380 Index
Thermoregulation (Continued) Trazodone, for sleep promotion (Continued) Viral infection(s), and sleep, 35f
and chest sweating, 31f structure of, 75f Vitaterna, M. H., 18
and metabolic rate, 30f vl-NTS (ventrolateral nucleus of the tractus solitarius),
and shivering, 30f Tremor, in Parkinson’s syndrome, 133f
and tachypnea, 30f Triazolam in control of breathing, 37f
vlPAG (ventrolateral periaqueductal gray), in REM
Theta activity, 264t for poor sleep, 76t
Thorpy, Michael, 18, 18f site of action of, 71f sleep, 23f
Thyroid disease, 228–233 for sleep promotion, 71, 71t VLPO (ventrolateral preoptic) system
structure of, 72f
hyperthyroidism as, 228 Tricyclic antidepressants (TCAs), REM suppression in REM sleep, 23f
atrial fibrillation in, 230f in sleep regulation, 21f, 22, 22f
causes of, 228t due to, 257t Vogel, Gerry, 13
Graves’ ophthalmopathy in, 228b, 229f Truck driver, patient interview video of apnea in, 348 Volitional movements, vs. restless legs syndrome, 120t
polysomnogram of sweat artifact in, 230f TSH (thyrotropin-secreting hormone), temporal von Baeyer, Johann Friedrich Wilhelm Adolf, 10
sleep findings in, 228b von Economo, Baron Constantine, 20f
symptoms of, 228b variations in, 57, 57f von Economo’s sleeping sickness, 20f
thyroid stare in, 228f Tuberomammillary nucleus (TMN), in sleep von Liebig, Justus, 10
von Mering, Joseph, 11
hypothyroidism as, 229–232 regulation, 21f, 22f VRG (ventral respiratory group), in control of
causes of, 231t Tumor necrosis factor alpha (TNF), and sleep, 34t,
sleep findings in, 231b breathing, 37f
symptom(s) of, 231b 35–36
of eyes, 232f Turek, F. W., 15, 18 W
of hair, 232f Turek plot, 18f Wadd, William, 9
macroglossia as, 232f Tylenol PM (diphenhydramine in combination), for Wake state instability, 28, 28f
over time, 232f Wakefulness
due to treatment of Graves’ disease, 231f sleep promotion, 75t
physiologic measurements of, 62f
thyroid mass lesions as, 233 U scoring of, 263, 264f
sleep apnea due to, 233f UARS. See Upper airway resistance syndrome (UARS). sympathetic activity during, 46f
sleep findings with, 233b Ulcer, duodenal, 237 Wakefulness-promoting agent(s), 76–78, 76t
types of, 233b Unisom Nighttime (doxylamine), for sleep promotion, amphetamines and related compounds as, 76t, 77
Thyroid mass lesions, 233 75t mechanism of action of, 77f
sleep apnea due to, 233f Upper airway, collapse of, 40f caffeine as, 78, 79f
sleep findings with, 233b Upper airway muscles, in obstructive sleep apnea, 41f for cataplexy, 76t
types of, 233b Upper airway obstruction, 360 for excessive daytime sleepiness/irresistible episodes
Upper airway patency, in obstructive sleep apnea,
Thyroid stare, 228f of sleep, 76t
Thyroiditis, 228t 41–42, 42f mechanism of action of, 77f
Thyrotropin-secreting hormone (TSH), temporal Upper airway resistance syndrome (UARS), 283 modafinil as, 76t, 77
variations in, 57, 57f with cardiac arrhythmia, 298f efficacy of, 78f
Timeline, of sleep medicine, 8–19 drilling down in, 295f, 296f mechanism of action of, 77f, 78f
Time-on-task effects, of sleep deprivation, 28, 28f vs. obstructive hypopnea, 298f pharmacokinetics of, 78t
Timing of sleep, control of, 24f, 25, 26f with prolonged obstructive hypoventilation, 297f for narcolepsy, 76t, 79f
TMN (tuberomammillary nucleus), in sleep regulation, with respiratory effort related arousal, 296f, 297f for poor sleep, 76t
sleep laboratory videos of, 357–358 relative efficacy of, 79f
21f, 22f sodium oxybate as, 76t, 78
TNF (tumor necrosis factor alpha), and sleep, 34t, with quiet snoring, 357 “Waterbags,” under eyes, due to CPAP treatment, 192f,
with variable snoring, 357, 358
35–36 snoring in 193f
Tongue quiet, 357 Waterhouse, John William, 7, 7f
variable, 357, 358 Waveforms, in sleep staging, 263, 264t
creased, 154, 155f time compression in, 295f Wells, William, 11
and pharynx, 158–160 Uvulopalatopharyngoplasty (UPPP), obstructive sleep Wenckebach second degree heart block, 319f
Westphall, Karl Friedrich Otto, 11
Mallampati Class I, 158, 159f apnea after, 163 Whole-organism sleep, 29
Mallampati Class II, 158, 159f clinical appearance of, 164f Willis, Sir Thomas, 9, 10f
Mallampati Class III, 160, 160f sleep laboratory video(s) on, 354 Winkelman, Juliane, 19
Mallampati Class IV, 160, 160f Workplace productivity, impact of sleep disorders on,
scalloped, 154, 155f V
Tongue enlargement Van Cauter, Eve, 19, 19f 85, 85b
