APT Practice Parameter for Standard Polysomnography APT ...

PUBLICATION OF THE APTASSOCIATION OF POLYSOMNOGRAPHIC TECHNOLOGISTS2006 • VOLUME 15 • NUMBER 4APT AnnouncesNew NameAPT PracticeParameter for StandardPolysomnographyDeep Brain Stimulation and SleepPathological YawningPulse Transit Time: A Useful Clinical Tool?Inadequate Sleep and DepressionThey Come From the Cortex

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Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgA2ZZZ MAGAZINE,EDITORIAL BOARDTHERESA SHUMARD, EDITOR-IN-CHIEFASSISTANT EDITORROBERT LINDSEY, MS, RPSGTAPT BOARD OFDIRECTORS LIAISONJON ATKINSON, RPSGTCARTOONISTBARBARA LUDWIG CULL, RPSGTSLEEP ARTSTERRIE EUBANKS, RPSGTCORRESPONDENTSIAIN BOYLE, RPSGT, CANADAPAMELA JOHNSON, RPSGT,AUSTRALIA/NEW ZEALANDWAYNE PEACOCK, RPSGT,UNITED KINGDOMROGERIO SANTOS DA SILVA, BRAZILASSOCIATE EDITORSJOSEPH ANDERSON, RPSGT,RPFT, CRTTKIM BURNS, RPSGTEDWIN CINTRON, RPSGTJOSHUA COLE, RPSGTBRENDAN DUFFY, RPSGTWILLIAM ECKHARDT, BS, RPSGTREG HACKSHAW, EDD, RPSGTJOANNE HEBDING, RPSGTREGINA PATRICK, RPSGTKIMBERLY TROTTER, RPSGT, MASPECIAL PROJECTSJAYME MATCHINSKI, ESQ.TRACY NASCAMARY JONES-PARKER, RRT,RPFT, RPSGTADVERTISINGSCOTT COLE, RPSGTLAURA LINLEY, RCP, RPSGTIn This Issue…President’s Message ..................................................................4Call for Awards ..........................................................................5Call for Volunteers ......................................................................5APT Practice Parameter for Standard Polysomnography ..................6A2Zzz Magazine Continuing Education Credit Offering ....................14APT CEC Evaluation Form ..........................................................15Deep Brain Stimulation and Sleep ................................................16Pulse Transit Time: A Useful Clinical Tool? ....................................18Cognitive Changes on PSG Technicians After Six Monthsof Nocturnal Shift Work ........................................................19Inadequate Sleep and Depression ................................................26MISSION STATEMENTA2Zzz Magazine is a peer-reviewed publication addressing the educationalneeds of the Sleep Technology Profession. Its mission is to provideprogressive technical information, current events relevant to the field, andan avenue of communication for members, presented in a professional andconstructive manner, to further the goals and promote unity in the SleepTechnology Profession. Readers of A2Zzz Magazine should be able to: 1)appraise Sleep Technology in basic science and clinical investigation; 2)interpret new information and updates on clinical diagnosis/treatment andapply those strategies to their practice; 3) analyze articles for the use ofsound scientific and medical problems; and 4) recognize the inter-relatedness/dependenceof sleep medicine with primary disciplines.ADVERTISING POLICYAs a service to our membership, A2Zzz Magazine prints information oneducational programs and products. It is not intended to imply that theprograms and products are approved by the Association ofPolysomnographic Technologists (APT) or the Board of RegisteredPolysomnographic Technologists (BRPT), or that they are endorsed as amethod of preparation for the BRPT examination. Professional productsand services are subject to approval by the A2Zzz Magazine Editor-in-Chief. Ad inquiries may be directed by e-mail to aptads@aptweb.org.For advertising billing questions, call 708-492-0796. Advertising rates,specs and info: www.aptweb.org/advertising.aspARTICLE SUBMISSIONS GUIDELINESResearch, feature and news manuscript submission guidelines, word limitsand e-mail submission instructions may be obtained from the Editor-in-Chief. All articles subject to standard, blind peer review. Article queriesshould be mailed directly to:Theresa Shumard, Editor-in-Chief • A2Zzz Magazine Editorial Office25 Madison St. • Shillington, PA 19607Phone: 610/796-0788 • Fax: 781/823-4787E-Mail: theresa.shumard@sunmed.comCopyright © 2006 by the Association of Polysomnographic Technologists. Allrights reserved. No part of this publication may be reproduced or transmittedin any form or by any means, electronic or mechanical, including photocopyor recording, or any information and retrieval system, without permissionin writing from: APT National Office, One Westbrook Corporate Center,Suite 920, Westchester, IL 60154. Opinions expressed in A2Zzz Magazineare not necessarily those of the APT Board of Directors.They Come From the Cortex ......................................................28Pathological Yawning..................................................................30APT Committee Roster, Board of Directors and Directory ..............31A2Zzz Technical