PSG T. Prep Flashcards
What is the maximal value for electrode impedances for EEG?
5000 Ohms
What is the minimum digital resolution?
12 bits per sample
What are the minimal and desirable sampling rates for EEG, EOG, EMG and ECG?
Minimal 200 Hz and Desirable 500 Hz
What are the LFF and HFF for EEG channels?
0.3 Hz and 35 Hz
What are the LFF and HFF for EOG channels?
0.3 Hz and 35 Hz
What are the LFF and HFF for EMG channels?
10 Hz and 100 Hz
What are the LFF and HFF for ECG channels?
0.3 Hz and 70 Hz
What are the LFF and HFF oronasal thermal flow and thoracoabdominal belt signals?
0.1 Hz and 15 Hz
What are the LFF and HFF nasal pressure channels?
0.03 Hz and 100 Hz
What are the LFF and HFF for snoring channels?
10 Hz and 100 Hz
For EEG, _____ Hz sampling rate and HFF settings may be increased.
500
Higher sampling rates on channels for EOG, EMG, ECG _________ define waveforms.
better
Which channel is exempt from the digital resolution standard?
Body position
Which channel can have a lower sampling rate?
Snoring channel
Which channel(s) can have impedances of 10 kOhms?
Limb EMG
What is the required display size for scoring and review of sleep data?
15 in screen, 1600 horizontal pixels, 1050 vertical pixels
Each channel must have its own ________ ____ ________.
50/60 Hz filter
Recommended montage derivation for EEG is:
F4-M1, C4-M1, O2-M1 with F3, C3, O1 and M2 as backups.
Standard electrode positions used are part of the _________ system.
10-20
M1 and M2 refer to which electrode placements?
left and right mastoid processes
__ - __ is NOT appropriate for measuring the amplitude of frontal activity for determination of slow wave activity.
FZ-CZ
Recommended EOG derivation and placement are:
E1-M2, E2-M2 with placements of E1 1 cm below and 1 cm lateral left outer canthus; E2 1 cm above and 1 cm lateral right outer canthus.
Conjugate eye movements result in ____ __ _____ deflections.
Out of phase
Acceptable derivations for EOG channels allow for detection of ______ eye movements.
Directional
How many electrodes are required for chin EMG?
3
The preferred abbreviations for sleep stages are:
W, N1, N2, N3 and R
Epochs are described as sleep if they contain: ____ seconds of sleep sequentially OR at least ______ of the epoch is ________.
30, half, sleep
Slow waves in sleep are defined as:
0.5-2.0 Hz AND minimum amplitude of 75 uV in Frontal channels
Define the four main frequencies of waveforms on EEG: delta, theta, alpha, beta
Delta 0-3.99 Hz, Theta 4-7.99 Hz, Alpha 8-13 Hz, Beta faster than 14 Hz
Wakefulness on EEG channels is defined as:
alpha rhythm posterior dominant in the occipital region with eye closure and attenuation to eye opening
Wakefulness is demonstrated in EOG, as: (include description of 4 types of eye movements)
1) Eye blinks - vertical eye movements 0.5-2 Hz; 2) Reading eye movements - slow followed by rapid phase
3) Rapid eye mvmts (REM) - irregular lasting <500 msec
4) Slow eye mvmts (SEM) - more regular, lasting >500 msec
Wakefulness is scored when the following conditions are met:
a) more than 50% of epoch is alpha in the occipital region
b) AND/OR any of the following: 1) eye blinks, 2) REM with normal chin muscle tone, 3) Reading eye movements
Time away from equipment is scored as ______.
wake
Stage N1 sleep is defined as:
1) Slow eye movements (SEM)
2) Low amplitude mixed frequency activity EEG (LAMF) (theta)
3) Vertex sharp waves (V waves) central region
4) Sleep onset - first epoch of any stage other than Wake (W)
LAMF is
Low amplitude mixed frequency activity on EEG found during N1
Describe the 7 characteristics of scoring N1 sleep.
1) PDR (Alpha) attenuated by 50% of LAMF
2) LAMF, V waves, SEM
3) Majority of epoch meets 1 and/or 2 AND absence of ANY other stage
4) Continue N1 until identifies another stage
5) When arousal in N2 - SCORE N1 if LAMF, - K/spindles or any other stage sleep
6) When arousal in REM- score N1 if LAMF, - alpha, + SEM, +chin at REM level
7) N1 until another stage identified
What EEG feature is acceptable but NOT required for N1?
