Download Sleep Disorders and Polysomnography: A Comprehensive Guide and more Exams Nursing in PDF only on Docsity! RPSGT EXAM PRACTICE TEST AND STUDY GUIDE QUESTIONS WITH COMPLETE 100% VERIFIED SOLUTIONS 2024/2025 The purpose of an intentional mask leak is to... Wash out CO2 and prevent rebreathing Recommended guidelines state that HSV can be considered when.... Cheyne Stokes and central Apneas have not been eliminated. What is aerophagia? The swallowing of air What is maxillomandibular advancement? Treatment that involves cutting and advancing the upper and lower jaw bones; enlarging and stabilizing the posterior airway. What is the PRIMARY function of the EPAP setting? To eliminate desaturations and arousals. According to guidelines, how many Hypopneas need to occur in peds pts prior to increasing pressure? 1 What are the AASM guidelines for supplemental O2 during PAP studies? 1lmp during PAP titration when SPO2 is less than or equal to 88% for 5 or more minutes and in the absence of obstructive events. If a pts Apneas are fixed at 10cm, but Hypopneas and snoring still occur at 16cm, what levels of BiLevel should be used? IPAP: 14 EPAP: 10 Which of the following can reduce the effectiveness of CPAP and why: Nasal spray, Alcohol, Anti depressants. Alcohol: impairs arousal response which can lead to longer than normal events and severe desats. Inhibits upper airway activity What syndrome would a pt with COPD and OSA have? Overlap syndrome What are hypoxemia and hypercapnia? Hypoxemia: very low 02 in the blood Hypercapnia: very high CO2 in the blood. What would a patient with both hypoxemia and hypercapnia most likely be diagnosed with? Hypoventilation What is an MWT's MOST important use? Measure patients ability to resist the urge to fall asleep Tricyclic antidepressants, large amounts of caffeine and large amounts of chocolate have been known to trigger what? REM sleep behavior disorder Recommended impedance for eeg and eog 5k ohms The amount of space needed to archive digitized data is MOST impacted by? Sampling rate Cortical activity is best described as Spontaneous arousal Calculate the AHI based on the following data 25 obstructive apneas 5 central apneas 23 mixed apneas 15 hypopneas 48 RERAS WHEN REVIEWING A PATIENT'S HISTORY IN PREPARATION FOR A POLYSOMNOGRAM, PHYSIOLOGIC FINDINGS SUGGESTIVE OF HYPOVENTILATION INCLUDE HYPOXEMIA AND HYPERCAPNIA WHEN THE AMPLITUDE OF A SIGNAL EXCEEDS THE PHYSICAL LIMITATIONS OF A CHANNEL THE MOST IMPORTANT ADJUSTMENT THE TECH CAN MAKE TO OPTIMIZE WAVEFORM DISPLAY IS TO DECREASE SENSITIVITY WHEN INTERMITTENT 60 HZ ACTIVITY OCCURS IN THE F4-M1 ELECTRODES DURING REM SLEEP THE BEST IMMEDIATE ACTION WOULD BE TO RELY ON F3-M2 A PATIENT WITH MILD DEMENTIA BECOMES MORE CONFUSED AND/OR AGITATED IN THE EARLY EVENING. THE PATIENT IS MOST LIKELY EXPERIENCING SUNDOWNING THE MOST COMMON METHOD TO MONITOR BLOOD OXYGEN SATURATION DURING POLYSOMNOGRAPHY IS PULSE OXIMETRY THE MOST APPROPRIATE ACTION A TECHNOLOGIST WOULD TAKE WHEN THERE IS CONFIRMED VENTRICULAR TACHYCARDIA GREATER THAN 30 SECONDS IS INITIATE EMERGENCY RESPONSE SYSTEM A PATIENT'S CHART INDICATES THAT THEY USE 30 L/MIN OF OXYGEN AT HOME. THE TECH NOTES THAT THE PHYSICIAN'S ORDERS FOR THE PSG SPECIFIES THE STUDY WITHOUT SUPPLEMENTAL OXYGEN AND TO ADD 1.0 L/MIN OXYGEN IF THE SATURATION IS LESS THAN 89%. THE BEST ACTION FOR THE TECH IS TO CALL THE PHYSICIAN FOR CONFIRMATION WHICH OF THE FOLLOWING IS THE MOST LIKELY EFFECT OF ZOLPIDEM AND ZALEPLON ON SLEEP ARCHITECTURE INCREASED SLEEP LATENCY WHICH OF THE FOLLOWING BEST DESCRIBES A REFERENTIAL MONTAGE THERE IS POTENTIAL FOR ELECTRODE CONTAMINATION ACCORDING TO RECOMMENDED GUIDELINES, THE DEVICE THAT SHOULD BE USED TO MONITOR AIRFLOW AND DETECT APNEA DURING A DIAGNOSTIC STUDY IS ORONASAL THERMAL SENSOR WHICH PROCESS WOULD BE AN ADEQUATE ROUTINE FOR DISINFECTING CUP ELECTRODES AFTER REMOVING ADHESIVE RESIDUE, GEL AND ORGANIC MATERIAL, AND WASHING IN WARM WATER AND MILD DETERGENT SOAKING IN 1: 10 BLEACH AND WATER FOR 10 MIN. WHICH OF THE FOLLOWING WOULD BE MOST IMPORTANT TO DOCUMENT DURING A POLYSOMNOGRAM POSITION CHANGES THE ELECTRODE ARRAY USED FOR RECORDING PHYSIOLOGIC ACTIVITY IS REFERRED TO AS MONTAGE ACCORDING TO RECOMMENDED GUIDELINES, THE MAXIMUM ELECTRODE IMPEDANCE FOR EEG AND EOG RECORDING IS 5000 OHMS ACCORDING TO RECOMMENDED GUIDELINES, UNATTENDED PORTABLE MONITORING CAN BE USED AS AN ALTERNATIVE TO IN LAB TESTING WHEN THERE IS A HIGH PROBABILITY OF MODERATE TO SEVERE OSA WITHOUT COMORBID CONDITIONS A SELF REPORTING TOOL USED TO EVALUATE SUBJECTIVE SLEEP QUALITY AND DISTURBANCE OVER THE PREVIOUS MONTH IS PITTSBURGH SLEEP QUALITY INDEX THE MOST APPROPRIATE SETTING A TECHNOLOGIST WOULD USE TO CONTROL THE FREQUENCY BAND OF WAVEFORMS ON A RECORDING IS THE (LOW FILTER (HIGH PASS FILTER) WHICH OF THE FOLLOWING CAN NEGATIVELY IMPACT ALL BIOELECTRIC CHANNELS CONTAMINATED M1 WHICH OF THE FOLLOWING SUBSTANCES CAN REDUCE THE EFFECTIVENESS OF PAP THERAPY ALCOHOLIC BEVERAGES A PATIENT THAT INTENTIONALLY ENGAGES IN BEHAVIORAL PATTERNS THAT ARE INCONSISTENT WITH SLEEPING WELL IS DEMONSTRATING INADEQUATE SLEEP HYGIENE WHAT IS THE BEST TOOL THAT A PHYSICIAN COULD USE TO MORE CLEARLY EXPLAIN THE RESULTS OF THE SLEEP STUDY AND THE IMPORTANCE OF THERAPY TO A PATIENT HISTOGRAM REAL TIME ACCESS TO PAP COMPLIANCE DATA IS AN EXAMPLE OF EFFICACY MONITORING A PROCESS TO DECREASE FEAR OF ARTIFICIAL CIRCUMSTANCES BY REPEATED AND CONTROLLED EXPOSURE TO A FEARED SITUATION IS DESENSITIZATION WHAT HAS THE LARGEST IMPACT ON ADHERENCE TO PAP THERAPY PATIENT EDUCATION WHICH STATEMENT IS TRUE REGARDING CPAP THERE IS ONE LEVEL OF PRESSURE FOR INSPIRATION AND EXPIRATION SLEEP DEBT CAN BEST BE DESCRIBED AS THE CUMULATIVE EFFECT OF INSUFFICIENT SLEEP ACCORDING TO RECOMMENDED GUIDELINES FOR PEDIATRIC CPAP TITRATION, HOW MANY HYPOPNEAS MUST OCCUR PRIOR TO INCREASING PRESSURE ONE EXCESSIVE WARMING AND HUMIDIFICATION WILL CAUSE WATER TO POOL IN THE CPAP TUBING MAXILLOMANDIBULAR ADVANCEMENT TREATS OSA BY ENLARGING AND STABILIZING THE UPPER AIRWAY IPAP 10 EPAP 14 DURING A CPAP TITRATION AT 15 CM H20, THE PATIENT IS RESTLESS AND CONTINUES TO HAVE FREQUENT OBSTRUCTIVE RESPIRATORY EVENTS. THE BEST ACTION IS TO CHANGE TO BI LEVEL DC Channel PSG channel derived from an external piece of equipment such as a PAP device or oximeter. Stray Capacitance When electrical signals from external sources interfere w/ signals derived from the pt. Amperes are measured in what units? Coulombs/second Time Axis Horizontal positioning of the pen. Common Mode Rejection The process by which a differential amplifier rejects identical inputs (unwanted signals). Mechanical Baseline Pen's vertical position when the power to the PSG is turned off. Electrical Baseline The vertical positioning of the pen w/ power of PSG turned ON. Capnometer A device used to measure the level of CO2 in a sample of air. Frequency Measured in hertz(Hz) or cycles/second. Paper Speed for PSG 10 mm/sec When a pt. looks towards an EOG electrode it causes what? A positive charge, or downward deflection. Rise Time Amount of time it takes for a wave to reach 63% of its peak. Sensitivity Setting for EEG Channel 7uV/mm or 70uV/cm *In pt.'s w/ low amplitude EEGs, the sensitivity can be adjusted to 5uV/mm or 50uV/cm Filter Settings for Respiratory Effort & Airflow LFF= 0.1Hz HFF= 15Hz Filter Settings for EOG LFF= 0.3Hz HFF= 35Hz High Level Disinfection Used for items that come into contact w/ non-intact skin, blood, and mucous membranes. DO THE NAPS OCCUR EVERY 2 HOURS FROM THE TIME THE PREVIOUS NAP ENDED OR EVERY 2 HOURS ON THE HOU R OR HALF-HOUR? Every 2 hours on the hour or half hour. HOW LONG BEFORE A NAP BEGINS SHOULD THE SUBJECT CEASE SMOKING? 30 minutes WHAT EPOCH SIZE IS BEST FOR RECORDING THE "MSLT"? 30 seconds. A MEAN SLEEP LATENCY OF INDICATES WHAT? Pathological sleepiness. A normal mean sleep latency is how many minutes? 10 - 20 minutes How many naps must have unequivocal periods of REM to arrive at a Diagnosis of Narcolepsy? 