Otolaryngol Clin N Am

40 (2007) 713–743

Interpretation of the Adult

Polysomnogram
Rahul K. Kakkar, MD, FCCPa,b,*,
Gilbert K. Hill, RPSGTa
a
North Florida South Georgia VAHS Sleep Disorders Center, #111A,
Malcom Randall Veterans Administration Medical Center,
1601 Archer Road, Gainesville, FL 32608, USA
b
Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida,
PO Box 100225, JHMHC, Gainesville, FL 32610-0225, USA

The term ‘‘polysomnography’’ (PSG) has Greek and Roman roots, and
refers to the recording of multiple sleep-related signals. It employs various
methods to simultaneously and continuously record neurophysiological,
cardiopulmonary, and other physiological parameters over the course of
several hours, usually during an entire night (overnight polysomnography).
PSG provides information on the physiological changes occurring in many
different organ systems in relation to sleep stages and wakefulness. It allows
qualitative and quantitative documentation of abnormalities of sleep and
wakefulness, sleep-wake transition, and of physiological function of other
organ systems that are influenced by sleep. Many of these, such as sleep
apnea, may not be present during wakefulness.
Four types of sleep studies are available, depending upon the number of
physiological variables recorded [1]:
Level I. Standard PSG with a minimum of seven parameters measured,
including electroencephalogram (EEG), electro-oculogram (EOG),
chin electromyogram (EMG), and EKG, as well as monitors for air-
flow, respiratory effort, and oxygen saturation. A technician is in con-
stant attendance.
Level II. Comprehensive portable PSG studies are essentially the same,
except that a heart rate monitor can replace the ECG and a technician
is not in constant attendance.

* Corresponding author. North Florida South Georgia VAHS Sleep Disorders Center,
#111A, Malcom Randall Veterans Administration Medical Center, 1601 Archer Road,
Gainesville, FL 32608.
E-mail address: rahul.kakkar@medicine.ufl.edu (R.K. Kakkar).

0030-6665/07/$ - see front matter. Published by Elsevier Inc.

doi:10.1016/j.otc.2007.04.003 oto.theclinics.com
714 KAKKAR & HILL

Level III. Modified portable sleep apnea testing is a cardiorespiratory

study in which a minimum of four parameters must be measured, in-
cluding ventilation (at least two channels of respiratory movement,
or respiratory movement and airflow), heart rate or EKG, and oxygen
saturation. Ventilation in this case is measured with at least two chan-
nels of respiratory movement or of airflow. Personnel are needed for
preparation, but the ability to intervene is not required for all studies.
Level IV. Continuous (single or dual) bioparameter recordings where
devices that measure a minimum of one parameter, usually oxygen
saturation are utilized.

This article focuses on interpretation of Level I studies (attended PSG).

According to the recently revised criteria published by the American Acad-
emy of Sleep Medicine (AASM), the following parameters should be re-
corded: Electroencephalogram (EEG) derivations (frontal, central and
occipital) (Fig. 1), bilateral Electrooculogram (EOG) (Fig. 2), Chin electro-
myogram (EMG) (Fig. 3), leg EMG, airflow, respiratory effort, oxygen

Fig. 1. The EEG electrodes are placed using the conventional 10–20 system. For sleep recording
and staging, the current standards require monitoring of at least central (C3, C4) and occipital
(O1, O2) derivations. Additional EEG electrodes can be placed depending on the need. The new
AASM standards to be published in spring 2007 will require frontal derivations to be recorded
as well. (Courtesy of Compumedics USA, El Paso, Texas; with permission.)
 INTERPRETATION OF THE ADULT POLYSOMNOGRAM 715

Fig. 2. Placement of EOG electrodes. See text for details. (Courtesy of Compumedics USA,
El Paso, Texas; with permission.)

saturation and body position [2]. EKG is recorded routinely during all PSG
studies. Video monitoring during a PSG, although not required, is extremely
valuable, both from a diagnostic as well as medico-legal perspective.
Additional variables can be recorded according to patient age, standards
of the sleep laboratory, and indication for performing the study. Examples

Fig. 3. Placement of submental EMG electrodes. A third electrode is often used and placed
under the chin. (Courtesy of Compumedics USA, El Paso, Texas; with permission.)
716 KAKKAR & HILL

of such additional variables include end-tidal carbon dioxide monitoring

(EtCO2), 16-channel EEG recording for seizures, esophageal pressure
monitoring (Pes), and pulse transit time (PTT). AASM [formerly The
American Sleep Disorders Association (ASDA)] recommends performing
at least 6 hours of overnight recording [1]. The neurophysiological, EKG,
and sound channels are sampled at 100 to 1000 Hz with 12- to 20-bit reso-
lution, respiratory mechanical channels at 50 Hz, and pulse oximetry and
body position, at a significantly lower rate. The modern day computerized
PSG systems provide powerful tools for technicians and physicians to cus-
tomize data acquisition. One can change reference electrodes, resolution,
and sensitivity, and add or remove digital filters to minimize recording arti-
facts. Many of these functions can be performed even after the data have
been acquired, which allows interpretation of the studies despite malfunc-
tion of certain equipment during the recording.
EEG is the recording of surface electrical activity of the brain. Only limited
EEG data are obtained during a PSG recording to help identify stages of sleep
and wakefulness. EOG is the recording of eye movements during sleep and
wakefulness. The cornea and retina form a dipole, with the cornea being neg-
ative in relation to the retina. A movement in the eyes changes the electrical
signal in the EOG electrodes, which is recorded as a deflection. The EOG
electrodes are placed slightly outside the outer canthus of each eye, with
one electrode being slightly lower than the other (see Fig. 2). This enables de-
tection of horizontal as well as vertical movements of the eyes. EEG, EOG,
and submental EMG are essential for sleep staging. Submental and leg
(tibialis anterior) EMG recordings are performed routinely during PSG.
The submental EMG recordings are essential for scoring sleep stages, espe-
cially rapid eye movement (REM) sleep. Three electrodes are placed for
submental EMG recordings, in order to have a backup in case one of them
malfunctions during the sleep study (see Fig. 3). Typically, the submental
EMG tone is lowest during REM sleep. It is also helpful in detecting sleep
bruxism (see below). Bilateral leg EMG recordings are used to diagnose
periodic limb movements of sleep (PLMS). Additional EMG recordings
can be used under special circumstances. For example, both upper and lower
extremity EMG can be recorded for suspected REM behavior disorder
(RBD), and gastrocnemius muscle EMG could be recorded for diagnosing
nocturnal leg cramps. Snoring is recorded with a microphone, and airflow
is measured with the help of a thermistor or with a nasal pressure monitor.
The thermistor measures changes in the electrical conductance in response
to temperature changes in the probe, which occur with inspiration and
expiration. Continuous recording of body position by an accelerometer is
important, because snoring and upper airway obstruction during sleep are
influenced by gravity [3,4]. The most common indication for performing
a PSG is diagnosis of sleep disordered breathing (SDB) and its treatment
with positive airway pressure (PAP). Other indications for PSG include:
evaluation for effectiveness of alternative treatments for SDB (eg, dental
 INTERPRETATION OF THE ADULT POLYSOMNOGRAM 717

