Polysomnography for the Sleep Technologist: Instrumentation, Monitoring, and Related Procedures

Front cover
Polysomnography for the Sleep Technologist Instrumentation, Monitoring, and Related Procedures
Copyright
Contributors
Reviewers
Dedication
Foreword
Preface
Acknowledgements
Table of contents
1 Overview of sleep medicine physiology and technology
Chapter outline
Learning objectives
Key terms
A history of sleep medicine technology
Sleep medicine throughout history
Research and theories
The evolution of polysomnography
Pioneers in sleep medicine
Nathaniel kleitman
Sleep stage scoring - R&K manual
American academy of sleep medicine (AASM)
Narcolepsy research
Obstructive sleep apnea research
Early treatment of OSA
Early sleep study data collection
Physiology for recording sleep-related parameters
Circadian variations related to wake and sleep
Opponent process model of sleep
How the body changes between sleep and wake
Neurotransmitters
Sleep phases and stages
Determining sleep stages using electroencephalography
Stages n1-n2 sleep
Stage n3 sleep
REM sleep
Physiological parameters evaluated by polysomnography
Monitoring vital signs
Special considerations
The sleep technologist
Provision of health care
Typical roles and duties of a sleep technologist
Training and certification
Scope of practice
Instrumentation
Performance of polysomnography
Professional education
Patient care and education
Communication
Additional tasks
Conclusion
Chapter summary
References
Review questions
2 Classification of sleep disorders
Chapter outline
Learning objectives
Key terms
The insomnias
Primary insomnias
Idiopathic insomnia
Fatal familial insomnia
Secondary insomnias
Adjustment insomnia
Psychophysiologic insomnia
Paradoxical insomnia
Inadequate sleep hygiene
Behavioral insomnia
Sleep-related breathing disorders
Central sleep apnea (CSA) syndromes
Cheyne-stokes
High-altitude periodic breathing
Drug-related csa
Obstructive sleep apnea (OSA) syndromes
Pediatric OSA
Sleep-related hypoventilation and hypoxemic syndromes
Sleep-related hypoventilation/hypoxemia due to medical conditions
Hypersomnias of central origin
Narcolepsy
Recurrent hypersomnias
Secondary hypersomnia
Circadian rhythm disorders
Delayed sleep phase disorder
Advanced sleep phase disorder
Free-running
Jet lag
Shift work disorder
Circadian disorder due to medical conditions
Parasomnias
Non-rapid eye movement (NREM) sleep parasomnias
Confusional arousal
Sleepwalking
Sleep terrors
Rapid eye movement (REM) sleep parasomnias
Nightmare disorder
Catathrenia
REM sleep behavior disorder (RBD)
Other parasomnias
Sleep-related dissociative disorder
Sleep enuresis
Sleep-related eating disorder (SRED)
Parasomnias related to drug or substance use
Testing for parasomnias
Sleep-related movement disorders
Restless leg syndrome (RLS)
Periodic limb movement disorder (PLMD)
Sleep-related bruxism
Sleep-related rhythmic movement disorder
Chapter summary
References
Review questions
3 Electronics and electricity
Chapter outline
Learning objectives
Key terms
Introduction to electricity
Forms of electricity
Static electricity
Charged particle interactions
Coulomb’s law
Conservation of charge
Electrochemical electricity
Photoelectricity
Thermoelectric effect
Piezoelectric effect
Electronic circuits
Open, closed, and short circuits
Current flow
Principles of current
Units and prefixes
Metric prefixes
Introduction to electrical components
Conductors
Resistance
Ohm’s law
Leakage current
Ground and power isolation
Ground
Power isolation
An overview of ancillary equipment
Devices used to monitor airflow
Thermal sensor
Pressure transducer
Oxygen sensors
Snore microphones
Position sensors
Chapter summary
References
Review questions
4 Frequency, voltage, and morphology of signals
Chapter outline
Learning objectives
Key terms
Essentials of physiologic waveforms
Frequency and duration
Calculation of duration (d) and frequency (f)
Amplitude
Morphology
Bioelectrical signals
Resting potential
Graded potential
Action potential
Polarity
Recording equipment, controls, and practices
Electrodes and electrode boards
Data acquisition systems
Electrode impedance
Recording polarity
Amplifiers
Direct current (DC) and alternating current (AC) amplifiers
Direct current (DC) amplifier
Alternating current (AC) amplifier
Differential amplifier
Derivations, montages, and recorder types
Derivations
Montages
The bipolar montage
The referential montage
Data recording
The recorder
Referential recording
Annotation and documentation
Signal sampling
Signal reconstruction
Sensitivity and gain
Sensitivity
Gain
Common mode rejection
Amplifier filters
The low-frequency filter and decay time constant
Low-frequency filter (LFF)
Decay time constant (TC)
The high-frequency filter
The 60-hz filter
Digital filtering
Frequency response
Additional testing equipment and considerations
