APT Practice Parameter for Standard Polysomnography APT

Transcription

PUBLICATION OF THE APT
ASSOCIATION OF POLYSOMNOGRAPHIC TECHNOLOGISTS
2006 • VOLUME 15 • NUMBER 4
APT Announces
New Name
APT Practice
Parameter for Standard
Polysomnography
Deep Brain Stimulation and Sleep
Pathological Yawning
Pulse Transit Time: A Useful Clinical Tool?
Inadequate Sleep and Depression
They Come From the Cortex
Because without you, people don’t sleep.
And without sleep, people don’t function well.
We can't shower you with cash, but we appreciate your
business. You insist on the most innovative sleep sensors.
We produce them. And without you, we don't function well.
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W E P U T Y O U F I R S T.
Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.org
A2ZZZ MAGAZINE,
EDITORIAL BOARD
THERESA SHUMARD, EDITOR-IN-CHIEF
ASSISTANT EDITOR
ROBERT LINDSEY, MS, RPSGT
APT BOARD OF
DIRECTORS LIAISON
JON ATKINSON, RPSGT
CARTOONIST
BARBARA LUDWIG CULL, RPSGT
SLEEP ARTS
TERRIE EUBANKS, RPSGT
CORRESPONDENTS
IAIN BOYLE, RPSGT, CANADA
PAMELA JOHNSON, RPSGT,
AUSTRALIA/NEW ZEALAND
WAYNE PEACOCK, RPSGT,
UNITED KINGDOM
ROGERIO SANTOS DA SILVA, BRAZIL
ASSOCIATE EDITORS
JOSEPH ANDERSON, RPSGT,
RPFT, CRTT
KIM BURNS, RPSGT
EDWIN CINTRON, RPSGT
JOSHUA COLE, RPSGT
BRENDAN DUFFY, RPSGT
WILLIAM ECKHARDT, BS, RPSGT
REG HACKSHAW, EDD, RPSGT
JOANNE HEBDING, RPSGT
REGINA PATRICK, RPSGT
KIMBERLY TROTTER, RPSGT, MA
SPECIAL PROJECTS
JAYME MATCHINSKI, ESQ.
TRACY NASCA
MARY JONES-PARKER, RRT,
RPFT, RPSGT
ADVERTISING
SCOTT COLE, RPSGT
LAURA LINLEY, RCP, RPSGT
MISSION STATEMENT
A2Zzz Magazine is a peer-reviewed publication addressing the educational needs of the Sleep Technology Profession. Its mission is to provide
progressive technical information, current events relevant to the field, and
an avenue of communication for members, presented in a professional and
constructive manner, to further the goals and promote unity in the Sleep
Technology Profession. Readers of A2Zzz Magazine should be able to: 1)
appraise Sleep Technology in basic science and clinical investigation; 2)
interpret new information and updates on clinical diagnosis/treatment and
apply those strategies to their practice; 3) analyze articles for the use of
sound scientific and medical problems; and 4) recognize the inter-relatedness/dependence of sleep medicine with primary disciplines.
In This Issue…
President’s Message ..................................................................4
Call for Awards ..........................................................................5
Call for Volunteers ......................................................................5
APT Practice Parameter for Standard Polysomnography ..................6
A2Zzz Magazine Continuing Education Credit Offering ....................14
APT CEC Evaluation Form ..........................................................15
Deep Brain Stimulation and Sleep ................................................16
Pulse Transit Time: A Useful Clinical Tool? ....................................18
Cognitive Changes on PSG Technicians After Six Months
of Nocturnal Shift Work ........................................................19
Inadequate Sleep and Depression ................................................26
They Come From the Cortex ......................................................28
Pathological Yawning..................................................................30
APT Committee Roster, Board of Directors and Directory ..............31
A2Zzz Technical Corner..............................................................32
Sleep Arts................................................................................33
Questions About Recertification? ................................................34
NewZzz Briefs ..........................................................................36
APT Product Order Forms ....................................................37-38
ADVERTISING POLICY
As a service to our membership, A2Zzz Magazine prints information on
educational programs and products. It is not intended to imply that the
programs and products are approved by the Association of
Polysomnographic Technologists (APT) or the Board of Registered
Polysomnographic Technologists (BRPT), or that they are endorsed as a
method of preparation for the BRPT examination. Professional products
and services are subject to approval by the A2Zzz Magazine Editor-inChief. Ad inquiries may be directed by e-mail to [email protected].
For advertising billing questions, call 708-492-0796. Advertising rates,
specs and info: www.aptweb.org/advertising.asp
ARTICLE SUBMISSIONS GUIDELINES
Research, feature and news manuscript submission guidelines, word limits and e-mail submission instructions may be obtained from the Editor-inChief. All articles subject to standard, blind peer review. Article queries
should be mailed directly to:
Theresa Shumard, Editor-in-Chief • A2Zzz Magazine Editorial Office
25 Madison St. • Shillington, PA 19607
Phone: 610/796-0788 • Fax: 781/823-4787
E-Mail: [email protected]
Copyright © 2006 by the Association of Polysomnographic Technologists. All
rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy or recording, or any information and retrieval system, without permission in writing from: APT National Office, One Westbrook Corporate Center,
Suite 920, Westchester, IL 60154. Opinions expressed in A2Zzz Magazine
are not necessarily those of the APT Board of Directors.
APT Membership Form ..............................................................39
SleepLand Calendar ..................................................................40
ADVERTISING INFORMATION
The APT offers a full range of advertising services. See
the advertising page drop-down menu at www.APTWEB.org,
fax 708-273-9344, e-mail [email protected] or phone
708-492-0796 for details.
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Have you moved?
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Your phone number?
If you have and have not notified
APT, you can go to the home page of
APTWEB to fill in your updated
information (www.APTWEB.org).
You wouldn’t want to miss your
membership benefits!
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APT NewZzz
President’s Message
BY CYNTHIA MATTICE, MS, RPSGT
Providing, Preserving and Promoting the
Sleep Technology Profession
As this year comes to a close, it is a great time to reflect on all that the
Association of Polysomnographic Technologists (APT) has accomplished to
meet the needs of our members and to look to the future of our profession.
Name Change, Bylaws and Articles of
Incorporation
I am pleased to announce that ballots are in! Representing the
largest number of responses in the history of the organization, 612
members voted to accept the name change from the Association of
Polysomnographic Technologists to the American Association of Sleep
Technologists. The revisions to the Bylaws and amendments to the
Articles of Incorporation were also accepted. Thank you once again for
providing your input and participating in this important process. Over the
coming months, additional information about transitioning to the new
name of our association will be published in A2Zzz Magazine, listed in
the APT Member Update as well as posted on the APT Web site.
A Successful 2006 Because of You
The APT continues to provide the Sleep Technology Profession with a
unified voice that represents more than 2,900 polysomnographic technologists across the United States. This is possible because of the support from each of you as APT members, the leadership of your Board of
Directors, and the valuable work of committee members. A heartfelt
“thank you” to each member for the countless hours you dedicated to the
APT and the valuable contributions you made to the organization.
Highlights of Our Year
The APT is committed to providing educational programs that broaden our knowledge, advocating on behalf of its members to protect the
profession and creating professional standards that ensure quality care.
The APT took action this past year to accomplish its mission and to
enhance educational goals.
The APT continued collaboration with the Board of Registered
Polysomnographic Technologists (BRPT) and the American Academy of
Sleep Medicine (AASM) to advance sleep technology to make certain that
enough well-trained technologists are available to meet current as well as
expected growth of the field. Let’s take a look at how the national educational standards for our profession, formal educational programs, on-going
training and certification requirements
have shaped our profession in 2006.
The Continuing Education Credit (CEC)
Program has been expanded to meet the
needs of sleep technologists by adding
CECs for reading A2Zzz Magazine,
Computer Based Learning Activities, In
Services/Case Conferences and Single
Lectures. To meet BRPT recertification APT President Cynthia Mattice
requirements the APT is pleased to report
a two-fold growth in 2006 with 284 educational programs requesting and
awarded APT CECs as compared to 130 in 2005. Check www.aptweb.org
for a list of educational opportunities granting APT CECs near you.
The Committee on Accreditation for Polysomnographic Technology
Education (CoA PSG) has received 13 requests for accreditation. Two
educational programs have now been accredited by the Commission on
Accreditation of Allied Health Education Programs (CAAHEP) and a third
has been recommended for accreditation during CAAHEP’s November
2006 meeting. To view the listing of these programs visit www.caahep.org/programs.aspx. The Accredited Sleep Technologist Education
Program (A-STEP) provides for standardized entry level training and has
accredited 16 programs (www.aasmnet.org/ASTEP/Providers.aspx). In
addition, the APT Textbook is near completion. It is anticipated that our
textbook will be available for sale at the APT Annual Meeting in
Minneapolis, MN (June 10-13, 2007).
As you can see, there are many exciting developments and opportunities for education of sleep technologists. With your ongoing support,
the APT will continue to work on your behalf to advance our profession
and provide you with the latest educational products and courses.
The Value of APT Membership
Our profession is unique because of the multidisciplinary nature of a
polysomnographic technologist. It is this diverse membership that makes
us a strong, vital professional membership association. For less than
$10 per month each of you as an APT member are investing in your professional development and the future of your career as well as ensuring
the vitality of sleep technology. You can realize the value of investing in
our career through membership in the APT.
Members receive several tools and resources to support continued
professional development. These benefits include A2Zzz Magazine, an
important resource for your career development; online forum, an
avenue for members to ask questions, exchange ideas and discuss
issues facing our profession; and important e-mail updates on issues
and trends that affect our professional environment. Members also benefit from educational programs that keep them abreast of new trends
and practices in the field and educational products that enhance their
knowledge of sleep technology — all at discounted prices.
Grow Your Profession by Giving Back
I challenge you to join APT’s growing ranks and get involved with
shaping your career! There are many ways to broaden your involvement
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in the APT. Choosing APT membership provides you the support you
need to make a commitment to be a lifelong learner.
As a member, you can volunteer to serve as a committee member
and be part of a team that provides input and recommendations to
advance our profession. The diversity of committee members is integral
in providing fresh perspectives, fulfilling the mandate of the committee,
and contributing to the overall strength of the APT. If you are interested
in participating as a committee member, look for information in this
issue about the 2007 Call for Volunteers. Being a volunteer is a wonderful way to be actively engaged in your profession.
Volunteer membership organizations rely on members’ commitment
of both time and expertise at not only the national level, but also locally in
your state, region or health care organization. To recognize the individual
members for their contributions to the profession, the APT has established the Awards Nomination process. I encourage you to recognize the
accomplishments of your peers by nominating them for an APT Award.
Additional information on the 2007 APT Award Nominations will be available on the APT Web site (www.APTWeb.org) in December 2006.
You will find many interesting facts and tidbits in this edition of A2Zzz
Magazine. I hope you will enjoy reading the articles from cover to cover
as I do and I know you learn something new with every issue and it is a
great way to get those CECs!
I am proud of the APT and its members and know we are moving in
a direction that will benefit each of you as a member and a provider of
sleep technology services. The APT Board of Directors welcomes input
from its members. Let me know if you have questions or ideas to pro-
pose, just take a few minutes to submit them to [email protected].
The FUTURE IS YOURS for the taking — shape it by your continued
APT membership. Your membership and active participation in the APT
activities not only provides financial support to build on the strong foundation, but it also insures that we have well trained sleep technologists
to care for patients with sleep disorders far into the future. H
Call for Awards
Each year the Association of Polysomnographic Technologists
(APT) recognizes individual members of the APT for professional
excellence, service and commitment to the association and the
sleep technology profession. For more information on how to nominate members of the APT for one or more of the APT awards visit
the APT Web site at www.APTWeb.org.
Call for Volunteers
Are you interested in contributing to the future of the Sleep
Technology Profession? Through committee service, a volunteer
member has an opportunity to actively participate in many new projects the APT will be working on in 2007. Members interested in
serving on one of the APT Standing Committees (Communications,
Education, Membership, Program, Standards and Guidelines
Regional Activities/Government Affairs) are invited to visit the APT
Web site at www.APTWeb.org.
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APT NewZzz
Association of Polysomnographic
Technologists — Practice Parameter for
Standard Polysomnography
Introduction
In response to the need to establish standards for the performance of sleep
studies, the APT Board of Directors initiated a development of the APT Practice
Parameter for Standard Polysomnography. The document has been finalized by
the APT Standards and Guidelines Committee and reviewed by the American
Academy of Sleep Medicine upon the APT Board of Directors’ request.
This practice parameter will assist sleep technologists in providing high
quality diagnostic testing that is consistent with accepted practice. The standards are not intended to be inclusive of all methods for performing sleep
studies. The APT Practice Parameter for Standard Polysomnography will
undergo periodic revisions to remain current with advances in the field, thus
ensuring that those who perform sleep studies are provided current practice
standards to facilitate competent and quality services.
Summary
The scope of polysomnography encompasses the monitoring of patients
in a sleep facility using an assortment of medical equipment that is simultaneously recorded on a multi-channel analog or digital system. The
Polysomnographic Technologist prepares for and monitors the recording,
requiring expertise in normal and abnormal sleep and multiple technical and
medical monitors. A polysomnogram (PSG) allows for the events occurring
in a variety of physiological systems to be observed simultaneously. Much of
its utility depends on the ability to correlate specific changes or abnormalities of one physiological parameter with specific conditions defined by another parameter or parameters. Consequently, polysomnography is a significantly more powerful and complex tool than could be provided by individual
or independent measurements of each variable.
The standard diagnostic sleep evaluation requires a complete PSG to
document sleep stages and arousals, respiration, limb movements, snoring,
oximetry, body position, and cardiac rhythm disturbances. The resulting documentation is used to diagnose or assess the treatment of sleep disorders.
(Refer to Practice Parameters for the Indications for Polysomnography and
Related Procedures: 2005.)1
Key Definitions
sleep facility — will refer to any Sleep Disorders Center or Sleep
Disordered Breathing Laboratory whether it is hospital based or independent.
sleep technologist — trainee, technician or technologist for the purpose of
this document. Note that the technologist designation usually refers to those
who have passed Board of Registered Polysomnographic Technologists (BRPT)
credentialing examination, Registered Polysomnographic Technologist (RPSGT).2
diagnostic coding — will refer to the ICSD (International Classification of
Sleep Disorders, Second Edition)3
apnea — episodes of non-respiration during sleep that last at least 10
seconds. See central, obstructive, or mixed sleep apnea.
bruxism — a parasomnia characterized by the grinding or clenching of
teeth during sleep.
cardiac arrhythmias — disturbance in the impulse formation, impulse
conduction or a combination.
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central apnea — the absence of effort; characterized by a simultaneous
cessation of airflow and effort.
electroencephalogram — also called an EEG; the measurement and
recording of brain wave activity. Frequency measurement in hertz ranging
from 0.5 - < 4 (delta), 4 - < 8 (theta), 8 - < 13 (alpha), and >= 13 (beta).
Electrodes are typically placed at C3, C4, O1, O2 positions on the scalp.
electrode — A conducting terminal for receiving or sending electrical signals. Electrodes in polysomnography conduct biopotentials from the patient
to the recording circuit. In this document “electrode” will refer to cup, snapon or disposable styles.
electrolyte — conductive substance (cream, gel, or paste) used to fill
electrode cups.
electromyogram — also called an EMG; the measurement and recording
of muscle activity, particularly under the chin, along the jaw, and on the legs.
electrooculogram — also called an EOG; the detection and recording of
eye movements, essential for determining the different sleep stages.
heart rate — the number of heart beats during a unit of time, usually
per minute.
hertz (Hz) — the unit of measurement for cycles per second; used to
measure EEGs .
hypopnea — a 30% or greater decrease in airflow and effort associated with at least a 3% to 4% drop in oxygen saturation or an EEG arousal.
montage — the term applied to the testing variables and their order on
polysomnogram paper or a computer monitor, such EEG, EOG, EMG, ECG
and so on.
myoclonus — muscle contractions in the form of abrupt jerks or twitches3
obstructive apnea — absence of airflow with continued effort.
PAP — Positive Airway Pressure is a pneumatic splint to maintain the
patency of the airway. Optimal pressure requirements are determined during a sleep study.
1. Continuous positive airway pressure (CPAP) delivers a constant optimal pressure to eliminate sleep disordered breathing and snoring.
2. Bi-level positive airway pressure delivers a separate pressure for
inspiration and expiration.
PAP interface — there are various types of nasal masks, nasal/oral
masks and endonasal cushion interfaces available to enable the sleep technologist to find the most comfortable fit for the patient.
polysomnogram — also called a PSG, sleep study, or sleep test; a noninvasive test that records vital signs and physiology during a night of sleep.
It includes measurements of EEG, EMG, EOG, and ECG as well as respiratory airflow, blood oxygen saturation, pulse rate, heart rate, body position, and
respiratory effort.
