Polysomnography is a comprehensive sleep study that involves monitoring biophysiological changes during sleep including brain waves, eye movements, muscle activity, heart rate, respiration, and oxygen levels. It is used to diagnose various sleep disorders like sleep apnea, insomnia, narcolepsy, and parasomnias. A polysomnography study involves setting up various sensors on the patient's head and body according to international standards and analyzing the recorded data to identify sleep stages and respiratory events during sleep. Polysomnography is considered the gold standard for diagnosing sleep disordered breathing like obstructive sleep apnea.

1. POLYSOMNOGRAPHY

2. REFERENCE
1. 2012 AASM manual for scoring of sleep and associated events
2. 2014 INOSA guidelines
3. 2016 AASM OSA guidelines
4. 2008 AASM guidelines on manual titration of PAP
5. Polysomnography for the sleep technologist by Buddy Marshall

3. INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS (ICSD 3)
Insomnias Sleep related breathing
disorders
Hypersomnias of
central origin
Circadian rhythm
disorders
Parasomnias Sleep related movement
disorders
Other sleep
disorders

4. INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS (ICSD 3)
Sleep related breathing disorders
Central sleep apnea
(CSA) syndromes
Obstructive sleep apnea
(OSA) syndromes
- Complete or partial upper
airway obstruction causing
apnea, hypopnea and
snoring
Sleep related
hypoventilation and
hypoxemic syndrome
- obesity
hypoventilation
syndrome
- hypoventilation
with a normal lung
function
Sleep related
hypoventilation and
hypoxemia due to
medical conditions
- overlap syndrome
(COPD + OSA)
- neuromuscular
disorders
- chests wall
disordersPrimary CSA
- cessation of both
airflow and
respiratory effort in
an intermittent or
cyclical pattern
resulting from CNS
dysfunction
CSA with Cheyne
stokes breathing
- older men
during transition
from wake to
NREM
- CHF, stroke,
renal failure
High altitude
periodic breathing
- ascend to high
altitude
- adaptation occurs
Drug related CSA
- long acting opiods
regularly for at least 2
months

5. Polysomnography is a comprehensive recording of biophysiological
changes that occur during sleep.
PSG includes:-
1. Identification of sleep stage
2. Analysis of patterns of respiration
3. Analysis of movement patterns
INTRODUCTION

6. Type 1: Fully attended polysomnography (≥ 7 channels) in a laboratory
setting
Type 2: Unattended polysomnography (≥ 7 channels)
Type 3: Limited channel study (using 4–7 channels)
Type 4: One or two channels usually using oximetry as one of the
parameters
TYPES OF SLEEP STUDY

8. INDICATIONS OF POLYSOMNOGAPHY
• Sleep related breathing disorders
• CPAP titration in OSA
• Assessment of treatment results-
OSA
• Sleep related behavioural disorders
• Atypical or unusual parasomnias
• Narcolepsy
• Neuromuscular disorder & sleep
related symptoms
• Paroxysmal arousal or seizure
phenomenon
• Periodic Leg Movements of Sleep
• Parasomnias not responding to
conventional therapy
American Academy of Sleep Medicine

9. PATIENT PREPARATION AND
ELECTRODE PLACEMENT

10.  Maintain a regular sleep wake rhythm before the test
 Avoid sleeping pills or narcotics for several days before study
 Avoid strenuous physical exercise on the day of study
 Not to drink coffee, tea or alcoholic beverages before study
 Report after a light meal, after using toilet and wearing loose comfortable dress
 Patient communication and reassurance
 Medical record review

11.  Complete list of medications the patient is taking
 Measure and record patients vitals
 Calibrate the equipment
 EEG application
- the AASM recommends 3 EEG derivations: F4-M1,
C4-M1 and O2-M1
- 10 -20 system of electrode placement
- 3 primary measurements are taken: head
circumference, nasion to inion, pre-auricular
point to preauricular point
- electrode placements are then measured in 10%
or 20% increments

13.  EOG electrode
- 1 cm below the left outer canthus and 1 cm above the right outer canthus
- reference to M2 electrode
 Chin EMG
- one in midline 1cm above the inferior edge of mandible.
- one placed 2 cm below the inferior edge of mandible and 2 cm to right of
midline.
- one placed 2 cm below the inferior edge of mandible and 2 cm to left of
midline.
 Lead II ECG

14. Limb EMG
- electrodes on anterior tibialis muscle group along the outside of tibial bone
- electrodes should be placed on both legs
- at least 2 -3 cm gap between electrodes
Respiratory monitoring sensors
- oral- nasal sensor to identify apnea
- nasal pressure transducer to record hypopnea and RERA
- respiratory inductance plethysmography (RIP) for chest (around the rib
cage under the armpits) and abdominal effort (around the abdomen at the
level of umbilicus)
- pulse oximetry (remove nail polish)