in acromegaly, 236f Van Gogh, Vincent, 4–5, 5f Wurtman, R. J., 13
in hypothyroidism, 232f Vasomotor symptoms, during menopause, 248–250,
Tonic-clonic seizures, generalized, upon awakening, Y
249f Yanagisawa, Masashi, 19
131 Venlafaxine, for cataplexy, 76t Yawning, in Parkinson’s syndrome, 133f
Tonsil(s), 161–163 Ventral medullary surface, in control of breathing, Young, Terry, 18
enlarged 38f Z
examination of, 149f, 163, 163f, 285f, 286f Ventral respiratory group (VRG), in control of Zaleplon
obstructive sleep apnea due to, 184–187, 184f,
285f, 286f breathing, 37f binding site of, 72f
Ventricular tachycardia, 321f, 322f, 323f for sleep promotion, 69t, 74f
Grade 0, 161, 161f structure of, 74f
Grade 1, 161, 161f with obstructive sleep apnea, 220f Zolpidem
Grade 2, 161, 161f Ventrolateral nucleus of the tractus solitarius (vl-NTS), binding site of, 72f
Grade 3, 161, 162f historical background of, 16
Grade 4, 161, 162f in control of breathing, 37f modified-release (extended-release), 72, 72f, 73f
trauma due to snoring of, 163, 163f Ventrolateral periaqueductal gray (vlPAG), in REM plasma concentration of, 72f
Tonsillar hypertrophy for sleep promotion, 69t, 72
examination of, 149f, 163, 163f, 285f, 286f sleep, 23f structure of, 72f
obstructive sleep apnea due to, 184–187, 184f, 285f, Ventrolateral preoptic (VLPO) system Zopiclone, for sleep promotion, 69t
Zucker, Irving, 14
286f in REM sleep, 23f
Toxic goiter, 228t in sleep regulation, 21f, 22, 22f
Transmural pressure, effect of obstructive sleep apnea Vertex sharp waves, 264t, 267t
Video(s)
on, 216, 217f patient interview (See Patient interview video[s])
Trazodone, for sleep promotion, 74–75, 75f sleep laboratory (See Sleep laboratory video[s])
Vigorous movements, in obstructive sleep apnea, 354
characteristics of, 75b Violent body movement, sleep laboratory videos on
obstructive sleep apnea with, 354
Violent dreams, 82
WEB IMAGES..........................................................................................................................................................................................................................
Cardiac Rhythm Abnormalities
ECG1-ECG2
2.05 mV
LAT-LAT-
512 uV
RAT-RAT-
512 uV
100
SaO2
%
80
THOR EFFORT
1.64 mV
ABDO EFFORT
2.05 mV
120
Pulse
bpm
40
75
ETCO2
mmHg
0
NASAL PRES
500 mV
Figure W80.
Examining Cardiac rhythm abnormalities in a sleep record. Because the data is digital, modern
data-acquisition systems allow the clinician to examine any channel, hide any channel, and
modify the gain, the size of the channel, and the epoch length. The reader will note that a variety
of epoch lengths are used and sometimes the top window may have a different epoch length
than the bottom window. Here the top window is 15 seconds, allowing one to view the
electrocardiogram (EKG) in high resolution. The EKG will usually be shown in the top windows
and the trace will be in red in this section. The bottom widow is the conventional 30 seconds.
The epoch lengths that will be displayed will be those that best show the findings. A high
sampling rate is required to be able to acquire the data and then display the EKG in high
resolution. This is an example of atrial fibrillation. There are no well-developed P waves and
there are many small waves arising from the atria. The ventricular response is irregularly
irregular.
e1
e2 Web Images
EMG1-EMG2
1.02 mV
C3-A2
128 uV
C4-A1
128 uV
O1-A2
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
1.64 mV
LAT-LAT-
RAT-RAT- 100
80
SaO2
%
THOR EFFORT
4.1 mV
ABDO EFFORT 120
4.1 mV 40
75
Pulse 0
bpm
ETCO2
mmHg
NASAL PRES
500 mV
Figure W81.
EKG waves. The EKG has identifiable waves. The P waves represent atrial depolarization.
The QRS complex is a surrogate for ventricular contraction. The Q wave is the first downward
deflection of the QRS. The R wave is the first upward deflection of the QRS. The S wave is a
downward deflection that follows the R wave.
The PR interval is the time between the start of the P wave and the start of the R wave and is
up to 0.2 seconds. The QT interval is the time from the start of the Q wave to the end of the
T wave. The PR interval can be shortened or prolonged in disease. Genetic diseases and
medications may be associated with long QT syndromes, which may result in severe
arrhythmias. This fragment is taken from an epoch length of 5 seconds.