Transduced signals
Ancillary equipment
The polysomnograph
Viewing the study
Data storage
Recorded data
The electroencephalogram (EEG)
The electrooculogram (EOG)
The chin electromyogram (EMG)
The limb electromyogram
Chapter summary
References
Review questions
5 Bioelectric signals of interest in sleep medicine
Chapter outline
Learning objectives
Key terms
Parameters typically evaluated by polysomnography
Electroencephalography
Low-amplitude, mixed-frequency (LAMF) waves
Alpha waves
Delta waves
Sawtooth waves
Theta waves
Sleep spindles
K complex
Vertex sharp waves
Electrooculogram
Recording methods and sleep-wake stage scoring
Electromyogram
Chin electromyogram
Leg electromyogram
Modified lead II electrocardiography (ECG)
Lead placement
Sleep/wake states
Aasm guidelines for wake and sleep stages1
Wake
Stage n1
Stage n2
Stage n3
Stage r
Chapter summary
Reference
Review questions
6 The recording of physiological parameters and electrical safety
Chapter outline
Learning objectives
Key terms
Recording physiological parameters
Baseline patient information
Machine calibrations
Amplitude, morphology, and decay time constant
All-channel calibration
Montage calibration
Signal calibrations
Physiologic calibrations
Physiologic calibration commands
Eyes open
Eyes closed
Eye deflections
Grit command
Limb movements
Breath commands
Electrocardiogram
Final observations
Lights out
Documentation during the recording
Optimizing the recorded data
Artifacts
Medical record documentation
Use and limitations of filters
Understanding the way filters work
Frequency response
Placement of electrodes
Adjustment of sensitivity and gain
Gain
Sensitivity
Waveform ruler
Electrical safety
Current, voltage, and resistance
Grounding and leakage current
Ground loops
Electrical shock
Chapter summary
References
Review questions
7 Data acquisition systems
Chapter outline
Learning objectives
Key terms
Principles of digital recording
Digitization and manipulation of data
Data storage
System components
Hardware components
Montages
Static and dynamic recording methods
Filtering
Derivations
Referential
Bipolar
Recording options
Referential recording
Differential recording
General software options for data display
Montage collection and review
Visual display
Display position
Display color
Window configuration
Look-back window
Histogram
Tabular data
Respiratory window
Full display
Visual filters
Automated sleep staging and event scoring
The recognition of sleep-wake stages and events
AASM recommendations
Respiratory events detection
Measurement technologies
Staging examples
Stage w: Wake
Stage n1
Stage n2
Stage n3
Stage r
Respiratory examples
Respiratory effort related arousal
Hypopnea
Apnea
Cheyne-stokes breathing
Sleep-related movement events
Periodic limb movements in sleep (PLMS)
Rhythmic movement disorder
REM sleep behavior disorder
Recent advancements in digital polysomnography
Wireless technologies
Spectral analysis of electroencephalogram data
Portable polysomnography devices
Remote monitoring
Chapter summary
References
Review questions
8 Sensors, transducers, and ancillary equipment
Chapter outline
Learning objectives
Key terms
Surface electrodes
Electrode types
Commonly used metals for electrodes
Electrode cups
Electrode wires
Specific use for electrodes
Electrode cables, connectors, and jumpers
Connectors
Jumpers
Use and care of reusable recording electrodes
Cleaning
Disinfection
Sterilization
Semicritical v. noncritical items
Interfacing electrodes with the input board
Derivations
The operation, use, and limitations of sensors
Recording EEG, EMG, EOG, and ECG with surface electrodes
Airflow and breathing effort transducers and recording systems
Monitoring airflow
Monitoring respiratory effort
Piezo technology
Diaphragmatic and intercostal EMG
Respiratory inductive plethysmography (RIP)
Snore microphones and sensors
Recording patient body position
Audiovisual monitoring and recording
Recording bioelectric and transduced signals
Differentiating signal types
Selecting an AC or DC amplifier
Sample rate requirements
EEG signals
Ancillary recorder signals, equipment and methodology
Recording and understanding the cyclic alternating pattern
An overview of pulse oximetry and oximeter sensors
Interfacing an ancillary device with the data acquisition system
Chapter summary
References
Review questions
9 The polysomnogram: Prestudy procedures, monitoring activities, and poststudy scoring and interpretation
Outline
Objectives
Key terms
Patient communication
Reviewing patient documents
Medical record review
Health care provider orders
Medications
Patient assessment
Technical considerations
Recording montage
Equipment calibrations
Electrode and sensor application
Electroencephalogram and electrooculogram electrode application
Electromyogram and non-cephalic sensor application
Respiratory monitoring sensors
