SLEEP STUDY: WHAT'S IT ALL ABOUT - RLS · PDF fileSLEEP STUDY: WHAT'S IT ALL ABOUT BRIAN KOO, ... REM Sleep Rapid Mixed freq Low amplitude ... Severe Obstructive Sleep Apnea Syndrome:

SLEEP STUDY: WHAT'S IT ALL ABOUT

BRIAN KOO, M.D.Ass is tan t Profes sor of Neurology

Yale Sc hool of Medic ineDirec tor, S leep Medic ine Program at

Connec ticu t Veterans Af fair s Healthcare

OUTLINE

Polysomnography What Is It? How Do I prepare for it? Why Would My Doctor Order it?/Why Might I need a sleep study? How is a sleep study interpreted?

What Happens Next?

WHAT YOU MIGHT LOOK LIKE

POLYSOMNOGRAPHIC RECORDING

Electroencephography (EEG): Sleep potentials mostly central

Electrooculography (EOG): Cornea: (+) charge; Retina: (-)charge

Electromyography (EMG): Chin muscle tone

SLEEP STUDY: LOGISTICS

Get there at 8-9PM.

Education about sleep disorder, mostly sleep apnea

Maybe fit for a mask if it is needed later

Sleep studies lasts from about 10-11PM until 5-6AM

Hook-up will take 30 minutes

Some paste on the scalp for EEG

Other electrodes placed with sticky sensors

It is not painful

30 SECOND EPOCH

STAGES OF SLEEPState Eye

MovementsEEG Chin EMG

RestingWakefulness

RapidFrequent

Mixed freqα: 8-12 Hz

High

Stage 1 (N1) Slow rolling θ Low

Stage 2 (N2) Infrequent θ, δ Low

Stage (N3) Infrequent δ Low

REM Sleep Rapid Mixed freq Low amplitude

Atonia

–Stage 1 –Stage 2 –SWS–REM

2-5%45-55%15-20%20-25%

STAGES OF SLEEPn Resting wakefulness

n EEG: α 8-12 Hz ■ Few eye movemenn Best seen eyes closed ■ High chin EMG

FALLING ASLEEP

STAGE 1 NREM SLEEP

STAGE 2 NREM SLEEP

STAGE 3 NREM SLEEP

REM SLEEP

HYPNOGRAM

14

� Technician or fellow stages each epoch of sleep

Breathing

15

NORMAL BREATHING

HOW DO I PREPARE FOR IT

Bring yourself on time

Do not drink alcohol that day or night

Do not drink caffeine after 12PM

Do not take a nap

If you take a sleeping medication, it is OK to take it unless your doctor tells you otherwise

If you wear a mouthpiece for bruxism, wear it unless your doctor tells you otherwise

WHY DID MY DOCTOR ORDER ONE?

By far the most common indication for a sleep study is to determine if there is sleep apnea.

OBSTRUCTIVE SLEEP APNEARepetitive decreases / cessations in breathing associated with loud snoring, witnessed apneas, waking up choking/gasping and excessive daytime sleepiness

OBSTRUCTIVE APNEAObstructive apnea: cessation in breathing ≥ 10 seconds with continued breathing effort often assoc with ≥ 3% O2 desaturation or arousal; 90% reduction in thermistor signal Obstructive Apnea

HYPOPNEAHypopnea: decrement of breathing by ≥ 30% (nasal pressure) for at least 10 seconds MUST BE assoc with ≥ 3% O2 desaturation arousal Hypopnea

CENTRAL SLEEP APNEARepetitive cessations in breathing and effort often but not necessarily associated with ≥ 3% O2 desaturation or arousal

Mild snoring

Witnessed apnea

Waking up gasping for air

Mild daytime sleepiness

SEVERE APNEA

SLEEP APNEA SEVERITY

Apnea-hypopnea index (AHI) = (apneas + hypopneas)

Mild: between 5 and 15 Moderate: between 15 and 30 Severe: Greater than 30

AHI does not distinguish obstructive vs. central

Distinction must be made in physician interpretation

Sleep (hrs)

OBSTRUCTIVE SLEEP APNEA

•AHI ≈ 90 ¡ Severe desaturation (60s)

•Sleep fragmentation

OTHER INDICATIONS

REM sleep behavior disorder Acting out dreams Often injury to self or bed partner

Parasomnia Sleep walking, night terror

Seizure May do full montage EEG

THESE ARE NOT INDICATIONS

Insomnia

RLS: RLS diagnosis is made in the office by history

Sleep study can be done in those with insomnia or RLS if sleep apnea or parasomnia is suspected.

