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The AASM Manuaifor th Scoring o Sleepnd Associated EventsRules Terminology nd Technical Specifications

CO NRAD 10ER, MD SO NIA A NCOLl IsRAEL, P A l DREW L. CH ESSON JR. , MD ANDS T UART F. Q UAN, MD fOR THE A ;\IERICAN A CADEMY Of S LEEP M EDICINE

AMERICAN A CADEMY OF S LEEI' M EDICI , W ESTCIIESTER, IL

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Copyright 2007 American Academy of Sleep Medicine , 1 Westbrook Corporate Center, Suite 920, Westchester, IL60154, U.S.ACopies of the manual are available from the American Academy of Sleep Medicine in the U.S .A.Ali rights reserved. Unless authorized in writing by the S . no portion of this book may be reproduced or usedin a manner inconsistent with the copyright. This applies to unauthorized reproductions in any form, includingcomputer programs .

Correspondence regarding copyright permissions should be directed to the Executive Director, American Academyof Sleep Medicine, 1 Westbrook Corporate Center, Suite 920, Westchester, IL 60154 , U.S.A. Translations to otherlanguages must be authorized by the American Academy of Sleep Medicine, U.S.A.Recommended Citations(Numerical)Iber C.Ancoli-Israel S, Chesson A, and Quan SF for the American Academy of Sleep Medicine. The S Manual forthe Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, 1s1ed. : Westchester,Illinois: American Academy of Sleep Medicine, 2007.

(Alphabetical)Iber C, Ancoli-Israel S, Chesson A, and Quan SF for the American Academy of Sleep Medicine. The S Manual forthe Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, 1 \ ed.: Westchester,Illinois: American Academy of Sleep Medicine, 2007.Library of Congress Control Number: 0-9657220-4-X

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TABLE OF CONTENTS

pagesContributorsandAcknowledgements 6Preface 9

11evelopmentProcess

Scoring anual

1. Key 15II. ParameterstoBeReportedforPolysomnography 17III. Technicaland Digital Specifications 19IV. Visual Rules 23

Visual Rules forAdults 23VisualRulesforChildren 32

V. Arousal Rule 37VI. CardiacRules 39VII. MovementRules 41VIII. RespiratoryRules 45

RespiratoryRules forAdults 45RespiratoryRules for Children 48

IX. ProceduralNotes 51X. GlossaryofTerms 59

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ContributorsEditor, Conrad IberSteering Committee: Conrad Iber, Chair

Sonia Ancoli-Israel , Andrew L. Chesson Jr., Stuart F. QuanTask Forces:

Arousal Ronald D. Chervin, MD, MS Rochester, MNMichael H. Bonn et, PhD , Chair University of Michigan, Ann Arbor, MI Carol L. Rosen , MDWright State University, Dayton, OH Meir Kryger, MD Rainbow Babies & Children 's Hospital,Karl Doghramji, MD University of Manitoba, Winnipeg , MB Cleveland, OHThomas Jefferson University, Phiadelphia, Canada Stephen Sheldon, DO , FAAP,PA Clete A. Kushida, MD , PhD, RPSGT Children 's Memorial Hospital, Chicago, ILTimothy Roehrs, PhD Stanford University, Stanford, CA Stuart F Ouan, MDWayne State University, Detroit, MI Beth A Malow, MD , MS University of Arizona, Tucson, A lSteph en Sheldon, DO , FAAP Vanderbilt University, Nashville , TNChildren 's Memorial Hospital, Chicago, IL Michael H. Silber, MBChB RespiratoryEdward J. Stepansk i, PhD Mayo Clinic College of Medicine, Susan Redlin e, MD, MPH , ChairRush University Medical Center, Chicago, IL Rochester, MN Case Western Reserve University,Arthur S. Wallers, MD Michael V. Vitello , PhD , Cleveland, OHNJ Neuroscience Institute at JFK Medical Univers ity of Washington, Seattle, WA Rohit Budh iraja, MDCenter, Edison, NJ Andrew L. Ches son Jr, MD , LSU Southern Arizona VAHeallhcare System,Merrill S. Wise, MD Heallh Sciences Center in Shreveport, Southern Arizona, Tucson, A lMethodist Healthcare Sleep Disorders Shreveport , LA Dav id Gozal, MDCenter, Memphis , TN University of Louisville, Louisville, KYAndrew L. Chesson Jr, MD Geriatrie Vishesh K. Kapur, MD , MPHLSU Heallh Sciences Center in Sonia An coli-I srael, PhD , Chair University of Washington, Seattle, WAShreveport, Shreveport, LA University of California, San Diego, CA Carol L. Marcus, MB, BChDonald L. Bliwise , PhD Children 's Hospital of Philadelphia,Emory University Medical Scnool, Atlanta, Philadelphia, PASean M. Caples, DO, Cha ir GA Jason H. Mateika , PhDMayo Clinic College of Medicine, Susan Redlin e, MD, MPH Wayne State University and John D.Rocheste r, MN Case Western Reserve University, Dingell VAMedical Center, Detroit, MI

Cardiae

Cleveland, OH Reena Mehra , MD, MSMayo Clinic College of Medicine,Virend K. Somers, MD, PhD, Co-Cha ir Edward Stepanski, PhD Case Western Reserve University,Rochester, MN Rush University Medical Center, Chicago, IL Cleveland, OHMichael V. Vitiello, PhD Sariam Parthasarthy, MDMichael E. Adams, Research AssociateHolston Valley Medical Center, Kingsport, University of Washington, Seattle, WA SAVAHCS and University of Arizona,TN Timothy 1 Morgenthaler, MD Tucson, A lWilliam G. Colts, MD Mayo Clinic College of Medicine , Kingm an Strohl, MDNorthwestern University, Chicago, IL Rochester, MN Case Western Reserve University,Cleveland , OHRainbow Babies & Children's Hospital, Movements Merrill S. Wise , MDCleveland, OH Arthur S. Walters, MD, Chair Methodist Healthcare Sleep Disorders

Thomas Kara , MD

Parvin Doro stkar, MD

JFK Medical Center, Edison, NJ Center, Memphis , TNMayo Clinic College of Medicine, Richard P. Allen , PhD Stuart F Ouan , MDRochester, MN Johns Hopkins University, Baltimore , MD University of rizona, Tucson, A lTimothy 1 Morgenthaler, MD Donald L. Bliw se, PhDMayo Clinic College of Medicine, Emory University Medical Scnoot, Atlanta, VisualRochester, MN GA Michael H. Silber, MBChB, Cha irSudhansu Chokroverty, MD ,FRCP Mayo Clinic College of Medicine,Rainbow Babies & Children 's Hospital,Carol L. Rosen, MD NJ Neuroscience Institute at JFK, Edison, Rochester, MNCleveland, OH NJ Sonia Ancoli-Israel, PhDWayne A. Hening , MD , PhD, University of California, San Diego, CARush University Medical Center, Chicago, UMDNJ - RW Johnson Medical School , Michael H. Bonnet , PhDNew Brunswick, NJ Wright State University, Dayton , OH

Edward J. Stepanski, PhDIL Clete A. Kushida, MD , PhD , RPSGT Sudhansu Chokroverty, MD FRCPWin K. Shen , MD Stanford University, Stanford , CA NJ Neuroscience Institute at JFK MedicalRochester, MNMayo Clinic College of Medicine, Gilles Lavigne, DMD, PhD , FRCD Center, Edison, NJKalyanam Shivkumar, MD Universite de Montreal Sleep Disorder Mad elein e Grigg-Damberger, MDDavid Geffen School of Medicine at UCLA, Laboratory, Sacre Coeur Hospital, University of New Mexico School ofLos Angeles , CA Montreal, QC Canada Medicine, Albuquerque, NM

Daniel Picchielli , MD Max Hirshkowitz , PhDConrad Iber, MD University of Illinois, Urbana, IL Baylor College of Medicine & VAMC,University of Minnesota Medical School, Sonia Ancoli-Israel, PhD Houston, TXMinneapolis, MNHennepin County Medical Center and

University of California , San Diego, CA Sheldon Kapen, MDWayne State Univ. Med. School andDigital Pediatrie VAMC, Detroit, MIMadeleine Grigg-Damberger, MD, Chair Sharon Keenan, PhD, ABSM, RPSGT,University Hospital , Department of University of New Mexico School of REEGTMedicine, Sleep Laboratory, Marburg,

Thomas Penzel, PhD , ChairMedicine, Albuquerque, NM The School for Sleep Medicine, Inc., Palo

Germany David Gozal, MD, Co-Chair Alto, CAMax Hirshkowitz, PhD, Co-Chair University of Louisville , Louisville , KY Meir Kryger, MDBaylor College of Medicine & VAMC, Caro le L. Marcus, MBBCh University of Manitoba, Winnipeg, MBHouston , TX Children 's Hospital of Philadelphia, CanadaPhilad elphia, PA Thomas Penzel, PhDSchool of Clinical Polysomnography, Timothy 1 Morgenthaler, MD University Hospital, Department ofMedford, OR

Nic Butkov, RPSGTMayo Clinic College of Medicine, Medicine, Sleep Laboratory, Marburg,

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GermanyMark Pressman, PhDLankenau and Paoli Hospitals,Wynnewood, PAConrad [ber, MDHennepin County Medical Center andUniversity o Minnesota Medical School,MNConsensus Process ContributorsDig italJohn Harsh, PhDThe University of Southern Mississippi,Hattiesburg, MSovementsCarlos H. Schenck, MDUniversity of Minnesota Medical School,Minneapolis, MNMark W. Mahowald, MDHennepin County Medical Center andUniversity of Minnesota Medical School,Minneapolis, MN

Acknowledgements

PediatrieLaurel Wills, MDMinnesota Regional Sleep DisordersCenter, Minneapolis, MNVisualDonald L. Bliwise, PhDEmory University Medical School, Atlanta,GA

Industry PanelEric StubnaRespironicsGeorge MinasyanRespironicsMarc PaliottaAstroMedLiz KealyCompumedicsRichard Bogan, MDSleepMed, Incorporated

Technical PanelMarietta Bibbs, RPSGTSleep Management Centers LLC, CapeCoral, FLMark DiPhillipo, RPSGTCenter for Sleep Medicine, Lafayette Hill,PAAngela Giacomini, RPSGTStn ord University Center, Stanford, CACameron Harris , RPSGTMayo Clinic College of Medicine,Rochester, MNTerrence Malloy, RPSGTAtlanta School of Sleep Medicine &Technology, Atlan ta, GARawan Nawabit, RPSGTCase Western Reserve University,Cleveland, OHAndrea Patterson , RPSGTHennepin County Medical Center,Minneapolis, MNLinda WebsterMed One MedicalSalt Lake City, UT

The Steering Committee gratefully acknowledges the scoring schemat ics provided by Richard B. Berry that provideillustration of adult visual scoring rules.The Steering Committee acknowledges AASM Leadership that served over the course of this project and prov ideddirection and support : Michael Sateia President 2004-2005; Director 2002-2006), Lawrence Epstein President2005-2006 ; Director 2002-2007), Michael Silber President 2006-2007; Director 2003-2008), Alejandro ChediakPresident-elect 2006-2007 ; Director 2004-2009)ln addition the Steering Committee acknowledges the following Directors : Barbara Phillips 2001-2004), W VaughnMcCa 2001-2004), J. Baldwin Smith III 2002-2004) , Donna Arand 2003-2006) , Richard Berry 2005-2008),David Bruce 2006-2008) , Lee Brown 2006-2009), Nancy Collop 2006-2009), Mary Susan Esther 2004-2007),Clete A. Kushida Secretary/Treasurer 2006-2009; Director 2005-2009), Stephen Sheldon Secretary/Treasurer2003-2006 ; Director 2000-2006), John Shepard 2003-2005), Arthur Spielman 2006-2008), and Patrick Strollo, Jr.2005-2008).

