Polysomnography for the Sleep Technologist : Instrumentation, Monitoring, and Related Procedures

The only sleep technology text written by experienced polysomnography educators, Polysomnography for the Sleep Technologist: Instrumentation, Monitoring, and Related Procedures covers the procedural knowledge you need to understand sleep studies. A sequential learning model systematically covers electronics, instrumentation, recording parameters, data acquisition, ancillary equipment, troubleshooting, recording quality, infection control, basic positive pressure therapy, and cardiopulmonary monitoring and intervention essential to polysomnography. In-depth discussions of polysomnographic technology in the clinical evaluation, physiological monitoring and testing, instrumentation, diagnosis, infection control, management and prevention of a wide spectrum of sleep-related disorders and daytime alertness offers comprehensive coverage of polysomnography technology. Expert content written by the same authors who were instrumental in producing a standardized model curriculum outline. Unique sequential approach builds concepts over time and simplifies the material’s complexity. Over 150 full-color graphs, charts, and illustrations supply visual guidance. End-of-chapter review questions help you assess your knowledge and prepare for certification as a sleep technologist. Chapter outlines, learning objectives, key terms and a bulleted chapter summary supplies a standard format to help you identify and focus on key content. Front cover Polysomnography for the Sleep Technologist Instrumentation, Monitoring, and Related Procedures Copyright Contributors Reviewers Dedication Foreword Preface Acknowledgements Table of contents 1 Overview of sleep medicine physiology and technology Chapter outline Learning objectives Key terms A history of sleep medicine technology Sleep medicine throughout history Research and theories The evolution of polysomnography Pioneers in sleep medicine Nathaniel kleitman Sleep stage scoring - R&K manual American academy of sleep medicine (AASM) Narcolepsy research Obstructive sleep apnea research Early treatment of OSA Early sleep study data collection Physiology for recording sleep-related parameters Circadian variations related to wake and sleep Opponent process model of sleep How the body changes between sleep and wake Neurotransmitters Sleep phases and stages Determining sleep stages using electroencephalography Stages n1-n2 sleep Stage n3 sleep REM sleep Physiological parameters evaluated by polysomnography Monitoring vital signs Special considerations The sleep technologist Provision of health care Typical roles and duties of a sleep technologist Training and certification Scope of practice Instrumentation Performance of polysomnography Professional education Patient care and education Communication Additional tasks Conclusion Chapter summary References Review questions 2 Classification of sleep disorders Chapter outline Learning objectives Key terms The insomnias Primary insomnias Idiopathic insomnia Fatal familial insomnia Secondary insomnias Adjustment insomnia Psychophysiologic insomnia Paradoxical insomnia Inadequate sleep hygiene Behavioral insomnia Sleep-related breathing disorders Central sleep apnea (CSA) syndromes Cheyne-stokes High-altitude periodic breathing Drug-related csa Obstructive sleep apnea (OSA) syndromes Pediatric OSA Sleep-related hypoventilation and hypoxemic syndromes Sleep-related hypoventilation/hypoxemia due to medical conditions Hypersomnias of central origin Narcolepsy Recurrent hypersomnias Secondary hypersomnia Circadian rhythm disorders Delayed sleep phase disorder Advanced sleep phase disorder Free-running Jet lag Shift work disorder Circadian disorder due to medical conditions Parasomnias Non-rapid eye movement (NREM) sleep parasomnias Confusional arousal Sleepwalking Sleep terrors Rapid eye movement (REM) sleep parasomnias Nightmare disorder Catathrenia REM sleep behavior disorder (RBD) Other parasomnias Sleep-related dissociative disorder Sleep enuresis Sleep-related eating disorder (SRED) Parasomnias related to drug or substance use Testing for parasomnias Sleep-related movement disorders Restless leg syndrome (RLS) Periodic limb movement disorder (PLMD) Sleep-related bruxism Sleep-related rhythmic movement disorder Chapter summary References Review questions 3 Electronics and electricity Chapter outline Learning objectives Key terms Introduction to electricity Forms of electricity Static electricity Charged particle interactions Coulomb’s law Conservation of charge Electrochemical electricity Photoelectricity Thermoelectric effect Piezoelectric effect Electronic circuits Open, closed, and short circuits Current flow Principles of current Units and prefixes Metric prefixes Introduction to electrical components Conductors Resistance Ohm’s law Leakage current Ground and power isolation Ground Power isolation An overview of ancillary equipment Devices used to monitor airflow Thermal sensor Pressure transducer Oxygen sensors Snore microphones Position sensors Chapter summary References Review questions 4 Frequency, voltage, and morphology of signals