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periodic limb movements of sleep — also called PLMS or nocturnal
myoclonus. Characterized by repetitive movement that usually occurs in the
lower extremities, but can also occur in the upper extremities. Monitoring
the anterior tibialis EMG reveals repetitive contractions lasting 0.5 to 5.0
seconds at approximate intervals of 20-40 seconds in intervals of 5 seconds
to 90 seconds. Sleep disruption is noted due to associated short arousals
or awakenings.
2.0 Recording Techniques
restless legs syndrome — (RLS) is a movement disorder with complaints of a strong urge to move the legs and crawling sensation in the legs.
These sensations are relieved with movement, such as walking.
2.1.1 Routine Variables
Purpose
To define the methods and requirements for recording each of the variables in a polysomnogram and their integration within diagnostic protocols.
1.0 Introduction
Standard polysomnography is a complex evaluation used as a quantitative diagnostic measurement of multiple physiological parameters during
sleep. This practice parameter will address PSG evaluations attended by a
sleep technologist that are provided in a sleep facility.
Sleep technologists are specially trained to perform polysomnography for
the diagnosis and treatment of sleep/arousal disorders. They are part of a
team under the direction of a physician who practices sleep disorders medicine. The team works in concert to ensure the proper diagnosis, appropriate management, and education for individuals that experience sleep disorders. They follow patient sensitive standards of care, which are the foundation for clinical/technical decision-making.
This practice parameter does not include pediatric polysomnography,
home or unattended PSG evaluations, the therapeutic use of PAP or oxygen.
1.1 Indications for Standard Polysomnography
Standard PSG evaluation is necessary because physiological functions
change during the sleeping state and many disorders are specifically induced
by sleep. There are over 80 specific disorders of sleep and arousal that are
identified in the ICSD-2. A PSG evaluation is one of the tools used by physicians that can result in a specific diagnosis of a sleep disorder that might
otherwise remain obscure. The AASM Practice Parameter for
Polysomnography and Related Procedures: An Update for 20051 relates only
to the recording and use of standard policies and procedures for the diagnostic evaluation of sleep disorders in a sleep facility. It does not address
interpretation of the PSG evaluation or the management of patients with
sleep/arousal disorders.
The most common reasons for an individual to be referred to a sleep
facility for evaluation include: (1) episodes of sleep at inappropriate times; (2)
difficulty sleeping during scheduled sleep periods; (3) difficulty staying awake
during scheduled wake periods; (4) atypical behavioral events during sleep;
(5) documentation of the effectiveness of various therapeutic interventions
utilized for the management of the documented sleep disorder; (6) witnessed
apnea and snoring.
1.2 Patient Referral Dynamics
Standard PSG evaluations can be carried out within the sleep facility
where patients are primarily physician-referred and their subsequent care
is the responsibility of the referring physician; or within the sleep facility
where patients are either self- or physician-referred and in which complete
clinical evaluation and treatment plans are formulated and implemented by
the sleep specialist.
2.1 Physiological Parameters Measured and
Equipment Parameters
This section will discuss the physiological parameters that are necessary
to record during standard PSG to provide adequate data for interpretation
by the sleep specialist.
2.1.1.0 Impedance
It is the goal of polysomnography to capture the best quality recordings
of the physiological channels. The best recordings are artifact free and have
the maximum waveform amplitude possible. Because the subtle variations in
current are muted by impedance, it is the goal of polysomnography to get
the lowest impedance possible. The pathway in question is comprised of the
source of the current being measured in each locale of the body, the various
levels of tissue and the actual electrode cups and wires. It is through these
layers that conductance is thwarted by impedance. Lower impedance allows
higher conductance and produces larger amplitude waveforms. It is the goal
of electrode application to obtain the lowest impedance possible without
compromising patient comfort and skin integrity. To obtain the lowest possible impedance values it is necessary to abrade the skin area where the electrode is to be placed to the extent that the dead outer epidermal layer (stratum corneum) is removed without disrupting the dermis. To maximize the signal quality and minimize patient discomfort the sleep technologist should
scrub only the area where the electrode will be placed. For optimal signal
quality it is necessary to match the input impedance of all electrodes pairs
as closely as possible. Impedance mismatching allows current to pass
through to the amplifier and can lead to artifact. Common mode rejection is
the cancellation of voltages equal to both input electrodes. Impedance mismatching also impairs common mode rejection. Therefore, optimal signal
quality is possible when impedances are low enough to maximize amplitude,
take advantage of common mode rejection, and avoid impedance mismatching. Ideally, impedances should range from 1-5k ohms regardless of the
amplifier that is used, although its effect is less pronounced in some recent
high input impedance amplifier designs.
The standard for electrode impedance upper limit is 5k ohms for EEG & EOG.4
The guideline is that impedances are as closely matched as possible.5
The standard for electrode impedance upper limit is 10k ohms for EMG.6
The guideline is that impedances are as closely matched as possible.
The standard for electrode impedance upper limit is 20k ohms for EKG.
The guideline is that impedances are as closely matched as possible
2.1.1.1 Electrode Preparation and Application
The area where the electrode is to be placed is prepared by abrading
the skin to allow optimal impedance without disrupting the dermis. The sleep
technologist should take care to scrub only the area where the electrode will
be placed. Electrodes should be of ample length for input from the electrode
site to the headbox.
There are two methods used to secure the disk electrodes. First, the
electrode disks are filled with electrolyte or electrode paste. The collodion
method uses an air compressor to attach collodion saturated gauze squares
placed over the electrode disk securely to the electrode site.
With the electrode paste method, for scalp electrode sites, a small
mound of electrode paste is placed on a gauze square. Care should be taken
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APT — Practice Parameter for
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to keep the electrode paste around the electrode disk as the electrode site
is the entire area that electrode paste touches the electrode site. For other
electrode sites, fill the electrode disk with electrode paste and secure to the
electrode site with tape or medical adhesive.
Various types of single use adhesive electrode disks are available and “snap
on” electrode wires of appropriate length provide for input to the headbox.
After use, electrode disks and wires should be cleaned and disinfected
according to facility protocols for infection control.
2.1.1.2 Electroencephalogram (EEG)
The EEG is the primary variable to document wakefulness, arousals and
sleep stages during the sleep study. A single central channel referenced to
an ear mastoid site (e.g. C3-A2 or C4-A1) is sufficient for evaluating waveforms. The mastoid is located posterior to each pinna. However, additional
channels are required to provide redundancy and to more accurately determine sleep onset (e.g. O1-A2). The electrodes should be placed on the scalp
according to the International 10-20 System.7 Additional electrodes may be
used as directed by the sleep facility’s medical director for the evaluation of
a patient with a possible nocturnal seizure disorder. Again, these electrodes
would be placed according to the International 10-20 System. Electrodes are
applied according to section 2.1.1.1. The amplifier settings and calibration
requirements for the recording of the EEG signal will vary according to the
equipment specifications.
2.1.1.3 Electro-Oculogram (EOG)
The EOG recording aids the identification of sleep onset by monitoring for
slow, rolling eye movements that occur with transition to Stage 1 sleep and
rapid eye movements (REMs) that occur during Stage REM sleep. At least
two channels of EOG are recommended. Each EOG channel records from an
electrode placed approximately 1 cm lateral to, and approximately 1 cm
above or below the outer canthus of the eye. An equal displacement of the
electrodes insures equal amplitude of the conjugate eye movements. An ear
mastoid site is generally used as a contra-lateral reference for each channel. With these derivations, conjugate eye movements produce out-of-phase
voltage deflections in the two channels; whereas simultaneous EEG activity is
usually in phase. To distinguish between vertical and lateral eye movement,
additional EOG montages can be applied using a supranasion reference electrode that produces deflections in phase with vertical eye movements. A
supranasion reference electrode alone, however, may result in the integration of EEG activity with extra ocular movement potentials. Consequently,
other reference locations may be required for specific circumstances.
Electrodes are applied according to section 2.1.1.1. The amplifier settings
and calibration requirements for the recording of EOG signals will vary
according to equipment specification.
2.1.1.4 Chin Electromyogram (EMG)
The recording of EMG activity in the chin area is used for determining
the level of muscle tone, which significantly decreases during REM sleep and
may also be reduced with sleep onset. This channel also provides supplemental information regarding patient movements and arousals and may be
useful in distinguishing artifact in other channels. A single channel is sufficient with 2 electrodes placed 2-4 cm apart with one on the mental and one
on the submental region. Alternatively, electrodes can both be placed on
mental or submental regions. Another variation with one on the masseter
muscle on the jaw line can be used to better distinguish Bruxism. A third
electrode is recommended as a back up electrode placement. Electrodes are
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requirements for the recording of the EMG signal will vary according to
2.1.1.5 Upper Airway Sound Recording
Snoring is measured with a snore microphone or sound transducer.
There are several types of snore monitoring devices available commercially.
The snore sensor or microphone should be placed over the trachea or on the
side of the neck and can be secured with tape. The sleep technologist should
feel for the area of maximum vibration while the patient hums or snores. This
will allow for recording of the snore sounds. The polygraph settings for detecting snore sounds are the same as those used for submental EMG detection.
2.1.1.6 Electrocardiogram (ECG)
The ECG serves as a monitor of heart rhythm disturbance. A single ECG
channel is sufficient for standard PSG monitoring. The electrode placement
is not critical but should be carefully documented. Typically, two or three
electrodes are used in Lead I or Lead II placement format. Electrodes are
requirements for the recording of the ECG signal will vary according to
2.1.1.7 Respiration (Measures of Airflow and
Respiratory Effort)
Airflow and respiratory effort channels are utilized during the standard
PSG to monitor respiration specifically for the detection of apneas and hypopneas and other sleep related breathing disorders. It is important to record
at least three respiratory parameters: nasal/oral airflow, thoracic effort and
abdominal effort. Various transducers may accomplish the recording of airflow exchange. Two widely used but often less sensitive methods are thermistors and thermocouples. Pressure transducers offer a sensitive method
of recording airflow. It may be necessary to use both methods of measurement to achieve accuracy from nasal and oral flow. It is important that both
nasal and oral flow is monitored because air exchange can occur through a
combination of any of the three orifices. Secure flow sensors with tape.
Monitoring the respiratory effort can be accomplished by several methods, including intercostals EMG electrodes; thoracic and abdominal piezoelectric belts, impedance pneumography or strain gauges; or inductive
plethysmography that permits differentiation between abdominal and thoracic movement. The most accurate measure of respiratory effort is
esophageal pressure manometry; however, correct placement of the tube is
difficult and can cause patient discomfort and sleep disturbance.
The sleep technologist and medical director should evaluate the various
flow and effort sensors available to determine the most appropriate for
recording of these parameters in the sleep facility. Some of the points to
compare would be the need for a calibrated signal for a quantitative signal
versus qualitative signal, patient comfort, cost, replacement frequency, susceptibility to artifact, etc. The amplifier settings and calibration requirements
for recording respiration signals will vary according to equipment specifications. Because apneas and hypopneas frequently trigger arousals and interrupt the normal sleep cycle, it is important that respiration is recorded to
allow for the development of a sleep profile with which the breathing disturbance can be correlated.
2.1.1.8 Blood Oxygenation (Oxygen Saturation — SpO2)
The diagnosis of obstructive sleep apnea during the standard PSG
requires the continuous monitoring and display of blood oxygen saturation
levels to provide crucial information about the severity of the sleep related
breathing disorder. Pulse oximetry transmits two wavelengths of light
through a pulsatile vascular bed to measure arterial oxygen saturation. Pulse
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oximetry is frequently the method used to monitor blood oxygen levels in the
sleep facility because of the ease and comfort to the patient. Pulse oximetry
measurement is done with a finger probe, although other placements such
as the earlobe or toe may be used depending on the patient. It should be
noted that pulse oximetry does not reflect total gas exchange and therefore,
cannot detect changes in PaCO2. Commercially available oximeters can be
easily interfaced with the PSG acquisition equipment. It is necessary to carefully evaluate the pulse oximeter for use in the sleep facility for sampling rate
and analog output to interface with the polygraph. The output on the oximeter must be recorded through a DC amplifier and is displayed simultaneously with other pertinent PSG variables. The polygraph DC amplifier requires
calibration and the output can be displayed linearly or numerically, depending
on the acquisition system. In some systems, the pulse oximeter may be built
into the amplifier box of the PSG acquisition equipment.
2.1.1.9 Capnography
Capnography can be used to measure the patient’s carbon dioxide (CO2)
level. There are two types: end tidal and transcutaneous. In a transcutaneous PCO2 (TC PCO2) recording, the sleep technologist would place the TC
CO2/PO2 electrode directly to the skin, heated to 42-45 degrees centigrade. Care must be taken to insure that the electrode temperature does
not burn patients with fragile skin. This sensor measures the transpired
PCO2, which fairly accurately reflects the tissue PCO2. This is the preferred
method for monitoring neonates in an intensive care setting; however, in
adults it is accurate only in patients with good tissue perfusion.
End tidal capnography is commonly used in children and some adults to
measure PCO2 with a nasal or nasal/oral cannula or a tight fitting mask to
produce numerical and graphical displays of CO2 levels. End tidal measurement reflects the concentration of CO2 in the lungs and in the blood at the
end of expiration. The normal range is 35-45 mmHg.
2.1.1.10 Limb Movement
Additional causes of sleep disturbances that may need to be identified
and treated are restless legs syndrome (RLS) and periodic limb movements
of sleep (PLMS). These leg movements are often visually detectable during
the monitoring process. Monitoring the anterior tibialis muscles allows for
the determination of the severity of the disorder by quantifying the rate of
movements as well as the correlation with EEG arousal. Two electrodes are
placed on the anterior tibialis muscle of each leg and secured with tape to
record each leg separately. Although, one electrode can be placed on each
leg and referenced together to record both legs on one channel, this is not
optimal and may affect scoring periodic limb movements according to AASM
published guidelines. Electrodes are applied according to section 2.1.1.1.
2.1.1.11 Body Position/Movement
Body position can be monitored with various commercially available body
position monitoring devices. These devices use mercury switches and can be
interfaced on the polygraph if an AC channel is available. Alternatively, the sleep
technologist can observe the patient and document body position changes on
the recording. For report generation, it is optimal to be able to correlate body
position in the assessment of sleep disordered breathing. Simultaneously
recorded EEG channels will determine if movements originate from wake or
sleep and whether arousals correlate with limb or body movement.
2.1.1.12 Behavioral Observation
The capability to observe the patient during the recording of the standard PSG is required for patient safety as well as clinical and technical
assessment. This can be done with a video monitoring system that allows
the sleep technologist to visually observe the patient and document observations (i.e. body position, body movements, etc.) during the study. The audio
monitoring allows the patient to communicate with the sleep technologist as
well as providing a mechanism for the technical staff to document snoring
sounds and other patient vocalizations during the sleep study. PSG data
acquisition systems often are equipped with the capacity for digital video
monitoring which can be viewed on the computer monitor and archived
simultaneously with the PSG data.
2.2.0 Recording Protocol
The standard PSG protocol is designed to obtain the maximum clinically
relevant physiological information with the least disruption of the patient’s
normal sleep patterns. The sleep study should be initiated as close as possible to the patient’s normal sleep time and conducted in a quiet, comfortable room that resembles a bedroom or hotel room. PSG acquisition equipment should be physically separated from the patient with appropriate shielding of light and sound. Interruptions during the night can be kept to a minimum with “back-up” electrodes and sensors utilized when feasible.
The standard PSG recording montage should consist of the measurement
of the above-defined parameters. An example of a montage is as follows:
2.2.1 Montage Filter and Sensitivity Settings
Channel
Derivation
Sensitivity
L outer Canthus
LOC-A2
5-7 uv/mm
High Filter Low Filter
35 Hz
.3 Hz
R outer Canthus
ROC-A1
5-7 uv/mm
35 Hz
.3 Hz
Chin EMG
Pg1-Pg2-Pgz
10 uv/mm
90-120 Hz 5-10 Hz
Central EEG
C3-A2/C4-A1 5-7 uv/mm
30-35 Hz
Occipital EEG
O1-A2/O2-A1 5-7 uv/mm
30-35 Hz
.3 Hz
.3 Hz
Left Anterior Tibialis
LAT1 LAT2
10 uv/mm
70 Hz
10 Hz
Right Anterior Tibialis
RAT1 RAT2
10 uv/mm
70 Hz
10 Hz
ECG
ECG1 ECG2
20 uv/mm
15-35 Hz
1 Hz
Snore*
—
20 uv/mm
70 Hz
10 Hz
Air Flow*
—
20 uv/mm
5 Hz
.1 Hz
Thoracic Effort Belts*
—
10-100 uv/mm
5 Hz
.1 Hz
Abdominal Effort belts*
—
10-100 uv/mm
5 Hz
.1 Hz
CPAP*
DCx
—
5 Hz
—
SpO2
DCx
—
5 Hz
—
*suggested settings vary for different technologies
60 Hz notch filters are OFF under normal circumstances so as not to filter out 60 Hz contributions to EEG & EOG8.
The sleep facility director should determine the specific montage and the
equipment and recording devices to be used.