The Steering Committee would like to acknowledge the administrative support of AASM staff : Jennifer Markkanen,Richard Rosenberg, and Maria DeSena . We particularly wish to acknowledge the support and expertise of JeromeA. Barrett, who provided continuous supervisory support of staff throughout the project.

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PREF CE

Sleep that knits up the ravel! d sleave ofcare,The death ofeach day S life, sore labour s bath,

Balm ofhurt minds, great nature ssecond course,Chiefnourisher in life 'sf east.

- Macbeth. Act II, Sc. ii.

ln its simplest and most positive terms, sleep is a desired state of unconsciousness . Each evening wewillingly and most pleasantly surrender ourselves ta a state of disconnection and vulnerability, expectingta be safe, restored, and comforted upon awakening many hours later. It is no small wonder that this stateand ifs unique attributes have long provoked fascination. As the inquisitive science of sleep began tacatalog the unique and varying texture of this state over the past 75 years, standard metrics were needed tacharacterize what could be observed. After many germinal studies and an evolving consensus at the time,standardized methods for characterizing normal sleep were published in 968 by Allan Rechtschaffen andAnthony Kales.Although the utility and durabilityofthe first manual forcharacterizing normalsleep have servedcountlessmillions who have had sleep studies, the advancing science of sleep and the rapidly emerging field of sleepmedicine require a more comprehensive system of standardized metrics that considers events occurringoutside of normal brain activity. Sleep disorders are now recognized as a major public health burden thatmust be addressed in any standardized methodology for characterizing the events and nature of sleep.The explosion of technology and scientltic information has provided many opportunities for evolution in thisprocess of revising the manner in which we measure and catalog ail the attributes of sleep.

ln 2003, the Board of Directors of the American Academy of Sleep Medicine approved the proposeddevelopment of a new scoring manual. The vision of the developmentof a new manual was a very consideredprocess, including a blueprint for future revisions which would address the needs of the ever- changing fieldof sleep. This process, which was initiated in 2004 and is described in the ensuing sections of this menuet,has incorporated both a standardized review of evidence as weil as a standardized method of consensusin oroer to draft rules, specifications, and terminology that may better reflect the current weight of scieniiticevidence and expertise in the field of sleep.

Although the development of the scoring manual has been supervised by a steering committee, itssuccess and execution have hinged on the expertise and dedicated effort of the task force members whohave executedbath the evidence reviewand consensus processes as weil as the committed and outstandingstaff of the American Academy of Sleep Medicine (AASM) who provided invaluable logistical support.

SM Scoring Manual Steering Committee :Conrad Iber, ChairSonia Ancoli-Israel, Andrew L. Chesson, Jr and Stuart F Quan

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DEVELOPMENTPROCESS

HI TORICAL BACKGROUNDThe science of sleep emerged as a discipline as a result

of the development of tools able to detect and record boththe activity of the brain and the physiologie events that occur during this unique and sometimes vulnerable state . Thegerminal reports of methods that were eventually employed tocharacterize electrical activity of sleep include the recordingof brain surface electrical activity in animais in 18753 and thesubsequent demonstration of the ability to detect and characterize wakeful activity in humans with external scalp recordings in 1929.4 Detection and record ing of electrical activityof the human heart had been developing at about the sametimes with identification of cardiac electrical wavefonns byEinthoven in 18956 occurring at nearly the same time as thecharacterization of human brain activity. Although allusionsto abnormal breathing during sleep date to antiquiry? combining breathing and brain monitoring in physiologie recordingsto identify pathologie conditions during sJeep evolved in themid-twentieth century. Respiratory recordings at this timeidentified periodic interruptions in breathing effort that wereboth obstructive and non-obstructive. Sleep recordings weretermed polysomnography to recognize the multiple physiologic paramete rs that were being recorded during sleep. Additional parameters were added when limb myoclonus wasdescribed in 1953 1 and identification of its polysomnographiccorrela tes were folded into the emerging image of normaland abnormal physiologie activity during sleep.

In 1937 , scalp brain recordings during polysornnographyinitially focused on visually identifiable patterns of brainactivity during NREM sleep. Continuous periods of brainwavefonn patterns such as alpha and delta activity, as weil asisolated wavefonns including K complexes, spindles, vertexwaves, and posterior occipital sharp transients were identifiedduring this period. P- Rapid eye movements (REM) associated with respiratory and cardiac effects were identified in1953 by Aserinsky and Kleitman and later more formallyincorporated into the stage of REM sleep.

Although there were several early efforts to characterize thepatterns ofsleep,IJ,'4S6demonstration ofrather poor reliability in scoring these patterns provided the needed rationalefor a standardized scoring manual. After several exploratorymeetings in the early 1960s and Iively consensus meetings inApril 1967, an enduring standardized scoring manual for normal sleep was developed and published under the directionofAllan Rechtschaffen and Anthony Kales.' There have beenseveral subsequent initiatives to develop rules for scoringsleep since 1968 including an effort by the Sleep DisordersAtlas Task Force of the Amer ican Sleep Disorder Associationin 1992 19 and preJiminary studies of automatic methods bythe SIESTA group. The recognition of qualitative differences in sleep in newborns resulted in publication of a separatemanual for this age group in 1971. 21Since the publication ofthe scoring manual by Rechtschaffen and Kales 38 years ago,there has been a rich evolution in our understanding of sleep.

The evolving science of sJeep and the clinical field of sleepmedicine are employing novel metrics to characterize sleep.Developmental changes are recognized that affect the characterization of sleep throughout the lifespan. The nature and importance of sleep-related phenomena such as arousal, cardiacdysrhythmias , respiratory patterns, movements, and behaviorsare now areas of both clinical practice and scientific discovery. A more comprehensive scoring manual has been neededthat would incorporate these evolutionary changes as weil asnewer technical methods and capabilities .

CORING MANUAL DEVELOPMENTThe development ofthis new scoring manu al was designed

to encourage a visible and standardized decision-rnaking process that wou Id broadly represent expertise in the field . Thegoal was to create a manual that reflected current knowledgeand that would provide more comprehensive standardizedspecification s and scoring rules for characterizing naturalsleep as commonly perfonned in polysomnography. Potentialrules that were drafted reflected evidence for reliability andvalidity as assessed by content experts performing structuredevidence review or convening for a standardized consensuswhen evidence was lacking. Visibility of the process and unstructured feedback was encouraged by open discussions atmeetings of the Associated Professional Sleep Societies in2004-2006. Structured feedback on drafted rules was provided by a panel of sleep technologists and a panel of industryexperts prior to finalization by content experts and approval oradjudication by a steering committee . The key for the recommendation tenninology and the tenninology that was used forthe decision-rnaking process may be found in Sect ion I, Key.An outline of the details of the procedural processes in decision-making may be found in the procedura l notes on pages51-57 (Section IX). For the details of the rationale and basesof the decisions, the reader is referred to the review papers ofthe respective task forces published as an issue of the JournalofClinical Sleep Medicine.

The principal participants in the scoring manual development process included a) a supervising steering committee of4 individuals appointed by the AASM Board of Directors, b) 8task forces leaders with content expertise selected by the steering committee, c) 8-12 task force members for each task forcewho were chosen by consensual agreement of the task forceleaders and steering committee and d) the extremely able administrative staff of the AASM . Steering committee membersalso attended task force activities as liaisons to help guide theevidence review and consensus processes. Task forces usedan evidence-based process to do literature searches, grade evidence and create evidence-based tables on their topics , whichsummarized the accumulated evidence. Using this material ,they wrote review papers on the topies of their task force assignments. The evidence review papers were periodically reviewed by the steering committee for format and progress .

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Review papers were sent for independent outside review, andthe reviewers' cornrnents were addressed. Upon completion,review papers were approved by the Scoring Manual SteeringCommittee and subsequently by the AASM Board of Directors.

Following construction of the review papers and based ontheir literature review, task forces identified a list of potential specifications and principles for which rules might be appropriate. Task force leaders, in conjunction with the steering committee, constructed ballots for potential scoring rules,technical specifications, and reporting parameters. Utilizingthe RAND/VCLA Appropriateness Method and the evidence gathered in the review paper process, these considerations were subjected to a formai series of ballots to determinethe soundness of principles upon which to develop final rules .Using the final ballot data , preliminary scoring rules were thendrafted by the steering committee. The task force chairs, andindustry and technical panels reviewed the draft rules to provide comments regarding feasibility and appropriateness. Final modifications were made by the steering committee. Thescoring rules were then reviewed by the AASM Board of Directors who approved the rules following final modificationsby the steering committee.

The task force meetings commenced in July 2004; the final rules, terminology and specifications were drafted in May2006 and approved by the Board of Directors in December2006.

