Pediatric Scoring Review

Cindy Nichols, PhD, FAASM, Cindy Nichols, PhD, FAASM, CBSMCBSM

Munson Sleep Disorders CenterMunson Sleep Disorders Center

Traverse City, MITraverse City, MI

I do not have any potential conflicts of interest to disclose.

Objectives

Describe the context for the AASM Describe the context for the AASM Scoring ManualScoring Manual

Describe pediatric PSG scoring rules and Describe pediatric PSG scoring rules and recent updatesrecent updates

Compare and contrast adult and Compare and contrast adult and pediatric scoringpediatric scoring

Opening Comments

Pediatric PSGs often have more artifact that Pediatric PSGs often have more artifact that adult PSGs, and are more susceptible to adult PSGs, and are more susceptible to GIGO. Excluding artifact from real data is GIGO. Excluding artifact from real data is one of the one of the most important tasksmost important tasks of the of the scoring technologist.scoring technologist.

PSG scoring rules artificially dichotomize PSG scoring rules artificially dichotomize developmental and other aspects of sleep developmental and other aspects of sleep scoring, but this is scoring, but this is notnot a rationale for a rationale for breaking the rules.breaking the rules.

Scoring tech thought this was “pop artifact”; acquiring tech made no observational comment

Same with PS = 10mm/sec

Introduction

Pediatrics are defined as children age 2 Pediatrics are defined as children age 2 months post term (vs. neonates).months post term (vs. neonates).

There is no precise upper age boundary There is no precise upper age boundary for pediatric visual (staging) rules; age for pediatric visual (staging) rules; age 18 is conventional.18 is conventional.

Criteria for respiratory events can be Criteria for respiratory events can be used for children <18 years, but an used for children <18 years, but an individual sleep specialist can choose to individual sleep specialist can choose to score children score children >>13 years using adult 13 years using adult respiratory criteria.respiratory criteria.

Iber C et al. American Academy of Sleep Medicine (AASM), 2007.

• Prior to using this manual, there was no certainty that events were scored similarly between sleep centers.

• This lack of inter-center consistency in scoring led to a reimbursement crisis, with the potential that sleep studies would not be paid for by Medicare or other third party payers

• The AASM responded by inviting experts in all aspects of PSG who volunteered thousands of hours to review the literature and establish new scoring rules. The AASM provided administrative and clerical support for this effort.

Terminology of Sleep Stages in Children

Similar to adults for stages W, N1, Similar to adults for stages W, N1, N2, N3, and R.N2, N3, and R.

An added category of N (NREM) is An added category of N (NREM) is used for infants 6 months post-used for infants 6 months post-term and younger.term and younger.

Electrode Placement and Sensitivities

Electrode placement for chin EMG can be Electrode placement for chin EMG can be reduced from 1 cm to 0.5 cm in children with reduced from 1 cm to 0.5 cm in children with small head size, at the discretion of the small head size, at the discretion of the technologist.technologist.

Begin with EEG sensitivity (vertical scaling) of 7 Begin with EEG sensitivity (vertical scaling) of 7 µµV/mm but it is permissible to reduce this to 10 V/mm but it is permissible to reduce this to 10 or 15 or 15 µµV/mm. This will result in some difficulty V/mm. This will result in some difficulty viewing spindles and other low voltage fast viewing spindles and other low voltage fast frequencies (LVFF), so scoring and review should frequencies (LVFF), so scoring and review should be performed with portions of the recording at 7 be performed with portions of the recording at 7 µµV/mm to accurately recognize these V/mm to accurately recognize these frequencies.frequencies.

Scoring W In some children age 2 months – 6 months, and In some children age 2 months – 6 months, and

in children with developmental delays, NREM in children with developmental delays, NREM sleep may contain no spindles, K-complexes, or sleep may contain no spindles, K-complexes, or high amplitude 0.5-2 Hz slow wave activity. high amplitude 0.5-2 Hz slow wave activity. Score these epochs as N.Score these epochs as N.

For the purpose of scoring W and NREM sleep in For the purpose of scoring W and NREM sleep in children, the term “dominant posterior rhythm” children, the term “dominant posterior rhythm” (DPR) replaces the term “alpha rhythm”.(DPR) replaces the term “alpha rhythm”.

