Procedures in the Sleep Laboratory

AAST Technologist Fundamentals Date: May 7, 2017 Focus Conference Location: Orlando, Florida Workshop Procedures in the Sleep Laboratory Laree Fordyce, RST, RPSGT, CCRP

Conflict of Interest Disclosures for Speakers X 1. I do not have any potential conflicts to disclose. 2. I wish to disclose the following potential conflicts of interest: Type of Potential Conflict Details of Potential Conflict Grant/Research Support Consultant Speakers Bureaus Financial support Other 3. The material presented in this lecture has no relationship with any of these potential conflicts, OR 4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:

Objectives 1. Review the American Academy of Sleep Medicine practice parameters for testing; and 2. Discuss recording, documentation and reporting techniques for Polysomnography, MSLT, MWT and Home Sleep Apnea Testing (HSAT).

AASM Practice Parameters for Testing http://www.aastweb.org/technical-guidelines PSG MSLT MWT HSAT

PSG

Recording Polysomnography When starting a study, we need to make sure that we have a history, physical exam, previous test results, referral and insurance information, physician s orders, etc.) The sleep technologist prepares for and monitors the recording, requiring expertise in normal and abnormal sleep and multiple technical and medical monitors. The sleep technologist verifies and maintains the quality of the recording and can decipher artifact from true physiological signals. The technologist can recognize when medical intervention is required and responds according to the protocols provided by the medical director. Therefore, attended polysomnography by a trained sleep technologist produces the highest quality clinical tool.

Documentation The sleep technologist is the eyes and ears of the interpreting sleep physician.

What do you see?

Sweat artifact TECH NOTE: Pt sweating +++, turned on Fan

What is happening here?

Poor impedance of M2 electrode

Documentation The sleep technologist is the eyes and ears of the interpreting sleep physician. Document everything you observe. Document any changes that you make throughout the recording.

Reporting The standard diagnostic PSG requires the recording and evaluation of sleep stages and arousals, respiration, limb movements, snoring, oximetry, body position, and cardiac rhythm disturbances. The resulting documentation is used to diagnose or assess the treatment of sleep disorders

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STAGES OF SLEEP Stage W Stage N1 Stage N2 Wakefulness NREM1 NREM2 Stage N3 NREM3 Stage R REM

The Polysomnographic Report Patient Information: Name: Ht-cm: Interpreting Physician: Age: Wt-kg: Referral Provider: DOB : BMI: Recorded By: Sex: Neck Circumference: Study Indication: PHN : Study # : ----------------------------------------------------------------------------------------------------------------------- Polysomnography was conducted on the night of 24/03/2016. The following parameters were monitored: frontal, central and occipital EEG, electro-oculogram (EOG), sub-mental EMG, nasal and oral airflow, anterior tibialis EMG, body position and electrocardiogram. Additionally, thoracic and abdominal movements were recorded by inductance plethysmography. Oxygen saturation (SpO2) was monitored using a pulse oximeter. The tracing was scored using 30 second epochs. Hypopneas were scored per AASM definition VIII4.B (3% desaturation). Tech Comments:

Sleep Summary Lights Out: 8:30:17 PM Stage Duration % TST Lights On: 5:53:47 AM N1 3.5 min 0.6% Total Recording Time (TIB): 563.5 min N2 266.5 min 48.5% Total Sleep Time (TST): 549.0 min N3 158.5 min 28.9% Sleep Period Time: 555.5 min R 120.5 min 21.9% Sleep Onset: 8:35:47 PM --------------------------------------------------------------------------------------------------------------------------------------- Sleep Efficiency: 97.4 % Latencies From Lights Out From Sleep Onset Wake After Sleep Onset (WASO): 9.0 min N1 5.5 min 0.0 min Wake During Sleep 6.5 min N2 7.0 min 17.0 min Total Wake Time: 14.5 min N3 22.5 min 17.0 min % Wake Time: 2.6 R 222.5 217.0 min

Respiratory Summary Central Mixed Obstructive Avg Max # Avg Max # Avg Max # Apneas, NREM: 14 11.0 16.0 0 0.0 12 13.4 12 Apneas, REM: 2 10.8 11.0 - -- 10 15.8 17 Apneas, Total: 16 11.0 16.0 0 0.0 13 14.5 29 --------------------------------------------------------------------------------------------------------------------------------- Event Statistics Total WAI # W/O AI Apneas: 29 3.2 10 1.1 Hypopneas: 36 3.9 20 2.2 A + H Total: 65 AHI: 7.1 30 3.2 ---------------------------------------------------------------------------------------------------------------------------------- Oximetry Data Min SpO2 value TST: 87% Average SpO2 (TIB): 96% Min SpO2 w/ Respiratory Event: 89% Average SpO2 (TST): 96% Desaturations #: 4 Desaturation Index: 0.4/hr