Ali scoring manual committee members completed AASMconftict of interest statements. Steering Committee membersdid not have any Level 1 conflicts of interest with any monitoring deviee that might be affected by the development ofany recommendation. Potential conflicts of task force members were reviewed by the steering committee for decisionregarding inclusion or exclusion of participants in task forceactivities. No approved task force members had Level l conflicts in the scope of their respective tasks.

T SK FORCESSix task forces were developed to review evidence for the

scoring manual. The 6 task forces covered each of the majorareas: visua l scoring, digital seo ring, arousal , movement, respiratory issues, and cardiac issues.

Two additional special population task forces were createdfor pediatries and geriatries. In addition to task force liaisonsfrom each of the other areas, the geriatrie and pediatrie taskforces each included 5 sleep medicine specialists with expertise in the age range under consideration.

Each of the 6 topical task forces was made up of at least 5experts in the specifie content area of sleep medicine, alongwith an advisor who represented expertise in evidence review,and liaisons from the pediatrie and aging task forces and thesteering committee, for a total of 8-13 task force members.Task forces spent 8-20 hours in either phone or face-to-faceconferences over the 18 months of evidence review and consensus activity.

As described above, each task force was charged with theAASM Manualfor Scoring Sleep 2007

task of identifying papers relevant to their topics, reviewingthe papers and extracting evidence information, writing a review paper and, in conjunction with the steering committee,developing a RAND ballot and voting on it.

As evidence papers were identified within the topical taskforces, those portions of the review process that were relevantto either pediatrie or geriatrie populations were assigned tothe appropriate liaison member for consideration and modification . RAND ballots that were constructed by the topicaltask forces were reviewed by the Pediatrie and Geriatrie TaskForces and items were identified for modification and balloting to develop separate age-appropriate scoring rules,

Within pediatries, separate scoring rules were developed inareas of visual scoring, respiratory events, and cardiac events.These differences are outlined within their respective sectionsof the scoring manual.

Within geriatries, the only rule that needed to be votedupon by the Geriatrie Task Force was the question ofwh th ramplitude criteria for SWS should be different in oider adultsthan in younger adults The result of the final vote was thesame in both the Geriatrie Task Force and the Visual TaskForce, and therefore no adjudication was needed.

EVIDENCE REVIEWTask forces were charged with developing review papers

that addressed evidence supporting reliability and validity oftechnical specifications and the related components of scoring in each of 6 content areas: visual, digital , arousaI, respiratory, cardiac, and movements. The specifie details of each taskforce evidence review and search focus can be found in themethods section of the individual review papers.

In ail evidence review papers, a computer-based PubMedliterature search was performed for ail human studies, in English, published between 1968 and September 2004 , using keywords identified by the task forces . For the assignments, therespective task forces selected between 91 and 372 articles asappropriate for formal evidence review. Evidence was thenextracted by task force members under the direction of a taskforce liaison with previous experience in evidence grading.

The criteria for evidence levels generally folJowed Sackett, although in sorne instances appropriate modificationswere made to complement the nature of the content area. lnthe case of digital signal analysis, where sampling methodswere critical to evidence review, comparison of identical epochs or events was mandated, and a minimum sample sizewas required for each level of evidence.

CONSENSUSWhen there was insufficient Level 1 or Level 2 evidence

for clear evidence-based rule development, terminology orspecifications, a consensus process based on considerations inthe appropriate review paper was ernployed. This consensusprocess followed the standardized RANDIUCLA Appropriateness Method. RAND ballots were constructed to formalJy

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assess consensus opinion regarding terminology, technicalspecifications, and the components of scoring rules. The ballots were developed by the task forces and submitted to thesteering committee for approval. In compliance with RANDmethods, 9 to Il partic ipants cornpleted each series of ballots.Task force members and liaisons participated in balloting. Ifless than 9 voting members were available, additional expertswere selected by the steering committee to assist with the balloting process.In order to encourage single recommendations , consensusballots were constructed when possible to address mutuallyexclusive options. In order to encourage a progressive decision-making process, participants were directed, when feltappropriate by the steering committee, to achieve agreementon the validity, reliability and final preference for any of theoptional choices.

At least 2 rounds of consensus were convened for each taskforce : round 1 was completed individually without discussion by task force members, whereas round 2 was completedfollowing a face-to-face or conference cali discussion of theRAND items and the results of the first vote. In 2 task forces,selected items from round 1 were approved by the task forcebecause of agreement during round 1 voting.

For balloting, items were rated on a 9-point scale for appropriateness and a 4- letter rank for specifying a judgment regarding whether the decision was being made on evidence vs.opinion . The classic definition of agreement was assessedusing definitions from the RAND manual :

Agreement for or against: No more than 2 panelists ratethe indication outside the 3-point region (1-3; 4-6; 7-9)containing the median.Disagreement: At least 3 panelists rate the indication inthe 1-3 region, and at least 3 panelists rate it in the 7-9region .Indeterminate: Criteria are not met for agreement or disagreement.

In order to ensure that consensus rested as much as possiblewithin the content expertise of the task force, an additionalround with discussion was employed for initially indeterminate decisions within a series of mutually exclusive options.In instances when there was indeterminate agreement fromthe RAND process after the series of ballots and there wasinsufficient evidence for recommendation from the task forceamong 2 options used in practice, the steering committee adjudica ted a recommended and an alternative acceptable ruIe orspecification. Any items that did not achieve consensus duringround 3 or additional rounds were adjudicated by the steeringcommittee. Only 9 items required adjudication by the steeringcommittee.

Following the decisions regarding standardized rules by thetask forces, the geriatrie and pediatrie task forces reviewedresults of balloting to determine what items required modification or revision for age and pediatrie considerations. Aseparate evidence review was then conducted and a singleround of RAND balloting was completed with interaction toconclude the pediatrie and age modifications for items withlimited evidence.

INDUSTRY ND TECHNIC L REVIEWTechnical and industry panels were constituted for the pur

pose ofobtaining structured input on preliminary rules draftedafter evidence review and consensus. These panels were askedto evaluate the appropriateness of proposed rules and to comment on any perceived impediments to implementation. Technical panels met by conference cali to allow interaction priorto drafting their input. The structured input from the industryand technical panels then were provided to task force leaderswho developed a rationale for either modifying the rule(s) orfor retaining the original language. The structured input frompanels and responses from task force leaders were used by thesteering committee in crafting the final rules and in the finaladjudication when there were substantial differences.

Industry input was also solicited during a face-to-facemeeting with task force chairs, members of the steering committee, and AASM staff on July 16, 2004 . Representativesfrom several software and hardware companies involved inpolysomnography data acquisition or scoring were invited todiscuss and provide materials regarding potential reportingparameters, the current state of digital acquisition of polysomnographic data, and automated scoring. Information exchanged at this meeting was used to focus the assignments ofthe scoring manual task forces .

SLIMM RY ND FUTURE EDITIONSThe reader will find that this edition of the AASM Manual

for the Scoring of Sleep and Associated Events has a com-prehensive scope which incorporates events, technical specifications, pediatrie scoring, as well as modified staging terminology and rules. Arousals, movements, respiratory events,and cardiac events are now folded into the standardized scoring system using both new and existing evidence as weIl asconsensus. The design of decision-making encouraged boththe retention of existing valid and reliable methods when appropriate and the development of new terminology, specifications, and rules when supported. The rules and specificationsin the visual scoring of sleep retain much of the framework ofRechtschaffen and Kales, based on the accumulated validityand reliability of this scoring system, with some new definitions and rule modifications as weil as with new rules for pediatric visual scoring. A visible format is provided for identifying evidence and/or consensus-driven recommendationsas weIl as optional specifications or rules for scoring. Whilerules and definitions are the product of evidence review andconsensus, explanatory notes have been added following eachrule to provide additional clarifications that were not derivedfrom consensus. Readers are referred to the review papers formore detailed analysis of the rationale underpinning the recommendations in the manual.

The expanded choice of analytical tools used in this editionreflects the evidence review and consensus processes. The useof digital interfaces has required extensive specifications thatwere not necessary in the previous standardized scoring manual. The scope and methods characterizing respiratory events

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has been extended from earlier pra ctices to address new evidence. Based on curr ent evidence and consensus, certain areasof active investigation have not been util ized for digital rulesin this edition. Quantitat ive electroencephalography, cyclicaltemating pattern, and methods characterizing autonomieevents have not been incorporated although a process for revision has been created to incorporate techn iques if accumulating ev idence supports their utili ty.Though schematics are used to assist in demonstrating visuaIand respiratory rules, readers will note thar reproductionsof sleep recordings do not accompany the rules . Thi s scoring manual does not incorporate an atlas of visually presentedexamples and emphasizes instead an articulation of rules andspecifications based on a standardized decision-making process and designed to encourage the o bjective basis for implementation of staging and event rul es, The rules are craft ed asa platform to support the evolution of both non-vi sual and vsuaI methods for the future .The science of sleep and the speci alty of sleep med icinehave evolved rap idly since the initial attempts in the 1930sto develop a con sistent frame work to describe the complexity of sleep. Although the first generally accepted scoringmanual by Rechtschaffen and Kales has served the field weil ,the need for modifi cation and additions has been apparentto sleep scientists and clinicians for a number of years. Thisnew scoring manual rep resents an attempt to combine the bestavailable evidence with the op inion of experts in sleep science and medicine. owever, ju st as the field of sleep is nota static doctrine, th is manual is not intended to remain immutable. It is the intenti on of the stee ring committee that thisscoring manual should be reviewed on a periodic basis withadditions, modifi cations, and deletions made based on newscientific data accumulated over interim periods. In this manner, the scoring manual will become a "living" document thatincorporates new information as it becomes available .REFERENCES1. RechtschaffenA, Kales A.A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of HumanSubjects. US Department of Health, Education, and WelfarePublic Health Service - NIH/NIND; 1968.2. lber C. Development of a new manual for characterizing sleep.Sleep 2004;27:190-2.3. Caton R. The electric currents of the brain. Br Med J1875;2:278.4. Berger H. Uber das Elektroenkelphalogramm des Menshcen.Arch Pyschiatr Nervenkr 1929;87:527-70.5. Waller A. A demonstration on man of electromotive changes accompanying the heart's beat. J Physiol 1887;8:229-34.6. Einthoven W Uber die form des menschlichen electrocardiogramms. Arch Gesamte Physiol 1895;60:101-23.7. Ancoli-Israel S. "Sleep is not tangible" or what the Hebrewtradition has to say about sleep. Psychosomatic Medicine2001;63:778-87.8. Gastaut H, Tassinari CA, Duron B. Polygraphic study of diurnaland nocturnal (hypnic and respiratory) episodal manifestations