appliances or surgical procedures, diagnosis of sleep-related seizures,

parasomnias, and evaluation of erectile dysfunction with nocturnal penile
tumescence [NPT]).

Important considerations
Polysomnography is considered to be the ‘‘gold standard’’ for diagnosing
SDB and other sleep disorders. A gold standard should have 100% sensitivity
and specificity [5]; however, like most other diagnostic tests, PSG is not ideal,
but rather the best available method to diagnose SDB. Furthermore,
breathing disturbances may vary from night to night within certain limits
[6,7]. Some sleep disorders such as nocturnal laryngospasm, sleep-related
epilepsy, or parasomnias that occur episodically may be missed in a one-night
recording [8].
A PSG should always be interpreted in light of a patient’s clinical history.
The physician’s orders should be reviewed to determine the reason for
obtaining the PSG and for the type of study requested. The interpreting
physician should ascertain that the PSG was performed as requested. If
a split-night study (diagnostic and PAP titration in the same night) was
ordered but the patient has difficulty sleeping, demonstrates only mild ob-
structive sleep apnea (OSA), or does not tolerate the PAP trial, it is helpful
to write a brief explanation as to why PSG was not performed as requested.
This helps the referring physician to decide whether to order another study
with PAP trial, or to refer the patient for alternative therapies.
It is pertinent to review the referring physician’s notes and the prestudy
questionnaire before interpreting PSG. The referring physician’s notes
provide information on comorbid conditions that may increase the likeli-
hood of prevalence of certain sleep disorders. For example, heart failure
with ejection fraction of less than 40% increases the risk of having
Cheyne-Stokes breathing, hypothyroidism increases the likelihood of having
OSA, and Parkinson’s disease is associated with higher incidence of RBD.
The physician’s notes are also helpful in explaining certain findings on
the PSG, such as cardiac arrhythmias or abnormal oxygen saturation at
baseline.
Generally, each patient is given a pre-study questionnaire to fill out
before performing the PSG. This questionnaire provides sleep history in
greater detail than is usually available otherwise. The questionnaire is
intended to obtain information on patient’s sleep-wake schedule and various
sleep symptoms such as snoring, excessive daytime sleepiness, witnessed
apneas, irresistible urge to move legs, dream enactment, teeth grinding,
cataplexy, and so forth. The patient’s usual bedtime and rise time are taken
into account when commenting on sleep latency and efficiency (see below).
Some degree of insomnia can be expected in the unfamiliar environment of
the sleep laboratory, especially on the first night (first-night effect) [9].
718 KAKKAR & HILL

Most questionnaires also incorporate the Epworth Sleepiness Scale (ESS)

[10,11]. ESS has eight questions about subjective sleepiness under routine
activities, and the patient answers them on a scale of 0 to 3, the highest pos-
sible score being 24 (Appendix, Table 1). A score of 12 or more is indicative
of excessive daytime sleepiness, whereas a score of 10 to 12 is considered
borderline. It should be noted that many patients who have SDB and low
ESS score may show hypersomnia on objective measures such as the Multi-
ple Sleep Latency Test (MSLT) [12]. The patient is also asked about any
sedatives taken before the PSG. The authors do not administer, nor do
we recommend administering, any medications (other than patient’s usual
regimen) for the purpose of promoting sleep during PSG recording. Most
patients are able to sleep for sufficient duration in the sleep laboratory to
allow acquisition of interpretable data.
Because most sleep centers do not have nurses at night, dispensing the
medications and assessment of patients before discharge after the study
may compromise patient safety if medications are administered for the sleep
study. Sedatives have unpredictable side effects, and may impair the
patient’s driving ability the next morning. They also skew the sleep archi-
tecture, can potentially worsen obstructive sleep apnea or attenuate central
sleep apnea, RBD, and PLMS, thus interfering with the diagnosis. Other
medications, which could affect sleep, should also be noted. For example,
many antidepressants suppress REM sleep and increase EMG tone during
REM sleep.
The importance of technician comments cannot be overemphasized,
because they provide an excellent source of additional information. The
technician should fill out a checklist, which includes information about noc-
turnal oxygen usage, sedative, and alcohol usage among other things. The
technician also makes notes of additional monitoring performed during
the study (EtCO2, Pes) so that the reviewing physician can modify the mon-
tage when analyzing PSG data. Any technical difficulties encountered during
the recording and any specific problems encountered by the patient, such as
pain, panic, or breathing difficulty, that could be corroborated with the PSG
findings are also mentioned. If a PAP titration is performed, the technician
makes note of types of interfaces tried, interface with the best fit, patient
preference for a specific interface, mouth breathing, use of humidifier, chin-
strap, and use of bi-level PAP. Each time a change is made in PAP setting,
the technician cites the reason for this. All this information should be taken
into account for correct interpretation of a PSG.
Last but not the least, a post-study questionnaire completed by the
patient after the PSG provides an important insight into the patient’s overall
experience. If PAP titration was performed, it is important to note the
patient’s attitude toward PAP therapy. Specific problems reported by the
patient during PAP titration (eg, nasal congestion, claustrophobia or pres-
sure intolerance), can be specifically targeted and the treatment tailored to
individual needs of the patient.
 INTERPRETATION OF THE ADULT POLYSOMNOGRAM 719

