The AASM Manual for the Scoring of Sleep and Associated Events RULES, TERMINOLOGY AND TECHNICAL SPECIFICATIONS AASM SLEEP MEDICINE” VERSION 2.6The AASM Manual for the Scoring of Sleep and Associated Events RULES, TERMINOLOGY AND TECHNICAL SPECIFICATIONS VERSION 2.6 Richard B. Berry, MD (2018-19 Chair); Stuart F. Quan, MD (2019-20 Chai); Alexandre R. Abreu, MD; Marietta L. Bibbs, RPSGT, ; Lourdes DelRosso, MD; Susan M. Harding, MD; Molly-Min Mao, MS, RRT, RPSGT, RST; David T. Plante, MD; Mark R. Pressman, PhD; Matthew M. Troester, DO; Bradley V. Vaughn, MD for the American Academy of Sleep Medicine AAS mM American Academy of a i SLEEP MEDICINE”&... Printed in the U.S.A. 120 American Academy of Sleep Medicine, 2510 North Frontage Road, Darien, IL 60561, U.S.A. Copies of this manual, and annual subscriptions to the online manual, are available at www.aasm.org All rights reserved, Unless authorized in writing by the AASM, no portion of this manual may be reproduced ‘or used in a manner inconsistent with the copyright. This applies to unauthorized reproductions in any form, including online use Translation of this content into another language is expressly probibited without the prior written consent of the American Academy of Sleep Medicine. Please submit translation and copyright requests to [email protected] or send! inquiries to ‘American Academy of Sleep Medicine Attn: Copyright Administrator 2510 N Frontage Road Darien, IL 60561-1511 United States Recommended Citation: Berry RB, Quan SF, Abreu AR, et al; for the American Academy of Sleep Medicine. The A4SM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Version 2.6. Darien, IL: American Academy of Sleep Medicine; 2020.&.. of Contents Contributors 4 Dedication 6 I. User Guide 7 11, Parameters to be Reported for Polysomnography 8 IIL Technical and Digital Specifications 12 1V, Sleep Staging Rules Part 1: Rules for Adults 17 Part 2: Rules for Children 33 Part 3: Rules for Infants 37 V. Arousal Rule 46 VI. Cardiac Rules 47 VII. Movement Rules 49 VIIL. Respiratory Rules Part I: Rules for Adults 56 Part 2: Rules for Children 64 1X. Home Sleep Apnea Testing (HSAT) Rules for Adults Part 1: HSAT Utilizing Respiratory Flow and/or Effort Parameters 69 Part 2: HSAT Utilizing Peripheral Arterial Tonometry (PAT) 75 X. Development Process 78 XI. Procedural Notes 79 XIL. Glossary of Terms 97us intributors Editors VERSION 2.6 (2020) Richard B. Rerty, MD, 201819 Chait Stunt. Quan, MD, 2019-20 Chair Alexandre R, Abe, MD Marietta L. Bis, RPSGT, CCSH Loutdes DelRosso, MD Sosan M. Harding MD “Molly-Min Mao, MS, RRT, RPSGT, RST David T. Plante, MD Mark R, Pressman, PHD Matthew M, Troester, DO Bradley V. Vaugha, MD Sherene M. Thomas, PAD, Saf VERSION 2.5 2018) Richard B. Berry. MD, Chair Claude L. Alberta, BST, RPSGT Susan M. Harding MD Robin M, Lloyd, MD David T Plante, MD Stuart F. Quan, MD Matthew M, Troester, DO Bradley V. Vaugha, MD Sherene M, Thomas, PAD, Saft VERSION 2.4 (2017) Richard B. Berry. MD, Chair Rita Brooks, MEd, RST, RPSGT CChaslne E, Gamaldo, MD Susan M. Harding, MD Robin M. Lloyd, ND Stuaet Quan, MD Matthew M, Tosser, DO Bradley V. Vougha, MD Sherene M. Thomas, PAD, Saf VERSION 2.0.2-2.3 (2013-2016) Richard, Berry, MD Rita Brooks, MEd, RST, RPSGT CChatlne E. Gamaldo, MD Susan M. Harding, MD Robin M. Lloyd, MD Carole L. Marci, MBEC Bradley V. Vaugha, MD Madeleine Grigg-Damberger, MD (Infant Sleep Staging Roles Consultant, version 2.2) “Matk S. Scher, MD (fant Sleep Staging Rules Consultan, version 2.2) Sherene M. Thomas, PAD, Saf VERSION 2.0-2.0.1 2012-2013) Richard, erry, MD Rita Brooks, MEd, RST, RPSGT CChatlne E, Gamaldo, MD Susan M. Harding, MD Bradley V. Vaugha, MD Micelle Tangredi, PRD, Sta Serene M. Thomas, PRD, Stal! FIRST EDITION (2007-2011) CConead ber, MD Sonia Ancol-lsae, PAD Andrew L, Chesson J, MD Stuart F. Quan, MD Task Forces FIRST EDITION (2007-2011) AROUSAL Michse! H. Bonnet, PAD, Chair right State University Dayton, OH Karl Doghramj, MD Thomas Jefferson University, Philadelphia, PA Timothy Roches, PRD Wayne State Univer, Detrot, ME Stephon Sheldon, DO, FAAP. Children's Memorial Hoxphal, Chicago, I [Edward J, Sepanski PRD Rush University Meicol Comer, Chicago, I Achur S. Walters, MD NI Neuroscience tite at JFK Medical Cente, Bison, NI Meri $, Wise, MD Methodist Healthcare Sleep Disorders Center Memphis, IN Andrew L. Chesson J, MD {SU Health Scionces Center in Shreesport, Shreveport LA CARDIAC Sean M. Caples, DO, Chie Mayo Clini Calege of Medicine, Rochester MN Vitend K. Somers, MD, PAD, Co-Chair Mayo Clint Collegeof Medicine, Rochester, MN Holston Valley Medical Center, Kingsport, TN Wiliam G. Cott, MD Northwestern Unversity, Chicago, I Patvia Docostkar, MD Rainbow Bables and Childrens Hospital Cleveland, Of Thomas Kara, MD Mayo Clint Collegeof Medicine, Rochester, MN Timothy’. Morgethaler, MD Mayo Clinic College of Medicine, Rochester MN Carol L. Rosen, MD Rainbow Babies and Children’s Hospital Cleveland, Of Ruth University Medical Center, Chicago, IL Win K. Shen, MD Mayo Chine College of Medicine, Rochester, MN ‘alyanam Shiskumar, MD David Gefen School of Medicine at UCLA Los Angeles. CA Conrad thet, MD Hennepin County Meicol Center and University of Manesota Medical School, Minneapolis, MN DIGITAL ‘Thomas Penze, PRD, Chair University Hospital, Department of Medicine, Sleep Laboratory, Marburg, Germany Max Hitsbkowitz, PRD, Co-Chait Baylor College of Medicine and VAMC Houston, TX ‘ie Buthow, RPSGT School of Clinical Polysomnography, Medford, OR Ronald D. Chervin, MD, MS Meir Kryger, MD University of Manitoba, Winnipeg, MB Canada Clete A, Kush, MD, PRD, RPSGT Sanford University, Stanford, CA th A. Malo, MD, MS Vanderbilt University, Nashville, TN Miche H. ier, MBCHB Mayo Clinic College of Medicine, Rochester, MN Michael V. Vitello, PRD. University of Washington, Seat, WA Andrew L, Chesson I, MD LSU Health Sciences Center in Shreveport Shreveport, LA GERIATRIC Soni Ancol-fsrel, PRD, Chir University of California, San Diego, CA Donald. Bliwise, PAD Emory University Medical School, Atlanta, GA ‘Susan Redline, MD, MPH (Cave Western Reserve Unversity Cleveland, OH Edward Stpanski, PhD Ruth University Medical Center, Chicago, Ik Micha! V. Vill, PD University of Washington, Seattle, WA Timothy L Morgenthalr, MD Mayo Clini College of Medicine, Rochester, MN MOVEMENTS Arthur, Waters, MB, Chie PK Medical Center, Edison, NI Richard P. Allen, PHD Johns Hopkins Universtiy, Balimore, MDoe Emory University Medical School, lana, GA Sadhansw Chokroverty, MD, FRCP J Neurascience Initiate at JFK Medical Center Edison, NI Wayne A. Hening, MD, PAD UMDNJ RW Johnson Medical School, New Brunswick, NI (Clete A. Kushida, MD, PRD, RESGT Stanford University, Sanford, CA Gilles Lavigne, DMD, PAD, FRCD Universite de Montreal Sleep Disorder Laboratory Sucre Coeur Hospital Montreal, OC Canada Daniel Peshietti, MD University of Minos, Urbana, Sonia Anooitsac, PAD University of Caioria, San Diego, CA PEDIATRIC Madeleine Griga-Dambergee, MD, Chair University of New Meri School of Medicine, Albuquerque, NM David Gozal, MD, Co-Chair University of onde, Loutvile, KY Carole L, Marcas, MBC University of Pemsrlsania, Philadelphia, PA ‘Timothy 1. Morgenthaler, MD Mayo Clini Coleg of Medicine, Rochester, MN Carol L. Rosen, MD Rainbow Babes and Children's Hospital Cleveland, OF Stephen Sheldon, DO, FAAP. Children's Memorial Hospital, Chicago, I Swart F. Quan, MD Brigham and Women’s Hospital ond Harvard Medical School. Boston, Mt RESPIRATORY Richard B, Berry, MD, Chair University of Florida Health Science Center Goinsvile, FL Carle L, Marcas, MBC University of Pemsrlsania, Philadelphia, PA Sram Parthasarathy, MD SAVAHICS and University of Arizona, Tucson, AZ Conrad ther, MD Hennepin County Medical Center and University of Minnesota Medical School. Minneapolis MIN Reena Mebra, MD, MS Case Western Reserve University, Cleveland, OH Daniel. Gottlieb, MD VA Boston Healthoare System and Boston University School of Medicine, Boston, MA Kingman Strohl, MD Stuart F. Quan, MD Brigham and Womens Hosphal and Harvard Medical School, Boston, MA Sally L, Davidson Ward, MD Childrens Hospital of Lox Angeles, Keck School of Medicine. University of Southern California, Los Angeles. C4 David Gozal, MD Corner Children’ Hospital and University of Chicago, Chico, Ie \Vishesh K. Kapur, MD, MPH UW Medicine Slep Cente, Unversity of Washingin, Seale, WA Rohit Buds, MD Southern Arizona VA Healthcare Stem, Southern arizona Teton, AZ Sosan Redline, MD, MPH Brigham and Womens Hospital, Beth Irae! Deaconess Medical Center and Harvard Medical School, Boston,MA VISUAL (SLEEP STAGING) Michal H. Silber, MCAB, Chai Mayo Chine College of Medicine, Rochester, MIN Sonia Ancol-srel, PAD University of California, San Diego, CA Michal H. Bonnet, PAD Wright State University, Dayton, Of Sudhsnss Chokroverty, MD, FRCP NU Neuroscience Institute at JFK Medical Center Edson, ND Madeleine Grigg-Damberget, MD University of New Mexico School of Medicine, Albuguergue, NM Max Hirshkowitz, PD Raslor College of Medicine and VAMC, Houston, TX Sheldon Kapen, MD Wayne State University Medical Schoo! and VAMC, Detroit AE ‘Sharon Keenan, PD, ABSM, RPSGT, REEGT The Schoo for Sleep Medicine, In, Palo Alto, CA Mois Kryger, MD University of Manitoba, Winnipeg, MB Canada Thomas Penzel, PD University Hospital, Department of Medicine Sleep Laboratory, Marburg, Germany Mark Pressman, PAD Lankenau and Paol Hospal, Winewood, PA CConesd Ther, MD Hennepia County Medial Cemer and Universi of Minnesota Medical School, MN Acknowledgements ‘The American Academy of Sleep Medicine acknowledges th 2019-2020 Board of Ditectors that served over the couse ofthis project and provided direction and suppor: Kelly A. Carden, MD, MBA Faria Abbas-Feinberg, MD R. Nisha Aurora, MD Douglas Kirsch, MD David Kristo, MD Raman Malhotra, MD Jenifer Matin, PAD Fri Olson, MD. Kennan Rama, MD Carol Rosen, MD James Rowley, MD “Anita Shelgkar, MD, MEPE ‘Steve Van Hout Executive Director All scoring schematis that provide illsration of sleep staging, respiratory and movement scoring fles were provided by Richa B. Berry, MD.S]Baication The Scoring Manual Committee acknowledges the invaluable service of our colleague and friend, Carole L. Marcus, MBBCh, who served on this Board from 2012-2016.63... Guide Organization of the Manual The AASM Manual for the Scoring of Sleep and Associated Events is designed to guide users through the technical aspects of conducting routine polysomnography (PSG) testing as well asthe analytic scoring and interpretation of PSG results. The rules for PSG testing and scoring are divided over seven chapters (II-VIII) of the manual. Chapter II specifies all of the parameters that should be reported in a routine PSG test, Chapter III details the digital and filter settings that are recommended for routine PSG recording. Chapters IV-VIII provide additional technical specifications as well as scoring rules for the major categories of testing: sleep staging, arousal, cardiac, movement, and respiratory. Chapter IX provides technical specifications and scoring rules for home steep apnea testing including those utilizing respiratory flow and/or effort and those utilizing peripheral arterial tonometry (PAT). Chapter X (Development Process) details the process by which the rules were developed. An outline of the evidence level and decision-making process for each rule may be found in chapter XI (Procedural Notes). Lastly, chapter XIL is, a glossary of the terminology used throughout the manual While the rules in most chapters apply to patients of all ages, rules for adult and pediatric populations are separated in chapters IV (Sleep Staging Rules) and VIII (Respiratory Rules) due to critical age-specific differences in testing and scoring. The rules within each chapter are organized into categories designated by an upper case letter. The rules themselves are num- bred and may have several components that are identified by lower case letters IN EACH S ECTION, ALON WITH THE RULES, YOU WILL NOTI The type of rule: ‘RECOMMENDED These rules are recommended for the routine scoring of in-laboratory polysomnography or home sleep apnea testing. ‘secepraaie These are rules that may be used as alternatives to the recommended rules at the discretion of the clinician or investigator, ‘orriONAL TThese are suggested rules for uncommonly encountered events, events not known to have physiologic significance or events for which there was no consensus decision, Scoring may be performed at the discretion of the clinician or investigator. Notes: If applicable, notes are positioned at the end ofa category in order to provide additional information that is critical for carrying out the rules, Rules are followed by superscripts that signify the correspondling note (ex.”!*), Sleep Facility Accreditation AASM sleep facility accreditation requires compliance with all of the rules, definitions, and notes in this manual. According to the AASM, rules specified to be recommended, acceptable, or optional are all acceptable methods for scoring. Based on the diseretion of the clinician or investigator, a specific center or laboratory may use the acceptable rule in place of the recommended rule without any risk to accreditation. Optional rules may be followed in addition to the recommended and acceptable rules without any risk to accreditation, For further information please contact the accreditation department at the AASM (accreditation @aasm.org),CBr aramcters to be Reported for Polysomnography Recommended parameters must be reported. Optional parameters may be monitored at the discretion of the clinician or investigator and if monitored, should be reported. A. General Parameters 1. Electroencephalogram (EEG) derivations neconenoeo 2. Electrooculogram (BOG) derivations econuenoeo 3.Chin electromyogram (EMG) neconenoeo 4. Leg electromyogram (EMG) econenoeo 5. Airflow signals neconenoeo 6. Respiratory effort signals econenoeo 7. Oxygen saturation econenoeo 8. Body position neconenoeo 9, Eletrocardiogram (ECG) neconenoeo 10, Synchronized PSG video reconuenoeo B. Sleep Scoring Data 1 Lights out clock time (hrsmin) econenoeo 2. Lights on lock time (hr:min) necomenoeo 43. Total sleep time (TST; time spent in NI +N2-+N3+R, in min) necomenoeo 4. Total recording time (TRT; “lights out” to “lights on” in min) neconmsnoso 5. Sleep latency (SL; lights out tfirst epoch of any slep in min) necomenoeo 6.StageR latency (sleep onset to first epoch of stage R in min) necomenoeo 7. Wake after sleep onset (WASO; TRI ~ SL.