Polysomnography in the evaluation of sleep-disordered breathing in adults
- David Schulman, MD, MPH, FCCP
David Schulman, MD, MPH, FCCP
- Associate Professor of Medicine
- Associate Division Director for Education Pulmonary, Allergy, Critical Care and Sleep Medicine
- Emory University School of Medicine
Sleep-disordered breathing consists of several separate disorders, including obstructive sleep apnea (OSA), central sleep apnea (CSA), both with and without Cheyne-Stokes respiration, and sleep-related hypoventilation, in which abnormal breathing events during sleep are associated with adverse clinical outcomes. While each of these disorders has a characteristic presentation, history and physical examination alone are insufficient to make a definitive diagnosis, and formal sleep testing is required for diagnosis [1,2].
The current reference standard for formal evaluation of sleep-disordered breathing is attended polysomnography (PSG). Rules governing the performance and scoring of PSG are published and reviewed on an ongoing basis by the American Academy of Sleep Medicine (AASM), and accredited sleep laboratories are required to follow these guidelines .
This topic will review the technical specifications, scoring, and summary terms used to characterize sleep-disordered breathing in adults undergoing attended PSG. The clinical features and diagnosis of sleep-related breathing disorders are reviewed separately. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults" and "Central sleep apnea: Risk factors, clinical presentation, and diagnosis" and "Clinical manifestations and diagnosis of obesity hypoventilation syndrome".)
Home sleep apnea testing and the role of PSG for the evaluation of nonrespiratory sleep disturbances are also reviewed separately. (See "Home sleep apnea testing for obstructive sleep apnea in adults" and "Polysomnography in the evaluation of abnormal movements during sleep" and "Polysomnography in the evaluation of parasomnias and epilepsy".)
The performance of polysomnography (PSG) requires monitoring of a number of physiologic signals, all of which are relevant in the assessment of sleep-disordered breathing (table 1). These signals are typically displayed in an organized montage for ease of viewing during study review (waveform 1).
- Myers KA, Mrkobrada M, Simel DL. Does this patient have obstructive sleep apnea?: The Rational Clinical Examination systematic review. JAMA 2013; 310:731.
- Hoffstein V, Szalai JP. Predictive value of clinical features in diagnosing obstructive sleep apnea. Sleep 1993; 16:118.
- Berry RB, Brooks R, Gamaldo CE, et al. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, version 2.4, American Academy of Sleep Medicine, Darien IL 2017.
- Norman RG, Ahmed MM, Walsleben JA, Rapoport DM. Detection of respiratory events during NPSG: nasal cannula/pressure sensor versus thermistor. Sleep 1997; 20:1175.
- Chervin RD, Aldrich MS. Effects of esophageal pressure monitoring on sleep architecture. Am J Respir Crit Care Med 1997; 156:881.
- Caples SM, Rosen CL, Shen WK, et al. The scoring of cardiac events during sleep. J Clin Sleep Med 2007; 3:147.
- Bonnet MH, Doghramji K, Roehrs T, et al. The scoring of arousal in sleep: reliability, validity, and alternatives. J Clin Sleep Med 2007; 3:133.
- Ruehland WR, Rochford PD, O'Donoghue FJ, et al. The new AASM criteria for scoring hypopneas: impact on the apnea hypopnea index. Sleep 2009; 32:150.
- Loredo JS, Clausen JL, Ancoli-Israel S, Dimsdale JE. Night-to-night arousal variability and interscorer reliability of arousal measurements. Sleep 1999; 22:916.
- Cherniack NS, Longobardo GS. Cheyne-Stokes breathing. An instability in physiologic control. N Engl J Med 1973; 288:952.
- Bonnet MH, Arand DL. EEG arousal norms by age. J Clin Sleep Med 2007; 3:271.
- American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014.
- Guilleminault C, Stoohs R, Clerk A, et al. From obstructive sleep apnea syndrome to upper airway resistance syndrome: consistency of daytime sleepiness. Sleep 1992; 15:S13.
- Sulit L, Storfer-Isser A, Kirchner HL, Redline S. Differences in polysomnography predictors for hypertension and impaired glucose tolerance. Sleep 2006; 29:777.
- Punjabi NM, Caffo BS, Goodwin JL, et al. Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med 2009; 6:e1000132.
- RECORDED SIGNALS
- Sleep staging
- Respiratory airflow
- Respiratory effort
- Pulse oximetry
- Cardiac rhythm
- IDENTIFICATION AND SCORING OF EVENTS
- General principles
- Respiratory effort-related arousals
- Cheyne-Stokes respiration
- INTERPRETATION AND SUMMARY MEASURES
- Measures of sleep quality
- Measures of sleep-disordered breathing severity
- - Apnea-hypopnea index
- - Respiratory disturbance index
- - Degree of hypoxemia
- Presentation of summary data