2 naps. What is the Narcoleptic Tetrad? Excessive daytime sleepiness, hypnagogic hallucinations, sleep paralysis, cataplexy. How is the mean sleep latency calculated? Sum of all latencies, divided by total# of naps. During REM, inhibition of thermoregulatory mechanisms lead to what state? Poikilothermia. What equation best expresses time constant? TC= C x R TC=Time Constant C= Capacitance R= Resistance What sleep stage requires at least 20% but no more than 50% of the epoch to consist of wave of 2 cps or slower w/amplitudes greater than 75 uV. Stage 3. AN EPOCH THAT DOES NOT MEET THE CRITERIA FOR ACTIVE SLEEP OR QUITE SLEEP IS CALLED WHAT? Intermediate Sleep TRACE ALTERNANT PATTERN IS ASSOCIATED WITH WHAT STAGE OF SLEEP IN THE INFANT? Quiet Sleep (NREM Sleep) INFANT BREATHING PATTERNS THAT ALTERNATES REGULAR BREATHING WITH 5-10 SECONDS OF APNEA? Periodic Breathing. REM OCCUPIES WHAT PERCENTAGE OF SLEEP IN THE NEONATE AT TERM? 50%. A FUNCTION THAT EXPRESSES THE FREQUENCY OF EYE MOVEMENTS PER UNIT TIME DURING SLEEP STAGE REM? REM Density. KNOW AS THE PACEMAKER FOR MAMMALIAN CIRCADIAN RHYTHMS? Suprachiasmatic Nucleus (SCN). A COMPLAINT OF MORNING HEADACHES ASSOCIATED WITH SEVERE SLEEP APNEA IS A RESULT OF WHAT? Severe oxygen desaturation and hypercapnia (Elevated levels of carbon dioxide in the blood). No smoking is allowed within _____ minutes of starting MSLT nap and no strenuous activity within ____ minutes of a nap. 30;15 Maintenance of Wakefulness Test determines patient's ability to stay awake in the daytime. During MWT, patient is placed at rest, sitting in bed with low lights for ___ 40 minute periods spaced at 2 hours. 4 Tracheostomy An opening directly into the trachea bypasses the obstruction and opens the airway, but it is invasive and can result in many complications, so it is rarely done.-can be blocked during waking hours and opened during sleep.-usued as last resort usually in elderly or morbidly obese, facial abnormalities etc Higher Sampling Rates are needed to detect seizure activity in infant and child PSG'S. What sampling Rates for EOG AND EMG recordings during psg for seizure acivity? greater than or equal to 500 Hz for EOG and greater than or equal to 200 Hz for EMG recording. Initiate Low-Flow Supplemental Oxygen at how many liters per minute when SpO2 falls below 85% on ambient room air. 1 liter per minute Monitor SpO2 carefully to ensure it increases to at least __% 90% Titrate oxygen by slowly increasing the flow rate by _._ liters per minute at a time until the SpO2 is 90% or more, but do not exceed 4 liters/min. without a physicians order. 0.5 l/min. Obesity Hypoventilation Syndrome occurs when the body mass index is __kg/m2 or more, resulting in impaired respirations,hypoxia, and hypercapnia during sleep. The obesity results in impairment of muscles of muscles of inspiration, restricting the thorax and causing hypoventilation, leading to hypercapnia. 30 You should begin CPAP when the patient is ready for sleep and start it at the lowest setting, usually _ cm H20 and maintain the low pressure until the patient falls asleep. 5 Increase Positive Airway Pressure during CPAP titration by _ cm h20 at a time, usually at 15 minute intervals, and observe effects, including changes in oxygen saturation, EEG,EMG, and ECG. 1 Ensure that the patient is in what body position during titration for part of the titration period? supine Respiratory Effort Related Arousal (RERA) Occurs when the airway narrows during sleep, usually indicated by snoring. Although the constricted airway does not result in apnea or hypopnea, it does cause a brief arousal. For scoring of a RERA, there should be a sequence of respirations indicating increased respiratory effort or flattening of nasal pressure waveforms with a duration of ___ seconds or more. 10 Hypoventilation based on PaCO2 scores on awakening and not on persistent desaturation.-the use of other sensors is not considered adequate to determine this. To score Hypoventilation, the PaCO2 level (immediately upon awakening) increases __mm Hg or more as compared to the baseline awake/supine value. 10 Bruxism teeth grinding Stages of sleep should be reported in minutes, minutes of latencies, and percentage of TST ________ should be reported as a total number, index number, numbers occurring in REM sleep and in non-REM sleep for all different types and associations. Arousals Sinus Bradycardia is caused by a decreased rate of impulses from the sinus node. The pulse and ECG usually appear normal except for at a slower rate. (Less than 50-60 beats per minute). Sinus Bradycardia is scored during sleep with a sustained heart rate of less than __ beats/min for patients 6 years of age or more. 40 Alternating Leg Muscle Activation (ALMA) Occurs with a rapid alternating activation of EMG's in the lower extremities. - may be associated with PLM'S. Usually considered benign, do not require treatment, and are unrelated to sleep disorders. An ALMA Series requires at least _ Alma's at a minimum frequency of 0.5 Hz and a maximum frequency of 3.0 Hz. 4 Hypnagogic Foot Tremors tremors that occur during sleep onset in one or both feet that are most common in stage wake but may continue into stages 1 and 2. Hypnagogic Foot Tremors are scored with a minimum of _ EMG bursts in the frequency range of 0.3-4.0 Hz. 4 Hypnagogic Foot Tremors have a frequency of _._-_._ Hz. 0.3-4.0 Cheyne-Stokes Respirations periodic breathing characterized by periods of apnea, alternating with rapid respirations that increase in intensity and then decrease in a crescendo-decrescendo pattern. What respirations are common before death or can occur with central nervous system damage (ex: brain tumor), hyperventilation, and heart failure. Cheyne-Stokes Criteria for scoring Cheyne-Stokes respirations includes _ or more consecutive cycles of crescendo- decrescendo pattern and one of the following: To score an apnea, it must last __ seconds or more and the thermal sensor must drop at least 90% or more below baseline. 10 Obstructive Inspiratory effort continues or increases throughout the apneic period. Central Inspiratory effort is absent during apneic period. Mixed Inspiratory effort is absent for the initial apneic period but resumes during the second half of the apneic period. Example of Mixed Apnea How many stages does the normal conduction of the heart have? 4 SA Node primary pacemaker Purkinje Fibers stimulate the myocardial cells to contract the ventricles Pediatric Sleep scoring rules apply to children _ months post term or older. 2 Sleep Spindles occur at _-_ months or older 2-3 K complexes and slow-wave activity occur at _-_ months or older 4-6 Stages 1, 2, and 3 can be scored in most infants at _-_ months or older. 5-6 REM Sleep occupies about 25% of TST for adults. Dreaming as well as sexual arousal (penile/clitoral erection) most often occurs in what stage of sleep? REM Non-REM and REM cycles occur about every _._-_hours. 1.5-2 What sleep stage are sawtooth theta waves most likely to be present? REM How many seconds of chin activity in REM for it to be scored as an arousal? 1 Excessive Fragmentary Myoclonus (EFM) Twitching movements of the fingers, toes, and mouth that may occur in any stage, including wake. To score EFM, activity needs to continue for at least __ minutes of Non-REM sleep with at least 5 EMG potentials per minute. 20 Pediatric Scoring of Wake uses the __________ _________ _________ rather than the term 'alpha rhythm.' Dominant Posterior Rhythm (DPR) If there is no reactive alpha waves or age-appropriate DPR, score wake with _________ _____________. Eye Movements What is the recommended square feet for patient rooms? 140 Electroencephalogram (EEG) Measure the electrical activity within the brain through the scalp electrodes to rule out seizure disorders and to determine characteristics of the sleep-wake state. Alpha wave frequency 8-13 Hz Beta wave frequency 13-30 Hz Delta wave frequency < 0.5-4Hz Theta wave frequency > 4-7 Hz How many leads are typically used for the EEG channels during a nocturnal PSG?-although more may be applied to diagnose seizure disorders 6 Electrocardiogram (ECG) Record and display electrical activity of the heart through a number of different wave-forms, complexes, and intervals. P wave wave in ECG that represents the beginning of electrical impulses in the Sinus Node, which spread through the atria (muscle depolarization). QRS Complex wave in ECG that represents ventricular muscle depolarization and atrial repolarization. T wave wave in ECG that represents ventricular muscle repolarization (resting state) as cells regain negative charge. U wave wave that represents repolarization of the Purkinje Fibers Anterior Tibialis Electromyogram (atEMGs) monitor the electrical activity in the leg muscles allowing for monitoring of periodic leg movement during the PSG because electrical activity is absent when the muscle is relaxed and increases with movement. Actigraphy non-invasive method of monitoring human rest/activity cycles.