~ "TST, in min)®! necomenoeo 8. Percent sleep efiieney (TST /TRT = 100) econmsnoso 9. Time in each stage (in min) neconmsnoso 10, Percent of TST in each stage (time in each stage TST) « 100, necomuenoeoNote 1. Wake after sleep onset includes all wake activity, including time out of bed. Time with the patient disconnected from the recording equipment should be scored as stage W. Brief episodes of sleep during this time if they occur, are net considered significant forthe stage scoring summary. C. Arousal Events 1. Number of arousals 2. Arousal index (Arl; number of arousals x 60 / TST) D. Cardiac Events 1. Average heart rate during sleep 2. Highest heart rate duri sleep 3. Highest heart rate during recording 4. Occurrence of bradycardia (if observed); report lowest heart rate 5. Oceurrence of asystole (if observed); report longest pause 6. Occurrence of sinus tachycardia during sleep (if observed); report highest heart rate 7. Occurrence of narrow complex tachycardia (if observed) ); report highest heart rate 8. Occurrence of wide complex tachycardia (if observed); report highest heart rate 9. Occurrence of at brillation (if observed); report average heart rate 10, Occurrence of other arrhythmias (if observed); list arrhythmia E. Movement Events 1. Number of periodic limb movements of sleep (PLMS) 2, Number of periodic limb movements of sleep (PLMS) with arousals 3. PLMS index (PLMSI; PLMS x 60 / TST) 4. PLMS arousal lex (PLMSArl; PLMS with arousals * 60 /'TST) 5. REM without atonia (RWA) ** Note I, Ifelecting to measure RWA, the leads used to determine the presence of RWA should be included in the PSG report (¢., chin, chin and lower limbs, chin and upper limbs).Respiratory Events®’ smber of obstructive apne: 2. Number of mixed apneas RECOMMENDED 3. Number of central apneas RECOMMENDED 4. Number of hypopneas RECOMMENDED 5. Number of obstructive hypopneas coPTioNAL 6. Number of central hypopneas covrionat 7. Number of apneas + hypopneas RECOMMENDED 8. Apnea index (AL; (# obstructive apneas + # central apneas + # mixed apneas) x 60 / TST) RECOMMENDED 9, Hypopnea index (HI; # hypopneas x 60 / TST) RECOMMENDED 10, Apnea-hypopnea index (AHI; (# apneas + # hypopneas) x 60 / TST) REcoMMENDED 11. Obstructive apnea-hypopnea index (OAH; (# obstructive apneas + # mixed apneas + arroma # obstructive hypopneas) x 60 / TST) 12. Central apnea-hypopnea index (CAHI; (# central apneas +# central hypopneas) « 60/TST) OPTIONAL 13, Number of respiratory effort-related arousals (RERAS) oPrionaL 14, Respiratory effort-related arousal index (RERA index; # of RERAS * 60 / TST) oPrionaL 15, Respiratory disturbance index (RDI; # apneas + # hypopneas + # RERAs) x 60/ TST) ‘orrionat 16. Number of oxygen desaturations >3% or >4% comrionat 17, Oxygen desaturation index >3% or >4% (ODI; # oxygen desaturations >3% or 24% x 60/TST) OPTIONAL 18, Arterial oxygen saturation, mean value RECOMMENDED 19, Minimum oxygen saturation during sleep®* RECOMMENDED 20, Occurrence of hypoventilation during diagnostic study Adults ‘omrionat Children RECOMMENDED 21. Occurrence of hypoventilation during PAP titration’ Adults (OPTIONAL Children comrionat 22, Occurrence of Cheyne-Stokes breathing in adults RECOMMENDED 10&. Duration of Cheyne-Stokes breathing (absolute or as a pe entage of total sleep time) or the number of Cheyne-Stokes breathing events. ee 24, Occurrence of periodic breathing in children RECOMMENDED 25. Occurrence of snoring ‘OPTIONAL Note 1 Note 2 Note 3 Note 4 Note 5. Using supplemental oxygen may cause an underestimation of respiratory events which should be taken into consideration by the interpreting physician The criteria used to score a respiratory event as a hypopnea (either rule 1A or 1B) should be specified in the PSG report. Percent time spent below a given threshold of oxygen desaturation may be reported at the discretion of the clinician, If electing to measure the arterial PCO> or surrogate during sleep in cases wher ‘occurrence/absence of hypoventilation must be included in the PSG report is optional to do so, the Reporting the occurrence of Cheyne- and/or central hypopneas are present. ‘Stokes breathing in the PSG report is required only if central apneas, G, Summary Statements 1. Findings related to sleep diagnoses ecouenoeo 2. BEG abnormalities ecouenoeo 3. ECG abnormal ecomenoeo 4. Behavioral observations necouMenoe 5. Sleep hypnogram common "1]Brectnicai and Digital Specifications A. Digital Specifications for Routine PSG Recordings” 1. Maximum Electrode Impedances: 5 K 0" |RécouuexeD 2. Minimum Digital Resolution: 12 bits per sample /REConuenoeo 3. Sampling Rates Desirable Minimal EEGY 500 Hz 200 Hz RECOMMENDED FOG’ 500 Hz. 200 Hz RECOMMENDED EMG’ 500 Hz. 200 Hz RECOMMENDED ECGY 500 He. 200 He RECOMMENDED Airflow 100 Hz, 25 Hz RECOMMENDED Oximetry, Transcutaneous PCO2* 25 Hz lo He. RECOMMENDED Nasal Pressure, End-Tidal PCOp, PAP Device Flow” 100 Hz, 25 Hz RECOMMENDED Esophageal Pressure 100 He, 25 Hz RECOMMENDED Body Position!" LHe LHe RECOMMENDED Snoring Sounds™"* 500 Hz. 200 He RECOMMENDED Rib Cage and Abdominal Movements 100 Hz, 25 Hz RECOMMENDED 4. Routinely Recorded Filter Settings Filter EGS 0.3 He RECOMMENDED BOG"? 0.3 He 35He RECOMMENDED EMG’ 1oHz 100 Hz RECOMMENDED ECGS 0.3 He 70 Hz RECOMMENDED Oronasal Thermal Flow, Thoracoabdominal Belt Signals 0.1 He Is Hz RECOMMENDED Nasal Pressure manor ae) 100 Hz RECOMMENDED PAP Device Flow pe pe RECOMMENDED Snoring 10Hz 100 Hz, RECOMMENDED 12Note 1 Note 2. Note 3 Note 4 Note 5 Note 6. Note 7. Note 8. Note 9. Note 10, Note 11 Note 12 Note 13. Note M4. In the absence of clear preferences, use similar settings among leads to simplify technical implementation, This applies to measured EEG and EOG electrode impedance. Electrode impedances should be rechecked during a recording when any pattern that might be artifactual appeats. The AASM Scoring Manual currently does not specify maximum impedances for ECG or for EMG of the legs. However, it is suggested that the impedance be adjusted so thatthe baseline amplitude is minimized, For EEG, 500 Hz. sampling rate could improve resolution of spikes in the EEG and better maintain details of the waveform, For more detailed EEG analysis, sampling rate and high-frequency filter settings may be inereased. In these circumstances, the sampling rate should be at least 3 times the highest frequency of interest. For EOG, using the $00 Hz desirable EEG sampling rate also allows the reflection of the EEG in this lead as an EEG backup and may better define some artifacts in these leads. This applies to submental and leg EMG, Higher sampling rates better define waveforms; while the waveform itself is not an issue, a better-defined waveform can help avoid amplitude attenuation as the envelope of the rapidly oscillating signal is interpreted For ECG, 500 Hz sampling rate can better define pacemaker spikes and ECG waveforms, however, pacemaker spikes can be seen at 200 Hz, and the evaluation of cardiac ischemia by ECG waveform is not ‘a common PSG issue. Higher frequencies may be required for complex waveform analysis and research applications. For oximetry, 25 Hz sampling is desirable to assist with artifact evaluation, For nasal pressure transducer technology (especially with settings which identify snoring occurring on top of the airflow waveform), this higher frequency may be of benefit for better definition of vibration and snoring. The body position channel is exempt from the digital resolution standard. However, the recommended sampling rate of 1 Hz remains in effect. For snoring sound, 500 Hz sampling rate can better define amplitude variation by clearer waveforms with See ee a ee an ae ge ceed EMG). Ifa preprocessing of snoring results in a continuous sound loudness level or in a sound intensity level, then a much lower sampling rate is acceptable, That sampling rate is not specified because it depends on the preprocessing of the sound in order to produce loudness, For rib cage and abdominal movements using inductance plethysmography, cardiogenic oscillations can be better seen and may result in better artifact assessment at a higher sampling rate To accommodate older equipment, filter settings in the range of 30-35 Hz may be used to comply with the recommendations of 35 Hz, This applies most specifically in the context of EEG and EOG high filter settings. For ECG, low-frequency settings and wide bandwidth minimizes distortion in a 12 lead ECG; however, in PSG recording with single-channel modified lead If used for identifying basic heart rates and dysrhythmias, it may not be as necessary. Advanced cardiac assessment may be mote optimal using a low-frequency filter of 0.3 Hz for slower parts ofthe cardiac cycle, The channel is susceptible to artifacts at this setting due to patient movement, perspiration, muscle activity and electrode displacement, Artifact is les likely atthe settings when standard ECG leads are used for cardiac monitoring, 13PSG Recording Features 1. A toggle switch permitting visual (ot standard, negative 50 pV DC ealibratio signal for all channels to demonstrate polarity, amplitude and time constant settings for each RECOMMENDED recorded parameter . A separate 50/60 Hz filter control for each channel RECOMMENDED 43. The capability of providing the minimal recommended sampling rate (or higher) for all signals as specified in IIIA. econenoee 4. A method of measuring actual individual electrode impedance against a reference (the latter peeoutenoe® may be the sum of all other applied electrodes) 5. The capability of retaining and viewing the data in the exact manner in which it was recorded by the attending (echnologist (i., retain and display all derivation changes, RECOMMENDED sensitivity adjustments, filter settings, temporal resolution) 6. The capability of retaining and viewing the data in the exact manner it appeared whe scored by the scoring technologist (i., retain and display all derivation changes, sensi RECOMMENDED adjustments, filter settings, temporal resolution) 7.A filter design for data collection which functionally simulates or replicates conventional (analog-style) frequency response curves rather than removing all activity and harmonics RECOMMENDED within the specified bandwidth 8, An electrode selector process with the flexibility for choosing and/or changing electrode aot input signal derivations without relying on a common reference electrode C. Use Systems with the Following PSG Display and Display Manipulation Features 1. The display for scoring and review of sleep study data must meet or exceed the following, criteria: 15-inch sereen size, 1,600 pixels horizontal and 1,050 pixels vertical . Histogram with stage, respiratory events, leg movement events, 02 saturation, body position, (¢-gs supine, prone, lateral) and arousals, with cursor positioning on histogram and ability to RECOMMENDED jump to the page 43. Ability to view a screen on a time scale ranging from the entire night to windows as small as ae eCoMMENDED 4. Recorded video data must be synchronized with PSG data and have an accuracy of at least gecouwenoes ‘one video frame per second 5. Page automatic turning and automatic scroll common 6. Channel-off control key oF toggle common 1.0h vert contrat key or toggle commana 8. Change order of channel by lick and drag commana 9, Display setup profile (including colors) which may be activated at any time commun 10, Fast Fourier Transformation or spectral analysis on specifable interval omitting segments gprgyat marked as data artifact) 14Perform the Following Digital Analyses of PSG 1. Ability to display whether sleep stage scoring was performed visually or computed by the ecowenoeD system 2. Ability to turn off and on, as demanded, highlighting of EEG patterns used to make sleep 9 stage decisions (for example sleep spindle, K complex, alpha activity) 3. Ability to turn off and on, as demanded, highlighting of patterns identifying respiratory Ces ‘events (for example apneas, hypopneas, desaturation) 4. Ability to turn off and on, as demanded, highlighting of patterns identifying the movement aT analysis (for example PLMs) E. Perform the Following Calibrations to Document Appropriate System Response®'™ 1. Perform and document an impedance check of the EEG, EOG and EMG electrodes’ [RECOMMENDED 2. Record a minimum of 30 seconds of EEG with patient awake lying quietly with eyes open’ RECOMMENDED 3. Record a minimum of 30 seconds of EEG with patient lying quietly with eyes closed ‘RECOMMENDED 4. Ask the patient to look up and down without moving head (8) [RECOMMENDED 5. Ask the patient to look left and right without moving head («5) [RECOMENDED 6. Ask the patient to blink (x5) [RECOMMENDED 7. Ask the patient to grit teeth and/or chew (S seconds)®* [RECOMMENDED 8. Ask the patient to simulate a snore or hum (S seconds)" [RECOMMENDED 9, Ask the patient to breathe normally and assure that airflow and effort channel signals are ares synchronized 10, Ask the patient to perform a breath hold (10 seconds)” [RECOMMENDED 11, Ask the patient to breathe normally and upon instruction to take a breath in and =a ‘out—check polarity and mark the record IN and OUT accordingly” 12. Ask the patient to breathe through the nose only (10 seconds) *? RECOMENDED 13. Ask the patient to breathe through the mouth only (10 seconds) [RECOMMENDED 14, Ask the patient to take a deep breath and exhale slowly cea (protonged expiration—10 seconds)” 15, Ask the patient to flex the left foot/raise toes on left foot (*5)% econmenoeo 16. Ask the patient to flex the right foot/raise toes on right foot (*5)°* RECOMENDED 17. Ask the patient to flex/extend the fingers on the left hand, as appropriate, if upper extremity Seriya EMG is recorded” 15Se 18, Ask the patient (oflex/extend the fingers on the right hand, as appropriate, if upper extremity EMG is recorded” omens 19. Adjust EKG signal to provide a clear waveform—the R wave should deflect upward ornionaL 20, Perform and document a repeat impedance check of the EEG, EOG and EMG electrodes at pcouenoeo the end of the PSG recording™!! 