Chapter outline Learning objectives Key terms Essentials of physiologic waveforms Frequency and duration Calculation of duration (d) and frequency (f) Amplitude Morphology Bioelectrical signals Resting potential Graded potential Action potential Polarity Recording equipment, controls, and practices Electrodes and electrode boards Data acquisition systems Electrode impedance Recording polarity Amplifiers Direct current (DC) and alternating current (AC) amplifiers Direct current (DC) amplifier Alternating current (AC) amplifier Differential amplifier Derivations, montages, and recorder types Derivations Montages The bipolar montage The referential montage Data recording The recorder Referential recording Annotation and documentation Signal sampling Signal reconstruction Sensitivity and gain Sensitivity Gain Common mode rejection Amplifier filters The low-frequency filter and decay time constant Low-frequency filter (LFF) Decay time constant (TC) The high-frequency filter The 60-hz filter Digital filtering Frequency response Additional testing equipment and considerations Transduced signals Ancillary equipment The polysomnograph Viewing the study Data storage Recorded data The electroencephalogram (EEG) The electrooculogram (EOG) The chin electromyogram (EMG) The limb electromyogram Chapter summary References Review questions 5 Bioelectric signals of interest in sleep medicine Chapter outline Learning objectives Key terms Parameters typically evaluated by polysomnography Electroencephalography Low-amplitude, mixed-frequency (LAMF) waves Alpha waves Delta waves Sawtooth waves Theta waves Sleep spindles K complex Vertex sharp waves Electrooculogram Recording methods and sleep-wake stage scoring Electromyogram Chin electromyogram Leg electromyogram Modified lead II electrocardiography (ECG) Lead placement Sleep/wake states Aasm guidelines for wake and sleep stages1 Wake Stage n1 Stage n2 Stage n3 Stage r Chapter summary Reference Review questions 6 The recording of physiological parameters and electrical safety Chapter outline Learning objectives Key terms Recording physiological parameters Baseline patient information Machine calibrations Amplitude, morphology, and decay time constant All-channel calibration Montage calibration Signal calibrations Physiologic calibrations Physiologic calibration commands Eyes open Eyes closed Eye deflections Grit command Limb movements Breath commands Electrocardiogram Final observations Lights out Documentation during the recording Optimizing the recorded data Artifacts Medical record documentation Use and limitations of filters Understanding the way filters work Frequency response Placement of electrodes Adjustment of sensitivity and gain Gain Sensitivity Waveform ruler Electrical safety Current, voltage, and resistance Grounding and leakage current Ground loops Electrical shock Chapter summary References Review questions 7 Data acquisition systems Chapter outline Learning objectives Key terms Principles of digital recording Digitization and manipulation of data Data storage System components Hardware components Montages Static and dynamic recording methods Filtering Derivations Referential Bipolar Recording options Referential recording Differential recording General software options for data display Montage collection and review Visual display Display position Display color Window configuration Look-back window Histogram Tabular data Respiratory window Full display Visual filters Automated sleep staging and event scoring The recognition of sleep-wake stages and events AASM recommendations Respiratory events detection Measurement technologies Staging examples Stage w: Wake Stage n1 Stage n2 Stage n3 Stage r Respiratory examples Respiratory effort related arousal Hypopnea Apnea Cheyne-stokes breathing Sleep-related movement events Periodic limb movements in sleep (PLMS) Rhythmic movement disorder REM sleep behavior disorder Recent advancements in digital polysomnography Wireless technologies Spectral analysis of electroencephalogram data Portable polysomnography devices Remote monitoring Chapter summary References Review questions 8 Sensors, transducers, and ancillary equipment Chapter outline Learning objectives Key terms Surface electrodes Electrode types Commonly used metals for electrodes Electrode cups Electrode wires Specific use for electrodes Electrode cables, connectors, and jumpers Connectors Jumpers Use and care of reusable recording electrodes Cleaning Disinfection Sterilization Semicritical v. noncritical items Interfacing electrodes with the input board Derivations The operation, use, and limitations of sensors Recording EEG, EMG, EOG, and ECG with surface electrodes Airflow and breathing effort transducers and recording systems Monitoring airflow Monitoring respiratory effort Piezo technology Diaphragmatic and intercostal EMG Respiratory inductive plethysmography (RIP) Snore microphones and sensors Recording patient body position Audiovisual monitoring and recording Recording bioelectric and transduced signals Differentiating signal types Selecting an AC or DC amplifier Sample rate requirements EEG signals Ancillary recorder signals, equipment