V waves
What EOG feature is acceptable but NOT required for N1?
SEM
Which comes first: SEM or attenuation of alpha?
SEM
N2 is defined by:
1) K complexes
2) sleep spindles
Well delineated, negative sharp wave followed by a positive wave, lasting >0.5 sec, maximal frontal region
K complex
train of distinct sinusoidal waves of 11-16 Hz, lasting >0.5 Hz, seen maximally in the central or vertex region
Sleep Spindles
Stage N2 is differentiated from N1 by:
K complexes with spindles; or K complexes with arousals; IF K complex without spindles
Where else can spindles be found?
Frontal region
When staging sleep, if a K complex occurs in first half of epoch- entire epoch is
N2
When staging sleep, if a K complex happens in the second half of epoch, entire epoch is
N1
If a delay exists between arousal and K complex, epoch is
N1
Stage N2 is scored when the following criteria are met:
a) does not meet N3
b) if last half of previous epoch OR first half of current epoch has >/= 1 k complex or spindle
c) majority of epoch meets N2
d) same/next epoch has arousal - epoch BEFORE arousal is N2
e) epochs with k complex/spindles followed by LAMF & NO arousal - N2
f) Epoch following N3 - NOT N3, W, or R is N2
N2 scoring stops when:
a) transition to W, N3 or R
b) arousal with LAMF
c) Major body movement followed by SEM & LAMF
N3 sleep is defined by:
slow wave activity (0.5-2 Hz)
>75 uV
Frontal region
N3 sleep is scored when:
> 20% of epoch consists of slow wave activity regardless of age
Stage N4 sleep is defined by
Trick question- no longer defined separately. N4 is replaced with N3.
T/F K complex can be considered a slow wave.
True -if it meets slow wave activity criteria, of 0.5-2 hz, > 75 uV and frontal
T/F N3 sleep does NOT have spindles.
False- spindles may be present in N3 sleep.
REM sleep is defined by the following criteria:
a) REM - rapid eye movements, irregular, <500 msec
b) LOW chin EMG - lowest of entire recording
c) Sawtooth waves maximal central region
d) Transient, brief, irregular EMG <0.25 seconds
REM is scored when the following criteria are met:
1) LAMF EEG activity
2) LOW chin EMG majority of epoch
3) Absence of K complexes and/or spindles
4) REMs
5) NO arousals
6) Continue R if MAJORITY of epoch contains segment meeting R
Scoring for REM ends when:
1) Transition to another stage W, N2, N3
2) Increase in CHIN EMG
3) Arousal w/ LAMF & SEM
4) Major body movement with LAMF/SEM, decrease in CHIN EMG
5) Arousal associated K complexes/spindles in FIRST half & NO REMs
Majority of epoch rule applies to which stages?
N2 and REM
First half and last half of epoch rule apply to which stages?
N2 and REM
T/F Alpha can increase in REM for some people.
True, but it is slower in REM than during wakefulness, just more abundant.
If SEM occur during REM, they must be accompanied by __ _________ to change the scoring to N1.
an arousal
REM, low chin EMG and sleep spindles and/or K complexes typically occur during the ______ ____ ______ of the night.
first REM period
Major body movements are defined as
movement or muscle artifact obscuring the EEG for MORE than half of an epoch
If major body movement and <15 second of alpha is present, score is
wake
Epoch 1 - W, Epoch 3 is N2, epoch 2 has a major body movement with no discernable alpha, what is epoch 2 scored as?
Wake
Epoch 1 - N2, Epoch 3 - N2, epoch 2 has a major body movement with no discernable alpha, what is the score for epoch 2?
N2
Arousals are defined by:
1) sudden shift in EEG frequency (anything above delta)
2) must be >3 seconds
3) must follow >10 seconds of stable sleep
4) If during REM - chin EMG must increase simultaneously for >1 second
T/F An arousal cannot be scored if the 10 seconds of stable sleep occurred during an epoch marked wake.