14 AASM Manua/ fo r Scoring Sleep 2007

of Pickwick syndrome. Revue Neurologique 1965;112:568-79.9. Bulow K. Respiration and wakefulness in man. Acta PhysiolScand 1963;59:1-110.10. Symonds CP. Nocturnal myoc1onus. J Neur Neurosurg Psychiatry 1953;16(3):166-71.Il. Coleman RM, Pollak CP, Weitzman ED. Periodic movements insleep (nocturnal myoclonus): relation to sleep disorders. Ann NeuroI 1980;8:4 6-21.12. Loomis AL, Harvey EN, Hobart GA. Cerebral states duringsleep, as studied by human brain potentials. J Exper Psychol1937;21:127--44.13. Blake H, Gerard R, Kleitman N. Factors including brain potential s during sleep. J Neurophysiol 1939;2:48-60.14. Gibbs E, Lorirner F, Gibbs F.Atlas of Electroencephalography.In: Volume 1, Methodology and Controis. 2nd ed. Reading,MA: Addison-Wesley Publishing Company; 1950:90-6.15. Aserinsky E, Kleitman N. Regularly occurring periods of eyemotility and concomitant phenomena during s eep. Science1953;11 8:273-4.16. Dement WC, Kleitman N. Cyclic variations in EEG duringsleep and their relation to eye movements, body motility anddreaming. Electroencephal ogr Clin Neurophysiol 1957;9:67390.17. Williams RL, Karacan 1 Hursch C. Electroencephalography ofHuman Sleep: Clinical Applications. New York: John WileySons; 1974.18. Monroe LJ. Inter-rater reliability and the role of experience inscoring EEG sleep. Psychophysiol 1967;5:376-84.19. EEG arousals: scoring rules and examples: a preliminary reportfrom the Sleep Disorders Atlas Task Force of the ArnericanSleep Disorders Association. Sleep 1992;15:173-84.20. Grube G, Flexer A, Dorffner G. Unsupervised continuous sleepanalysis. Methods Find Exp Clin Pharmacol 2002;24 SupplD:51-6.

2 1. Anders T, Emde R, Parmelee A (eds). A Manual Of Standardized Terminology, Techniques and Criteria For Scoring StatesOf Sleep and Wakefulness ln Newborn Infants. UCLA Brain Information Service. NINDS Neurological Information Nerwork;/971.22. Sackett DL. Rules of evidence and clinical recommendati onsfor the management of patients. Can J Cardiol 1993;9:487-9.23. Fitch F, Bernstein SJ, Aguilar MS, et al. The RANDIUCLAAppropriateness Method User's Manual. Santa Monica, CA:RAND Corporation; 200 1.


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1 RULES[RE OMMENDED]

[ALTERNATIVE]

[OPTIONAL]

PROCEDUR L NOTES[STANDARD][GUIDELINE][CONSENSUS]

[ADJUDICATION]

1 KEY

These rules are recommended for the routine scoring of polysomnography.These are rules that may be used as alternatives to the recommended rules at the di scretion of theclinician or investigator.These are suggested rules for uncommonly encountered events, events not known to have physi-ologie significance or events for which there was no consensus deci sion . Scoring may be performedat the discretion of the clinician or investigator.

Recommendation based on level 1 evidence or overwhelming level 2 evidence.Recommendation based on level 2 evidence or a consensus of level 3 evidence.Recommendation with less evidence than guideline for which agreement was reached in a stand ard-ized consensus process based on available information .Recommendation from the steering committee based on ail available information. Adjudication wasonly performed a when there was insufficient evidence and no consensus agreement or b in con-junction with task force leaders on issues regarding minor clarifications and add itions to rules.

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Il PARAMETERS TO BE REPORTED FOR POLYSOMNOGRAPHY1 POLYSOMNOGRAPHYA Parameters

1) EEG derivations2) EOG derivations3) Chin EMG4) Leg EMG derivations5) Airftow parameters6) Effort parameters7) Oxygen saturation8) Body posi tion

B Sleep Scoring Data1) Light s out dock time (hr:min)2) Lights on dock time (hr:min)3) Total sleep time (TS T; in min )4) Total recording time (" Iights out" to " lights on" in min )5) Sleep latency (SL; lights out to first epoch of any sleep in min)6) Stage R latency (sleep onset to first epoc h of Stage R in min)7) Wake after sleep onset (WASO; Stage W during B4, minus B5, in mi n).8) Percent sleep efficiency (B31B4)x 1009) Tim e in each stage (min)

10) Percent ofTST in each stage (B9 values/83 )x 100Nole: Wake afier sleep onset includes ail wake activity including wake Ui bed.

C. Arousal Events1) The number of arou sa ls2) The arousal index (Ar ; C Ix60 /B3)

D Resp iratory Events1) Number of obstructive apneas2) Number of mixed apn eas3) Number of cen tral apneas4) Number ofhypopneas5) Number of apneas + hypopneas6) Apnea ind ex (A I; (D I+D2+D3)x60/837) Hypopnea index (HI; D4x601B3)8) Apnea + Hypop nea index (AHI; D5x60/B3)9) Resp iratory effort related arou sals, total number

10) Respiratory e ffort related arousal index (D9x60/B3 )II ) Ox ygen des aturations 2 3% or 2 4%, total number12) Oxygen desaturation index 2 3% or 2 4% (DI; D 11x60 /83 )13 Con tinuousoxygen saturation, mean value14) Mi nimum oxygen saturation dur ing sleep

[RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOM MEND ED][RECOMM END ED]

[RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED][R ECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED]

[RECO MME NDED][R ECOM ME ND ED]

[RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED]

[OPTIONAL][O PTIONAL][OPTIONAL][OPTIONAL]

[RECOMMENDE D][RECOMMEND ED]

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15) Occurrence of hypoventilation (yes 1no) [OPTIONAL]16) Occurrence of Cheyne Stokes breathing (yes 1no) [RECOMMENDED]

No/es:1. For oxygen desaturation, percent time spent below a given threshold may he reported al /he discretion o /he investigator2. ln adults, the choice o ypopnea defini /ion recommended, Vll.4A or al/erna/ive, Vll.4B) should he specified in D4, D5, D7, DB.E ardiac Events

1) Average heart rate during sleep [RECOMMENDED]2) Highest heart rate during sleep [RECOMMENDED]3) Highest heart rate dur ing recording [RECOMMENDED]

Occurrence of the fo/lowing arrhythmias yes/no). Ifpresent, listarrhythmia and heart rate orduration ofpause .4) Bradycardia; report lowest heart rate observed5) Asystole; report longest pause observed6) Sinus tachycardia durin g s leep; repor t highest heart rate observed7) Narro w complex tachycardia ; report highest heart rate observed8) Wide complex tachycardia; report highesr heart rate observed9) Atrial fibrill ation

Occurrence oftheother arrhythmias yes/no).10) If present , list arrhythm ia

F Movement Events1) Number of periodic limb movements of sleep (PLMS)2) Number of periodic limb movements of sleep (PLM S) with arous als3) PLMS index (PLMSI; FI x60/B3)4) PLMS arousal index (PLMSArl ; F2x60/B3)

G Summary Statements1. Findings related to sleep diagnoses2. EEO abnorrnalities3. ECO abnormalities4. Behavioral observations5. Sleep hypnogram

[RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED]

[RECOMMENDED]

[RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED]

[RECOMMENDED][RECOMMENDED][RECOMMENDED][RECOMMENDED]

[OPTlON L]

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III TECHNICAL AND DIGITAL SPECIFICATIONS1. SPECIFICATIONSA. Digital Specifications for Routine PSG Recordings (Notes) [RECOMM ENDED]

Maximum Electrode Impedances 5KMinimum Digital Resolution 12 bits per sampleSampling Rates Desirable Minimal

G 500 Hz2 200 Hz1OG 500 Hz4 200 HzMG 500 Hz5 200 Hz

ECG 500 Hz6 200 HzAirflow 100 Hz 25 HzOximetry 25 Hz? 10 HzNasal Pres sure 100 Hz8 25 HzEsophageal Pressure 100 Hz 25 HzBody Position 1Hz 1 HzSnoring Sounds 500 Hz9 200 HzRib Cage and Abdominal Mo vements 100 Hz 'o 25 HzRoutinely Recorded Filter Settings Low Frequency Filter High Frequency Filter lIEEG 0.3 Hz 35 HzJEOG 0.3 Hz 35 HzMG I Hz5 100 Hz5

ECG 0.3 Hz" 70HzRespiration 0.1 Hz 15 HzSnoring 10 Hz 100 Hz

Notes:l . This applies to me asured EEG and EDG electrode Impedan ce. Electrode Impedances should be rechecked during a recording when any

p attern that might be art ifactual appears .2, For EEG, 500 Hz could improve resolution ofspikes in the EEG and beuer maintain details o f the waveform.3. For more detailed EEG analysis, sampling rate and high frequency filter settings may be increased. ln these circumstances, the samplingrate s hould be at least 3 times the high frequency filter settings.4, For EDG, using the 500 Hz desirable EEG sampling rat e also allows the reflection of the EEG in this lead as an EEG backup and may

beller define so me artifacts in these leads.5, This applies to submental an d leg EMG. High er sampling ra tes better defin e waveforms; white the waveform itself is not an issue, a

better defin ed wav eform ca n h elp avoid amplitude attenuation as the envelope o f the rapidly osc illating signal is read and interpreted.6, For ECG, 500 Hz can beller defin e pa cemaker spikes and ECG wav eforms, however p acemaker sp ikes can be seen al 200 Hz and the

evaluation o fcardiac ischemia by ECG waveform is nol a usual PSG issue. Higher fre quencies may be required f or complex waveformanalysis and research applications,

7. For ox imet ry, 25 Hz is desirable 1 ass ist with artifact rej eciion.8. For nasal pressure transducer technology (especially with settings which identify snoring occurring on top of the airflow 11 a ve form ),

this higher frequency may be o fbenefi t fo r better definition o fflauening, plateauing, and/or fiuuering in the wave airflow form.9. For snoring sound, 500 Hz can beuer define amplitude variation by clearer waveforms with more accurate amplitude det ermination as

the envelope of the rapidly osc illating signal is interpreted, (as f or EMG), a preprocessing ofsnoring results in a continuous soundloudness level or in a so und intensi ty level, then a mu ch lower sampling rate is acceptable, That sampling rate is not specified becauseit depen ds on the preprocessing o f the so und in order to produce loudness.