-monitors gross motor activity (like a fitbit). True or False? Duration of sleep is not important for the MWT generated by the patient's tissue and motion recorded by surface electrodes Transduced Signals These derive from sensors that convert action, such as chest wall movement, into electrical signal generated by the sensor instead of the body. Equipment Signals Sometimes ancillary equipment, such as a carbon dioxide analyzer is used during the PSG. - This equipment, which has seperate signal displays, outputs, and processing units, may be stand-alone or interfaced with the digital PSG equipment. Physiological bio-calibrations calibrations performed by the technologist to evaluate signals generated by the patient. - should be repeated at the end of the study to ensure that leads and and sensors remain in the correct position and that the recordings were accurate. macroshock shock that involves large and quite perceptible currents passing from one external surface area to another rise time constant time required for pen to reach 63% of signal amplitude fall time constant time required for a pen to descend to 37% of signal amplitude when a DC calibration signal is applied to an amplifier sleep spindle is how many Hz 12-14 Hz Active Sleep REM in the infant How many sleep-onset REM episodes in a series of 5 naps are diagnostic for narcolepsy? 2 naps lower portion of temporal bone behind ear mastoid alpha intrusion term used for a brief superimposition of EEG alpha activity on sleep activities during a stage of sleep An electrode closest to the cornea will register as negative or positive deflection? positive An electrode closest to the retina will register as a negative or postitive deflection? negative Resistor Device used to limit the passage of electrical current Respiratory Disturbance Index (RDI) measures apneas, hypopneas, and RERA's per hour of TST normal sinus rhythm Regular Rhythm; Rate of 60-100 bpm; P-waves present/up-right before each QRS complex; Time interval same for all beats. REM occupies what percent of sleep in the neonate term 50% After sleep onset occurs in MSLT, when is the nap terminated? 15 mins from 1st epoch of sleep Trace Alternant Pattern is associated with what stage of sleep in the infant? Quiet Sleep Trace Alternant Bursts of slow waves, at times intermixed with sharp waves and intervening periods of relative quiescence (quiet and inactive) with extreme low-amplitude activity A mean sleep latency of <5 mins during MSLT indicated what? Pathological Sleepiness Bio-electrical potentials voltages originating from living tissues What sleep stage? *low voltage *mixed frequency EEG 2-7 Hz *slow eye movements *tends to be relatively short, ranging from 1-7 mins. Stage 1 Ohm's law equation E= I x R Ohm's law states that the current through a conductor between 2 points is directly proportional to the voltage across the 2 points. Hypoxemia Abnormally low blood cO2 saturation level Sundowning Term linked with pts experiencing evening and nocturnal hallucinations associated with dementia Anterior Tibialis Leg muscle used to monitor/record myoclonic events Voltage calculation V= A x S Suggested Solution to soak contaminated electrodes 5% Hypochlorite Solution (Household Bleach) Complaints of Severe Sleep Apnea and morning headaches is a result of??? Severe O2 Desat and Hypercapnia Beta Activity EEG Activity with a frequency greater than 13 Hz In 1953, Aserinsky and Kleitman associated what with dreaming during sleep? Rapid Eye Movements Alpha Activity in REM is _-_ Hz slower than during wakefulness 1-2 Periodic Breathing Gain Ratio of output voltage to input voltage, amplifier sensitivity Periodic Breathing most commonly occurs in quiet sleep or active sleep? Active Device used to convert non-electrical physiologicak activity into electrical signals Transducer In order to assess the occurrence of REM during the MSLT, the test should continue for how long after the 1st epoch of sleep? 15 mins The number of waves, or pen deflections, recorded in 1 second signal frequency Jaw Muscle Masseter A patient can become the pathway of least resistance and therefore susceptible to shock when what occurs? when not all equipment attached to patient is connected to a common ground Ultradian Rhythm refers to what period of time less than 24 hrs Ultradian Rhythm of alternating sleep cycles has a period of how many minutes during infancy? 30-70 mins Which type of montage is recommended in order to maximize the the voltages recorded during PSG? Referential montage using contralateral ear references Time Constant Response time of the polygraph pens in relation to high and low frequency filter settings during a calibration procedure What initial effect does administering supplemental O2 have on the OSA patient? a significant increase in apnea duration with associated hypercapnia and respiratory acidosis Conductor Any Material capable of transmitting electrical current How many naps are usually performed during an MSLT? 4-5 An epoch that does not meet criteria for Active Sleep or Quiet Sleep is called indeterminate sleep Sleep Efficiency Ratio of TST to total time in bed Bipolar Derivation Signals obtained by comparing voltages from 2 exploring electrodes. K-complex should exceed 0.5 secs with well-delinated negative sharp wave followed by a positive component REM sleep is associated with what changes in the autonomic nervous system? *Variable Heart Rate *Irregular Respirations *Decrease in Tonic Muscle Activity How long before a nap begins in MSLT should the subject cease smoking 30 mins Electronic Device designed to reduce or eliminate unwanted frequencies from passing through the amplifier Filter Mu Rhythm Morphologically and Topographically distinct EEG activity seen in the central areas; frequency is about 9 Hz Amplitude of this wave is sometimes as high as 200 uv Vertex Sharp Wave Resistance Opposition to an electrical current Attenuation Reduction in size on amplitude of signal Monomorphic distinct EEG activity appearing to be composed of one dominant frequency Hyperventilation Rapid,depp, breathing resulting in reduced levels of CO2 in the blood An instrument used to measure electrical resistance Ohmmeter The degree to which an amplifier will reject a common mode signal is expressed as what? Common Mode Rejection Ratio Vital Capacity A person's maximum breathing ability Signal obtained from a pair of electrode sensors Derivation A person with Ondine's Curse would be expected to have what type of respiratory impairment Central Aveolar Hypoventilation Central Aveolar Hypoventilation Syndrome Respiratory Arrest during Sleep Jactatio Capitis Noctuna Head Banging Thermocouple Device containing two dissimilar metals, which generate an electrical signal in response to temperature variations. True or False? Thermoregulatory responses such as, swetain and panting, are noted in REM, but are absent in NREM. False; Sweating and Panting are seen in NREM, but are absent in REM REM Density A function that expressed eye movements per unit time during REM Sinus Tachycardia example Ventricular Fibrillation example Idioventricular Rhythm example Ventricular Asystole example First-Degree Atrioventricular Block example Second Degree Atrioventricular Block Type 1 example Second-degree atrioventricular block type 2 example Third Degree Atrioventricular Block example Wide Complex Trachycardia example Right Bundle Branch Block example Left Bundle Branch Block example Frequency number of waves/cycles generated per second Amplitude vertical height of wave determined by electrical voltage Setting of __ microvolts/cm used for EEG,EOG, and EMG.-1 cm high 50 filters can later be applied to 'clean up' recording- however, can cause a 'phase shift' that causes wave to appear earlier or later. 60 Hz notch (band reject) rarely used filter because it can interfere with recordings-used mainly on anterior tibialis EMG's Band-Pass filter record frequencies only within a particular range Sampling Rate must be selected before testing when converting analog to digital recordings as they cannot be changed afterward in the way that filters can be changed.-determines the Amplitude (height) of the waveform.- higher sampling rate necessary to achieve adequate waveform The appearance of the waveform is ______ ___ ________ affected by filters Interictal Epileptiform Activity electrical discharges that occur between epileptic seizures Frontal Lobe Epilepsy seizures occurs primarily during what? sleep Seizure Activity is most common in what stage? Stage 2 A Psg may help to differentiate between OSA and _______ ________ Epilepsy, which can result in similar symptoms of choking and EDS. -Some cases may have both present. Frontal Lobe Frontal Lobe Epilepsy is more easily identified with _-channel EEG recordings. 