Video recording
The authors routinely perform video recording on all patients coming to
our sleep laboratories, and a written consent for this is obtained from every
patient. Video recording should begin from the time of starting the hookup,
and should continue until the study is completed. It provides objective
assessment of seizures, sleep-related movement disorders, and parasomnias.
It can also be used to confirm the patient’s position in case of doubt. It may
sometimes be possible to see mouth opening and paradoxical respiratory
movements on the video. Video also provides added security to the
patient and the laboratory personnel from inappropriate interaction or
allegations of such an interaction. The video files typically consume a large
amount of storage space. DVD and tape drives are the currently preferred
methods of storing video data.

Electroencephalography and electro-olfactography

A standard 10 to 20 EEG electrode placement system is used in placing
the electrodes for recording of sleep (see Fig. 1). The recommended standard
derivations for EEG recording are F4-M1, C4-M1, O2-M1. The EOG elec-
trodes (ROC and LOC) are placed as shown in Fig. 2. Mastoid (auricular)
electrodes are used as references. Conventionally right-sided electrodes are
assigned even numbers (C4, O2) and left sided electrodes are assigned an
odd number (C3, O1). The EEG electrodes could be referenced to mastoid
electrodes (M1 and M2 [A1 and A2 in older terminology]) (see Fig. 1) or to
a common reference electrode. Typically right-sided electrodes (O2, C4 and
ROC) are referenced to left mastoid (M1) electrode and left sided electrodes
(O1, C3 and LOC) are referenced to right sided electrodes (M2). The
drawback of using mastoid electrodes is that EKG artifact commonly
appears in these electrodes making it difficult to staging sleep in some old
systems (Fig. 4). With the older systems, placing the auricular electrodes
higher, jumping the two auricular electrode, or using a common reference
electrode can minimize EKG artifact. The newer PSG systems use software
to filter EKG artifact.
Before reviewing digital PSG, it is important to ensure proper setting of
the desktop display for resolution. It is recommended that the monitor for
reviewing PSG should have a resolution of at least 1280  1024 and be
20 inches or larger for proper identification of waveforms and sleep staging
and video reviewing [13]. The digital systems allow creation, storage, and in-
dividual configuration of several different montages for different users. One
can adjust the sensitivity, trend color, and display range among many other
variables. The display range is usually between 10 to 480 seconds. Sleep
is usually staged according to the Rechtschaffen and Kales criteria in
30-second epochs [1]. In case of difficulty, reducing the display range to
10 seconds is helpful in recognition of EEG waveforms. On the other
720 KAKKAR & HILL

Fig. 4. EKG artifact (solid arrows). Note the presence of prominent EKG artifact in the EEG
(C3, C4, O1, and O2) and EOG (ROC, LOC) channels. It persisted despite re-referencing the
derivations to average (AVG) of all electrodes.

hand, detection of certain respiratory patterns is better appreciated by

compressing the waveforms obtained over 60 to 480 seconds on the screen
(Fig. 5).
Another important consideration is checking the biocalibration data.
Before the actual sleep recording is started, the technicians ask patients to
perform certain voluntary maneuvers such as closing and opening of the
eyes, moving the eyes vertically and horizontally, moving the legs, clenching
the teeth, rapid breathing, and breath holding. This is useful in ensuring that
all the electrodes are functioning and are recording the signal as intended.
These waveforms serve an important reference for comparison later during
the sleep study. The technicians also check and document impedance in the
beginning and periodically during the study, to ensure accuracy of the
recorded parameters.

Sleep staging
Until recently sleep staging was based on the original Rechtschaffen and
Kales’ criteria devised more than 30 years ago. The AASM task force has
recommended implementation of new criteria for sleep staging, which will
replace the current staging system [2]. Sleep is now scored in the following
stages; stage awake (W), NREM stages 1, 2, 3 ( N1, N2 and N3 respectively)
and stage REM (R) sleep. EEG, EOG and chin EMG are required to score
 INTERPRETATION OF THE ADULT POLYSOMNOGRAM 721

Fig. 5. Value of different display ranges. (A) Displaying the trends in 10-second range increases
the resolution of EEG waveforms. Alpha waves are clearly recognized in the EEG (C3, C4, O1,
and O2) tracings. Frequency is determined by counting the ‘‘peaks’’ in one-second interval. (B)
Displaying the data in a compressed format (display range 480 seconds) accentuates the classi-
cal pattern of Cheyne-Stokes breathing.

the sleep stages. The identification of EEG waveforms is helpful in scoring

sleep. The central leads (C4 and C3) are most helpful in the identification of
EEG waveforms, except alpha waves, which are most prominent in the
occipital leads.
There are four different waveforms based upon the frequency of the
rhythm, alpha waves are fast frequency (8–12 Hz) (Fig. 6). Beta waves
(Fig. 7) consists of fast frequency of greater than 13 Hz. They are most
722 KAKKAR & HILL

Fig. 6. The arrow points towards alpha waves (30-second montage; vertical grid lines are
1 second apart). Note that they are most prominent in occipital leads.