15. STAGING THE SLEEP

16. Stages of sleep:
Stage N1
Stage N2
Stage N3
Stage R
• Scoring by Epoch-Scored in 30 second sequential epoch
• Assign a stage to each epoch.
• If two or more stage coexist during single epoch, assign the
stage comprising the greatest portion of epoch

20. Frequency band width
Frequencies in polysomnography limited to 4 distinct patterns:
Delt
a
< 4
Hz
Hert
z
Thet
a
4-7
Hz
Alph
a
8 - 13
Hz
Bet
a
>13
Hz
Delt
a
Thet
a
Alph
a
Bet
a

21. EEG waves can be described in terms of their SHAPE:
Vertex
waves
sharp positive waves,
theta frequency range,
occuring latter part of
Stage1
K
Complex
sharp positive wave,
followed by slower
negative component,
seen in Stage 2
Sawtooth
waves low amplitude
sawtooth
appearance
seen in REM
Spindl
e
short rhythmic
waveform clusters
of 12-14 Hz
seen in stage2

22. Light
sleep
Deep
sleep
Stage 1
Stage 2
Stage 3(4)
REM
Non
Rapid
Eye
Mov

29. INTERPRETATION AND MONITORING OF
RESPIRATORY EVENTS

30. AASM manual of scoring sleep 2012

31. Detection of snoring
For snoring detection AASM recommends several sensors
- nasal pressure transducers (high frequency oscillations)
- piezoelectric sensors to detect vibration
- acoustic sensors (microphone)
Detection of hypoventilation
- gold standard is determining arterial PaCO2
- as drawing of arterial sample is difficult during sleep, an elevated PaCO2
obtained immediately after waking would provide evidence of hypoventilation during
sleep.
- ET CO2 and transcutaneous PCO2 are surrogate markers
- transcutaneous PCO2 is preferred in patients with lung disease, significant
mouth breathing or those who are using supplemental oxygen or mask ventilation.
AASM manual of scoring sleep 2012

32. AASM definition of
1. Apnea Hypopnea Index (AHI)
- apneas and hypopneas per hour of sleep
2. Respiratory Disturbance Index (RDI)
- apneas + hypopneas + RERA per hour of sleep
3. Oxygen Desaturation Index (ODI)
- number of ≥ 3% arterial oxygen desaturation per hour of sleep
AASM manual of scoring sleep 2012

33. AASM manual of scoring sleep 2012

34. • Obstructive apnea: If the event meets apnea criteria and associated with
continued or increased inspiratory effort throughout the entire period of absent
airflow.
• Central apnea: If the event meets the apnea criteria and associated with absent
inspiratory effort through the entire period of absent airflow.
• Mixed apnea: If the event meets apnea criteria and is associated with absent
inspiratory effort in the initial portion of event followed by resumption of
inspiratory effort in second portion of event.
AASM guideline of scoring sleep 2012
TYPES OF APNEAS

40. AASM manual of scoring sleep 2012

41. AASM manual of scoring sleep 2012

42. AASM manual of scoring sleep 2012

44. AASM manual of scoring sleep 2012

46. AASM manual of scoring sleep 2012

48. AASM manual of scoring sleep 2012

49. DIAGNOSIS OF OSA

50. INOSA guidelines 2014
AASM OSA guidelines
2017

51. AASM OSA guidelines
2017

52. AASM OSA guidelines 2017

53. AASM OSA guidelines 2017

54. AASM OSA guidelines 2017

55. MANUAL TITRATION OF POSITIVE
AIRWAY PRESSURE IN PATIENTS WITH
OSA

56. AASM guidelines on manual titration of PAP in patients with OSA 2008

57. MANUAL TITRATION IS THE GOLD STANDARD
AASM guidelines on manual titration of PAP in patients with OSA 2008

58. AASM guidelines on manual titration of PAP in patients with OSA 2008

59. AASM guidelines on manual titration of PAP in patients with OSA 2008

60. AASM guidelines on
manual titration of
PAP in patients with
OSA 2008

61. AASM guidelines on manual titration of PAP in patients with OSA 2008

62. AASM guidelines on
manual titration of PAP
in patients with OSA
2008

63. AASM guidelines on manual titration of PAP in patients with OSA 2008

64. AASM guidelines on manual titration of PAP in patients with OSA 2008

65. AASM guidelines on manual titration of PAP in patients with OSA 2008

66. AASM guidelines on manual titration of PAP in patients with OSA 2008

67. AASM guidelines on manual titration of PAP in patients with OSA 2008

68. AASM guidelines on manual titration of PAP in patients with OSA 2008

69. AASM guidelines on manual titration of PAP in patients with OSA 2008