-Hypoxemia
Hypoxemia
Low oxygen levels
Unifocal PVCs
Originate from a single site
Multifocal (multiform) PVCs
Originate from more than one site and have different shapes
Couplets
2 consecutive PVCs
Bigeminy
PVC alternating with a normal beat
Trigeminy
PVC occurring every 3rd beat
Quadrigeminy
PVC occurring every 4th beat
RERA
Respiratory effort-related arousal
Score a RERA when
1. Breathing for at least 10 seconds shows increasing RIP amplitudes or flattening of the nasal pressure signal followed by an arousal
2. The event is not an apnea or hypopneas
Hypoventilation is scored when
1. End-tidal CO2 or transcutaneous CO2 rises 10 mmHG above the level recorded with patient awake and lying down
2. Low oxygen desaturation is not enough to score hypoventilation
Score Cheyne Stokes breathing when
There are at least 3 cycles of rising and falling breathing amplitude and at least 1 of the following:
1. 5 or more central apneas/hr of sleep
2. The rising and falling pattern lasts at least 10 min
EEG Arousal
-An abrupt shift in EEG frequency, which may include theta, alpha, or frequencies > than 16 HZ but not spindles, that lasts for 3 or more secs.
-Must follow at least 10 secs of sleep
-Arousals may be scored from either central or occipital channels
Arousals in REM require an increased in
Chin tone
Physiological changes that may accompany Arousals
-Increased in EEG frequency
-K complex followed by a shift in EEG frequency
-Increased in chin tone
-Hypernea
-Increase in heart rate
-Eye blinks
-Evidence of body movement
-Electrode popping
Hyperpnea
Increases in breathing rate or volume
Score a hypopnea when(1)
1. The nasal pressure amplitude drops by at least 30% of baseline
2. The duration of the drop is at least 10 secs.
3. There is at least a 4% desaturation
4. At least 90% of the event duration meets the amplitude criteria
Score a hypopnea when (2)
1. The nasal pressure amplitude drops by at least 50% of baseline
2. The duration of the drop is at least 10 secs
3. There is at least a 3% desaturation or an arousal
4. At least 90% of the event duration meets the amplitude criteria
Actigraph
A device used to measure movement, usually over long periods of time.
Bipolar Montage
A channel setup based on recording from two exploring electrodes.
Dopamine
A chemical in the brain that is responsible for arousal of the cortex, movement, and responsiveness.
End Tidal CO2
A reading of carbon dioxide levels in the blood as measured by expired air.
GABA (Gamma-Aminobutyric Acid)
A neurotransmitter involved in relation, sleep and decreased emotional reaction and sedation.
Glutamate
Excitatory amino acids that project to the cortex, forebrain and brainstem.
Histamine
A chemical in the brain responsible for activation of the cortex.
High Frequency Filter (HFF)
A tool or device on a PSG which sets a limitation to the high frequency signals that are allowed to pass through the amplifier.
Histogram
A display of sleep stages achieved through the sleep period.
Hyperventilation
A state of excessively fast breathing, resulting in decreased CO2 levels and increased O2 levels in the blood.
Biofeedback
A treatment for insomnia in which a patient learns to control biological activity.
WHAT MONTAGE IS GENERALLY USED FOR THE MSLT
THE CORE CHANNELS; 2 EOG, 4 EEG, CHEIN EMG, EKG
HOW MANY MINUTES AFTER LIGHTS OUT (IF NO SLEEP IS SEEN) IS THE STANDARD MSLT TERMINATED?
20 MINUTES
IN ORDER TO ASSESS THE OCCURRENCE OF REM SLEEP DURING THE MSLT, THE TEST SHOULD CONTINUE FOR HOW LONG AFTER THE FIRST EPOCH OF SLEEP?
15 MINUTES
WHEN DOES SLEEP ONSET OCCUR WHEN SCORING AN MSLT?
THE TIME FROM LIGHTS OUT TO THE FIRST EPOCH SCORED AS SLEEP
INFANT BREATHING PATTERN THAT ALTERNATES REGULAR BREATHING WITH 5-10 SECONDS OF APNEA.
PERIODIC BREATHING
RAPID DEEP BREATHING, RESULTING IN REDUCED LEVELS OF CO2 IN THE BLOOD.
HYPERVENTILATION
INSUFFICIENT BREATHING VOLUMES, RESULTING IN INCREASED LEVELS OF CO2 IN THE BLOOD.
HYPOVENTILATION
ABNORMALLY LOW BLOOD OXYGEN SATURATION LEVEL.
HYPOXEMIA
NORMAL ARTERIAL pCO2 VALUE
35-45 mmHg
IF THE CIRCUMFERENCE MEASUREMENT OF THE HEAD IS 60 CM, WHAT IS THE DISTANCE OF T4 ELECTRODE FROM THE Fp2 ELECTRODE?