2.2.2 Instrumentation
The equipment used to gather, analyze & store the data from the sleep
study must be maintained and documented as such by a trained biomedical
technician or other responsible party. Differential amplifiers are designed to distinguish between the desired physiologic voltage at the exploring electrode site
and all other unwanted voltages from the body & the external environment
using common mode rejection. The standard minimum limit for PSG common
mode rejection ratio is 10,000:1. The signal must be sampled often enough
to provide an accurate waveform but not so often as to use unnecessary
resources. According to Nyquist theory this minimum rate is 2 times the highest frequency being measured.9 The standard lowest rate is 2.5 times for
polysomnography and equates to the setting of 256 Hz found in most systems.
Proper electrode placement; clean site preparation; proper sampling; filtering and amplification provide good physiologic basis for conversion to a
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patient to relax and try not to move.
E/C
Eyes Closed for 30 seconds
Ask the patient to close their eyes and look straight ahead.
E/O
Eyes Open for 30 seconds
Ask the patient to open their eyes and look straight ahead.
LR
Look Right
Ask the patient without moving his/her head look to the
right then back to the center.
LL
Look Left
Ask the patient without moving his/her head look to the
left then back to center.
LU
Look Up
Ask the patient to keep their eyes closed and without
moving his/her head look up then back to the center.
LD
Look Down
Ask the patient to keep their eyes closed and without
moving his/her head look down and back to the center.
BLNX
Blink eyes
Ask the patient to blink his/her eyes 5 times.
JAW
Bite down on Jaw
Ask the patient to bite down on the jaw or clench the teeth.
SNORE
Snore sound
Ask the patient to simulate a snore sound or clear throat.
FLEX
Flex foot
Ask the patient to point and flex each big toe (foot) separately. Annotate each leg separately on the recording.
Repeat 2 times on each leg.
IN/OUT
Breathe In and Out
Ask the patient to breathe normally, and then upon your
instruction take a breath in and out. Mark the record IN
and OUT accordingly.
HOLD
Take a deep breath and Hold
Ask the patient to breath normally and then on your
instruction take in a deep breath and hold it for 10 seconds (to a count of 10), then resume normal breathing.
digital representation. The digital signals must be displayed and recorded
such as to maximize appropriate visualization of the recorded signals. Proper
screen resolution is most often determined by the video equipment manufacturers and should not be altered to manipulate things like font size. For
PSG viewing on the monitor, use the highest resolution available and recommended by the manufacturer.
2.2.3 Calibration
In order to validate the study it is necessary to perform a pre- and a
post-calibration to illustrate that the system was properly calibrated and all
equipment and sensors are working correctly throughout the study.
2.2.3.1 Amplifier Calibration
If available to the PSG data acquisition system, the first calibration should
be an all channel calibration that passes a known signal voltage, usually 50
uv/sec for an epoch of 30 seconds at 10 mm/sec, through the amplifiers
while each recording channel is set to the same sensitivity and filtering (this
generally applies to analog PSG data acquisition systems). The resulting
waveforms should be saved as part of the permanent record. If the waveforms do not show equal and correct amplitude and fall times then adjustments must be made to the channel in question until there is uniformity.
2.2.3.2 Montage Calibration
After the specific montage for the study has been chosen, in analog PSG
data acquisition systems a documentation of the sensitivities and filter settings should be made (see example chart above). Any further changes to
sensitivity and filter settings should be documented in either analog or digital PSG data acquisition systems. A calibration signal must be validated on a
digital PSG data acquisition system to verify signal integrity.
2.2.3.3 DC Instrument Calibration
Before the study is run a calibration check of all attached DC instruments, such as pulse oximeters, must be made to insure that minimum and
maximum values correspond to physiologic variables. For example, the minimum and maximum readings of oximeters should be set to translate at zero
and 100. Many digital PSG data acquisition systems have integrated this
function into the amplifiers.
2.2.3.4 Physiological Calibration
After the amplifier calibration has been performed, physiological calibrations are conducted to insure the quality of the recorded signal. This provides
a reference while monitoring, scoring, and interpreting the polysomnogram.
All calibration signals must be annotated.
Ask the patient to lie supine, if possible, through the patient calibration
procedure and follow the instructions listed below in section 2.2.3.3.1.
Verify the quality of the signal and make adjustments as necessary to the
electrodes, thermistor, or belts, or to the sensitivity, gain, polarity or filter
settings. Replace electrodes or sensors as necessary.
MUELLERS Mueller’s maneuver
Ask the patient to hold breath and try to take 5 breaths
against a closed airway, then resume normal breathing.
Begin “Lights Out” procedure. Instruct the patient to move to a comfortable sleeping position and go to sleep. Remind the patient that the sleep
technologist is readily available and if the patient should need anything to call
the sleep technologist.
2.2.3.4.2 Post Calibrations
2.2.3.4.1 Physiological Calibration Instructions
Annotate instructions on the computer screen or write on the paper
recording as the patient is instructed to perform the calibration procedures.
Give the instructions slowly and clearly. Below is a standard set of patient calibrations. Follow the facility’s calibration procedure, making sure that there
is one for each type of channel. Body position can be visually verified and
oximetry should be double-checked if not within a normal range. Instruct the
10
At the end of the study, perform “Lights On” procedure. Enter the room
to wake the patient and turn on the light. Repeat both amplifier and physiological calibrations before ending the recording.
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2.3 Routine for Standard PSG
The protocol of the standard PSG should be clearly established by the
sleep facility. Detailed clinical information about the patient’s sleep-related
problem as well as a medical history is necessary. The sleep technologist
should apply the required electrodes and monitoring devices to monitor the
channels listed in the montage. The sleep technologist will begin the recording after insuring that impedances are acceptable, sensors and equipment
are functioning properly and all calibrations have been performed. “Lights
Out” and “Lights On” times should be clearly documented. The sleep technologist will continuously monitor the patient’s clinical status, body position,
and document changes on the sleep study and/or on a form designed by the
sleep facility as defined by written protocol. Ideally, 8 hours of recording time
should be obtained; however, a minimum of 6 hours is recommended for a
standard PSG. The sleep technologist will assist the patient as necessary
during the recording (helping them to the bathroom, addressing comfort
issues, etc.) Intervention with therapy (oxygen, PAP) may be initiated per the
facility’s protocol. After “Lights On” procedures have been performed, the
electrodes and monitoring devices should be removed with care and cleaned
according to infection control standards.
2.4 Artifact Recognition and Correction
The sleep technologist is responsible for monitoring and maintaining the
integrity of each recorded channel. This requires that the sleep technologist
differentiate between normal and abnormal patterns as well as patient-generated variations vs. true artifact. Once an artifact is identified, the sleep
technologist must determine when it is necessary to make appropriate
adjustments. Ideally, all channels should be artifact-free during the recording.
The sleep technologist should use a systematic approach to troubleshooting artifact by tracing the recorded circuit from the patient to the
computer monitor. Environmental interference (fans, cell phones, etc.) may
have an effect on the recording and should be annotated.
ing medical conditions, currents medications, special therapy (i.e. supplemental O2). Any previous special procedures the patient has had that might
influence the study results (i.e. LAUP, UPPP, somnoplasty, bariatric surgery)
and any previous sleep studies or diagnostic testing such as nocturnal oximetry. This should be accomplished with a complete sleep history questionnaire
completed prior to arrival at the sleep facility as well as receiving a history
and physical from the referring physician.11
3.3 Technical Documentation
3.3.1 Log
The sleep technologist should log notable events that occur during the
study in chronological order. Notable events include “Lights Off”, sleep onset,
“Lights On”, the sleep technologist entering or leaving the patient’s room, the
patient getting out of bed, initiating or adjusting PAP or oxygen therapy, position changes, technical difficulties, environmental disturbances, and any
other observation that might be helpful to the interpreting physician.
3.3.2 Summary
The sleep technologist should completely summarize the technical and
behavioral observations of the standard PSG. This can be done on a form
designed by the sleep facility or within the context of the format set forth by
the manufacturer of the PSG data acquisition equipment. The summary
should include comments on sleep architecture behavioral observations,
myoclonus/limb movements, respiratory characteristics and heart
rate/ECG observations. The sleep technologist should also add any significant medical or sleep-related information discovered during patient assessment, testing, or before discharge.
3.3.3 Sleep Parameters
The report summary should describe should include the details of the
analysis of sleep stage scoring as well as clinical event scoring.
Typical patient circuit:
3.3.3.1 Sleep Stage Parameters
PATIENT Þ SENSOR Þ HEADBOX Þ AMPLIFIER Þ COMPUTER
Total Recording Time (TRT) / Time in Bed (TIB) is defined as the time
from “lights out” to “lights on”. Total Sleep Time (TST) is the total time asleep
after sleep onset. To determine the how well the patient slept, the Sleep
Efficiency (SE) is calculated by dividing the TST by the TRT.
3.0 PSG Documentation
The results of the standard PSG procedure must be presented in a comprehensive and concise report that summarizes all observations and analysis of the recorded physiological parameters. This report is typically presented in a chart form containing all paperwork pertaining to the patient’s
care at the sleep facility. The sleep technologist is responsible for completing a log and summary of the sleep study findings and events. In addition,
the sleep technologist is responsible for ensuring that all other required documents are available before the study begins (history and physical, previous
test results, referral, insurance information, bedtime questionnaires, etc.)
These documents must also provide an integrated report, highlighting the
sleep technologist’s observations of possible medical significance for the
interpreting physician. The following sections delineate the minimal information that should be included in technical documents.10
Sleep studies are gathered on 30 second “epochs”. The unequivocal
sleep onset is the first of three consecutive epochs of Stage 1 sleep or the
first epoch of any other sleep stage. Sleep Onset Latency (SOL) is the time
from “lights out” to the sleep onset. Latencies to sleep stages are determined from sleep onset to the first epoch of that sleep stage.
Wake after Sleep Onset (WASO) is the time awake after sleep onset until
“lights on”. To determine the percentage time spent in each of the sleep
stages during the sleep study, the total minutes of the sleep stage is divided
by the TST. This percentage can them be compared to normative values to
document the fragmentation of the sleep architecture.12
3.3.3.2 Clinical Event Parameters
3.1 Patient Identification
In compliance with the Health Insurance Portability and Accountability
Act (HIPAA), the PSG data and all reports should be clearly labeled on each
page with the patient’s full name, date of birth and date of the study. Any
additional information, such as identification numbers required for retrieval
can also be included. Likewise, all long-term storage mediums should be adequately labeled.
3.2 Patient History
The patient’s chart should contain sufficient history information to document the reason why the study was recommended, i.e. any significant exist-
To determine the severity of the sleep related disturbances, the indices
of the clinical events is compared to normative values. The sleep technologist will calculate the index by taking the number of clinical events divided by
the TST. These indices include the apnea index (AI), hypopnea index (HI),
apnea/hypopnea index (AHI), periodic limb movement (PLM) index, spontaneous arousal index, apnea/hypopnea arousal index, PLM arousal index, and
arousal index.
Usually the PSG acquisition equipment will analyze the heart rate and oxygen saturation and report the mean, maximum and lowest value by TRT, TST
continued on page 12
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and sleep state, i.e. NREM and REM.
4.2 Sleep Facility Organization and Record Keeping
The sleep technologists should follow the sleep facility departmental policy and procedure manual. Patient charts, in either print or electronic format should be organized and available for appropriate use in the sleep facility. HIPAA guidelines should be followed regarding confidentiality of patient
records16. Equipment, sensor and recording procedures should meet the
standards of the manufacturer.
3.3.4 Sleep Related Breathing Events
The summary should document sleep related breathing events with
respect to sleep state. Information should be provided concerning the breathing rate while awake and asleep, the presence or absence of snoring, the
presence of paradoxical breathing, the number and index of apneic and/or
hypopneic events, the longest apneic and/or hypopneic event, the mean and
nadir oxygen desaturation. Notation should be made if sleep state or body
position is related to the apnea/hypopnea index and/or desaturation.
3.3.5 Heart Rate/ECG Observation
Typical heart rate values while awake and asleep (REM and NREM)
should be annotated and the summary should document extreme values
occurring transiently. Arrhythmias should be documented with respect to
frequency of occurrence and type. It is particularly important to describe
the occurrence of heart rate changes or arrhythmias with respect to sleep
state (REM, NREM) and sleep related breathing events such as O2 desaturations and apneic events.13
3.3.6 Limb Movements
Limb movement activity is recorded from the extremities and must be
evaluated in terms of frequency of occurrence and periodicity, sleep/wake
status, and presence or absence of subsequent arousal.
Rhythmic leg movements observed during wakefulness can indicate
Restless Legs Syndrome (RLS). The sleep technologist should ask about
symptoms of RLS during patient assessment (difficulty initiating sleep due to
a need to move) and document any relevant patient comments as well as evidence of RLS in the recording.
3.3.7 Behavioral Observations
Any unusual or atypical behavioral events should be documented during
the patient’s sleep and wakefulness by the sleep technologist during the
standard PSG. The sleep technologist should describe in detail what the
behavior is and how it relates to the polysomnographic recording (i.e. nocturnal eating, enuresis, rocking). When arousals are noted during the standard PSG, the sleep technologist should document the cause of the arousal, i.e. as the result of apneic events, myoclonus, spontaneous or environmentally evoked.
Storage of the recorded PSG data on CD, DVD, hard drive or other
media should be both secure and easily available for retrieval. If video recording, either digital or VHS, is used, an edited version that preserves the
recorded events is acceptable and should be referenced appropriately. The
length of storage all patient data should be in compliance with the statutes
set forth by the state in which the data is obtained and stored.
4.3 Patient Safety
In the context of the technical sleep study, patient safety begins from the
point of the patient’s arrival until the patient leaves the lab (see 4.4.5). Of
course, ordering and performing the appropriate test based on the patient’s
history and physical and previous test results is the responsibility of the sleep
facility under direction from a physician.
4.3.1 Safety of the Sleep Facility
The sleep facility must be safe and easily accessible to all staff and
patients. The sleep facility must be handicapped accessible, meet fire code
and health department regulations, and maintain electrical and mechanical
safety. The patient rooms must be clean and have adequate audio and video
monitors for patient safety and clinical assessment17. All products used on
patients should have Material Safety Data Sheets available in the sleep facility. All flammable materials must be stored in a fire safe. Follow the sleep
facility policy related to patient safety and security.
4.3.2 Safety equipment
The sleep facility should have equipment available for patient care and
emergencies: resuscitation bags, back boards, oxygen, biohazard spill kits,
refrigeration for patient medication, blood pressure cuffs, Automated
External Defibrillators (AED) and first aid kits.
4.3.3 Patient Medical History and Current
Medical Status
It is the sleep technologist’s responsibility to know and understand the
patient’s medical history, allergies and current medical status in order to
alter procedures, contact a physician, or transfer the patient to emergency
care, as necessary.
4.3.4 CPR Certification
4.0 Standards of Practice
4.1 Qualifications of Sleep Technologists
Sleep technologists performing sleep studies should demonstrate
knowledge of the polysomnographic recording instrumentation, including
operating procedures, electrode application, calibration methods and routine troubleshooting as well as the ability to recognize sleep stages, as outlined in the APT/AASM Sleep Technologist, Technician and Trainee Job
Descriptions14. The sleep technologist must have a thorough understanding
of normal and abnormal sleep patterns and sleep disorders. The sleep technologist also must be trained in basic cardiopulmonary resuscitation (CPR)
or professional rescuer adult/child CPR and automated external defibrillator (AED). Refer to the AASM accreditation guidelines for standards on
patient: technologist ratio15. The facility should consider the experience of
the technologists as well as the difficulty of the studies being performed
when deviating from a 2:1 ratio.
12
All sleep technologists must be CPR certified. The Professional Rescuer
by the American Red Cross or BLS Healthcare Provider Course by the
American Heart Association is recommended.
4.3.4 Clinical Intervention and Emergency Procedures
The sleep facility should have written guidelines for initiating any medical
intervention (supplemental oxygen, patient transfer, CPR). There should also
be a written plan for handling environmental disasters (e.g. tornado, fire,
flood, etc.)18
4.3.5 Patient Discharge Guidelines
The sleep technologist should make sure that the patient has had
enough sleep and is not under the influence of medication or alcohol before
release from the sleep facility. An early release form should be completed
per sleep facility policy. Patients who have not had enough sleep should be
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encouraged to stay and sleep (with visual monitoring), even if the recording
has been discontinued per facility policy.
4.4 Infection Control
4.4.1 Patient Contact Procedures
Sleep technologists should exercise Universal Precautions and precautions for prevention of the spread of tuberculosis or other infectious diseases
as appropriate19,20. Frequent hand washing is essential for the protection of
both patients and sleep technologists. All items that will be in contact with a
patient must be cleaned and disinfected before use.
4.4.2 Equipment Decontamination
There must be clearly designated areas for clean and dirty equipment
and sensors.
4.4.3 Non-Disposable or Reusable Items
Non-disposable or reusable items include items such as pneumo-tachometers, electrodes, respiratory belts, thermocouples, and body position sensors.
