An Update on AASM Scoring Rules - …montanasleepsociety.com/Portals/0/9-29 1000 - 1045 AASM...

9/21/16

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AnUpdateonAASMScoringRules

DonnaArand,PhD,DABSM,FAASMWrightStateUniversitySchoolofMedicine

KeEeringMedicalCenter

ObjecJves

•  BeabletodiscussnewAASMscoringchanges•  DifferenJatebetweenadult,pediatricandinfantscoringrules

•  Applynewrulesappropriately

AASMScoringChangesEffecJveOctober1,2016

•  NewtechnicalspecificaJonsforMovementRules•  NewrulesforscoringPLMS•  Revisionofscoringofbruxism•  Newruleforstagingwhen3stagesarepresentinoneepoch

•  ClarificaJononscoringarousalsprecedingtransiJontowake

•  NewPediatricandInfantstagescoringrulesandrespiratoryclarificaJons

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ScoringStage2ClarificaJons•  EpochsfollowingstageN3arescoredstageN2ifnotmeetcriteriaforstageN3,WorREM

•  Endstage2iftransiJontostageW,N3,REMorarousaltoLAMF

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

Stage2withBodyMovement

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

Amajorbodymovementfollowedbyasloweyemovementisstage1,otherwisestage2

Amajorbodymovementfollowedbyasloweyemovementisstage1,otherwisestage2

ScoringStage3ClarificaJons

•  StageN3>20%ofepochisslowwaveacJvity•  KcomplexesareconsideredslowwavesiftheymeetdefiniJonofSWacJvity

•  PathologicalwaveformsthatmeetSWacJvitysuchasthosegeneratedbymetabolicencephalopathiesandepilepJcacJvityarenotconsideredslowwaveacJvityofsleep

•  SleepspindlesmaypersistinstageN3•  EyemovementsnottypicallyseeninstageN3

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ScoringStageREMClarificaJon

•  ScoreREMinsleepepochsprecedingstageREMintheabsenceofREMsifALLthefollowingarepresent:–  EEGshowsLAMFwithoutKcomplexorsleepspindles–  ChinEMGlowatstageRlevel–  Nointerveningarousal–  SEMsa^erarousalorstageWareabsent

•  A^erdefinitestageREM,conJnuetoscorestageREMinabsenceofREMsifallthefollowingmet:–  EEGshowsLAMFwithoutKcomplexorsleepspindles–  ChinEMGislowatstageRlevelformajorityofepoch–  Nointerveningarousal

StageRrulestakeprecedenceoverstageN2rulesifepochmeetsstageREMcriteria.

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

StartofREM

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

StartofREM

StageRrulestakeprecedenceoverstageN2rulesifepochmeetsstageREMcriteria.

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

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Scoringwith>3Stagesinoneepoch

•  If>3stagesinasingleepochdonotincludewake,assignthepredominantsleepstage

•  If>3stagesoccurinasingleepochandincludewake– Scorewakeifgreaterthan50%ofepochiswake– Scorethepredominantsleepstage(N1,N2,N3,orR)ifwakeis<50%ofepoch

SchemaJcof3StagesinOneEpoch

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

SleepStageScoringinChildren>2monthspost-term

•  StagesW,N1,N2,N3,R,N(NREM)•  ScorestageNwhen

–  allepochsofNREMhavenosleepspindles,Kcomplexesorhighamplitude0.5-2Hzslowwaves

•  ScorestageN2andNwhen–  someepochshavespindlesorKcomplexesscoreasStage2.IfotherNREMepochshavenoSWSinmorethan20%ofepoch,scoreStageN.

•  ScorestageN2,N3andNwhen–  Ifsomeepochshave>20%SWS,scoreStageN3.IfotherNREMepochshavenospindlesorKcomplexes,scoreasStageN

•  ScorestageN1,N2,N3andRwhen–  NREMhasspindles,KcomplexesandSWSthenscoreNREMininfantasStageN1,N2orN3asinolderchildoradult

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ScoringStageWinChildren•  ScorestageWwhenmorethan50%ofepochcontainseitherorboth– Ageappropriateposteriordominantrhythm(slowerinchildren)overoccipitallobe(alpharhythmwithEC)

– FindingsconsistentwithStageW•  Eyeblinks•  Readingeyemovements•  RapideyemovementswithnormalorhighchinEMG

ScoringStageN1inChildren

•  IfPDRpresent,ScoreStageN1ifPDRisaEenuatedorreplacedbylowampmixedfrequency(LAMF)>50%ofepoch

