Review of Sleep Stage

Scoring and Discussion of

New AASM Rules

Joyce Black RPSGT, CRT

Clinical Sales Trainer
Philips Respironics

Staging Sleep

 Sleep Staging used to be done according to “A Manual

of Standard Terminology, Technques and Scoring
System for Sleep Stages of Human Subjects” by
Rechtschaffen and Kales

 Today sleep stage scoring is done according to “The

AASM Manual for the Scoring of Sleep and Associated
Events”

The New Rules

  The AASM Manual For

The Scoring Of Sleep
& Associated Events
  Terminology

  Technical

Specifications
  Rules

  www.AASMnet.org

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 Organization of the Manual

  Intent & Development process

  Key to terminology
  Parameters to be reported for PSG
  Technical & Digital specifications
  Visual rules (adult & children)

Intent & Development Process

  Standardized review of evidence and method of

consensus
  Intended to better reflect current scientific evidence and
expertise in the field
  Considers changes in technology available now vs 1968
  Analog to Digital recordings

  Four channels recorded to sixteen or more!

  Availability of new transducers and synchronized

video as standard features

  Need to define how we view data on “monitors”

Only 9 of 118 rules could be

supported by Level I or II
evidence!
Key to terminology
  Procedural Notes
  Standard (7)

  Based on level 1 evidence or overwhelming level 2

  Guideline (2)
  Level 2 evidence or consensus of level 3
  Consensus (100)
  Agreement reached via a consensus process
  Adjudication (9)
  When there was insufficient evidence and no

consensus
  Issues of minor clarification or additions to rules

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 Sections of the Manual
  Visual Rules
  Arousal Rules
  Cardiac Rules

  Respiratory Rules (adult and children)

  Glossary

VISUAL RULES

Signal Generation for EEG

  Measurements are done for
precise placement of the
electrodes
  Sites are cleaned to achieve
the best signal and adherence
  The electrical activity produced
by the body is very low voltage
  This electrical activity needs to
be filtered and amplified

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 EEG Electrodes – Modified 10/20
  Used for Sleep Staging
  Occipital Leads are best to
show alpha activity and sleep
onset
  Frontal Leads are best to
show Delta Activity – slow
wave sleep
  Central leads are main
scoring leads
  M1and M2 are silent
electrodes used as references

EOG Left and Right Electro-oculogram

ROC

LOC

Eye Blinks
Electro-oculography picks up the
inherent voltage of the eye. The cornea
has a positive voltage output, while the
retina has a negative voltage output.
Positive is downward deflection
Negative is upward deflection

Look Left
Waveform
Orientation

Eyes are monitored to differentiate REM Sleep and slow rolling eye movements

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Look Right
Waveform
Orientation

Look Down
Waveform
Orientation

Look Up
Waveform
Orientation

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Cross Your Eyes
Waveform
Orientation

If you see this the

polarity is wrong on
one of the channels.

Don’t Even Think This is Correct!

Waveform
Orientation

If you see this the

polarity is wrong on
one of the channels.

Electromyelogram EMG

Mental and Submental EMG

records muscle Tone. This is
a mandatory recording
parameter for staging sleep
(REM vs. NREM).
Yawns, swallows, and tooth
grinding may also increase
muscle tone.

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 Waveforms

  Scoring of Sleep Stages needs a

minimum of:
  EEG leads - central, frontal, and occipital
leads (F4 – M1, C4 – M1, O2 – M1)
  EOG leads - left eye and right eye

  EMG - one submental / one mental EMG

channel

Parameters That Effect The Signal

  Type of Amplifier
  Sampling Rate
  CPS or Hertz
  Sensitivity
  Low Pass Filter
  High Pass Filter
  Notch Filter
  Polarity
  Calibration

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 Visual Rules

Visual Brain
Stage Comment
Waveform Region
8-13hz, >0.5 sec, <50µv
Alpha Rhythm W Occipital
Attenuates with EO - usually
Vertex Sharp N1 Central < 0.5 sec, stands out

K Complex N2 Frontal Total duration > 0.5 sec

Sleep Spindle N2 Central 11 – 16 Hz (10-14 Hz Usual)

Slow (Delta) Waves N3 Frontal 0.5 – 2 Hz

Sawtooth waves REM Central 2 – 6 Hz

Sleep Spindle K complex

Filter Settings

Channel LFF HFF Sensitivity Min. Samp.

Rate
EEG
EEG 0.3 Hz
0.3 Hz 35 Hz 77uV/mm
35 Hz uV/mm 200 Hz
200 Hz
EOG
EOG 0.3 Hz
0.3 Hz 35 Hz
35 Hz 7 uV/mm
7 uV/mm 200 Hz
200 Hz
EMG 10 Hz 70 Hz 2 uV/mm 200 Hz
EMG 10 Hz 70 Hz 2Varies
uV/mmto see 200 Hz
good signal
EKG 1Hz 70 Hz 20 uV/mm 200 Hz
Snore 10 Hz 100 Hz 7 uV/mm 200 Hz
Air / Eff/ 0.1
Airflow 0.1 Hz
Hz 15
15 Hz
Hz 7 7uV/mm
uV/mm 25
25 Hz
Hz
Effort

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 Technical & Digital Specifications
  Filter settings are listed as Low & High frequency
filtering in Hz (cycles per second)

  Filter settings have several foot notes for why choice

was made and when acceptable alterations should
occur e.g.
  EEG LFF 0.3 Hz, HFF 35 Hz recommended

  HFF > 35 Hz should be considered and

sampling rate should be at least 3X the HFF

setting for more detailed EEG analysis (e.g.
spikes)

Visual Rules
  Epoch based
  30 second epoch
  Majority of the epoch rules
  If 2 or more stages co-exist on a single epoch, it is

staged as the sleep stage comprising the majority of

the epoch
  Sleep onset is the start of the first epoch scored as any
stage of sleep
  New stage 1 (N1) definition for non-alpha generators is
included

Visual Rules
  Stages 3 & 4 are combined
  Movement time (MT) has been eliminated
  3-minute rule for stage 2 is eliminated
  Frontal leads recommended for scoring slow wave
(N3) sleep
  Alternative EEG and EOG derivations are proposed

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 Wake

• >50% of each epoch contains Alpha activity (8-13 Hz)

• No Alpha
• Eye blinks at a frequency of 0.5 – 2 Hz
• Reading eye movements
• Irregular conjugate rapid eye movements with normal or relatively
high submental EMG muscle tone

Stage N1

• Slow rolling eye movements in the EOG channels

• Low amplitude, mixed frequency activity (4-7 cps.)
• Vertex sharp waves (< 0.5 seconds) stands out from background
• There may be Alpha activity within <50% of the epoch.

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 Stage N2

• Background EEG is Theta (3-7 cps.)

• One or more K-Complexes (=/ > 0.5 sec)
• One or more trains of Spindles (11-16 Hz commonly 12-14 Hz)
]

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 Stage N3

•  Slow waves frequency of 0.5 to 2 Hz and peak to peak

amplitude of 75 uV measured over frontal lobe
•  = / > 20% of each epoch and must contain Delta activity

Stage R

•  Conjugate rapid eye movements

•  Low tonic submental EMG
•  Sawtooth waves (often serrated looking 2-6 Hz waveforms)
•  Mixed frequency EEG

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Let’s Do Some Scoring!

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