i

Evincepub Publishing
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First Published by Evincepub Publishing 2019
Copyright © Dr. Tripat Deep Singh 2019
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ISBN: 978-93-90197-55-2
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 Basic Polysomnography
An Algorithmic approach to Sleep Scoring

Dr. Tripat Deep Singh

MBBS, MD (Physiology), RPSGT, RST
International Sleep Specialist
(World Sleep Federation Program)

Disclosure: Author is employee of Philips Respironics Singapore

Copyright© Tripat Deep Singh 2020

Cover page photo: Photo by Fabian Oelkers on Unsplash

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iv
 Preface
X
As a student and teacher of Polysomnography for 14yrs, I learnt a lot from my students.
A lot happens in the classroom beyond teaching. Classroom taught me how to simplify
the complex material for students to understand.

This book is a compilation of all I learnt in the classroom while teaching and what was
created on the whiteboard to simplify things. This book is not a substitute for AASM
Scoring manual. It is just my approach to scoring Sleep and associated events. This book
is not for teaching everything about Polysomnography but it is about an “Algorithmic
Approach” to sleep scoring and associated events.

In this book, Expert scorers will find a refreshing new approach to Scoring Sleep and
associated events and beginners in the field of Sleep technology will find a guided and
methodical approach to learn about Scoring Sleep and associated events.

After writing the “Algorithms” presented in this book, I realized that I have embarked on
a journey which will keep me busy for a long time to improve/enhance the algorithms as
the field advances.

I dedicate this book to my teachers- Dr. K. Ravi who taught me to ask the right scientific
questions, to Late Dr. Vijayan who showed faith in me as a Sleep Medicine student, to
Late Dr. Susheela Veliath who honed my teaching skills, to Dr. H. N. Mallick who allowed
me to be creative in the field of Sleep and to Dr. Teofilo Lee Chiong from whom I learnt
the art of simplifying the things and to all the students and teachers that have enriched
me over all these years.

I am grateful to Dr. Deepak Shrivastava for critically reviewing the content several times
and giving valuable feedback to improve/enhance the content of this book and also for
providing the EKG tracings to be included in this book.

I am indebted to my family for loving and supporting me at every step. I owe it to them
for allowing me to do what I liked the most even if it meant not following the conventional
paths.

Dr. Tripat Deep Singh

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 Contents
X
Chapters Page
No.
Chapter 1: Introduction 1-2

Chapter 2: Bio Signals to record Sleep 3-4

Chapter 3: PSG appearance of Sleep Waveforms 5-11

Chapter 4: PSG features of Sleep Stages 12-17

Chapter 5: Algorithmic approach to Sleep Staging 18-51

a. Algorithm 1: Transitioning from Stage W to different
Sleep stages
b. Algorithm 2: Continuation of Stage N1 and Transition
from Stage N1 to other Sleep Stages
c. Algorithm 3: Continuation of Stage N2 and Transition
from Stage N2 to other Sleep Stages
d. Algorithm 4: Continuation of Stage N3 and Transition
from Stage N3 to other Sleep Stages
e. Algorithm 5: Continuation of Stage R and Transition
from Stage R to other Sleep Stages

Chapter 6: Algorithmic approach to scoring Arousals 52-55

a. Algorithm 6: Scoring of Arousals

Chapter 7: Patient Sensors to record Respiratory Events 56

Chapter 8: Algorithmic approach to scoring Respiratory 57-67

Events
a. Algorithm 7: Respiratory Event Scoring for Level-1
Sleep Study. Based on AASM 2012 Recommended
definition of Hypopnea

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 b. Algorithm 8: Respiratory Event Scoring for Level-1
Sleep Study. Based on AASM 2012 Acceptable
definition of Hypopnea
c. Algorithm 9: Respiratory Event Scoring for Level-3
Sleep Study. Based on AASM 2012 Recommended
definition of Hypopnea when Sleep is not recorded
d. Algorithm 10: Pediatric Respiratory Event Scoring for
Level-1 Sleep Study. Based on AASM 2012
Recommended definition of Hypopnea

Chapter 9: Patient sensors to record Limb Movements 68

Chapter 10: Algorithmic approach to scoring Periodic Limb 69-74

Movements in Sleep (PLMS)
a. Algorithm 11: Scoring Periodic Limb Movements in Sleep
(PLMS)

Chapter 11: Algorithmic approach to scoring Cardiac Events 75-78

a. Algorithm 12: Diagnostic approach for
Tachyarrhythmias
b. Algorithm 13: Diagnostic approach for
Bradyarrhythmias

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 Dr. Tripat Deep Singh

Chapter 1
Introduction
X
While scoring the sleep study one is supposed to analyze and score the following
parameters before Sleep report can be generated -

a. Sleep Staging
b. Arousal scoring
c. Respiratory event scoring
d. Movement event scoring
e. Cardiac event scoring

To master the above concepts, you would take the following approach in this book-
a. First learn about some basics about how to record Sleep, Respiration, Limb
movements and Cardiac activity
b. Then you will learn about PSG features of Sleep waveforms and different Sleep
stages
c. Finally, you will go through the “Algorithmic” approach to score Sleep and
associated events
d. I have developed “13 Algorithms” and we will try to analyze Sleep study data
through these algorithms using Polysomnography tracings

While scoring the Sleep study I advise to take a 4-pass approach-

a. First, score Sleep stages and Arousals in 30sec epochs

b. Second, score Respiratory events in 2min or 5min window
c. Thirdly, score Movement events in 2 min window
d. Fourth, score Cardiac events in 30 sec epochs

How to use this Book?

If you are a beginner in the field of Sleep Scoring, my advice to you is as follows-

1. Understand the contents of “Chapter 3 & 4” very well before going to “Chapter 5”
2. While going through “Algorithms 1-5”, do not get intimidated by their look. Keep
the following scheme in your mind- Whenever you go to an epoch to determine its
Sleep Stage, first rule out an arousal, then Stage R, then Stage N2 and lastly Stage
N3.

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Basic Polysomnography

We will learn my algorithmic approach to score these events in coming chapters.

