Arousal

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Arousal

• Rules

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Arousal Rule

• Scoring Arousals
• Score arousal during sleep stages N1, 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 last 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.

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Arousal Rule 1

• Subjects must be asleep, defined as gt10
  continuous seconds of the indication of any stage
  of sleep, before an EEG arousal can be scored.

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Arousal Rule 2

• A minimum of 10 continuous seconds of intervening
  sleep is necessary to score a second arousal.

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Arousal Rule 3

• The EEG shift must be 3 seconds or greater in
  duration to be scored as an arousal.

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Arousal Rule 4

• Arousals in NREM sleep may occur without
  concurrent increases in submental EMG amplitude

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Arousal Rule 5

• Arousals are scored in REM sleep only when
  accompanied by concurrent increases in submental
  EMG amplitude.
• Scoring of an arousal during REM required a
• Concurrent increase in submental EMG lasting at
  least 1 second

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Arousal Rule 6

• Arousals cannot be scored based on changes in
  submental EMG amplitude alone.

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Arousal Rule 7

• Artifacts, K complexes or Delta waves are not
  scored as arousals unless accompanied by an EEG
  frequency shift in at least one derivation
• For an arousal to be associated with a K
• complex, it must commence no more than 1
• second after termination of the K complex

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Arousal Rule 8

• The occurrence of pen blocking artifact should be
  considered an arousal only if as EEG arousal
  pattern is contiguous
• The Pen blocking event can be included in
• reaching duration criteria

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Arousal Rule 9

• Non-current, but contiguous EEG and EMG changes,
  which were individually less than 3 seconds but
  together greater than 3 seconds in duration are
  not scored as arousals.

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Arousal Rule 10

• Intrusion of alpha activity of less than 3
• seconds duration into NREM sleep at a rate
• greater than 1 burst per 10 seconds is not
  scored as an EEG arousal.
• Three seconds of alpha sleep is not scored as an
• arousal unless a 10 second episode of alpha-free
• sleep precedes.

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Arousal Rule 11

• Transitions from one stage of sleep to another
  are not sufficient of themselves to be scored as
  EEG arousals unless they meet the criteria above.
  

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Going With the Flow

• New Trends in PSG Sensors

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the sensor used to detect the absence of
airflowfor identification of apnea is an
oronasal thermal sensor

Thermocouple
Thermistor
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• the sensor used to detect the flow reduction for
  the purpose of identifying hypopneas is the nasal
  air pressure transducer.

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• The sensor for detection of respiratory effort is
  either calibrated or uncalibrated inductance
  plethysmography

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Event Scoring

• Respiratory Rules for Adults

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Scoring Apneas ( recommended)

• Score an apnea when all of the following criteria
  are met
• There is a drop gt 90 drop in the thermistor
  from of baseline
• The duration of the event last at least 10
  seconds
• At least 90 of the events duration meets the
  amplitude reduction criteria for apnea
• Identification of an apnea does not require a
  minimum desaturation criteria.

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Apnea Classification ( recommended)

• Classify an apnea in an adult based upon
  inspiratory effort
• Score a respiratory event as an Obstructive apnea
  if it meets criteria and is associated with
  continued or increased inspiratory effort
  throughout the entire period of absent airflow.

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• 2) Score a respiratory event as a central apnea
  if it meets apnea criteria and is associated
  with absent inspiratory effort throughout the
  entire period of absent airflow.

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• Score a respiratory events as mixed apnea if it
  meets the apnea criteria and is associated with
  absent inspiratory effort in the initial potion
  of the event, followed by resumption of
  inspiratory effort in the second portion of the
  event

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Hypopnea Rules (recommended)

• Score a hypopnea if all of the following criteria
  are met
• The Nasal pressure signal ( or those of the
  alternative hypopnea sensor) drop by gt30 of the
  baseline
• The duration of this drop occurs for a period
  lasting at least 10 seconds
• There is a gt 4 desaturation from pre-event
  baseline
• At least 90 of the event's duration must meet
  the amplitude reduction of criteria for a
  hypopnea

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Respiratory Effort Related Arousal Rule
(optional)

• If there is a sequence of breaths
• lasting 10 seconds characterized
• by increasing respiratory effort or
• flattening of the nasal pressure
• waveform leading to an arousal
• From sleep when the sequence of
• breaths does not meet criteria for
• an apnea or hypopnea

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Hypoventilation Rule

• Hypoventilation during sleep as present if there
  is a gt 10 mmHg increase
• in PaC02 ( End tidal CO2 or transcutanous) during
  seep in comparison to an awake supine value.
• Notes
• Persistent oxygen desaturation is not sufficient
  to document hypoventilation.
• An increase PaCO2 value obtained immediately upon
  awakening from sleep is suggestive of sleep
  hypoventilation.

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7. Cheyne Stokes Breathing Rule ( recommended)

• Score Cheyne stokes breathing if there are at
  least 3 consecutive cycles of cyclical crescendo
  and decrescendo change in breathing amplitude and
  at least 1 of the following
• Five or more central apneas or hypopneas per hour
  of sleep
• The cyclic crescendo and decrescendo change in
  breathing amplitude has duration of at least 10
  consecutive minutes.

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Celebrities on CPAP
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Normal Breathing

• Normal breathing appears as a series of
  "sinusoidal" inspiratory waveforms of equal
  deflection.

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Good bye