Skin preparation
Electrode metal recording properties
Recording the sleep study
Prebedtime activities
Questionnaire
Physiologic calibrations
Monitoring and documenting
Quality monitoring
Record-keeping
Response to clinical events
Conclusion of the sleep study
Poststudy activities
Physiologic calibrations
Electrode and sensor removal
Poststudy patient instructions
Scoring and report tabulation
Scoring
Study status tracking
Data tabulation and report elements
Data tabulation
Report elements
Documenting medication use
Interpretation
Patient follow-up
Quality measurements
Interscorer reliability
Therapy compliance monitoring
Chapter summary
References
Review questions
10 Recognizing, evaluating, and minimizing recording artifacts
Chapter outline
Learning objectives
Key terms
Electrode and sensor application
Electrode application methods
Collodion
Conductive paste
Electrode removal
Gloving
Electrode-site preparation
Electrode composition
Electrode impedance
Low impedance value
High impedance value
Electrode impedance summary
Signal processing
Differential amplifier
Common mode rejection ratio (CMRR)
Filters
Low-frequency filter (LFF)
High-frequency filter (HFF)
50/60 hz filter
Artifact isolation
Line frequency artifact
Muscle artifact
Muscle artifact variants
Respiratory event
Leg cramps
Abdominal effort
Bruxism
EEG arousal
Body rocking
Electrocardiographic artifact
ECG artifact variants
Slow-frequency artifacts
Sweat artifact
Respiratory artifact
Pulse artifact
Cardioballistic artifact
Channel-blocking artifact
Electrode popping artifact
Airflow signal artifacts
Respiratory effort sensor artifact
Oximetry artifacts
System reference artifact
Various other artifacts
Implanted electrical devices
Cardiac pacemakers
Atrial pacemaker
Ventricular pacemaker
Atrioventricular (AV) sequential pacemaker
Fixed-rate and demand pacemakers
Artifact response
Chapter summary
References
Review questions
11 The cardiopulmonary system: Essentials for the polysomnographic technologist
Outline
Learning objectives
Key terms
Anatomy and physiology of the respiratory system
The thorax
Thoracic cage
Lungs
The muscles of ventilation
Anatomy and physiology of the cardiovascular system
Heart
Oxygenation of the blood
Ventilation and diffusion
Oxygen transport
Carbon dioxide transport
Lung volumes and capacities
Arterial blood gas interpretation and manipulation
Regulation of breathing
Central chemoreceptors
Peripheral chemoreceptors
Microscopic stretch receptors
Changes during sleep
Changes in tidal volume and alveolar ventilation
Changes in blood gas values
Changes in heart rate and rhythm
Visual assessment of cardiopulmonary status
Respiratory status
Body habitus
Skin tone
Monitoring the electrocardiogram
Modified lead II derivation
The electrical pathway
The PQRST complex
Dysrhythmia interpretation
The technologist’s guide to dysrhythmias
Sinus mechanisms
Normal sinus rhythm
Sinus arrhythmia
Sinus bradycardia
Sinus tachycardia
Sinoatrial block (sinoatrial pause)
Sinus arrest
Atrial rhythms
Premature atrial contraction
Atrial tachycardia
Multiformed atrial rhythm
Atrial flutter
Atrial fibrillation
Junctional rhythms
Premature junctional complex
Junctional escape beats
Junctional escape rhythm
Accelerated junctional rhythm
Junctional tachycardia
Ventricular rhythms
Premature ventricular complexes (contractions)
Premature ventricular complexes
Unifocal premature ventricular complexes
Multifocal premature ventricular complexes
R-on-t premature ventricular complexes
Ventricular bigeminy
Ventricular trigeminy
Ventricular escape beats
Idioventricular rhythm
Accelerated idioventricular rhythm
Monomorphic ventricular tachycardia
Polymorphic ventricular tachycardia
Ventricular fibrillation
Asystole (cardiac standstill)
Atrioventricular blocks
First-degree atrioventricular block
Second-degree atrioventricular block
Second-degree AV block type I
Second-degree AV block type II (mobitz type II)
Third-degree AV block (complete heart block)
Chapter summary
References
Review questions
12 Noninvasive monitoring of gas exchange during testing
Chapter outline
Learning objectives
Key terms
Overview of gas exchange
Hypoxia
Hypoxia classification
Causes of hypoxia
Monitoring oxygenation and ventilation
Monitoring carbon dioxide
Oxygenation and acid-base balance overview
Arterial values of blood gases
Assessment of ph values
Pulse oximetry
Origins of pulse oximetry
Theory of operation
Contraindications, precautions, and infection control
Precautions
Routine safety practice
Infection control
Limitations to testing and the reliability of results
Oxyhemoglobin dissociation curve
Additional considerations for pulse oximetry monitoring
Technical and environmental considerations
Software limiting factors for oximetry
Optimizing oximetry during polysomnography
Recording oximetry data
Oximetry calibration