Corner..............................................................32Sleep Arts................................................................................33Questions About Recertification? ................................................34NewZzz Briefs ..........................................................................36APT Product Order Forms ....................................................37-38APT Membership Form ..............................................................39SleepLand Calendar ..................................................................40ADVERTISING INFORMATIONThe APT offers a full range of advertising services. Seethe advertising page drop-down menu at www.APTWEB.org,fax 708-273-9344, e-mail APTads@aptweb.org or phone708-492-0796 for details.Have you moved?Changed your email address?Your phone number?If you have and have not notifiedAPT, you can go to the home page ofAPTWEB to fill in your updatedinformation (www.APTWEB.org).You wouldn’t want to miss your?membership benefits!3

APT NewZzzPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgPresident’s MessageBY CYNTHIA MATTICE, MS, RPSGTProviding, Preserving and Promoting theSleep Technology ProfessionAs this year comes to a close, it is a great time to reflect on all that theAssociation of Polysomnographic Technologists (APT) has accomplished tomeet the needs of our members and to look to the future of our profession.Name Change, Bylaws and Articles ofIncorporationI am pleased to announce that ballots are in! Representing thelargest number of responses in the history of the organization, 612members voted to accept the name change from the Association ofPolysomnographic Technologists to the American Association of SleepTechnologists. The revisions to the Bylaws and amendments to theArticles of Incorporation were also accepted. Thank you once again forproviding your input and participating in this important process. Over thecoming months, additional information about transitioning to the newname of our association will be published in A2Zzz Magazine, listed inthe APT Member Update as well as posted on the APT Web site.A Successful 2006 Because of YouThe APT continues to provide the Sleep Technology Profession with aunified voice that represents more than 2,900 polysomnographic technologistsacross the United States. This is possible because of the supportfrom each of you as APT members, the leadership of your Board ofDirectors, and the valuable work of committee members. A heartfelt“thank you” to each member for the countless hours you dedicated to theAPT and the valuable contributions you made to the organization.Highlights of Our YearThe APT is committed to providing educational programs that broadenour knowledge, advocating on behalf of its members to protect theprofession and creating professional standards that ensure quality care.The APT took action this past year to accomplish its mission and toenhance educational goals.The APT continued collaboration with the Board of RegisteredPolysomnographic Technologists (BRPT) and the American Academy ofSleep Medicine (AASM) to advance sleep technology to make certain thatenough well-trained technologists are available to meet current as well asexpected growth of the field. Let’s take a look at how the national educationalstandards for our profession, formal educational programs, on-going4training and certification requirementshave shaped our profession in 2006.The Continuing Education Credit (CEC)Program has been expanded to meet theneeds of sleep technologists by addingCECs for reading A2Zzz Magazine,Computer Based Learning Activities, InServices/Case Conferences and SingleLectures. To meet BRPT recertification APT President Cynthia Matticerequirements the APT is pleased to reporta two-fold growth in 2006 with 284 educational programs requesting andawarded APT CECs as compared to 130 in 2005. Check www.aptweb.orgfor a list of educational opportunities granting APT CECs near you.The Committee on Accreditation for Polysomnographic TechnologyEducation (CoA PSG) has received 13 requests for accreditation. Twoeducational programs have now been accredited by the Commission onAccreditation of Allied Health Education Programs (CAAHEP) and a thirdhas been recommended for accreditation during CAAHEP’s November2006 meeting. To view the listing of these programs visit www.caahep.org/programs.aspx.The Accredited Sleep Technologist EducationProgram (A-STEP) provides for standardized entry level training and hasaccredited 16 programs (www.aasmnet.org/ASTEP/Providers.aspx). Inaddition, the APT Textbook is near completion. It is anticipated that ourtextbook will be available for sale at the APT Annual Meeting inMinneapolis, MN (June 10-13, 2007).As you can see, there are many exciting