Various disinfectant products are available commercially. These products are
labeled with the instructions for disinfecting reusable items and the reusable
items should have instructions for disinfecting and cleaning recommended by
the manufacturer. When reusable items become contaminated and disinfecting is not feasible, gas or heat sterilization may be used or the item should be
properly disposed of. Bed linens should be handled with the assumption that
biohazard could be present. Overall, it is recommended to use disinfecting
products or procedures that are approved for the medical setting.
4.4.4 Disposable Items
The syringe and flat-tipped needle used to inject electrolyte into the cup
of electrodes should be discarded after use with the needle placed in a
receptacle for needles21. Disposable sensors should be disposed of after
use. Likewise, nasal cannulas used for administering oxygen or to monitor
flow with a pressure transducer are for single patient use only. These types
of products should be disposed after each patient use.
11. American Academy of Sleep Medicine, eds. Standard 17: Charting. In:
Standards for Accreditation of a Sleep Disorders Center. Westchester,
Illinois: 2006.
12. Redline S, Kirchner HL, Quan SF, et al. The effects of age, sex, ethnicity, and sleep-disordered breathing on sleep architecture. Arch Intern
Med 2004; 164:406-418.
13. Somers VK, Javaheri S. Cardiavascular effects of sleep-related breathing disorders. In: Kryger MH, Roth T, Dement WC, eds. Principles and
Practices of Sleep Medicine, 4th ed. Philadelphia: Elsevier Saunders;
2005: 1182-1186.
14. Association of Polysomnographic Technologists, eds. Job Descriptions.
Westchester, IL. Available at: http://aptweb.org/pdf/JobDescriptions.pdf
15. American Academy of Sleep Medicine, eds. Standard 3: Personnel.
Standards for Accreditation of a Sleep Disorders Center. Westchester,
IL: 2006.
16. Health Insurance Portability and Accountability Act of 1996 Available at:
http://www.cms.hhs.gov/HIPAAGenInfo.
17. American Academy of Sleep Medicine, eds. Standard 8: Facility and
Equipment. Standards for Accreditation of a Sleep Disorders Center.
Westchester, Illinois: 2006.
18. Occupational Safety & Health Administration, Occupational Safety and
Health Standards: Exit Routes, Emergency Action Plans, and Fire
Prevention Plans — 1910 Subpart E App. Available at:
http://www.osha.gov/pls/oshaweb.
19. Centers for Disease Control. Guidelines for preventing the transmission
of tuberculosis in health-care settings, with special focus on HIV-related
tissues. MMWR 1990; 39 (RR-17): 1-29.
20. Centers for Disease Control. Update: Universal Precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus,
and other bloodborne pathogens in healthcare settings. MMWR 1988;
37: 377-382, 387-388.
21. Occupational Safety & Health Administration, Occupational Safety and
Health Standards: Bloodborne pathogens — 1910.1030. Available at:
http://www.osha.gov/pls/oshaweb.
Footnotes
1. Kushida CA, et al., Practice Parameters for the Indications for
Polysomnography and Related Procedures: An Update for 2005 Sleep
2005;28:499-529.
2. Association of Polysomnographic Technologists, eds. Job Descriptions.
Westchester, IL. Available at: http://aptweb.org/pdf/JobDescriptions.pdf
3. American Academy of Sleep Medicine, eds. International Classification of
SLEEP DISORDERS, 2nd ed, Diagnostic and Coding Manual. Westchester,
Illinois, 2005.
4. Chokroverty S. Polysomnographic technique: an overview. In: Sleep
Disorders Medicine 2nd ed. Boston: Butterworth Heinemann; 1999:
158. ; Butkov N. Atlas of Clinical Polysomnography, vol.1. Ashland, OR:
Synapse Media, 1996: 11. Lee-Chiong T, Sateia M, Carskadon M, eds.
Sleep Medicine. Hanley & Belfus, 2002: 615.
5. Tyner F, Knott J, Mayer W Jr. Fundamentals of EEG Technology Volume
1: Basic Concepts and Methods. New York: Raven Press;1983: 126.
6. Lee-Chiong T, Sateia M, Carskadon M, eds. Sleep Medicine. Hanley &
Belfus, 2002: 647.
7. Jasper H.H. The ten twenty system of the International Federation.
Electrencephalogr Clin Neurophysiol, 1958; 10:371-375.
9. Butkov N. Atlas of Clinical Polysomnography, vol.1. Ashland, OR: Synapse
Media, 1996: 6.
10. Forouzan BA, Fegan SC. Data Communications and Networking 2nd ed.
Boston: McGraw-Hill, 2001:105.
10. Chokroverty S. Polysomnographic technique: an overview. In: Sleep
Disorders Medicine 2nd ed. Boston: Butterworth Heinemann; 1999: 159.
APT Continuing Education
Credit Program —
NEW Applications are
Now Available
To meet the growing professional and educational needs of the
Sleep Technology Profession, the Association of Polysomnographic
Technologists (APT) has revised and expanded the Continuing
Education Credit (CEC) Program. Educational Providers now have
the opportunity to apply for APT CECs through four educational
categories:
1. In-Service/Case Conference — (one to two hour program)
2. Single Lecture/Workshop — (one to two hour program)
3. Educational Programs, Training Course, Seminar, etc. —
(more than two hour program)
4. Computer Based Learning Activities (i.e. CD-ROM’s,
DVD’s, Webinars, and Internet)
For additional information on the new APT CEC applications,
visit the APT Web site at www.APTWeb.org.
13
A2Zzz Magazine Continuing Education
Credit Offering
Instructions for Earning Continuing
Education Credit
A Trainee, Technician or Technologist working in the Sleep
Technology Profession towards achieving the Registered
Polysomnographic Technologist (RPSGT) credential or re-certification of
the RPSGT credential may read A2Zzz Magazine and earn Association
of Polysomnographic Technologists (APT) Continuing Education Credits
(CECs) by completing an APT CEC A2Zzz Magazine evaluation form, on
the next page, and fax or mail the completed form to the APT national office to receive 1.5 APT CECs. This service is an APT member benefit and there is no fee to APT members. Individuals who are not members of the APT and are interested in earning APT CECs will be
required to pay an administrative fee of $20 per issue.
To earn APT CECs, carefully read A2Zzz Magazine and complete the APT CEC Evaluation Form found on the next page. The
completed evaluation form must be received by the APT national
office by March 1, 2007. A certificate awarding APT CECs will be
sent within 4 to 6 weeks of the submission deadline. It is the
responsibility of the individual to maintain a record of their APT
CEC certificates.
It is required that four out of the six articles in this issue listed below be read and
that a corresponding page number be
included on your APT CEC Evaluation Form
in order to receive APT CEC credit:
Accreditation Statements
This activity has been planned and implemented by the APT Board
of Directors and approved by the Board of Registered Polysomnographic
Technologists (BRPT). The APT Board of Directors has established this
program to meet the educational needs of the Sleep Technology
Profession. Each individual should only claim those credits that he/she
actually spent in the educational activity.
Statement of Educational Purpose /
Overall Education Objectives
A2Zzz Magazine is a peer-reviewed publication addressing the
educational needs of the Sleep Technology Profession. Its mission
is to provide progressive technical information and an avenue of
communication for members, presented in a professional and constructive manner, to further the goals, and promote unity in the
Sleep Technology Profession. Readers of A2Zzz Magazine should
be able to: 1) appraise Sleep Technology; 2) interpret new information and updates relating to the Sleep Technology Profession; 3)
analyze articles for the use of sound principles and practices; and
4) recognize the inter-relatedness/dependence of sleep medicine
with primary disciplines.
14
Page 6: APT Practice Parameter for Standard Polysomnography
Objective: To impart an understanding of the placement of electrodes and sensors used during polysomnography, polysomnographic
recording techniques and theory, standard recording protocol, including calibration, instrumentation, montage, and also the need for documentation and review of patient sleep history.
Page 16: Deep Brain Stimulation and Sleep
Objective: Impart an understanding of the fact that since its introduction, the use of deep brain stimulation (DBS) has been expanded
to treat other disorders such as epilepsy and depression, among
others. Scientists are beginning to investigate the possibility of using
DBS to treat certain sleep disorders. DBS stimulates areas in the
brain involved in sleep and some studies show that it can modify
sleep architecture.
Page 18: Pulse Transit Time: A Useful Clinical Tool?
Objective: Defines Pulse Transit Time (PTT) as the time it takes
for the arterial pulse pressure wave to travel from the aortic valve to
a peripheral site. The article discusses the use of PTT in representing respiratory effort by detecting changes in the blood pressure
oscillations associated with pleural pressure swings. Blood pressure
surges, also detected by PTT, have been associated with microarousals. The history of PTT, research findings and its use clinical
practice are discussed.
Page 26: Inadequate Sleep and Depression
Objective: Imparts an understanding that more than 80% of people with depression experience sleep disturbances. Insomnia is the
best predictor for individuals with depression. Predictions state that
major depression will be the second leading cause of disability by
2020. The article proposes that all patients should be asked if they
have difficulty sleeping as part of their routine health screenings in
considering the link between inadequate sleep and depression.
Page 28: They Come From the Cortex
Objective: Discusses where scalp potentials come from, what produces these voltages and how volume conduction, tissue dipoles and
geometric orientation affect EEG tracings. It also discusses that information that can be derived from these waves forms once conducted
through tissue and recorded through amplifiers.
Page 30: Pathological Yawning
Objective: This case study examines a 50-year-old woman who has
been followed for dymelinating disease and who developed excessive
or pathological yawning, or “chasm.” Not from being fatigued or
bored, pathological yawning is medically defined as a complex arousal reflex that arises from the brainstem and is thought to counteract
hypoxemia in the brain. Some of the known causes of pathological
yawning include encephalitis, seizures, tumors of the fourth ventricle
region, multiple sclerosis, progressive supranuclear palsy, electroconvulsive therapy and neuroleptic withdrawal.
APT CEC Evaluation Form
To earn APT CECs, carefully read four of the articles (see previous page for list) designated for APT CECs and mark your responses for each article and its page number on this form. Completely answer all questions and fax or mail this form to the APT national office (fax number/address indicated at the bottom of this page). In order to receive credit, this evaluation form must be answered completely and postmarked by March 1, 2007.
A certificate awarding 1.5 APT CECs will be mailed to you four to six weeks following this date. There is no charge to members of the APT for this
service. Non-members must include payment of a $20.00 administrative fee with this form.
For items 1-2, please use the following scale:
5=Strongly Agree, 4=Agree, 3=Unsure, 2=Disagree, 1=Strongly Disagree
1. Educational value:
I learned something new that was important.
I verified some important information.
I plan to discuss this information with colleagues.
I plan to seek more information on this topic.
My attitude about this topic changed in some way.
This information is likely to impact my practice.
2. Readability feedback:
I understood what the authors were trying to say.
I was able to interpret the tables/figures (if applicable).
Overall, the presentation of the article enhanced my
ability to read and understand it.
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4. Commitment to change:
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__________________________________________________________________________________________________________________________________________________________________________________
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Please return this completed form, postmarked no later than March 1, 2007, to the APT National Office:
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15
Deep Brain Stimulation and Sleep
BY REGINA PATRICK, RPSGT, ASSOCIATE EDITOR
n 1995 in Europe, Canada and Australia, a newly-approved medical
device — a deep brain stimulator — was used to treat people who had
essential tremors (i.e., tremors with no apparent cause). Two years
later in 1997, the United States Food and Drug Administration gave its
approval for the device to treat people with essential tremors. Since its
introduction, use of deep brain stimulation has been expanded to treat
other disorders such as epilepsy, depression, and especially the rigidity,
tremors, bradykinesia (slow movement), and gait difficulties of advanced
Parkinson’s disease. More than 30,0001 people worldwide have been
implanted with a deep brain stimulator since 1995. Scientists are beginning to investigate the possibility of using deep brain stimulation (DBS) to
treat certain sleep disorders. DBS stimulates areas in the brain involved
in sleep and some studies show that it can modify sleep architecture.
I
Deep brain stimulation (DBS) initially came about as a treatment for
pain. One theory2 on the genesis of pain viewed pain as the result of
somatic signals being blocked from stimulating certain areas (e.g., ventrotposterior nuclei) of the thalamus. With this view in mind, G. J.
Mazars2 and other scientists in the 1970s began experimenting with
artificially stimulating the thalamus in an effort to reduce pain. Artificial
stimulation was accomplished with the implantation of an electrode to
the brain which was attached to a device that generated pulses.
Scientists soon began to note that the surgery also stopped abnormal movements (e.g., “jumping stumps” in amputees) in intractable pain
patients. This led to the speculation3 that the thalamus plays a role in
both pain and movement and that stimulating the thalamus may also
reduce abnormal movements. Many studies subsequently investigated
the use of thalamic surgery to improve movement.
Initially, thalamic surgery for restoration of movement involved
destroying tiny areas of the thalamus or nearby structures such as the
globus pallidus and subthalamic nucleus. However in the 1980s, neurosurgeon Alim-Louis Benabid noted during surgery that when a stimulating
electrode was placed on thalamic areas involved in movement, the person’s movement immediately
improved although the area
had not yet undergone tissue destruction. This
observation led him to
suggest that permanent
stimulation of the areas
rather than destruction
of the tissue may be able
to reduce tremors in
people. He worked in
collaboration with a
medical device company to develop an
implantable neurostimulator to specifically treat
tremors.
Deep brain stimulation surgery4 now typically
involves implanting a lead
16
into two areas near the thalamus: the
globus pallidus and the subthalamic nucleus (STN, a mass of gray matter is located
just below the thalamus). The tip of the
lead contains four electrodes which each
stimulates a discrete area of tissue. An
extension wire connects the other end of
the lead to a neurostimulator. The neurostimulator produces the stimulatory
pulses which are transmitted through the Regina Patrick
extension wire to the lead.
Before surgery, the person’s head is placed within a stereotactic
frame (e.g., Leksell G frame) so that measurements can be made in
order to determine precisely where to insert the lead. The frame also
keeps the person’s head stabilized during the surgery.
Once measurements are made, a small area on the scalp is anesthetized and a small circular (approximately 0.5 inch diameter) opening
is bored in the skull near the coronal suture (the junction line of the
frontal bone with the parietal bone). The lead is inserted until it reaches
the basal ganglia. Since the patient remains awake during this portion of
the surgery, a surgeon does neurological tests and asks the patient to
describe sensations the patient is experiencing. This helps the surgeon
to more accurately determine that the lead is being inserted into the correct area. Once the lead is in the right position, the patient then undergoes general anesthesia so that the neurostimulator can be implanted.
The neurostimulator is a small device about 3 inches round and 1/2
inch thick. It is inserted through an incision made beneath the collar
bone. An extension wire from the neurostimulator is passed up beneath
the skin through the neck toward the bore hole in the skull. The extension wire connects with the lead at the bore hole. Depending on whether
one side or both sides are affected by impaired movement, a person
may be implanted with a unilateral or bilateral stimulator system.
After surgery, a physician adjusts the neurostimulator’s stimulation
parameters (i.e., amplitude [voltage], signal frequency, and pulse width
[length of stimulation]). The usual stimulation parameter ranges are an
amplitude of 1 to 3 volts, signal frequency range of 135 to 185 cycles
per second, and a pulse width of 60 to 120 microseconds.
The subthalamic nucleus (STN) and globus pallidus are located in
close proximity to each thalamus. The STN and globus pallidus have
many interconnecting pathways with each other. The globus pallidus also
has connections to the thalamus, midbrain, and other basal ganglia such
as the caudate nucleus.
The role of the STN and globus pallidus in sleep is unclear.
However, scientists have begun to discern the neural activity of these
structures during sleep and wake. For example, studies5,6 show that
cortical activity has an excitatory influence on the STN but the ability
of the STN to respond to the excitatory effects of cortical neurons is
modulated by the inhibitory influence of the globus pallidus which contains many GABAergic neurons. (GABA, gamma-amino butyric acid, is
a neuroinhibitor.)
ß
The STN-globus pallidus network has connections to the reticular
nuclei of the thalamus which in turn has connections to the midbrain reticular activating system. Increased activity of the midbrain reticular activating system from sleep to wake increases the activity of the globus pallidus.
receive inhibitory input from midbrain reticular neurons and other structures. Consequently, waking activity of the STN is not inhibited and insomnia results. Although DBS does not destroy tissue, it neurologically mimics
the effect of thalamotomy and inadvertently resulted in insomnia.
The globus pallidus fires in a random pattern rapidly during wake and
less rapidly during slow wave sleep but during rapid eye movement (REM)
sleep its firing rate increases dramatically. The STN fires at a virtually constant rate throughout sleep and wake but the quality of the firing changes
from a random pattern in wake to a burst pattern in slow wave sleep. The
function of changes in activity of the STN-globus pallidus network from sleep
to wake is unknown but they may play a role in information processing.
Scientists are trying to determine if DBS could be used to treat restless leg syndrome, periodic limb movement, or REM sleep behavior disorder. Results have been conflicting.