Selecting the appropriate oximeter for both in-lab and out-of-lab testing
Monitoring ventilation during sleep
Impact of hypoventilation during sleep
End-tidal carbon dioxide monitoring
Monitoring CO₂ in the adult population
Theory of operation
Sidestream ETCO₂ monitors
Displaying ETCO₂ data
Advantages and limitations of technology
Comparison of obtained values
Contraindications, precautions, and infection control
Transcutaneous monitoring of oxygen and carbon dioxide
Advantages and limitations of technology
Comparison of obtained values
Contraindications, precautions, and infection control
Analysis of acid-base balance of arterial blood gas results
Chapter summary
References
Review questions
13 Diagnosis, treatment, and outcome management of sleep-disordered breathing
Chapter outline
Learning objectives
Key terms
Respiratory event recognition
Paradoxical breathing
Central apnea
Cheyne-stokes respirations
Mixed apnea
Hypopnea
Complicated breathing patterns
Titration techniques
Continuous positive airway pressure
Guidelines for titrating cpap
Titration variations based on age
Managing complications and side effects of CPAP therapy
Spontaneous bilevel positive airway pressure (BPAP-S)
Indications for transition from CPAP
Guidelines for titration of BPAP-S
Central apnea, cheyne-stokes respirations, and cpap-emergent central apnea
BPAP therapy as noninvasive ventilation for central apnea
Indications for use
Guidelines for titration
Adaptive servo ventilation
Indications for use
Guidelines for titration
Treatment challenges
NPPV in complex respiratory diseases
Chronic hypoventilation syndromes
Indications for NPPV
Goals of NPPV
Guidelines for titration with NPPV
Spontaneous timed or timed mode
Inspiratory to expiratory ratio
Special considerations for the use of NPPV
Chronic obstructive pulmonary disease and overlap syndrome
Chronic obstructive pulmonary disease
Restrictive lung disease
Selection of NPPV device settings
General recommendations for NPPV
Conditions associated with the use of NPPV
Contraindications for NPPV
Optimizing NPPV
Supplemental oxygen
Guidelines for use of supplemental oxygen
Considerations for the use of supplemental oxygen
Alternative treatments for obstructive sleep apnea
Tracheostomy
Advantages
Disadvantages and risks
Oral appliances
Surgical procedures
Outcome management for positive airway pressure therapy
Management of side effects
Emerging role of clinical sleep educator
Efficacy monitoring
Effect of heated humidification and nasal congestion
Unintentional leak
Chapter summary
References
Review questions
14 Infection control and emergent response in the sleep center
Outline
Learning objectives
Key terms
Infection control overview
Transmission of infection
Standard precautions
Hand hygiene
Recommendations for hand hygiene in ambulatory care settings⁵
Disinfection
Personal protective equipment (PPE)
Respiratory hygiene and cough etiquette
Transmission-based precautions
Airborne precautions (<5 microns)
Droplet precautions (>5 microns)
Contact precautions
Nosocomial and parenteral infections
Prions
Cleaning, disinfection, and sterilization
Barrier measures
Electrodes and sensors
Artifacts caused by soiled electrodes
Positive airway pressure equipment cleaning and disinfection
PAP interface
PAP devices used in the home
Material safety data sheet
Emergencies in the sleep center
Response to life-threatening emergencies
Facility emergency policies
Protocol: Cardiac dysrhythmia intervention for the sleep technologist
Group I
Group II
Group III
Idioventricular rhythms
Fire safety
Fire prevention
Fire preparedness
Fire response and evacuation
Fire drills
Fire extinguishers and fire hoses
Electrical safety
Creating a safe environment
Equipment safety checks
Electricity and the patient
Chapter summary
References
Review questions
APPENDIX I Fundamental math concepts
Vocabulary
Fractions, ratios, and proportions
Addition and subtraction of integers
Multiplication of positive and negative numbers
Algebra basics
Evaluating the expression
Solving equations for a specific variable
Parenthesis
Exponents
Multiplication/division
Addition/subtraction
Mean, median, and mode
APPENDIX II Common report parameters and recommended settings
Multiple sleep latency testing
Initial sleep latency
The mean sleep latency
Polysomnography
Total recording time
Wake after sleep onset
Total sleep time
The sleep period
Sleep efficiency
Total wake time
Various indices
APPENDIX III Measurements and conversions
The metric system
Units of scientific measurement
Practical application of measurements
Length (distance and height)
Distance conversions
Weight (mass)
Time
Voltage
Practical application of S = V/D
Determining military time
Volume
Converting temperature scale
Glossary
Answers to end-of-chapter questions
Index
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Z