4 Temporal Lobe epilepsy is more accurately identified with __-channel EEG recording. 18 A __ ________ may be placed in the esophagus to diagnose gastric acid reflux in infants and children. - infants will have thin wire with sensor at end passed nasally, while older children or adults may be able to swallow sensor with fluids. pH Sensor What is a co-morbid condition? presence of 1 or more diseases co-occurring with primary disease The newborn (0-1 months) sleeps about __._ hours a day, evenly spaced throughout the day. 16.5 The 2-4 month old infant sleeps about __ hours per day 15 The 4-6 month old child sleeps about __-__ hours a night with 2-3 daytime naps with TST of 14.25 hours. 10-11 _____________ _________ occurs when there is an imbalance between the heart's demand for oxygen and the supply. Myocardial Infarction (MI) ____________ may relieve symptoms of an Acute Asthma Attack, as patients may become hypoxic. Bronchodilators With Chronic ______, permanent damage to the airways may cause decreased oxygen saturation during sleep and disordered sleep. Asthma If nocturnal is severe, the patient may require supplemental Oxygen (1-2 l/min.) Hypoxia RACE stands for what? -Rescue -Alarm -Contain -Evacuate Patient Education Materials should not be written higher than __th - __th grade level. 6th-8th It is important that the technologist establishes ______ with the patient. trust Functional Outcomes of Sleep Questionnaire tool to assess whether excessive sleepiness persists- should be assessed with this after PSG and PAP titration to look for improvement Maintain a distance of _ feet or more from coughing person when possible. 3 _________ recordings may be stored in patient charts Paper Continuous Quality Improvement (CQI) Represents the concept that most processes can be improved.-uses scientific method of experimentation. ________________ is based on the principle that fluid flows from areas of higher pressure to areas of lower pressure. Hemodynamics Pulmonary Embolism 1 or more of the arteries in the lungs becomes blocked by a blood clot Oxyhemoglobin Dissociation Curve graph that plots the percentage of hemoglobin saturated with oxygen (y axis) and differential partial pressures of oxygen (PaO2 Levels) (x axis). Cyanosis A bluish discoloration of the skin and mucous membranes due to the tissues near the surface having low oxygen saturation. Barotrauma injury caused by increased air or water pressure. (common of ear)-Ventilator management may require a higher PaCO2 to prevent this Type 1 Sleep Study Nocturnal PSG; at least 12 channels. This type is used to diagnose OSA as well as other sleep disorders Types 2, 3, and 4 Sleep Study Modified Home Sleep Studies, using portable devices.-only appropriate for OSA patients because they provide limited information The Respiratory System during wake is under primary control of the _________ Nervous System Autonomic Acute Respiratory Distress Syndrome Condition in which fluid collects in the lungs' air sacs depriving organs of oxygen. Periodic Breathing is common with ___________ ________ ______________. Congestive Heart Failure Hypotonia (Floppy Baby Syndrome) low muscle tone and strength Minute Ventilation amount of volume of gas inhaled or exhaled from a person's lungs per minute Upper Airway Resistance increases during what stage of sleep? REM Snoring results from vibration within the respiratory system, often within the throat or nasal passage.-the sound arises from tissues vibrating against each other. When relating to ___________ _________ only, snoring is not a threat to health even if it is annoying. Nasal Obstruction The ____________ _________ slows down during sleep as a protective mechanism to prevent aspiration Gastrointestinal Tract It is likely that _________ will increase if the patient lies in the right lateral decubitus positon GERD Uvulopalato-Pharyngoplasty (UPPP) If OSA relates to a narrowed airway, the excess tissue may be removed from the uvula and the soft palate, and the tonsils and adenoids are also removed. Uvulopalatal Flap (UPF) Patients with COPD who are receiving high fractions of inspired oxygen may actually have increased _____ _________ levels. Carbon Dioxide Nasal Cannulae (prongs) Most common delivery system for oxygen because of ease of use. _________ is needed for oxygen flow rates of 4 L/min or more. Humidification Venturi Mask Oxygen mask that comes with different size color-coded nozzles to control the FIO2 accurately, with different sizes providing different rates.-often used on patients with COPD. An infant with ___ is fitted with apnea alarms, which typically awaken the infant and trigger respirations. CSA High-Flow Oxygen Delivery Devices provide oxygen at flow rates higher than the patient's inspiratory flow rate at a specific medium-to-high fraction of inspired Oxygen (FIO2), UP TO 100%. -Usually not used in sleep center and humidification is usually required because the high flow is drying. Low-Flow Oxygen Delivery Devices provide 100% oxygen at flow rates lower than the patient's inspiratory flow rate, but the oxygen mixes with room air Supplemental Low-Flow Oxygen used with a PSG, the use of which must be explained by technologist Initiate ;ow-Flow Supplemental O2 at 1 L/min when SpO2 falls below __% on ambient room air. 85 Monitor SpO2 when on oxygen to ensure it increases to at least __%. 90 Do not exceed 4 L/min of supplemental O2 without what? specific physician's order Infants younger than _ months may be started on CPAP immediately without prior practice or behavioral training. 9 Pierre Robin Syndrome Present at birth;child has smaller than normal lower jaw, a tongue that falls back into the throat, and difficulty breathing Patient Education increases __________. Compliance Begin CPAP titration at the lowest setting, usally _ cm H2O 5 Increase PAP pressure _ cm H2O at time set intervals, usually about every 15 minutes and observe effects, 1 Titration is done in the second half of the night during a split-night test (at least _ hours). 3 Adaptive Servoventilation devices provide a baseline positive airway pressure abd breathing assist to ensure adequate ventilation (at preset level) with each breath to __% of average for the patient. 90 Upper Airway Resisitance Syndrome (UARS) characterized by AHI of 5 or less but with increased numbers of RERA'S because of airway Resistance to breathing during sleep caused by small, restricted airways. C-Flex (by Respironics) expiratory pressure relief device that is a modified CPAP machine that has some elements of BIPAP- Provides a steady inspiratory pressure but allows patients to select a reduction in pressure during expiration (1-3 cm H2O). EPR (by ResMed) expiratory pressure relief device, provides smiliar relieef of pressure during exhalation but does so by reducing motor speed. Nasal Pillows work best with what nostril shape? -may be impossible to fit otherwise Round Nasal Masks are not effective for....? mouth breathers and those without teeth Orofacial Masks masks that aren't good for those who are claustrophobic Which masks are most appropriate for those with nasal congestion and other nasal obstructions that cause them to breathe primarily through their mouth? Oral Masks Air Hunger when some patients feel short of breathe while using positive airway pressure ________ __________ almost always relates to air leaks and air blowing across the eyes.-can cause conjunctivitis too Eye Irritation _____ _______ are a common complaint with PAP, especially with Nasal Pillows. Nose Bleeds What dies A.W.A.K.E stand for?????? (educates people about sleep apnea). Alert, Well, and Keeping Energetic Patient follow-up almost always necessary to ensurance compliance with PAP therapy. Re-accreditation occurs every _ years for sleep centers. 5 Sleep Center Staff must include a _____ _________with a license to practice and a diplomate of the American Board of Sleep Medicine (ABSM) Medical Director Health Insurance Portability and Accountability Act of 1996 addresses the rights of the individual related to privacy of health information. Confidentiality Activate medical procedures immediately for? ventricular fibrillation What type of therapy do ALS pts. typically get? Bi-PAP Complex apnea: The start or continuation of central apneas while on CPAP. COPD/ overlap syndrome Pts who have both COPD and OSA the distance between FP1 and O1 is 25cm. what is the distance between F3 and C3? 