Researchers Alex Iranzo et al.7 and Isabelle Arnulf et al.8 in separate
studies found that stimulation of the STN in people with Parkinson’s disease subjectively improved sleep quality and improved objective measures
of sleep. For example, in the Iranzo study, polysomnography revealed that
the subjects’ arousal index (number of arousals/hour) decreased by
37.7%; wakefulness after sleep-onset (WASO) decreased by 10.6%; the
amount of slow wave sleep (stage 3/4) increased by 43.2%; and the
longest period of uninterrupted sleep increased by 53.5%. In the Arnulf
study, polysomnography showed that the subjects’ total sleep time
increased by 47%; wakefulness after sleep-onset (WASO) decreased by
51 minutes; and sleep efficiency (the ratio created by dividing total sleep
time divided by duration of the sleep period) increased by 36%.
Both Iranzo and Arnulf note that symptoms of REM sleep behavior disorder (e.g., vocalizations, movements during sleep, restless legs/arms)
remained despite improvement of other sleep characteristics. Both
researchers theorize that this may occur because pathways affected by
STN stimulation do not affect the neurons of the upper brainstem which
play a role in REM sleep atonia. Since the upper brainstem neurons are
not stimulated, REM sleep behavior symptoms can manifest.
Other researchers9 have similarly found that DBS increases in slow
wave sleep (stage 3/4), decreases in WASO, and increases periods of
uninterrupted sleep. However, French physicians Christelle Monaca et
al.10 in 2004 reported the case of DBS therapy inducing insomnia in a
patient. The patient, a 48 year old woman with Parkinson’s disease,
complained that after surgery she was able to sleep for about 1 hour at
night. The patient would wake up, eat, and feel compelled to remain
active at night. A polysomnogram performed three months after DBS
surgery confirmed the patient’s insomnia — during the study night she
slept for about 80 minutes. Interestingly, the patient’s insomnia did not
result in the expected excessive daytime sleepiness.
Nine months after surgery, the patient’s right side had not fully
responded to DBS. The surgeons as a result decided to reposition the left
DBS lead. Magnetic resonance imaging (MRI) performed before repositioning revealed that the right lead was placed in the posterior part of the
STN while the left lead had been placed on the outer front portion of the
STN. After repositioning the left lead, the patient’s right-sided movement
improved and her insomnia and nocturnal eating immediately stopped.
Monaca et al. theorize that insomnia may have resulted from the position of the left electrode. It may be that at its more anterior position on the
STN, the lead may have been stimulating descending fibers to the hypothalamus. (The hypothalamus controls appetite as well as certain aspects
of sleep.) Monaca et al. point out that animal studies and similarly some
human studies show that severe insomnia can result when the thalamus is
removed. They believe that thalamotomy affects the ability of the STN to
A 2006 Baylor College of Medicine study11 found that stimulating the
ventralis intermedius nucleus (Vim) of the thalamus did not reduce restless leg syndrome in people who also had essential tremors. Okun et
al.12 report the case of a woman whose symptoms of restless legs
improved after she had undergone DBS surgery to stimulate the globus
pallidus. Kedia et al.13 report that restless legs syndrome appeared in
their subjects after STN stimulation; they concede that reduction of
medication after surgery may have played a role in the manifestation of
the disorder. Several researchers (e.g., Arnulf and Iranzo) have noted no
improvement of REM sleep behavior disorder with DBS despite the
improvement in muscle control after surgery.
Such conflicting results are not discouraging. Apparent failures of
DBS treatment to alleviate symptoms in these disorders help scientists
to more clearly understand pathways involved in sleep and wake. This
understanding may yet be utilized in the future to improve sleep. H
References
1. Information About Deep Brain Stimulation: Patient Guide, (Sarl, France:Medtronic, 2004),
9, 14.
2. Duncan GH, Kupers RC, Marchand S, et al., “Stimulation of Human Thalamus for Pain
Relief: Possible Modulatory Circuits Revealed by Positron Emission Tomography,” Journal
of Neurophysiology, 80:3326-3330, 1998.
3. Mazars GJ, Merienne L, Cioloca C, “Control of dyskinesias due to sensory deafferentation
by means of thalamic stimulation,” Acta Neurochirurgica Supplement, 30:239-243, 1980.
4. Information About Deep Brain Stimulation: Patient Guide, (Sarl, France:Medtronic, 2004), 4-6.
5. Magill PJ, Bolamm JP, Bevan MD, “Relationship of activity in the subthalamic nucleusglobus pallidus network to cortical electroencephalogram,” Journal of Neuroscience,
20(2):820-833, Jan 15, 2000.
6. Urbain N, Gervasoni D, Souliere F, et al., “Unrelated course of subthalamic nucleus and
globus pallidus neuronal activities across vigilance states in the rat,” European Journal of
Neuroscience, 12(9):3361-3374, Sep 2000.
7. Iranzo A, Valldeoriola F, Santamaria J, et al., “Sleep symptoms and polysomnographic
architecture in advanced Parkinson’s disease after chronic bilateral subthalamic stimulation,” Journal of Neurology, Neurosurgery, and Psychiatry, 72:661-664, 2002.
8. Arnulf I, Bejjani BP, Garma L, et al., “Improvement of sleep architecture in PD with subthalamic nucleus stimulation,” Neurology, 55:1732-1734, Dec 2000.
9. Cicolin A, Lopiano L, Zibetti M, et al., “Effects of deep brain stimulation of the subthalamic
nucleus on sleep architecture in parkinsonian patients,” Sleep Medicine, 5:207-210, 2004.
10. Monaca C, Ozsancak C, Defebvre L, et al., “Transient insomnia induced by high-frequency
deep brain stimulation in Parkinson disease,” Neurology, 62(7):1232-1233, Apr 13, 2004.
11. Ondo W, “Vim deep brain stimulation does not improve pre-existing restless legs syndrome in patients with essential tremor,” Parkinsonism and Related Disorders,
12(2):113-114, March 2006.
12. Okun MS, Fernandez HH, Foote KD, “Deep brain stimulation of the GPi treats restless legs
syndrome associated with dystonia,” Movement Disorders, 20(4):500-501, Apr 2005.
13. Kedia S, Moro E, Tagliati M, et al., “Emergence of restless legs syndrome during subthalamic stimulation for Parkinson disease,” Neurology, 63(12):2410-2412, Dec 28, 2004.
About the Author
Regina Patrick, RPSGT, is a noted freelance medical writer and sleep technologist that works
at St. Vincent Mercy Sleep Disorders Center in Toledo, OH. She is a regular contributor and
serves on the A2Zzz Magazine Editorial Board as an Associate Editor. She also contributes
to other publications in the sleep field. Patrick is a past recipient of the APT Dr. Allen
DeVilbiss Literary Award for literary excellence for articles published in A2Zzz Magazine. She
may be contacted through the APT National Office at [email protected].
17
Pulse Transit Time: A Useful
Clinical Tool?
BY KIMBERLY TROTTER, M.A., RPSGT, ASSOCIATE EDITOR
What is Pulse Transit Time?
ulse Transit Time (PTT) is the time it takes for the arterial pulse
pressure wave to travel from the aortic valve to a peripheral site1.
It is usually measured from R wave on electrocardiogram (ECG) to the
pulse wave arrival at the finger (using oximetric photopleythsmography).
P
PTT has been shown to represent respiratory effort by detecting
changes in the blood pressure oscillations associated with pleural pressure swings (pulsus paradoxus)2. Blood pressure surges, detected by
PTT, have been associated with micro-arousals as well3.
History
Pulse Transit Time (PTT) has been used since the 1970s as an indicator of blood pressure changes1. Recently, PTT changes have been correlated with arousals4,5. Some research has gone as far as theorizing
that changes in PTT may denote arousals without the need for EEG5.
Research Results
Many studies include both adult and pediatric populations. Correlations
between electroencephalogram (EEG) arousals or sleep fragmentation,
increased respiratory effort — esophageal pressure (Pes), thoracic, and
abdominal respiratory effort — and PTT changes are shown.
Pediatric Studies
There have been many studies that show a correlation between Pes
change and PTT change in children4, however, some of these studies discuss limitations in studying a pediatric population, including excessive
movement artifact.
In some of these pediatric studies, PTT was shown to be slightly more
sensitive to detecting respiratory events than Nasal Pressure (NP) alone.
PTT is non-invasive, and does not disturb sleep or modify upper airway as Pes has been shown to do4,5,6.
Adult Studies
The adult studies show similar results to pediatric studies. Again, NP
was shown to be just slightly less sensitive that PTT in detecting respiratory events, especially upper airway resistance syndrome (UARS) or
respiratory effort related arousals (RERAs).
PTT is a desirable measurement for respiratory disturbance
because it is non-invasive, and it is semi-quantitative. It has been shown
to reveal micro-arousals and increased respiratory effort2,7,8.
Should it be used in your lab?
PTT can be a useful addition to NP or replacement for Pes, enabling
more sensitive monitoring for UARS/RERAs. There are PTT monitors
built into some of the sleep monitoring systems, such as the Respironics
Alice 5. It is up to the technologist to let the data acquisition system
manufacturers know that we are interested in studying PTT as a useful
addition or tool for recognizing UARS/RERAs. H
18
References
1. Smith, R. et al. Pulse Transit Time: an Appraisal of
Potential Clinical Applications. (1999). Thorax
54;452-457.
2. Pitson, D. et al. (1995). Use of Pulse Transit Time
as a Measure of Inspiratory Effort in Patients With
Obstructive Sleep Apnea. Eu Respir J 8:1669-74.
3. Pitson, D. et al. (1994). Changes in Pulse Transit
Time and Pulse Rate as Markers of Arousal From Kimberly Trotter
Sleep in Normal Subjects. Clin Sci 87:269-73.
4. Pepin, J. et al. (2005). Pulse Transit Time Improves Detection of Sleep Respiratory Events
and Microarousals in Children. Chest 127;772-730.
5. Katz, E. et al. (2003). Pulse Transit Time as a Measure of Arousal and Respiratory Effort
in Children with Sleep-Disordered Breathing. Pediatr Res 53:580-588.
6. Pagani, J. et al. (2003). Pulse Transit Time as a Measure of Inspiratory Effort in Children.
Chest 124:1487-1493.
7. Argod, J. et al. (2000). Comparison of Esophageal Pressure with Pulse Transit Time as
a Measure of Respiratory Effort for Scoring Obstructive Non-apneic Respiratory Events.
Am J Respir Crit Care Med July;162(1): 87-93.
8. Poyares, D., et al. (2002). Arousal, EEG Spectral Power and Pulse Transit Time in UARS
and Mild OSAS Subjects. Clin Neurophysiol Oct;113(10):1598-1606.
About the Author
Kimberly Trotter, MA, RPSGT, is the Practice Manager for the University of California at San
Francisco (UCSF) Sleep Disorders Center, Pulmonary Function Lab and Pulmonary
Department at Mount Zion Hospital. She is a past APT Board Member, Association for the
Study of Dreams former member, and a longtime sleep technologist. She is also an A2Zzz
Magazine Associate Editor.
Committee on Accreditation for
Polysomnographic Technology
Education (CoA PSG)
Is your Polysomnographic Technology
Training Program accredited? The CoA
PSG is now accepting applications for
accreditation from allied health education programs.
CoA PSG accreditation is the gold standard for Sleep Technology educational
programs and has several benefits:
• Access to formal and standardized
educational resources
• Recognition of your program’s quality
curriculum and instruction
• Recognition by the Commission on Accreditation of Allied Health
Education Programs (CAAHEP)
• Prepares your students for the national credentialing examination
• Recognition by professional societies, including the American
Academy of Sleep Medicine, Association of Polysomnographic
Technologists and Board of Registered Polysomnographic
Technologists
Visit www.caahep.org/accredit.aspx?ID=obtainCredit for information
on the accreditation standards and guidelines or contact Dr. Richard
Rosenberg at (708) 492-0930 for more information.
Cognitive Changes
on PSG Technicians
After Six Months
of Nocturnal
Shift Work
BY ROGERIO SANTOS DA SILVA, PH.D., RPSGT
Study performed by: Francisco Gregorio de Oliveira, Rogerio
Santos da Silva, Lia Alves Simoes Matuzaki, Maria de Lourdes
Lefevre Assumpcao, Fernanda Kelly Gimenes Bertini, Ruth
Ferreira Santos, Sergio Tufik.
Sleep Institute/AFIP; Sleep Medicine and Biology Discipline —
Psychobiology Department — Federal University of Sao Paulo.
Abstract
Objectives
To evaluate the effects of nocturnal shift work on cognitive function of PSG technicians who had never worked during nocturnal
shift before.
Methods
The performance of 18 PSG technicians, aged 20-35 years old,
were evaluated before and six months after the beginning of nocturnal shift work. The schedule was 3-12 hours shifts. The following neuropsychological tests battery was administered including tests of general nonverbal intelligence, attention, verbal and
nonverbal memory, and executive functions. The results were statistically analyzed using Student’s t-test.
Results
Significant differences between the performance of the PSG
technicians before and after six months of nocturnal shift were
observed, respectively: attention — increase of wrong answers
in the Tolouse-Pieron Test (3.8+/-1.2 vs. 13.8+/7.7)(p<0.001); motor ability — decrease of number substitutions in the Symbols Test (55.1+/-5.1 vs. 46.7+/6.8)(p<0.001); increase of duration of the Trail Making test
(47.7+/-13.1 vs. 67.1+/-17.7)(p<0.001); impairment of
memory evaluated by Rey-Osterrieth Complex Figure Test
(29+/-2 e 24.6+/-2.6)(p<0.001). However, forgetfulness
rates in immediate and late recover were similar between evaluations (-2.2+/-1.8 vs. -3.7+/-3.6)(p = 0.1). Measures of trait
(41.1+/-1.7 vs. 36.1+/-5.9)(p<0.001) and state (40.9+/-2.1
vs. 38.4+/-4.2)(p<0.03) anxiety by Spielberger State Trait
Anxiety Inventory (STAI) showed decrease after six months of
night shifts.
Conclusion
These findings suggest that six months of nocturnal shift work
exposure contributed to cognitive impairment and anxiety
decrease. However, these attention, motor ability, and memory
changes were not out of the normality. H
19
The APT wishes to acknowledge and
thank the following organizations
for their generous support and
investing in the future of the Sleep
Technology Profession by becoming
APT Supporter Members:
Pro-Tech Services
DeVilbiss
Respironics
Sleepmate
Cadwell Laboratories
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A New Look...
A
New
Name...
American
Association
of
Sleep
Technologists (AAST)
The Same Mission... To promote and advance the
sleep technology profession
or nearly 30 years the Association of
F
Polysomnographic Technologists (APT) has
been the only professional society that is dedicated
exclusively to the needs of sleep technologists.
The AAST remains committed to providing opportunities
for professional development, to promoting technical
and clinical excellence, and to preserving the autonomy
and future of the sleep technology profession.
As the field of sleep medicine grows the AAST
continues to be the leading voice for sleep technologists,
making sure that our members are recognized as
qualified healthcare professionals who ensure the
safe and accurate assessment and treatment of
sleep disorders.
Very Active Fall for
Regional Sleep Education!
APT 2006 Fall
Review Course
Held in Indianapolis in October, the course is held
annually and is aimed at technicians preparing to sit
for their board examinations, as well as seasoned
professionals wanting a comprehensive refresher
course to obtain continuing education credit. The
APT’s reputation for being committed to providing
high-quality education resulted in this year’s annual
review course boasting one of the highest numbers
of attendees in APT history.
Montana Regional Sleep Seminar 2006
The Sleep Center at St. Vincent Healthcare in Billings, sponsors the fall conference annually in the hospital’s adjacent Mansfield Health Education Center. So many sleep technologists attended this year’s conference, it was necessary for at-the-door registrants to participate via overview lecture rooms. A state-of-theart facility, the center has telecommunications capability in all of the meeting rooms, an auditorium with
seating for 250 and a contemporary medical library. Named for the legendary Montana Senator Mike
Mansfield and his family, the center opened in 2002.
Attendees review a PSG paper tracing for artifact.
Glenn Roldan, annual speaker, conducts a board
examination review. The next conference is slated
for September 6-8, 2007 in Billings, MT.
Karen Allen, organizer, and Kim Trotter, popular annual
speaker and A2Zzz Magazine Associate Editor, participate in a CPAP mask-fitting workshop with attendees.
Sleep technologists attend clinical breakout sessions
for CEC credit at the patient conference.
Dr. William Dement signs autographs for attendees at
the Talk About Sleep (TAS) Inaugural Patient Sleep
Conference held in Minneapolis, Minnesota in October.
The conference was the first of its kind for patients.
Dr. James O’Brien, TAS President, and speakers Dr.
Dement, Ed Grandi, American Sleep Apnea
Association Director, Dr. David Rapoport, New York,
and Dr. Mark Abraham, Louisiana, with TAS Vice
President and sleep patient Tracy Nasca.