Fig. 7. Beta waves (black arrows) recorded during a documented period of wakefulness during
the PSG (see technician notations on top and bottom of (A). (A) 30-second and (B) 10-second
display periods showing difference between beta and alpha (white arrows) rhythms.
 INTERPRETATION OF THE ADULT POLYSOMNOGRAM 723

prominent during stage awake and eyes open. They are of low amplitude
and disappear during sleep. The frequency for theta waves ranges from
4–8 Hz (Fig. 8) and for delta waves it is less than 4 Hz (Fig. 9). Theta
frequency is the most prevalent frequency seen during a polysomnography.
In addition to these four frequencies, four morphologic waveforms are
important. Vertex waves are sharp negative waves (in EEG terminology,
a negative wave causes an upward deflection) (Fig. 10). They first appear
in stage N1 sleep and are most abundant during stage N2 sleep. K-complex
is a biphasic wave with an initial upward (negative) deflection followed by
a slower downward (positive) deflection (see Fig. 8). Sleep spindles are
so-named because of their characteristic shape. They have a frequency of
12 to 14 Hz and duration of 0.5 to 1.5 seconds (Fig. 11). K-complexes
and sleep spindles are characteristic of stage 2 sleep. Sawtooth waves also
have a characteristic appearance (Fig. 12). They have low amplitude and
are in the theta frequency.
Staging of sleep is performed in 30-second epochs, and is more of
a pattern recognition exercise. An epoch is assigned a sleep stage according
to the predominant stage present in that epoch. Stage awake with open eyes
is characterized by presence of low amplitude beta rhythm. Stage awake
with eyes closed is characterized by prominent alpha waves (see Fig. 6).
As the patient becomes drowsy, slow lateral eye movements (SEM) are often
seen while alpha activity is still prominent (Fig. 13). Stage N1 sleep is the
most difficult of all stages to recognize because it is not defined by the pres-
ence of any particular waveform, but rather by the disappearance of alpha

Fig. 8. Theta waves (black arrow) and K-complexes (white arrows) in a patient in stage 2 sleep
(30-second montage; vertical grid lines are 1 second apart).
724 KAKKAR & HILL

Fig. 9. The solid arrows point towards the delta waves (30-second montage; vertical grid lines
are 1 second apart). For sleep staging, the duration should be at least 0.5 sec (frequency 2 Hz or
less) and amplitude should be more than 75 mV. The reference marker for voltage is displayed
in lower right hand corner (broken arrow).

waves and the onset of a mixed frequency, low amplitude pattern. Other
clues to the presence of stage N1 sleep are the appearance of SEM, a decrease
in EMG tone, and the appearance of vertex waves (although they are not
required to identify stage N1 sleep). Appearance of K-complexes and sleep

Fig. 10. Vertex waves, shown by the solid arrow, in a series (30-second montage; vertical grid
lines are 1 second apart). Note that they do not have a component of positive (downward)
deflection and are much narrower than K-complexes. They appear in stage 1 sleep, but are most
prominent during stage 2 sleep.
 INTERPRETATION OF THE ADULT POLYSOMNOGRAM 725

Fig. 11. Sleep spindles, shown by the solid arrow, (10-second montage; vertical grid lines are
1 second apart). Note the characteristic shape, frequency and duration.

Fig. 12. Sawtooth waves (solid arrow). Note characteristic appearance. They are in theta
frequency and are most prominent during REM sleep.
726 KAKKAR & HILL

Fig. 13. Stage 1 sleep. Note the onset of low amplitude, mixed frequency waveforms in EEG
channels and slow eye movements (SEM) in EOG channels.

spindles is diagnostic of stage N2 sleep. Previously stages 3 and 4 were

scored separately. According to new terminology they are scored together
as stage N3. This stage is also called delta sleep. These waves are character-
ized by amplitude of at least 75 mV, and must have a frequency of 2 Hz or
less. Thus all delta waves do not qualify to be scored for the purpose of
defining stage N3 sleep. If delta waves occupy more than 20% of the epoch,
it is scored as stage N3; if they occupy more than 50% of the epoch, it is
scored as stage 4 sleep. REM sleep is defined by the presence of rapid eye
movements (Fig. 14) and decrease in submental EMG tone to its lowest level
(REM atonia). It is important to differentiate REM from SEM activity,
because the background EEG frequencies during REM sleep and stage 1
may look very similar to each other. Sawtooth waves are also seen predom-
inantly during REM sleep, but are not required to score REM sleep.
Abundance of sawtooth waves and absence of vertex waves helps differen-
tiate REM sleep from stage 1 sleep. An arousal is defined as an abrupt
change in the EEG frequency to alpha, theta, or faster frequency lasting
at least 3 seconds [14]. If only delta waves or K-complexes occur, it is not
scored as an arousal. An arousal in non-REM (NREM) sleep requires
only a shift in the EEG frequency, whereas to score an arousal during
REM sleep, both a shift in EEG frequency and an increase in submental
EMG tone are required [14].
 INTERPRETATION OF THE ADULT POLYSOMNOGRAM 727

Fig. 14. REM. Notice sharp deflections in EOG channels and compare them with SEM shown
in Fig. 13. Normal ‘‘phasic’’ bursts in leg EMG during REM sleep are also present (arrows).

A sleep hypnogram is a summary of the entire night’s PSG data in

a graphic form (Fig. 15). It gives a good snapshot of sleep architecture,
distribution of respiratory events, and oxygen saturation trends in different
sleep stages, sleep position, and at different times of the study night. It is

Fig. 15. Hypnogram. (Courtesy of Compumedics USA, El Paso, Texas; with permission.)
728 KAKKAR & HILL