6.25cm which body position typically reduces the patency of the upper airway during sleep resulting in sleep apnea? supine Cheyne- stokes points to what condition? CHF REM behavior disorder usually begins after age 60 what might be seen in a PT. with lesions in the suprachiasmatic nucleus? altered circadian rhythm electrode pops can be caused by? impedance difference between electrodes if the circumference is 58cm what is the difference between T3 and O1? 11.6cm if the circumference is 58cm what is the difference between FP2 and T4? 11.6cm if the circumference is 58cm what is the difference between FP2 and O2? 23.2cm if the circumference is 58cm what is the difference between FP1 and T5? 17.4cm maximum electrode impedance is? 5k the AASM recommended starting pressure for adults and children? 4cm The AASM recommended IPAP and EPAP starting pressure for both adults and children? IPAP:8cm EPAP:4cm AASM recommended maximum CPAP pressure for adults? 20cm AASM recommended maximum IPAP pressure for Bi-PAP in adults? 30cm AASM recommended maximum CPAP pressure for children <12 years? 15cm AASM recommended maximum IPAP pressure for child <12 years on Bi-PAP? 20cm AASM recommended minimum IPAP-EPAP differential? 4cm AASM recommended maximum IPAP-EPAP differential? 10cm The AASM recommends CPAP pressure increase for how many obstructive events in children <12? 1 event The AASM recommends CPAP increase for how many obstructive events in adults? 2 events The AASM recommends IPAP and EPAP pressure increase for how many obstructive events in children <12? 1 event The AASM recommends IPAP and EPAP pressure increase for how many obstructive events in adults? 2 events The AASM recommends CPAP pressure increase for how many hypopneas in children <12? 1 hypopnea The AASM recommends CPAP pressure increase for how many hypopneas in adults? 3 hypopneas The AASM recommends IPAP pressure increase for how many hypopneas in children <12? 1 hypopnea The AASM recommends IPAP pressure increase for how many hypopneas in adults? 3 hypopneas The AASM recommends CPAP or IPAP pressure increase for how many RERAS in children <12? 3 RERAS The AASM recommends CPAP or IPAP pressure increase for how many RERAS in adults? 5 RERAS The AASM recommends CPAP or IPAP pressure increase for how many min. of loud snoring in children <12? 1 min The AASM recommends CPAP or IPAP pressure increase for how many min. of loud snoring in adults? 3 min An optimal pressure should have an RDI of? <5 A good pressure should have an RDI of? <10 An adequate pressure should reduce baseline RDI by what %? 75% The duration of a titration should be > how many hours? > 3 hours which PAP type automatically increases CPAP or BPAP (IPAP/EPAP) as needed to maintain airway patency and then decreases the pressure if no abnormal respiratory events are detected within a set period of time? • ask about RLS or bruxism • observe pt. During sleep to determine if PAP setting is still in place • reassess type of mask used. What is Genioglossus advancement? GA enlarges the hypo-pharyngeal area and is recommended for those who's youngest fall back and obstruct airways. The genioglossus muscle attaches the tongue to the lower jaw at a bony prominence. GA moves this prominence forward and reattaches the tongue in a more anterior position preventing the tongue from blocking the airway. This procedure may be done along with uvulopalatal flap and radiosurgical tongue reduction. GA is often more successful that a uvulopalatopharyngoplasty. What is a Hyoid Myotomy? HM enlarges the hypophayngeal area by pulling the hyoid bone forward, opening the airway. It is indicated for those with airway blockage at the epiglottis or base of the tongue. May be done wit GA or alone. What is Uvulopalatopharyngoplasty (UPPP)? If OSA is related to a narrowed airway then the excess tissue may be removed from the uvula and soft palate, the tonsils and adenoids are also removed. It is painful but is used for pts. Who are unable to use PAP therapy. It may be a better option than a tracheotomy for severe cases. What is Uvulopalatal flap (UPF)? UPF removes minimal tissue from the soft palate lifting it and removing the tonsils to increase the size of the airway. This is less invasive than UPPP, but is still quite painful. What is a Maxillomandibular advancement (MMA)? MMA is recommended for pts with severe OSA that does not respond to other surgical treatments or CPAP. Both the mandible and maxilla are fractured on both sides, metal spacers are placed between the bones and the mid face is brought forward up to about 12mm to enlarge posterior airway. May change the appearance of the face. What is maxillomandibular expansion (MME)? MME is recommended for those whose jaws are not wide enough and involves cutting into both sides of the mandible and maxilla and placing distractors which essentially stretch and expand the jaw leaving a gap between the teeth which is later corrected with orthodontics. What is the pillar procedure? The pillar minimally invasive procedure is used to treat obstruction cause by the soft palate. It involves suturing three small inserts into soft palate to provide support. Effective for mild - moderate OSA. What is a tracheostomy? An opening directly into the trachea that bypasses the obstruction and opens the airway. What is ALMA? Occurs with rapid alternating activation of (emg) in the lower extremities How do you score ALMA? An ALMA series requires at least 4 ALMAS at a minimum frequency of 0.5hz and maximum frequency of 3.0hz. Duration usually ranges from 100-500 milliseconds. Almas are considered benign, do not require treatment, and are unrelated to sleep disorders. what is the Criteria for scoring (RBD)? 1) REM epoch with 50% or more increased cEMG (chin) activity. 2) Burst of muscle activity. Usually lasting 0.1-0.5 sec. with amplitude increased over baseline. What is the criteria for scoring Bruxism? Increased of cEMG activity at least two times regular amplitude. 1) Phasic (brief): sequence of at least 3 with duration for each 0.25 - 2 sec. 2) Tonic (Sustained) duration of 2 sec. or more How many stages does a normal heart conduction have? 4 What sleep disorder is caused by amphetamine intoxication? Insomnia Total sleep reduced with increased sleep latency and sleep disturbance. EMG shows increased muscle activity. Stage REM sleep and N3 decreased are a side effects to what type of drug intoxication? Amphetamines What sleep disorder is caused by Amphetamine withdrawal? Hypersomnia Prolonged sleeping during the . REM and N3 increased. MSLT shows increased sleepiness during day as well. These are all side effects to withdrawal from which type of drug? Amphetamines What sleep disorder is caused by caffeine use? Insomnia Increased wakefulness and decreased sleep are does dependent. PSG shows increased sleep latency and wakefulness and decreased N3. These are side effects to the use of which drug type? Caffeine What sleep disorder is caused by caffeine withdrawal? Hypersomnia Increased sleeping and daytime sleepiness are common symptoms for withdrawal from which drug type? Caffeine What sleep disorder is caused by alcohol intoxication? Insomnia Acute intoxication: increased sleeping and decreased wakefulness for 3-4 hours with increased N3 and reduced REM sleep. Complete intoxication: decreased N3 increased wakefulness, and increased REM with restlessness and vivid dreams. these are symptoms of intoxication from which drug type? Alcohol What type of sleep disorder is caused by alcohol withdrawal? A patient reports a complete nasal obstruction prior to PAP titration. The technologist should: Inadequate sleep hygiene A patient that intentionally engages in behavorial patterns that are inconsistent with sleeping well is demonstrating: Sundowning A patient with mild dementia becomes more confused and/or agitated in the early evening. The patient is MOST LIKELY expierencing. Call the physician for confirmation A patient's chart indicates that they use 3.0 L/min of oxygen at home. The technologist notes that the physican's orders for the PSG specifies starting the study without supplemental oxygen and to add 1 L/min oxygen if the SpO2 is less than 89%. The BEST action for the technologist is to: COPD and OSA A patient's history indicates a diagnosis of overlap syndrome. The technologist can anticipate that the patient has: Desensitization A process to decrease fear of artificial circumstances by repeated and controlled exposure to a feared situation is: Pittsburgh Sleep Quality Index A self-reporting tool used to evaluate subjective sleep quality and disturbance over the previous month is: Aerophagia A side effect of CPAP