The AASM Manual for the

Scoring of Sleep and

Associated Events

Respiratory Rules
Kannan Ramar, MD
Respiratory Rules
Technical Considerations
Event Duration
Apnea
Hypopnea
RERA
Hypoventilation
Cheyne Stokes
 Technical Considerations for
Airflow
Use a thermal sensor to detect apnea.
Use nasal pressure to detect hypopnea
A square root transformation may be used to correct a small
bias for over scoring hypopnea.
Use alternate sensors if recommended
sensor is unreliable
For hypopnea, inductive plethysmography is considered an
alternate).
Technical Considerations for
Respiratory Effort

Use esophageal pressure or inductive

plethysmography to detect respiratory
effort.
Diaphragmatic/intercostal EMG is considered an
alternative sensor for respiratory effort ( no
recording specifications are given).
Technical Considerations for
Blood Oxygen

Pulse oximetry should be used to

measure blood oxygen.
The maximum acceptable moving
average window is 3 seconds.
 Event Duration
For apnea or hypopnea:
Beginning of event is nadir preceding the first
breath of event
End of event is beginning of first breath that
approximates baseline (not defined).
When baseline cant be determined,
terminate:
When there is a clear and sustained increase in
amplitude.
When there is resaturation of at least 2%.
Nadir preceding Beginning of first breath
1st reduced breath Approximating baseline
 Apnea

Thermal sensor amplitude

attenuated 90%.
Duration 10 seconds.
90% of event meets amplitude
criteria.
No saturation criterion.
 Apnea
Obstructive if sustained or increased
inspiratory effort throughout.
Central if inspiratory effort absent.
Mixed if inspiratory effort initially
absent but resumes in latter portion
of event.
 Absent Airflow

10 Seconds

Paradoxical motion
Obstructive Apnea
Thermal

Pressure

10 Seconds
Snore

SpO2

RIP Sum

RIP RC

RIP ABD
Pressure

10 seconds
Snore

SpO2

RIP Sum

RIP RC

RIP ABD
Thermal

Pressure
10 seconds
Snore

SpO2

RIP Sum

RIP RC

RIP ABD
 Absent Airflow
10 Seconds

Absent Effort

Sleep onset Central Apnea

Thermal

Pressure

Snore
10 seconds

SpO2

RIP Sum

RIP RC

RIP ABD
 10 Seconds

Central Obstructive

Mixed Apnea
 Hypopnea
Abandoned but still recognized by CSM
Reduction of nasal pressure amplitude
of 30%.
Duration 10 seconds.
Desaturation 4% below pre-event
baseline.
90% of event meets amplitude criteria.
 Reduced Airflow

Snoring

10 Seconds Desaturation >= 4%

Phase Shift

Hypopnea
Thermal

Pressure

10 seconds
Snore

SpO2

RIP Sum

RIP RC

RIP ABD
 Hypopnea
Alternative Recommended
Reduction of nasal pressure amplitude
of 50% 30%.
Duration 10 seconds.
Desaturation 3% below pre-event
baseline or an arousal.
90% of event meets amplitude criteria.
Cheyne Stokes Breathing
Three consecutive cycles of cyclical
crescendo-decrescendo change in
breathing amplitude.
AND
Five or more central apneas or
hypopneas per sleep hour.
OR
Crescendo-decrescendo pattern has
duration of 10 minutes.
 Crescendo- Decrescendo pattern

10 Seconds

Cheyne Stokes Breathing

 Respiratory Event Related
Arousal (RERA)
OPTION Recommended

Ten or greater second sequence of

breathes.
Evidence of increased respiratory effort,
flow limitation or both.
Terminal arousal.
Does not meet apnea or hypopnea criteria.
 Flow Limitation

10 Seconds

Respiratory Effort Related Arousal

 Flow Limitation

Crescendo Snoring
10 Seconds

Respiratory Effort Related Arousals

RERA
 Arousal

Not an apnea or
Finite duration 10 sec. hypopnea (or is it?)

Flow limitation Snoring

 Hypoventilation
OPTION Recommended
Ten mm Hg or greater increase of
PaCO2 during sleep compared to
wake (supine).
May be measured with end tidal or
transcutaneous capnometry.
THE END