21. Repeat physiological calibrations at the end of the PSG recording RECOMMENDED Note 1. Perform physiological calibrations for all patients to the extent thatthe patient is able to cooperate and ‘complete the requested maneuvers. Note 2. Document all calibrations. Verify that the signal appropriately responds to the requested patient maneuvers. Repeat calibrations as needed to document a working signal for all recording parameters. Note 3. Measured EEG, EOG and EMG channel impedances should be 5 K @ or less and relatively equal. Limb EMG impedances of 10 K Q or less are acceptable, but impedances of 5 K 0 or less are preferred. Recheck impedances during the recording when any pattern that might be artifact appears. Note 4. Check EEG channels for blocking, 60 Hz, EKG, and sweat or respiratory artifact and make any necessary adjustments to assure a readable EEG recording. Note 5. Adjust chin EMG to an adequate sensitivity while patient is awake. In an awake relaxed patient the chin EMG signal should be visible (at least 1-2 mm amplitude). During chewing or teeth gritting maneuvers the chin EMG signal should be at least double the size ofthe baseline signa. Note 6, Check the integrity of the snore microphone or sensor by asking the patient to simulate a snore and hum. Adjust as necessary to provide a clear signal with activity. Activity should be negligible with quiet breathing. Note 7. Adjust all respiratory channels to provide a large clean signal with each respiration. Observe and document the signal direction during inhalation and exhalation. Airflow and effort and signals should be in phase with respect to each other. Adjust belt position to attain a readable signal on all airflow and effort channels. Assure that airflow and effort signals respond appropriately toa 10 second breath hold. Note 8, Adjust limb EMG signal to reflect a low background; check signal with bilateral limb movements to verify noticeable deflection with movement. Note 9. Ifrecording the flexor digitorum superficialis, the patient should flex the fingers at the base (avoid bending at the distal two joints) If recording the extensor digitorum communis, the patient should extend their fingers ‘back without moving their wrist. Note 10. Compare heart rate (HR) to EKG signal (heart rate is collected from pulse oximetry) to assure HR accuracy. Note 11. Repeat the impedance check and physiological calibrations after lights on in the morning, 16 h€3:.-<, Staging Rules Part 1: Rules for Adults A. Technical Specifications for Electroencephalogram (EEG) 1.-The recommended EEG derivations are:'!? RECOMMENDED a. FMI b.co-MI © O2-MI Backup electrodes should be placed at F3, C3, O1 and M2 to allow display of F3-M2, C3-M2 and O1-M2 if electrodes malfunction during the study. (see Figure 1A) 2. Acceptable EEG derivations are: AecePrasue a FrCz b. C202 © CMI Backup electrodes should be placed at Fpz, C3, O1, and M2 to allow substitution of Fpz for Fz, C3 for Cz or C4, O1 for (Oz and M2 for M1 if electrodes malfunction during the study. (see Figure 1B) 3. EEG electrode position is determined by the International 10-20 System. (see Figure 1) | RECOMMENDED A. RECOMMENDED B. ACCEPTABLE Figure 1. Images iuetrating the placement of electrodes uiized in the recommended (A) and acceptable (B) derivations forelectroencepnalography (EEG) during polysomnography. The electrode placement land nomenclature follow the International 10:20 System. Illustration may not be to seal, Inion | ozs Amoi Aen of hep Medi Alright eure Note 1. Ata minimum, frontal, central, and occipital derivations (3 EEG channels) are required to stage sleep. Note 2. MI and M2 refer to the left and right mastoid processes. MI is the standard reference electrode for recording EEG. If MI fails during the recording, backup electrodes should be used and referenced to M2. Note 3. Fz-Cz is not appropriate for measuring the amplitude of frontal activity for determination of slow wave activity, When using the acceptable EEG derivations and the acceptable EOG derivations (Figure 2), the EI-Fpz derivation should be used to measure frontal slow wave amplitude. Used in this way, Fpz will be the active electrode recording frontal activity and El the reference electrode in a referential derivation. When using the acceptable EEG derivations and the recommended EOG derivations, EEG amplitude to determine slow wave activity should be measured using the C4-MI derivation (C3-M2 if either C4 or MI electrodes ‘malfunetion). When using the recommended EEG derivations and recommended EOG derivations, the EEG amplitude is measured using the derivation F4-ML h rsion26 17Piechnical Specifications for Electrooculogram (EOG) 1. The recommended EOG derivations and electrode positions are:»! (see Figure 2) RECOMMENDED ‘a, Derivations: El-M2 and E2-M2 ’, Electrode positions: El is placed 1 em below and | em lateral to the Ieft outer canthus and E2 is placed 1 em above and | em lateral to the right outer eanthus 2. Acceptable EOG derivations and electrode positions ar a, Derivations: El-Fpz and E2-Fpz b, Electrode positions: El is placed | cm below and 1 em lateral to the outer canthus of the left eye and E2 is placed em below and I em lateral to the outer eanthus of the right eye (gee Figure 2B) |Accepraste A. RECOMMENDED U ce} RIGHT Figure 2. ‘A.Recommended and B. acceptable Serivations for electrooculogram (E06). tustration may not be to scale, 200 American Academy of Seep Mesicln. Al ight reserved. Note 1 When using the recommended EOG derivations, if the M2 reference electrode fails, El and E2 should be referenced to ML Note 2, When using the recommended electrode derivations, conjugate eye movements result in out-of-phase deflections. The acceptable derivations allow determination of the direction of eye movements (i. vertical ‘movements will show in-phase deflections and horizontal eye movements, out-of-phase deflections).PYechnical Specifications for Electromyogram (EMG) 1. Three electrodes should be placed to record chin EMG: REcoMMeNoe0 One in the midline 1 em above the inferior edge of the mandible (see ChinZ.in Figure 3) », One 2 em below the inferior edge of the mandible and 2 em to the right ofthe midline (see Chin? in Figure 3) « One 2 em below the inferior edge of the mandible and 2 cm to the left ofthe midline (see Chin] in Figure 3) 2. The standard chin EMG derivation consists of either of the electrodes below the mandible referred to the electrode bove the mandible. The other inferior electrode is a backup electrode to allow for continued display of EM ifone of the primary electrodes malfunctions.! RECOMMENDED activity Figure 3. Piacement of electrodes on ‘the chin for electromyogram (EMG) recording. lustration may not Beto Note 1. ITEMG electrode ChinZ (above the mandible) fails during the recording, it should be replaced, if possible Otherwise, reference electrodes Chin2 and Chin! (below the mandible) to each other. D. General Scoring of Sleep Stages 1. The following terminology should be used for the stages of sleep in adults: | RECOMMENDED a, Stage W (Wakefulness) b. Stage NI (NREM 1) N2(NREM 2) N3(NREM 3) «Stage R (REM) 2. Score epochs using the following par 8, Score sleep stages in 30-second, sequential epochs commencing at the start of the study. b. Assign a stage to each epoch, ©. If two or more stages coexist during a single epoch, assign the stage comprising the greatest portion of the epoch. 4d, When three or more segments of an epoch meet criteria for different stages (stage W, NI, N2, N3, R): i. Score the epoch as sleep ifthe majority of the epoch meets criteria for stage NI, N2, N3, or R ii, Assign the sleep stage that occurs for the majority of sleep within the epoch. (see Figure 4) eters: RECOMMENDED Score in accordance with the following definitions for EEG frequencies: | RECOMMENDED a, Slow wave activity: frequency of 0.5-2.0 Hz and peak-to-peak amplitude of >75 wV, measured over the frontal regions b. Delta waves are 0-399 Hz . Theta waves are 4-7.99 Hz d. Alpha waves are 8-13 Hz. ¢, Beta waves are greater than 13 HzFigure 4. In this epoch, there isan rea ial segment mestng enter fr ; | stage W (ta seconds) scone com we | Segment mosting ertera for stage ' ‘NT Gt seconds) anda final segment ; we | meeting rte for stage N2 coms "(7 seconds) The epochs sored a3 : i | sleep asthe majoty ofthe epoch s eve | sleep. The epoch Scored a stage I | Nias the maory of sleep stage Nt E2M2 ‘any, The folowing epoch would be scored : "as sage 2 unless thre was evidence chinens | | fashit'o another sleep stage. (See subsequent sections in this chapter for defintions of alpha rythm, LAMP, and Keompiex) (© 2020 American Acadony of Sleep Mesicine. Alleghts rarer. Note |. When referring to scoring, use the term “stage R,” and when referring to the physiological state, use the term “REM sleep” (e.g, REM Sleep Behavior Disorden). E. Scoring Stage WY" 1, Score in accordance with the following definitions: RECOMMENDED Alpha rhythm (posterior dominant rhythm in adults and older children): An EEG pattern consisting of trains of sinusoidal 8-13 Hz activity recorded over the occipital region with eye closure and attenuating with eye opening. Eye blinks: closed. “onjugate vertical eye movements ata frequency of 0.5-2 Hz present in wakefulness with the eyes open or Reading eye movements: Trains of conjugate eye movements consisting ofa slow phase followed by a rapid phase in the ‘opposite direction as the individual reads, Rapid eye movements (REMSs): Eye movements recorded in the EOG derivations consisting of conjugate, irregular, sharply peaked eye movements with an initial deflection usually lasting <300 msec. While rapid eye movements are characteristic of stage R sleep, they may also be seen in wakefulness with eyes open when individuals visually scan the environment. (See Figure 5) Slow eye movements (SEM): Conjugate, reasonably regular, sinusoidal eye movements with an initial deflection that "usually lasts >00 msec, Slow eye movements may be seen during eyes closed wake and stage NI 2. Score epochs as stage W when more than 50% of the epoch contains EITHER 2a or 2b or BOTH: (Gee Figure 6) Recowmenoeo a, Alpha rhythm (posterior dominant rhythm) over the occipital region (individuals generating alpha rhythm with eye closure) b. Other findings consistent with stage W (all individuals) i, Eye blinks (0.5 to 2 Hz) ii, Rapid eye movements associated with normal or high chin muscle tone iii, Reading eye movements 20 hean wnat My BN Af Seratrots YF VI Cot "eee tae PI Pipe keyed ara onan St Asnanrrnanrnseniicrrdtall yell vent a Ad lincvky a reeks) \ pyrene \ eae wee Nevatrey | \ fy if ‘ Chin EMG ssenetemtentvenenntiogtelnhesstheenteininaiatlaeatinieln esteem eealicee Figure 6. An epoch of stage W with both alpha rythm (posterior dominant rhythm) and REMS. Note the EMG activity inthe chin Note 1, Stage W represents the waking state, ranging from full alertness through early stages of drowsiness. Electrophysiological and psychophysiological markers of drowsiness may be present during stage W and may persist into stage NI Note 2. In stage W, the majority of individuals with eyes closed will demonstrate alpha rhythm (posterior dominant rhythm), The EEG pattern with eyes open consists of low-amplitude activity (chiefly beta and alpha frequencies) without the rhythmicity of alpha rhythm. About 10% of individuals do not generate an alpha shythm upon eye closure, and a further 10% may generate a limited alpha rhythm. In these individuals, the occipital EEG activity is similar during eye opening and eye closure. Note 3, The EOG during wakefulness may demonstrate rapid eye blinks at a frequency of about 0.5-2 Hz. The carliest sign of drowsiness is the absence of eye blinks, As drowsiness develops, slow eye movements may develop, even in the presence of continued posterior dominant rhythm. Ifthe eyes are open, voluntary rapid eye movements or reading eye movements may be seen Note 4. The chin EMG during stage W is of variable amplitude but is usually higher than during sleep stages. Note 5, Time with the patient disconnected from the recording equipment should be scored as stage W. Brief episodes of sleep during this time, ifthey occur, are not considered significant for the stage scoring 21PScoring Stage Ni 1 ‘core in accordance with the following definitions: RECOMMENDED Slow eye movements (SEM): Conjugate, reasonably regular, sinusoidal eye movements with an initial deflection that usually lasts >500 msec, Slow eye movements may be seen during eyes closed wake and stage NI ixed-frequency (LAMF) EEG Vertex sharp waves (V waves): Sharply contoured waves with duration <0,5 seconds (as measured at the base of the wave), maximal over the central region and distinguishable from the background activity. They are most often seen during transition to stage NI sleep but can occur in either stage NI or N2 sleep. These waveforms typically first appear at 4-6 months post-term. Sleep onset: The start ofthe first epoch scored as any stage other than stage W. (In most individuals this will usually be the first epoch of stage N1.) Low-amplitude, n tivity: Low-amplitude, predominantly 4-7 Hz activity 2. In individuals who generate alpha rhythm, score stage N1 if the alpha rhythm is attenuated and replaced by low= amplitude, mixed-frequency activity for more than 50% of the epoch.” RECOMMENDED 3. In individuals who do not generate alpha rhythm, score stage NI commen phenomena: !*?°S!S° RECOMMENDED ‘a, EEG activity in range of 4-7 Hz. with slowing of background freque », Vertex sharp waves «, Slow eye movements - by 21 Hz from those of stage W 4, An epoch is scored as stage N1 if the majority of the epoch meets the criteria for stage NI (EEG showing LAMF EEG activity) in the absence of evidence for another sleep stage. Subsequent epochs with an EEG showing LAMF EEG activity are scored as stage NI until there is evidence for another sleep stage (usually stage W, stage N2 or stage R). (Gee Figure 7) RECOMMENDED Stage Stage Figure 7. Transition from stage W to stage Nt in a patient whe does nat generate alpha rythm (posterior dominant chyth) with eye closure tis assumed the EEG in epochs 52 and 62 do not meet criteria F.3.a hati, stage Nt cannot be scored based on the EEG criteria, 'A. Epoch 52 continues to be scored as stage W since the slow eye movement occurs inthe latter part ofthe epoch, Stage N1 is considered to start withthe occurrence ofthe slow eye ‘movement. Therefor, epoch 52 is scored as stage Ni B. Epoch 62 i scored as stage N1 since the slow eye movement occurs inthe fst ha ofthis ‘epoch. Epoch 63 continues as stage NT untl there is evidence of stage N2 withthe appearance ‘ofa K complex in the fst half of epoch 64‘ow-amplitude, mixed-frequency activity without one or more K complexes and/or sleep spindles until there is evidence for another stage of sleep (see G. Scoring Stage N2). RECOMMENDED 6, When an arousal interrupts stage R sleep and is followed by a low-amplitude, mixed-frequency EEG without posterior dominant rhythm AND with slow eye movements, score the portion of the record containing the eye movements as stage NI even if the chin EMG activity remains low (at the stage R level). Continue to score stage NI until there is evidence for another sleep stage (see G.2 for scoring stage N2 and 1.3 for scoring stage R). RecowmenoeD Note 1, Vertex sharp waves may be present but are not required for scoring stage NI. Note 2. The EOG will often show slow eye movements in stage NI, but these are not required for scoring Note 3. During stage N1, the chin EMG amplitude is variable, but often lower than in stage W. Note 4. As slow eye movements often commence before attenuation of alpha rhythm, sleep lateney may be slightly shorter for some individuals who do not generate alpha rhythm compared to those who do. Note 5. Theta frequency (4-7.99 Hz) waveforms that are of pathological origin (such as those resulting from ‘neurological impairment, encephalopathy or epilepsy) should not be considered toward the determination of stage NI sleep. In a person with a slow background EEG in the awake state, further non-pathological slowing of the background activity of >1 Hz from that seen in the wake state would be considered evidence of stage NI sleep. G. Scoring Stage N2 1. Score in accordance with the following definitions: | RECOMMENDED K complex: A well-delineated, negative, sharp wave immediately followed by a positive component standing out from the background EEG, with total duration >0.5 seconds, usually maximal in amplitude when recorded using frontal derivations. For an arousal to be associated with a K complex, the arousal must either be concurrent with the K complex. ‘oF commence no more than 1 second after termination of the K complex. (see V. Arousal Rule) Sleep spindle: A train of distinct sinusoidal waves with frequency I1-16 Hz (most commonly 12-14 Hz) with a duration 5 seconds, usually maximal in amplitude in the central derivations, 2. Begin scoring stage N2 (in absence of e of that epoch or the last half of the prev’ a, One ormore K complex ». One or more sleep spindl (eria for N3) if EITHER OR BOTH of the following oceur during the first half us epoch: !