DPR gradually increases in frequency until it DPR gradually increases in frequency until it meets criteria for alpha.meets criteria for alpha.

DPR is usually slightly asymmetrical (higher on DPR is usually slightly asymmetrical (higher on the R)the R)

More About Dominant Posterior Rhythm (DPR)

This is defined as the dominant reactive EEG This is defined as the dominant reactive EEG rhythm over the occipital regions in relaxed rhythm over the occipital regions in relaxed wakefulness with eyes closed (evolves into “adult wakefulness with eyes closed (evolves into “adult alpha”).alpha”).

DPR is reactive, attenuating with eye opening or DPR is reactive, attenuating with eye opening or attention. attention.

DPR amplitude is usually >50 DPR amplitude is usually >50 μμV.V. DPR is slower in infants and younger children.DPR is slower in infants and younger children. DPR first develops by age 3-4 months post-term; DPR first develops by age 3-4 months post-term;

frequency is 3.5-4.5 Hz in infants 3-4 months, 5-6 frequency is 3.5-4.5 Hz in infants 3-4 months, 5-6 Hz by 5-6 months, and 7.5-9.5 Hz by age 3 in most.Hz by 5-6 months, and 7.5-9.5 Hz by age 3 in most.

Dominant Posterior Rhythm (DPR) is not all “pseudo-alpha”

DPR typically contains intermixed slower EEG DPR typically contains intermixed slower EEG rhythms including rhythms including posterior slow waves of youthposterior slow waves of youth (PSW) which are:(PSW) which are: intermittent runs of bilateral but often asymmetric intermittent runs of bilateral but often asymmetric

2.5-4.5 Hz slow waves superimposed, riding upon, 2.5-4.5 Hz slow waves superimposed, riding upon, or fused with the DPR (looks a little like “alpha-or fused with the DPR (looks a little like “alpha-delta”; can be mistaken for low frequency artifact or delta”; can be mistaken for low frequency artifact or N3)N3)

usually >120% of DPR voltageusually >120% of DPR voltage usually blocked with eye opening and usually blocked with eye opening and disappeardisappear

with drowsiness and sleepwith drowsiness and sleep uncommon in children <2 years, have maximal uncommon in children <2 years, have maximal

incidence in age 8-14, and are uncommon after age incidence in age 8-14, and are uncommon after age 2121

Other Waves Seen Mixed In With DPR

DPR typically contains intermixed slower EEG DPR typically contains intermixed slower EEG rhythms including:rhythms including: Posterior slow waves of youth (PSW)Posterior slow waves of youth (PSW) Random or semi-rhythmic occipital slowingRandom or semi-rhythmic occipital slowing

is <100 is <100 μV, 2.5-4.5 Hz rhythmic or μV, 2.5-4.5 Hz rhythmic or arrhythmic activity lasting <3 seconds.arrhythmic activity lasting <3 seconds.

is a normal finding in EEGs of children 1-is a normal finding in EEGs of children 1-15 years, especially prominent in age 5-7.15 years, especially prominent in age 5-7.

With increasing age, the amount of With increasing age, the amount of intermixed slowing decreases and its intermixed slowing decreases and its frequency increases.frequency increases.

A Few More Wake Rhythms

MuMu 8-10 Hz8-10 Hz Resembles alpha but does not block with eye Resembles alpha but does not block with eye

openingopening Blocks contralaterally with movement, intent to Blocks contralaterally with movement, intent to

move, or tactile stimulation of an extremitymove, or tactile stimulation of an extremity More common in femalesMore common in females

LambdaLambda Sharp, fairly rhythmic waves with negative Sharp, fairly rhythmic waves with negative

deflection deflection Often present unilaterallyOften present unilaterally Usually seen in well-lighted room if child is Usually seen in well-lighted room if child is

looking at a patterned designlooking at a patterned design

MUMU

Sens 7uv/mm HFF 70Hz LFF 1.0 Hz PS 30mm/secSens 7uv/mm HFF 70Hz LFF 1.0 Hz PS 30mm/sec

Same with sens 15uv/mmSame with sens 15uv/mm

Same with PS 10mm/sec and only central and occipital channelsSame with PS 10mm/sec and only central and occipital channels

Sens 5uv/mm HFF 70Hz notch off LFF 1.0Hz PS 30mm/secSens 5uv/mm HFF 70Hz notch off LFF 1.0Hz PS 30mm/sec

Lambda

Same sample with central and occipital only, same settingsSame sample with central and occipital only, same settings

Same sample at 10mm/secSame sample at 10mm/sec

Scoring W

Score epochs as W when more than 50% of Score epochs as W when more than 50% of the epoch has either reactive alpha or age-the epoch has either reactive alpha or age-appropriate DPR over the occipital region.appropriate DPR over the occipital region.