False - as long as the 10 seconds of stable sleep occurred immediately prior to the arousal, an arousal can be scored.
Arousals are scored from what derivations?
central and occipital
Which channel must be included to score arousals?
EEG
A simple description for placement of cardiac leads in sleep is
passenger seatbelt
Artifact is minimized in cardiac leads by using what application?
standard ECG electrode application
Sinus Tachycardia
sustained >90 beats/minute in adults
Bradycardia
sustained <40 beats/minute for ages 6+
Asystole
No beat for more than 3 seconds for ages 6+
V-Tach
Also known as wide complex tachycardia - 3 consecutive beats >100 beats/minute, QRS duration of >120 msec
SVT
Superventricular tachycardia, narrow complex tachycardia - 3 consecutive beats >100 beats/minute, QRS of <120 msec
Atrial Fibrillation
irregularly irregular ventricular rhythm WITH consistent P waves, rapid oscillation, variable sizing, shapes and timing
Sinus rates are _____ in children than in adults
Faster
Sustained sinus bradycardia or tachycardia must have ___ seconds of stable rhythm.
30
Report significant arrhythmias if:
ECG is quality recording
Report ectopic beats if:
clinically significant
Leg movement monitors are placed
1) longitudinally
2) symmetrically
3) middle of anterior tibialis
4) bilaterally
T/F Impedances for leg movement monitors can be <25 kOhms.
False, should be <10 kOhms, but <5 is ideal.
T/F Notch filter should be avoided on leg movement monitors.
True
Leg movements are not scored if:
occurring within a 0.5 second window before or after any respiratory event
What is the cutoff time frame for an associated arousal and limb movement?
within 0.5 seconds
How many arousals are scored when multiple PLMs (periodic limb movements) and associated 3 sec arousals occur within 10 seconds?
Only the first arousal is scored.
Which muscles are monitored in the upper extremities for PLMS?
Flexor Digitorum Superficialis
Extensor Digitorum Communis
What condition is monitored with leads on the masseter muscle?
Bruxism
What additional monitoring is essential for the diagnosis of RMD (rhythmic movement disorder)?
Video PSG
What action should the patient perform to calibrate leads on the anterior tibialis?
point toes toward head
What action should the patient perform to calibrate leads on the flexor digitorum superficialis?
bend at base of fingers
What action should the patient perform to calibrate the leads on the extensor digitorum communis?
extend fingers back without moving the wrist
What action should the patient perform to calibrate the leads on the masseter muscle?
bite down
Define a significant leg movement event.
Duration 0.5-10 sec
Amplitude: Increase of 8 uV ABOVE resting EMG
Timing: EITHER a) point where 8 uV increase happened OR b) point of amplitude drop to 2 uV, after 0.5 sec duration
PLMS are scored based on: number ____ and period ___ _____ ____ -onset to onset.
4 Limb movements
5-90 seconds apart
Leg movements on 2 different legs, within 5 seconds are counted as ___ ____
1 limb movement
ALMA (define term)
Alternating Leg Muscle Activation
4 alternating LM
Frequency 0.5-30 Hz
Alternating between legs
duration of 100-500 msec
benign
HFT (define term)
Hypnagogic Foot Tremor
4 bursts
0.5-4.0 Hz
duration 250-1000 msec
benign movement
EFM (define term)
Excessive Fragmentary Myoclonus
duration 150 msec
20 min of NREM sleep
5 EMG potentials/min
benign movement
Bruxism (define term)
brief OR sustained elevations of chin EMG
BRIEF: 0.25-2 seconds & episodes sequentially
Sustained: duration of >2 seconds
>2x background chin EMG
separated by >3 sec stable background
RBD (define term)
REM Sleep Behavior disorder
1) Tonic sustained activity in >50% of epoch
2) Phasic excessive transient muscle activity in >50% of 10-“3 second mini epochs”
3) Either or BOTH - sustained EMG in chin and/or excessive transient EMG chin/limb during REM
T/F Transient EMG and occasional visible twitching of small muscle groups are normal in REM.
True
RBD is a loss of ______ during REM sleep.
atonia
RMD (define term)
Rhythmic Movement Disorder
1) Freq: 0.5-2.0 Hz
2) >/= 4 mvmts
3) 2x background EMG activity
What tool is used to measure apneas?