10. For rib cage an d abdominal mo vements using indu ctance plethysmography, cardiogenic oscillations ca n be better seen and may resultin beu er arti fact assessment.

11. To accommodate older equipment. filter settings in the range of 30-35 Hz may be used to comply with the above recommendations of 35Hz, This applies most specifically in the context of EEG and EDG high fi l ter settings.

12, For ECG , 1011' frequency settings an d wi de bandwidth minimizes distortion in a 12 lead ECG ; ho wever in PSG recording fo r s inglechannel modified lead Il usedfor identifying bas ic heart l'ales and dysrhythmias, it may not be as necessary. Advanced cardiac assessment may be more optimal using an LF F of 0.3 Hzfor slo wer parts of the cardiac cycle . The c hannel is susceptible ta artifacts at thissetting due ta patient movement, perspiration. musc le activity and electrode displacemenl with more sweat artifact, which is a cammonproblem in the laborat ory. It is less likely a problem using standard ECG leads with good contact and s tability o fapplication than usingGleadsfor cardiac monitoring.

General note: in the absence o fc1ear preferences, there is consensus 1 use s imilar seuings among lea ds to simplify technical implementation.

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B igital PSG Recording FeaturesDigital systems must include the following features

1) A toggle switch permitting visual (on-screen) standard negative 50 IlV DCcalibration signal for a1l channels to demonstrate polarity, amplitude and timeconstant settings for each recorded parameter

2) A separate 50/60 Hz filter control for each channel3) The capabil ity ofselecting sampling rates for each channel4) A method ofmeasuring actual individual electrode impedance against a reference

(the latter may be the sum of ail other applied electrodes)5) The capabili ty ofretaining and viewing the data in the exact manne r in which it

was recorded by the attending technologist (i.e ., retain and display ail derivationchanges , sensitivity adjustments, filter settings, temporal resolution)

6) The capabi lity of retaining and viewing the data in the exact manner it appearedwhen it was scored by the scoring technologis t (i.e., retain and display ailderivation changes, sensitivity adjustments, filter settings, temporal resolution)

7) A filter design for data collection which functionally simulates or replicatesconventional (analog-style) f requency response curves rather than removing ailactivity and harmonies within the specitied bandwidth

Digital systems should include the following features8) An electrode selector process with the flexibility for choosing and/or changing

electrode input signal derivations without relying on a common referenceelectrode

C Rules for PSG isplay and isplay ManipulationSystems must include the following PS features

l) Resolution of a digital screen and video card must be at least 1600 x 1200 fordisplay and scoring of raw PSG data

2) Histogram with stage, respiratory events, leg movemen t events, O2 saturation,and arousals, with cursor positioning on histogram and ability to jump to thepage

3) Ability to view a screen on a time scale ranging from the entire night to windowsas small as 5 seconds

4) Recorded video data mus t be synchronized with PSG data and have an accuracyof at least one video frame per second

Systems should include the following PS features5) Page automatic turning and automat ic scroll ing6) Channel off control key or toggle7) Channel invert control key or toggle8) Change order of channel by click and drag9) Display setup profiles (including colors) which may be activated at any time

10) Fast Fourie r Transformation or spectral analysis on specifiable interval (omittingsegments marked as data artifact)

[RECOMMENDED]

[RECOMMENDED][RECOMMENDED][RECOMMENDED]

[RECOMMENDED]

[RECOMMENDED]

[RECOMMENDED]

[OPT ONAL]

[RECOMMENDED]

[RECOMMENDED]

[RECOMMENDED]

[RECOMMENDED]

[OPTIONAL][OPT ONAL][OPTIONAL][OPTIONAL][OPTIONAL][OPTIONAL]

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D Digital Analysis o PSGigital sleep systems must include the abilityta:

1) Identify whether sleep stage sco ring was performed visually or computed bythe system

Dgital sleep systems shauld include the capabilityta turn offand on sdemanded highlighting for:2) Patterns identifying sleep stage decisions (for cxample sleep spindle,K complex,

alph a, delta)3) Patterns ident ifying the respiratory anal ysis (for example apneas, hypopneas,

desaturations)4) Patterns identifying the movement analysis for example PLM s)

[RE OMMENDATION]

[OPTIONAL][OPTI ON AL][OPTIONAL]

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IVVISUAL RULESVlsUAL RUL S FOR ADULTs

1TECHNICAL SPECIFICATIONSA Electroencephalogram EEG)

1) The recommended derivations are: [RECOMMENDED]a. F4 M 1b. C -M4 Jc. 0 2-M)Backup electrodes should be placed at F3, C O[ and M2ta allow display ofF 2, C -M2and 0 [-M2ifelectrodes malfunc3 3-M 3tian during the study.

2) Alternative acceptable derivations are: [ALTERNATIVE]a. F -Cz zb. C-Oz zc C4-M[Backup electrodes should be placed at F , C 0[ and M2ta allow substitution of F for F C for C or C for andpz 3 pz z 3 z 4 J zM2 for M[ if electrodes malfunction during the study.

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3) EEG electrode position is detennined by International 10-20 System [RECOMMENDED]Note:1. A minimum of3 EEG derivations are required in order tosample activity f rom thefrontal central and occipital regions.2. M and Ml refe r to the left and right mastoidprocesses.B Electrooculogram EOG)

1) The recommended EOG derivations are: [RECOMMENDED]a. El is placed 1 cm below the left outer canthus)l-M2b. E2-M2 E2 is placed 1 cm above the right outer canthus)o o

Right Left 2) Alternative acceptable derivations are: [ALTERNATIVE]

a. E,-F El is placed 1 cm below and 1 cm lateral to the outer canthus of the left eye)pzb. E F E is placed 1 cm below and 1 cm lateral to the outer canthus of the right eye)2- pz 2

C) C)Right Left

Note: The alternati ve derivations record the direction ofeye movements i.e. vertical movements will show in-phase deflections n horizontaleye movements out-of-phase defiections.

C Electromyogram EMG) [RECOMMENDED]1) Three electrodes should be placed to record chin EMG:

a. One in the midline 1 cm above the inferior edge of the mandibl eb. One 2 cm below the inferior edge of the mandible and 2 cm to the right of the midlinec. One 2 cm below the inferior edge of the mandible and 2 cm to the left of the midline

2) The standard chin EMG derivation consists of either of the electrodes below the mandible referred to the electrode abovethe mandible. The other inferior electrode is a backup electrode to allow for continued display of EMG activity if 1 of the primary electrodes malfunctions.2 SCORING OF SLEEP STAGES [RE OMMENDED]A. Stages Sleep

1) The following tenninology is recommended for the stages of sleep:a. Stage W Wakefulness)b. Stage NI NREM 1)c. Stage N2 NREM 2)d. Stage N3 NREM 3)e. Stage R REM)

Note: Stage N3 represents slow wave sleep and replaces the R K nomenclature ofst ge 3 and stage 4 sleep.B. Scoring by Epochs [RECOMMENDED]

1) Score sleep stages in 30 second sequential epochs commencing at the start of the study.2) Assign a stage to each epoch.3) If 2 or more stages coexist during a single epoch , assign the stage comprising the greatest portion of the epoch.

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3. STAGEW [RECOMMEND ED]DefinitionsAlpha rh ythm : Trains of sinusoida l 8- 13 Hz activity recorded over the occipital region with eye closure, attenuating with eye opening.Eye blinks: Conjugate vertical eye movements at a frequency of 0.5-2 Hz prese nt in wakefulness with the eyes open or closed.Reading eye movements: Trains of conjugate eye movements consisting of a slow phase followed bya rapid phase in the opposite direction as the subjcc t reads.Rapid eye movem en ts REM): Conjugate, irregular, sharply peaked eye movements with an initial deflection usually lasting 500msec.Low amplitude, mixed fr equency activity: Low amplitude, predominantly 4-7 Hz activity.Vertex sharp wav es (V waves): Sharply contoured waves with duratio n


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5. STAGE N2 [RECOMMENDED]Definitions K complex:Awell-delineatednegativesharpwaveimmediatclyfollowed byapositivecomponent standingout l'romthe backgroundEEG,with totalduration seconds,usuallymaximal inamplitudewhenrecordedusi ng fron talde rivations.For an amusai tobe associatedwitha Kcomplex, itmustcommence nomore than 1secondafterterminationof the Kcomplcx. Sleep spindle: A train of distinct waveswith frequency 11-16Hz(most cornmonly 12-14Hz)withaduration seconds, usually maximalinamplitude usingcentralderivations .

RulesA. The following rule defines thestartof aperiod of stage N2 sleep :

1) Begin scoring stage N2 (in absenceof criteria for N3) if 1or bothof the following occur during the firsthalfof that epochorthelast halfof thepreviousepoch:a. OneormoreKcomplexesunassoc iatedwitharousalsb. Oneormore trainsof sleep spindles

ie:1. Continue 1 score stage NI for epochs with arousal-associated K complexes but no spontan eous K complexes or sleep spindles.2. For the purpos es ofscoring N2 sleep, arousals are defined according 1 arousal mie I.B.The following rule defines continuation of a period of stage N2 sleep:

1) Continuetoscoreepochswithlowamp litude, mixed frequencyEEGactivitywithoutKcomplexesorsleepspindlesasstageN2 ifthey areprecededbya)Kcomplexesunassociatedwith arousalsorb)sleepspindles.C. The following ruledefines theend ofa period of stage N2 sleep .