and methodology Recording and understanding the cyclic alternating pattern An overview of pulse oximetry and oximeter sensors Interfacing an ancillary device with the data acquisition system Chapter summary References Review questions 9 The polysomnogram: Prestudy procedures, monitoring activities, and poststudy scoring and interpretation Outline Objectives Key terms Patient communication Reviewing patient documents Medical record review Health care provider orders Medications Patient assessment Technical considerations Recording montage Equipment calibrations Electrode and sensor application Electroencephalogram and electrooculogram electrode application Electromyogram and non-cephalic sensor application Respiratory monitoring sensors Skin preparation Electrode metal recording properties Recording the sleep study Prebedtime activities Questionnaire Physiologic calibrations Monitoring and documenting Quality monitoring Record-keeping Response to clinical events Conclusion of the sleep study Poststudy activities Physiologic calibrations Electrode and sensor removal Poststudy patient instructions Scoring and report tabulation Scoring Study status tracking Data tabulation and report elements Data tabulation Report elements Documenting medication use Interpretation Patient follow-up Quality measurements Interscorer reliability Therapy compliance monitoring Chapter summary References Review questions 10 Recognizing, evaluating, and minimizing recording artifacts Chapter outline Learning objectives Key terms Electrode and sensor application Electrode application methods Collodion Conductive paste Electrode removal Gloving Electrode-site preparation Electrode composition Electrode impedance Low impedance value High impedance value Electrode impedance summary Signal processing Differential amplifier Common mode rejection ratio (CMRR) Filters Low-frequency filter (LFF) High-frequency filter (HFF) 50/60 hz filter Artifact isolation Line frequency artifact Muscle artifact Muscle artifact variants Respiratory event Leg cramps Abdominal effort Bruxism EEG arousal Body rocking Electrocardiographic artifact ECG artifact variants Slow-frequency artifacts Sweat artifact Respiratory artifact Pulse artifact Cardioballistic artifact Channel-blocking artifact Electrode popping artifact Airflow signal artifacts Respiratory effort sensor artifact Oximetry artifacts System reference artifact Various other artifacts Implanted electrical devices Cardiac pacemakers Atrial pacemaker Ventricular pacemaker Atrioventricular (AV) sequential pacemaker Fixed-rate and demand pacemakers Artifact response Chapter summary References Review questions 11 The cardiopulmonary system: Essentials for the polysomnographic technologist Outline Learning objectives Key terms Anatomy and physiology of the respiratory system The thorax Thoracic cage Lungs The muscles of ventilation Anatomy and physiology of the cardiovascular system Heart Oxygenation of the blood Ventilation and diffusion Oxygen transport Carbon dioxide transport Lung volumes and capacities Arterial blood gas interpretation and manipulation Regulation of breathing Central chemoreceptors Peripheral chemoreceptors Microscopic stretch receptors Changes during sleep Changes in tidal volume and alveolar ventilation Changes in blood gas values Changes in heart rate and rhythm Visual assessment of cardiopulmonary status Respiratory status Body habitus Skin tone Monitoring the electrocardiogram Modified lead II derivation The electrical pathway The PQRST complex Dysrhythmia interpretation The technologist’s guide to dysrhythmias Sinus mechanisms Normal sinus rhythm Sinus arrhythmia Sinus bradycardia Sinus tachycardia Sinoatrial block (sinoatrial pause) Sinus arrest Atrial rhythms Premature atrial contraction Atrial tachycardia Multiformed atrial rhythm Atrial flutter Atrial fibrillation Junctional rhythms Premature junctional complex Junctional escape beats Junctional escape rhythm Accelerated junctional rhythm Junctional tachycardia Ventricular rhythms Premature ventricular complexes (contractions) Premature ventricular complexes Unifocal premature ventricular complexes Multifocal premature ventricular complexes R-on-t premature ventricular complexes Ventricular bigeminy Ventricular trigeminy Ventricular escape beats Idioventricular rhythm Accelerated idioventricular rhythm Monomorphic ventricular tachycardia Polymorphic ventricular tachycardia Ventricular fibrillation Asystole (cardiac standstill) Atrioventricular blocks First-degree atrioventricular block Second-degree atrioventricular block Second-degree AV block type I Second-degree AV block type II (mobitz type II) Third-degree AV block (complete heart block) Chapter summary References Review questions 12 Noninvasive monitoring of gas exchange during testing Chapter outline Learning objectives Key terms Overview of gas exchange Hypoxia Hypoxia classification Causes of hypoxia Monitoring oxygenation and ventilation Monitoring carbon dioxide Oxygenation and acid-base balance overview Arterial values of blood gases Assessment of ph values Pulse oximetry Origins of pulse oximetry Theory of operation Contraindications, precautions, and