CHIN(1) CHIN(1)
250 uV 250 uV
C3-A2 C3-A2
125 uV 125 uV
C4-A1 C4-A1
125 uV 125 uV
O1-A2 O1-A2
125 uV 125 uV
O2-A1 O2-A1
125 uV 125 uV
ROC-A1 ROC-A1
125 uV 125 uV
LOC-A2 LOC-A2
125 uV 125 uV
ECG ECG
625 uV 625 uV
LEG(L) LEG(L)
LEG(R) LEG(R)
100 100
SaO2 SaO2
%0 %0
THOR RES THOR RES
x1 x1
ABDO RES ABDO RES
x1 x1
80 80
PULSE PULSE
bpm bpm
30 30
76 76
PCO2 PCO2
mmHg mmHg
-4 -4
POSITION POSITION
CPAP 30 CPAP 30
cmH2O 2 cmH2O 2
AIRFLOW AIRFLOW
62.5 uV 62.5 uV
Figure W82.
Irregular rhythm. Wandering pacemaker. To optimize the display of the EKG, the top window
shows a 10-second epoch. The bottom window is 1 minute to show the change in pulse rate.
During the course of the night, patients may display different types of cardiac arrhythmias.
This fragment is from a 30-year-old woman with a history of severe insomnia, waking up with
palpitations and drenched with sweat. She had developed features of psychophysiologic
insomnia. In this fragment, the patient has a normal sinus rhythm. The next two fragments show
arrhythmias occurring at other times during the night.
Web Images e3
CHIN(1) CHIN(1)
250 uV 250 uV
C3-A2 C3-A2
125 uV 125 uV
C4-A1 C4-A1
125 uV 125 uV
O1-A2 O1-A2
125 uV 125 uV
O2-A1 O2-A1
125 uV 125 uV
ROC-A1 ROC-A1
125 uV 125 uV
LOC-A2 LOC-A2
125 uV 125 uV
ECG ECG
625 uV 625 uV
LEG(L) LEG(L)
LEG(R) LEG(R)
100 100
SaO2 SaO2
%0 %0
THOR RES THOR RES
x1 x1
ABDO RES ABDO RES
x1 x1
80 80
PULSE PULSE
bpm bpm
30 30
76 76
PCO2 PCO2
mmHg mmHg
-4 -4
POSITION POSITION
CPAP 30 CPAP 30
cmH2O 2 cmH2O 2
AIRFLOW AIRFLOW
62.5 uV 62.5 uV
Figure W83.
Irregular rhythm. Wandering pacemaker. This is the same patient as in Figure W82. In this
fragment, there is some irregularity seen in the ventricular rate. There are subtle differences in
the P waves. This EKG fragment meets the criteria of a wandering pacemaker: Variability in
P-wave configuration, an atrial rate less than 100 beats per minute, and an irregular ventricular
rate.
CHIN(1)
250 uV
C3-A2
125 uV
C4-A1
125 uV
O1-A2
125 uV
O2-A1
125 uV
ROC-A1
125 uV
LOC-A2
125 uV
ECG
625 uV
LEG(L)
LEG(R)
100
SaO2
%0
THOR RES
x1
ABDO RES
x1
80
PULSE
bpm
30
76
PCO2
mmHg
-4
POSITION
CPAP 30
cmH2O 2
AIRFLOW
62.5 uV
Figure W84.
Irregular rhythm. Wandering pacemaker. In this fragment, there are further changes in the
configuration of the P waves, and in the middle are changes that at first glance appeared to be
consistent with a flutter fibrillation pattern. In fact, the calculated rate of the apparent flutter
waves is about 700 beats per minute. In atrial flutter, the atrial rate will usually vary between
250 and 300 beats per minute. Note that at times there are abrupt drops in the heart rate.
At the extreme right of the epoch, the apparent heart rate was in the high 30s to low 40s.
The heart rate data were obtained from the output of a pulse oximeter, and manual calculation
of heart rate from the EKG indicated that the heart rate was much higher. It is possible that the
abrupt drop in heart rate reflected a drop in blood pressure due to the arrhythmia.
e4 Web Images
CHIN(1)
250 uV
C3-A2
125 uV
C4-A1
125 uV
O1-A2
125 uV
O2-A1
125 uV
ROC-A1
125 uV
LOC-A2
125 uV
ECG
2.5 mV
LEG(L)
125 uV
LEG(R)
125 uV
100
SaO2
%
85
THOR RES
x1.5
ABDO RES
x1
120
PULSE
bpm
40
50
PCO2
mmHg
-4
AIRFLOW
31.3 uV
Figure W85.
Chaotic cardiac rhythm in a patient with heart failure. Note the Cheyne Stokes respiration.
The underlying rhythm is atrial fibrillation because there are no well-developed P waves.
There are several abnormal QRS configurations noted: (a) Wide complex beats that are quite
different in configuration, which would make them either high junctional beats with abnormal
conduction, low junctional beats, or ventricular beats. There is no compensatory pause after the
beats. (b) Narrow complex beats that might be high junction. (c) A string of five identical wide
complex beats with an underlying rate of 72 beats per minute. This would be high for either a
junctional rhythm or a ventricular rhythm escape rhythm and would thus be either a low
junctional tachycardia or ventricular tachycardia.