helpful to open a window for the hypnogram simultaneously while review-

ing the PSG. This allows one to easily select the part of the study one may
wish to see. One can also switch the epochs rapidly for comparison of sleep
stages and efficacy of different PAP settings.
The most relevant parameters are: total recording time, total sleep time
(TST), sleep period time (SPT), time in bed (TIB), sleep efficiency (SE), sleep
latency and REM sleep latency, and sleep stage distribution. These are typ-
ically expressed in minutes (except sleep efficiency, which is a percentage). It
is also important to note the percentage of time spent in the supine position.
Total recording time is the interval from the beginning of the sleep recording
to the end of the sleep recording. In addition to TST, it comprises the time
taken up by wakeful periods. TST is the amount of actual sleep time in
a sleep episode. TST is the total of all REM and NREM sleep in a sleep ep-
isode. SPT is the period of time measured from sleep onset to final awaken-
ing. In addition to the TST, it comprises the time taken up by arousals and
movement time (MT) until wake-up. SE is the percentage of time actually
spent sleeping during the period when the patient is given an opportunity
to sleep. Thus, it is the percentage of TST during TIB. Sleep efficiency above
85% is considered to be normal. SE is reduced in the elderly and in patients
who have insomnia. It is generally reduced in patients who have narcolepsy,
as opposed to patients who have idiopathic hypersomnia, in whom very high
sleep efficiency is seen (sometimes O99%). It could be high or low in pa-
tients who have SDB, depending upon the degree of sleepiness and the sever-
ity of sleep fragmentation with respiratory events. PAP and medications can
variably affect SE, whereas psychiatric conditions, pain syndromes, breath-
ing difficulties, and urinary symptoms usually decrease it.
Sleep latency (SL) is the time elapsed between lights out to the first epoch
of sleep (usually stage 1). Normal adult SL is considered to be 10 to 25 min-
utes. Generally, it is shortened in sleep deprivation and SDB, and in condi-
tions causing hypersomnia. It may be falsely prolonged in an otherwise
sleepy patient who has taken a nap in the afternoon before coming to the
sleep center, in patients who have late bedtime (delayed sleep phase), or in
shift workers. It may be prolonged in patients who have restless legs syn-
drome (RLS) and insomnia. RLS may be suspected in patients who have
prolonged SL, and a notation of irresistible desire to move their legs at night
in the sleep questionnaire, and characteristic movements may be evident on
video recording. RLS is a clinical diagnosis, however, and should not be di-
agnosed by PSG. When RLS is suspected, one should alert the referring
physician toward this possibility in the final report. Thus prestudy question-
naire, medical history, medications, and technician notes are important
when commenting on abnormal SL.
REM sleep latency (RL) is defined as the time elapsed from the onset of
sleep to the first epoch of REM sleep. Thus RL may not necessarily be pro-
longed with the prolonged SL. A short REM sleep latency on nocturnal PSG
(as opposed to MSLT) is most commonly seen in narcolepsy, depression, and
 INTERPRETATION OF THE ADULT POLYSOMNOGRAM 729

with certain medications such as bupropion [15–17]. It hasbeen also been

reported in normal individuals who have SDB [18]. Other potential causes
include sleep deprivation, withdrawal from REM suppressants such as
tricyclic, monoamine oxidase inhibitors (MAOI), withdrawal from selective
serotonin reuptake inhibitors (SSRI), serotonin and noradrenaline reuptake
inhibitors (SNRI) antidepressants, withdrawal from alcohol, and SDB.
Sleep stage distribution varies with age [19]. NREM sleep constitutes
about 75% to 80% of sleep, in which stage N2 is the most abundant
(45%–55%), followed by stage N3 (13%–23%), and stage 3 (3%–8%).
REM sleep constitutes about 20% to 25% of sleep time [19]. In general,
slow wave sleep and REM sleep decrease with age, whereas sleep latency,
stage N1 sleep, and wake after sleep onset (WASO) increase with age [20].
When interpreting a PSG for SDB, it is important to note if REM sleep
was recorded, and whether any REM sleep was noted in the supine position.
This is important both during the diagnostic and the PAP titration studies,
because OSA is generally more severe during REM sleep and in the supine
position [3,4]. One must note whether the therapeutic pressure chosen after
the PAP trial was effective during REM sleep and in the supine position.
Sometimes prolonged periods of REM sleep are observed during PAP titra-
tion, representing a rebound phenomenon from chronic REM sleep depriva-
tion in sleep apneics. During these periods, oxygen desaturation may be
significant, and occasionally worse than the degree of hypoxemia seen
during the diagnostic study. Clinical judgment is required to make a decision
on whether a pressure increment is warranted, and depends on severity of
desaturations, frequency and length of respiratory events, snoring, pressure
intolerance, mask leaks, and existence of concurrent cardiopulmonary con-
ditions. Sometimes supplemental oxygen is required to alleviate hypoxemia.
Before prescribing supplemental oxygen with PAP, one should bear in mind
that the oxygen concentrators used at home deliver only low flow of oxygen
(maximum 6 liters per minute [LPM]), which further gets significantly
diluted by the high flows of PAP [21]. In addition, the concentrators are
bulky, noisy, and cumbersome. Overnight pulse oximetry is an inexpensive
way to determine if the patient has significant oxygen desaturation while
using PAP at home.

Electromyography and leg movements

Submental and bilateral leg EMG recordings are standard during a PSG
recording. The submental EMG is essential for scoring REM sleep, and is at
its lowest amplitude during REM sleep. A useful way to discern this is to
increase the sensitivity of EMG and compare the amplitude to that recorded
during other sleep stages. Short bursts in leg or submental EMG associated
with eye movements during REM sleep is a normal finding (see Fig. 14) and
should not be confused with periodic limb movements (PLM) (Figs. 16).
730 KAKKAR & HILL

Fig. 16. Periodic limb movements causing arousals.

According to the old definition, periodic limb movements are character-

ized by occurrence of short bursts of EMG activity in limb EMG channels
lasting 0.5–5 seconds and are associated with flexion of knee, dorsiflexion of
ankle and extension of great toe. Scoring requires at least a sequence of four
movements occurring at least 5 seconds apart and not more than 90 seconds
apart [22]. This definition required that EMG tone must increase by at least
25% of baseline [22]. According to the World Association of Sleep Medi-
cine, PLMS can be scored up to 10 seconds in duration and must have an
absolute threshold value of 8 mV at the onset [23]. This new definition of
PLMS has been adopted and recommended by AASM in their scoring man-
ual [2]. The PLMS occur with a periodicity of 20–40 seconds, predominantly
during stages N1 and N2 and during the first one third of the night. A PLM
index (number/hour) of 5 is required for diagnosis. To meet the scoring cri-
teria, PLM must not be preceded by a respiratory event. Many laboratories
 INTERPRETATION OF THE ADULT POLYSOMNOGRAM 731

also report PLM arousal index (number/hour of PLM resulting in arousal);