Periodic Leg Movements Total # Limb Movement 83 Limb Movement Index 9.0 Total # PLMS 28 PLMS Index 3.0 Total # PLMS Arousals: 7 PLMS Arousal Index: 0.8 -------------------------------------------------------------------------------------------------------- Arousals Respiratory: Leg Movements: Snore: Spontaneous: Total: Arousal Index: REM: 3 1 0 3 7 3.5 NREM: 27 31 0 77 135 18.9 Arousals: 30 32 0 80 142 15.3

MSLT

MSLT Box 1 Recommendations for the MSLT Protocol (Adapted from Carskadon and colleagues, Guidelines for the multiple sleep latency test (MSLT): a standard measure of sleepiness 9. Modified by collective expert opinion using Rand/UCLA Appropriateness Method) 1. The MSLT consists of five nap opportunities performed at two hour intervals. The initial nap opportunity begins 1.5 to 3 hours after termina- tion of the nocturnal recording. A shorter four-nap test may be performed but this test is not reliable for the diagnosis of narcolepsy unless at least two sleep onset REM periods have occurred. 2. The MSLT must be performed immediately following polysomnography recorded during the individual s major sleep period. The use of MSLT to support a diagnosis of narcolepsy is suspect if TST on the prior night sleep is less than 6 hours. The test should not be performed after a split- night sleep study (combination of diagnostic and therapeutic studies in a single night). 3. Sleep logs may be obtained for 1 week prior to the MSLT to assess sleep-wake schedules. 4. Standardization of test conditions is critical for obtaining valid results. Sleep rooms should be dark and quiet during testing. Room tempera- ture should be set based on the patient s comfort level. 5. Stimulants, stimulant-like medications, and REM suppressing medications should ideally be stopped 2 weeks before MSLT. Use of the patient s other usual medications (e.g., antihypertensives, insulin, etc.) should be thoughtfully planned by the sleep clinician before MSLT testing so that undesired influences by the stimulating or sedating properties of the medications are minimized. Drug screening may be indicated to ensure that sleepiness on the MSLT is not pharmacologically induced. Drug screening is usually performed on the morning of the MSLT but its timing and the circumstances of the testing may be modified by the clinician. Smoking should be stopped at least 30 minutes prior to each nap opportunity. Vigorous physical activity should be avoided during the day and any stimulating activities by the patient should end at least 15 minutes prior to each nap opportunity. The patient must abstain from any caffeinated beverages and avoid unusual exposures to bright sunlight. A light breakfast is rec- ommended at least 1 hour prior to the first trial, and a light lunch is recommended immediately after the termination of the second noon trial. 6. Sleep technologists who perform MSLTs should be experienced in conducting the test. 7. The conventional recording montage for the MSLT includes central EEG (C3-A2, C4-A1) and occipital (O1-A2, O2-A1) derivations, left and right eye electrooculograms (EOGs), mental/submental electromyogram (EMG), and electrocardiogram (EKG). 8.. Prior to each nap opportunity, the patient should be asked if they need to go to the bathroom or need other adjustments for comfort. Standard instructions for bio-calibrations (i.e., patient calibrations) prior to each nap include: (1) lie quietly with your eyes open for 30 seconds, (2) close both eyes for 30 seconds, (3) without moving your head, look to the right, then left, then right, then left, right and then left, (4) blink eyes slow- ly for 5 times, and (5) clench or grit your teeth tightly together. 9. With each nap opportunity the subject should be instructed as follows: Please lie quietly, assume a comfortable position, keep your eyes closed and try to fall asleep. The same instructions should be given prior to every test. Immediately after these instructions are given, bedroom lights are turned off, signaling the start of the test. Between naps, the patient should be out of bed and prevented from sleeping. This generally requires continuous observation by a laboratory staff member. 10. Sleep onset for the clinical MSLT is determined by the time from lights out to the first epoch of any stage of sleep, including stage 1 sleep. Sleep onset is defined as the first epoch of greater than 15 sec of cumulative sleep in a 30-sec epoch. The absence of sleep on a nap opportunity is recorded as a sleep latency of 20 minutes. This latency is included in the calculation of mean sleep latency (MSL). In order to assess for the occurrence of REM sleep, in the clinical MSLT the test continues for 15 minutes from after the first epoch of sleep. The duration of 15 minutes is determined by clock time, and is not determined by a sleep time of 15 minutes. REM latency is taken as the time of the first epoch of sleep to the beginning of the first epoch of REM sleep regardless of the intervening stages of sleep or wakefulness. 11. A nap session is terminated after 20 minutes if sleep does not occur. 12. The MSLT report should include the start and end times of each nap or nap opportunity, latency from lights out to the first epoch of sleep, mean sleep latency (arithmetic mean of all naps or nap opportunities), and number of sleep-onset REM periods (defined as greater than 15 sec of REM sleep in a 30-sec epoch). 13. Events that represent deviation from standard protocol or conditions should be documented by the sleep technologist for review by the inter- preting sleep clinician.