developments and opportunitiesfor education of sleep technologists. With your ongoing support,the APT will continue to work on your behalf to advance our professionand provide you with the latest educational products and courses.The Value of APT MembershipOur profession is unique because of the multidisciplinary nature of apolysomnographic technologist. It is this diverse membership that makesus a strong, vital professional membership association. For less than$10 per month each of you as an APT member are investing in your professionaldevelopment and the future of your career as well as ensuringthe vitality of sleep technology. You can realize the value of investing inour career through membership in the APT.Members receive several tools and resources to support continuedprofessional development. These benefits include A2Zzz Magazine, animportant resource for your career development; online forum, anavenue for members to ask questions, exchange ideas and discussissues facing our profession; and important e-mail updates on issuesand trends that affect our professional environment. Members also benefitfrom educational programs that keep them abreast of new trendsand practices in the field and educational products that enhance theirknowledge of sleep technology — all at discounted prices.Grow Your Profession by Giving BackI challenge you to join APT’s growing ranks and get involved withshaping your career! There are many ways to broaden your involvement➟

APT NewZzzPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgin the APT. Choosing APT membership provides you the support youneed to make a commitment to be a lifelong learner.As a member, you can volunteer to serve as a committee memberand be part of a team that provides input and recommendations toadvance our profession. The diversity of committee members is integralin providing fresh perspectives, fulfilling the mandate of the committee,and contributing to the overall strength of the APT. If you are interestedin participating as a committee member, look for information in thisissue about the 2007 Call for Volunteers. Being a volunteer is a wonderfulway to be actively engaged in your profession.Volunteer membership organizations rely on members’ commitmentof both time and expertise at not only the national level, but also locally inyour state, region or health care organization. To recognize the individualmembers for their contributions to the profession, the APT has establishedthe Awards Nomination process. I encourage you to recognize theaccomplishments of your peers by nominating them for an APT Award.Additional information on the 2007 APT Award Nominations will be availableon the APT Web site (www.APTWeb.org) in December 2006.You will find many interesting facts and tidbits in this edition of A2ZzzMagazine. I hope you will enjoy reading the articles from cover to coveras I do and I know you learn something new with every issue and it is agreat way to get those CECs!I am proud of the APT and its members and know we are moving ina direction that will benefit each of you as a member and a provider ofsleep technology services. The APT Board of Directors welcomes inputfrom its members. Let me know if you have questions or ideas to pro-NewZzzAPTpose, just take a few minutes to submit them to aptaction@aptweb.org.The FUTURE IS YOURS for the taking — shape it by your continuedAPT membership. Your membership and active participation in the APTactivities not only provides financial support to build on the strong foundation,but it also insures that we have well trained sleep technologiststo care for patients with sleep disorders far into the future. ★Call for AwardsEach year the Association of Polysomnographic Technologists(APT) recognizes individual members of the APT for professionalexcellence, service and commitment to the association and thesleep technology profession. For more information on how to nominatemembers of the APT for one or more of the APT awards visitthe APT Web site at www.APTWeb.org.Call for VolunteersAre you interested in contributing to the future of the SleepTechnology Profession? Through committee service, a volunteermember has an opportunity to actively participate in many new projectsthe APT will be working on in 2007. Members interested inserving on one of the APT Standing Committees (Communications,Education, Membership, Program, Standards and GuidelinesRegional Activities/Government Affairs) are invited to visit the APTWeb site at www.APTWeb.org.5