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 Dr. Tripat Deep Singh

Chapter 2
Bio-Signals to record Sleep
X
To study Sleep, one need to record the following bio-signals-

1. Electroencephalography (EEG)
2. Electrooculography (EOG)
3. Chin Electromyography (EMG)

Electroencephalography (EEG)

 EEG electrodes are placed based on 10-20 International EEG electrode placement
System
 Minimum 3 EEG electrodes need to be placed on the patient during Level-1 and
Level-2 Sleep study
 American Academy of Sleep Medicine (AASM) recommends- one Frontal lead (F4),
one Central Lead (C4) and one Occipital lead (O2)
 Back up EEG electrodes may be placed on F3, C3 and O1
 Frontal lead is recommended to record K-Complex and Delta Waves
 Central lead is recommended to record Sleep Spindles, Vertex Sharp Wave, Saw
Tooth Wave
 Occipital lead is recommended to record Alpha Waves
 Reference lead are placed on left mastoid process- M1/A1 and Right Mastoid
process- M2/A2

Electrooculography (EOG)

 Recommended EOG Derivations

 Right EOG (REOG) is placed 1cm out and above the right outer canthus
 Left EOG (LEOG) is placed 1cm out and down from left outer canthus
 Both are referenced to M2
 REOG is sometimes labelled “E2” and LEOG as “E1”

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Basic Polysomnography

Chin Electromyography (EMG)

 AASM recommends minimum 3 electrodes to be placed on the chin

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 Dr. Tripat Deep Singh

Chapter 3
PSG appearance of Sleep Waveforms
X
Sleep waveforms in EEG

Characteristic Sleep EEG waveforms are- Alpha, Low Amplitude Mixed Frequency
(LAMF), Sleep Spindle, K-Complex, Saw Tooth Waves, Vertex Sharp Wave and Slow
Waves.

EEG waveforms are defined based on following features-

1. Amplitude: It simply means height of the wave. It indicates the amount of voltage
measured and its units are microvolts (µV)
2. Frequency: the number of waves per second, usually abbreviated Hz (for Heinrich
Hertz)
3. Shape: How the wave looks like- smooth and sinusoidal or sharp, regular or
irregular
4. Distribution: Which part of the scalp is it located- Frontal, central, occipital.
5. Duration: How long the wave lasts.

Alpha LAMF Sleep K-Complex Slow Saw Vertex

waves Spindle waves Tooth Sharp
waves Wave

Amplitude Not Low Not Not Defined 75 µV Not Not

Defined Defined Defined Defined

Frequency 8-13H 4-7Hz 11-16Hz <2Hz 0.5-2Hz 2-6Hz 2Hz

Shape Regular Irregular sinusoidal Negative Not Like Pointed

and deflection Defined teeth of and
Sinusoidal followed by handsaw sharp
Positive
deflection

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Basic Polysomnography

Distribution Occipital All EEG Central Frontal Frontal Central Central

EEG leads leads EEG Leads EEG leads EEG EEG EEG
leads Leads Leads
Duration Not Not 0.5sec 0.5sec Not Not <0.5sec
Defined Defined Defined Defined

Table 1: Different EEG waveforms characteristics

PSG appearance of EEG Waveforms

Alpha waves

Fig 1: This is a 30sec epoch. The box in above pic highlights alpha waves, which are seen
in frontal and central EEG leads as well in addition to occipital EEG leads

Sleep Spindle

Fig 2: This is a 30 sec epoch. Background EEG is LAMF and the two boxes at 12 and 15sec
respectively highlight the Sleep Spindle. In this case Sleep Spindles are seen in frontal

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 Dr. Tripat Deep Singh

EEG leads as well in addition to Central EEG leads. EOG does not show any eye
movement.

K-Complex

Fig 3: First pic shows a K-complex. It is characterized by a negative deflection (red line in
second pic) followed by positive deflection (green line in 2nd pic)

Fig 4: This is a 30sec epoch. There are 2 K-Complex in above pic, at 22 sec and between
27-28sec (Red boxes). Duration of these K-complexes is >0.5sec. K-complex can have
varied morphology. Appreciate that amplitude of K-Complex is maximal in Frontal EEG
leads and it decreases in Central EEG leads. EOG does not show any eye movement.
Background EEG is LAMF.

Fig5: This figure explains how to measure the duration of K-Complex (Red line shows
that duration of this K-Complex is 1sec). It should be 0.5sec.

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Basic Polysomnography

Slow Waves

Fig 6: This is a 30sec epoch. All EEG leads show Slow waves. EOG does not show any eye
movements. EEG waveforms are reflected in EOG.

Fig 7: This figure explains how to measure the amplitude of Slow waves. This is a 30sec
epoch. Slow waves have an amplitude of 75µV. Reference lines have been drawn with
help of software for F3A2 channel, top line is +37.5µV and bottom line is -37.5µV. Any
waveform that touches both the lines have an amplitude of 75µV.

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 Dr. Tripat Deep Singh

Saw Tooth Waves

Fig 8: Saw Tooth waves. 30sec epoch. Note that saw tooth waves appear just before burst
of REM in EOG.

Fig 9: Saw Tooth waves. 30sec epoch. Note that saw tooth waves appear just before burst
of REM in EOG.

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Basic Polysomnography

Vertex Sharp Wave

Fig 10: This is a 30sec epoch. This pic shows Vertex Sharp wave between 29-30sec (Red
Box). Please note that its appearance is pointed and duration is <0.5sec. It is present in
central channels but appears in Frontal channels as well. Background EEG is LAMF and
there are no eye movements in EOG.

Sleep Waveforms in Electrooculogram (EOG)

There are four main types of EOG waveforms in PSG-

1. Slow Eye Movements (SEM)- Slow rolling, round waveforms with initial deflection
lasting >0.5sec

Fig 11: REOG and LEOG show slow rolling eye movements. Also shown is how to
measure the time of initial deflection, which is measured from the base to the top of the
wave (Red Lines)

2. Rapid Eye Movements (REM)- fast rise, sharp waveforms with initial deflection
lasting <0.5sec

Fig 12: REOG and LEOG showing Rapid Eye Movements. Also shown is how to measure
the time of initial deflection, which is measured from the base to the top of the wave (Red
line)
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 Dr. Tripat Deep Singh

3. Reading Eye Movements- Conjugate movements with an initial slow phase

followed by rapid phase in the opposite direction

Fig 13: LEOG and REOG shows Reading Eye Movements. In the orange box, red line
shows the slow wave and green line shows the rapid phase in the opposite direction.

4. Eye Blinks- Conjugate vertical eye movements with a frequency of 0.5-2Hz

Fig 14: Eye Blinking

Let’s learn in next chapter how to use these waveforms to identify different Sleep stages.