OTHER THINGS THAT CAN BE SEEN IN PSG

Some things that are recorded on PSG Trying to see if these exist are not necessarily indications for a sleep study

PERIODIC LIMB MOVEMENTS DURING SLEEP

INDIVIDUAL LEG MOVEMENTS

Individual limb movementsDorsiflexion of foot (anterior tibialis)Dorsiflexion great toe and extension of toesFlexion at kneeFlexion at hipDuration between 0.5 and 5 seconds

PERIODIC LIMB MOVEMENTSPeriodic limb movements during sleep (PLMS)Series of at least four individual leg movements in successionNo less than 5sec and no more than 90 sec apart

QUANTIFICATION OF PLMS Periodic limb movement index (PLMI): total number of

periodic limb movements per hour of sleep

PLMI: anywhere between 0 and 150 More typically PLMI between 30 and 60

PLM arousal index (PLMAI): total number of PLMS followed by EEG arousal per hour of sleep; PLMAI > 5

Polysomnography Report

Patient: DOB:

Gender: Male BMI: 42.2

Study Date:

Referring physician: JOHN Smith M.D.

Indications: Referred to rule out Sleep Apnea.

Symptoms: snoring, sleepiness

Epworth sleepiness scale: NA

Co-morbidities: HTN, DM

Diagnosis: Obstructive Sleep Apnea 327.23

*****************************************************************************

IMPRESSION:

1. Severe Obstructive Sleep Apnea Syndrome: The patient has an overall Apnea

Hypopnea Index (AHI) of 32.5/hr. on this study as well as severe oxygen

desaturation.

2. Hypoxemia: The patient was saturating 80-84% without oxygen. While on 2 lpm

oxygen, saturations were for the most part above 90%. Sleep apnea did continue

even on oxygen.

RECOMMENDATIONS:

In lab CPAP titration given hypoxemia

SUMMARY OF DATA:

SLEEP ARCHITECTURE:

Polysomnography was performed on the night of 7/11/2015 from 22:45:17 until

05:41:48. The Time-in-Bed, Sleep-Period Time, Total-Sleep Time, and Sleep

Efficiency (TST/TIB) were 423.6 minutes, 407.0 minutes, 324.5 minutes, and

77.9%, respectively. The sleep latency and stage N2 latency were 9.5 and 0.5

minutes, respectively. REM latency was 171.0 minutes. The sleep architecture

was as follows:

Minutes % TST

Wake Time after Sleep Onset: 82

Stage N1: 34 10

Stage N2: 191 59

Stage N3: 50 15

REM: 48 14

Sleep efficiency TST/TIB: 77.9%

AROUSALS:

There were a total of 79 arousals with an arousal index of 14.6/hr. Of those,

31 were respiratory related, 9 were PLM related and 39 were spontaneous.

RESPIRATORY:

The Apnea-Hypopnea Index through the night was 34.4/hr. The REM AHI was 37.5.

The supine AHI was 61.3.

Number Index (p/hr. sleep)

Obstructive Apneas: 10 1.8

Central Apneas: 0 0.0

Mixed Apneas: 0 0.0

Hypopneas: 174 30.7

Central Hypopneas: 0 0.0

Apnea-Hypopnea (AHI) 32.5

OXYGENATION:

With the patient awake and breathing ambient air, the average arterial oxygen

saturation was 90 % and during sleep the average arterial oxygen saturation

was 91 % with a nadir arterial oxygen saturation of 0 %. Time spent below 90%

oxygen saturation was 179.8 minutes and 55.4 % of total sleep time. The

oxygen desaturation index (4%) was 8.9. The oxygen desaturation index (3%)

was 16.3.

CARDIAC:

The mean heart rate was 84 bpm.

Cardiac arrhythmias:

Bradycardia: No

Sinus Tachycardia: No

Wide Complex Tachycardia: No

Narrow Complex Tachycardia: No

Asystole: No

Atrial Fibrillation: No

Other arrhythmias: Occasional PVCs noted

MOVEMENT EVENTS:

There were 239 periodic limb movements during sleep for a periodic limb

movement index (PLMI) of 44.2/hr. There were 9 periodic limb movements during

sleep associated with arousal for a periodic limb movement arousal index

(PLMAI) of 1.7.

WHAT’S NEXT

If you do have sleep apnea Continuous positive airway pressure therapy

WHAT’S NEXT

If you do have sleep apnea Oral appliance therapy

WHAT’S NEXT

If you don’t have sleep apnea

Depends on symptoms that you do have You are sleepy You could have another sleep disorder Should see an experienced sleep physician

You snore loudly Oral appliance Sleep on your side

Q & A

3006 Bee Caves Rd. | Suite D206 | Austin, TX 78746 | 512.366.9109 [email protected]

SLEEP STUDY: WHAT’S IT ALL ABOUTBRIAN KOO, M.D.

SLEEP STUDY: WHAT'S IT ALL ABOUT - RLS · PDF fileSLEEP STUDY: WHAT'S IT ALL ABOUT BRIAN KOO, ... REM Sleep Rapid Mixed freq Low amplitude ... Severe Obstructive Sleep Apnea Syndrome:

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