•  IfnoPDR,scoreStageN1beginningwiththeearliestofANYofthefollowing:–  4-7Hzwithslowingofbackgroundby>1Hzfromwake–  Sloweyemovements–  Vertexsharpwaves– Hypnogogichypersynchrony(burstshighamp3-4.5Hz)– Diffuseoroccipitaldominanthighamprhythmic3-5Hz

ScoreStageN2,N3andREMinChildrenSameasAdult

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InfantScoring•  0-2mospostterm(37-48wksconceptualage)•  Stages:–  StageW–  StageN(NREM)–  StageR(REM),–  StageT(TransiJonal)

•  StageTscoredifcharacterisJcsofStageRandN•  Scorebasedonbehavior,regularityofrespiraJonEEGandEOGpaEerns

•  RegularityorirregularityofrespiraJonmostreliableforscoring•  Firstsleepepocho^enREM•  TracealternantpaEerncommon

Stage Behavior Respira0on EEG EOG ChinEMG

W EyesOpenFeedingCrying

Irregular Lowvoltageirregularormixed

REMs,blink present

N EyesclosedReducemvtvs.wakeSucking

Regular TracealternateHighvoltslowMixedvoltageSpindles

EC,noEMs Present

R EyesclosedSmallmovements

Irregular Lowvoltageirregularormixed

EC,REMs Low,transientmvt

CharacterisJcsofInfantStages

StageWinInfant

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StageNinInfant

•  Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

StageNinInfantTraceAlternant

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

EEGinInfant

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

W,stageR

stageN

W,stageR

StageN

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ScoringStageRinInfants

•  StageRhas4ormoreofthefollowingincludingirregularrespiraJonandREM:–  LowchinEMG–  EyesclosedandatleastoneREM–  IrregularrespiraJon– Mouthing,sucking,twitches–  Nosleepspindles

•  ScoreRinconJguousepochswithoutremsifallarepresent:–  EEGismixedfrequency,nospindles,notracealternate–  ChinEMGislow–  Nointerveningarousal

StageRinInfants

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

ScoringStageT

•  ScoreasstageN,RorWifonlyonecharacterisJcisdiscordantforstate

•  ScorestageTifepochcontainseither– 3NREM+2REMcharacterisJcs– 2NREM+3REMcharacterisJcs

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StageT(transiJonal)

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

AnteriorTibialisElectrodePlacements

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

Recommended

FlexorDigitorium

ExtensorDigitorium

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

OpJonal

OpJonal

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ScoringPLMS• IndividualLMduraJonisbetween0.5-10sec• FirsttwoPLMSarecountedasonebecause<5secseparaJon• PeriodlengthtothesecondLMismeasuredfromonsetofthefirstLMingroupconsideredtobeasingleLM.

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

AssociaJonofPLMSandArousal

simultaneous overlap

<0.5secseparaJon

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

ArousalsandPLMs<10secApartWhenPLMsoccur<10secapartandeachisassociatedwithanarousal,onlythefirstarousalshouldbescored(assumingitisprecededbyatleast10secofsleep).BothLMsarescoredbutonlyonearousal

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LMsandInterveningWake•  WhenawakeperiodlasJng<90sec.separatesaseriesofLMs,theLMsprecedingwakecanbeincludedwiththesubsequentLMsaspartofaseries.(recommended)

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

RhythmicMovementDisorder•  Timesynchronized-videoPSGfordiagnosis(recommended)

•  Paraspinalmuscleselectrodeplacement(opJonal)

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

REMSleepBehaviorDisorder

•  MusthaveJmesynchronizedaudio-equippedvideoPSGforcomplexmotoracJvityandvocalizaJons(recommended)

•  DiagnosisofRBDrequireseither:– DemonstraJonofabehavioralorvocalepisode– CharacterisJcclinicalhistoryofdreamenactment andREMsleepwithoutatonia

•  PSGshowssustainedmuscleacJvityinREMand/orexcessivetransientmuscleacJvityinREM

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MasseterElectrodePlacementforDetecJngBruxism

OpJonal-canusechinEMG

Berry,RBetal.TheAASMManualfortheScoringofSleepandAssociatedEvents:Rules,TerminologyandTechnicalSpecificaJons,Version2.3Darien,IL,AASM2016

Bruxism

• 

ArousalsDuringWake

•  Arousalsoccurringduringanawakeepochbetween"lightsout"and"lightson"shouldbescoredandusedforcomputaJonofthearousalindex.