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Basic Polysomnography

Chapter 4
PSG features of Sleep Stages
X
AASM has given the following nomenclature for Sleep Staging in Adults-

1. Non Rapid Eye Movement Sleep (NREM)- It has three substages-

a. Stage N1
b. Stage N2
c. Stage N3

2. Rapid Eye Movement Sleep (REM)- It is referred to as Stage R

3. Wakefulness- It is referred as Stage W

While scoring, there are three concepts regarding any Sleep Stage-

a. Scoring first epoch of any Sleep Stage

b. Continue scoring a particular Sleep Stage after identifying the first epoch
c. Stop scoring a particular Sleep Stage and shift to another stage

PSG features of Stage W (Epoch 1)

a. Scoring first epoch of Stage W

1. EEG: In EEG, Alpha waves should be present for more than 15sec of the epoch

Optional Features of Stage W

2. EOG: Presence of the following support Stage W-

a. Rapid Eye Movements (REM), or

b. Eye Blinking, or
c. Reading Eye Movements, or

3. Chin EMG: High. It is always higher than Sleep stages N1, N2, N3 and REM

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 Dr. Tripat Deep Singh

b. Continue scoring Stage W: as long as Alpha waves are seen for >15sec in the epoch.
If Alpha waves are not seen, presence of REM, Eye Blinking or Reading Eye
Movements support the Stage W
c. Stop Scoring Stage W- When scoring criteria for Stage N1, Stage N2, Stage N3 or
Stage R are met, stop scoring Stage W

Epoch 1: Stage W. 30sec epoch. EEG: Alpha waves present prominently in occipital leads
(O1A2 & O2A1) for almost 30sec. EOG: Eyes closed and Slow Eye Movements (SEM)
present, Chin EMG: High.

Sleep onset: It is defined as appearance of any stage of Sleep other than Stage W

PSG features of Stage N1 (Epoch 2)

a. Scoring first epoch of Stage N1

1. EEG: In EEG, alpha waves should be replaced by Low Amplitude Mixed Frequency
(LAMF) waves for >15sec without Sleep spindles or “K-complex unassociated with
arousal”

Supporting criteria

2. EOG: SEM present or no eye movements. REM should be absent

3. EMG: Chin EMG tone decreases as compared to wakefulness
4. EEG: Vertex sharp wave may be present

b. Continue scoring Stage N1: After scoring first epoch of Stage N1, continue scoring
Stage N1 as long as EEG is LAMF without Sleep spindles or “K-complex

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Basic Polysomnography

unassociated with arousal” and EOG does not show REM or Slow waves are not
present for >6sec.
c. Stop scoring Stage N1: When scoring criteria for Stage W, Stage N2, Stage N3 or
Stage R are met, stop scoring Stage N1

Epoch 2: Stage N1. 30sec epoch. Previous epoch was Stage W. In this epoch, EOG: Shows
SEM, EEG: Alpha activity is replaced with LAMF for 24sec, EMG: Chin EMG tone is high
and has not decreased compared to Stage W. This epoch is scored as Stage N1 because
alpha activity is replaced with LAMF for >15sec without sleep spindle or K-Complex and
no REM is present in EOG.

PSG features of Stage N2 (Epoch 3)

a. Scoring First epoch of Stage N2:

1. EEG: There will be two scenarios-

1. Scenario 1: If Sleep Spindle or “K-Complex not associated with arousal” is

present in the first half of the epoch, then score the current epoch as Stage N2.

2. Scenario 2: If Sleep Spindle or “K-Complex not associated with arousal” is

present in the second half of the epoch, then score the next epoch as Stage N2
if in next epoch EEG shows LAMF activity with or without Sleep Spindle or
“K-Complex not associated with arousal” or no Slow waves >6sec, EOG shows
no REM and there is no arousal

2. EOG: No eye movements

3. EMG: Chin EMG is decreased compared to Stage W and Stage N1

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 Dr. Tripat Deep Singh

Epoch 3: Stage N2. 30sec epoch. Previous epoch was Stage N1. Sleep Spindle is present in
the first half of this epoch.

b. Continue scoring Stage N2:

Score any epochs following the Epoch 3 as Stage N2 if-

1. EEG: Shows LAMF activity with or without Sleep Spindle or “K-Complex not
associated with arousal” or Slow waves for >6sec. EEG does not show any arousal.
2. EOG: Shows no REM or no eye movements
3. EMG: Chin EMG tone remains low
4. Epoch with criteria for termination of Stage N2 scoring does not appear (Stage W,
Stage N3, Stage R, Arousal or Major body movement followed by SEM)

c. Stop scoring Stage N2:

1. When scoring criteria for Stage W, Stage N3 or Stage R are met

2. Also, if there is an Arousal in EEG which is not followed by Sleep Spindle or
“K-Complex not associated with arousal” stop scoring Stage N2 and change to
Stage N1 if EEG is LAMF without Slow waves >6sec and EOG does not show
REM.
3. Major Body Movement flowed by SEM

PSG features of Stage N3 (Epoch 4)

a. Scoring first epoch of Stage N3

1. EEG: Shows Slow waves for 6 or >6sec of the epoch
2. EOG: Shows no eye movements. EEG waves are sometimes reflected in EOG
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Basic Polysomnography

3. EMG: Chin EMG is low as compared to Stage W, N1 or N2

Epoch 4: Stage N3. 30sec epoch.

b. Continue scoring Stage N3: As long as an epoch have >6sec of Slow waves, continue
scoring Stage N3
c. Stop scoring Stage N3: When Slow waves are not present for >6sec and scoring
criteria for Stage N2, Stage R or Stage W are met

PSG features of Stage R (Epoch 5)

a. Scoring first epoch of Stage R: All 3 of following should be present-

1. EEG: LAMF activity

2. EOG: Presence of Rapid Eye Movements (REM)
3. EMG: Chin EMG tone is very low as compared to Stage W, N1, N2 or N3

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 Dr. Tripat Deep Singh

Epoch 5: Stage REM. 30sec epoch. EEG shows LAMF activity, EOG shows REM and chin
EMG is very low.

b. Continue scoring Stage R

Once you start scoring Stage R, score all subsequent epochs as Stage R even in absence of
REM if-

1. EEG: Shows LAMF activity without Sleep Spindle and K-Complex unassociated
with arousal.
2. EOG: REM may or may not be present
3. EMG: Chin EMG remains low comparable to previous Stage R epochs.
4. Criteria for termination of Stage R are not met.

c. Stop Scoring Stage R: Stop scoring Stage R when the epochs fulfilling criteria for
other sleep stages are present in absence of REM in EOG or Chin EMG is elevated.

Let’s learn the algorithmic approach to score different Sleep stages recorded during the
PSG.I have found the algorithmic approach to do Sleep staging quite easy for the students
to grasp the key concepts. Next chapter will take you through an algorithmic approach
for scoring Sleep and associated events.

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Basic Polysomnography

Chapter 5
Algorithmic Approach to Sleep Staging
X
In this chapter you will go through 5 different algorithms for doing scoring for Stage W,
Stage N1, Stage N2, Stage N3 and Stage R and transition to other sleep stages.

The start point of every algorithm is marked by green box. Always start from the green box
and then follow the algorithm.