1) EndstageN2sleepwhen 1of thefollowingeventsoccurs:a. TransitiontostageWb. Anarousal(changetostageNI untilaKcomplexunassociatedwithanarousalorasleepspindleoccurs)(See

Figure 1)c. Amajorbodymovementfollowedbysloweyemovementsand lowamplitudemixed frequencyEEG withoutnon

arousalassociatedKcomplexesorsleepspindles(scoretheepochfollowingthemajorbody movement asstageNI; score theepochasstageN2 if there arenosloweyemo vements;theepochcontaining the body movement isscoredusingcriteria inSection8)(SeeFigure2)

d. TransitiontostageN3e. Transitiontostage R

poch poch50 5 5 53 50 5 5 53

1 1 1 1 1 .1 WlthKcomplex 1 1 complex 1 1 arousal 1 1 11 1 : 1

111

111

11 il R .. I 1 1EMG,-EMG z ,. 11 1

StageN2 StageN2 Stage N1 Stage N2 Stage N2 Stage N2 Stage N1 StageN2Figure1

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Epoch Epoch50 51 5 53 50 51 5 531 1 1 Body 1 Body 1

1 rnovernnt Irnovernent: K complex : I l 1 1 11 1C M1 : : 11 - - - - - - - - - , - - . 11 1 J 1o-M alpha 1 12 1 1 11 11 111 1: i :~1 1EMG,-EMG 2 1 11 11 11 1

Stage N2 Stage N2 Stage N2 Stage N2 Stage N2 Stage N1 Stage N1 Stage N2Figure2

Notes:1. The EOG usually shows no eye movement activity during stage N2 sleep. but slow eye movements may persist in some subjects.2. ln stage N2. the chin EMG is variable amplitude. bill isusually lower than in stage W and may be as low as in slage R sleep.6. STAGE N3 [RECOMMENDED]

Definition Slowwaveactivity: Waves of frequency 0.5 Hz-2 Hzand peak-to-peak amplitude >75 J I V,measuredover the frontalregions .

RuleA. Score stage N3 when 20% or more of an epoch consists of slowwave activity, irrespective of age.Noies:1. Sleep spindies may persist in stage N3 sleep.2. Eye movements are nol typically seen during stage N3 sleep.3. ln stage N3. the chin EMG isof variable amplitude. often lower than in stage N2 sleep and sometimes as low as in stage R sleep.7. STAGE R [RECOMMENDED]

DefinitionsRapid eye mo vements (REM : Conjugate, irregular, sha rp ly peaked eye movements withaninitial deflection usually lasting


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B. The following rule defines the continuation ofa period of stage RsleepContinue ta sco re stage R sleep,even in theabsence of rapid eye movements, forepochs following 1or more epochs of stageRas defined in A above, if the EEG continues to show low amplitude, mixed freque ncy activity wi thou t K complexes or sleepspindles and the chin EM G tone remai ns low. (Figure 3)

Epoch Epoch50 51 52 53 50 51 52 53

1 i1 1 1 11Kcomplex 1 1Kcomplex 1

t ---- ---- : : --t- -----'-- .:. .. .. ..Y- :1 1: - - ~ REM REM

1Ez M z:

1t r I 1:1J11EMG-EMG 2 :1 - - - t - - - . . . l . . . . - _ ~ ....... EMG -EMG2 IMI 11- - - - - - - . . . . . . . L - - - - _ ~ - -

1 1 1StageR Stage R StageR Sage N2 StageR Stage R Stage N1 Stage N2Figure 3

C. The following rule defines theend ofa period of stage Rsleep1) Stop scori ng stage R sleep whe n 1 or more of the followi ng occur:

a. There is a transition to stage W or N3b. An increase in chin EMG tone above the level of stage Ris seen and criteria for stage N I are met (Figure 4)c. An arousa l occurs followed by low amplitude, mixed frequ ency EEG and slow eye move ments (score as stag e NI;

if no slow eye move ments and chin EMG tone remains low, con tinue to score as s tage R) (Figure 5)d. A major body movement followed by slow eye movements and low amplitude mixed freque ncy EEG without

non-arousal asso ciated K com plexes or s leep spindles (score the epoch following the major body movement asstage N I; if no slow eye movements and the EMG tone remains low, continue to score as stage R; the epochcontaining the body movement is scored using criteria in Section 8) (Figure 6)

e. One or more non-am usai associated K complexes or sleep spindles are present in the first half of the epoc h in theabse nce of rapid eye movements, eve n if chin EMG tone remains low (score as stage N2) (Figure 7)

Epoch Epoch50 51 52 53 50 51 52 53

C4-M1OZ M 1E1 M Z

REM

111

1 . 1Low amPltu j1 mixed traqua ev1 1111111

1

11 1IKcomplex 1

1\r-- :1r-C4-M1OZ M 1E1 M Z

REM

11 11Law ampliludJ1mixed frequerky1 1111111

11 1IKcomplex 11\r-- :1r-

EZ MZ 11 EzM z11

EMG -EMG2 EMG -EMG2:h1 111 Stage R Stage R StageN1 Stage N2 StageR StageR Stage R StaqeN2

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Epoch Epoch50 5 52 53 50 5 52 53

1 1 11 1 1 1 1

: 1Kcomplex 1 Arosal 1Kcomplex 1C 1 1 1r o u s ~ 1 4 -M 1:-----t--- 'M _ 1 ----- t--- ;N!I .< 1 _ 11 1 . V- 11 1 11 1 1 i l 1O M --------+1- 1 _ IM I. 1 JI 1 ~2 2 1 V 1 T V' \---IV 1 ~ VI1 1 1 1 1 l , 11 1EMG,-EMG , 1 1 ~ t 1 l .11 EMG,-EMG : - ~ III

1 1 1 1 1Stage R tageR tage N1 tage N2 StageR tageR tage R Stage N2

Figure 5

- - - 1 - - - - 11 I (REM 1

Epoch Epoch50 5 52 53 50 5 52 531 1 Body 1Body , 1rnovernent ,

1 C -M

11

EMG,-EMG ,,--- --1

4102-M1E1-M 2E2 -M 2

EMG,-EMG, 1Stage R Stage R Stage R Stage R Stage R Stage N1 Stage N1 Stage N1

1 movemenl '111

~ 1 J j 11111111- - - ...-1

111 1_-----' ' ' '- ' ' ' ' ' '--

Figure 6

Epoch Epoch50 5 52 53 50 5 52 53

1 1 i1 1 11 Kcomplex 1 Kc0 nflex1

1 ; l . _ ~ ,1,11

-----.----------L-t-REM 1 1 EM,E1 -M 2 ~ L _ L ~ ~ _,11 11E2 -M 2 ~ r t : ~ r l 1

, 1 1, 1 IEMG,-EMG, : -+ - ---L ...:.....MG,-EMG, '1- . . . . : . . . -1, 1Stage R Stage R Stage N2 Stage N2 Stage R Stage R Stage R Stage N2

Figure 7

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D Score epochs atthe trans itionbetween stage N and stage Ras follows1) In between epochs of defin ite stage N2 and defini te stage R, score an epoch with a distinct drop in chin EMG in the first

hal f of the epoch to the level seen in stage R as stage R if ail of the follow ing criteria are met, even in the absence of rapid eyemovements Figure 8):a. Absence of non-arousal associated K co mplexesb. Absence ofs leep spind les

2) In between epochs of definite stage N2 and definite stage R, score an epoch with a distinct drop in chin EMG in the firsthalf of the epoch to the level seen in stage R as stage N2 if a il of the follow ing criteria are met Figure 9A):a. Presence of non-arousal associated K complexes or sleep spindlesb. Absence of rapid eye movements

3) In between epochs of definite stage N2 with minimal chin EMG tone and definite stage R without furth er drop in chinEMG tone, score epochs as stage R if a l of the followi ng are met, even in the absence of rapid eye movements Figure 98) :

a. Abse nce ofnon-arousal associatcd K complexesb. Absence of sleep spindles

Epoch Epoch50 51 52 53 50 51 52 531 11 1

1 Kcomplax 1 Kcomplax1 1C4 M 1 C 4 M 11 111 1102-Ml : 11 02-Ml 11 1 1

1 1 1EM 1 1 REM1 1E1-M2 1 E1-M211 11 1E2-M2 1 E2-M2 11 11 1 1EMG,-EMG, li Unb EMG,-EMG, i , l

1 11StageN2 StageR Stage R StageR StageN2 StageN2 StageR StageR

Figure 8

Epoch Epoch50 51 52 53 50 51 52 531 1 11 1 1

1 Kcomp lax Sle ep 1 1 Kcomplax1 sp indle 11 11C4 M 1: 1 1 1 C4 M 1 :1 1 11 Sleep 11 11 spindle l 1 1 1 11 11

1 1 1 REM 1 1 REM1 11 1 1E -M 1 E -M 11 21 1 211 1E2-M2: E2-M2:1 111 1EMG,-EMG,/r1.1H t EMG,-EMG'I1 1 1

StageN2 SageN2 Stage N2 SageR Stage N2 Stage R Stage R Sage RA BFigure 9

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Notes:1. Low amplitude, mixed frequ ency activity in stage R resembles that seen in stage NI . ln some individuals, a greater amount ofalpha

activity can be seen in stage R than in stage NI . The alpha frequency in stage R oflen is 12 Hz slower than during wakefulness.2. The fo llowing ph enomena are strongly supportive of the presence ofstage R sleep and may be helpful when the stage is in doubt:

a. Sawtooth wavesb. Transient muscle activity (Sawtooth waves and transient muscle activity may be present but are not required f or scoring stage R.)

3. At times, especially in thefirst REM sleep period of the night, K complexes or sleep spindles may be interspersed among epochs ofwhatotherwise appears 1 be stage R sleep. The above rules indicale that epochs with rapid eye movements should be scored as stage Reven in the presence ofK complexes or spindles. However if rapid eye movements are absenl, subsequent epochs with K complexes orspindles should be scored as stage N2, even if chin muscle tone remains low.

8. MAJOR BODY MOVEMENTS [RECOMMEND ED]DefinitionMajor body movem ent Movernent and muscle artifact obscuring the EEG for more than hl an epoch to the ext ent that the sleep stagecannot be deterrnined

RulesScore an epoch with a major body movement as follows:A. Ifalpha rhythm is present for part ofthe epoch (even


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VISUAL RULES FOR CHILDREN

1 AGES FOR WHICH PEDIATRIC SLEEP SCORING APPLY: [RECOMMENDED]A Pediatrie sleep scoring rules can be used to score sleep and wakefulness in children 2months post-term orolder.NOIes:1. For children less than 2 months post-term, ref er la discussion in the Pediatrie Task Force revie w paper.2. There is no precise upper age boundary fo r pediatrie visual rules; ref er la discussion in the Pediatrie Tas k Force review p aper.2 TERMINOLOGY OF SLEEP STAGES [RECOMMENDED]A. The following terminology should be used when scoring sleep in children 2 months post-tarrn orolder:

1) Stage W (Wakefulness)2) Stage N I (NREM 1)3) Stage N2 (NREM 2)4) Stage N3 (NREM 3)5) Stage N (NREM)6) Stage R (REM)

3 TECHNICAL CONSIDERATIONSSee adult sleep scoring rules and digital PS section fortechnical considerations other than those in the notes belowNotes:1. Adult electrode derivations fo r EEG . EOG and chin EMG are acceptable fo r recording sleep excep t that the distance between the chin

EMG electrodes oft en needs la be reducedf rom 2 cm 10 1 cm and the distance fr om the eyes in EO G electrodes often need ta be reducedfrom 1 cm la 0 .5 cm in children and infa nts with small head size.