CHIN(1)
C3-A2
C4-A1
O1-A2
O2-A1
ROC-A1
LOC-A2
ECG
1.25 mV
LEG(L) 100
90
125 uV
LEG(R)
125 uV
SaO2
%
THOR RES
x2
ABDO RES
x1
PULSE 120
bpm 40
76
PCO2
mmHg
-4
Figure W86.
Ventricular tachycardia. This corresponds to the data shown on the previous fragment, but the
epoch length is one minute. There are 11 abnormal wide complex beats. The pulse channel
indicated the heart rate has increased to about 111 beats per minute for these abnormal beats,
but it is difficult to see the individual beats. The next fragment shows the same fragment at an
epoch length of 30 seconds. Manually calculating the rate from the EKG indicates that the rate
is actually about 160 beats per minute. In this example, the rate on the recording is obtained
from the output of an oximeter and not from the EKG and not all the beats were detected.
Web Images e5
Neurologic Diseases
MOVEMENT DISORDERS
EMG1-EMG2
1.02 mV
C3-A2
128 uV
C4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
LAT-LAT-
1.02 mV
RAT-RAT-
445.2 uV
100
SaO2
%
80
THOR EFFORT
4.1 mV
ABDO EFFORT
4.1 mV
120
PULSE
bpm
40
75
ETCO2
mmHg
0
NASAL PRES
500 mV
Figure W111.
Periodic limb movements in sleep. There is little effect of these movements except some of the
movements appear to be associated with changes in the electroencephalogram (EEG).
EMG1-EMG2
1.02 mV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
LAT-LAT-
256 uV
RAT-RAT-
512 uV
100
SaO2
%
80
THOR EFFORT
16.4 mV
ABDO EFFORT
21.8 mV
90
Pulse
bpm
40
50
ETCO2
mmHg
0
NASAL PRES
250 mV
Figure W112.
Periodic movements in sleep. On examining the electromyogram (EMG), the twitches may have
differing configurations. Here each twitch has a rectangular configuration.
e6 Web Images
EMG1-EMG2
1.02 mV
C3-A2
128 uV
C4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
LAT-LAT-
512 uV
RAT-RAT-
512 uV
100
SaO2
%
80
THOR EFFORT
1.02 mV
100
Pulse
bpm
40
75
ETCO2
mmHg
0
NASAL PRES
62.5 mV
Figure W113.
Periodic movements in sleep. On examining the EMG, the twitches may have differing
configurations. Here each twitch begins with a high-amplitude spike and tapers down
(black/white).
EMG1-EMG2
1.02 mV
C3-A2
128 uV
C4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
LAT-LAT-
512 uV
RAT-RAT-
256 uV
100
SaO2
%
80
THOR EFFORT
1.02 mV
75
ETCO2
mmHg
0
NASAL PRES
62.5 mV
Figure W114.
Periodic movements in sleep. On examining the EMG, the twitches may have differing
configurations. Here each twitch begins with a high-amplitude spike and tapers down (color).
Web Images e7
CHIN(1)
250 uV
C3-A2
125 uV
C4-A1
125 uV
O1-A2
125 uV
O2-A1
125 uV
ROC-A1
125 uV
LOC-A2
125 uV
ECG
2.5 mV
LEG(L)
125 uV
LEG(R)
125 uV
100
SaO2
%
75
THOR RES
x1
ABDO RES
x1
120
PULSE
bpm
40
50
PCO2
mmHg
0
CPAP 20
cmH2O 0
Figure W115.
PLMS interacting with OSA. This 70-year-old patient was referred for evaluation after he was
told by a nurse in hospital after he had had heart surgery, “How can anybody sleep with you?”
The patient has a history of snoring, and the nurse had observed a great deal of movements by
him while he slept. He was iron deficient and had a 50-year snoring and daytime sleepiness
history. There was no history of restless legs. This would be scored as both obstructive apnea
and periodic limb movements.
SEIZURE
LOC-A1
ROC-A1
C3-A1
O2-A1
CHIN1-CHIN2
FP1-F7
F7-T3
T3-T5
T5-O1
FP2-F8
F8-T4
T4-T6
T6-O2
FP1-F3
F3-C3
C3-P3
P3-O1
FP2-F4
F4-C4
C4-P3
P3-O2
ECG1-ECG2
RIGHT IC 1-RIGHT IC 2
Airflow2
125 mV
THOR
1.02 mV
ABD 100.0
80.0
1.37 mV
SaO2
%
Figure W116.
Seizure disorder. This is from the same patient as in Figure W101. Central apneic episode
associated with significant desaturation is the sole manifestation of the seizure. The true nature
of the event (a right-sided seizure) would not be evident without a full seizure montage.