however, there is no agreement on whether PLM arousal index correlates
with daytime symptoms. Most patients who have PLM do not require treat-
ment unless they are symptomatic. Prolonged sleep latency in association
with significant PLM on PSG should alert one to the possibility of RLS.
Excessive EMG tone and abnormal limb movements during REM sleep
are seen in REM behavior sleep disorder and in patients treated with certain
antidepressants [24,25]. The movements in RBD are complex and semi-
purposeful, and are often associated with vocalization. The accompanying
EEG does not show epileptiform activity. It should be remembered that
RBD is a clinical entity, and should not be diagnosed based upon PSG find-
ings alone in the absence of symptoms. RBD should be differentiated from
seizures, which are uncommon during REM sleep and usually have a repet-
itive pattern. Because only four EEG derivations are used, characteristic
EEG activity may not be apparent during a routine PSG recording, espe-
cially with frontal lobe epilepsy, and a note of this limitation of PSG should
be made in the report. A whole night PSG with 16-channel EEG is recom-
mended for diagnosing nocturnal seizures. RBD should be differentiated
from confusional arousals, which are more common in younger subjects,
whereas RBD is usually seen in elderly individuals. In confusional arousals
the subjects usually arouse from stage 3 or 4 sleep, dream recall is not
common, and significant autonomic activation (tachycardia, sweating)
may be seen. Video recording, heart rate changes, and technician notes
are extremely important for assessment of parasomnias.
Another common finding on EMG is sleep bruxism (Fig. 17). During
bruxism, repetitive submental EMG bursts are seen, occurring at a frequency
of 1 to 2 Hz and causing artifact in all EEG and EOG channels. Similar find-
ings can be seen in orofacial dyskinesia and rhythmic tongue movement
disorder. A characteristic loud gritting sound is heard on the voice record-
ing, and is diagnostic of bruxism. Therefore, confirmation by listening to the
characteristic gritting sounds is important to make a diagnosis. Masseter
muscle EMG recording is more sensitive than chin EMG for detecting
and differentiating bruxism from other conditions.

Airflow and respiration

The most common reason for performing a PSG is to establish a diagnosis
of SDB. Obstructive sleep apnea is the most common sleep diagnosis.
Central sleep apnea (CSA) is much less common and is diagnosed in fewer
than 10% of patients presenting for a PSG [26]. Most patients who have
CSA have concomitant OSA. Airflow has been conventionally measured us-
ing an oral-nasal thermistor probe or thermocouple. The underlying concept
is that respiratory air flow causes a change in temperature and the conduc-
tance of the thermistor, which is recorded as an electrical signal. It can
detect airflow from the nose as well as the mouth, but it has low sensitivity
732 KAKKAR & HILL

Fig. 17. Bruxism. 29-year-old female with subvalvular stenosis was noted to have several
episodes of prolonged 1–2 Hz disturbance in EEG and chin EMG. Prominent gritting sounds
were heard on video replay.

to detect respiratory events, especially hypopneas. Nasal pressure can be

monitored using cannulae similar to ones used for oxygen therapy
(Fig. 18). They are much more sensitive than a thermistor probe, especially
for detection of hypopneas (Fig. 19). For OSA, the events show not only
a decrease in the pressure, but also a characteristic flattening. Thus both
the amplitude and shape of nasal pressure tracing should be observed.
The authors routinely use nasal pressure monitoring in addition to oral-
nasal thermistor. Nasal pressure may not be reliable in the event of mouth
breathing, but the nasal pressure never drops to zero even with mouth
breathing, and there is no flattening of the waveform (Fig. 20). Also, there
may be a concomitant increase in thermistor signal. Another drawback of
nasal pressure is that the cannulae can become occluded with moisture
and nasal secretions. Respiratory excursions are measured by placing piezo-
electric belts on the chest and abdomen. They do not quantitatively measure
the effort, tend to dislodge overnight, and are not very sensitive in obese
patients. Respiratory inductance plethysmography (RIP) belts are better
for detection of respiratory movements.
An apnea in adults is defined on PSG by cessation of airflow for 10 or
more seconds. According to an AASM task force (Chicago criteria) it is
not important to distinguish obstructive apneas from hypopneas, because
they have similar pathophysiology [27]. Accordingly, a 50% reduction in
 INTERPRETATION OF THE ADULT POLYSOMNOGRAM 733

Fig. 18. Nasal pressure cannulae. (Courtesy of Compumedics USA, El Paso, Texas; with
permission.)

the amplitude of a valid measure of breathing from baseline is adequate to

identify a ‘‘respiratory event,’’ and does not require oxygen desaturation
or arousal to define it. Baseline is defined as mean amplitude for 2 minutes
preceding the respiratory event, or the mean amplitude of the three largest
breaths in the 2 minutes preceding onset of the event (in individuals who
do not have a stable breathing pattern). If there is clear reduction (but

Fig. 19. Nasal pressure tracing (marked NPRES) shows significant decrease in amplitude,
characteristic flattening, and reflection of snoring during a hypopnea while there is little change
in the thermistor signal (marked AIRFLOW).
734 KAKKAR & HILL

Fig. 20. An example of exaggerated mouth breathing. Increased signal at mouth transition
from additional sensor at mouth. Note the nasal pressure signal does not disappear. (Courtesy
of Compumedics USA, El Paso, Texas; with permission.)

!50%) in any of the valid measures of breathing lasting 10 or mores

seconds, and it is either associated with oxygen desaturation of 3% or
greater or results in an arousal, it is also a scorable event (see Fig. 20)
[27]. An apnea is termed obstructive if it is associated with a discernible
respiratory effort (Fig. 21). An apnea is termed central if there is no
discernible respiratory effort associated with cessation of airflow [27].
AASM task force criteria require measurement of esophageal pressures