2. An initial EEG sensitivity of 7 IlV/mm (vertical scaling) is approprialef or routine PSG recordings but the sensitivity oft en needs la beadjusted in infants and younger children typically la 10 or even 15 IlV/mm. If sensitivilies of 10 01'15 IlV/mm are used, parlions o f thesleep recording should be reviewed using 7 IlV/mm in arder la disp lay and recognize low voltage[as ter frequencies (including spindlefreq uenc ies).

4 SCORING SLEEP STAGES [RECOMMENDED]Because of the variability ofsleep in nfants 4 possible scenarios are described below:A. Ifail epochs ofNREM sleep contain no recognizable sleep spindles, Kcomplexes orhigh-amplitude 0.5 to2 Hz slow wave activity, score ail epochs ofNREM sleep as stage N (NREM).B If some epochs ofNREM sleep contain sleep spindles or Kcomplexes, score those as stage N2 (NREM 2 . If in the remainingNREM epochs, there isno slow wave activity comprising more than 20% ofthe duration ofepochs , score as stage N (NREM).C.lfsome epochs ofNREM sleep contain greater than 20% slow wave activity, score theseas stage N3 (NREM 3 . If inthe remainingNREM epochs, there are no K complexes orspindles thenscore as stage N (NREM).D IfNREM issufficiently developed that some epochs contain sleep spindles or Kcomplexes and other epochs contain sufficientamounts ofslow wave activity, then score NREM sleep in this infant as either stage N1, N2 or N3 as inan older chiIdoradult.NOIes:1. Sleep spindles usually are present in NREM sleep of infants 2 la 3 months post-term or aider.2. K complexes are usually present in NREM sleep in infants 4 la 6 months pos t-term or aider.3. Slow wave activity r? 5 Il 0.5-2 Hz typ ical/y in thefro ntal regions) is usually present 4 la 5 months post-term.4. NREM sleep can be scored as stage NI . N2 or N3 in most infants S- months post-term or aider, occasionally in in fants as young as 4

la 45 months post term.5. Non EEG correlates are very helpful in recognizing NREM and RE M sleep in infa nts 6 months post-term or younger. These correlates in

RE M sleep inclu de the presence ofirregular respiration, chin EMG atonia, transiat muscle activity, and rapid eye movements. In NRE Msleep, correlates include regular respiration, no or rare vertical eye movements, and preserved chin EMG tone.

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5.STAGEW [RECOM MENDED]Definitions Alpha r hythm: Tra insof sinusoidal 8- 13 Hz activity recorded over the occipital region present with eye closure and whieh is reactive (attcnuatcswitheyeopening). Eyc blinks: Co nj ugateverticaleye movementsata frequeney01'0.5-2 Hzpresent inwakefulnesswith cyes open orclosed, Reading eye movernents :Trainsof conjugate eye rnovementsconsisting ofa slow phase followcd by a rapid phase inthe opposite di rectionastheehild rcadsor visuallyscans theenvironrnent. Rapid eye movements (REM): Conjugatc , irregular,sharp lypeakcd cyemovemcnts with an initialdeflection usually lasting 50 f-ly.

RulesA. In children thedominant posterior rhythm replaces the term alpha rhythm for the purposes of scoring wakefulness andNREMstages.B. Score epochs as stage Wwhen more than 50% of the epoch haseither reactive alpha or age-appropriate dominant posteriorrhythmover the occipital region.C. If there is nodiscernable reactive alpha ornoage-appropriate dominant posterior rhythm, scoreepochs asstage Wif anyofthefollowing arepresent:

1) E ye blinks at afrequency of 0. 5-2 Hz2) Reading eye movements3) I rregular conjugate rap id eye movem ents associated w it h normal o r high chin mu scle tone

Notes:1. The dominant posterior rhythm (DPR) over the occipital derivat ions in adults has amplitude of 8 Hz (range 7.5to 9.5

Hz).e. A m ean alpha fr equency of9 Hz is fo und in 65%of9 year olds and increases to 10 Hz in 65%byage 15.1 The average amplitude the dominant posterior rhythm in children is 50-60 JI ' 9 ofchildren have >100 JIV (especially between6-9 years); children rarely have alpha acti vity


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6. STAGE N1 [RECOMMENDED]DefinitionsSlow eye movernents SEM): Conjugate , reasonably regul ar, sinusoidal eye movements with an initial deflection whi ch usually last>500 msec .Low amplitude, mixed frequency activity: Low amplitude, predominantly 4-7 Hz ac tivity.Vertex sharp wa ves (V wa ves): Sharply contoured wa ves with du ration 200 f lV 4-6 Hz theta activity ma.ximalover the frontocentral or cenlral regions.3. Sleep onset fro m 3years on is ofte n characterized by a 1-2 Hz slowing of the dominant posterior rhythm frequency and/or the dominanlposterior rhythm of ien becomes diffusely distributed then is gradually replaced by relalively low voltage mixed frequen cy EEG activity.

4. In most subje cts sleep onsel will be the fi rst epoch of stage NI but in infants you nger than 3 months post-term, this is often stage R.5. Rhythmic anterior theta activi ty (RAT) are l'uns ofmoderate voltage 5-7 Hz theta activity over thefro ntal regions is commonly seen in

adolescents and young adults when drowsy, may first appear around 5 years ofage.6. Vertex sharp waves are monophasic surfac e-negative sharp waves maximal over the cenlral regions which last


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8 STAGE N3Same as adult rules n section IV. 6.

Note: Slow wave activity SWA) in pediatrie populations oflen 100 to 400 IlV 0.5 to 2.0 Hz activity maximal over the recommended derivations in the frontal scalp regions F , F.) first appears as early as 2 months, more oflen about 3 to 4.5 months post-term.4

9 STAGESame as adult rules section IV. 7.

Note: The continuous low voltage, mixedfrequency EEG activity o stage R in infants and children resembles adults though the dominantfrequencies increase with age: approximately 3 Hz activity at 7 weeks post-term; 4 5 Hz activity with bursts o saw tooth waves at 5months; 4 6 Hz at 9 months; and prolonged runs or bursts o notched 5 to 7-Hz theta activity at 1 to 5 years age. By 5 to 10 years oage, the low voltage mixedfrequency activity in stage R resembles that o adults

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VAROUSALRULE 1 SCORINGAROUSALS [RE OMMENDED]A. Score arousal during sleepstages N1, N2, N3, or R if there is an abruptshift of EEG frequency including alpha, theta and/orfrequenciesgreaterthan 16Hz(butnotspindles)that lasts at least3 seconds,with at least10secondsofstablesleepprecedingthechange.Scoringofarousalduring REM requiresa concurrentincrease insubmental EMG lastingat least1second.Notes:1. Arousal scoring should incorporate informationfrom both the occipital and central derivations.2. Arousal scoring can be improved by the use additional information in the recording such as respiratory events and/or additional EEG

channels. Scoring arousals , however cannot be based 0 /1 this additional information alone and such information does not modify anythe arousal scoring ru/es.

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VI. CARDIAC RULES 1 TECHNICALSPECIFICATIONS [RE OMMENDED]A.AsinglemodifiedelectrocardiographLead Ilusingtorsoelectrodeplacement isrecommended.

Notes:1. ddilional leads may be placed if clinically-indicated at the discretion of the practitioner2. Increas ing image size on display may improve detection ofarrhyth mias.3. While class ically Lead Il is derived fro m electrodes placed on the right arm and left leg. the electrodes may be placed on the torso

aligned in parallel to the right shoulder and lefl hip.4. Standard ECG electrode applicalions are superior la EEG eleclrodes in minimizing artifact.2.SCORINGRULES [RE OMM ENDED]A. Scoresinustachycard iaduringsleep forasustained sinusheart rateofgreaterthan 90beatsperminute for adults.B.Scorebradycardiadu ring sleepforasustained heartrateof lessthan 40/minuteforages6 yearsthrough adult.C. Score asystole for cardiac pauses greater than 3seconds for ages 6years through adult.D.Score wide complex tachycardia fora rhythm lasting a minimum of3 consecutive beats ata rate greater than 100 per minutewith QRS duration ofgreater than orequal to120msec.E. Scorenarrowcomplextachycardiafora rhythm lastingaminimumof3 consecutivebeatsata rateofgreaterthan 100per n-utewith QRSdurationof lessthan120msec.F. Score atrial fibrillation if there isan irregularly irregular ventricular rhythm associated with replacement ofconsistent Pwavesby rapid oscillationsthat vary insize shape,andtiming.NOIes:1. Significanl arrhythm ias such as heart black should be reported if the quality o f the single lead is sufficient for accurate scoring.2. Ectop ie beats should be repo rted iffe lt to be clinically signifi canl.3. Sinus rates vary according 1 age in children, with faster rates iny oung children as compared 1 adults . For typical sinus rates in chil

dren, ref er 1 the Cardiac Task Force review paper.

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VII MOVEMENTRULES 1 SCORINGPERIODICL1MB MOVEMENTS INSLEEP(PLMS) [RECOMMENDED]A The following rulesdefineasignificant leg movement(LM)event:

1) The minimumdur ationof aLMevent is0.5second s 2) The maximumdurationof aLMevent is 10 seconds. 3) The minimumamplitudeofa LMevent isan8uv increase inEMGvoltageaboverestingEMG. 4) The timin gof the onset ofa LM event is defined as the point at which there is an 8 uv-increase in EMG vol tage abo ve

restingEMG.5) The t imingof the endingofaLM event isdefined asthestartof aperiod lastingat least 0.5 secondsduring whichthe

EMG does not exceed2 IlVabove restingEMG .B The following rules definea PLM series:

1) The minimumnumberof consecutiveLMeventsneed ed todefineaPLMseries is4LMs.2) The minimumperiodlengthbetweenLMs (definedas the timebetweenonsetsof consecutiveLMs) toincludethem as

partof aPLM seriesis5seconds .3) The maximum periodlengthbetweenLM s(definedas thetimebetweenonsetsof consecutiveLM s)toincludethem as

partof aPLM seriesis90sec.4) Legmovementson2differentlegssepara tedby lessthan 5seco ndsbetweenmo vementonsets are countedasasin glelegmovement.