°*! RECOMMENDED 's unassociated with arousal 43. Score a given epoch as stage N2 if the majority of the epoch meets criteria for stage N2. If the waveforms in ru G.2.a oF G.2.b are followed by an arousal in the same or subsequent epoch (sce Figure 8), the segment of the recording preceding the arousal is considered stage N2 (see rule G.6.b).!™’ RECOMMENDEDoe Epoch B. Epoch Epoch soot 82 83 oo 2 3 nn 2 cox fo ety J) esa at ne ee om A}. 02-M1 + ° : ! 02-M1 - ene maa pA fn 4 A Chin EMG ae peeeeninenes — Chine > 1 Chin MG mone N2NQ WIND N2_N2 NTN N2_NT_NT_N2 Stage Stage Stage Figure 8 Start and continuation of stage N2. The EEG is assumed to show LAMF unless otherwise depicted. ‘A. Start of N2. Epoch 60 is scored as stage N2 as there is aK complex (unassociated with an arousal) in the frst half ofthe epoch (rule 6.2) Epoch 51 is stage N2 as this stage continues for the majority ofthe epoch (ule G.3), Following an arousal, epoch 52 is Scored as stage Nt (rule G.6.b unl there is evidence for another stage of sleep. A K complex is noted in the last half of epoch 52 land epoch $3 s scored as stage N2 (ule G2), BB At the end of epoch 6, theres a K complex associated with an arousal. Epoch 62 is scored as stage N1 (ule G.6.). AK. complex associated with an arousal not considered evidence for stage N2. Epoch 63 s scored as stage N? by rule G2. C-AK complex occurs in the ast half of epoch 70 but stage N2 is considered to be present ony upto the arousal in epach 71 Epoch 71 fs scored as stage NT as tha majority ofthe epoch follows the arousal, Epoch 72 is scored as stage NT as the K complex does net occur until the second half ofthe epoch, 1 2020Americen Academy Shnp Mein. Alright reserved 4. Continue to score epochs with low-amplitude, mixed-frequency EEG activity without K complexes or sleep spindles as stage N2 if they are preceded by epochs containing EITHER of the following and there is no intervening Arousal: RECOMMENDED ‘a. K complexes unassociated with arousals b, Sleep spindles 5. Epochs following an epoch of stage N3 that do not meet criteria for stage N3 are scored as stage N2 if there is no 1g arousal and the epoch does not meet criteria for stage W or stage R. (sce Figure 9) RECOMMENDED Epoch 200 Epoch 201 Fem A Raha Real, vow com | WA Ahonen Ant ait gl Pall “Tt oom f\" Vreeland ner? ere Mlle) sear bat Vw wal aravecrmnn iat corti EME yl pide Mahdi anmclonasd seinen Hat alert Chin EMG uM Stage N3 Stage N2 Figure 9, Transition from stage NS to stage N2. The vertical distance between the lines in F4-Mt is 75 Epoch 201 does nat have sufficient slow wave activity o mest ertria fr stage N3. There sno intervening arousal. Epoch 201 ie scored as stage N2 24 Aas hind scoring stage N2 sleep when ONE of the following events occurs: °°" RECOMMENDED ‘a. Transition to stage W b. An arousal followed by low-amplitude, mixed-frequency EEG (change to stage N1 until a K complex unassociated with an arousal ora sleep spindle occurs) (see Figure 8). This assumes that the epoch does not meet criteria for stage R (rule 13) (ce Figure 12C), . A major body movement followed by slow eye movements and low-amplitude, mixed-frequency EEG without non-arousal associated K complexes or sleep spindles (Score the epoch following the major body movement as stage NI; score the epoch as stage N2 if there are no slow eye movements; the epoch containing the body movement is scored using the major body movement rules under section J) (see Figure 10) 4. Transition to stage N3 «, Transition to stage R. Figure 10. End of stage N2 dus toa major body movement. The EEG is assumed tocontainow-amplitude, mixed-trequency activity unless otherwise depicted. ‘A. Epoch 52 continues tobe scored as stage N2 as the major body movernent is NOT followed by slow eye movements. Epoch 51 is scored according tothe major body movement rules (section J). As epach 51 does not contain alpha activity {and an epoch of stage W does nat precede o follow the epoch, the major body ‘movement is scored the same as the epoch that follows i (stage N2: rule 4) B. Epoch 62 is scored as stage N1 (stage N2 ends following the major body movement) as the body movement is followed by slow eye movements and Iow- “amplitude, mxed-trequency EEG (ule G.6.0, Epoch 63 fs scored as stage N2 as a K complex unassociated with an arousal cecurs in the first half of the epoch, (2020 american Academy o Sloup Mein. lights reserved. Note 1. An epoch of stage N2 meeting criteria in rule G.2 is termed definite stage N2. If there is a conflict between a stage N2 and stage R scoring rule, the stage R rule takes precedence (see 14). Note 2. Continue to score stage NI for epochs with arousal-associated K complexes unless they contain sleep spindles or K complexes not associated with arousals, Note 3. For the purposes of scoring N2 sleep, arousals are defined according to the arousal rule in chapter V. (V.A.1) Note 4, For scoring epochs with a mixture of K complexes andior sleep spindles and REMs, see rule 1.7 Note 5, The EOG usually shows no eye movement activity during stage N2 sleep, but slow eye movements may persist in some individuals, Note 6. Instage N2, the chin EMG is of variable amplitude, but is usually lower than in stage W, and may be as low as in stage R sleep,PScoring Stage N3*: 1 ‘core in accordance with the following definition: RECOMMENDED Slow wave activity regions referent + Waves of frequency 0.5 Hz-2 Hz and peak-to-peak amplitude >75 jV, measured over the frontal ed to the contralateral ear or mastoid (F4-MI, F3-M2). 2. Score stage N3 when 220% of an epoch consists of slow wave activity, respective of age. | RECOMMENDED Note 1. Stage N3 represents slow wave sleep and replaces the Rechtschatten and Kales nomenclature of stage 3 and stage 4 sleep. Note 2. K complexes would be considered slow waves if they meet the definition of slow wave activity. Note 3. Pathological wave forms that meet the slow wave activity criteria, such as those generated by metabolic encephalopathies, epileptic, or epileptiform activity, are not counted as slow wave activity of sleep. Similarly, ‘waveforms produced by artifact or those of non-cerebral origin should not be included in the scoring of slow Note 4. Sleep spindles may persist in stage N3 sleep. Note 5. Eye movements are not typically seen during stage N3 sleep. Note 6. In stage N3, the chin EMG is of variable amplitude, often lower than in stage N2 sleep and sometimes as low as in stage R sleep. I. Scoring Stage R 1. Score in aceordance with the following definitions: RECOMMENDED Rapid eye movements (REMs): Eye movements recorded in the EOG derivations consisting of conjugate, irregular, sharply peaked eye movements with an initial deflection usually lasting <500 msec. While rapid eye movements are characteristic of stage R sleep, they may also be seen in wakefulness with eyes open when individuals visually scan the environment. Low chin EMG tone: Baseline EMG activity in the chin derivation no higher than in any other sleep stage and usually at the lowest level of the entire recording, Sawtooth waves: An EEG pattern consisting of trains of sharply contoured or triangular, often serrated, 2-6 Hz ‘waves maximal in amplitude over the central head regions and often, but not always, preceding a burst of rapid eye ‘movements. sient muscle activity: Short irregular bursts of EMG activity usually with duration <0.25 seconds superimposed ‘on low EMG tone, The activity may be seen in the chin or anterior tibial EMG derivations, as well as in EEG or EOG. deviations, the later indicating activity of cranial nerve innervated muscles (facial and scalp muscles). The activity is often maximal when associated with rapid eye movements. 2. Score stage R sleep in epochs with ALL of the following phenomena (definite stage R):*!92°05°" ecoMMENDED ‘2. Low-amplitude, mixed-frequency (LAMF) EEG activity without K complexes or sleep spindles », Low chin EMG tone for the majority of the epoch and concurrent with REMs ¢. REMS at any position within the epoch . Score segments of sleep preceding and contiguous with an epoch of definite stage R (as defined in I.2), in the absence of rapid eye movements, as stage R if ALL of the following are present: (see Figures 11, 12 and 13) RECOMMENDED ‘a, The EEG shows low-amplitude, mixed-frequency activity without K complexes or sleep spindles’ b. The chin EMG tone is low (at the stage R level) c. There is no intervening arousal (see Figure 12C) 4d. Slow eye movements following an arousal or stage W are absent ™*Epoch B. Epoch Epoch so st 5259 oo or a 6s nin pa Fat FAM Few cama cant coy Stage Stage Stage Figure 11, Start of stage R. [A. Epoch 52 isan epoch of definite stage R. Epoch 63 is scored as stage R by rule LS (REM continuation rule) BB. Epoch 61 i scored as stage NI as alpha s replaced by iow-amplitude, mixed-trequency (LAMF) EEG activity. ASEM is present Inthe second haif ofthe epoen. While not required for scaring stage NI, the presence ofthe SEM prevents the epoch from being scored as stage R (ule 1.2). Epoch 62 is scored as stage R by rule Epoch 71 is scored as stage Ras the majorty ofthe epoch meets the criteria of rule. Stage Stage Stage Figure 12, Start of stage R. {A Transition rom definite stage N2 (epoch 50) to defite stage R (epoch 59). The EEG ofthe majority of epoch 51 and all of epoch 52 has low-amplitude, mixed-frequency (LAMF) EEG without sleep spindles or K complexes and chin EMG is atthe stage R level. [As the epochs 51 and 52 are contiquous with definite stage R (Epoch 52), they ae scored as stage R. B. Epoch 60 isan epoch of definite stage N2. Epoch 61 is scored as stage N2 by the stage N2 continuation rule. Epochs 62 and 63 are scored as stage Ras the EEG has LAMF activity without K complexes or sleep spindles, the chin EMG is atthe stage R level, ‘and the epachs are contiquous with an epoch of defnte stage F (epoch 64). Note that, using rule G.2, epoch 62 would be scored as stage N2. However, the stage R rule (3) takes precedence . Using rule 6.6.5, epoch 71 would be scored as stage Nt (arousal ends stage N2}, However, REM rule I takes precedence and ‘epochs 72 and 73 are scored as stage R.28 rah ES won fF of od com ttt cous He NE NEA ENE NE NNER Stage Stage Stage Figure 13. Scaring stage R. ‘A. Atransiion between definite stage N2 (epoch 50) and definite stage R (epoch 83). Epoch £2 ie scored as stage Ras the EEG shows low-ampitude, mxed-trequeney (LAMF) without K complexes or slaep spines and the chin EMG falls tothe tage R level atthe end of epoch 51 B.A transition between definite stage N2 (epoch 60) and definite stage R (epoch 62). Stage N2 is considered to continue until the last K complex or sleep spindle. ©. Epoch 72's scored as stage Fas the majority of epoch 72 (oloing the sleep spindle in the fist haf ofthe epoch) hasan EEG with LAM activity without K complexes or sleep spindles, the chin EMG is at the stage F level, and this portion ofthe record is Contiguous with definite stage Repech 73). Note that, by rule G.2, epoch 72 would be scored as stage N2. However, rule takes precedence overrule G.2. As the majority of epoch 72 meets rule. eltra, the epoch is seared as stage R. 4. If the majority of an epoch contains a segment of the recording meeting criteria for stage R (1.2, 1.3, 1.5), the epoch is scored as stage R. Stage R rules take precedence over stage N2 rules. (see Figure 12, epoch 62 and Figure 13, epoch 72) RECOMMENDED ‘5. Continue to score segments of sleep that follow one or more epochs of definite stage R (as defined in 1.2),in the absence of rapid eye movements, as stage R if ALL of the following are present: (see Figures 14-18) RECOMMENDED ‘a. The EEG shows LAME EEG activity without K complexes or sleep spindles b. The chin EMG tone is low (atthe stage R level) for the majority of the epoch. . There is no intervening arousalaOR OR ND ROR NN Stage Stage Figure 14. Continuation and end of stage A. The EEG is assumed to contain low amplitude, mixed-trequency activity uniess otherwise depicted, ‘A. Epoch 60 is definite stage R (rule 1.2), Epochs 51 and 82 continue to be s8ored as stage Ras the chin EMG remains low and the EEG does not contain K ‘complexes of sloop spindies. Epoch 52 s scored as stage Ras the chin EMG tone {600s not increase until the last half of the epoch. Epoch 53 s scored as stage N2 ‘iven that the K complex is unaseociated with an arousal in the fist half ofthe B. Epoch 60 is definite stage R and Epoch 61 continues to be scored as stage Ras the chin one remains low and the EEG contains low-amplitude, mixed-trequency activity. Epoch 62s not scored as stage as the chin tone isnot low for the ‘majority ofthe epoch, Enoch 62 is scored.as stage Ni given the ow-ampitude ‘mixed-trequeney EEG pattern and the absence of K complexes or sleep spindles In the fst hal ofthe epoch, a pte . to hater at othe ot LAL ot erat AL Lah i 4 er tot tt evar Wa aT tat ah ae Tat Bek ah ee Figure 18. nd of Stage A when an arousal is followed by slow eye movernents. The EEG is assumed to contain low-ampliude, ‘mixed-frequency activity uniess otherwise depicted [A Stage is interrupted by an arousal followed by ow-ampltude, mixed-frequency EEG without slow eye movements. Epoch 52 Continues ob scored as stage Ras the EEG shows a low-ampltude, mixed-trequency patter, and the majority ofthe epoch contains low chin EMG tone ft the stage Aleve, Compare the effects ofan arousal interrupting stage R with one ntxtupting N2 (Figure 8) B, Stage Fs interrupted by an arousal followed by slow eye