The end points are marked by blue boxes. Whenever you reach a blue box, go to the respective
algorithm of the Sleep stage shown in the box, eg: if you were following the algorithm of
Stage W and end up in a blue box stating Stage N1, then you will go to the algorithm for Stage
N1 and follow it further for Sleep staging. You will need to switch between different
algorithms while doing Sleep staging.

When you are in Stage N2 or Stage R, there can be couple of different scenarios when you
go to the next epoch. The Green box in the algorithms for Stage N2 and Stage R diverge
into these different scenarios. You will need to identify the waves present in the epoch
and then accordingly follow the appropriate scenario.

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 Dr. Tripat Deep Singh

Algorithm 1: Transitioning from Stage W to different Sleep stages

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Basic Polysomnography

“Algorithm 1” -Example 1

Let’s learn to apply below part of “Algorithm 1” to PSG tracing in Fig 1

Let’s take the part of “Algorithm 1” shown on the

left-hand side and try to apply the algorithmic
approach to PSG tracings along the red arrows to
understand scoring Stage W. (Fig 1)

Fig 1: Stage W. 30sec epoch. EEG: Alpha waves present prominently in occipital leads
(O1A2 & O2A1) for almost 30sec. EOG: Eyes closed and Slow Eye Movements (SEM)
present, Chin EMG: High.

Following the algorithm above, the epoch in fig 1 is scored as Stage W because in EEG,
Alpha waves in Occipital leads are present for >50% of the epoch.

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 Dr. Tripat Deep Singh

“Algorithm 1” -Example 2

Let’s try to apply this part of the “Algorithm 1” to

PSG tracing in Fig 2 along the red arrows to
understand “Scoring of Stage W”.

Fig 2: Stage W. 30sec epoch. EEG: Alpha waves not present, EOG: Eyes open and Reading
Eye movements and Blinking present; Chin EMG: High.

Following the algorithm above, the epoch in fig 2 is scored as Stage W even in absence of
Alpha activity because Blinking in EOG supports Stage W.

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Basic Polysomnography

“Algorithm 1” -Example 3

Let’s try to apply below part of “Algorithm 1” to PSG tracing along the red arrows to
understand scoring “First epoch of Stage N1 after Stage W”. (Fig 3 & 4)

Let’s start from Stage W shown in Fig 3.

Fig 3: Stage W. 30sec epoch. Previous epoch was Stage W. This epoch is scored as Stage
W because alpha waves are present for >15sec.

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 Dr. Tripat Deep Singh

Next Epoch in Fig-4 is contiguous with epoch in Fig 3 and fig 4 epoch is scored as Stage
N1 following the algorithm above because-

a. EEG shows LAMF>50% of the epoch, and

b. EOG does not show REM and chin tone is not low and is comparable to epoch
scored as Stage W in Fig 3, and
c. No Sleep Spindle or “K-Complex unassociated with arousal” present in the first or
2nd half of the epoch
d. EEG does not show >6sec of Slow waves, and

Fig 4: Stage N1. 30sec epoch.

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Basic Polysomnography

Algorithm 2: Continuation of Stage N1 and Transition from Stage N1 to other Sleep

Stages

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 Dr. Tripat Deep Singh

“Algorithm 2” -Example 1

Let’s try to apply below part of “Algorithm-2” along the red arrows to understand rules
for “Continuing scoring Stage N1”. (Fig 5 & 6)

Let’s start from Stage N1 shown in Fig 5.

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Basic Polysomnography

Fig 5: Stage N1. 30sec epoch. Previous epoch was Stage N1 (Fig 4). In this fig, EEG: LAMF
in entire epoch, EOG: Shows SEM, EMG: Chin EMG tone has decreased compared to
Stage W (Fig 3). This epoch is scored as Stage N1 because LAMF is present in entire epoch
without sleep spindle or “K-Complex unassociated with arousal” or Slow waves >6sec and
no REM is present in EOG and previous epoch was Stage N1 (Fig 4)

Next Epoch in Fig-6 is contiguous with epoch in Fig 5, it is scored as Stage N1 following
the algorithm above because-

a. EEG is LAMF in whole epoch and EOG does not have REM and EEG have No
Arousal, and
b. There is no Sleep spindle or “K-Complex unassociated with arousal” in the EEG
in first part of the epoch, and
c. There is “K-Complex unassociated with arousal” in the EEG in second part of the
epoch, and
d. There is no >6sec of Slow waves

Fig 6: Stage N1. 30sec epoch. Previous epoch was Stage N1 (Fig 5).

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 Dr. Tripat Deep Singh

“Algorithm 2” -Example 2

Let’s try to apply below part of the “Algorithm 2” to PSG tracing along the red arrows to
understand rules for “Termination of scoring Stage N1”. (Fig 7 & 8)

Let’s start from Stage N1 shown in Fig 7.

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Basic Polysomnography

Fig 7: Stage N1. 30sec epoch. Previous epoch was Stage N1. In this fig, EEG: LAMF in
entire epoch, EOG: Shows SEM, EMG: Chin EMG tone has decreased compared to Stage
W. This epoch is scored as Stage N1 because LAMF is present in entire epoch without
sleep spindle or “K-Complex unassociated with arousal” or Slow waves >6sec and no
Arousal. There is no REM present in EOG and previous epoch was Stage N1.

Epoch in Fig 8 is contiguous with epoch in Fig 7. Epoch in Fig 8 is scored as Stage N2
following the algorithm because-

a. EEG is LAMF and there is no arousal

b. EOG does not have REM even though chin tone
is little decreased
c. There is a sleep spindle and “K-Complex
unassociated with arousal” in EEG in the first part
of the epoch
d. EEG does not have >6sec of Slow waves

Therefore, epoch in Fig 8 is scored as Stage N2

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 Dr. Tripat Deep Singh

Fig 8: Stage N2. 30sec epoch. Previous epoch was Stage N1 (Fig 7).

“Algorithm 2” -Example 3

Let’s try to apply this part of the “Algorithm 2” to

PSG tracing along the red arrows to understand
rules for “Termination of scoring Stage N1”. (Fig 8
& 9)

Let’s start from Stage N1 shown in Fig 8.

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Basic Polysomnography

Fig 8: Stage N1. 30sec epoch. Previous epoch was Stage N1. In this fig, EEG: LAMF in
entire epoch, EOG: Shows SEM, EMG: Chin EMG tone has decreased compared to Stage
W. This epoch is scored as Stage N1 because LAMF is present in entire epoch without
sleep spindle or “K-Complex unassociated with arousal” or Slow waves >6sec and no
Arousal. There is no REM present in EOG and previous epoch was Stage N1.