Notes:1. An LM should not be scored if l occurs during a periodfr om 0.5 seconds preceding an apnea or hypopnea to 0.5 seconds fo llowing anapnea or hypopnea.2. An arousal and a PLM should be considered associated with each other when there is


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3. SCORING HYPNAGOGIC FOOT TREMOR (HFT) [OPTIONAL]A. The following rules define HFT:

1) The minimum number of bursts needed to make a train of bursts in hypnagogic foot tremor is 4 bursts.2) The minimum frequen cy of the EMG bursts in hypnagogic foot tremor is 0.3 Hz.3) The maximum frequency of the EMG bursts in hypnagogic foot tremor is 4.0 Hz.

Noies:1. The usual range/or duration 0/hypnagogic foo t tremor is 250-1000 msec.2. HFT may simply be benign movement phenomenon associated with characteristic EMG patterns as there have been no reported clinicalconsequences.4 SCORING EXCESSIVE FRAGMENTARY MYOCLONUS (EFM) [OPTIONAL]A The following rules define EFM :

1) The usuaI maximum EMG burst duration seen in fragm entary myoclonus is ISO msec2) At least 20 minutes ofNREM sleep with EFM must be recorded3) At least 5 EMG potentials per minute must be recorded

Noies:1. EFM may be a benign movement phenomenon associated with a characteristic EMG patt ern as there have been no reported clinical

consequences.2. ln many cases no visible movements are presenl. Grossje rk-like movements across thejoinl spaces are nol observed. When minor move

men! across a j oint space is present, the movement resembles the small twilch-like movements of thefi ngers, toes, and the corner of themouth intermiuently seen in REM sleep in normal individuals.

3. In some cases when visible movement is presenl, the EMG burst duration may be > 150 msec.5 SCORING BRUXISM [RECOMMENDED]A. The following rulesdefine bruxism:

1) Bruxism may consist of brief (phasic ) or sustained (tonie) elevations of chin EMG activity that are at least twice theamplitude of background EMG.

2) Brief elevations of chin EMG activity are scored as bruxism if they are 0.25-2 seconds in duration and if at least 3 suchelevations occur in a regular sequence.

3) Sustained elevations of chin EMG act ivity are scored as bruxi sm if the duration is more than 2 seconds.4) A period of at least 3 seconds of stable background chin EMG must occur befo re a new epi sode of bruxism can bescored.

5) Bruxism ca n be scored reliabl y by audi o in combination with polysomnography by a minimum of2 audible tooth grind ing episodes/night of polysomnography in the absence of epilepsy.

Noies:1. ln sleep,j aw contractionfrequ ently occurs. This contraction can lake Zforms: a) sustained (tonie) jaw c1enching tonie contractions or

b) a series 0/repetitive brie /(phasic) muscle contractions termed rhythmic masticatory muscle activity (RMMA).2. ln addition 10 the recommended placemenl chin EMG electrodes as noted in section IVA.I .c, additional masseter electrodes may be

placed at the discretion of the investigator or clinician.6. SCORING PSG FEATURES OF REM SLEEP BEHAVIOR DISORDER (RBD): [RECOMMENDED]

DefinitionsSustained muscle aetivity (tonie aetivity) in REM sleep: An epoch of REM sleep with at least 50% of the duration of the epoch havinga chin EMG ampl itude greater than the minimum amplitude than in NREM .Excessive transient muscle activity phasic activity) in REM sleep: In a 30-second epoch of REM sleep divided into [0 sequential 3second mini-epochs, at least 5 (50%) of the mini-epochs conta in bursts of transient muscle activity. In RED , excessive transient muscleactivity bursts are 0.1 - 5.0 seconds in durati on and at least 4 times as high in amplitude as the background EMG activity.Rule:1) The polysomn ographic characteristics of RBD are characterized by either or both of the following features:

a. Sustained muscle acti vity in REM sleep in the chin EMGb. Excessive transient muscle activity during REM in the c hin or limb EMG

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Notes :1. Time synchronized video PSG audio or a characteristic clinical history are necessary to make the diagno sis ofRBD in addition to po ly

somnographic evidence ofREM without atonia or excessive transient muscle activity in REM2. Transient muscle activity andoccasional accompanying visible twitching of small muscle groups are a normal ph enomenon seen in REM

sleep (see 1V Au t 7 . When larger muscle groups are involved, this activity is not associated with large. overt muscular activity actingacross large joints. When smaller muscle groups are involved, the movement often involves the distal muscles of the hands andface orthe corners of the mouth. Transient muscle activity may be excessi ve in RBD.

3. The s ustained muscle activity or the excess ive transient muscle activity observe d in REM sleep may be interrupted by superimposed(usually dream-enacting) behaviors ofRBD.

4. ln normal individuals there is an atonia seen in REM sleep in the chin and anterior tibialis EMG. ln this state the baseline ampl itude ofthe EMG signal decreases markedly. This atonia ofREM sleep is lost to a considerable extent in RBD, with variable frequency, and asa result, the EMG baseline amplitude is often highe r ln this situation, the EMG can be said to be in a tonie rather than atonie state.

7. SCORING THE PSG FEATURES OF RHYTHMIC MOVEMENT DISORDER [RE OMMENDED]A. The following rule defines the polysomnographic characteristics rhythmic movement disorder:

1 Th e minimum frequency for scoring rhythmic movements is 0.5 Hz2 Th e maximum frequency for scoring rhythmic movements is 2.0 Hz3 Th e minimum number of individual movements requ ired to make a c1uster of rhythmic movements is 4 movements4 Th e minimum amplitude of an individual rhythmic burst is 2 time s the background EMG activity

Notes :1. Bipo lar surface electrodes shou ld be placed to record electrical activity ofthe large muscle groups involved.2. Time synchronized video PSG, in addition to polysomnographic criteria, is necessary to make the diagnosis ofrhythmic movement dis

order.

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VIII. RESPIRATORY RULESRESPIRATORY RULES FOR ADULTS

1 TECHNICAL CONSIDERATIONS [RECOMMENDED]A. The sensor to detect absence ofairflow foridentification ofan apnea isan oronasal thermal sensor.B. The sensor fordetection ofairflow foridentification ofa hypopnea isa nasal airpressure transducer with orwithout square roottransformation of the signal.C. The sensor fordetection of respiratory effort iseither esophageal manometry, orcalibrated or uncalibrated inductance pleth-ysmography.D. The sensor fordetection of blood oxygen ispulse oximetry with a maximum acceptable signal averaging time of3 seconds.Notes:l . Alternative sensors are to be used when the signal from the recommended sensor is not reliable.2. The alternative signalto detect absence ofairflow for identification ofan apnea when the thermistor signal is unreliable is a nasal air

pressure transducer.3. An alternative sensor for detection of effort is diaphragmatic/intercostal EMG.4. For scoring ofhypopnea when the nasal pressure deviee is not functioning, alternative sensors including uncalibrated or calibrated

inductance plethysmography or an oronasal thermal sensor may be used.5. A small bias i.e., more events in reporting hypopneas attheflow threshold recommendedfor scoring hypopneas (


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51POCH 5

ThennalSensor

InduclancPlethSum

Sp 2

1 sec -Figure 2

A. Score a hypopnea ifail of the following criteria are met (See Figure 2): [RECOMMENDED]1) The nasal pressure signal excurs ions (or those of the alternative hypopnea sensor) drop by 2:30% of baseline2) The duration of this drop occurs for a period lasting at least 10 seconds3) There is a 2:4% desaturation from pre-event baseline4) At least 90% of the event's duration must meet the amplitude reduction of criteria for hypopnea

B. Score a hypopnea ifail of the following criteria are met: [ALTERNATIVE]1) The nasal pressure signal excursions (or those of the alternative hypopnea sensor) drop by 2:50% of baseline2) The duration of this drop occurs for a period lasting at least 10 seconds3) There is a 2:3% desaturation from pre-event baseline or the event is associated with arousal4) At least 90% of the event's duration must meet the amplitude reduction of criteria for hypopnea

Note:J. The definition ofhypopnea used (VJl.4.A or VJl.4.B) should be specified in the PSG report.2. Classification ofa hypopnea as obstructive, central, or mixed should not beperformed without a quantitative assessment of ventilatory

effort (esophageal manometry, calibrated respiratory inductance plethysmography, or diaphragmatic/intercostal EMG).

5 RESPIRATORY EFFORTRELATED AROUSAL RULEA. Score a respiratory effort-related arousal (RERA) (Figure 3): [OPTION]

1) f there is a sequence of breaths lasting at least 10 seconds characterized by increasing respiratory effort or f1attening ofthe nasal pressure waveforrn leading to an arousal from sleep when the sequence of breaths does not m t criteria for anapnea or hypopnea.

Notes:J. With respect to scoring a RERA, use ofesophageal pressure is the preferredmethod ofassessing change in respiratory effort, although

nasal pressure and inductance plethysmography can be used.

6 HYPOVENTILATION RULE [OPTION]A. Score hypoventilation during sleep as present ifthere isa mm Hg increase in PaC02 during sleep in comparison toan awakesupin value.Notes:J. Persistent oxygen desaturation is not sufficient to document hypoventilation.2. An increased PaCO! value obtained immediately upon awakening from sleep is suggestive ofsleep hypoventilation.3. At this time, there is insufficient evidence to allow specification ofsensors for direct or surrogate measures ofPaCO Both end-tidall

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ThennalSensor

InductanCllPlethSum

Sp 2

1 secFigure 1

4 HYPOPNEA RULES

46


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EPOCH 50 5

111'11Therm alf\J \J \ VV\J VV\f\MSensor

11

lnductanPlethSum

Sp0210sec

Figure 3CO and transcutaneous CO may be used as surrogate measures ofPaC i there is demonstration ofreliability and validity within2 2 2laboratory practices.

4. At this time there is insufficient evidence to allow specification ofa duration ofhypoventilation though the duration should be sufficientto account for the efJects of response time of the sensor usedand to exclude briefchanges that reflect sensor artifact.

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