(Contributed by Mark Mahowald, MD.)
e8 Web Images
LOC-A2
85.3 uV
ROC-A1
170.7 uV
C3-A2
170.7 uV
O2-A1
170.7 uV
Chin1-Chin2
128 uV
Fp1-F7
85.3 uV
F7-T3
85.3 uV
T3-T5
85.3 uV
T5-O1
85.3 uV
Fp2-F8
85.3 uV
F8-T4
85.3 uV
T4-T6
85.3 uV
T6-O2
85.3 uV
Fp1-F3
85.3 uV
F3-C3
85.3 uV
C3-P3
85.3 uV
P3-O1
85.3 uV
Fp2-F4
85.3 uV
F4-C4
85.3 uV
C4-P4
85.3 uV
P4-O2
85.3 uV
ECG1-ECG2
1.02 mV
Figure W117.
Seizure disorder. "Rolandic" spikes (seen in benign Rolandic epilepsy). This is the same epoch
as the previous figure except the epoch length is 30 seconds. It is sometimes easier to detect
a pattern with a longer epoch length. (Contributed by Mark Mahowald, MD.)
LOC-A1
ROC-A1
C3-A1
02-A1
CHIN1-CHIN2
FP1-F7
F7-T3
T3-T5
T5-01
FP2-F8
F8-T4
T4-T6
T6-02
FP1-F3
F3-C3
C3-P3
P3-01
FP2-F4
F4-C4
C4-P3
P3-02
ECG1-ECG2
RIGHT IC 1-RIGHT IC2
Airflow2
125 mV
THOR
1.02 mV
ABD 100.0
80.0
1.37 mV
SaO2
%
Fig W118.
Seizure disorder. This is from the same patient as Figure 101. Central apneic episode
associated with significant desaturation is the sole manifestation of the seizure. The true nature
of the event (a right-sided seizure) would not be evident without a full seizure montage.
Contributed by Mark Mahowald MD.
Web Images e9
Artifacts in Sleep Recordings
E2-M130s
E1-M2
F4-M1
C4-M1
O2-M1
F3-M2
C3-M2
O1-M2
Chin1
Chin2
Figure W202.
Artifacts in polysomnography. There are many artifacts that appear in the recordings obtained in
the sleep laboratory. Some of the artifacts merely make some channels noisy, whereas
others make channels completely uninterpretable. Sometimes artifacts actually end up being
useful in the interpretation of the recording or help in understanding the patient’s clinical
status. In this example, there is a broad band of black that appears in four of the channels
(Channels 1, 3, 4, and 5) making it difficult to use them for scoring. Figures W111 and W112
show what can be done in such a situation.
New Web-only Sections
SLEEP STAGING
EMG1-EMG2
1.02 mV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
LAT-LAT-
512 uV
RAT-RAT-
512 uV 100
SaO2
%
90
THOR EFFORT
4.1 mV
ABDO EFFORT
4.1 mV
Pulse 90
50
bpm 75
ETCO2 0
mmHg
NASAL PRES
500 mV
Figure W126.
Sleep stages. Transition from wake to stage N1. Note that alpha activity starts to attenuate
at the middle of the epoch. There are slow eye movements present that start to attenuate
towards the end of the epoch.
e10 Web Images
EMG1-EMG2
102.4 uV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
Figure W127.
Sleep staging. Wakefulness with slow eye movements at the beginning of night. There is a great
deal of alpha activity in the EEG channels.
EMG1-EMG2
102 uV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 uV
LAT-LAT-
512 uV
RAT-RAT-
512 uV
SaO2
%
THOR EFFORT
4.1 mV
ABDO EFFORT
4.1 mV
Pulse
bpm
ETCO2
mmHg
NASAL PRES
500 mV
Figure W128.
Sleep stages. Transition from wake to stage N1. Note that alpha activity starts to attenuate
at the middle of the epoch. There are slow eye movements present that start to attenuate
towards the end of the epoch.
Web Images e11
EMG1-EMG2
102.4 uV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 uV
Figure W129.
Sleep stages. Transition from wake to stage N1. Note that alpha activity starts to attenuate
at the middle of the epoch. There are slow eye movements present that start to attenuate
towards the end of the epoch.
EMG1-EMG2
102.4 uV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 uV
LAT-LAT- 100
512 uV 90
RAT-RAT-
512 uV
SaO2
%
THOR EFFORT
4.1 mV
ABDO EFFORT
4.1 mV
Pulse 90
bpm
50
ETCO2 75
mmHg
0
NASAL PRES
500 mV
Figure W130.
Vertex sharp waves. A sharp wave is seen in central (C4-A1, C2-A2) leads and the occipital
leads (O1-A2, O2-A1) 7 seconds into the epoch. These are most often seen in stage N1.
Spindles start to appear shortly after. The latter are an indicator of Stage N2.
e12 Web Images
EMG1-EMG2
102.4 uV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 uV
Figure W131.
Vertex sharp waves. A sharp wave is seen in central (C4-A1, C2-A2) leads and the occipital
leads (O1-A2, O2-A1) 7 seconds into the epoch. These are most often seen in stage N1.