Next epoch in Fig 9 is contiguous to epoch in fig 8. It is scored as Stage R following the
algorithm because-

1. EEG is LAMF
2. EOG shows REM
3. Chin tone is low compared to Stage N1 (Fig 8)

Therefore, epoch in fig 9 is scored as Stage R

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 Dr. Tripat Deep Singh

Fig 9: REM. 30sec epoch. Previous epoch was Stage N1 (Fig 8).

After scoring Stage R we need to go to the previous epoch (Fig 8) following the algorithm
and need to look for 4 things-

1. Is EEG LAMF without sleep spindle and “K-complex unassociated with arousal”?
2. Does EEG have any Arousal?
3. Is chin EMG low and comparable to Stage R?
4. No SEM following arousal or Stage W?

When we go to previous epoch which was Stage N1 (Fig 8), we find that-

a. EEG LAMF without sleep spindle

and “K-complex unassociated with
arousal”
b. EEG have no arousal
c. But chin EMG is not low and is
not comparable to Stage R
d. SEM are present but not following an arousal or Stage W

All the four criteria are not met and we will not change the stage of the previous epoch.
Following next step in the algorithm, we will go back to epoch in Fig 9 and continue
scoring Stage R.

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Basic Polysomnography

Algorithm 3: Continuation of Stage N2 and Transition from Stage N2 to other Sleep

Stages

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 Dr. Tripat Deep Singh

“Algorithm 3” -Example 1

Let’s try to apply below part of the “Algorithm-3” to PSG tracings along the red arrows to
understand “Continue scoring Stage N2”. (Fig 10 & 11)

Let’s start from Stage N2 in Fig 10.

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Basic Polysomnography

Fig 10: Stage N2. 30sec epoch. Previous epoch was Stage N1.
Next epoch in Fig 11 is contiguous to epoch in Fig 10. We will continue scoring Stage N2
following the algorithm above because-

a. EEG is LAMF and there is

no Arousal
b. EOG does not have REM
and chin tone has not
decreased compared to the
previous epoch
c. EEG does not have Sleep
Spindle or “K-complex
unassociated with arousal” in
first half but there is a Sleep
Spindle towards the end of the
epoch.
d. EEG does not show >6sec
of Slow waves

Epoch in Fig 11 is scored as

Stage N2.

Fig 11: Stage N2. 30sec epoch. Previous epoch was Stage N2 (Fig 10).

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 Dr. Tripat Deep Singh

Next epoch in Fig 12 is

contiguous to epoch in Fig 11.
Now, when we go to next epoch
(Fig 12) and apply this part of
the “Algorithm-3” along red
arrows, we continue scoring
Stage N2 because-

a. EEG is LAMF and there is

no Arousal
b. EOG does not have REM
and chin tone is decreased
compared to the previous
epoch
c. EEG have a “K-complex
unassociated with arousal” in
the first and 2nd half of the
epoch.
d. EEG does not show >6sec
of Slow waves

Epoch in Fig 12 is scored as Stage N2.

Fig 12: Stage N2. 30sec epoch. Previous epoch was Stage N2 (Fig 11).

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Basic Polysomnography

“Algorithm 3” -Example 2

Let’s try to apply below part of the “Algorithm-3” to PSG tracings along the red arrows to
understand “Terminating scoring of Stage N2”.

Let’s start with Stage N2 in Fig 13.

Fig 13: Stage N2. 30sec epoch. Previous epoch was Stage N2 (Fig 11)

Next epoch in Fig 14 is contiguous to epoch in Fig 13. In fig 14 epoch, we will terminate
scoring Stage N2 and score it Stage N1 following the algorithm above because-

a. EEG have an arousal in the first

half of the epoch
b. After arousal, EEG is LAMF
without Sleep spindle or K-Complex
unassociated with arousal”
c. EOG does not have REM

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 Dr. Tripat Deep Singh

d. EEG does not have Slow waves >6sec

Fig 14: Stage N1. 30sec epoch. Previous epoch was Stage N2 (Fig 13).

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Basic Polysomnography

“Algorithm 3” -Example 3

Let’s try to apply below part of the “Algorithm-3” to PSG tracings along the red arrows to
understand “Continuation of scoring Stage N2”.

Let’s start with Stage N2 in Fig 15.

Fig 15: Stage N2. 30sec epoch. Previous epoch was Stage N2 (Fig 11)

Next epoch in Fig 16 is contiguous to epoch in Fig 15. Continue to score Stage N2 in
epoch in Fig 16 by applying the above algorithm because-

a. EEG shows an Arousal in 2nd half

of the epoch
b. Before arousal, EEG is LAMF
without sleep spindle. There is a “K-
Complex associated with arousal” in
2 part of the epoch
nd

c. EEG does not have >6sec of Slow waves before the arousal
d. EOG does not have REM
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 Dr. Tripat Deep Singh

Fig 16: Stage N2. 30sec epoch. Previous epoch was Stage N2 (Fig 15).

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Basic Polysomnography

Algorithm 4: Continuation of Stage N3 and Transition from Stage N3 to other Sleep

Stages

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 Dr. Tripat Deep Singh

Algorithm 4” -Example 1

Let’s try to apply below part of the “Algorithm-4” to PSG tracings along the red arrows to
understand “Continuation of scoring Stage N3”.

Let’s start with Stage N3 in Fig 17.

Fig 17: Stage N3. 30sec epoch.

Next epoch in Fig 18 is contiguous to epoch in Fig 17. Next epoch in Fig 18 is scored as
Stage N3 following the above algorithm because-

a. EEG shows >6sec of Slow waves (Red underlined waves in Fig 18)

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Basic Polysomnography

Fig 18: Stage N3. 30sec epoch.

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 Dr. Tripat Deep Singh

“Algorithm 4” -Example 2

Let’s try to apply below part of the “Algorithm-4” to PSG tracings along the red arrows to
understand “Termination of scoring Stage N3”.

Let’s start from Stage N3 in Fig 19.

Fig 19: Stage N3. 30sec epoch.

Next epoch in Fig 20 is contiguous to epoch in Fig 19. Next epoch in Fig 20 is scored as
Stage R following the above part of “Algorithm 4” because-

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Basic Polysomnography

a. EEG does not show >6sec of Slow waves

b. EEG is LAMF and no Arousal
c. EOG shows REM
d. Chin tone has decreased

Epoch in Fig 20 is scored as Stage R.

Fig 20: Stage R. 30sec epoch.

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 Dr. Tripat Deep Singh

Algorithm 5: Continuation of Stage R and Transition from Stage R to other Sleep Stages

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Basic Polysomnography

“Algorithm 5” -Example 1

Let’s try to apply below part of the “Algorithm-5” to PSG tracings along the red arrows to
understand “Continuation of scoring Stage R”.

Let’s start from Stage R in Fig 21.