Fig. 21. Obstructive apnea with paradoxical breathing. Note the out-of-phase movements in
chest and abdominal effort during the obstructive sleep apnea, which returns to in-phase
movements at the termination of the event.
 INTERPRETATION OF THE ADULT POLYSOMNOGRAM 735

to distinguish between central and obstructive sleep apnea events; however,

most laboratories in the country do not measure esophageal pressures, and
rely on other less accurate methods of determining respiratory effort. Par-
adoxical motion in chest and abdominal belts is highly suggestive that the
apnea is obstructive (see Fig. 21). This refers to out-of-phase movements
of chest and abdominal waveforms. One should be careful in such
instances to make sure that the respiratory signal in preceding epochs
and following the apnea returns to in-phase excursions. If out-of-phase
waveforms are persistent, it may indicate reversed polarity in the belts.
Paradoxical motion without OSA can be seen in patients who have severe
chronic obstructive pulmonary disease (COPD), with morbid obesity, and
in patients who have quadriplegia.
Apnea hypopnea index (AHI) is the number of respiratory events scored
per hour of sleep. AASM defines OSA as mild if AHI is 5 to 15, moderate if
it is 16 to 30, and severe if it is greater than 30. Another measure of severity
is the degree of hypoxemia; however, there is no universally accepted way of
defining the severity, because symptoms and oxygen desaturation may not
correlate well with the AHI. One of the biggest controversies in sleep med-
icine is the definition of hypopnea. The AASM Clinical Practice Committee
and centers of Medicare and Medicaid services (CMS) define hypopnea in
adult patients as an abnormal respiratory event lasting at least 10 seconds,
with at least a 30% reduction in thorocoabdominal movement or airflow as
compared with baseline, and with at least a 4% oxygen desaturation [28].
There are several other definitions and different sleep laboratories define
hypopneas extremely variably. Such a wide variation in the criteria and
the inter-observer variability in scoring PSG can have a huge impact on
the ‘‘severity’’ of sleep apnea as defined by one laboratory versus another
laboratory. It has been shown that this can result in a 10 fold variation in
severity of SDB as defined by AHI, and a 16 fold variation in the prevalence
of OSA [29,30].
Coexisting medical disorders such as hypothyroidism or cardiovascular
disease should be taken into account while interpreting a borderline study.
Many patients, especially young women, have severe daytime hypersomno-
lence and history of snoring. Despite the scarcity of scorable respiratory
events, many of them will exhibit either crescendo snoring culminating in
arousal (Fig. 22), or periods of prolonged snoring associated with con-
comitant flattening of nasal pressure tracing. If Pes is recorded in these
patients, excessive swings in the negative Pes are recorded. These findings
are suggestive of upper airway resistance syndrome (UARS) [31,32]. There
is considerable debate whether UARS is a separate clinical entity or a
mild form of OSA. UARS is more prevalent in younger women who have
lower body mass index (BMI) than their counterparts who have OSA, who
most often tend to be middle-aged obese men.
Unlike OSA, CSA is a heterogeneous entity consisting of many different
disorders. One of the common manifestations of CSA, especially in patients
736 KAKKAR & HILL

Fig. 22. Crescendo snoring culminating in arousal.

who have severe left ventricular dysfunction, is Cheyne-Stokes breathing

(Fig. 23). It has a characteristic crescendo, decrescendo morphology. Pes
monitoring is the best available method to distinguish CSA from OSA.
Emergence of CSA during PAP titration usually disappears with time;

Fig. 23. Cheyne-Stokes breathing. Note characteristic crescendo decrescendo pattern in breath-
ing effort, paralleling the airflow.
 INTERPRETATION OF THE ADULT POLYSOMNOGRAM 737

however, some patients may show worsening CSA and oxygen desaturation
with continuous positive airway pressure (CPAP) or bi-level PAP titration.
This is called complex sleep apnea [33]. Several treatment options are avail-
able for the treatment of complex sleep apnea.
Continuous pulse oximetry is used to assess baseline oxygen saturation
and degree of hypoxemia during PSG recording. The authors prefer not
to use supplemental oxygen during diagnostic or PAP titration studies as
long as severe hypoxemia (!80%) is not present. Supplemental oxygen
may make recognition of hypopneas difficult [34]. Many patients on noctur-
nal oxygen therapy for mild nocturnal hypoxemia often do not require
supplemental oxygen with PAP therapy. This is because PAP increases
the functional residual capacity (FRC), which is critical in determining
oxygenation in an individual. True oxygen desaturation with respiratory
events is associated with a smooth drop in the pulse oximetry tracing and
recovery to baseline upon termination of the event (see Figs. 19 and 21).
Respiratory events may cause an arousal resulting in abrupt movements
of limbs. Such movements may make recognition of the pulse wave difficult,
and result in an artifactual lowering of pulse oximetry. Abrupt drops and
recovery in pulse oximetry signal are usually indicative of artifacts and
should be ignored. A drop in oxygen saturation to zero is always artifactual
(Fig. 24). Some of the manufacturers offer real time display of pulse pleth-
ysmography signal. This is particularly helpful in differentiating true oxygen

Fig. 24. Excessive leak during PAP titration causing ‘‘hypopnea.’’ Note a leak greater than
60 L/min (1 L/sec). Associated arousal caused artifactually low reading of oxygen saturation
at 0%.
738 KAKKAR & HILL