If there is no discernable reactive alpha or no If there is no discernable reactive alpha or no age-appropriate DPR, score W if any of the age-appropriate DPR, score W if any of the following are present:following are present: eye blinks at a frequency of 0.5-2 Hzeye blinks at a frequency of 0.5-2 Hz reading eye movementsreading eye movements irregular conjugate REMs associated with irregular conjugate REMs associated with

normal or high chin muscle tonenormal or high chin muscle tone

Scoring WIt is important to differentiate occipital sharp It is important to differentiate occipital sharp

waves occurring in stage W from K-complexes waves occurring in stage W from K-complexes which are characteristic of stage N2.which are characteristic of stage N2. Occipital sharp waves typically occur 100-500 Occipital sharp waves typically occur 100-500

msec after an eye blink or eye movement.msec after an eye blink or eye movement. Occipital sharp waves are typically single Occipital sharp waves are typically single

monophasic or biphasic <200 V sharp waves over monophasic or biphasic <200 V sharp waves over the occipital derivation and usually last 200-400 the occipital derivation and usually last 200-400 msec.msec.

The initial component is surface-The initial component is surface-positivepositive, the next , the next is negative and has a steep ascending wave front, is negative and has a steep ascending wave front, and the final descending phase of the second and the final descending phase of the second component is less steep.component is less steep.

Eye Movements in W

Spontaneous eye closure in children, Spontaneous eye closure in children, particularly infants, typically signals particularly infants, typically signals drowsiness. (Zoom video in on eyes while drowsiness. (Zoom video in on eyes while scoring!)scoring!)

The highest amplitude and sharpest The highest amplitude and sharpest component of reading eye movements in component of reading eye movements in children is usually surface-negative in the children is usually surface-negative in the occipital derivations, typically lasts 150-occipital derivations, typically lasts 150-250 msec, and has amplitude up to 65 250 msec, and has amplitude up to 65 μμV.V.

Scoring N1 In children who generate DPR, score N1 if the In children who generate DPR, score N1 if the

posterior rhythm is attenuated or replaced by low posterior rhythm is attenuated or replaced by low amplitude mixed frequency activity for more than amplitude mixed frequency activity for more than 50% of the epoch.50% of the epoch.

In children who do not generate a DPR (often seen In children who do not generate a DPR (often seen with psychoactive medications), score N1 with psychoactive medications), score N1 commencing with the earliest of any of the commencing with the earliest of any of the following phenomena:following phenomena: 4-7 Hz activity with slowing of background 4-7 Hz activity with slowing of background

frequencies by frequencies by >>1-2 Hz from stage W1-2 Hz from stage W slow eye movementsslow eye movements vertex sharp waves or rhythmic anterior theta vertex sharp waves or rhythmic anterior theta

activityactivity hypnagogic hypersynchronyhypnagogic hypersynchrony 3-5 Hz diffuse or rhythmic occipital predominant 3-5 Hz diffuse or rhythmic occipital predominant

high amplitude rhythmhigh amplitude rhythm

Drowsiness in W-N1

Drowsiness in infants up to 6-8 months is Drowsiness in infants up to 6-8 months is characterized by the gradual appearance of characterized by the gradual appearance of diffuse high amplitude (75-200 diffuse high amplitude (75-200 μμV) 3-5 Hz V) 3-5 Hz activity which is typically of higher amplitude, activity which is typically of higher amplitude, more diffuse, and 1-2 Hz slower than the more diffuse, and 1-2 Hz slower than the waking EEG background activity.waking EEG background activity.