Fig 21: Stage R. 30sec epoch. Previous epoch was Stage N2. It is Stage R because EEG
have LAMF, EOG have REM and chin EMG tone is low. In EEG, there is no arousal or
>6sec of Slow waves.

Next epoch in Fig 22 is contiguous to epoch in Fig 21. Next epoch in Fig 22 is scored as
Stage R following the above part of “Algorithm 5” because-

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 Dr. Tripat Deep Singh

a. EEG is LAMF without Sleep spindle or “K-complex unassociated with arousal”

and no arousal
b. EOG have REM
c. Chin tone is low and comparable to previous epoch in Fig 21

Epoch in Fig 22 is scored as Stage R.

Fig 22: Stage R. 30sec epoch. Previous epoch was Stage R (Fig 21).

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Basic Polysomnography

“Algorithm 5” -Example 2

Let’s try to apply below part of the “Algorithm-5” to PSG tracings along the red arrows to
understand “Continuation of scoring Stage R”.

Let’s start from Stage R in Fig 23.

Fig 23: Stage R. 30sec epoch. Previous epoch was Stage R (Fig 21).

Next epoch in Fig 24 is contiguous to epoch in Fig 23. Next epoch in Fig 24 is scored as
Stage R following the above part of “Algorithm 5” because

a. EEG have LAMF activity without Sleep Spindle or “K-Complex unassociated with
arousal”, there is no Arousal in first or second half of the epoch and no >6sec of
Slow waves

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 Dr. Tripat Deep Singh

b. EOG have no REM

c. Chin EMG tone is low and comparable to previous epoch of Stage R in Fig 23

Epoch in Fig 24 is scored as Stage R.

Fig 24: Stage R. 30sec epoch. Previous epoch was Stage R (Fig 23).

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Basic Polysomnography

“Algorithm 5” -Example 3

Let’s try to apply below part of the “Algorithm-5” to PSG tracings along the red arrows to
understand “Termination of scoring Stage R”.

Let’s start from Stage R in Fig 25.

Fig 25: Stage R. 30sec epoch. Previous epoch was Stage R (Fig 24)

Next epoch in Fig 26 is contiguous to epoch in Fig 25. Next epoch in Fig 26 is scored as
Stage N1 following the above part of “Algorithm 5” because-

a. EEG have arousal in the first half which is followed by SEM. After arousal EEG is
LAMF activity without Sleep spindle or “K-Complex unassociated with arousal”.
EOG does not show REM.

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 Dr. Tripat Deep Singh

Epoch in Fig 26 is scored as Stage N1.

Fig 26: Stage N1. 30sec epoch. Previous epoch was Stage R (Fig 25)

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Basic Polysomnography

Chapter 6
Algorithmic Approach to scoring Arousals
X
Algorithm 6: Scoring of Arousals

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 Dr. Tripat Deep Singh

“Algorithm 6” -Example 1

Let’s try to apply below part of the “Algorithm-6” to PSG tracings along the red arrows to
understand “Scoring Arousal in Stage NREM Sleep”.

Epoch in Fig 27 have One

Arousal (Red Box) following
the above part of “Algorithm”
because -

a. Sleep Stage is Stage N2

b. There is sudden change in
EEG frequency in the range of
alpha activity lasting >3sec
c. There is >10sec of stable
sleep before the EEG frequency
change

Therefore, the frequency

change in epoch in Fig 27 is
scored as Arousal.

Fig 27: Arousal in Stage N2. 30sec epoch. Previous epoch was Stage N2 (Fig 1).

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Basic Polysomnography

“Algorithm 6” -Example 2

Let’s try to apply below part of the “Algorithm-6” to PSG tracings along the red arrows to
understand “Scoring Arousal in Stage REM Sleep”.

Epoch in Fig 28 have

One Arousal (Red Box)
following the above
part of “Algorithm”
because -

a. Sleep Stage is Stage R

b. There is sudden
change in EEG
frequency in the range of
alpha activity lasting
>3sec
c. There is >10sec of
stable sleep before the
EEG frequency change,
and
d. Chin EMG is elevated along with frequency change >1sec

Therefore, the frequency change in epoch in Fig 28 is scored as Arousal.

Fig 28: Arousal in Stage R. 30sec epoch. Previous epoch was Stage R.

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 Dr. Tripat Deep Singh

“Algorithm 6” -Example 3

Let’s try to apply below part of the “Algorithm-6” to PSG tracings along the red arrows to
understand “Not Scoring Arousal in Stage REM Sleep”.

Epoch in Fig 29 have

no Arousal (Red Box)
despite having EEG
frequency change in
alpha range >3sec
preceded by >10sec of
stable sleep
following the above
part of “Algorithm”
because –

a. Chin EMG is
not elevated >1sec
concurrently with
change in EEG
frequency

Fig 29: Stage R. 30sec epoch. Previous epoch was Stage R. There is no arousal in this epoch

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Basic Polysomnography

Chapter 7
Sensors to record respiratory events
X
Following Respiratory parameters are recorded during a routine Sleep study-

Respiratory Parameter Sensor Clinical Importance

Oronasal Thermal Sensor To define Apnea

Airflow
Nasal Pressure Transducer To define Hypopnea

Respiratory Effort Respiratory Inductance Helps to differentiate

Plethysmography (RIP) Belts. Obstructive from Central
One on Thorax and one on event
Abdomen

Oxygen Saturation Finger Pulse Oximetry Helps to assess

desaturation severity

Snoring Microphone or Nasal Clinical symptom of OSA

Pressure Transducer or CSA

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 Dr. Tripat Deep Singh

Chapter 8
Algorithmic Approach to scoring Respiratory
Events
X
Algorithm 7: Adult Respiratory Event Scoring for Level-1 Sleep Study. Based on AASM
2012 Recommended definition of Hypopnea.

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Basic Polysomnography

“Algorithm 7”- Example 1

Let’s try to apply below part of the “Algorithm-7” to PSG tracing in Fig 30 along the red
arrows to understand “Scoring of Obstructive Apnea (OA)”.

In Fig 30, there are 3 OA

following the above part of
“Algorithm 7” because-

a. Airflow amplitude has

decreased by 90% on
oronasal thermal sensor
(Flow), and
b. Duration of drop in
amplitude is 23 sec for OA1,
27sec for OA 2 and 19sec for
OA3, and
c. Respiratory effort (THO
and ABD channels) is present
throughout the duration of Apnea in all the three apneas

Fig 30: Obstructive Apnea (OA). 2min window. This figure shows three OA (OA 1, OA 2
& OA 3). In this fig, Flow channel records from oronasal thermal sensor, PFlow record
from nasal pressure transducer, THO and ABD channels record respiratory effort from
Thorax and Abdomen respectively, “micro channel” records snoring and CFlow channel
records patient airflow from PAP device.