Multiple Sleep Latency Test - Recording 4-5 nap opportunities performed at 2 hour intervals Following a PSG» follow patient s habitual schedule (sleep logs)» use for narcolepsy diagnosis is suspect if TST < 6 hours, usefulness» not after split night study with CPAP First test: 1.5-3 hrs. after lights on Stimulants, stimulant-like medications and REM suppressing medications should be stopped 2 weeks prior to MSLT Drug screening may be indicated Smoking stopped at least 30 minutes prior to each nap No caffeine No sleep/dozing between tests

Multiple Sleep Latency Test - Documentation Montage (EEG, EOG, EMG and EKG) Bio-cals prior to each nap. Instruct patient to Please lie quietly, in a comfortable position with your eyes closed Sleep onset:» first epoch of any stage of sleep» Nap will be terminated after 15 minutes from sleep onset» if no sleep, latency is 20 min

MSLT - Reporting The MSLT report should include: - the start and end times of each nap or nap opportunity, - latency from lights out to the first epoch of sleep, - mean sleep latency (arithmetic mean of all naps or nap opportunities), - number of sleep-onset REM periods (defined as greater than 15 sec of REM sleep in a 30-sec epoch).

SLEEP ONSET (Clinical MSLT, AASM recommends for PSG)

MWT Box 2 Recommendations for the MWT protocol (Developed from methods of Doghramji and colleagues, A normative study of the maintenance of wakefulness test (MWT), 1997. 10 Modified by collective expert opinion using Rand/UCLA Appropriateness Method) 1. The 4-trial MWT 40-minute protocol is recommended. The MWT consists of four trials performed at two hour intervals, with the first trial beginning about 1.5 to 3 hours after the patient s usual wake-up time. This usually equates to a first trial starting at 0900 or 1000 hours. 2. Performance of a PSG prior to MWT should be decided by the clinician based on clinical circumstances. 3. Based on the Rand/UCLA Appropriateness Method, no consensus was reached regarding the use of sleep logs prior to the MWT; there are instances, based on clinical judgment, when they may be indicated. 4. The room should be maximally insulated from external light. The light source should be positioned slightly behind the subject s head such that it is just out of his/her field of vision, and should deliver an illuminance of 0.10-0.13 lux at the corneal level (a 7.5 W night light can be used, placed 1 foot off the floor and 3 feet laterally removed from the subject s head). Room temperature should be set based on the patient s com- fort level. The subject should be seated in bed, with the back and head supported by a bedrest (bolster pillow) such that the neck is not uncom- fortably flexed or extended. 5. The use of tobacco, caffeine and other medications by the patient before and during MWT should be addressed and decided upon by the sleep clinician before MWT. Drug screening may be indicated to ensure that sleepiness/wakefulness on the MWT is not influenced by substances other than medically prescribed drugs. Drug screening is usually performed on the morning of the MWT but its timing and the circumstances of the testing may be modified by the clinician. A light breakfast is recommended at least 1 hour prior to the first trial, and a light lunch is rec- ommended immediately after the termination of the secondnoon trial. 6. Sleep technologists who perform the MWT should be experienced in conducting the test. 7. The conventional recording montage for the MWT includes central EEG (C3-A2, C4-A1) and occipital (O1-A2, O2-A1) derivations, left and right eye electrooculograms (EOGs), mental/submental electromyogram (EMG), and electrocardiogram (EKG). 8. Prior to each trial, the patient should be asked if they need to go to the bathroom or need other adjustments for comfort. Standard instructions for bio-calibrations (i.e., patient calibrations) prior to each trial include: (1) sitlie quietly with your eyes open for 30 seconds, (2) close both eyes for 30 seconds, (3) without moving your head, look to the right, then left, then right, then left, right and then left, (4) blink eyes slowly for 5 times, and (5) clench or grit your teeth tightly together. 9. Instructions to the patient consist of the following: Please sit still and remain awake for as long as possible. Look directly ahead of you, and do not look directly at the light. Patients are not allowed to use extraordinary measures to stay awake such as slapping the face or singing. 10. Sleep onset is defined as the first epoch of greater than 15 sec of cumulative sleep in a 30-sec epoch. 11. Trials are ended after 40 minutes if no sleep occurs, or after unequivocal sleep, defined as three consecutive epochs of stage 1 sleep, or one epoch of any other stage of sleep. 12. The following data should be recorded: start and stop times for each trial, sleep latency, total sleep time, stages of sleep achieved for each trial, and the mean sleep latency (the arithmetic mean of the four trials). 13. Events that represent deviation from standard protocol or conditions should be documented by the sleep technologist for review by the sleep specialist.