is: A. Hyperventilation B. CO2 Retention C. Aerophagia D.Intentional Leak .5 seconds According to RECOMMENDED guidelines, the minimum duration of a significant leg movement is: Occurrence of hypoventilation during the diagnostic study in adults According to RECOMMENDED guidelines, an optional parameter to include in the report for an adult polysomnogram is: Has not eliminated Cheyne Stokes respiration or central emergent apneas. According to RECOMMENDED guidelines, adaptive servoventilation can be considered during a titration studey when a down titration: 5 minutes According to RECOMMENDED guidelines, CPAP should be increased at an interval no less than: Had REM on at least two nap opportunities According to RECOMMENDED guidelines, four nap opportunities on a MSLT would be acceptable when the patient: Oronasal thermal sensor According to RECOMMENDED guidelines, the device that should be used to monitor airflow and detect apnea during a diagnostic study is: 500 Hz According to RECOMMENDED guidelines, the sampling rate to provide the optimal resolution for recording EEG in a patient with suspected nocturnal seizures is: There is a high probability of moderate to severe OSA without comorbid conditions According to RECOMMENDED guidelines, unattended portable monitoring can be used as an alternative to in-lab testing when: 5000 ohms According to RECOMMENDED guidelines, the maximum electrode impedance for EEG and EOG recording is: End-tidal CO2 According to RECOMMENDED guidelines, which of the following should be included when recording pediatric patients? The stage that is the greatest portion of the epoch According to the RECOMMENDED guidelines, when coexisting sleep stages occur in a signle epoch, the epoch should be scored: Confirm accuracy of report components An important responsibility of the scoring technologist is to: 11 Calculate the AHI based on the following data: 25 obstructive apneas 5 central apneas 23 mixed apneas 15 hypopneas 48 RERAs 65 arousals 360 min of sleep Change to bi-level During a CPAP titration at 15 cm H2O, the patient is restless and continues to have frequent obstructive respiratory events. The BEST action is to: IPAP 14 / EPAP 10 During a titration study the patient's apneas are eliminated at 10 cm H2O but hypopneas and snoring continue at 16 cm H2O. According to RECOMMENDED guidelines, the appropriate pressures to begin a bilevel titration are: Follow protocol for supplemental oxygen During CPAP titration at 10 cm H2O, SpO2 values range between 80 and 85% for 10 minutes despite absence of respiratory events. What is the BEST action for the technologist to take? Reposition and adjust PAP interface During stage N2 sleep, the patient changes position and the technologist notes increased snoring and an increasing leak. The technologist should: Water to pool in the CPAP tubing Excessive warming and humidification will cause: REM and slow wave rebound In patients with severe sleep-disordered breathing, the most commonly seen response resulting from successful PAP titration is: Historgram What is the BEST tool that a physician could use to more clearly explain the results of the sleep study and the importance of therapy to a patient? 4 cm H2O What is the RECOMMENDED starting pressure for pediatric and adult CPAP titration? Schedule desensitization When a patients complains of claustrophobia, is unable to tolerate PAP and requests to end the PSG, the next BEST step is to: Rely on F3-M2 When intermittent 60 Hz activity occurs in the F4-M1 electrodes during REM sleep, the best IMMEDIATE action would be to: Hypoxemia and hypercapnia When reviewing a patient's history in preparation for a polysomnogram, physiologic findings suggestive of hypoventilation include: Decrease sensitivity When the amplitude of a signal exceeds the physical limitations of a channel the MOST important adjustment the technologist can make to optimize waveform display is to: Alcohol consumption prior to testing Which of the following is the MOST LIKELY cause of a 35 minute REM latency? Conjunctivitis Which of the following is MOST likely to occur due to an improperly fitting PAP interface? Alcoholic beverages Which of the following substances can reduce the effectiveness of PAP therapy Position changes Which of the following would be MOST important to document during a polysomnogram? Increased sleep efficiency Which of the following is the MOST LIKELY effect of Zolpidem and Zaleplon on sleep architecture? Dislodged system reference electrode Which of the following can negatively impact all bioelectric channels? There is a potential for electrode contamination Which of the following BEST describes a referential montage? Soaking in 1:10 bleach and water for 10 minutes Which process would be an adequate routine procedure for disinfecting cup EEG electrodes after removing adhesive residue, gel and organic material, and washing in warm water and mild detergent? The is one level of pressure for inspiration and expiration Which statement is true regarding CPAP? Physiological Which type of calibration is based on a series of patient instructions intended to verify the signal response and qualtiy? Which type of calibration is based on a series of patient instructions intended to verify the signal response and quality? Physiological What is the MOST LIKELY effect of zolpidem and zaleplon on sleep architecture? Increased Sleep Efficiency What best describes a referential montage? There is a potential for electrode contamination. What is most important to document during a PSG? Position Changes When reviewing a patients history in preparation for a PSG, physiologic finding suggestive of hypoventilation include? Hypoxemia and Hypercapnia A patients history indicated a diagnosis of overlap syndrome. The technologist can anticipate the patient has? COPD and OSA The syndrome characterized by prolonged episodes of severe hypoxemia and associated PaC02 elevation that worsens during sleep is? Obesity Hypoventilation The ability to remontage while recording on digital equipment is the result of? CMR "Common Mode Rejection" According to the recommended guidelines, the device that shold be used to monitor airflow and detect apnea during a PSG is? Oronasal Thermal Sensor Accoring to the recommended guidelines, what should be included when recording pediatric patients? End-Tidal C02 What is the most common method to monitor blood O2 saturation during a PSG? Pulse Oximetry What is the most important reason for performing a MWT? Measure the patients ability to resist the urge to fall asleep. When the amplitude of a signal exceeds the physical limitations of a channel the MOST important adjustment the technologist can make to optimize the waveform display is to? Decrease Sensitivity A self-reporting tool used to evaluate subjective sleep quality and disturbance over the previous month is? Pittsburgh Sleep Quality Index Adult Mild RDI 5 to < 15 Adult Moderate RDI 15 to 30 Adult Severe RDI more than 30 Child Mild RDI 1 to < 5 Child Moderate RDI 5 to < 10 Reasons to Increase IPAP only in CHILD (list) 1 hypopnea, 3 RERAs, 1min of loud snoring Reasons to Increase IPAP only in ADULT (list) 3 hypopnea, 5 RERAs, 3 min of loud snoring Bi-PAP Optimal, Good, Adequate Titration Same Parameters as CPAP Supplemental O2 recommended when PT is (short answer) when SpO2 is less than 88% for 5mins of longer while patient is awake Location to connect O2 on CPAP Equipment (short answer) Connect through CPAP Tubing by use of adapter or T connector Recommended starting rate for O2 1 L/min rate of O2 increase (short answer) Increase 1 L/min with 15 min intervals until pt is with in 88%-94% SpO2 reason to lower O2 (short answer) When CPAP/Bi-PAP pressure in Increased. Split -Night studies (list/ short answer) more than 3 hours of Titration time, Should not be performed on children (<12yo), pressure increase with minimum of 2cm with interval of 5 min or more TST: Total Sleep Time Time in minutes and/or # of epochs of Sleep (not including WASO, Arousals, and TNR) TRT: Total Recording Time Time in mins Lights out - Lights on Sleep Latency Time from Lights out to the first epoch of sleep Stage R Latency Time from Sleep onset to the first epoch of REM WASO: Wake After Sleep Onset Time(mins) the patient is wake after AFTER sleep onset. including time not connected/recorded. WASO= TRT-SL-TST Sleep Efficiency Percent TST/TRT x 100 Time in each stage # of epochs and mins Percent of TST in each stage Time in stage(n1,n2,n3,R)/TST x 100 Arousal Index #of arousals x 60 / TST Heart Rate Average BPM, Highest during