movements and iow ampiltude, mixed-frequency. Because siow eye movements are present folowing the arousal, Epoch 62 Is Scored as stage N1 even though chin activ is atthe stage R lev. ‘Stage N1 continues until there is evidence for another sleep stage {here stage N2 in epoch 63) . Stage Ri intoruptad by an arousal followed by slow eye movements and low ampitude, mixed-frequaney EEG. However, the ‘majority of epoch 72 does not contain iow eye movements and is scored as stage R based on rule 1.9 a epoch 73 s definite stage R. 1. Stage Fis interrupted by an arousal followed by slow eye movements and low ampitude, mixed-trequency EEG with chin activity a the stage Flevel. Epoch 82 is scored as stage Ni even if the chin activity Isa the stage Flevel asthe major of the epoch Contains stow eye movements, Stage NI continues unt there evidence of another sleep stage (ere definite stage R in epoch 89),oe Stage Figure 16. End of stage F due to @ major body movement. The EEG is assumed to Contain lou-ampltude mixed-trequency activity unless otherwise depicted [A Epoch 52 continues as stage Fas the EEG contains low-ampltude mixed frequency activity the chin EMG tone is ow, and slow eye movements do NOT follow the mejor body movement, Note that if Epoch St was scored as stage W ‘based on the appearance of alpha activity, stage R would end (movement rules in J, BB. Epoch 62 Is not scored as stage F even ifthe EEG exhibits iow-ampltude rmixed-requency activity and the chin tone remains low because slow eye ‘movernents follow the major body movernent. {©2020 American Acodemyo Siep Maicne. Al ghs reserve, A. Epoch Epoch one 6 one revs tt | een} tt Stage Stage Figure 17. Transition trom stage Ro stage N2, The EEG is assumed to contain lost-amplituce, mixed- frequency activity unless otherwise depicted [A. Epoch 50s definite stage R, Epoch 51s scored as stage R by rule 1S (Continuation of stage R rule, Epach 52 is an epoch of definite stage N2 given the K. ‘complex in the fst half ofthe epoch 1B. Epoch 62s ecored as stage Ras the K complex does not occur unt the second part ofthe epoch.Stage Stage Stage Stage Figure 18, Mixture of REMs and K complexes. ‘A. Epoch 81 is scored as stage Fas the majority ofthe epoch is considered stage R(ruleL7). Epochs 51 and 52 are scovedas stage Rbyrule is. BB. Epochs 60 and 61 are scored as stage Fas the majority ofthe epochs are considered stage F (ule L7. (Epoch 71 is scored as NT as the ch EMG is not at the stage Flevel forthe majority of the epoch. Epoch 72 isan epoch of finite stage N2. Note that ule .3 does not apply for epoch 72 as the chin EMG isnot atthe stage R leva D. The maorty of epoch 80 is considered stage Rule 7b) so the epoch is scored as stage R. Most of epoch 81 is considered stage N2 fule 17.) so the epoch is scored as stage N2. Epoch 82's Scored as stage F by rule 3. Fule 3 takes precedence over the stage N2 rule G.2. Epoch 83 is an epoch of definite stage F. 6. End scoring stage R sleep when ONE OR MORE of the following occur: RECOMMENDED a. There isa transition to stage W or N3 ». An inerease in chin EMG tone above the met (see Figure 14, epoch 62) When an arousal interrupts Stage R and is followed by a low-amplitude mixed-frequency EEG without posterior dominant rhythm AND slow eye movements, score the portion ofthe record containing the slow eye movements as Stage N1 even if the chin EMG activity remains low (at stage R level). Continue to score stage NI until there is evidence for another stage, usually stage N2 (see G.2) or Stage R (see 1.2 and 1.3) If there are no slow eye movements and chin EMG tone remains low, continue to score as stage R. (see Figure 15) 4. A major body movement followed by slow eye movements and low-amplitude, mixed-frequency EEG without non-arousal associated K complexes or sleep spindles (Score the epoch following the major body movement as stage NI; ifn slow ‘eye movements are present and the EMG tone remains low, continue to score as stage R; the epoch containing the body movement is scored using the criteria under heading J) (see Figure 16) ¢, One or more non-arousal associated K complexes or sleep spindles are present in the first half ofthe epoch in the absence of rapid eye movements, even if chin EMG tone remains low (Score the epoch as stage N2) (see Figure 17) el ofstage R is seen for the majority of the epoch and criteria for stage NI are 7. Score segments of the record with low chin EMG activity and a mixture of REMs and sleep spindles and/or K complexes as follows: 92° RECOMMENDED a. Segments between two K complexes, two sleep spindles, or a K complex and sleep spindle without intervening REMS are ‘considered to be stage N2. bb. Segments of the record containing REMs without K complexes or sleep spindles and chin tone at the REM level are considered to be stage R. Ifthe majority of an epoch contains a segment considered to be stage N2, itis scored as stage N2. Ifthe majority of an epoch contains a segment considered to be stage R, itis scored as stage R. (see Figure 18)Note 1. Epochs defined by rule L2 are called epochs of definite stage R. Note 2, Low-amplitude, mixed-frequency activity in stage R resembles that seen in stage NI. In some individuals, 4 greater amount of alpha activity can be seen in stage R than in stage NI. The alpha frequency in stage R often is 1-2 Hz slower than during wakefulness. Note 3. Sawtooth waves or transient muscle activity are strongly supportive of the presence of stage R sleep and may be helpful when the stage is in doubt, however, they are not required for scoring stage R. Note 4, For scoring epochs with low chin EMG tone and a mixture of REMs and K comple? 17, cs or sleep spindles see Note 5. Slow eye movements can occur during stage R but slow eye movements following an arousal in combination with an EEG showing LAMF activity suggests a transition to stage NI evea if the chin tone remains low. Note 6, Segments of the record with low chin EMG activity and a mixture of REM and sleep spindles and/or K complexes usually occur during the first REM period of the night. J. Scoring Epochs with Major Body Movements 1, Score in accordance with the following definition: | RECOMMENDED Major body movement: Movement and muscle artifact obscuring the EEG for more than half an epoch to the extent that the sleep stage cannot be determined - Ifalpha rhythm is present for part of the epoch (even <1S seconds duration), score as stage W. RECOMMENDED 3. If no alpha rhythm is discernible, but an epoch scoreable as stage W body movement, score as stage W. RECOMMENDED her precedes or follows the epoch with a major 4. Otherwise, score the epoch as the same stage as the epoch that follows it. "RECOMMENDED 32@..-, Staging Rules Part 2: Rules for Children A. Ages for Which Pediatric Sleep Staging Rules Apply 1. Pediatric sleep staging rules can be used to score sleep and wakefulness in children 2 months post-term or older.®!°? RECOMMENDED Note 1, For infants less than 2 months post-term, refer to IV. Sleep Staging Rules Part 3: Rules for Infants, Note 2. There is no precise upper age boundary for pediatric sleep staging rules; refer to discussion in the Pediatrie Task Force review paper! Reference 1. Grigg-Dambenger M, Gozal D, Marcus CL Sleep Med. 2007;3(2):201-240, al, The visual scoring of sleep and arousal in infants and children. J Clin B. Technical Specifications 1c IV. Sleep Staging Rules Part 1: Rules for Adults and IIL. Technical and Digital Specifications for technical considerations other than those in the note below.”! RECOMMENDED Note 1. Adult electrode derivations for EEG, EOG and chin EMG are acceptable for recording sleep except that the distance between the chin EMG electrodes often needs to be reduced from 2 em to 1 cm and the distance from the eyes in EOG electrodes often need to be reduced from 1 em to 0.5 em in children and infants with small head size C. General Scoring of Sleep Stages 1. The following terminology should be used when scoring sleep in children 2 months post-term or older: a. Stage W (Wakefulness) b. Stage NI (NREM 1) «, Stage N2 (NREM 2) d. Stage N3 (NREM 3) ce, Stage N (NREM) £ Stage R (REM) Not all sleep waveforms are well developed by 2 months post-term, therefore, the following possible scenarios may ‘apply: SU2AiNuns 2. [fall epochs of NREM sleep contain no recognizable sleep spindles, K complexes or high-amplitude 0.5-2 Hz slow ‘ave activity, score all epochs as stage N (NREM). RECOMMENDED 43. If some epochs of NREM sleep cont: remaining NREM epochs, there is no slow wave activi stage N(NREM). RECOMMENDED in sleep spindles or K complexes, score those as stage N2 (NREM 2). Ifin the comprising more than 20% of the duration of epochs, score as 4. Ifsome epochs of NREM sleep contain greater than 20% slow wave activity, score these as stage N3 (NREM 3). [fin the remaining NREM epochs, there are no K complexes or spindles then score as stage N (NREM). RECOMMENDED 5. If NREM is sufficiently developed that some epochs contain sleep spindles or K complexes and other epochs contain sufficient amounts of slow wave activity, then score NREM sleep in this infant as either stage NI, N2 or N3 as in an older child or adult, RECOMMENDED 33Note 1. Sleep spindles may be seen by age 6 weeks ~ 3 months post-term and are present in all normal infants by age 2-3 months post-term. Ar this age the spindles are asynchronous between the hemispheres but become more synchronous over the first year of life. Note 2. K complexes are usually present by age 3-6 months post-term. Note 3. EEG activity of 0.5-2 Hz with a typical amplitude of 100-400 iV in the frontal regions may frst appear by 2 months of age and is usually present by age 4~S months post-term. The eriteria for slow wave activity are the same as for adults (amplitude >75 lV of 0.5-2 Hz ). Note 4, NREM sleep can be scored as stage NI, N2 or N3 in most infants by age 5-6 months post-term and ‘occasionally in infants as young as 4 months post-term, Note 5. In infants younger than 6 months post-term, non-EEG parameters are helpful in distinguishing NREM sleep from REM sleep. In REM sleep these parameters include the presence of irregular respiration, loss of chin ‘muscle tone, transient muscle activity (muscle twitches), and rapid eye movements. In NREM sleep, they consist of regular respiration, absence of eye movements, and preserved chin musele tone. D. Scoring Stage W 1, Score in accordance with the following definitions: !®?” “ReconwenoeD Eye blinks: Conjugate vertical eye movements ata frequency of 0.5-2 Hz present in wakefulness with eyes open or closed. Reading eye movements: Trains of conjugate eye movements consisting ofa slow phase followed by a rapid phase in the ‘opposite direction as the child reads or visually scans the environment, Rapid eye movements (REMSs): Eye movements recorded in the EOG derivations consisting of conjugate, irregular, sharply peaked eye movements with an initial deflection usually lasting <300 msec. While rapid eye movements are characteristic of stage R sleep, they may also be seen in wakefulness with eyes open when individuals visually scan the environment. Posterior dominant rhythm (PDR): The dominant reactive EEG thythm over the occipital regions in relaxed wakefulness ‘with eyes closed which is slower in infants and young children and attenuates with eye opening or attention. Frequency is 3.5-4.5 Hz when first seen in infants 3-4 months post-term, 56 Hz by 56 months, and 7.5-9.5 Hz by 3 years of age and amplitude is usually >50 uv. In older children and adults, posterior dominant rhythm is often referred to as alpha rhythm. ®!" (Gee Table 1) Tabie 1. tial age of waveform appearance. Waveform ‘Age of Initial Appearance Sleep spindles 6 weeks ~3 months poster K complexes 3-6 months postterm Siow wave activity 2-5 months postterm Posterior dominant htm Frequency of 35-45 Hz 3-4 months postterm Frequency of 5-6 Hz 5-6 months postterm Frequency of 75-95 Ha 3 years “Mean fequency of 9 Hz 9 years “Mean fequency of 10 Hz 1s years Vertex sharp waves 46 months posttrm Hypaagoaie hypersyachrony (HH) 3-6 months posttermAAge-appropriate posterior dominant rhythm over the occipital region (individuals generating alpha rhythm with eye closure) b. Other findings consistent with stage W (all individuals) i, Eye blinks (05-2 Hz) ji, Rapid eye movements associated with normal or high chin muscle tone iii, Reading eye movements Note 1, The PDR in infants and children typically contains intermixed slower EEG rhythms including: 4. Posterior slow waves of youth (PSW) which are intermittent runs of bilateral but often asymmetric 2.54.5 Hz slow waves superimposed, riding upon, or fused with the PDR, are usually <120% of PDR voltage, block with eye opening and disappear with drowsiness and sleep, PSW are uncommon in children <2 years of age, have a maximal incidence between ages 8-I4 years, and are uncommon after age 21 y ». Random or semi-rhythmic occipital slowing: <100 4, 2.54.5 Hz rhythmic or arrhythmic activity lasting <3 seconds; a normal finding in EEGs of children ages 1-15 years, especially prominent in ages 5-7 years; the amount of intermixed slowing decreases and its frequency increases with increasing age. Note 2. Spontaneous eye closure in infants signals drowsiness. Note 3. The highest amplitude and sharpest component of reading eye movements in children is usually surface- negative in the occipital derivations, typically lasting 150-250 msec, and having amplitudes up to 65 wV. E. Scoring Stage N1 ‘ore in accordance with the following definitions: | Recowmenoeo Slow eye movements (SEM): Conjugate, reasonably regular, sinusoidal eye movements with an initial deflection that usually lasts >S00 msec. Slow eye movements may be seen during eyes closed wake and stage NI Low-amplitude, mixed-frequency (LAMF) a yy: Low amplitude, predominantly 47 Hz activity. Vertex sharp waves (V waves): Sharply contoured waves with duration <0.5 seconds (as measured at the base of the ‘wave), maximal over the central region and distinguishable from the background activity. They are most often seen during transition to stage NI sleep but can occur in either stage NI or N2 sleep. These waveforms typically first appear ‘at 4-6 months post-term, Sleep onset: The start of the first epoch scored as any stage other than stage W. (In most subjects this will usually be the first epoch of stage NIL) Hypnagogic hypersynchrony (HH): Paroxysmal bursts or runs of diffuse, high-amplitude, sinusoidal, 75-350 4, 3-4\5 Hz waves which begin abruptly, are usually widely distributed but often are maximal over the central, frontal, or frontocentral sealp regions. These waveforms can occur in stage NI and N2. 