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 Dr. Tripat Deep Singh

“Algorithm 7”- Example 2

Let’s try to apply below part of the “Algorithm-7” to PSG tracing in Fig 31 along the red
arrows to understand “Scoring of Central Apnea (CA)”.

In Fig 31, there are 3 CA

following the above part of
“Algorithm 7” because-

a. Airflow amplitude has

decreased by 90% on
oronasal thermal sensor
(Flow), and
b. Duration of drop in
amplitude is 19 sec for first
CA, 24sec for second CA and
18sec for third CA, and
c. Respiratory effort (THO
and ABD channels) is absent
throughout the duration of Apnea in all three apneas.

Fig 31: Central Apnea (CA) in Level 1 & 2 diagnostic sleep study. 2min window. Oronasal
thermal sensor records three CA (Red Box). In this fig, Flow channel records from
oronasal thermal sensor, PFlow records from nasal pressure transducer, THO and ABD
channels record respiratory effort from Thorax and Abdomen respectively, “micro
channel” records snoring.

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Basic Polysomnography

“Algorithm 7”- Example 3

Let’s try to apply below part of the “Algorithm-7” to PSG tracing in Fig 32 along the red
arrows to understand “Scoring of Mixed Apnea (MA)”.

In Fig 32, there MA following

the above part of “Algorithm
7” because-

a. Airflow amplitude has

decreased by 90% on
oronasal thermal sensor
(Flow), and
b. Duration of drop in
amplitude is 30sec, and
c. Respiratory effort (THO
and ABD channels) is absent
during the first part of Apnea
(CA) and respiratory effort is
present during the second part of the apnea (OA)

Fig 32: Mixed Apnea (MA). 2min window. In this fig, Flow channel records from oronasal
thermal sensor, PFlow records from nasal pressure transducer, THO and ABD channels
record respiratory effort from Thorax and Abdomen respectively, “micro channel”
records snoring.

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 Dr. Tripat Deep Singh

“Algorithm 7”- Example 4

Let’s try to apply the below part of the “Algorithm-7” to PSG tracing in Fig 33 along the
red arrows to understand “Scoring of Obstructive Hypopnea as per 2012 Recommended
definition”.

Fig 33 shows 2 Obstructive Hypopneas (In Red Box). They are scored as Obstructive
Hypopnea by applying the above part of “Algorithm 7” because-

a. Amplitude of airflow on oronasal thermal sensor (Flow Channel) is not dropped by

90 or >90%.
b. Amplitude of airflow on nasal pressure transducer (PFlow Channel) is dropped by
>30%.
c. Duration of airflow amplitude drop in both cases is >10sec
d. Amplitude drop >30% is associated with >3% drop in oxygen desaturation. In first
event, there is saturation drop from 98 to 90%, which is 8% drop and second event
saturation drops from 97 to 91%, which is 6% drop in saturation.
e. Therefore, 2 events are scored as Hypopnea.
f. Both Hypopneas have snoring (Micro channel) present during the event. That is
why they are scored as Obstructive Hypopnea.

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Basic Polysomnography

Fig 33: Obstructive Hypopnea. 5min window. In this fig, Flow channel records from
oronasal thermal sensor, PFlow records from nasal pressure transducer, THO and ABD
channels record respiratory effort from Thorax and Abdomen respectively, “micro
channel” records snoring.

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 Dr. Tripat Deep Singh

“Algorithm 7”- Example 5

Let’s try to apply the below part of the “Algorithm-7” to PSG tracing in Fig 34-35 along
the red arrows to understand “Scoring of Cheyne Stokes Breathing”.

In Fig 34-35, there is presence of Cheyne Stoke’s Breathing (CSB) following the above part
of “Algorithm 7” because-

a. Airflow amplitude has decreased by 90% on oronasal thermal sensor (Flow), and
b. Duration of drop in amplitude is >30sec for all 3 events, and
c. Respiratory effort (THO and ABD channels) is absent throughout the duration of
Apnea in all three apneas.
d. Hence, we have 3 consecutive Central apneas

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Basic Polysomnography

e. These 3 consecutive Central apneas are separated by crescendo-decrescendo

breathing pattern (Fig 34)
f. Cycle length is 175sec (Fig 35)
g. CAI as seen in the patient report was 10/hr over the whole night

Fig 34: This is a 10min window. In this fig, Flow channel records from oronasal thermal
sensor, PFlow records from nasal pressure transducer, THO and ABD channels record
respiratory effort from Thorax and Abdomen respectively, “micro channel” records
snoring.

Cycle Length

Cycle length is the time from the beginning of a central apnea to the end of the crescendo-
decrescendo respiratory phase. (Fig 35)

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 Dr. Tripat Deep Singh

Fig 35: This is a 10min window. In this fig, Cycle length is 175sec. In this fig, Flow channel
records from oronasal thermal sensor, PFlow records from nasal pressure transducer,
THO and ABD channels record respiratory effort from Thorax and Abdomen
respectively, “micro channel” records snoring.

Algorithm 8: Adult Respiratory Event Scoring for Level-1 Sleep Study. Based on AASM
2012 Acceptable definition of Hypopnea.

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Basic Polysomnography

Algorithm 9: Adult Respiratory Event Scoring for Home Sleep Testing (HST). Based on
AASM Recommended definition of Hypopnea when Sleep is not recorded.

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 Dr. Tripat Deep Singh

Algorithm 10: Pediatric Respiratory Event Scoring for Level-1 Sleep Study. Based on
AASM 2012 Recommended definition of Hypopnea.

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Basic Polysomnography

Chapter 9
Sensors to record Limb Movements in Sleep
Study
X
 During routine Sleep study, EMG from lower limbs is recorded to record limb
movements

 2 electrodes are placed on each leg on Anterior Tibialis muscle

 EMG from upper limbs can also be recorded if REM Sleep Behavior Disorder is
suspected

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 Dr. Tripat Deep Singh

Chapter 10
Algorithmic Approach to scoring Periodic Limb
Movements in Sleep (PLMS)
X
Algorithm 11: Scoring Periodic Limb Movements in Sleep (PLMS)

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Basic Polysomnography

Let me explain few basic facts about limb movements mentioned in “Algorithm 11” before
we go to actual PSG tracings

1. How to identify consecutive Limb movements?

 Duration between limb movements is measured from the beginning of one

movement to the beginning of the next movement
 2 consecutive limb movements should be separated by 5sec but less than 90sec
 2 Limb movements on two separate legs should be separated by 5sec to be
considered consecutive movements

Fig 36: This fig explains how to measure duration between limb movements and how to
establish 4 consecutive limb movements for PLM. See explanations below.

