polysomnography and polygraphy€¦ · polygraphy raphael heinzer werner strobel. which type of...
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Polysomnography andPolygraphy
Raphael Heinzer
Werner Strobel
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Which type of study ?
Corral-Penafiel J et al.: Eur Respir Rev 2013; 22:312-24
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PSG: the newest reference of OFSP / BAG
Cited from the Swiss Sleep Society 2001 (!!), on the actual website of OFSP / BAG
Not further specified on Tarmed, KLV. Legally only few regulationsor specifications forperforming PSG’s
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Polygraphie: how it should be done by ENT doctors according to OFSP / BAG
Schweizerische Gesellschaft für Otorhinolaryngologie 2015, source document on the website of BAG / OFSP
Improved Watchpat™ from 2017 acceptable ?
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Recommended Reading
Journal of Clinical Sleep Medicine, Vol. 8, No. 5, 2012, p 597-619
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How are you scoring ?
2012 Rules ?
2007 Rules ?
Chicago 1999 ?
Your own Rules ?
Do you mention it on the report ?
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How are you scoring ?
2012 Rules 2007 Rules ?
Chicago 1999 ?
Your own Rules ?
Mention it on the report !
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Recommended sensors
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Alternative sensors
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10 seconds is 10 seconds
Apnoea and hypopnoea start «from the nadirpreceding the first breath that is clearly reducedto the beginning of the first breath thatapproximates baseline breathing amplitude»
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Scoring apneas
• Drop in peak signal excursion by ≥ 90 % of pre-event baseline (ideally using an oronasal thermal sensor)
• The duration of the ≥ 90 % drop in sensor signal is ≥ 10 sec
→ no desaturation needed, no arousal needed
Note: if a portion of a respiratory event that would otherwisemeet criteria for hypopnea meets criteria for apnea, the entireevent should be scored as an apnea. The duration of the event isfrom the nadir in flow to the start of the first breath thatapproximates baseline breathing (new)
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Apnea ?
17 sec
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11 sec
4 Central apneas ? Bradypnea ?
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Apnoea ?
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6.7 sec
10.4 sec
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10.2 sec
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Obstructive Apneas (and 1 mixed apnea)
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What is the difference ?
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Obstructive ? Central ? Mixed ?
No clear definition of the minimum or maximum lengthof the obstructive part in mixed apnea !!
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Scoring Hypopnoes
peak signal excursion drops by ≥ 30 % from baseline(preferably nasal pressure) AND
the duration of the ≥ 30 % drop is ≥ 10 sec AND
there is a ≥ 3 % oxygen desaturation from pre-event baseline OR the event is associated with an arousal
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2007 Hypopnea 2012
Nasal pressure signal drop by ≥ 30% from baseline
Duration of this drop for ≥ 10 sec ≥ 4 % O2 desaturation from pre-
event baseline
Alternative
Nasal pressure signal drop by ≥ 50% from baseline
Duration of this drop for ≥ 10 sec ≥ 3 % O2 desaturation from pre-
event baseline or event associatedwith an arousal
Nasal pressure signal drop by ≥ 30% from baseline
Duration of this drop for ≥ 10 sec ≥ 3 % O2 desaturation from pre-
event baseline or event associatedwith an arousal
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To differentiate between obstructive andcentral hypopnoeas
For an obstructive hypopnoea at least one of thefollowing criteria must be met:
Snoring during the event
Increased inspiratory flattening of the nasal pressuredevice compared to baseline
Thoracoabdominal paradox occurs during the eventbut not during pre-event breathing
For a central hypopnoea, none of these criteria must bepresent
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> 10 secNasal pressure ↓≥ 3 % Desat.Hypopnoea
> 10 secNasal pressure ↓≤ 3 % Desat.??
Hypopnoea ?
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> 10 secNasal pressure ↓≥ 3 % Desat.Hypopnoea
> 10 secNasal pressure ↓no Desat.no ArousalNo Hypopnoea
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Hypopnea ?
Length > 10 sec30 % drop in nasal pressure ???Only 2 % saturation drop !
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Length- Amplitude- Desaturation Arousal→ no hypopnea
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Apnea? Dropped bei 30 % frombaseline ?
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Hypopneoas ? Length > 10 secDecreased amplitude ?Arousal ??
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Cheyne-Stokes-Respiration
Score as CSR, if there are
≥ 3 episodes of consecutive central apneas and / orhypopneas separated by a crescendo-decrescendo change in breathing amplitude with a cycle length > 40 sec
And
≥ 5 central apneoas / hypopnoeas per hour of sleepover 2 hours of monitoring
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Cycle: 62 sec
Cheyne-Stokes-Breathing ?
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?
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Cheyne-Stokes-Breathing ?
Cycle length 38 – 46 secNo crescendo – decrescendo pattern→ No Cheyne-Stokes-Breathing
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Cheyne-Stokes-Breathing ?
Cycle length ≈ 20 sec«apneas» partially < 10 sec
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Central hypopnoeas ?
Length > 10 sec Flow reduced No desaturation → Arousal ?
No snoring No flattening No thoracoabdominal paradox
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42 years old, female, daytimesomnolence, ESS 14. BMI 42 kg/m2
Obstructive sleep apnea withREM-hypoventilation ?
Bilevel ventilation ?
Interstitial lung disease Daytime PaCO2 4.3 KPa Nocturnal capnography:
peak TcCO2 6.3 KPa
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Scoring Hypoventilation
Score hypoventilation if either
• There is an increase in the arterial PaCO2 (or TcCO2) to a value > 7.3 KPa for ≥ 10 minutes
OR
• There is ≥ 1.3 KPa increase in PaCO2 (or surrogate) during sleep (in comparison to an awake supinevalue) to a value ≥ 6.6 KPa for ≥ 10 min
→ no hypoventilation without CO2-monitoring
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Bad or missing signal: what are you doing ?
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Is the x-flow helpful ?
All events > 10 secAll events with desaturation > 3 %No snoring, no paradox breathingApnea vs. hypopnea: difficult→ score as hypopnea ??
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