2. In individuals who generate a posterior dominant rhythm (PDR), score stage N1 if the PDR is attenuated or replaced by low-amplitude, mixed-frequeney activity for more than 50% of the epoch.) RECOMMENDED 3. In individuals who do not generate a posterior do of the following phenomena: RECOMMENDED «a, Activity in the range of 4-7 Hz with slowing of background frequencies by >I-2 Hz from those of stage W b, Slow eye movements «. Vertex sharp waves 4, Hypnagogic hypersynchrony €. Diffuse or occipital-predominant, high-amplitude, rhythmic 3-5 Hz activity ant rhythm, seore stage NI commencing with the earliest of ANYNote 1. In most individuals sleep onset will be the first epoch of stage NI, but in infants younger than 2 months post- term, this is often stage R. Note 2, Drowsiness in infants up to 6-8 months of age is characterized by the gradual appearance of diffuse, high- amplitude (often 75-200 yi) 3-5 Hz activity which is typically of higher amplitude, more diffuse, and 1-2 Hz slower than the waking EEG background activity. Note 3. Drowsiness in children 8 months to 3 years is characterized by either diffuse runs or bursts of rhythmic or semi-thythmie bisynchronous 75-200 pV, 3-4 Hz activity often maximal over the occipital regions and/or hhigher amplitude (>200 nV) 4-6 Hz theta activity maximal over the frontocentral or central regions. Note 4, Sleep onset from 3 years on is often characterized by a 1-2 Hz slowing of the PDR frequency and/or the PDR often becomes diffusely distributed then is gradually replaced by relatively low-voltage, mixed-frequency EEG activity. Note 5. Hypnagogic hypersynchrony is a distinctive EEG pattern of drowsiness and stage NI that often disappears ‘with deeper stages of NREM sleep. HH is seen in approximately 30% of infants at 3 months post-term, 95% of all normal children ages 6-8 months, and is less prevalent after age 4-5 years; itis seen in only 10% of healthy children by age 11 and is rarely seen after age 12 years. F. Scoring Stage N2 1: ‘ame as the adult rules found under the adult sleep staging rules heading G.®!” RECOMENDED Note 1. Sleep spindles are usually are first seen in infants 46 weeks post-term as brief bursts of low-amplitude, less- sinusoidal 12-14 Hz activity maximal over the vertex region, are usually well-developed and are present in all normal infants 8-9 weeks. Note 2. Eighty percent of children <13 years of age have two independent scalp locations and frequency ranges for sleep spindles: 10.0-12.75 Hz over the frontal and 12.5-14.75 Hz maximal over the central or centroparietal region Note 3. K complexes are usually present S-6 months post-term and are maximal over the pre-frontal and frontal regions, as they are in adults. G. Scoring Stage N3 1 fame as the adult rules found under the adult sleep staging rules heading H.®! Recommenoeo Note I. Slow wave activity in pediatric populations is often of high amplitude (100-400 pV), 0.5-2.0 Hz activity, ‘maximal over the recommended derivations in the frontal scalp regions and first appears as early as 2 ‘months, more often 34.5 months post-term, H. Scoring Stage R 1, Same as the adult rules found under the adult sleep staging rules heading I.®' RECOMMENDED Note 1. The continuous, low-amplitude, mixed-frequency EEG activity of stage R in infants and children resembles adults although the dominant frequencies increase with age: approximately 3 Hz activity at 7 weeks post- term, 4-5 Hz activity with bursts of sawtooth waves at 5 months, 4~6 Hz at 9 months, and prolonged runs or bursts of notched 5-7 Hz theta activity at 1-S years of age may populate the background activity, By 5-10 cars of age, the low-amplitude, mixed-frequency activity in stage R is similar to that of adults 36 AAs h€3:.-<, Staging Rules Part 3: Rules for Infants A. Ages for Which Infant Sleep Staging Rules Apply 1. Infant sleep staging rules should be used to score sleep and wakefulness in infants 0-2 months post-term (37-48 weeks conceptional age). !°="* RecowmenoeD Note 1. Conceptional age (CA) is gestational age (GA) at birth plus the number of weeks postpartum. Ga is the time elapsed between the first day of the mother’s last menstrual period and the day of delivery expressed in completed weeks. Ifthe pregnancy was achieved using assisted reproductive technology, GA is calculated by adding 2 weeks to the CA. Chronological age (or postnatal or legal age) isthe time elapsed since birth (can b expressed in days, months, or years). Note 2. At birth, an infant is classified as one of the following: premature (<37 weeks gestation); full-term (37-42 .weeks); or post-term (born after 42 weeks). A neonate isa child during the first 28 days after birth; an infant isa child age | to 12 months! Note 3. Knowing an infant's CA is crucial for interpreting the normalcy, immaturity or abnormality of an EEG or PSG because the brain and the EEG continue to develop and mature at a similar rate independent of whether the infant isin utero or post-delivery. Note 4, For premature infants (<37 weeks CA) refer to discussion in the Pediatric and Infant Scoring Task Force review paper? References 1. Engle WA; American Academy of Pediatrics Committee on Fetus and Newborn. Age terminology during the perinatal period. Pediatrics. 2004;114(5):1362—1364 2, Grigg-Dambenger M, Gozal D, Marcus CL, etal. The visual scoring of sleep and arousal in infants and children. J Clin Sleep Med. 2007;3(2):201-240. B. Technical Specifications 1.See y. Sleep Staging Rules Part 1: Rules for Adults and IIT. Technical and Digital Specifications for technical derations other than those below. RECOMMENDED 2. Adult electrode derivations for EEG, EOG and chin EMG are acceptable when recording sleep except that the distance between the chin EMG electrodes often needs to be reduced from 2 em to 1 em and the distance from the eyes in EOG electrodes often need to be reduced from 1 to 0.5 em because of small infant head sizes. | RECOMMENDED 43. Since sleep spindles are often asynchronous in children until 2 years of age, and may be more prominent in the midline central (C3-Cz, C4-Cz) and central derivations (C3-M2, C4-M1), simultaneous display of the recommended and backup electrodes and Cz (midline central) may be considered (e.g., montage to consider: F4-M1, C4-M1, O2-M1, F3- M2, C3-M2, O1-M2, C4-Cz, C3-Cz)..' OPTIONAL 4. Since behavioral patterns are extremely useful, synchronized video and audio recording is highly desirable, | RecoMeNoED Note 1. Since rudimentary sleep spindles first appear at 43 to 48 weeks CA at the midline central (Cz, vertex) region and are often asynchronous, simultaneous display of left, right and midline central EEG channels may be considered (e.g., C3-Cz, Cz-C4), In infants this age, sleep spindles are often low voltage 12-14 Hz, not the wider range of 11-16 Hz seen at later ages,General Scoring of Sleep Stages 1. The following terminology should be used when scoring sleep in in (37-48 weeks CA): !°? RECOMMENDED a, Stage W (Wakefulness) ». Stage N (NREM) . Stage R (REM) 4. Stage T (Transitional) nts 0-2 months post-term 2. Score epochs using the following rules: RECOMMENDED ‘a, Score sleep stages in 30-second, sequential epochs commencing at the start ofthe study b, Assign a stage to each epoch . If two or more stages coexist, assign the stage comprising the greatest portion of the epoch 4. Iftwo or more PSG characteristics are discordant for stage R or stage N sleep, score the epoch as stage T (Transitional) sleep «. Score sleep onset as the first epoch of sleep 3. Sleep and wakefulness in infants 38 to 48 weeks CA are scored based on behavioral observation; regularity or irregularity of respiration; and EEG, EOG, and chin EMG patterns defined in Tables 1-6. REcouenoeo 4. Score sleep based on behavioral characteristics as defined in Table 1.°* \RecowMENDED Table 1. Behavioral characteristic of sleep stages. Stage _ Behavioral Characteristics ‘alm or active with ejes open, scanning eye movements; Brief eye closure can oceur wit eying N yes closed, few movements, sucking can occur R Eyes closed, REM scen under closed eyelids, squiming, sucking, grimacing, small movements ofthe face ois 5. Score sleep based on the respiration characteristics as defined in Table 2..°" RECOMMENDED ‘Table 2. Respiration characteristics of sleep stages, Stage _ Respiration Characteristics Irregular, rapid, and shallow N Regul R Irregular, some central pauses (my oF may not meet eriteria fr apnea)ore sleep based on the EEG characteristics as defined in Table 3. (see also Figure 1) RECOMMENDED Table 3. EEG characteristics of sleep stages. Patterns EEG Characteristics Stage(s) Discontinuous This BEG pater in fullterm infansis generally only seen i stageN sleep. tis characterized by atleast 3 alternating runs or biltrallysymmeteicl synchronous high voltage (50-150) burst of I-3 Ha dl aetiviy lasting 5-6 seconds (range 3-8 N conde) alternating with periods of kwer amplitude (25-50 V) 4-7 Hz thes sctivity (ange 4-12 seconds ‘Continuous Lom slugs) inn ow oe mene ay wih dan prema i a High otagesow (VS)! Continous synchronous symmetrical peominany high vols 3 Hrd activity. Nearly R Mined 00) Sih ie penodtyTheamplnoe sfower hansen inthe HVS pte ary N Waveforms of interest sipypingast20 | 12 a ost prominent in miine central (CZ) and centadeivaions. | y Occur only inst High votage slow (HVS) Low votage irregular (LM Mixes Trace aternant (TA) Figure 1. Sample 30 second tracings of EEG characteristics of seep stages. 7. Score sleep in accordance with the following definitions and based on the EOG characteristics as defined in ‘Table 4. RECOMMENDED Eye blinks: Conjugate vertical eye movements at a frequency of 0 5-2 Hz present in wakefulness with eyes open or closed 39‘anning eye movements: Trains of conjugate eye movements with eyes open consisting of a slow phase followed by a rapid phase in the opposite direction as the infant visually scans the environment or follows objects. ®!* Rapid eye movements (REMs): Eye movements recorded in the EOG derivations consisting of conjugate, irregular, sharply peaked eye movements with an initial deflection usually lasting =300 msec, While rapid eye movements are characteristic of stage R sleep, they may also be seen in wakefulness with eyes open when individuals visually sean the ‘environment, Table 4. £0G characteristics of sleep stages. Stage E0G Characteristies, Wake Eye blinks, REMs,seanning eye movements; tansiet eye closes maybe seen in wakefulness especially when the infant is rying N Byes losed, not moving R Eyes closed with REMs 8. Score sleep in accordance with the following definitions and based on the chin EMG patterns as defined in Table S. RECOMMENDED Low chin EMG tone: Baseline EMG activity in the chin derivation no higher than in any other sleep stage and usually at the lowest level ofthe entire recording ‘Transient musele activity: Short irregular bursts of EMG eetivity usually with duration <0.25 seconds superimposed ‘on low EMG tone. The activity may be seen in the chin or anterior tibial EMG derivations, as well as in EEG or EOG. deviations, the latter indicating activity of cranial nerve innervated muscles (facial and scalp muscles). The activity is ‘often maximal when associated with rapid eye movements. Table 5. Chin EMG pattems of sleop stages. Stage | Chin EMG Patterns Wake Present, movement artiiet N Present; ould be lower than waks R Low, TMA may oecur 6. Summary of state charactvistcs. Stage Behavioral Respiration EEG £0 hin Ema = Eyes ope CFMB gular ioc REM, Binks S- prog pel TA.HVS.slecp | Eyescloedwithno N (tyes closed Regul Sy sce Present orlow period sucking — ™ Secssional stare) Mor pos om TMA my k Se regular ee Byesctoed witha LOX TMA may Small movements (easly HVS) ceur EMss LVI low voltage itroglar, M= mixed, TA =tracealternant, HVS = high voltage slow, REMs = rapid eye movementsNote 1 Note 2 Note 3 Note 4 Note 5 Note 6. Note 7. Note 8. Note 9. Note 10, Note 11 Note 12, Note 13. Note M4. Note 15, Note 16 If NREM is sufficiently developed so that some epochs contain sleep spindles or K complexes and other epochs contain sufficient amounts of slow wave activity, then score NREM sleep in this infant as either stage NI, N2 or NB as in IV. Sleep Staging Rules Part 2: Rules for Children, C5. Stage N is analogous to the previously used terminology of “quiet sleep,” stage R is analogous to the previously used terminology of “active sleep.” and stage T is analogous to the previously used terminology of “indeterminate sleep.” Up until 2 to 3 months post-term, the first epoch of sleep in infants is often stage R. ‘The transition to sleep in an infant is characterized by relative immobility, absence of focused attention, and intermittent eye closure. [fan infant's eyes are closed for more than 3 minutes, the infant is considered asleep. Theta and delta activity, especially over the frontal derivations, may increase in amplitude in transitions between W and sleep onset. Regularity or irregularity of respiration during sleep is the most reliable PSG characteristic in differentiating stage N and stage R sleep, respectively. Periodic breathing is common during stage R sleep and may rarely occur during stage N sleep in normal infants The EEG patterns of transitional sleep may contain any of the EEG characteristics outlined in Table 3 Pathological EEG waveforms, such as those from spike and slow wave, projected rhythms or those generated ddue to underlying pathology, should not be included in defining stage or state as noted in Table 3. Itis permissible to look at preceding and following epochs to identify the trace alternant (TA) pattern, Trace alternant (TA) first appears at 37 weeks conceptional age (CA), is the predominant EEG pattern in stage N sleep at 40 weeks CA and unlikely to be seen after 44 weeks CA. After 42 weeks CA, interburst intervals (IBIs) of TA last only 1-2 seconds and the BI is of higher amplitude. TA after 44 weeks CA is replaced by high voltage slow (HVS) activity High voltage slow (HVS) activity is the more mature EEG pattern of stage N sleep at term, Its characterized by continuous synchronous symmetrical 100-150 jtV 1-3 Hz delta activity which often has an occipital or central predominance. Since rudimentary sleep spindles first appear at 43 to 48 weeks CA at the midline central (Cz, vertex) region and are often asynchronous, simultaneous display of left, right and midline central EEG channels may be considered (e.g, C3-Cz, Cz-C4), In infants this age, sleep spindles are often low voltage 12-14 Hz, not the wider range of 11-16 Hz seen at later ages. Since sleep spindles are often asynchronous in children until 2 years of age, simultaneous display of the recommended and backup electrodes may be considered (e.g., montage to consider: F3-M2, F4-M1, C3-M2, C4-MI, O1-M2, O2-MI, C3-Cz, Cz-C4), ‘Scanning eye movements can be seen as early as 2 weeks post-term. Stage T (Transitional) is scored when 3 NREM and 2 REM or 2 NREM and 3 REM characteristics are present. In epoch(s) contiguous and following an epoch of definite stage R (¢., containing REM). aPScoring Stage W 1. Score epochs as stage W if either a, b, or c is present for the majority of the epoch:!