Spindles start to appear shortly after. The latter are an indicator of Stage N2.
EMG1-EMG2
102 mV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
LAT-LAT- 100
512 uV 90
RAT-RAT-
512 uV
SaO2
%
THOR EFFORT
4.1 mV
ABDO EFFORT
4.1 mV
Pulse 90
bpm
50
ETCO2 75
mmHg
0
NASAL PRES
500 mV
Figure W132.
Sleep stages. Stage N2. This shows sleep spindles and K complexes.
Web Images e13
EMG1-EMG2
102.4 uV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
Figure W133.
Sleep stages. Stage N2. This shows sleep spindles and K complexes.
EMG1-EMG2 O2-A1
102 mV 128 uV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
LAT-LAT- 100
512 uV 90
RAT-RAT-
512 uV
SaO2
%
THOR EFFORT
4.1 mV
ABDO EFFORT
4.1 mV
Pulse 90
bpm
50
ETCO2 75
mmHg
0
NASAL PRES
500 mV
Figure W134.
Sleep stages. Stage N2. Spindles. The window in the middle has captured 1 second of data of
a spindle. There are 12 cycles—typical for spindles.
e14 Web Images
EMG1-EMG2 O2-A1
102.4 mV 128 uV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
Figure W135.
Sleep stages. Stage N2. Spindles. The window in the middle has captured 1 second of data of
a spindle. There are 12 cycles—typical for spindles.
EMG1-EMG2
102 mV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
LAT-LAT- 100
512 uV 90
RAT-RAT-
512 uV
SaO2
%
THOR EFFORT
4.1 mV
ABDO EFFORT
4.1 mV
Pulse 90
bpm
50
ETCO2 75
mmHg
0
NASAL PRES
500 mV
Figure W136.
Sleep stages. Stage N (old stage 3). More than 25% of this epoch is made up of slow (delta)
waves.
Web Images e15
EMG1-EMG2
102.4 mV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
Figure W137.
Sleep stages. Stage N (old stage 3). More than 25% of this epoch is made up of slow (delta)
waves.
EMG1-EMG2
1.02 mV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
LAT-LAT- 100
512 uV 90
RAT-RAT-
512 uV
SaO2
%
THOR EFFORT
4.1 mV
ABDO EFFORT
4.1 mV
Pulse 90
bpm
50
ETCO2 75
mmHg
0
NASAL PRES
500 mV
Figure W138.
Sleep stages. Stage N (old stage 4). Almost the entire epoch is made up of slow-wave sleep.
e16 Web Images
EMG1-EMG2
102.4 mV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
Figure W139.
Sleep stages. Stage N (old stage 4). Almost the entire epoch is made up of slow-wave sleep.
EMG1-EMG2
1.02 mV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
LAT-LAT- 100
512 uV 90
RAT-RAT-
512 uV
SaO2
%
THOR EFFORT
4.1 mV
ABDO EFFORT
4.1 mV
Pulse 90
bpm
50
ETCO2 75
mmHg
0
NASAL PRES
500 mV
Figure W140.
Rapid eye movement (REM) sleep. The eye channels (ROC-A1 and LOC-A2) show rapid eye
movements. There is no chin EMG activity.
Web Images e17
EMG1-EMG2
102.4 mV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
Figure W141.
REM sleep. The eye channels (ROC-A1 and LOC-A2) show rapid eye movements. There is no
EMG chin activity. Sleep scoring channels shown full screen.
EMG1-EMG2
1.02 mV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
LAT-LAT- 100
512 uV 90
RAT-RAT-
512 uV
SaO2
%
THOR EFFORT
4.1 mV
ABDO EFFORT
4.1 mV
Pulse 90
bpm
50
ETCO2 75
mmHg
0
NASAL PRES
500 mV
Figure W142.
Sleep stages. REM sleep. Stage R. There are sawtooth waves just to the right of the middle of
the upper window.
e18 Web Images
EMG1-EMG2
102.4 mV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
Figure W143.
Sleep stages. REM sleep. Stage R. There are sawtooth waves just to the right of the middle of
the upper window.
EMG1-EMG2
1.02 mV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
LAT-LAT- 100
512 uV 90
RAT-RAT-
512 uV
SaO2
%
THOR EFFORT
4.1 mV
ABDO EFFORT
4.1 mV
Pulse 90
bpm
50
ETCO2 75
mmHg
0
NASAL PRES
500 mV
Figure W144.
Sleep stages. Theta activity. This is seen in the middle of the epoch. This rhythm (4–7 cps) can
be found in stages N1 and R.
Web Images e19
EMG1-EMG2
102.4 mV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
Figure W145.
Sleep stages. Theta activity. This is seen in the middle of the epoch. This rhythm (4–7 cps) can
be found in stage N1 and R.