sleep, Highest during TRT Bradycardia If reported; Lowest BPM during TRT Types of Tachycardia -Sinus tachycardia -Narrow complex tachycardia -Wide complex tachycardia Atrial Fibrillation Report average BPM Arrhythmias List types of arrhythmias Movement events - # PLMS and PLMS with arousal - PLMS and PLMArI index ( # of events x 60 / TST) Asystole Pauses for 3 seconds or longer between heart beats Respiratory Events # of; Apneas (Ob,C,M), Hypopneas (Ob,C), RERAs Apnea Index AI; (# obstructive apneas + # central apneas + # mixed apneas) × 60 / TST) Hypopnea Index HI; (# hypopneas × 60 / TST) Obstructive apnea-hypopnea index (no centrals) OAHI; (# obstructive apneas + # mixed apneas + # obstructive hypopneas) × 60 / TST) Central apnea-hypopnea index (only centrals) CAHI; (# central apneas + # central hypopneas) × 60 / TST) RERA Index # of RERAs x 60 / TST Respiratory Disturbance index RDI; (# apneas + # hypopneas + # RERAs) × 60 / TST) Oxygen Desaturation index # oxygen desaturations ≥3% or ≥4% × 60 / TST) Oxygen saturation Mean value and Minimum during sleep Types of breathing patterns - Hypoventilation with or without CPAP - Cheyne-Stokes breathing (duration, or # of events) - Periodic breathing (children only) - Snoring Narcolepsy Inability to maintain wakefulness/alertness during major waking episodes of the day, occurring daily for at least 3 months MSLT score of <5mins Parasomnia Abnormal movements/behavior right before, during, after sleep, or during transition into or out of sleep. a. time not connected is W. b. 10% of people dont have Alpha with eyes closed. Stage N1: EOG Slow Eye Movement (SEM) not required Stage N1: EEG Low Amplitude Mixed Frequency (4-7hz), V-Waves, No Spindles,K-complex, delta waves, alpha, sawtoothwaves. Stage N1: EMG Varies but is usually lower amplitude than Stage W Vertex Sharp Waves (V-Waves) <.5 seconds, distinguishable form background activity, can persists in n2 sleep. Are NOT required to score N1 Stage N1: Beginning in PTs with Posterior Dominate Rhythm When Posterior Dominate Rhythm(alpha) attenuates and is replaced my LAMF Stage N1: Beginning PT's without Posterior dominant rhythm a. slowing of background frequency by > or = 1hz b. vertex sharp waves c. SEM comencement Stage N1: Appears After any epoch with LAMF, no evidence of another sleep stage AND AFTER an arousal or major body movement.. Stage N1: Ends When Evidence of any other sleep stage apears Stage N1: Arousal during N2 All epochs after the arousal are N1 until evidence of another sleep stage appear. Stage N1: Arousal during REM All epochs after the arousal are N1 ONLY if LAMF AND SEM are present Stage N2: EEG K complex and Sleep Spindle, LAMF in the background K Complex Sharp negative wave preceding a slow positive wave lasting longer than 0.5 seconds Sleep Spindle A short burst of rhythmic activity 11-16hz lasting longer than 0.5 seconds Stage N2: EMG low amplitude, lower than awake and N1. Stage N2: EOG Commonly there is no movement Stage N2: Onset a. The Epoch with a K complex or Sleep spindle in the first half OR b. if K complex or sleep spindle occurs in the second half then the next epoch will be the first for N2 Stage N2: Continues Even with no spindles or K complexes and LAMF is present UNLESS evidence for REM appears without an interrupting Arousal, N1 or N3 Stage N2: Transition into N1 After an arousal and LAMF is present and/or SEM. Stage N2: Transition into N3 When an Epoch is 20% or more Slow Wave Sleep (Delta) Stage N2: Transition into REM If there is Evidence for REM all preceding epochs WITHOUT K complexes or spindles in the second half but contain LAMF are REM Possible drop in EMG tone (not required) Stage N3: EEG contains Slow wave (Delta) activity, possible to contain k-complex or sleep spindles in first epoch of N3 Delta Waves >75microvolts lasting more than 0.5 seconds and a frequency of 0.5-2hz Stage N3: EMG Lower Amplitude than N1 or N2 may be equal to REM Stage N3: EOG Usually no activity Stage N3: Begins When 20% or more of an epoch is Slow wave sleep. Sleep spindles may persist Stage N3: Ends After an arousal or major body movement and/or a shift into LAMF in the EEG Stage REM: EEG LAMF with Saw Tooth Theta waves. Sleep Spindles and K complexes are ABSENT. Saw Tooth Theta Waves Trains of Sharply contoured or triangular waves at 2-6hz Stage REM: EMG Muscle tone is at it lowest but Transient Muscle Activity may occur Transient Muscle Activity Short Irregular burst of EMG acitivty <0.25seconds. may be associated with Eye Movements Stage REM: EOG Irregular, sharply peaked movements lasting <500msec Stage REM: Begins The epoch with Rapid Eye Movement and Low EMG amplitude often preceded by LAMF, Sawtooth Theta waves Stage REM: Onset The First Epoch (and all others after it) with LAMF and WITHOUT K complexes/Sleep Spindles or an arousal that precede a Rapid Eye Movement with low EMG Amplitude. Stage REM: Continues Infant Stage W: EEG Characteristics Low voltage irregular(LVI), Mixed (M) Infant Stage W: EOG characteristics Blinking, REM, Scanning movements, brief evey closures (longer than blink) Infant Stage W: EMG Present, Movement artifacts Infant Stage N: Behavioral characteristics Reduced movement (relative to wake), eyes closed, periodic sucking, occasional startle. Infant Stage N: Respiration Regular Infant Stage N: EEG Trace Alternate (TA), High Voltage Slow(HVS), Sleep spindles or Mixed (M) Infant Stage N: EOG Eyes closed, no movements Infant Stage N: EMG Present or Low (relative to wake) Infant Stage R: Behavioral Eyes closed, small movements Infant Stage R: Respiratory Irregular Infant Stage R: EEG Low voltage irregular (LVI) or Mixed (M) infant Stage R: EOG REMS or No eye movements (only after Definite REM) Infant Stage R: EMG low, Transient Muscle activity(TMA) may occur Infant EEG Characteristics: Trace Alternate (TA) At least 3 alternating runs of bilateral Symmetrical synchronous High voltage, 1-3hz delta activity that last 5-6sec, ALTERNATING WITH lower amplitude 4-7hz theta activity lasting 4-12 secs Infant EEG Characteristics: Low Voltage irregular (LVI) Continuous LAMF WITH Delta and Predominately Theta activity. Infant EEG Characteristics: High Voltage Slow (HVS) Continuous Symmetrical High voltage 1-3hz delta activity Infant EEG Characteristics: Mixed (M) Both high voltage and low voltage happening non-periodically, Lower voltage than HVS Infant EEG Characteristics: Sleep Spindles 12-14hz activity prominently in the central region, ONLY in Stage N sleep. Progesterone Hormone that causes drowsiness especially in the first trimester of pregnancy Pregnancy effect on sleep Total Sleep time decreases, Shortness of breath, Insomnia, Sleep apnea. Cardiac Output The amount of blood that is pumped through the ventricles in one minute Stroke volume Amount of blood EJECTED by the ventricle in one contraction Vascular resistance The amount of resistance that must be overcome to push blood through the circulatory system Systemic circulation The flow of Oxygenated blood away from the heart and Deoxygenated blood back to the heart. Systemic Vascular Resistance The amount of resistance in systemic circulation Pulmonary Circulation The flow of Deoxygenated blood away from the heart To the lungs and oxygenated blood back to the heart. Pulmonary vascular resistance The amount of resistance in the pulmonary circulation Cardiac Index A measure of Cardiac performance in relation to the size of the individual. measures in L/min/squared meter Excessive Fragmentary myoclonus at least 5 twitching movements that occur every minute for 20 mins during NREM sleep Hypnagogic foot tremor HFT: A minimum of 4 HFT burst are needed to make a train. frequency of the burst range from .3hz- 4.0hz Rhythmic movement disorder Involuntary, repetitive movements that range between .5hz-2.0hz. 4 movements are required to mark a single cluster of movements. Periodic Leg Movements in Sleep: Single event PLMS: Duration range from .5-10 seconds, increase of z8uv, the end begins when there is at least .5 seconds of EMG tone that is no more than 2uv higher than resting EMG amplitude. PLMS Series at least 4 LM events are needed to become a series, LM events with in the SAME series can be 5-90 seconds apart. LM events on different legs that happen within 5seconds of each other count as a SINGLE movement PLMS and Arousals Arousals and LMs that occur in a PLM series should be considered associated with each other if both happen simultaneously, overlap, or is there is <.5secs between the two events. Temporal Lobe Epilepsy Seizures that occur primarily in the temporal