*? (Figure 2) | RECOMMENDED ‘a Byes are wide open (For the majority of the epoch) ». Vocalization (whimpering, crying, ete) or actively feeding . All ofthe following are met i, Eyes are open intermittently ii, REMS or scanning eye movements ii, Sustained chin EMG tone with bursts of muscle activity in, Irregular respiration EEG: LVI or M™* Figure 2. A 30 second tracing of stage W in an infant, EEG: mixed frequency pattern; EOG: REMSs present; Chin EMG: present (high: Fespiration: regular, Behavior: eyes open, moving head. The thermal Sensor isan oronasal low sensor. Note I. Wake is most reliably scored by behavioral observations, because many of the distinctive EEG features of ‘wakefulness are not seen until after 2 months post-term, Note 2. W (Wakefulness) is characterized by an EEG background of continuous, symmetrical, irregular, low-to- ‘medium amplitude mixed-frequencies which may include: (a irregular theta and delta activity (to 100 pV) ‘maximal in O1, O2; (b) diffuse irregular alpha and beta activity (to 30 wV); (€) rhythmic theta activity (to 50 LAV), offen maximal in C3, Cz, C4 or (d) artifacts from body movements, and eye movements. Note 3 This may have superimposed frequent movement artifactsMScoring Stage N (NREM) 1¢ N if four or more of the following are present, including regular respiration, for the majority of the “2 (Figures 3 and 4) | RECOMMENDED a, Eyes closed with no eye movements ». Chin EMG tone present «, Regular respiration (post sigh respiratory pauses may occur) 4, Trace alternant (TA), high voltage slow (HVS), or sleep spindles present «, Reduced! movement relative to wake PPDDDND Figure 3. A 30 second tracing of stage N sleepin an infant. EEG: Trace alternant; EOG: no REMS: Chin EMG: present; Respiration: regula, Behavior: eyes closed, no movements. The thermal sensor is an oronasal flow sensor. Figure 4. 30 second tracing of stage N sleep in an infant, EEG: HVS; EOG: no eye movements; Chin EMG: present Respiration: regula, Behavior: eyes closed, no movements. The thermal sensor i an oronasal flow sensor. be 12 2020 Amerieon Academy a Note 1. Chin EMG in stage N is variable; it is generally lower than Wake and higher than in stage R. That is, if chin EMG activity is present (higher than stage R) this is evidence for stage N (Table 5). However, stage N can still be scored with low EMG tone provided at least four other criteria for stage N including regular respiration are met. Note 2. Regularity or irregularity of respiration during sleep is the most reliable PSG characteristic in differentiating stage N and stage R sleep, respectively.PScoring Stage R 1, Score stage R sleep (definite R) in epochs with 4 or more of the following criteria present, including irregular respiration AND rapid eye movement: (Figure 5) RECOMMENDED a, Low chin EMG (for the majority of the epoch)" », Eyes closed with at least one rapid eye movement (concurrent with low chin tone) ¢. Irregular respiration «d, Mouthing, sucking, twitches or brief head movements EEG exhibits a continuous pattern without steep spindles’ 2. Score segments of sleep contiguous with and following an epoch of definite R (as defined in F.1) in the absence of rapid exe movements, as stage Rif ALL of the following are present: RECOMMENDED 1, The EEG shows low or medium amplitude mixed-frequency activity without trace alternant or sleep spindles b. The chin muscle tone is low for the majority of the epoch ¢. There is no intervening arousal (see chapter V. Arousal Rule, same rule as for children and adults) JESS PEEPS EEE SS ESS ESSE Figure 6. A 30 second tracing of stage R sleep in an infant. EEG: LVI; EOG: REM: Chin EMG: low; Respiration: irregular Behavicr: eye movernents noted with small movernents of mouth. The thermal sensor isan oronasal flow sensor. Note 1. In infants, the first epoch of sleep is most commonly stage R. Given the difficulty in determining sleep onset, an epoch of definite stage R is required to begin scoring this sleep stage Note 2. Epochs of stage R sleep containing periods without atonia (sustained activity or transient muscle activity in the chin EMG) are not uncommon in infants. Bursts of muscle activity during stage R often occur associated ‘with movements. The intervening chin EMG activity between movements is usually Tow. Note 3. Continuous EEG pattern includes low voltage irregular (LVI), high voltage slow (HVS), and mixed (M) (Table 3),PScoring Stage T 1. Score an epoch as stage N, stage R or stage W if only one PSG characteristic is discordant for the sleep state,9!°° RECOMMENDED 2. Score an epoch as stage T (transitional) if it contains either 3 NRE! 3. REM characteristics. (Table 6, Figure 6) RECOMMENDED \d 2 REM characteristics or 2 NREM and Figure 6. A 30 second tracing of Transitional (7) sleep in an infant. EEG: LVI; EOG: no REMSs: Chin EMG: absent ow) Respiration: regular, Behavioral: no movements, eye closed. Three characteristics of stage R (LVL, Chin EMG absent, regular respiration) and two characteristics of NREM (no movement, no FEMS) are seen inthis epoch. This assumes that the epoch was not immediatly preceded by an epoch of definite The thermal sensor isan oronasal flow sensor. Note 1. Transitional (T) or indeterminate sleep is common in infants because of discordant features (contains physiological markers of more than one sleep state). Note 2. The terminology Transitional (T) sleep is favored over indeterminate sleep as the sleep stage most often ‘occurs in transitions from stage W to stage R sleep, before awakening and at sleep onset. H. Reference The following reference applies to content throughout chapter IV. Sleep Staging Rules Part 3: Rules for Infants. 1. Anders T, Emde R, Parmele A.A Manual of Standardized Terminology, Techniques and Criteria for Scoring of States of Sleep and Wakefulness in Newborn Infants, Los Angeles, CA: UCLA Brain Information Service/BRI Publications Office, NINDS Neurological Information Network; 1971| Rule Scoring Arousals 1. Score arousal during sleep stages NI, N2, N3, or R if there is an abrupt shift of EEG frequency including alpha, theta and/or frequencies greater than 16 Hz (but not spindles) that lasts at least 3 seconds, with at least 10 seconds of stable sleep preceding the change. Scoring of arousal during REM requires a concurrent increase in submental EMG lasting at least 1 second.S!°2°5° RECOMMENDED Note I. Arousal scoring should incorporate information from the frontal, central, and occipital derivations Note 2, Arousal scoring can be improved by the use of additional information in the recording such as respiratory events and/or additional EEG channels, Scoring of arousals, however, cannot be based on this additional information alone and such information does not modify any of the arousal scoring rules, Note 3. Arousals meeting all scoring criteria but occurring during an awake epoch in the recorded time between “lights out” and “lights on” should be scored and used for computation of the arousal index. Note 4, The 10 seconds of stable sleep required prior to scoring an arousal may begin in the pre including a preceding epoch that is scored as stage W eding epoch, Note 5 An arousal may still be scored ifit immediately precedes a transition to stage W. That is, both the arousal and transition to wake are scored 46CBearsiac Rules Al (echnical Specifications 1. Use a single modified clectrocardiograph Lead II and torso electrode placement.®!°* "= (see Figure 1) RECOMMENDED Figure 1. Diagram of Lead Iiplacement an torso during cardiac recording. Iustration may not be to scale. Note 1. Additional leads may be placed if clinically indicated at the discretion of the practitioner, Note 2. Increasing the image size on the display may improve detection of arrhythmias. Note 3, While classically Lead Il is derived from electrodes placed on the right arm and left leg, the negative electrode may be placed below the right clavicle at the mid-clavicular line and the positive electrode on the left lower chest at the anterior axillary line in the 6 or 7 intercostal space. Note 4. Standard ECG electrode applications are superior to EEG electrodes in minimizing artifact. ' SM Scoring Manwal Version 2.6. 47P scoring Cardiac Events™’ |. Score sinus tachycardia during sleep for a sustained sinus heart rate of greater than 90 beats per minute for adults. . Score bradycardia during sleep for a sustained heart rate of less than 40/minute for ages 6 years through adult.®* RECOMMENDED . Score asystole for cardiae p: Ises greater than 3 seconds for ages 6 years through adult, RECOMMENDED 4. Score wide ymplex tachycardia for a rhythm lasting a minimum of 3 consecutive beats at a rate greater than 100 per minute with QRS duration of greater than or equal to 120 msec. RECOMMENDED . Score narrow complex tachycardia for a rhythm lasting a minimum of 3 consec per minute with QRS duration of less than 120 msec. RECOMMENDED fe beats ata rate of greater than 100 ‘core atrial fibrillation if there are irregularly irregular QRS complexes associated with replacement of consistent P waves by rapid oscillations that vary in size, shape, and timing. REcowMENDED Note 1 ignificant arthythmias such as heart block should be reported if the quality of the single lead is sufficient for accurate scoring, Note 2, Ectopic beats should be reported if felt to be clinically significant. Note 3. Sinus rates vary according to age in children, with faster rates in young children as compared to adults. For typical sinus rates in children, refer to the Cardiac Task Force review paper! Note 4, Sustained sinus bradycardia or tachycardia is defined by more than 30 seconds ofa stable rhythm to distinguish it from transient responses, associated sleep disordered breathing events or arousals, Reference 1. Caples SM, Rosen CL, Shen WK, ct al. The scoring of cardiac events during sleep. J Clin Sleep Med. 2007;3(2):147-1S4,wT Movement Rules A. Technical Specifications” 1. For monitoring leg movements (LMs), surface electrodes should be placed longitudinally and symmetri ‘middle of the anterior tibialis muscle so that they are 2~3 cm apart or 1/3 of the length of the anterior tibialis muscle, whichever is shorter. Both legs should be monitored for the presence of the leg movements. Separate channels for ‘each leg are strongly preferred. Combining electrodes from the 2 legs to give I recorded channel may suffice for some I settings, although it should be recognized that this strategy may reduce the number of detected LMs. (sce Figure 1) RECOMMENDED Figure 1. Placement of electrodes on the Anterior tibial muscle for monitoring leg movements. istration may not be to scale. 122020 Armerican Acedemyo Stnp Meine. Alright reverse 2. For monitoring leg movements, use of 60 Hz (notch) filters should be avoided. Impedances need to be less than 10,000 £2. Less than 5,000 is preferred but may be difficult to obtain. REcoumeNDeD 3. Movements of the upper limbs may be sampled using a similar method as for legs if clinically indicated. (sce Figures 2 and 3) OPTIONAL Figure 2. Placement of tlectrades on the flexor digitorum supericialis for detecting transient muscle activity in REM seep. stration may not be to scale (02020 American Academy of Step Melcne. Allright ereried. fal Version 2.6 49Figure 3. Placement of electrades on the extensor digitorum communis fr detecting transient ‘muscle activity in REM sleep. lustration may not be to scale, 4. For detecting bruxism, in addition to the recommended placement of chin EMG electrodes as noted in the adult sleep staging rules chapter (IV.C), additional masseter electrodes may be placed if clinically indicated.” Gee Figure 4) opmionat Figure 4. Placernent of electrades on the masseter muscie for detecting bruxism, Iustration may not be toscale, it muscle activity in REM sleep, use one of the following EMG recordings: oPTionAL 4, Flexor digitorum superficialis (sce Figure 2) », Extensor digitorum communis (See Figure 3) 6. For diagnosis of RBD, time-synchronized, audio-equipped video PSG is essential to document complex motor ations during REM sleep. A diagnosis of RBD is based on demonstration of such episodes or a characteristic clinical history of dream enactment in addition to polysomnographic evidence of REM sleep without atonia, RECOMMENDED 7. For monitoring rhythmic movement disorder (RMD), bipolar surface electrodes should be placed to record electrical activity of the large muscle groups involved.” (see Figure 5) oPTionat 8, For diagnosis of RMD, time-synchronized video PSG is necessary to accurately chat to polysomnographic criteria, RECOMMENDED wterize the disorder, in additionFigure 5. Placement of slectrodes on the neck paraspinal muscies for monitoring ehythmic movement disorder. Mustration may not be toscale, Note 1. For accurate electrode placement, the patient should be asked to activate the muscle so that the muscle can be ‘more readily felt. The following are the actions to activate various muscles: + Anterior tibialis: patient should raise foot toward their head or flex their foot up + Flexor digitorm superficialis: patient should bend only at the base of their fingers (avoid bending at the distal two joints) + Extensor digitorum communis: patient should extend their fingers back without moving their wrist + Masseter: patient should bite down, Note 2. Iftwo electrodes are used (see Figure 4), they should be 2-3 cm apart. A single masseter electrode may be used using a chin EMG electrode as the reference. Note 3. Surface electrodes should be placed 2-3 cm apart, B. Scoring Periodic Limb Movements in Sleep (PLMS) 1. The following define a significant leg movement (LM) event: ®! | RECOMMENDED ‘The minimum duration of a LM event is 0.5 seconds, b. The maximum duration of a LM event is 10 seconds. . The minimum amplitude of a LM event is an 8 yV increase in EMG voltage above resting EMG (duration of at least 0.5 secones). 