Maintenance of Wakefulness Test - Recording 4 Trial opportunities performed at 2 hour intervals A PSG prior to the MWT will be decided by the clinician based on circumstances» First test: 1.5-3 hrs. after lights on The room should be maximally insulated from external light. The light source should be positioned slightly behind the subject s head but outt of his/her field of vision The use of tobacco, caffeine and other medications by the patient before and during MWT should be addressed and decided upon by the sleep clinician before MWT. Drug screening may be indicated to ensure that sleepiness/wakefulness on the MWT is not influenced by substances other than medically prescribed drugs.

Maintenance of Wakefulness Test - Documentation Montage (EEG, EOG, EMG and EKG) Bio-cals prior to each nap. Instruct patient to Please sit still and remain awake for as long as possible. Look directly ahead of you, and do not look directly at the light. Sleep onset:» Trial is 40 minutes» first epoch of any stage of sleep, trial is terminated» if no sleep, latency is 40 min

MWT - Reporting The MWT data should be recorded: - start and stop times for each trial, - sleep latency, total sleep time, - stages of sleep achieved for each trial, - the mean sleep latency (the arithmetic mean of the four trials).

HSAT

What is a Home Sleep Apnea Test? Type 2 PM: full unattended polysomnography ( 7 channels) Type 3 PM: limited channel devices (usually 4 7 channels) Must include airflow and effort channels Type 4 PM: 1 or 2 channels usually including oximetry as one of the parameters

HSAT Indicated for adult patients with a high pretest probability of moderate to severe OSA. HSAT is not appropriate and is contraindicated for: - pediatric patients - patients with comorbid medical conditions including, but not limited to, moderate to severe pulmonary disease, neuromuscular disease, or congestive heart failure, and patients suspected of having other sleep disorders HSAT is also contraindicated for patients with medical or cognitive issues that impact the safety of a patient using the device unattended. HSAT should not be used for general screening.

AASM Guidelines for PM JCSM Journal of Clinical Sleep Medicine, Vol. 3, No. 7, 2007

What device do I use?

The PM device used for HSAT by a sleep center should be chosen carefully for its intended purpose by the technical staff and medical director. - Factors to consider are ease of use by the patient, - recording parameters - the ability to customize the raw data view, - the ability to customize reports, - Cost; the device, the cost of consumables (cannulas, disposable sensors, batteries), database features, and the availability of technical support.

Physiological and Recording For Type 2 devices only: Parameters EEG electrodes should be placed according to the International 10-20 system of Electrode Placement (3). The recommended EEG derivation is F4-M1, C4-M1, and O2-M1 recorded at a minimum sampling rate of 200 Hz with impedances of 5 KΩ or less. The recommended sampling rate is 500 Hz; filter settings for this parameter are LFF 0.3 Hz and HFF 35 Hz. EOG electrodes should be placed at E1 and E2 according to AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications standards (4). The recommended EOG derivation is E1-M2, E2-M2 recorded at a minimum sampling rate of 200 Hz with impedances of 5 KΩ or less. The recommended sampling rate is 500 Hz filter settings for this parameter are LFF 0.3 Hz and HFF 35 Hz. Chin EMG electrodes should be placed above and below the mandible on the mental and submental muscles of the chin as specified in the AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications standards. The derivation for recording chin EMG consists of a submental electrode referred to the electrode placed above the mandible on the mental muscle. The minimum sampling rate is 200 Hz. The recommended sampling rate is 500 Hz. Filter settings for this parameter are LFF 10 Hz and HFF 100 Hz.