23
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Inadequate Sleep and Depression
BY JOSHUA COLE, RPSGT, ASSOCIATE EDITOR
S
leep disturbances are becoming quite familiar to those screening
patients for depression. Inadequate sleep and depression seem to
be inexplicably related, but the answer to the age old “chicken or the
egg” quagmire has long been elusive. Are the two linked? Can one lead
to the other? Numerous studies seem to express the same sentiment;
inadequate sleep and depression are linked but we have yet to determine
if one definitively leads to the other.
identifying those at risk for depression.
“Sleep is as essential as diet and exercise.
Inadequate sleep can result in fatigue,
depression, concentration problems, illness and injury.”3 But, is this true in all
cases? How and why does inadequate
sleep lead to depression?
Poor sleep hygiene will confuse the body and seriously disrupt one’s
life. Overconsumption of caffeine and alcohol, conducting physical exercise too closely to bedtimes and lingering in bed can all predispose one
to inadequate sleep. Habits such as these have been proven to lead to
mood changes, depression and frustration with sleep and everyday activities.2 These interferences eventually decrease one’s quality of life, by
repeating cycles that lead to altered states and increase one’s susceptibility to depression.
Approximately 50% of depressed outpatients and 80% of those hospitalized for Joshua Cole
depression experience some form of
sleep disturbance. One disturbance is known as “excessive sleep effort”
and is becoming increasingly more common in patients with depression.
Excessive sleep effort was identified after researchers began to classify
depression into subgroups, such as “hopelessness depression.” Those
suffering from hopelessness depression often view themselves as failures and have difficulty believing in their own ability to live everyday life.
Those with symptoms of “excessive sleep effort” experience heightened
frustration and arousal from trying to fall asleep and being unable to do
so. These patients often make statements like, “No matter what I do, I
just can’t sleep...” A better understanding of mind-body interaction, biological processes and the effects of sleep in the development of depressive symptoms is needed to solidify the link between poor sleep hygiene
and depression.4
Recent debate is more focused on the links of specific sleep disorders to depression as opposed to the bigger picture of whether poor
sleep hygiene or sleep patterns contribute to depression and whether
the treatment of one may possibly alleviate the other or slow the development thereof.2 “Insomnia may also signal depression or anxiety. Often
times, insomnia exacerbates the underlying condition by leaving the
patient fatigued and less able to cope and think clearly.”3
Research has shown that restless legs syndrome and sleep apnea
are now being addressed along with insomnia as possible indicators for
Primary sleep disorders including narcolepsy, sleep apnea and
insomnia have been proven to cause a reduced quality of life.
Researchers have classified sleep disorders associated with depression into one
of two categories: Sleep Apnea and
Insomnia. During the years of 19941999, a cross section survey of 19,000
randomly selected persons between the
ages of 15-100 years old, showed that
more than 2% of subjects had
Obstructive Sleep Apnea and another
2.5% had some other type of respiratory
related sleep disorder. Nearly one fifth of
those with a sleep disorder also had a
major depressive disorder. After the controlling factors of obesity and hypertension were considered and eliminated, the
odds of having a sleep disorder were
5.26% higher for those who had also
been diagnosed with depression. As the
understanding of the relationship
between sleep and depression grows, we
may find that the detection and treatment
of one could be the deciding factor in the
successful prevention or slowed progression of the other.5
Insomnia is still the most common
sleep disorder cited by those with depression. Insomnia predicts mania and conversely depression can predict sleep
ß
26
Neurobiological factors along with psychological and physiological
processes may determine one’s predisposition to depression. The long
struggle to link inadequate sleep and depression led to an early consensus that depression causes insomnia. However, once antidepressants
were introduced as treatment, studies found that they were successful
at improving symptoms of depression but did not alleviate insomnia and
actually interfered with sleep patterns in some cases.6
The long held assumption that insomnia is a symptom or side effect
of depression is being challenged with suggestions that insomnia may
make patients more likely to become and/or remain mentally ill. Those
most at risk for first time onset of depression are those who suffer from
severe “middle insomnia”, where the patient wakes up frequently
throughout the night but eventually falls back asleep each time. Two new
studies show that insomnia may indeed precede depression.6 “The odds
of developing depression are increased during a year of insomnia,” says
Dr. Ruth M. Benca, “There is a 40% elevated risk.”1 Michael Perlis,
Director of the University of Rochester Sleep Research Laboratory, said,
“The new findings are especially significant because they suggest that
targeted treatment for insomnia will increase the likelihood and speed of
recovery from depression.”6
Approximately 100 million Americans suffer from insomnia and
more than 80% of people with depression experience sleep disturbances.5 “Insomnia is the best predictor for individuals with depression.
Major depression will be the second leading cause of disability by 2020.
References
1. Pueschel, Matt. Sleep Shown As Central To Overall Physical Health. U.S. Medicine
Information Central. July 2004; Available at: http://www.usmedicine.com/ Accessed
September 26, 2006.
2. SleepEducation.com. Inadequate Sleep Hygiene, Updated March 1, 2005. Available at:
http://www.sleepeducation.com Accessed August 29, 2006
3. National Sleep Foundation. Insomnia/Basics Reviewed by David N. Neubauer, M.D., M.A.
March 28, 2005 Available at: http://www.sleepfoundation.org/sleeptionary/index
Accessed August 29, 2006
4. Haynes, Ph.D., Patricia L. No Sweet Dreams Sleep Review Vol. 6, No. 7, Nov 2005 (48-50)
5. Zoidis, M.D., John D. Sleep and Depression Sleep Review Vol. 6, No. 3, May/June 2005
(38-42)
6. Media Release — University of Rochester Medical Center. Relationship Between Insomnia and
Depression Revealed, June 22, 2005. Available at: http://www.scienceagogo.com/news
Accessed September 26, 2006
7. Roman Ph.D, Viktor, Walstra, Irene, Luiten, Ph.D., Paul G.M., and Meerlo, Ph.D, Paul.
Too Little Sleep Gradually Desensitizes the Serotonin 1A Receptor System Journal SLEEP,
Vol. 28, Issue 12, 2005 (1505-1510) Available at: http://www.journalsleep.org.
Accessed August 29, 2006
About the Author
Joshua Cole, RPSGT, is a diagnostic sales representative for Respironics, Inc. He is an associate editor for A2Zzz Magazine and a member of the APT Communications Committee. Cole
resides in Southern California and may be contacted though the APT National Office at
[email protected].
MVAP MEDICAL SUPPLIES • 2005 SLEEP CATALOG • MVAP MEDICAL SUPPLIES • 2005 SLEEP CATALOG
MVAP MEDICAL SUPPLIES • 2005 SLEEP CATALOG • 2005 SLEEP CATALOG • MVAP MEDICAL SUPPLIES
In 2005, researchers conducted a study hypothesizing that chronic sleep loss can lead to depression, due to the desensitization of the
serotonin receptor. This desensitization can eventually lead to the drop
or interruption of serotonin transmission, a proven indicator of depression. A link here would be valuable considering serotonin is the very
thing many antidepressants are designed to regulate. In this study,
rats were subjected to only 4 hours sleep per day. After 2 days, there
was no effect on the serotonin levels. After 8 days however, the serotonin receptor system was desensitized. Control experiments indicated that the effects of sleep restriction were not due to forced activity
or stress. Most importantly, the desensitization of the serotonin (5HT1A) receptor persisted for many days even with unlimited recovery
sleep. Normalization occurred gradually but took at least 7 days.
Findings concluded that, “Chronic sleep restriction causes a gradual
and persistent desensitization of the 5-HT1A receptor system,” showing a link between chronic sleep loss and sensitivity to disorders such
as depression associated.7
All patients should be asked if they have difficulty sleeping as part of
their routine health screening,” according to Dr. Benca.1 Calling for an
emphasis on an “integrative psychophysiological perspective” when
studying the link between inadequate sleep and depression may be beneficial.4 An acceptance and understanding of this relationship could be
expedited by combining polysomnograms and routine psychological
exams in patient evaluations. H
MVAP MEDICAL SUPPLIES • 2005 SLEEP CATALOG • 2005 SLEEP CATALOG • MVAP MEDICAL SUPPLIES
problems, creating a potential two-way relationship. Sleep lab studies of
psychiatric patients show profound sleep abnormalities. Inadequate
sleep and problems with sleep continuity contribute to mood and anxiety
disorders and increased rates of mental stress among insomnia
patients. Approximately 33% of patients with insomnia have a depressive or anxiety disorder compared to 11% of patients without insomnia.
“Insomnia increases the risk for depression later in life. Insomnia precedes depression 41% of the time and follows depression 29% of the
time. In recurrent depression, insomnia appears first over 50% of the
time,” said Dr. Ruth M. Benca, M.D., Ph.D., professor in the
Department of Psychiatry at the University of Wisconsin-Madison. Since
insomnia precedes depression and acute depression worsens insomnia,
could both possibly result from similar neurobiological abnormalities? Dr.
Benca poses the question of whether there is an underlying process that
fosters this relationship.1
MVAP MEDICAL SUPPLIES • 2005 SLEEP CATALOG • MVAP MEDICAL SUPPLIES • 2005 SLEEP CATALOG
27
They Come From the Cortex
BY WILL ECKHARDT, BS RPSGT CRT, ASSOCIATE EDITOR
here do scalp potentials come from and what produces these
voltages? How do volume conduction, tissue dipoles and geometric orientation affect the electroencephalogram (EEG)? What information can we derive from these waves forms once conducted through
tissue and recorded through our amplifiers? We will explore these issues.
W
We record the EEG from scalp electrodes commonly placed by what
is know as the International 10-20 System of Electrode Placement
(albeit modified generally in sleep studies). Hans Berger recorded the
first human EEG in the1920’s. We have come along way in the equipment used in recording the EEG but the source remains the same. EEG
is a means of looking at voltages derived from our cortex which vary as
a function of time and their spatial distribution in relation to the recording electrode.
EEG can be recorded via scalp electrodes or from intracranial electrodes. Scalp sites sample from a larger area than intracranial placement. Intracranial sites provide more local sampling giving generally
different data from that of the global scalp recordings. Scalp EEG is
now believed to be derived from postsynaptic potentials (postsynaptic
potentials are changes in the electrical potential of the neuron that
receives information at a
neuronal junction or
synapse) from the cortex
that summate and reach
the scalp giving us our
EEG waveforms. Intrinsic
cell currents (produced by
ionic channel activation)
may contribute to the EEG
but is still under investigation. Action potentials
were once thought to
contribute to the EEG but
recently have been dismissed as their temporal
limits are too short.
Fig. 1 Pyramidal Cell
Fig. 2 Dipole
28
The cortex is composed of a dense collection of neuron cell bodies
with
myelinated
and
unmyelinated fibers running through it. It is less
then 5 mm thick. The cortex covers both cerebral
hemispheres of the brain.
There are millions of neurons within the cortex,
each having contact with
thousands of other neurons. The cortex has
areas with distinct functions and EEG output. The
neurons receive input
from subcortical areas via
the thalamus. The cerebral cortex and
the thalamus often work together in generating brain rhythms1. These wave
forms are derived from the summation of
different rhythms rather than being a
rhythm generated by a single cell or
group of cells. The cortex also sends
input signals to other areas within the
cortex via association fibers. Efferent
(directed away) signals are sent to many Will Eckhardt
other brain structures e.g. the brainstem, thalamus, cerebellum, the basal nuclei and the spinal cord.
Most of the cortex has six layers of neurons and is called the neocortex. Cytoarchitecture is the distribution of these neurons. Pyramidal
cells (see Fig 2) the most common neurons within the cortex, are
named such due to their cell body shape. Although they are found in all
layers other than layer 1, they are they are most predominant in layers
2, 3, and 5.2
Pyramidal neurons have a cell body, an axon, a single apical dendrite
and a number of basal dendrites. Their axon originating on the base of
the cell body leaves the cortex being the output pathway of the cortex.
Axons can branch many times contacting hundreds of other neurons.
These neurons are layered and project into other areas via their axons
and axon collaterals. Pyramidal neurons are associated with excitatory
neurotransmitters. Other neurons in the cortex are local and stay within the area of their cell body. These are known as interneurons. These
neurons are often inhibitory.
Presently we believe EEG potentials are due to excitatory postsynaptic potentials (EPSP) and inhibitory postsynaptic potentials (IPSP) propagated by the cell body and dendrites of thousands of synchronized
pyramidal neurons3. The summation of these potentials is facilitated buy
the architecture of pyramidal neurons. These neurons are oriented in a
columnar structure with apical dendrites pointing toward the cortical
surface. These very small dipoles (see Fig 2 — a separation of unlike
charges) therefore have similar orientations. The Solid Angle (see Fig 3
— a measure of the apparent cross-sectional area of an object as
viewed from a distance) of the dipole and the actual voltage of the dipole
generated by a single cell is too small to produce recordable EEG at the
surface. It is the summation of solid angles and synchronization of potentials in groups of neuronal synapses that enables the EEG to be recordable at the surface of the head.
There can be a great deal of difference in the recording from two
electrodes spaced only millimeters apart which was previously thought
to imply the activity was from the immediate proximity of the surface
electrode4. Those electrodes far apart and producing the same wave
forms were considered linked to a common source. The solid angle theorem (discussed below) and summation of the potentials is now considered to be the means by which we record postsynaptic potentials at the
surface electrode.
The small area within the cortex created by summated activity in
neighboring active cells has been referred to as a dipole layer (see Fig.
ß
2). A dipole layer can have infinite orientations with respect to scalp
electrodes. The electrodes on the scalp “see” only the potentials and
polarity of the potential pointed at them. Each orientation will produce
a unique result because of the effect on the solid angle (see Fig. 3) the
dipole presents to the recording electrodes. The surface area of the
dipole layer and the orientation of the layer with respect to the electrodes have profound effects on the recording of electrical potentials.
Due to volume conduction (the process of current flow through the tissues between the electrical generator and the electrode) and summation of solid angles we see data from sources of at least several centimeters, independent of our electrode size, and potentially generated
by many local sources. Due to the solid angle theorem and volume conduction the closest electrode to the neuronal generator may not always
record the largest potential5. Differing placement of the recording electrode around the circumference of the area will result in marked
changes in the solid angle even though the event itself remains
unchanged. The polarity of the event also depends on electrode placement not whether the event is due to EPSP or IPSP, the former being
a positive potential and the latter being negative.
Sleep is a normal function of our brains. There are regions of the
brain and brainstem that promote wakefulness. As the influence of “the
wakefulness generators decreases, neurons that promote sleep
become active. Sleep ensues as a light transitional stage and becomes
a more synchronized form (within the bandwidth that we view in
polysomnography) as more neuronal networks are involved.
Transmission between neurons is enhanced during wake and REM
whereas during NREM sleep a blocking of afferent information is seen in
the thalamus1. The brains activity, during wake and REM, are nearly the
same. Although the afferent information stops during NREM sleep, the
cortex remains active. The corticothalamic conection remains active as
do the corticocortical communications. Brainstem stimulation and the
response of the thalamocortical cells on the other hand are associated
with EEG activation and neuronal excitability that creates an activated
state vs. a sleep state.
In conclusion what is it that the EEG shows me? As you know we can
determine NREM, REM, and wake. We can also determine normal EEG,
being a lack of clinically significant patterns associated with disorders.
Abnormal EEG can also be determined but does not necessarily mean a
clinically significant disorder. This is why MRI is an often utilized diagnostic tool in relation to brain function.
Electrophysiologists study potentials generated by just one neuron or
even small groups recorded with microelectrodes or mesoelectrodes.
We, in sleep, are dealing with oscillating macroscopic potentials recorded from the scalp6. To name a few illnesses that EEG may be utilized in
the diagnosis and treatment of: strokes, brain tumors, infectious diseases, severe head injury, and brain death. The EEG is merely one of
many tools in assessment of brain function but remains the gold standard in evaluation of sleep state.
Now I shall block the afferent information from my brainstem reticular formation and let sleep ensue. H
References:
1. Mircea Steriade. Principles and Practice of Sleep Medicine 2006 Elsevier Chapter 9 Brain
Electrical Activity and Sensory Processing During Waking and Sleep States:101
2. Duane E. Haines. Fundamental Neuroscience, Second Edition:508
3. Bruce J. Fisch. Fisch & Spehlmann’s EEG Primer Basic Principles of Digital and Analog
EEG, Third Revised and Enlarged Edition: 4-9
4. R Cooper, J.W. Osselton, J.C. Shaw. EEG Technology Second Edition: 8-13
5. Volume Conduction Principles in Clinical Neurosurgery. February 2005. Veterinary
Neurology and Neurosurgery.
http://www.neurovet.org/Electrophysiology/VolumeConduction/VolCondPartABcite.htm
6. Paul L. Nunez, Ramesh Srinivasan Electric Fields of the Brain The Neurophysics of EEG
Second Edition: 3-4
About the Author
Will Eckhardt, RPSGT, CRT, is a member of the APT Board of Directors and serves as the
APT Board Liaison for the APT Standards and Guidelines Committee. He is a board member
of the New England Polysomnographic Society (NEPS) and is NEPS Education Committee
Chair. His full time position is with Sleep HealthCenters where he is the Director of Education.