12 CM
WHAT IS THE MINIMUM PAPER SPEED RECOMMENDED TO ALLOW CLEAR VISUAL RESOLUTION OF ALPHA AND SLEEP SPINDLES?
10 MM/SEC
LIST THE 4 SKULL LANDMARKS USED IN THE 10-20 SYSTEM OF ELECTRODE PLACEMENT
NASION, INION, RIGHT PREAURICULAR, AND LEFT PREAURICULAR
THE DEGREE TO WHICH AN AMPLIFIER WILL REJECT A COMMON MODE SIGNAL IS EXPRESSED AS WHAT?
COMMON MODE REJECTION RATIO
NREM SLEEP IN THE INFANT IS KNOWN AS?
QUIET SLEEP
Reflux is identified in the distal esophagus by a drop in the pH to below what?
4.0
A patient is susceptible to shock when
ALL the equipment is not connected to a common ground.
What are the effects of chronic alcoholism on sleep?
Reduction of delta sleep and REM sleep.
REM percentage of sleep for a neonate at term?
50%
Thermoregulatory responses such as sweating and panting are noted in NREM or REM sleep?
NREM. They are absent in REM sleep because of Poikilothermia.
What are anatomic abnormalities that predispose to OSA?
1) nasal obstruction
2) adenotonsillar hypertrophy
3) macroglossia
4) micrognathia
5) retrognathia
What are some factors that are responsible for or related to insomnia?
Nightmares
Sleep apnea
Restless-leg syndrome
Myoclonus
Drug-inducing insomnia
Insomnia due to brain damage
Which of these types studies usually includes full EEG montage to rule out seizure activity?
REM Behavior Disorder Study
Which of these types studies usually includes additional EMG lead on the arm?
REM Behavior Disorder Study
Which of these types studies usually includes additional EOG channels?
MSLT
Which of these types studies usually includes a pressure channel and additional airflow channel?
CPAP
Which of these types studies requires a patient to try to stay awake for a period of time in a darkened room?
MWT
Which of these types studies usually includes a series of 4-5 naps?
MSLT
Sleep onset during MSLT is defined as
The first epoch of sleep
On a CPAP/BiPAP machine, the amount of air the patient is breathing is referred to as the
Tidal volume
It is important to record the most accurate Lights Out time so that
You have the correct sleep'onset latency
If you have LOC giving the apprOpriate signal while performing blinking movements during Bio-
Calibrations, but the ROC does not move, you assume all the following except
That's how it is supposed to look
How does a thermistor pick up a signal?
temperature change
How does a snore microphone pick up a signal?
by vibration
Why is it important not to tell the patient the results of the study?
liability
A low frequency filter is used to
Selectively attenuate undesirable slow frequencies
A fast frequency filter is used to
Selectively attenuate undesirable fast frequencies
In polysomnography, the recording of eye movements is based on
The electrical potential difference between the cornea and the retina of each eye
Score Hypoventilation in Adults
If EITHER:
A) There is an increase in the arterial PCO2 (or surrogate) to a value >55mmHg for >than or = to 10 min.
B) There is > than or = to 10mmHg increase in arterial PCO2 (or surrogate) during sleep (in comparison to an awake supine value) to a value exceeding 50mmHg for > than or = to 10 min.
Score Hypoventilation in Children
During sleep when >25% of the tst as measured by either the arterial PCO2 or surrogate is spent with a PCO2 > 50 mm Hg.
Score Periodic Breathing
If there are > than or = to 3 episodes of central pauses in respiration (absent airflow and inspiratory effort) lasting >3 seconds separated by less than or equal to 20 seconds of normal breathing.
Score Cheyne-Stokes Breathing
If BOTH:
A) There are episodes of > than or = to 3 consecutive central apneas/or central hyponeas separated by a crescendo/decrescendo change in breathing amplitude with a cycle length of greater than or equal to 40 sec.
B) There are > than or = to 5 central apneas and/or central hypopneas per hour of sleep associated with the crescendo/decrescendo breathing pattern recorded over > than or = to 2 hours of monitoring.
Score RERA in Adults
If there is a sequence of breaths lasting > than or = to 10 seconds characterized by increasing respiratory effort or by flattening of the inspiratory portion of the nasal pressure (diagnostic study)for Pap flow device (in titration) waveform leading to arousal from sleep when the sequence of breaths does not meet criteria for an apnea or hypopnea.
Score RERA in Children
If there is a sequence of breath laughing greater than or equal to 2 breaths (or the duration of two breaths during Baseline breathing) that do not meet criteria for an apnea or hypopnea and lead to in arousal from sleep. The breathing sequence can be characterized when one or more of the following is present:
a) increasing respiratory effort
b) flattening of the inspiratory portion of the nasal pressure (diagnostic study) or Pap device (titration study) waveform
c) snoring
d) An elevation in the end-tidal PCO2 above pre-election baseline
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