EMG1-EMG2
1.02 mV
C3-A2
128 uV
C4-A1
128 uV
Fr3-A2
128 uV
Fr4-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV
ROC-A1
128 uV
LOC-A2
128 uV
ECG1-ECG2
2.05 mV
LAT-LAT-
512 uV
RAT-RAT-
512 uV
100
SaO2
%
80
THOR EFFORT
2.05 mV
120
Pulse
bpm
40
50
ETCO2
mmHg
0
POSITION
CPAP Pres20
cmH2O 0
NASAL PRES
500 mV
Figure W146.
Sleep staging. Wakefulness with slow eye movements at the beginning of night. There is a great
deal of alpha activity in the EEG channels.
e20 Web Images
Rapid Review of Polysomnographs
C3M2
O1M2
E2M1
E1M2
EKG
EMGSM
FlowN/O
Figure W147.
PSG sample of premature atrial contractions.
C3M2
O1M2
E2M1
E1M2
EKG
EMGSM
FlowN/O
Figure W148.
PSG sample of Wenckebach during Stage R sleep.
Web Images e21
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
FlowN/O
Figure W149.
PSG sample of premature ventricular contractions.
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
FlowN/O
EffortRC
EffortABD
Figure W150.
PSG sample of atrial fibrillations.
e22 Web Images
E2M1
E1M2
C3M2
O1M2
EMGSM
EKG
FlowN/O
EffortRC
EffortABD
Figure W151.
PSG sample of EKG sinus pauses.
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
FlowN/O
Figure W152.
PSG sample of bigeminy.
Web Images e23
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
FlowN/O
EffortRC
EffortABD
Figure W153.
PSG sample of a long run of tachycardia.
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
FlowN/O
EffortRC
EffortABD
Figure W154.
PSG sample of ventricular tachycardia.
e24 Web Images
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
FlowN/O
Figure W155.
PSG sample of ventricular tachycardia.
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
FlowN/O
EffortRC
EffortABD
Figure W156.
PSG sample of quadrigeminy.
Web Images e25
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
FlowN/O
EffortRC
EffortABD
Figure W157.
PSG sample of Mobitz II.
E2M1
E1M2
EMGSM
F4M1
O4M1
O2M2
EKG
Figure W158.
PSG sample of bundle branch block.
e26 Web Images
WAKE
REM
N1
N2
N3
Figure W159.
Histogram for patient with congestive heart failure.
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
Snore
FlowNP
FlowN/O
EffortRC
EffortABD
SaO2
Figure W160.
PSG sample from a patient with mixed apnea episodes and abnormal EKG.
Web Images e27
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
Figure W161.
PSG sample of abnormal EKG in a patient with mixed apnea episodes.
WAKE
REM
N1
N2
N3
SaO2
Time
Figure W162.
Histogram from a patient with chronic obstructive pulmonary disease-obstructive sleep apnea
(COPD-OSA) overlap syndrome.
e28 Web Images
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
FlowN/O
Figure W163.
PSG sample of an EKG sinus pause in a patient with COPD-OSA overlap syndrome.
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
FlowN/O
Figure W164.
PSG sample of EKG couplets in a patient with COPD-OSA overlap syndrome.
Web Images e29
WAKE
REM
N1
N2
N3
SaO2
Time
Figure W165.
Histogram from a patient with insomnia associated with pain.
C3M2
O1M2
E2M1
E1M2
EMGSM
Figure W166.
PSG sample of EEG alpha intrusions in a patient with insomnia associated with pain.
e30 Web Images
F3M2
C3M2
O1M2
E2M1
E1M2
EMGSM
Figure W167.
PSG sample of EEG alpha-delta sleep in a patient with insomnia associated with pain.
C3M2
O1M2
E2M1
E1M2
EMGSM
EMGLAT
EMGRAT
FlowNP
FlowN/O
Figure W168.
PSG sample of cyclic alternating pattern activity (2.5-minute tracing).
Web Images e31
F3M2
C3M2
O1M2
E2M1
E1M2
EMGSM
Figure W169.
PSG sample of cyclic alternating pattern activity (30-second tracing).
E1M2
E2M1
EMGSM
F4M1
C4M1
O2M1
EKG
EMGLAT
EMGRAT
Snore
FLOWN/O
Figure W170.
PSG sample of PLM-associated cyclic alternating pattern activity with a missing leg movement.
e32 Web Images
WAKE
REM
N1
N2
N3
Time
Figure W171.
Histogram from patient with restless legs syndrome.
E2M1
E1M2
C3M2
O1M2
EMGSM
EMGRAT
EMGLAT
FlowN/O
Figure W172.
PSG sample of restless leg activity—type 1.
Web Images e33
C3M2
O1M2
EMGSM
E2M1
E1M2
EMGRAT
EMGLAT
Snore
FlowN/O
Figure W173.
PSG sample of restless leg activity—type 2.
C3M2
O1M2
E2M1
E1M2
EKG
EMGSM
EMGRAT
EMGLAT
Snore
FlowN/O
Figure W174.
PSG sample restless leg activity—type 3.
e34 Web Images
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
EMGRAT
EMGLAT
FlowN/O
Figure W175.
PSG sample of periodic leg movements—right leg.