Eckhardt also is a faculty member at Northern Essex Community College where he teaches
in the polysomnography program and is a member of the advisory board. He is a member of
the A2Zzz Magazine editorial board and a recipient of the APT Dr. Allen DeVilbiss Literary
Award in 2004. He is also a member of the American Academy of Sleep Medicine Committee
on Polysomnographic Technologists Issues.
Sleep Disorder Technologists
University Services
Sleep Diagnostic & Treatment Centers
Locations in PA & NJ
Lansdale, NE & South Phila, Pottstown, Warrington, West Chester, PA & Voorhees NJ
Fig. 3 Solid Angle — The voltage recorded by each electrode is proportional to
the product of the solid angle and the actual voltage of the dipole. Even though
the cross-sectional area of the dipole layer is the same the voltages measured
by the two electrodes would differ from one another in amount because the solid
angles are different.
Full/ Part-time positions available. Qualified individuals should
be experienced in routine PSG testing, CPAP and BIPAP
titrations and nocturnal seizure testing. Opportunities for further
growth and development exist for motivated individuals. Send
resume to (610) 344-7922,[email protected].
Or call (610) 344-9921 for further information.
Multiple locations, good working environment, competitive pay.
www.uservices.com
29
Pathological Yawning
BY JOANNE HEBDING, RPSGT, ASSOCIATE EDITOR
hen I was a child, my mother told me yawning was from a lack
of oxygen, but I knew it was really from being bored. During my
search for information on yawning, I found out that Mom was right again!
W
Excessive or pathological yawning, or “chasm,” is medically defined
as a complex arousal reflex that arises from the brainstem and is
thought to counteract hypoxemia in the brain. This action is not from
being fatigued or bored.
Our Sleep Center recently saw a 50-year-old woman who has been
followed for dymelinating disease for the last decade. She recently was
hospitalized for shortness of breath. Her yawning began during that hospitalization although her demyelinating disease had not worsened. A cervical spine magnetic resonance imaging (MRI) test, with and without contract, revealed signal alterations consistent with demyelinating pathology, especially at C2-3 and C3-4. The yawning has worsened in the last
several months.
The phenomenon occurs throughout the day, and appeared to
decrease during her sleep period. Her yawning is characterized by a
wide-open jaw extension that has become quite exhausting for her jaw.
The patient does not complain of acute daytime hypersomnolence, and
scored well within normal limits on the Epworth Sleepiness Scale score.
She has difficulty initiating sleep due to muscular spasms, as well as
complaints of maintaining sleep for no apparent reason. She has noted
leg movements, as well as general body movements, but denied any leg
paresthesias, sleep paralysis, hypnagogic hallucinations or cataplexy. No
automobile accidents were reported associated with drowsiness.
Her neurologist ordered overnight polysomnography followed by a
multiple sleep latency test (MSLT). Sleep efficiency on the polysomnograms (PSG) was reported at 78.5% with a non-rapid eye movement
sleep (NREM) respiratory distress index
(RDI) of 16.8. Oxygen desaturations
were reported with a nadir of 87%.
Snoring was minimal. PLM arousal index
was 0; however, 16 spontaneous
arousals were reported. As per our split
protocol, CPAP was initiated and titrated
up to a maximal pressure of 7 cm. The
MSLT revealed a normal MLTS of 11.2
(>10 normal) with no rapid eye move- Joanne Hebding
ment sleep (REM) periods in 4 separate
naps. The patient has reported a good response to continuous positive airway pressure (CPAP). Trial dosage of levodopa (Sinemet) at
10/100 mg every morning was recommended by the sleep diplomate
who interpreted the studies.
Some of the known causes of pathological yawning include encephalitis, seizures, tumors of the fourth ventricle region, multiple sclerosis,
progressive supranuclear palsy, electroconvulsive therapy and neuroleptic withdrawal.1,2,3,4,5 Dopamine agonists, valproate overdose,
imipramine, withdrawal from morphine and estrogen substitution may
also induce pathological yawning.6,7,8,9 PLMS has been reported with
pathological yawning.10
Now every time I yawn, I remember my mom and wonder how she
got to be so smart! H
References
1. Arai K, Kita K, Komiyanma A, Saeki N, Nagao KI (1986) Profressive dysautonomia in
hemangioblastoma of the fourth venricle region. Brain Nerve 38: 195-200
2. D’Mello, DA, Vincent FM, Lerner MP (1988) Yawning as a complication of electroconvulsive therapy with concurrent neuroleptic withdrawal. J. Nerv Ment Dis 176: 188-189.
3. Fletcher S, cohen F, Borenstein F, Regev I, Vardi J
(1982) Yawning as a paroxysmal sign of diencephalic
seizures. Arch Psychol Psychiatry Neurol 43; 45-54
4. Postert T, Pohlau D, Meyes S, Nastos I, Przuntek H
(1996) Pathological yawning as a symptoms of multiple
sclerosis. J.Neurol 243: 300-301
5. Van Sweden B, Vanderhoven L, van Erp MG (1994)
Excessive yawning. Acta Neurol Belg 94: 150-151.
6. Goldberg RL (1983) Sustained yawning as a side effect
of imipramine. Int J Psychiatry Med 13: 277-280
7. Rollinson RED,Gilligan BS (1979) Post anoxic action
myoclonus Lance Adams syndrome responding to valproate. Arch Neurol 36_44-45
8. Stahle L (1992) Do autoreceptors mediate dopamine
agonist-induced yawning and suppressionof exploration?
A critical view. Psychoparmacology 106:1-13.
9. Van Sweden B,Vanderhoven L, van Erp MG (1994)
Excessive yawning. Acta Neurol Belg 94:150-151
10. Leonhardt M, Abele M, Klockgether T,Dichgans J, Well
M (1999) Pathological yawning (chasm) associated with
periodic leg movements in sleep: cure by levodopa. J.
Neurol 246; 621-622
About the Author
Joanne Hebding is APT Board Liaison to the APT
Communications Committee and an associate editor for
A2Zzz Magazine. A longtime sleep technologist and APT
member, Hebding resides in Miami, Florida.
30
2006-2007 APT
Committee Roster
2006-2007 APT
Board of Directors
COMMUNICATIONS COMMITTEE
Kimberly Burns, Committee
Louie Scalise
Chair
Erby Williams
Kenneth Chapman
Joanne Hebding, Board Liaison
Cynthia D. Mattice, Ex-Officio
Chris Cook
President
J. L. Magee
EXECUTIVE COMMITTEE
President: Cynthia Mattice
President-Elect: Jon Atkinson
Secretary: Cindy Kistner
Treasurer: Bill Rivers
EDUCATION COMMITTEE — CONTINUING EDUCATION CREDITS
Melinda Trimble, Committee
Ashwani Goyal
Chair
Kristine Bresnehan Servidio,
W. Michael Chris, Vice Chair
Board Liaison
Cyndi Hampton
President
Steven Lenik
EDUCATION COMMITTEE — EDUCATIONAL PRODUCTS
Melinda Trimble, Committee
David Wolfe
Chair
Kristine Bresnehan Servidio,
Michael Delayo, Vice Chair
Board Liaison
Christine Magruder
President
Terrance Malloy
E. Katrina Warren
MEMBERSHIP COMMITTEE
Jeffrey Smith, Committee Chair
Joseph Anderson
Iain Boyle
Laree Fordyce
Jane Hodges
Robert Evelyn
Robert Monroe
David Gregory, Board Liaison
President
PROGRAM COMMITTEE
Jeanette Robins, Committee
Chair
Jenny Jacobson
Mary Jones-Parker
Laura Linley
Michael Rizzitiello
Stephen Tarnoczy
Kimberly Trotter
Harry Whitmore
Debbie Akers, Board Liaison
President
REGIONAL ACTIVITIES/GOVERNMENT AFFAIRS COMMITTEE
Mary K Hobby, RRT, Committee Angela Neal,
Chair
Lori Speyrer
Shawn Cole, Committee Vice
Marilyn Swick, Board Liaison
Chair
Cynthia D. Mattice, MS, ExCharlotte Fromer
Officio President
Jennie Hall
STANDARDS AND GUIDELINES
Tina Jenkins, Committee Chair
Elise Franko, Committee Vice
Chair
Dennis Keene
Ginny Rueber
COMMITTEE
Frank Walther
William Eckhardt, Board Liaison
President
DIRECTORS-AT-LARGE
Debbie Akers
Kristine Bresnehan Servidio
William Eckhardt
Terrie Eubanks
David Gregory
Joanne Hebding
Marilyn Swick
APT Directory
Contact Us
If you have questions about any of the following, please
contact the APT National Office: Membership,
Advertising, Billing, Publications’ Circulation, Mailing
Labels, Products, Orders and General Questions.
APT National Office
Christopher Waring
APT Coordinator
One Westbrook Corporate Center
Suite 920
Westchester, IL 60154
Phone 708-492-0796
Fax 708-273-9344
[email protected]
Billing Questions
Phone (708) 492-0796
APTWeb
Website/Technical Issues
E-Mail [email protected]
Editorial Questions
If you have editorial questions, please contact:
A2Zzz Magazine Editorial Office
25 Madison St.
Shillington, PA 19607
Phone 610-796-0788
Fax 781-823-4787
[email protected]
Sleep-Related Organizations
American Academy of Sleep Medicine
One Westbrook Corporate Center, Suite 920
Phone 708-492-0930, Fax 708-492-0943
[email protected]
BRPT Management Office
8201 Greensboro Drive, Suite 300
McLean, VA 22102
Phone 703-610-9020, Fax 703-610-9005
[email protected], www.brpt.org
Committee on Accreditation for Polysomnographic Technology
Education (CoA PSG)
Visit www.caahep.org/accredit.aspx?ID=obtainCredit
for information on the accreditation standards and guidelines, or
contact Dr. Richard Rosenberg at (708) 492-0930.
31
Technical Corner
A2Zzz Technical Corner
BY CYNTHIA MATTICE, MS, RPSGT, APT PRESIDENT
Question
I am preparing an instructional lecture for my sleep center staff to
improve hand hygiene. What facts should be included?
Answer
It is important for staff in a sleep center to adhere to facility guidelines on hand hygiene and glove use. Hand hygiene includes hand washing with soap and water and the use of alcohol-based hand rubs. If
access to a sink for hand washing is not readily available, perhaps designating alcohol-based hand rub as the primary method for hand hygiene
and placing containers in central locations will improve staff compliance.
It is important for the staff to know that gloves do not replace proper
hand hygiene techniques. The technologist should know that wearing
gloves protects the patient from contamination and likewise protects them
from exposure to contaminates. Key to proper use of gloves is to remember to remove gloves after each use. For example, it is not acceptable to
leave the patient hook-up area and answer the phone without removing the
gloves. Gloves do become contaminated during patient hook-up and care
during the study. Perform hand hygiene as soon as gloves are removed.
Sleep technologists can become contaminated by toughing the
patient and the electrodes, sensors and continuous positive airway pressure (CPAP) masks. It is important to demonstrate proper precautions
when caring for multiple patients during a shift in the sleep center.
Studies have shown that the use of alcohol-based hand rubs are effective
in reducing the number of viable bacteria and viruses on hands, require
less time to use, can be made more accessible at the point of care and
32
cause less hand irritation and dryness
with repeated use. It is recommended
that a sufficient amount of alcohol-based
hand rub be applied to all surfaces of the
hands and fingers and rubbed in for at
least 15 seconds before the hands are
dry. Currently, alcohol-based hand rubs
are commercially available.
It is recommended that hand wash- APT President Cynthia Mattice
ing be performed for 15 seconds with
ample soap on all hand and finger surfaces before rinsing. Avoid contamination of hands after hand washing by using a paper towel to turn
off the faucet and other surfaces.
Discuss the following with the staff:
1. What types of patient care activities result in hand contamination?
2. What are the advantages and disadvantages of hand washing and
alcohol-based hand rubs?
3. What is the role of contaminated hands in the transmission of
pathogens and viruses?
The Institute for Healthcare Improvement has developed the “How-to
Guide: Improving Hand Hygiene.” It is available at www.IHI.org. This document is a complete resource on the subject, including assessment
questions and checklists. H
Sleep Arts
Crossword Puzzle
BY EDWIN CINTRON, RPSGT
Movie Review: The
Science of Sleep
BY TERRIE EUBANKS, RPSGT, A2Zzz Magazine SLEEP ARTS
COLUMNIST
he Science of Sleep is the title of a
new movie directed by Michael
Gondry. The film is a playful romantic fantasy set inside the topsy-turvy brain of
Stephane Miroux, played by Gael Garcia
Bernal, an eccentric young man whose
dreams constantly invade his waking life.
An acclaimed music video director,
Gondry compiled a DVD of videos that he
directed including Bjork, Beck, and The
White Stripes. His original screenplay for
Eternal Sunshine of the Spotless Mind
won a 2005 Academy Award.
T
Terrie Eubanks
The Science of Sleep presents an out
of the ordinary look at dream interpretation and its relationship to every
day life. Ghondry explores how the two intertwine and does so in imaginative and bizarre sequences. A modern day Sigmund Freud, the lead
character, Gael, loses himself and his audience somewhere between
REM and awake. Among elaborate sets, puppet-like characters and Pee
Wee Herman style antics, Gondry brings to realization my long held opinion that dreams are too bizarre to replicate on film.
For more than 50 years, there has been an underappreciated science of sleep. Does the misleading movie title lampoon a sleep discipline? Is sleep to be the Rodney Dangerfield in the realm of medicine?
Across
3. Where Kleitman discovered REM
4. Inflammation of the brain
6. RBD
9. Infant’s Sleep/Wake cycle
10. Loss of muscle tone
12. This mammal may only sleep for minutes at a time
15. A list of correlated symptoms
16. soothing sounds
17. A group of four symptoms
18. A bandstop filter
19. Bed accessory
Though sleep may not yet have the respect it deserves, it is more
vastly published throughout the arts and media. The fact that a movie
about sleep and dreams is being so highly promoted is a benefit. After
all, Mr. Dangerfield claimed to “get no respect” but was often in front of
microphone while protesting about it. H
Edwin Cintron
Down
1. Fear of the dark
2. To fall asleep
Solution on page 40!
5. Sleepwalking
6. Charge
7. How air creates a splint
8. Most effective at regulating the Suprachiasmatic Nuclei
11. Where POSTS appear
13. Number of winks to mean sleep
14. Central is not a brain lobe but a __________
15. Nap, in spanish
About the Author
Edwin Cintron, RPSGT is an instructor of Polysomnography at Erwin Technical Center in
Tampa, Florida and has been on the A2Zzz Magazine Editorial Board since 1998. Cintron
was the recipient of the of the 2005 APT Sharon Keenan Award and was the first ever recipient of the APT Dr. Allen DeVilbiss Literary Award in 2002.
About the Author
Terrie Eubanks is a newly-appointed columnist for the A2Zzz Magazine “Sleep Arts Page.”
Because the membership and the sleep field have had a longtime penchant for sleep’s influence on the arts, Eubanks will continue to explore similar topics where sleep inspires literature, music, art and entertainment. Eubanks, a poet herself, is a member of the APT Board
of Directors, and is a sleep technologist that works the night shift near Centralia, IL.
Show you care by
wearing the new…
Sleep Disorders
Awareness Pin
PRESENTED BY THE APT
Order form page 38
33
Questions About Recertification?
Part one of a two-part series on RPSGTs and recertification
Q. Why did the BRPT change the policy to require recertification
every 5 years?
A. The Board of Registered Polysomnographic Technologists (BRPT)
is a credentialing body and as such owes a duty to the public as well as
to RPSGTs. To ensure patient safety it is important for us to make every
attempt to assure that RPSGTs are properly trained and qualified. As
time goes on, every medical profession expands and adapts to new technology and science and the field of sleep technology is no exception.
We are also helping RPSGTs when we protect and promote the credential. State (and in some cases Federal) regulatory decision-makers
increasingly look to validated credentials in making decisions regarding
the practice of many allied health professions including sleep technology.
The BRPT has an obligation to protect, promote and defend the RPSGT
credential and strengthen its value.
Today, an allied health field such as polysomnography must provide
some credible measure of continued competency which is documented
in order to sustain its value. Ultimately, a rigorous exam and a strong
recertification program will benefit the profession of polysomnography
and will help ensure that the RPSGT is the credential of choice for technologists performing sleep studies.
Q. I’m a “grandfathered” RPSGT and someone on my staff is
under the 10-year recertification plan. Do the new recertification policies affect us?
A. Yes! All RPSGTs must now certify every 5 years in order to retain
the use of their credential including those who were previously “grandfathered” or those who were under the 10-year recertification policy.
Unless you already voluntarily “switched-early,” your 5-year recertification
period is effective January 1, 2007. (If you wrote to BRPT in the past
few months requesting an earlyswitch, then your 5-year period
begins from the date you
requested the switch.)
Q. Where can I find a list
of approved courses that offer
continuing education hours?