Drowsiness in children 8 months-3 years is Drowsiness in children 8 months-3 years is characterized by either diffuse runs or bursts characterized by either diffuse runs or bursts of rhythmic or semi-rhythmic bisynchronous of rhythmic or semi-rhythmic bisynchronous 75-200 75-200 μμV, 3-4 Hz activity often maximal over V, 3-4 Hz activity often maximal over the occipital regions the occipital regions and/orand/or higher amplitude higher amplitude (>200 (>200 μμV) 4-6 Hz theta activity maximal over V) 4-6 Hz theta activity maximal over the frontocentral or central regions.the frontocentral or central regions.

Drowsiness in W-N1

Sleep onset from 3 years on is often Sleep onset from 3 years on is often characterized by a 1-2 Hz slowing of the DPR characterized by a 1-2 Hz slowing of the DPR frequency frequency and/orand/or the DPR rhythm becomes the DPR rhythm becomes diffusely distributed then is gradually replaced diffusely distributed then is gradually replaced by relatively low voltage mixed frequency EEG by relatively low voltage mixed frequency EEG activity.activity.

In most children sleep onset will be the first In most children sleep onset will be the first epoch of stage N1 but in infants younger than 3 epoch of stage N1 but in infants younger than 3 months post-term, this is often stage R.months post-term, this is often stage R.

Rhythmic anterior theta Rhythmic anterior theta activity is commonly activity is commonly seen in adolescents and young adults when seen in adolescents and young adults when drowsy, and may first appear at age 5 years.drowsy, and may first appear at age 5 years.

Terms Related to Scoring N1

Slow eye movementSlow eye movement: conjugate, reasonably : conjugate, reasonably regular, sinusoidal eye movements with an regular, sinusoidal eye movements with an initial deflection which usually lasts >50 msecinitial deflection which usually lasts >50 msec

Vertex sharp wavesVertex sharp waves: sharply contoured waves : sharply contoured waves with duration <0.5 sec maximal over the with duration <0.5 sec maximal over the central region and distinguishable from the central region and distinguishable from the background activity; can be seen in bursts or background activity; can be seen in bursts or runsruns

Rhythmic anterior theta activityRhythmic anterior theta activity: runs of 5-7 Hz : runs of 5-7 Hz rhythmic theta activity maximal over the rhythmic theta activity maximal over the frontal or frontocentral regionsfrontal or frontocentral regions

Terms Related to Scoring N1 (continued)

Hypnagogic hypersynchronyHypnagogic hypersynchrony: : paroxysmal bursts or runs of diffuse high paroxysmal bursts or runs of diffuse high

amplitude sinusoidal 75-350 amplitude sinusoidal 75-350 μμV, 3-4.5 Hz V, 3-4.5 Hz waves which begin abruptly, are usually waves which begin abruptly, are usually widely distributed but often maximal over widely distributed but often maximal over the central, frontal, or frontocentral scalp the central, frontal, or frontocentral scalp regions and alternate with LVMF activity regions and alternate with LVMF activity (always score N1 if you see this)(always score N1 if you see this)

becomes less prevalent after age 4-5 becomes less prevalent after age 4-5 years and is rarely seen after age 12 years and is rarely seen after age 12 yearsyears

Scoring N2

Same as adult rulesSame as adult rules Developmental notesDevelopmental notes

Spindles are usually first seen at age 4-6 Spindles are usually first seen at age 4-6 weeks and are usually well-developed by weeks and are usually well-developed by age 8-9 weeks.age 8-9 weeks.

Spindles are more prominent in frontal Spindles are more prominent in frontal placement up to age 13, then become more placement up to age 13, then become more prominent in central placements.prominent in central placements.

K complexes typically develop at 5-6 K complexes typically develop at 5-6 months post-term and are maximal over the months post-term and are maximal over the pre-frontal and frontal regions (like adults).pre-frontal and frontal regions (like adults).

Scoring N3

Same as adult rulesSame as adult rules Developmental notesDevelopmental notes

Slow wave activity first appears as early as Slow wave activity first appears as early as 2 months, more often about 3-4.5 months 2 months, more often about 3-4.5 months post-term.post-term.

Amplitude of slow waves is typically 100-Amplitude of slow waves is typically 100-400 400 μμV.V.