lobe lennox-gestaut syndrome Diuretics May lower potassium causing cramps, increase urinary output. Nicotine Reduced sleep duration and vivid dreams Selective serotonin reuptake inhibitors (SSRIs) EDS, and sleep disruption Thyroid hormone Disrupts sleep, heart palpatations, tremors, nervousness History and Physical: Sleep Disorders obstructive/central apnea, narcolepsy, circadian rhythm disorders, RLS, PLMS, parasomnia, insomnia History and physical: Respiratory Disorders COPD, Cystic Fibrosis, restrictive lung disease, and asthma History and physical: Neuromuscular Disease MS, ALS, myasthenia gravis, poliomyelitis, myotonic dystophy. History and physical: Spinal cord injury Bilateral Diaphragmatic paralysis Morning/Evening Questionnaires 19 questions about time preferences. determines when PT is most awake Morning Questionnair given after a PSG to determine if Varribles of the sleep lab effected sleep performance. Bed-partner Questionnair Given to PT's Bed-Partner(roommate). Gives insight to PT's behavior while in sleep that PT may not be aware of. Pre Sleep Questionnair Helps determine if the previous 24hrs were normal for the PT prior to PSG. Technologist may ask additonal questions. Sleep diaries Has two components: Evening- mood assesment, Medications taken, time of Lights out. Morning- Approximate sleep onset, #of arousals, 1-5 mood scale Stanford Sleepiness scale Assessment for EDS, 1-7 sleepiness scale used to describe different parts of the day. 4-7 correlates with EDS Epworth Sleepiness Scale Determines how likely PT will Fall asleep in a given scenario, 0-3 scale. Score of 9or< is high index for sleep. Sleep-Wake Activity Inventory Nine Statements that the PT will score with 1-9 scale. (1-always present, 9 never present). score of <50 mean sleepiness Fatigue Severity Scale 9 descriptions relating to fatigue, PT will score on 1-7. above 35 suggest high Fatigue Berlin Questionnair Determines risk of OSA or Progress after treament with PAP device. total of 14 questions in three categories: snoring, Fatigue, hypertension. High risk is positive in 2 or more category. Pittsburgh sleep quality index 19 questions which make up 7 sections that create a global score. This questionnaire help asses the PTs sleep quality after 1 month. STOP-BANG Obstructive Sleep Apnea screening tool. 8 yes or no questions which every "yes" answer is 1 point. less than 3 is low risk for OSA Bioelectric Signal Generated by the PT's Tissue and motion and recored by surface electrodes Transduced Signals Generated by sensors that convert action into electrical signals. Standard Time Scale 1cm/sec Frequency Waves/cycles per second Amplitude Vertical height of the wave Determined by voltage Standard Voltage setting 50 microvolts/cm (50 microvolts of signal produce a standard waveform that is 1cm high). Sensitivity Setting Adjust the visual height of the wave without changing the Time constant or Voltage Filters Used to Isolate Bandwidths and reduce outside interference. Low-Frequency Filters Used to eliminate signals below the normal bandwidth High-Frequency filters Used to eliminate signals above Normal bandwidth 60 Hz notch Used to remove Signals in 50-60hz range without affecting other frequencies Band-pass filters only record signals within a particular range Sample Rate: EEG Desirable: 500 hz Minimal: 200 hz Sample Rate: EOG Desirable: 500 hz Minimal: 200 hz Sample Rate: EMG Desirable: 500 hz Minimal: 200 hz Sample Rate: ECG Desirable: 500 hz Minimal: 200 hz Sample Rate: Airflow Increase in arterial PCO2 to a value of >55mmHg for z10mins OR z10mmHg increase during sleep compaired to awake lasting z10min Cheyne-Stokes Breathing Episodes of z3 consecutive central apneas/hyponeas separated by a crescendo-decrescendo change in breathing amplitude lasting z40seconds AND z5 central apnea/hypopneas per hour of sleep recorded over z2hours Ages to use Pediatric Respiratory Scoring rules Anyone younger than 18. Children z13yr may use adult rules Children Apena: General Parameters Drop is signal size by z90% for at least the minimum duration specified by obstructive/central/mixed criteria Children Apnea: Obstructive Meets Criteria for apnea and last the same duration as 2 breaths during baseline AND is associated with respiratory effort during absent airflow. Children Apnea: Central Meets apnea criteria with absent Inspiratory effort AND one of the follow is present: -event last z20sec -even lasts duration of two normal breaths with z3% desat or and arousal -two breath duration with decrease is heart rate (50BMP for 5sec or 60BPM for 15sec) Children Apnea: Mixed meets criteria for apnea for duration of 2 normal breaths and is associated with no effort and effort. Children Hypopnea: General parameters Decrease is signal height by z30% for 2 breath duration with z3% desaturation or associated with an arousal Children Hypopnea: Obstructive Criteria for hypopnea is met and is any of the following occur: -snoring during the event -inspiratory flattening on nasal pressure or papflow -thoracoabdominal paradox occurs during the event Children Hypopnea: Central Hypopnea Criteria is met and NONE of the Obstructive hypopnea criteria is met. Children RERAs When a sequence of breaths lasting z2 normal breath duration that result in an arousal and are characterized by one of the following: -snoring -increase respiratory effort -flattening of inspiratory part of the Pressure/PAP signal -increase in PCO2 above baseline Children Hypoventilation When >25% of TST contains a PCO2 of >50mmHg Children Periodic Breathing z3 episodes of central pauses in respiration lasting >3sec that are separated by 20 or less seconds of normal breathing. MSLT Multiple Sleep Latency Test: used to measure tendency to fall asleep. May diagnose Narcolepsy and Hypersomnia. MLST Montage Required Optional: all other leads - EEG - EOG - ECG -cEMG MSLT Procedure: When to start 1.5 - 3hrs after a PSG MSLT Procedure: Naps MSLT consists of 5 nap periods separated by breaks that are 2 hours long MSLT Procedure: PT preparation - PT should keep a 2 week sleep diary - Stimulants or sleep altering medications should be discontinued 2 weeks prior - PT must put on casual clothes MSLT Procedure: Before each nap - PT uses bathroom if needed - no smoking 30 mins before -no exercise 15 mins before - Biocalibrations MSLT Procedure: During the nap - PT attempts to fall asleep with lights out while lying in bed - If no sleep is recorded Nap ends after 20 mins (SL is 20mins) - If PT sleeps study ends 15 mins after sleep onset MSLT Procedures: After each nap - PT gets out of bed - Lights are on - Monitor PT to prevent sleeping during the break MSLT Procedure: Ends After 5th nap is concluded May end after 4 naps if no REM is recorded in any NAP. MSLT Diagnosis Sleep latency averaging 5mins or less means and had at least 2 Sleep Onset REM Periods, then the PT is Narcoleptic. MWT Maintenance of wakefulness test; Measures PT's ability to stay awake Oral Appliance Contraindication -If PT requires rapid initiation of treatment for severe symptomatic OSA, Active Cardiovascular comorbidities. - PT with prolonged low SaO2 - PT with Dental conditions that would prevent appliance retention in the mouth. Types of Oral Appliances - Mandibular Advancement splints - Tongue retaining device Mandibular Advancement Splints Most common oral appliance, Enlarge airway by re positioning anatomical features. Tongue Retaining device uses suction to move tongue to enlarge air way. Esophageal pH Monitoring Used on PTs with symptoms suggestive of GERD. Complex Sleep Apnea During a CPAP titration if Increasing the pressure eliminates Obstructive apnea but Central apneas begin to apear. Complex sleep apnea treatment Best choice is switching to ASV mode and if not possible to then use BPAP WITH a backup rate. Pneumothorax When lungs collapse due to negative pressure. Air between the lungs and the chest wall Pnuemothorax causes Lung damage by COPD, Cystic fibrosis or Pneumonia Mallampati score Scoring system to predict difficult intubation. Looks at size of the tongue and how wide the mouth can open. Air Hunger Respiratory distress, labored breathing or dyspnea. Feeling of suffocating ALMA Alternating Leg Muscle Activation: A single episode is at least four muscle activations that alternate between the legs .5-3hz strain gauge Mercury filled device thats used to measure Respiratory effort Impedance Pneumography A device that measure respiratory effort by measuring difference between two electrodes placed onto the chest. Intercostal EMG alternative to measure effort /OSA