infection control Precautions Routine safety practice Infection control Limitations to testing and the reliability of results Oxyhemoglobin dissociation curve Additional considerations for pulse oximetry monitoring Technical and environmental considerations Software limiting factors for oximetry Optimizing oximetry during polysomnography Recording oximetry data Oximetry calibration Selecting the appropriate oximeter for both in-lab and out-of-lab testing Monitoring ventilation during sleep Impact of hypoventilation during sleep End-tidal carbon dioxide monitoring Monitoring CO2 in the adult population Theory of operation Sidestream ETCO2 monitors Displaying ETCO2 data Advantages and limitations of technology Comparison of obtained values Contraindications, precautions, and infection control Transcutaneous monitoring of oxygen and carbon dioxide Advantages and limitations of technology Comparison of obtained values Contraindications, precautions, and infection control Analysis of acid-base balance of arterial blood gas results Chapter summary References Review questions 13 Diagnosis, treatment, and outcome management of sleep-disordered breathing Chapter outline Learning objectives Key terms Respiratory event recognition Paradoxical breathing Central apnea Cheyne-stokes respirations Mixed apnea Hypopnea Complicated breathing patterns Titration techniques Continuous positive airway pressure Guidelines for titrating cpap Titration variations based on age Managing complications and side effects of CPAP therapy Spontaneous bilevel positive airway pressure (BPAP-S) Indications for transition from CPAP Guidelines for titration of BPAP-S Central apnea, cheyne-stokes respirations, and cpap-emergent central apnea BPAP therapy as noninvasive ventilation for central apnea Indications for use Guidelines for titration Adaptive servo ventilation Indications for use Guidelines for titration Treatment challenges NPPV in complex respiratory diseases Chronic hypoventilation syndromes Indications for NPPV Goals of NPPV Guidelines for titration with NPPV Spontaneous timed or timed mode Inspiratory to expiratory ratio Special considerations for the use of NPPV Chronic obstructive pulmonary disease and overlap syndrome Chronic obstructive pulmonary disease Restrictive lung disease Selection of NPPV device settings General recommendations for NPPV Conditions associated with the use of NPPV Contraindications for NPPV Optimizing NPPV Supplemental oxygen Guidelines for use of supplemental oxygen Considerations for the use of supplemental oxygen Alternative treatments for obstructive sleep apnea Tracheostomy Advantages Disadvantages and risks Oral appliances Surgical procedures Outcome management for positive airway pressure therapy Management of side effects Emerging role of clinical sleep educator Efficacy monitoring Effect of heated humidification and nasal congestion Unintentional leak Chapter summary References Review questions 14 Infection control and emergent response in the sleep center Outline Learning objectives Key terms Infection control overview Transmission of infection Standard precautions Hand hygiene Recommendations for hand hygiene in ambulatory care settings5 Disinfection Personal protective equipment (PPE) Respiratory hygiene and cough etiquette Transmission-based precautions Airborne precautions ( 5 microns) Contact precautions Nosocomial and parenteral infections Prions Cleaning, disinfection, and sterilization Barrier measures Electrodes and sensors Artifacts caused by soiled electrodes Positive airway pressure equipment cleaning and disinfection PAP interface PAP devices used in the home Material safety data sheet Emergencies in the sleep center Response to life-threatening emergencies Facility emergency policies Protocol: Cardiac dysrhythmia intervention for the sleep technologist Group I Group II Group III Idioventricular rhythms Fire safety Fire prevention Fire preparedness Fire response and evacuation Fire drills Fire extinguishers and fire hoses Electrical safety Creating a safe environment Equipment safety checks Electricity and the patient Chapter summary References Review questions APPENDIX I Fundamental math concepts Vocabulary Fractions, ratios, and proportions Addition and subtraction of integers Multiplication of positive and negative numbers Algebra basics Evaluating the expression Solving equations for a specific variable Parenthesis Exponents Multiplication/division Addition/subtraction Mean, median, and mode APPENDIX II Common report parameters and recommended settings Multiple sleep latency testing Initial sleep latency The mean sleep latency Polysomnography Total recording time Wake after sleep onset Total sleep time The sleep period Sleep efficiency Total wake time Various indices APPENDIX III Measurements and conversions The metric system Units of scientific measurement Practical application of measurements Length (distance and height) Distance conversions Weight (mass) Time Voltage Practical application of S = V/D Determining military time Volume Converting temperature scale Glossary Answers to end-of-chapter questions Index A B C D E F G H I J K L M N O P Q R S T U V W X Z