The decrease in voltage with increasing age The decrease in voltage with increasing age is ascribed to increasing skull bone density.is ascribed to increasing skull bone density.

Scoring R

Same as adult rulesSame as adult rules Developmental notesDevelopmental notes

The LVMF dominant frequencies tend to The LVMF dominant frequencies tend to increase with age and resemble adult LVMF increase with age and resemble adult LVMF activity by age 5-10.activity by age 5-10.

Scoring Arousals

Same as adult ruleSame as adult rule

Scoring Cardiac Events Same as adult except for definition of sinus Same as adult except for definition of sinus

rates.rates. There is a paucity of heart rate data on children There is a paucity of heart rate data on children

during sleep.during sleep. Bradycardia for age 6 years and older is defined Bradycardia for age 6 years and older is defined

as a sustained HR <40 bpm.as a sustained HR <40 bpm. In children under age 6, sinus bradycardia can In children under age 6, sinus bradycardia can

be defined as 2 SD below the mean heart rate be defined as 2 SD below the mean heart rate during sleep. during sleep.

It is suggested that sinus tachycardia in children It is suggested that sinus tachycardia in children is defined as 2 SD above the mean heart rate is defined as 2 SD above the mean heart rate during sleep. during sleep.

Scoring Cardiac Events

ageage -2 SD (brady) +2 SD above -2 SD (brady) +2 SD above (tachy)(tachy)

1-1.51-1.5 92 92 136 136

2-42-4 67 67 119 119

5-75-7 64 64 100 100

8-118-11 53 53 92 92

Scoring Movements

Same as adult rulesSame as adult rules

Monitoring Devices for Respiration in Children

Best sensor for detection of apnea is oronasal Best sensor for detection of apnea is oronasal thermal sensor (same as adults).thermal sensor (same as adults).

Best sensor for detection of hypopnea (and Best sensor for detection of hypopnea (and alternate sensor for apnea) is a nasal air pressure alternate sensor for apnea) is a nasal air pressure transducer transducer withoutwithout square root transformation of square root transformation of the signal.the signal.

Acceptable sensors for detection of respiratory Acceptable sensors for detection of respiratory effort are esophageal manometry, or calibrated or effort are esophageal manometry, or calibrated or uncalibrated inductance plethysmography (same uncalibrated inductance plethysmography (same as adults). as adults). IC EMG is no longer recommended.IC EMG is no longer recommended.

Acceptable methods for assessing alveolar Acceptable methods for assessing alveolar hypoventilation are either transcutaneous (Thypoventilation are either transcutaneous (TCC) or ) or end-tidal (Eend-tidal (ETT)PCO)PCO22 monitoring. monitoring.

Monitoring Devices for Respiration in Children

Alternative sensors are to be used when the signal Alternative sensors are to be used when the signal from the recommended sensor is not reliable.from the recommended sensor is not reliable. The alternative signal to detect apnea is a nasal The alternative signal to detect apnea is a nasal

air pressure transducer.air pressure transducer. Alternative signals for identification of apnea Alternative signals for identification of apnea

are end-tidal PCOare end-tidal PCO22 and summed calibrated and summed calibrated inductance plethysmography.inductance plethysmography.

Alternative sensor for detection of airflow for Alternative sensor for detection of airflow for identification of hypopnea is an oronasal identification of hypopnea is an oronasal thermal sensor.thermal sensor.

Monitoring Devices for Respiration in Children

End-tidal PCOEnd-tidal PCO22 often malfunctions or provides often malfunctions or provides falsely low values in patients who have falsely low values in patients who have marked nasal obstructionmarked nasal obstruction profuse nasal secretionsprofuse nasal secretions are obligate mouth breathersare obligate mouth breathers are receiving supplemental oxygenare receiving supplemental oxygen

It is crucial to obtain a It is crucial to obtain a plateauplateau in the end-tidal in the end-tidal waveform for the signal to be considered valid.waveform for the signal to be considered valid.

Transcutaneous PCOTranscutaneous PCO22 monitoring provides only a monitoring provides only a semi-quantitative index of trends in alveolar semi-quantitative index of trends in alveolar ventilation, and varies unpredictably from the ventilation, and varies unpredictably from the PaCOPaCO22 (typically lower, and lagging after the (typically lower, and lagging after the event).event).