•  The10secondsofstablesleeprequiredpriortoscoringanarousalmaybeginintheprecedingepoch,includingaprecedingepochthatisscoredasstageW.(recommended)

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Two Arousals during Wake

LE - A1

RE-A1

EMG

C4-A1

Oz-A1

V5

ArousalPrecedingWake•  AnarousalmaysJllbescoredifitimmediatelyprecedesa

transiJontostageW.Thatis,boththearousalandtransiJontowakearescored(recommended)

LE - A1

RE-A1

EMG

C4-A1

Oz-A1

V5

RespiratorySensors(Adults&Peds)Parameter Recommended Alterna0veifRecFails

Apnea oronasalthermalsensor • Nasalpressuretransducer• RIPsum• RIPflow

Hypopnea Nasalpressuretransducer • Oronasalthermister• RIPsum• RIPflow• 2thoracoabdominalRIPbelts

• AHduringPAP PAPdeviceflowsignal

RespiratoryEffort esophagealmanometry2thoracoabdominalRIPbelts

•  Snoring(opJonal)

MicrophonePiezoelectricsensorNasalpressuretransducer

• HypovenJlaJon(opJonal)

ArterialPCO2TranscutaneousPCO2EndJdalPCO2

• HypovenJlaJonw/CPAP(opJonal)

ArterialPCO2TranscutaneousPCO2

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RespiratoryScoringClarificaJons

•  IfaporJonofarespiratoryeventthatwouldmeetcriteriaforhypopneameetscriteriaforapnea,scoreapnea

•  Ifapneaorhypopneabeginsorendsinanepochscoredsleeptheneventisscored

•  IfapneaorhypopneaoccursenJrelyduringawakeepoch,itisnotscored

ApneasandHypopneasthatCrossEpochsScoreapneasandhypopneasduringwakeifprecedingepochissleep

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ApneaDuringWake

ScoringofHypopneasinAdults•  Dropof>30%frompre-eventbaselineinnasalpressureexcursionor(PAPdeviceflow)oralternaJvehypopneasensor

•  DuraJonofdropis>10sec•  Thereisa>3%oxygendesaturaJonfrompre-eventbaselineoreventisassociatedwithanarousal(recommended)

•  Thereisa>4%oxygendesaturaJonfrompre-eventbaseline(acceptable)

•  ScoringhypopneasascentralorobstrucJveisopJonal

CLARIFICATIONCentralapneaswithinarunofCSRarescoredasindividualapneasCyclelengthisfrombeginningofcentralapneatotheendofthecrescendo/decrescendophase(orstartofnextcentralapnea)

CHYENESTOKESRESPIRATIONDefiniJonrequiresboth:•  >3consecuJvecentralapneasand/orcentralhypopneas

separatedbycrescendoanddecrescendobreathingandcyclelength>40sec

•  >5centralapneasandorcentralhypopneasperhourofsleepwithcrescendo/decrescendobreathingin>2hrs

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CHEYNESTOKESRESPIRATIONCLARIFICATION

•  IndividualcentralapneasinarunofCSRarescored•  Cyclelengthisfrombeginningofcentralapneatothe

endofthecrescendo/decrescendophase(orstartofnextcentralapnea)

ScoringObstrucJveApneainChildren(<18y.o.but>13canuseadultcriteria)

•  Signaldrop>90%inoronasalthermalsensorfrompre-eventbaseline

•  LastsatleasttheduraJonof2breathsduringbaselinebreathingANDisassociatedwithrespiratoryeffortthroughout

enJreperiodofabsentairflow

ScoringCentralApneainChildrenandInfants

AirflowSignaldrop>90%frombaselineandabsenteffortthroughouteventANDoneofthefollowing

•  Eventlasts>20sec•  LastsatleasttheduraJonof2breathsduringbaselinebreathingANDisassociatedwithanarousalor>3%arterialoxygendesaturaJon

•  EventlastsaleasttheduraJonof2breathsduringbaselinebreathingandisassociatedwithadecreaseinHR<50bpmfor>5secor<60bpmfor15sec(infantsunder1yrofage)

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ScoringMixedApneainChildren

•  MixedapneaisatleasttheduraJonof2breathsduringbaselinebreathingANDisassociatedwithabsentrespiratoryeffortduringpartoftheeventandpresenceofinspiratoryeffortinanotherporJonregardlessofwhichporJoncamefirst.

ScoringHypopneasinChildren

ScoreanhypopneaifALLofthefollowingaremet:•  Peaksignaldropby>30%ofpre-eventbaselineusingnasalpressure,PAPdeviceoralternaJve

•  The>30%droplasts>2breaths•  Thereisaa>3%oxygendesaturaJonfrompre-eventbaselineoreventisassociatedwithanarousal

PeriodicBreathingClarificaJon•  >3episodesofcentralpausesinrespiraJonlasJng>3secseparatedby<20secofnormalbreathing

•  Individualcentralapneasarealsoscored