Polysomnography:101

CSRT Sleep medicine 2010 St. Johns, Newfoundland

Bernie W. Miller, BS, RRTRPSGT

Instructor, Mayo College of Medicine

Sleep Medicine Center. Supervisor Mayo Clinic in Arizona

Disclaimer

I have no conflicts of interest and receive no compensation from any sleep equipment manufacturers

Historical Perspectives
1928 Berger placed electrodes on brain in a patient who had a missing skull 1937 Loomis suggested first EEG classification (A-E) 1953 Aserinsky and Kleitman discovered REM sleep 1963 Rechtschaffen & Kales manual 2007 AASM publishes the new manual

Rechtschaffen and Kales

EEG leads EMG of genioglossus EOG Sleep stage scoring only

AASM Manual
Iber C, Ancoli-Israel S, Chesson A, Quan SF for the American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, Ist Ed.: Westchester, Illinois: American Academy of Sleep Medicine, 2007

Recording System
Oscilloscope to paper, to computer
Electrode placement Jack box or head box, montage selector Amplifiers (amplification, filters, calibration) Computer was revolutionary!!!

International 10-20 System

Electrodes are placed apart 10 and 20% of the distance

From nasion to inion, preauricular points, and top of the head Odd numbers are on the left side, Even on the right

Changes in Montage
Reference electrodes (Just terminology) Number of EEG channels; Add Frontal leads (three channels and three backup channels) Alternative channels EOG electrodes EMG electrodes

AASM Reference Electrode Change

Auricular (A) electrode placement has been changed from ear to Mastoid (M).

A1
A2

changed to
changed to

M1
M2

AASM - EEG Derivations

Three channels

a. F4-M1 b. C4-M1 c. O2-M1

EEG - AASM
Backup channels

a. F3-M2 b. C3-M2 c. O1-M2

AASM Alternative Derivations

Three channels

a. Fz-Cz b. Cz-Oz c. C4-M1

Backup channels

a. Fpz-C3 b. C3-O1 c. C3-M2

Amplifiers
Alternating Current
fast frequencies EEG, EMG, EOG, EKG (has both HFF and LFF)

Direct Current
slow frequencies oximeter, CPAP, position (does not have LFF)

Common Mode Rejection

The ability of an amplifier to reject signals common to both electrodes and amplify the difference Same signals are called in phase or common mode

CMRR =

Difference in voltage Same voltage (rejected=0)

Differential AC Amplifiers
(C3)
G1 -70 V

AMP

-60 V

(A2) G2 -10 V

Amplifiers
Amplification of signals

Filters
Calibration

Amplification
Gain, not really relevant in the computer environment

Sensitivity

Sensitivity
Measure of OUTPUT of an input voltage The amount of voltage needed to deflect the recording pen a given distance Voltage= uV (microvolts) or mV (millivolts) Pen deflection= mm or cm

Sensitivity
Voltage Pen deflection

Sensitivity

Provides a uniform increase in the size of the waveforms

EEG CALIBRATION
Standard calibration 50 uV/cm (digital world 70 or 100 uv/cm) More deflection: Pen blocking artifacts Less deflection: Difficult to see low amplitude waveforms

Amplitude of 50 V at different sensitivity levels

2

1.5

Amplitude

0.5

0 100 50 25

V/cm

50 uv/cm in a 4 year old

70 uv/cm in a 4 year old

100 uv/cm in a child

The Digital World

Unfortunately in the digital world there are variability's from one software type to the other, filters may not filter uniformly. 0.3 LFF on one system may not be 0.3 LFF on another

Sampling Rates
Sample at 200 to 500 hz ???????????????????? Number of data points gathered per second

Filters
Helpful in removing unwanted noise/artifacts

1. 2. 3. 4.

Low frequency filter High frequency filter Notch filter ECG filter (during scoring)

EEG Filters
Variable reduction in amplitude 80% 70% 50% Progressive decrease in amplitude below (LFF) or above HFF) the cut off frequency

LFF and HFF

100 90 80 70 60 50 40 30 20 10 0 1.25Hz 2.5Hz 5.0Hz 10Hz

100 90 80 70 60 50 40 30 20 10 0 70Hz 140Hz 280Hz 560Hz

EEG HFF Settings

Sleep EEG waveforms occur at 35 hz/cps

Spike duration Spike frequency HFF for seizures

20-70 msec 14-50 Hz 70 Hz

EEG LFF Settings

To improve low frequency baseline or baseline drift / sweat artifact

LFF

0.3 Hz

LFF = None

LFF = 0.1

LLF = 0.3

Notch filter
Notch filters are designed to sharply attenuate a narrow frequency bandwidth within the range of 50 or 60 Hz. Notch filters are also known as 60Hz filters. These filters are used to eliminate the noise from electric power lines.

Filter Settings
EEG EOG EMG Snoring ECG Respiration Low 0.3 Hz 0.3 Hz 10 Hz 10 Hz 0.3 Hz 0.1 Hz High 35 Hz 35 Hz 100 Hz 100 Hz 70 Hz 15 Hz

Sampling Rates
Important in the computer age AASM suggests 500 hz for EEG/EOG/EMG/ECG Minimal 200 hz acceptable

EMG
Recorded as the potential between two surface electrodes placed several centimeters apart Typically, the chin (submental) muscle is used because it exhibits large differences during sleep, aiding in the identification of stages Wake - high activity Sleep - lower activity REM sleep - paralysis of skeletal muscles

EMG AASM
Three electrodes should be placed a. one in midline 1 cm above the inferior edge of the mandible b. one 2 cm below the inferior edge of the mandible and 2 cm to the right of midline c. one 2 cm below the inferior edge of the mandible and 2 cm to the left of midline

EMG
REM versus NREM Snoring

Swallowing
Bruxism GERD

EOG
The eyeball is a dipole where the cornea is positive and the retina is negative.

EOG
The electrode close to the retina will pick up a positive potential (down going wave).

EOG

V
Conjugate eye movements Out of phase pen deflections

EOG Placement
Usually from ROC and LOC

(option of more channels in MSLT)

ROC: One cm. superior and lateral from right outer canthus LOC: One cm. inferior and lateral from left outer canthus

EOG-AASM
Nomenclature is different ROC now E2, LOC E1 Reference electrodes placement (Additional ref now mandatory) Reference electrodes nomenclature now Ms Alternative electrodes

Recommended EOG - AASM

E1-M2
E1 is placed 1 cm inferior to the left outer canthus

E2-M1
E2 is placed 1 cm superior to the right outer canthus

Alternative EOG -AASM

E1-Fpz E1 is placed 1 cm inferior and 1cm lateral to the outer canthus of the left eye E2-Fpz E2 is placed 1 cm inferior and 1cm lateral to the outer canthus of the right eye

SEMs and REMs

SEMs initial deflection usually > 500msec (usually more than 2 seconds in duration)
REMs initial deflection usually < 500msec (usually less than 1 second in duration)

EOG
EOG records voltage changes caused by eye movement; EOG changes with sleep stage Wake: random, high amplitude: Stage 1: slow rolling:

REM: very flat with occasional rapid eye movements:

ARTIFACTS
Eye movements should be out of phase K-complexes should be in-phase Channels should not block
60 Hz Muscle tension Electrode popping ECG

Questions ?