Oronasal thermal airflow sensor
What tool is used to measure hypopneas?
nasal pressure transducer
What tools are used to measure respiratory effort?
esophageal manometry, RIP betls and PVDF belts
Duration of an apnea or hypopnea is measured by
a) nadir preceding first breath clearing reduced
b) to beginning of first breath returned to baseline
Apneas are scored when
BOTH 90% or greater drop from baseline AND at least 10 seconds
Obstructive apneas are scored when
continued or increased inspiratory effort throughout event
Central apneas are scored when
absent inspiratory effort throughout event
Mixed apneas are scored when
absent of inspiratory effort for first part of event AND/OR followed by resumption of inspiratory effort
T/F Apnea has to have a desaturation.
False - desat is NOT required to score an apnea
If event qualifies for hypopnea and apnea
Score apnea
1A Hypopnea
> 30% drop for >10 sec AND
3% desat from baseline OR arousal
1B Hypopnea
> 30% drop for >10 sec AND
4% desat from baseline
Obstructive hypopnea
any snoring, inspiratory flattening or paradox breathing
Central hypopnea
NONE snoring, inspiratory flattening, or paradox breathing
RERA in adults
sequence of breath >10 seconds
increased respiratory effort
flattening of inspiratory signal leading to arousal
Hypoventilation
EITHER:
-increase in PC02 >55 mmHg for >10 min
OR
->10 mmHg increase in PC02 during sleep and exceeds 50 mmHg >10 min
What is the conversion factor for hypoventilation scoring?
1 mmHg = 0.133kPa
Cheyne Stokes Breathing
BOTH
>3 consecutive CA or CH separated by a crescendo AND decrescendo in amplitude in a cycle for >40 seconds. AND
>5 CA or CH per hour of sleep over 2 hrs of monitoring
Define cycle length for Cheyne Stokes Breathing
time from beginning of CA to end of next C/D respiratory phase
HSAT Recommended parameters are:
type of device
type of airflow sensors
type of respiratory effort sensor
oxygen saturation
heart rate
HSAT options parameters are
body position
sleep/wake/REM time estimates
snoring (acoustic, piezo-electric, or pressure transducer)
To ID respiratory events on HSAT use:
At least one of:
oronasal thermal airflow sensor
nasal pressure transducer
RIPsum/RIPflow
PVDFsum
To monitoring respiratory effort on HSAT use:
One of the following in either single or dual models:
thoracoabdominal RIP/PVDF/Piezo belts
Pneumatic belts
HSAT oxygen saturation use
pulse ox
To monitor snoring in HSAT
use ONE of the following
acoustic sensor
piezo electric sensor
nasal pressure transucer
HSAT score apnea if:
BOTh - peak signal drop >90% of baseline AND duration of drop is >10 seconds
HSAT score obstructive if
meets apnea criteria AND
continued/increased effort throughout absent airflow
HSAT score central if
meets apnea criteria AND NO effort throughout absent airflow
HSAT score mixed if
meets apnea criteria with initial absent effort followed by effort with no airflow
HSAT Hypopnea - is rule 1 or rule 2 scored if NO sleep is recorded?
Rule 1
HSAT Hypopnea - is A or B scored if >4% O2 desat?
B
T/F HSAT Hypopnea is peak excursion drop of >50% of pre event baseline.
False - >30% drop
In HSAT, PAT stands for
Peripheral Arterial Tonometry
In HSAT, surrogate AHI is based on
estimated sleep time from actigraphy
In HSAT, raw tracings must be available in detail with the
ability to edit events.
HSAT requires at least ____ airflow sensor(s).
1
Monitoring time (MT) is defined as
total recording time minus periods of artifact and time patient was awake
REI is
respiratory event index
In HSAT, MT replaces
TRT - total recording time
Supplemental oxygen may blunt __________.
desaturations.
RIPsum is the sum of signal for
chest and abdomen belts
T/F Monitoring snoring and hypoventilation is optional.
True
T/F Transient muscle activity and occasional visible twitching of small muscle groups are a normal phenomenon seen in N2 sleep.
False, seen in REM
T/F Sinus rates vary by age with adults faster than children.
False, children sinus rates are faster than adults.