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
EMGRAT
EMGLAT
Snore
FlowN/O
Figure W176.
PSG sample of periodic leg movements—left leg.
Web Images e35
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
EMGRAT
EMGLAT
FlowN/O
Figure W177.
PSG sample of periodic leg movements—both legs simultaneously.
F3M2
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
EMGRAT
EMGLAT
FlowN/O
Figure W178.
PSG sample of periodic leg movements—both legs slightly offset.
e36 Web Images
C3M2
E2M1
E1M2
EMGSM
EKG
EMGRAT
EMGLAT
EMGIC
FlowN/O
Figure W179.
PSG sample of periodic leg movements—alternating legs.
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
EMGRAT
EMGLAT
FlowN/O
Figure W180.
PSG sample of periodic leg movements with CNS arousal (2-minute tracing).
Web Images e37
E2M1
E1M2
C3M2
O1M2
EMGSM
EMGRAT
EMGLAT
FlowN/O
Figure W181.
PSG sample of periodic leg movements with CNS arousal (15-second tracing).
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
EMGRAT
EMGLAT
Snore
FlowNP
FlowN/O
EffortRC
EffortABD
SaO2
Figure W182.
PSG sample of obstructive apnea episodes.
e38 Web Images
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
EMGRAT
EMGLAT
Snore
FlowNP
FlowN/O
EffortRC
EffortABD
SaO2
Figure W183.
PSG sample of mixed apnea episodes.
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
EMGRAT
EMGLAT
Snore
FlowN/O
EffortRC
EffortABD
SaO2
Figure W184.
PSG sample of obstructive hypopnea episodes.
Web Images e39
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
EMGRAT
EMGLAT
Snore
FlowNP
FlowN/O
EffortRC
EffortABD
SaO2
Figure W185.
PSG sample of respiratory effort related to arousal episodes.
C3M2
O1M2
E2M1
E1M2
EMGSM
EMGRAT
EMGLAT
EKG
Snore
FlowN/O
EffortRC
EffortABD
SaO2
Figure W186.
PSG sample of central apnea episodes.
e40 Web Images
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
EMGRAT
EMGLAT
Snore
FlowN/O
EffortRC
EffortABD
SaO2
Figure W187.
PSG sample of Cheyne Stokes respiration episodes.
EMGSM
C3M2
C4M1
O1M2
O2M1
E2M1
E1M2
EKG
EMGRAT
EMGLAT
Snore
FlowN/O
EffortRC
SaO2
Figure W188.
PSG sample of a nocturnal leg cramp.
Web Images e41
F3M2
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
EMGRAT
EMGLAT
Snore
FlowN/O
Figure W189.
PSG sample of a sleep bruxism episode.
E2M1
E1M2
EMGSM
C3M2
C4M1
O1M2
O2M1
T3M2
T4M1
EKG
EMGRAT
EMGLAT
Snore
FlowN/O
Figure W190.
PSG sample of a REM sleep behavior disorder episode.
e42 Web Images
E2M1
E1M2
EMGSM
C3M2
C4M1
O1M2
O2M1
T3M2
T4M1
EKG
EMGRAT
EMGLAT
Snore
FlowN/O
Figure W191.
PSG sample of a REM sleep behavior disorder episode with concurrent EEG spike activity.
F4M1
C4M1
O2M1
E2M1
E1M2
EMGSM
EKG
EMGRAT
EMGLAT
Snore
FlowN/O
Figure W192.
PSG sample of sleep talking.
Web Images e43
E2M1
E1M2
EMGSM
C3M2
C4M1
O1M2
O2M1
EKG
EMGRAT
EMGLAT
Snore
FlowN/O
Figure W193.
PSG sample of awakening from nightmare.
C3M2
O1M2
E2M1
E1M2
EMGSM
Figure W194.
PSG sample of an isolated EEG spike and wave.
e44 Web Images
E2M1
E1M2
C3M2
C4M1
O1M2
O2M1
EMGSM
Figure W195.
PSG sample of intermittent EEG spikes.
E2M1
E1M2
EMGSM
C3M2
O1M2
EKG
EMGRAT
EMGLAT
Figure W196.
PSG sample of a brief EEG spike and wave episode.
Web Images e45
C3M2
O1M2
C4M1
O2M1
T3T5
T4T6
E2M1
E1M2
EMGSM
Figure W197.
PSG sample of an EEG spike and wave episode.
F3M2
C3M2
O1M2
E2M1
E1M2
EMGSM
Figure W198.
PSG sample of rapid eye movements in non-rapid eye movement (NREM) sleep.
e46 Web Images
F3M2
C3M2
O1M2
E2M1
E1M2
EMGSM
EKG
Figure W199.
PSG sample of excessive EEG sleep spindle activity.
F3M2
C3M2
O1M2
E1M2
E2M1
EMGSM
EKG
Figure W200.
PSG sample of excessive rapid eye movement activity in Stage R sleep.
Web Images e47
C3M2
O1M2
C4M1
O2M1
EKG
FlowN/O
Figure W201.
PSG sample of sweat artifact.