In Fig 36, example 1 shows-

a. One limb movement on left (A) and one movement on right leg (B)
b. A and B are separated by 4sec only
c. For two movements on left and right leg to be considered separate movements,
they should be separated by >5sec
d. Hence, example 1 in Fig 36 shows only 1 limb movement

In fig 36, example 2 shows-

a. One limb movement on left (A) and one movement on right leg (B)
b. A and B are separated by 8secs
c. For two movements on left and right leg to be considered separate movements,
they should be separated by >5sec
d. Hence, example 2 in Fig 36 shows 2 consecutive limb movements, one on each leg.

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 Dr. Tripat Deep Singh

In fig 36, example 3 shows-

a. Four limb movements (A, B, C and D) on the left leg

b. A and B are separated by 15secs, B and C are separated by 8sec and C & D are also
separated by 8sec
c. For two movements to be considered consecutive, 2 limb movements should be
separated by >5sec but less than 90sec
d. Hence, example 3 in Fig 1 shows 4 consecutive limb movements on left leg, which
can be considered part of PLM.

2. How to establish relationship between Limb movement and respiratory event?

Do not score limb movements 0.5sec before start, during and 0.5sec after the end of the
respiratory event (Apnea/Hypopnea/RERA). (Fig 37)

Fig 37: In this fig, do not score limb movement no. 2 (0.5sec before start of OA) in epoch
2, limb movement no. 3 (During OA) in epoch 3 and limb movement no. 4 (0.5sec after end
of OA) in epoch 4. (OA: Obstructive Apnea) (Duration of each epoch is 30sec) In this fig,
there is no scorable limb movement which is part of PLMS.

Occurrence of respiratory event may stop the scoring of consecutive limb movements if
the consecutive movements are separated by >90sec. (Fig 38)

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Basic Polysomnography

Fig 38: Limb movements in epoch 1 and epoch 5 are separated by 100sec (>90sec) and
therefore cannot be considered consecutive movements. We will not score any limb
movement in epoch 1 and 5 because they are not part of PLMS. Limb movements in epoch
2-4 are not scored because they are occurring 0.5sec before to 0.5sec after the OA. In this
fig, there is no scorable limb movement which is part of PLMS.

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 Dr. Tripat Deep Singh

“Algorithm 11”- Example 1

Let’s try to apply below part of the “Algorithm-11” to PSG tracing in Fig 39 along the red
arrows to understand “Scoring of PLMS”.

Epoch in fig 39 have 5

consecutive limb movements
part of PLMS according to above
part of “Algorithm 11” because-

a. All 5 limb movements are

>0.5sec and <10sec
b. They are occurring during
Stage N3
c. Respiration is normal.
There is no respiratory event
(Apnea/Hypopnea/RERA)
d. Yes, there are 2 movements
separated by >5sec but <90sec
e. Yes, there are 5 consecutive limb movements
f. We will score all 5 limb movements as part of PLMS

Fig 39: 2min window. There are five consecutive limb movements (1-5) and respiration is
normal in this fig. So, we will score all five consecutive movements as they form part of
PLMS.

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Basic Polysomnography

“Algorithm 11”- Example 2

Let’s try to apply below part of the “Algorithm-11” to PSG tracing in Fig 39 along the red
arrows to understand “Scoring of PLMS”.

Fig 40 does have limb

movements which are >0.5sec
and <10sec occurring during
Stage N3 but are not scored as
PLMS according to above part
of “Algorithm 11” because-

a. All limb movements (Red

arrows) are occurring within
0.5sec before or 0.5sec after
the Obstructive Apnea (Red
box).

Fig 40: 2min window.

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 Dr. Tripat Deep Singh

Chapter 11
Algorithmic Approach to scoring Cardiac Events
X
Algorithm 12: Diagnostic approach for Tachyarrhythmias. Red Boxes are Emergency
Situation.

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Basic Polysomnography

“Algorithm 12”- Example 1

Let’s try to apply below part of the “Algorithm-12” to PSG tracing in Fig 41 along the red
arrows to understand “Scoring of Ventricular Fibrillation”.

Fig 41 shows ECG tracing

with Ventricular Tachycardia
according to this part of the
“Algorithm 12” because-
a. Heart rate is not normal. It
is 160 beats/min. Tachycardia
is present.
b. QRS complex is wide. In this
strip duration of QRS complex
is 0.36sec.
c. Patient was hemodynamically stable
d. RR interval is regular
e. AV-Dissociation present- There is no P-wave before any of the QRS-Complexes

ECG strip in Fig 41 shows Ventricular Tachycardia as per this part of the “Algorithm-12”

Fig 41. Ventricular Fibrillation

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 Dr. Tripat Deep Singh

“Algorithm 12”- Example 2

Let’s try to apply below part of the “Algorithm-12” to PSG tracing in Fig 42 along the red
arrows to understand the “Scoring of Sinus Tachycardia”

ECG strip in Fig 42 shows Sinus

Tachycardia following this part of the
“Algorithm 12” because-
a. Heart rate is not normal. It is
140beats/min. Tachycardia is present
b. QRS Complex is not wide. It is
narrow. Its duration is <0.12sec.
c. Patient was hemodynamically
stable
d. P-wave is clearly identifiable before
every QRS Complex
e. P-wave looks similar to sinus wave
and every wave have same
morphology

So, ECG strip in Fig 42 shows Sinus Tachycardia as per this part of the “Algorithm 12”

Fig 42. Sinus Tachycardia

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Basic Polysomnography

Algorithm 13: Diagnostic approach for Brady-arrhythmias. Red Boxes are Emergency
Situation.

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 Dr. Tripat Deep Singh

Message from the Writer

This was my learning as teacher so far in the Classroom. I hope you enjoyed it.

Please give your valuable feedback on this approach to improve/enhance future editions.

Email: [email protected]

Disclaimer:
I have tried to the best of my knowledge to present scientific facts in a classroom teaching
manner and every effort was made to maintain the accuracy of the facts. Any omissions will
be corrected in future editions. I hope students will accept my apologies if I was not able to
explain a complex subject in a simple and effective manner than was previously done in other
textbooks. The author cannot accept any legal responsibility for any errors or omissions and
cannot claim any warranty related to the material contained in this book. I will suggest
whenever you have doubt to refer to standard reference material and textbooks.

Major reference used in this book is-

1. Berry RB, Brooks R, Gamaldo CE et al. The AASM Manual for the scoring of Sleep
and associated events. Version 2.5. American Academy of Sleep Medicine, Darien, IL.
2018.

Note: If you would like to have high resolution images of the different algorithms used in this
book to be displayed in your Sleep labs, please drop an email to [email protected].
I will be happy to share them.

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