desaturation from an artifact, because the latter does not have the charac-
teristic waveform of a peripheral arterial pulse.
Snoring is recorded from a snore microphone, and the signal is
displayed as a continuous waveform. Technician notes are the most useful
way of assessing the severity of snoring. Snoring signal is also prominently
reflected in chin EMG, in nasal pressure tracing (see Fig. 22), and
occasionally in the thermistor tracing. Crescendo snores associated with
progressively increasing effort are indicative of upper airway obstruction.
It should be noted that crescendo snoring could also be seen in Cheyne-
Stokes breathing; however, an associated decrescendo component is
characteristic.
During a PAP titration study, the airflow signal is detected by the
device itself and is displayed as ‘‘C-flow.’’ One should look for the effective
pressure to eliminate apnea, hypopneas, hypoxemia, and snoring. Some
laboratories attempt to eliminate flow limitation also during PAP titration.
Persistent arousals with seemingly adequate titration are either caused by
underlying mild airway obstruction or by excessive pressure. Under such
circumstances, the technicians generally increase or decrease the pressure
according to their judgment, and compare the results on different pres-
sures. Occurrence of excessive air leak during PAP titration is a challenging
situation. Most modern PSG and PAP systems continuously display
breath-to-breath measurement of leak. Some leak (intentional leak) is
needed for the effective operation of PAP machines. Excessive leak is de-
fined as the degree of leak that compromises effectiveness of PAP therapy
(see Fig. 24). Different manufacturers have different guidelines for their
equipment, but a leak in excess of 0.4 liters per second is usually consid-
ered excessive. Leak can also be suspected by looking at the PAP wave-
form, which may show a sudden dip at the beginning of expiration.
Presence of snoring-like artifact during the expiration is also indicative
of air leak rather than upper airway obstruction. Excessive air leak can
be caused either by problems with the mask seal or by mouth opening;
however, true differentiation between the two may be difficult while look-
ing at the PSG data. The technician’s notes are quite valuable in making
this determination. Mask leaks are more common with full-face mask than
with nasal interfaces. When choosing a therapeutic pressure, the clinician
should ensure that it is effective in both supine position and during
REM sleep. Other factors in choosing a therapeutic pressure are the degree
of consolidated sleep obtained at that pressure, patient’s tolerance, degree
of air leak, and the length of time it was tested. The authors prefer to
choose the lowest effective pressure, provided it was tested for an adequate
length of time. If bilevel PAP was used, the technician should document
the reason for using it. If no therapeutic pressure could be determined, a re-
peat PAP titration should be requested. If supplemental oxygen was used,
one should ensure that it was indeed effective and necessary for treatment
of hypoxemia.
 INTERPRETATION OF THE ADULT POLYSOMNOGRAM 739

Electrocardiography
Patients who have SDB often exhibit cardiac arrhythmias at night
(Figs. 25, 26). Most laboratories monitor one EKG lead to determine heart
rate and to detect cardiac arrhythmias. The authors routinely record two
EKG leads. The extra EKG electrode provides a backup in case one
electrode becomes loose during the course of the study. The most common
arrhythmias noticed in patients who have OSA are sinus bradycardia, sinus
arrest, and sinus tachycardia. Periods of bradycardia intervening with nor-
mal heart rate or tachycardia are also sometimes noted in patients who have
OSA. The bradycardia is a result of massive vagal discharge that occurs with
breathing against a closed upper airway [35]. Termination of sleep apnea
invariably results in a surge in catecholamine levels, which results in tachy-
cardia and a rise in blood pressure [36]. It should be noted that atrial
fibrillation is especially common in OSA. Presence of atrial fibrillation is
one of the strongest independent predictors of the presence of OSA [37].
The medical director of the sleep laboratory should be alerted about any
dangerous arrhythmias.

Reporting a sleep study

The PSG report should be brief and succinct. The first part of the report
is generated automatically, and contains the patient’s demographic and
anthropometric information, indication for performing the PSG, the

Fig. 25. Atrial flutter appearing with an obstructive sleep apnea. The patient did not have any
previous history of cardiac arrhythmias and was noted to have three prolonged episodes of
atrial flutter during this PSG, which returned to normal sinus rhythm spontaneously.
740 KAKKAR & HILL

Fig. 26. Nonsustained ventricular tachycardia during a PSG recording.

physiological parameters that were recorded, the equipment used for record-
ing, and pertinent numerical data in tabular form. Any additional monitor-
ing, such as extra EEG or EMG derivations recorded during the study,
should also be mentioned. The tabular data should contain information
on recording time, TIB, TST, SPT, SE, SL, RL, sleep stage distribution,
percentage of time spent in supine position, total AHI, supine AHI, AHI
during REM sleep, the nature of respiratory events (obstructive or central),
whether baseline hypoxemia was present, degree of hypoxemia, heart rate,
and the PLM index. Some laboratories also report arousal index. There
are many other indices reported on the automatically generated PSG
reports. Most of the data in these reports are redundant and confusing,
and the clinical utility of many of these indices is unclear.
The descriptive part of the report should be brief, with emphasis on
important findings while avoiding unnecessary repetition of numerical
data. One should develop an overall impression of the study as opposed
to just the numerical interpretation, especially when reporting severity of
sleep apnea and prescribing an effective PAP setting. Long apneas may ar-
tificially lower the AHI, whereas many patients have severely disrupted
sleep or significant oxygen desaturation with respiratory events of short
duration. Lack of REM sleep or lack of sleep in the supine position may
underestimate the severity of sleep apnea, and a note should be made to re-
flect this. The AHI reflected on the PAP table may be misleading because it
does not characterize sleep consolidation, patient discomfort, or air leak.
Further, if only a short time is spent on a given pressure, it may artifactually
lower or elevate the AHI because of sampling error. On should always
 INTERPRETATION OF THE ADULT POLYSOMNOGRAM 741

mention whether or not the recommended pressure was adequately tested in

the supine position and during REM sleep. The occurrence of cardiac
arrhythmias and parasomnias should be documented, with the epoch num-
bers in which they occurred. Some sleep centers do not routinely archive the
video data because of the size of the files. If parasomnias or seizures are
documented, the laboratory should be instructed to store the video files
of that PSG.

Summary
PSG interpretation is a time-consuming process that requires close
attention to the patient’s history, medications, technician notes, pre- and
poststudy sleep questionnaires, and overall impression of the raw data. It
is a unique opportunity to correlate clinical and electrophysiological data,
however, and is a good investment of time toward improving patient
outcomes and avoidance of unnecessary testing. The adage, ‘‘Your
eyes see what your brain knows’’ holds particularly true for interpreting
a PSG.

Appendix
How likely are you to doze off or fall asleep in the following situations, in
contrast to feeling just tired? This refers to your usual way of life in recent
times. Even if you have not done some of these things recently, try to work
out how they would have affected you.
Use the following scale to choose the most appropriate number for each
situation:
 0 ¼ no chance of dozing
 1 ¼ slight chance of dozing
 2 ¼ moderate chance of dozing
 3 ¼ high chance of dozing

Table 1
Epworth sleepiness scale
Situation Chance of dozing
Sitting and reading
Watching TV
Sitting inactive in a public place (eg, a theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
Score: 0–10, normal range; 10–12, borderline; 12–24, abnormal.
742 KAKKAR & HILL

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