Required for RPSGT
Recertification = 50 continuing
education hours every 5 years
BRPT recommends earning 10
continuing education hours per
year to meet your total requirement of 50 continuing education hours required in 5 years.
A. At the BRPT web site you
may click on the Recertification
Note: You must earn a miniand Continuing Education butmum of 5 per year, but your
ton and then click on Continuing
total at the end of your 5-year
Education. A link is provided to
recertification period still must
the APT web site where courstotal 50. (BRPT is allowing you
es approved by the APT are listto earn less than 10 some
ed. In addition, the BRPT is
years in order to accommodate
working with other organizathose who have a year or two
tions to expand the courses listwhen circumstances such as illed and is maintaining a list on
ness, family matters, or materthe web site of known creditnity leave, make it difficult to
granting organizations as well
earn 10 in any particular year.
as courses reviewed for applicability to the recertification
hours. Most important to
remember — as long as your hours are earned from activities approved
by a credit-granting organization AND the hours are directly related to
the duties of a sleep technologist, those hours would likely be acceptable
for recertification.
Q. I live in a remote area. Are there ways for me to earn hours
without attending a sleep conference?
A. Yes. For example, the APT offers hours for
reading the A2Zzz Magazine by signing up on their
site so you can get an assessment tool for each
edition. Fees for those who aren’t members of APT
may apply. The link to their page is
www.aptweb.org/CECProgramCalendar.asp. Other
ways of earning hours include in-service or case
study training programs and online courses. If your
institution already holds this kind of session,
encourage administration to pursue obtaining credits from a credit-granting organization for these
meetings. BRPT’s Education Advisory Committee is
working with other organizations to ensure the
expansion of these options as well. Check the
www.brpt.org website for updated listings.
Q. Does it matter how many continuing education hours I obtain each year?
A. Yes! While BRPT recommends that you earn
10 each year during your 5-year recertification
period — thereby accumulating 50 total, be
ß
34
advised that under the new rules, it is required that you earn a minimum
of 5 continuing education hours each year. If at the end of the 5-year
period when the recertification application is reviewed, the minimum of
5 hours per year are not documented, your recertification by continuing
education hours will not be approved. Your option to maintain your credential at that point would be to retake and pass the current RPSGT
examination within 3 months following your recertification date.
Q. What if I do not recertify?
A. If you don’t recertify within ninety days after the date your recertification is due, you will no longer have the right to use the RPSGT credential.
Q. Can I retake the exam to recertify?
A. Yes, absolutely. While the BPRT encourages continuing education
on an ongoing basis, you may recertify by taking and passing the RPSGT
exam. If you choose this option, we recommend you take the exam 6
months before your recertification deadline to allow for any possible
retesting. Normal examination fees will apply under this option.
Q. How should I keep track of my continuing education hours and
what documentation do I need?
A. The BRPT has a form online at our web site that is strictly an
optional sample form that can be used. You do not have to use this form,
it is available if you would like to use it. Normally all that is required for
documentation is a copy of the signed certificate of hours earned. For
courses where only part of the course meets the applicability of being
related to the duties of a polysomnographic technologist, or for courses
where the content is not clear from the certificate copy you should also
attach a course outline or course content document. (use pdfs of cover
of Recertification Guidelines to illustrate, if needed)
More questions about recertification? Look for Part Two of this
series in the next issue of A2Zzz Magazine, or visit the BRPT Web
site at www.brpt.org to read the entire “Recertification Guidelines.”
For more information, call (703) 610-9020, or visit www.brpt.org. H
Q. How do I know if a course or activity is acceptable for RPSGT
continuing education hours?
A. If the activity has been granted hours by the APT, these hours are
acceptable if the activity has been granted hours by another credit-granting organization and the activity is directly related to the duties of a sleep
technologist it should be acceptable.
Policy and Procedure Manual
for Sleep Disorders Centers
APT is proud to present a Policy and Procedure Manual for
Sleep Disorders Centers. At the request of the APT Board of
Directors, the Standards and Guidelines Committee created a
reference manual to assist sleep disorders center personnel in
the development of their own policy and procedure manual.
This manual provides sample forms and policies, job
descriptions and core competencies for the Sleep Technology
Profession. The manual is intended to provide a standardized
guideline in the development of a policy and procedure
manual to quantify service and performance that ultimately
delivers quality patient care.
Order form page 37!
35
NewZzz Briefs
Pro-Tech Releases SleepEx®
SV™ — View, Score,
Interpret, Online... Anywhere™
Mukilteo, WA — Pro-Tech® Services, Inc, the leading manufacturer of
sleep diagnostic sensors, today announced the release of SleepEx SV, sleep
center management software. SleepEx SV is enhanced with additional key
features to meet the needs of discerning sleep lab managers and physicians.
SleepEx SV improves the efficiency of your business by providing you
remote access at anytime to manage your lab. Key features of this software include: online access to patient and staff scheduling for one or
more locations, centralizing your patient and staff database, and secure
data transfer of studies to be scored, interpreted and safely archived.
“We specifically designed SleepEx SV to meet the data management
needs of the sleep lab and help support their ability to turn-around study
results in a timely manner,” said Jim Johnson, President of Pro-Tech
Services, Inc.
SleepEx SV also offers physician over-read management capabilities,
core management reports, secure study storage and archiving, and an
optional DME module with digital signature. For a software demonstration, call 800-919-3900.
For those times your sleep lab is overloaded with studies to score, ProTech now offers scoring services. Visit www.pro-tech.com for more info.
For information on ordering these or other Pro-Tech Services, Inc.
products, visit www.pro-tech.com, or call 800-919-3900.
Classified Ads
Phoenix, AZ
Carl T. Hayden VA Medical Center is seeking candidates for two
Polysomnographic Technologists (Registered Respiratory Therapist)
vacancies in our Outpatient Respiratory Care Department. These
are permanent full-time positions for the night shift only with work
hours from 7:30 p.m. to 8:00 a.m. Excellent benefit package and
competitive salary. VA is an equal opportunity employer. Interested
applicants may obtain an application from: Human Resources
Management Service (05B1), Carl T. Hayden VA Medical Center,
650 E. Indian School Road, Phoenix, AZ 85012. Or call Darcy
Kinslow, at 602-277-5551 x7808.
Resource for CPAP
Patients that
Travel by Air
The American Sleep Apnea Association (ASAA) lists information
regarding security regulations for patients traveling by air.
Fact Sheet: Steps Taken to Ensure New Security Requirements
Preserve and Respect the Civil Rights of People with Disabilities
http://www.sleepapnea.org/news/travel.html
New Sleepmate Education
Facility Opens
Midlothian, VA — Sleepmate® Technologies announces the opening of
a state-of-the-art education facility. Located in our corporate headquarters, the classroom provides a complete environment to obtain certified
education. Additionally, the lab will have a variety of sleep industry equipment from major vendors and a patient hook-up and testing area to provide a complete training facility on the latest in sleep diagnostic practices.
Click on Education at our website (www.Sleepmate.com) for a complete class schedule, or call 800-639-5432. CEC (APT) and CECU
(AARC) included.
Sleepmate® Technologies has been setting the standard for excellence in the sleep diagnostic industry since 1985. Sleepmate® strives to
enhance the capabilities of sleep professionals and the success of
patient diagnostics.
We are committed to meeting the ever-changing needs of sleep professionals as effectively, efficiently and economically as possible. Our
desire to make things better by finding new solutions, new materials and
new systems for delivering state-of-the-art products and services
ensures that we stay one step ahead of the industry.
We Put You First. Because Without You People Don’t Sleep, And
Without Sleep People Don’t Function Well.
36
Barbara Ludwig Cull, RPSGT
Product Order Form
Educational/Technical Order Form
APT National Office
Phone (708) 492-0796, Fax (708) 273-9344
Educational Resources
QUANTITY
MEMBERS
NON-MEMBERS
1003
$325.00
$360.00
1004
$895.00
$895.00
1020
$65.00
$85.00
1021
$40.00
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TOTAL
APT Review Course — 3rd Edition (Individual)
Intense review preparing for the registry exam. Realtime video alongside an electronic presentation.
Includes CD, booklet and review test to complete and return for 15.75 CEC credits.
APT Review Course — 3rd Edition (Institutional)
Intense review preparing for the registry exam. Realtime video alongside an electronic presentation.
Includes CD, booklet and five review tests to complete and return for 15.75 CEC credits per test.
Normal and Abnormal Record Flashcards
Registry Exam Flashcards
Technical References
QUANTITY
MEMBERS
NON-MEMBERS
1140
$225.00
$260.00
1110
$10.00
$15.00
1120
$50.00
$85.00
1130
$60.00
$75.00
1133
$60.00
$75.00
1131
$25.00
$35.00
1132
$60.00
$75.00
TOTAL
APT Policy and Procedure Manual
A reference tool designed to assist sleep disorders center personnel in the development of their
policy and procedure manual. This manual provides sample forms and policies, job descriptions
and core competencies for the Sleep Technology Profession.
Filter Settings and Calibrations
Technical article written by Edwin Cintron, RPSGT.
2003 Demographic, Salary & Educational Needs Survey
Identifies PSG technologist practice environments, technologist characteristics, compensation,
and education.
R&K Scoring Manual Technical Manual
Written by A. Rechtschaffen and A. Kales. Includes standardized terminology, techniques and a
scoring system for sleep stages.
Pediatric Manual of Standardized Terminology
Current interest in infant sleep has made necessary a guide similar in scope to the R&K Scoring
Manual, which applies only to adults. There has been a need for a common system for sleep scoring
in the infant, as most researchers tend to employ diverse modifications of the adult scoring criteria.
Artifact & Troubleshooting Guide
“Sleeping on the Job”
Answers basic questions on site location, design, setup, staffing and more. Offers resources for
locating equipment and supplies and is highlighted by a sample Policy and Procedure manual
*Please note that the APT does not accept purchase orders or orders over the phone. Shipping and handling
charges for orders over six items will be charged based on cost. Orders may be expedited via UPS 2-Day
(where available) based on cost. International shipping is available through the United States Postal Service
and charged based on cost. The APT accepts no responsibility for loss of product.
Shipping and Handling*
$13.00
7.75% Sales Tax (IL residents only)
Total
Shipping & Payment Information
Name:
Shipping To: q Residential Address q Commercial Address
Member Number:
Payment By: q Check (US bank only) q Visa q Mastercard q American Express
Address:
Credit Card Number:
City:
Phone Number:
State
Zip
Verification Code:
Expiration:
Signature:
Rev. 8/06
37
Product Order Form
APT Promotional Item Order Form
APT National Office
Phone (708) 492-0796, Fax (708) 273-9344
APT Promotional Items
QUANTITY
APT Membership Pin
MEMBERS
NON-MEMBERS
2001
$10.00
2003
$10.00
$15.00
2020
$25.00
$30.00
2010S
$40.00
$90.00
2010
$35.00
$85.00
2011
$8.00
$10.00
2021
$35.00
$45.00
TOTAL
Sleep Disorders Awareness Pin
Show you care! Makes a great PSG Technologist Appreciation Week gift.
“Celestial Delectables” Cookbook
Silver Anniversary cookbook.
“Guardian Sleep” Print (Signed)
Limited edition series of 500 color prints (certificate included).
The original painting was rendered in oil and mixed media.
“Guardian Sleep” Print (Unsigned)
“Sentries of the Night” Print
Color print, measures approximately 8-1/2” x 11”.
APT Santa Flag
Display holiday spirit in your sleep lab! Measures 24” X 36”, vibrant colors. While supplies last!
APT Apparel Items
QUANTITY
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NON-MEMBERS
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APT Denim Shirt
High-quality denim shirt featuring the APT logo. Available sizes: S / M / L / XL / XXL / XXXL
2120
$40.00
$45.00
2130
$20.00
$25.00
2140
$35.00
$40.00
APT T-Shirt
High-quality t-shirt featuring the APT logo. Available sizes: S / M / L / XL / XXL / XXXL
APT Sweatshirt
High-quality sweatshirt featuring the APT logo. Available sizes: S / M / L / XL / XXL
*Please note that the APT does not accept purchase orders or orders over the phone. Shipping and handling
charges for orders over six items will be charged based on cost. Orders may be expedited via UPS 2-Day
(where available) based on cost. International shipping is available through the United States Postal Service
and charged based on cost. The APT accepts no responsibility for loss of product.
Shipping and Handling*
$13.00
7.75% Sales Tax (IL residents only)
Total
Shipping & Payment Information
Name:
Shipping To: q Residential Address q Commercial Address
Member Number:
Payment By: q Check (US bank only) q Visa q Mastercard q American Express
Address:
Credit Card Number:
City:
Phone Number:
Rev. 8/06
38
State
Zip
Verification Code:
Signature:
Expiration:
"
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39
SleepLand Calendar
25th Annual Conference on Sleep Disorders in Infancy & Childhood
January 25-27, 2007
The Annenberg Center for Health Sciences will hold this 25th
Anniversary meeting in Rancho Mirage, CA, near Palm Springs. For
more information or to register go to www.5StarMedEd.org/sleepdisorders or for more information, please e-mail [email protected].
2006 Southern Sleep Society Meeting
March 1-4, 2007
29th Annual Meeting will be held at The Francis Marion Hotel, 387 King
Street, Charleston, SC 29403. For more information, please visit
www.southernsleepsociety.org.
Spring Sleep Seminar
March 2-3 2007
Embassy Suites, Rogers, Arkansas. Call for Info 479-527-0471 or email
[email protected].
Pacific Northwest Sleep Association (PNSA) 2007 Biennial Meeting
Spring 2007
For more information, visit www.pnsleep.net.
Focus
April 19-21, 2007
7th annual conference, Opryland Hotel in Nashville, Tennessee. For budgeting purposes, attendees should know that the early registration fee will
be $295 and “significant others” will pay only $150 to come and enjoy the
conference and all that it offers, with their loved one (except for CEU’s). All
attendees who attended the 2006 Focus Conference will automatically be
eligible for a $50 discount off their 2007 registration fee (“significant others” do not receive discount). For more information, visit www.foocus.com.
American Association of Sleep Technologists (formerly the APT)
Annual Meeting
June 10-13, 2007
Minneapolis, MN. More information in Spring 2007.
Sleep 2007 — The 21st Annual Meeting of the Associated
Professional Sleep Societies (APSS)
June 9-14, 2007
Minneapolis, MN. Registration information available Spring 2007. Visit
www.apss.org.
New England Polysomnographic Society (NEPS) Annual Meeting
August 2007
For more information, visit www.nepolysomnographic.org.
World Federation of Sleep Research Societies World Congress 2007
September 1-8, 2007
Carins, QLD, Austrailia. For more information, please visit www.wfsrsms.org.
Montana Regional Sleep Seminar
September 6-8, 2007
Held at the Mansfield Health Education Center in Billings, Montana sponsored by The Sleep Center at St. Vincent Healthcare. The Technologist
Review Course will be back by popular demand. Speakers and topics to
be announced at a later date. For more information, call 1 (866) 4
SNORES or email [email protected].
19th Congress of the European Sleep Research Society
Fall 2008
Glasgow, Scotland. For more information visit: www.esrs.org.
Medtrade Spring 2007
April 24, 2007
The 2007 Medtrade Spring Exposition & Conference is about to heat
things up in Las Vegas! Continuum of Care: April 24th. Reimbursement
Conference. For more information, go to www.medtradespring.com.
25th Anniversary Meeting — SE/SW Regional Association of
Polysomnographic Technologists
May 3-6, 2007
“Sand Man Bring Me A Dream”. Hotel rooms at the Sheraton Oceanfront
Beach Hotel, Virginia Beach, Virginia (800-521-5635) are available at a
discounted rate of $129/night for single or double occupancy plus tax.
Reservations mentioning SE/SW RAPT must be made by 3/15/07 to
receive the group rate. Rooms reserved after that date will be at the current hotel room rates. Registration fees begin at $100.00 and higher for
pre-registrations. The agenda with the proposed CEUs will be available
after 11/1/06. For further information, contact Shalanda Virgil,
[email protected], or visit the website at www.sesw.org.
Crossword Puzzle Solution
40
from puzzle on page 33
Benelux Sleep Congress 2007
May 11-12, 2007
Grand Duchy of Luxemburg, Mondorf-les-Bains, the famous Luxemburg
thermal station, located near the French border. The conference will
focus on Sleep and Stroke, Sleep and Heart, and Sleep and Health. The
congress will be held under the patronage of the European Sleep
Research Society (ESRS), the Societe des Sciences Medicales of
Luxembourg, and the Ministry of Health of Luxemburg. For more information, visit: www.sommeil2007.lu.
New 3rd Edition
New Releases!
APT Review Course CD Sets
An excellent tool for registry board prep or as a review to enhance skills!
Sleep Stage Scoring • Arrhythmia Review
Artifact Recognition & Troubleshooting
Sleep Report Parameters & Calculations
Neurophysiology of Sleep • Nocturnal O2 Titration
For more information go to the APT website at www.aptweb.org
or see the APT product ordering form on page 37
41
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Transcription

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