Apnea Rules: Obstructive

Must meet all of the following:Must meet all of the following: event lasts for at least 2 missed breaths (or the event lasts for at least 2 missed breaths (or the

duration of 2 breaths as determined by baseline duration of 2 breaths as determined by baseline breathing pattern)breathing pattern)

event is associated with a >90% fall in the signal event is associated with a >90% fall in the signal amplitude for amplitude for >>90% of the entire respiratory 90% of the entire respiratory event compared to the pre-event baseline event compared to the pre-event baseline amplitude (same as adults but without the “9 amplitude (same as adults but without the “9 second rule”)second rule”)

event is associated with continued or increased event is associated with continued or increased inspiratory effort throughout the entire period of inspiratory effort throughout the entire period of decreased airflow (same as adults)decreased airflow (same as adults)

duration of the apnea is measured from the end duration of the apnea is measured from the end of the last normal breath to the beginning of the of the last normal breath to the beginning of the first breath that achieves the pre-event baseline first breath that achieves the pre-event baseline inspiratory excursion (same as adults)inspiratory excursion (same as adults)

Apnea Rules: Mixed

Must meet all of the following criteria:Must meet all of the following criteria: event lasts for at least 2 missed breaths (or the event lasts for at least 2 missed breaths (or the

duration of 2 breaths as determined by baseline duration of 2 breaths as determined by baseline breathing pattern)breathing pattern)

event is associated with a >90% fall in the event is associated with a >90% fall in the signal amplitude for signal amplitude for >>90% of the entire 90% of the entire respiratory event compared to the pre-event respiratory event compared to the pre-event baseline amplitude (same as adults except for baseline amplitude (same as adults except for the 9 second rule)the 9 second rule)

event is associated with absent inspiratory event is associated with absent inspiratory effort in the initial portion of the event, followed effort in the initial portion of the event, followed by resumption of inspiratory effort before the by resumption of inspiratory effort before the end of the event (same as adults)end of the event (same as adults)

Apnea Rules: Central

Event is associated with absent inspiratory Event is associated with absent inspiratory effort throughout the entire duration of the effort throughout the entire duration of the event and one of the following criteria is event and one of the following criteria is met:met: event lasts 20 seconds or longerevent lasts 20 seconds or longer event lasts at least 2 missed breaths (or event lasts at least 2 missed breaths (or

the duration of 2 breaths as determined the duration of 2 breaths as determined by baseline breathing pattern) by baseline breathing pattern) andand is is associated with an arousal, an awakening associated with an arousal, an awakening oror a a >>3% desaturation.3% desaturation.

Pediatric Hypopnea Rules

Score a respiratory event as hypopnea if it Score a respiratory event as hypopnea if it meets all of the following criteria:meets all of the following criteria: event is associated with a event is associated with a >>50% fall (adult is 50% fall (adult is

30%) in the amplitude of the nasal pressure or 30%) in the amplitude of the nasal pressure or alternative signal compared to the pre-event alternative signal compared to the pre-event baseline excursionbaseline excursion

event lasts at least 2 missed breaths (or the event lasts at least 2 missed breaths (or the duration of 2 breaths as determined by baseline duration of 2 breaths as determined by baseline breathing pattern) from the end of the last breathing pattern) from the end of the last normal breathing amplitudenormal breathing amplitude

fall in the nasal pressure signal amplitude must fall in the nasal pressure signal amplitude must last for last for >>90% of the entire respiratory event 90% of the entire respiratory event compared to the signal amplitude preceding the compared to the signal amplitude preceding the event (same as adult)event (same as adult)

event is associated with an arousal, awakening, event is associated with an arousal, awakening, or or >>3% desaturation (adult is 4%)3% desaturation (adult is 4%)