4. The timing of the onset of'a LM event is defined as the point at which there is an 8 pV increase in EMG voltage above resting EMG. The timing of th EMG does not exe ending of a LM event is defined as the start of a period lasting at least 0.5 seconds during which the 1d 2 pV above resting EMG. 2. The following define a PLM series: RECOMMENDED | a, The minimum number of consecutive LM events needed to define a PLM series is 4 LMs, ». The period length between LMS (defined as the time between onsets of consecutive LMs) to include them as part of a PLM. series is 5 to 90 seconds, , Leg movements on 2 different legs separated by less than 5 seconds between movement onsets are counted as a single leg movement. The period length to the next LM following this group of LMs is measured from the onset of the first LM to the onset of the next. (see Figure 6)Peis enath Figure 6. Tho frst two LMS are counted as one ae leg movement since the time from onset to onset od ‘of the LMs in the left anterior tibial EMG channel 3. An arousal and a limb movement that occur in a PLM series should be considered associated with each other if they ‘occur simultaneously, overlap, or when there is <0.5 seconds between the end of one event and the onset of the other event regardless of which is first. (See Figure 7) RECOMMEWED Epoch : 53 ee a cna | $9 A ' a o2mt LL ‘A cant a pan t exual/, Chin MG, hin Ewe rar! tor oS ar aoa “a ure t : Lar - ° 30 $0 ° 30 %0 Epoch st wean | 7 ‘a ; aM aa a oes A ng enn —$wt_ yj ; ip ell conte —\_— nih hin ve ar bat a ut — ~ ~ ~ — + 5 os 7 se 0 Figure 7. An arousal and LM occuring in a PLM series are considered tobe associate i they occur simultaneously (epochs 50 and Si), overlap (epochs 52 and 53) orf the time trom the end af one event to the start ofthe next i ass than 0.5 seconds, regardless which event comes first epoch 54), 52 hn LM should not be scored if it occurs during a period from 0.5 seconds preceding an apnea, hypopnea, or RERA to .5 seconds following the event. RECOMMENDED 5. When a period of wake <90 seconds separates a series of LMs, this does not prevent LMs preceding the period of wake {from being included with the subsequent LMs as part of a PLM series. (see Figure 8) RECOMMENDED — ti | Figure 8. Five Las are depicted |The fourth occurs in an epoch of wake | and cannot be counted a a PLM in | sloep. However, the other 4 LMs would | be included in the same PLM series. ‘lage N2 ‘StageN2 ‘Stage Ww Stage Nt Note | Note 2 Rule Le, defines a significant leg movement event by an absolute inerease of 8 pV above resting baseline for the anterior tibialis EMG. This requires a stable resting EMG for the relaxed anterior tibialis whose absolute signal should be no greater than +10 pV between negative and positive deflection (+5 wV) or +5 pV for rectified signals. When periodic limb movements occur with an interval of less than 10 seconds and each is associated with a> 3 second change in the EEGichin EMG meeting criteria for an arousal, only the first EEG/chin EMG change should be scored as an arousal (assuming its preceded by at least 10 seconds of sleep). Both limb ‘movements may be scored, assuming the onsets are separated by 5 seconds or more, but only one PLM associated with an arousal (and only one arousal) would be scored, C. Scoring Alternating Leg Muscle Activation (ALMA) 1. The following define ALMA: a. The minimum number of discrete and alternating EMG bursts of leg muscle activity events needed to score an ALMA series is 4 ALMAs. b. The minimum frequency of the alternating EMG bursts in ALMA is 0.5 Hz. «, The maximum frequency of the alternating EMG bursts in ALMA is 3.0 Hz. Note 1 Note 2 Note 3 ALMAS alternate between legs. ‘The usual range for duration of ALMA is 100-S00 msec: ALMA may simply be a benign movement phenomenon associated with characteristic EMG patterns as there have been no reported clinical consequences.PScoring Hypnagogic Foot Tremor (HFT) 1. The following define HFT:"'? oPnIONAL 4, The minimum number of EMG bursts needed to make a train of bursts in a HFT series is 4 HFT bursts. », The minimum frequency of the EMG bursts in a HFT is 0.3 Hz. . The maximum frequency of the EMG bursts in a HFT is 4.0 Hz, Note 1. ‘The usual range for duration of hypnagogic foot tremor is 250-1,000 msec. Note 2, HFT may simply be a benign movement phenomenon associated with characteristic EMG patterns as the hhave been no reported clinical consequences. Scoring Excessive Fragmentary Myoclonus (EFM) 1. The following define EFM: °° ononAL ‘The usual maximum EMG burst duration seen in fragmentary myoclonus is 150 msee. », Atleast 20 minutes of NREM sleep with EFM must be recorded. . At least 5 EMG potentials per minute must be recorded Note I. EFM may be a benign movement phenomenon associated with a characteristic EMG pattern as there have been no reported clinical consequences. Note 2. In many cases no visible movements are present. Gross, erk-like movements across the joint spaces are not observed. When minor movement across a joint space is present, the movement resembles the small twitch- like movements of the fingers, toes, and the corner of the mouth intermittently seen in REM sleep in normal individuals. Note 3. In some eases when visible movement is present, the EMG burst duration may be >150 msec, F. Scoring Bruxism 1. The following define bruxism:*!°* RECOMMENDED 4, Bruxism may consist of brief (phasic) or sustained (tonic) elevations of chin EMG activity that are at least twice the amplitude of background EMG. », Brief elevations of chin or masseter EMG activity are scored as bruxism if they are 0,25-2 seconds in duration and if at Teast 3 such elevations occur in a regular sequence, «. Sustained elevations of chin or masseter EMG activity are scored as bruxism if the duration is more than 2 seconds, 4A period of atleast 3 seconds of stable background chin EMG must occur before a new episode of bruxism can be scored. ¢. Bruxism can be scored reliably by audio in combination with polysomnography by a minimum of 2 audible tooth grinding episodesinight of polysomnography in the absence of epilepsy. Note I. In sleep, jaw contraction frequently occurs, This contraction can take 2 forms: (a) sustained (tonic) jaw clenching contractions or (b) a series of repetitive brief (phasic) muscle contractions termed rhythmic masticatory muscle activity (RMMA). Note 2. Characteristic changes in masseter EMG are often more prominent than changes in the chin EMG.MScoring REM Without Atonia (RWA) Scoring RWA is optional as noted in Parameters to be Reported (ILE). 1. If electing to score RWA, score in accordance with the following definitions ™: RECOMMENDED Excessive sustained muscle activity (tonic activity) in REM: An epoch of stage R with atleast 50% of the duration of the epoch having a chin EMG amplitude at least two times greater than the stage R atonia level (or lowest amplitude in NREM, if'no stage R atonia is present). Multiple segments may contribute to the total duration, but each segment must be greater than 5 seconds, Excessive transient muscle activity (phasic activity) in REM ™: In @ 30-second epoch of stage R divided into 10 sequential 3-second mini-epocks, at least 5 (50%) of the mini-epochs contain bursts of transient muscle activity in the chin or limb EMG. In RWA, excessive transient muscle activity bursts are 0.1-S.0 seconds in duration and at least two times as high in amplitude as the stage R atonia level (or lowest amplitude in NREM, if no stage R atonia is present) Any chin EMG act amplitude in NRI to 15 seconds). %%: Activity with a minimum amplitude two times greater than the stage R atonia level (or lowest 'M, ino stage R atonia is present) without regard to the duration of the activity (including bursts of $ 2. Ifelecting to score RWA, score an epoch as exhibiting RWA when one of the following is present:®!°2:S6°° a. Excessive sustained muscle activity in REM in the chin EMG (as defined in rule V.G.1) RECOMMENDED b. Excessive transient muscle activity during REM in the chin or limb EMG (as defined in rule V.G.1) RECOMMENDED ¢. At least $0% of 3 second mini-epochs contain any chin activity (as defined in rule V.G.1) or limb EMG activity (bursts of EMG activity 0.1-S.0 seconds in duration and at least two times as high in amplitude as the stage R atonia level or lowest amplitude in NREM, if no stage R atonia is present). Accxptaste 3. Ifelecting to score RWA, score the RWA index as the % of stage R epochs that meet in rule V.G.2.° options Note I. The definitions of sustained and transient muscle activity are based on duration rather than morphology. Although transient activity i often composed of intermittent brief bursts, activity with relatively constant amplitude that otherwise meets criteria VILG.2 qualifies as transient activity Note 2. Ifa periodic limb movement (PLM) is scored as part of a PLM series, it should not be counted in determining if an epoch has RWA. Note 3. Based on SINBAR (Sleep Innsbruck Barcelona) Group recommended criteria! Note 4, Epochs containing RWA with sustained chin activity as defined above may not meet criteria for stage R but in these eases, the epoch can still be scored as stage R if other criteria for stage R are met or if the epoch is, contiguous with an epoch scored as stage R. Note 5. Ifelecting to measure RWA, the leads used to determine the presence of RWA should be included in the PSG report (¢g., chin, chin and lower limbs, chin and upper limbs). Reference 1. Frauscher B; Iranzo A; Gaig C; Gschliesser V; Guaita M; Raifelseder V; Ehrmann L; Sola N; Salamero M; Tolosa E; Poewe W; Santamaria J; Hogl B; SINBAR (Sleep Innsbruck Barcelona) Group. Normative EMG values during REM sleep for the diagnosis of REM sleep behavior disorder, SLEEP 2012;35(6):835-847, H. Scoring the PSG Features of Rhythmic Movement Disorder 1. The following define the polysomnographic characteristics of rhythmic movement disorder: RECOMMENDED 1, The minimum frequency for scoring rhythmic movements is 0.5 Hz. b. The maximum frequency for scoring rhythmic movements is 2.0 Hz. ¢. The minimum number of individual movements required to make a cluster of rhythmic movements is 4 movements 4. The minimum amplitude of an individual rhythmic burst is 2 times the background EMG activity.eS. Respiratory Rules Part 1: Rules for Adults A. Technical Specifications 1 For identification of an apnea during a diagnostic study, use an oronasal thermal airflow sensor to monitor airflow.®' RECOMMENDED 2. For identification of an apnea during a diagnostic study when the oronasal thermal airflow sensor is not functioning or the signal is not reliable, use one of the following (alternative apnea sensors) ‘a, nasal pressure transducer (with or without square root transformation) RECOMMENDED b. Respiratory inductance plethysmography sum (RIPsum) (calibrated or uncalibrated) RECOMMENDED . Respiratory inductance plethysmography flow (RIPflow) (calibrated or uncalibrated) RECOMMENDED RECOMMENDED 4, For identification of a hypopnea during a diagnostic study when the nasal pressure transducer is not functioning or the signal is not reliable, use one of the following (alternative hypopnea sensors): »” a, oronasal thermal airflow RECOMMENDED , RiPsum (calibrated or uncalibrated) RECOMMENDED ¢. RIPfow (calibrated or uncalibrated) RECOMMENDED dual thoracoabdominal RIP belts (calibrated or uncalibrated) RECOMMENDED e.PVDEsum ACCEPTABLE ‘5. During positive airway pressure (PAP) titration, use the PAP device flow signal to identify apneas or hhypopneas. | RECOMMENDED 6. For monitoring respiratory effort, use one of the following: ‘a, esophageal manometry RECOMMENDED ». dual thoracoabdominal RIP belts calibrated or uncalibrated)™’ RECOMMENDED cc. dual thoracoabdominal PVDF belts ACCEPTABLE 7. For monitoring oxygen saturation, use pulse oximetry with a maximum acceptable signal aver: ata heart rate of 80 beats per minute, RECOMMENDED ng time of <3 seconds 8. For monitoring snoring, use an acoustic sensor (e.g., microphone), piezoelectric sensor or nasal pressure transducer.®* RECOMMENDED 9. For detection of hypoventilation during a diagnostic study, use arterial PCOp, transcutaneous PCO; or end-tidal PCOz.*°*” RECOMMENDED 10, For detection of hypoventilation during PAP titrati PCOz, oF use transcutaneous PCOz.™*" RECOMMENDED 56Note 1. Thermal sensors include thermistors, thermocouples, or poly vinylidene fluoride (PVDF) airflow sensors. Note 2. The RIPsum is the sum ofthe signals from thoracic and abdominal RIP sensors (belts) and excursions in the signal are an estimate of tidal volume. The RIPflow is the time derivative of the RIPsum and excursions in the signal are an estimate of airflow. The PVDFsum is the sum of signals from thoracic and abdominal PVDF sensors (belts). Recording of RIPsum, RIPAow, or PVDFsum is optional Note 3. Using the nasal pressure signal without square root transformation for scoring hypopneas will result in a slightly higher hypopnea index than scoring using a square root transformation of the signal. This difference is not clinically significant in most patients Note 4, A surface diaphragmatic/intercostal EMG signal may be used for detection of respiratory effort during apnea, hypopnea, or RERA events to complement effort belt signals when unambiguous inspiratory EMG bursts are visible during normal breathing, Various electrode placements have been used in the published literature. Some of the placements are illustrated in Figure 1. If one electrode placement does not yield a good signal, others may be tried. Some placements utilize an electrode above and another below a rib while others place both electrodes in the same intercostal space. Positions at the mid-clavicular, anterior axillary, and mid-axillary lines have been used. The 6th, 7th, or 8th intercostal space is commonly used but slightly higher or lower may result in a better signal in some patients, While low and high filter settings recommended for recording of the anterior tibial EMG can be used (low 10 Hz, high 100 Hz), ECG artifact will be reduced if a low filter setting of 25 1 40 Hzis used. Some polysomnography programs have an option for removal of ECG artifact from EMG signals. Figure 1. Several options for placement of electrodes (1.2.84) for recording the surface daphragmatic/chest wall EMG are shown, AAL is ‘the anterior axilary ine, MCL the mid-ctavicular line, Some sleep centers use electrades above and below a ib and others use twa eectrodae in the same intercostal space Note 5, Monitoring snoring is optional as noted in Parameters to be Reported (LF). Note 6. Monitoring hypoventilation is optional as noted in Parameters to be Reported (ILF), Note 7. a. . Clinical judgment is essential when assessing the accuracy of end-tidal PCO2 and transcutaneous PCO2 readings. The values should not be assumed to be accurate surrogates of the arterial PCO2 when the values do not fit the clinical picture. ». The transcutaneous PCO> sensor should be calibrated with a reference gas according to the manufacturer's recommendations and when the accuracy of the reading is doubtful. Of note, the value of the transcutaneous PCO typically lags behind changes in the arterial PCO2 by two minutes or more. «. The end-tidal PCO: often malfunctions or provides falsely low values in patients who have marked nasal obstruction, profuse nasal secretions, are obligate mouth breathers, or who are receiving supplemental ‘oxygen Iti crucial to obtain a plateau in the end-tidal waveform for the signal to be considered valid ‘ ‘SM Scoring Manual Version