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9/21/16
1
AnUpdateonAASMScoringRules
DonnaArand,PhD,DABSM,FAASMWrightStateUniversitySchoolofMedicine
KeEeringMedicalCenter
ObjecJves
• BeabletodiscussnewAASMscoringchanges• DifferenJatebetweenadult,pediatricandinfantscoringrules
• Applynewrulesappropriately
AASMScoringChangesEffecJveOctober1,2016
• NewtechnicalspecificaJonsforMovementRules• NewrulesforscoringPLMS• Revisionofscoringofbruxism• Newruleforstagingwhen3stagesarepresentinoneepoch
• ClarificaJononscoringarousalsprecedingtransiJontowake
• NewPediatricandInfantstagescoringrulesandrespiratoryclarificaJons
9/21/16
2
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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3
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
9/21/16
4
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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7
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
9/21/16
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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
9/21/16
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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)
9/21/16
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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
9/21/16
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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