Pediatric RERA Rules for Use with the Nasal Pressure Sensor

All of the following must be met:All of the following must be met: Event is associated with Event is associated with arousalarousal discernible fall in the amplitude of signal but less discernible fall in the amplitude of signal but less

than 50% in comparison to the baseline levelthan 50% in comparison to the baseline level flattening of the waveformflattening of the waveform event is accompanied by event is accompanied by snoring, noisy snoring, noisy

breathing, elevation in the end-tidal PCObreathing, elevation in the end-tidal PCO22 or or transcutaneous PCOtranscutaneous PCO22, or visual evidence of , or visual evidence of increased work of breathingincreased work of breathing

duration is at least two breath cycles (or the duration is at least two breath cycles (or the duration of 2 breaths as determined by baseline duration of 2 breaths as determined by baseline breathing pattern)breathing pattern)

Comments on Hypopneas and RERAS

Intolerance and malfunction of the nasal pressure Intolerance and malfunction of the nasal pressure sensor occurs more commonly in infants and children sensor occurs more commonly in infants and children than in adults. When this occurs, hypopneas may be than in adults. When this occurs, hypopneas may be scored using a thermal sensor if the signal quality is scored using a thermal sensor if the signal quality is adequate, following the same criteria used for adequate, following the same criteria used for scoring hypopneas with a nasal pressure sensor.scoring hypopneas with a nasal pressure sensor.

RERA in children RERA in children cannotcannot be scored without adequate be scored without adequate nasal pressure or esophageal pressure signal.nasal pressure or esophageal pressure signal.

Classification of hypopnea as obstructive, central, or Classification of hypopnea as obstructive, central, or mixed should not be performed without a mixed should not be performed without a quantitative assessment of ventilatory effort quantitative assessment of ventilatory effort (esophageal manometry or (esophageal manometry or calibratedcalibrated respiratory respiratory inductance plethysmography) inductance plethysmography) more on this ….more on this ….

Use of a derived signal is promising technology but Use of a derived signal is promising technology but notnot yet acceptable for scoring of respiratory events. yet acceptable for scoring of respiratory events.

Dr. Cindy

Proposed Definition for Central Hypopnea

Central hypopneaCentral hypopnea:  50-90% reduction in :  50-90% reduction in oronasal airflow for at least 10 seconds,  oronasal airflow for at least 10 seconds,  associated with 50-90% in-phase reduction associated with 50-90% in-phase reduction of thoracoabdominal movement, followed of thoracoabdominal movement, followed by oxygen desaturation of at least 3% (4% by oxygen desaturation of at least 3% (4% in adults).  The event should not be scored in adults).  The event should not be scored as central in the presence of snoring or as central in the presence of snoring or increase in submental EMG activity.  increase in submental EMG activity. 

Follow-up – will using this proposed rule jeopardize our accreditation status?

Per Dr. Rosenberg (AASM):

“Given the ambiguity of the scoring rules you will not be penalized on accreditation for specifying scoring criteria for central hypopnea.”

Hypoventilation and Periodic Breathing Rules

Score hypoventilation when >25% of the Score hypoventilation when >25% of the TSTTST (include only the time in which CO (include only the time in which CO22 measure is valid!) as measured by either measure is valid!) as measured by either the transcutaneous PCOthe transcutaneous PCO22 and/or end-tidal and/or end-tidal COCO22 sensor(s) is spent with a CO sensor(s) is spent with a CO22 >50 >50 mmHg.mmHg.

Score periodic breathing if there are >3 Score periodic breathing if there are >3 episodes of central apnea lasting >3 episodes of central apnea lasting >3 seconds separated by no more than 20 seconds separated by no more than 20 seconds of normal breathing.seconds of normal breathing.

This is the Last Slide . . . .

An understanding of the ontogeny of sleep is An understanding of the ontogeny of sleep is critical to expert pediatric sleep scoring.critical to expert pediatric sleep scoring.

Be on the lookout for interesting EEG Be on the lookout for interesting EEG waveforms in children. Capture examples and waveforms in children. Capture examples and share with your colleagues.share with your colleagues.

Identification of artifact by the acquiring tech Identification of artifact by the acquiring tech is critical to accurate scoring.is critical to accurate scoring.

Review your AASM 2007 manual and the Review your AASM 2007 manual and the articles in the accompanying JCSM issue at articles in the accompanying JCSM issue at least once per year and keep these references least once per year and keep these references at your work station.at your work station.

Check the AASM Scoring FAQs at least 4 times Check the AASM Scoring FAQs at least 4 times per year for scoring updates.per year for scoring updates.