HSAT Devices Type 2 4 Recording Parameters A nasal air pressure transducer is the most common mode of recording airflow in portable monitoring. The recommended respiratory effort sensor is calibrated or un-calibrated respiratory inductance plethysmography (RIP). The minimum acceptable sampling rate is 25 Hz. The preferred sampling rate is 100 Hz. Filter settings for the respiratory data are LFF 0.1 Hz, HFF 15 Hz. The recommended blood oxygen sensor is a pulse oximeter with an averaging time of < 3 seconds. Finger probes can be reusable or disposable. A slipped or disconnected oximeter probe is one of the more common reasons for PM failure. The minimum recommended sampling rate is 10 Hz. The preferred sampling rate is 25 Hz, which improves the ability to recognize artifact.

A pulse rate is generally obtained from the pulse oximeter. The minimum acceptable sampling rate is 10 Hz. The preferred sampling rate is 25 Hz, which improves the ability to recognize artifact. Modified Lead II is the recommended placement for recording the electrocardiogram (ECG). The minimum acceptable sampling rate is 200 Hz. The recommended sampling rate of 500 Hz improves waveform definition. Filter settings for ECG are LFF 0.3, HFF 70 Hz. Snoring can be derived from the nasal air pressure transducer signal, or can be recorded as a separate channel with a microphone device The minimum acceptable sampling rate for the collection of snoring sound or vibration data is 200 Hz. The preferred sampling rate is 500Hz. Filter settings are LFF 10 Hz, HFF 100 Hz.

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Initializing the HSAT Device - Re-charging or replacing the batteries for every test. - Previous data must be cleared before a new recording can be acquired. - Enter patient information can be entered and the device initialized to collect new data. - Devices can be set to start at a pre-set time, or can be manually started by the patient at bedtime. * It is important to know the maximum recording time capability, which might range from one to seven or more nights of recording time.

HSAT - Recording the patient picks up the PM device and is instructed how to apply it at home. Take a history, updated meds, changes in sleep patterns. Make sure the patient has take home instructions on how to apply the PM device. - Written instructions with pictorial diagrams of each component and step in the process - Many manufacturers provide video instruction accessible online or on a pre-recorded disk. - A demonstration on video or by the technologist educator can be followed by having the patient apply the device and sensors themselves. It is important for the patient to be given a 24-hour access phone number for technical support if any questions or problems arise.

HSAT - Documentation As with PSG, the sleep technologist is responsible for ensuring that all required documentation (history, physical exam, previous test results, referral and insurance information, physician s orders, etc.) is available and reviewed prior to dispensing the PM device for testing. Patient ID verification and insurance verification should be completed at intake, as well as the documentation that the privacy notice was made available to the patient. The sleep center may require the patient to sign a return agreement stating when and where to return the device that includes device replacement or late fee terms. A form that includes pre-sleep and post-sleep questions should be dispensed to the patient with the device and returned for the interpreting physician s review. A comprehensive database should be kept to track HSAT procedures, diagnosis codes, turnaround time, and failure rates. Optimally, this data should be tied to patient outcomes.

HSAT - Documentation DEVICE RETURN AND DATA UPLOAD the data should be checked for minimal adequacy (required signals recorded for a minimum time set by the center) and re-dispensed at the same visit when a failure is detected. Document any issues the patient had during the night.

HSAT - Reporting The scoring technologist evaluates whether the minimum data collection requirement has been met (set by the sleep center). The manufacturer may provide an automated analysis of the raw data, an experienced and qualified technologist must manually edit and verify the results. At minimum, respiratory events by type, oxygen desaturations, and fail periods must be accurately marked. Scoring should be performed in accordance with the AASM scoring manual (3). The scorer prepares a scoring report, which should indicate that the study was manually edited, and communicates any limitations to the recorded data, including failures. The scoring report and scored raw data is then made available to the interpreting sleep specialist for interpretation.

HSAT - Other All technical personnel must be trained by the Medical Director of the sleep center, a board certified sleep specialist, or a registered sleep technologist with the RST or RPSGT credential. Quality Assurance Equipment Safety Infection Control Equipment Decontamination

AASM Practice Parameters for Testing http://www.aastweb.org/technical-guidelines PSG MSLT MWT HSAT

What Factor does not matter when selecting a PM device? A. Ease of use by the patient B. Cost of consumables C. the ability to auto score the study D. the ability to customize reports

During an MSLT a patient has REM on Naps 2 and 3. Is a fifth nap needed? A. Yes B. No

Without any sleep, a MWT is performed for? A. 20 minutes B. 40 minutes C. 15 minutes D. 30 seconds

The recommended averaging time of a pulse oximeter is? A. < 1 second B. < 2 seconds C. < 3 seconds D.< 1 minute

When performing any study, which of the following is most important? A. Recording techniques B. Documentation techniques C. Reporting techniques D. All of the above

Questions??