APT NewZzzPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgAssociation of PolysomnographicTechnologists — Practice Parameter forStandard PolysomnographyIntroductionIn response to the need to establish standards for the performance of sleepstudies, the APT Board of Directors initiated a development of the APT PracticeParameter for Standard Polysomnography. The document has been finalized bythe APT Standards and Guidelines Committee and reviewed by the AmericanAcademy of Sleep Medicine upon the APT Board of Directors’ request.This practice parameter will assist sleep technologists in providing highquality diagnostic testing that is consistent with accepted practice. The standardsare not intended to be inclusive of all methods for performing sleepstudies. The APT Practice Parameter for Standard Polysomnography willundergo periodic revisions to remain current with advances in the field, thusensuring that those who perform sleep studies are provided current practicestandards to facilitate competent and quality services.SummaryThe scope of polysomnography encompasses the monitoring of patientsin a sleep facility using an assortment of medical equipment that is simultaneouslyrecorded on a multi-channel analog or digital system. ThePolysomnographic Technologist prepares for and monitors the recording,requiring expertise in normal and abnormal sleep and multiple technical andmedical monitors. A polysomnogram (PSG) allows for the events occurringin a variety of physiological systems to be observed simultaneously. Much ofits utility depends on the ability to correlate specific changes or abnormalitiesof one physiological parameter with specific conditions defined by anotherparameter or parameters. Consequently, polysomnography is a significantlymore powerful and complex tool than could be provided by individualor independent measurements of each variable.The standard diagnostic sleep evaluation requires a complete PSG todocument sleep stages and arousals, respiration, limb movements, snoring,oximetry, body position, and cardiac rhythm disturbances. The resulting documentationis used to diagnose or assess the treatment of sleep disorders.(Refer to Practice Parameters for the Indications for Polysomnography andRelated Procedures: 2005.) 1Key Definitionssleep facility — will refer to any Sleep Disorders Center or SleepDisordered Breathing Laboratory whether it is hospital based or independent.sleep technologist — trainee, technician or technologist for the purpose ofthis document. Note that the technologist designation usually refers to thosewho have passed Board of Registered Polysomnographic Technologists (BRPT)credentialing examination, Registered Polysomnographic Technologist (RPSGT). 2diagnostic coding — will refer to the ICSD (International Classification ofSleep Disorders, Second Edition) 3apnea — episodes of non-respiration during sleep that last at least 10seconds. See central, obstructive, or mixed sleep apnea.bruxism — a parasomnia characterized by the grinding or clenching ofteeth during sleep.cardiac arrhythmias — disturbance in the impulse formation, impulseconduction or a combination.6central apnea — the absence of effort; characterized by a simultaneouscessation of airflow and effort.electroencephalogram — also called an EEG; the measurement andrecording of brain wave activity. Frequency measurement in hertz rangingfrom 0.5 - < 4 (delta), 4 - < 8 (theta), 8 - < 13 (alpha), and >= 13 (beta).Electrodes are typically placed at C3, C4, O1, O2 positions on the scalp.electrode — A conducting terminal for receiving or sending electrical signals.Electrodes in polysomnography conduct biopotentials from the patientto the recording circuit. In this document “electrode” will refer to cup, snaponor disposable styles.electrolyte — conductive substance (cream, gel, or paste) used to fillelectrode cups.electromyogram — also called an EMG; the measurement and recordingof muscle activity, particularly under the chin, along the jaw, and on the legs.electrooculogram — also called an EOG; the detection and recording ofeye movements, essential for determining the different sleep stages.heart rate — the number of heart beats during a unit of time, usuallyper minute.hertz (Hz) — the unit of measurement for cycles per second; used tomeasure EEGs .hypopnea — a 30% or greater decrease in airflow and effort associatedwith at least a 3% to 4% drop in oxygen saturation or an EEG arousal.montage — the term applied to the testing variables and their order onpolysomnogram paper or a computer monitor, such EEG, EOG, EMG, ECGand so on.myoclonus — muscle contractions in the form of abrupt jerks or twitches 3obstructive apnea — absence of airflow with continued effort.PAP — Positive Airway Pressure is a pneumatic splint to maintain thepatency of the airway. Optimal pressure requirements are determined duringa sleep study.1. Continuous positive airway pressure (CPAP) delivers a constant optimalpressure to eliminate sleep disordered breathing and snoring.2. Bi-level positive airway pressure delivers a separate pressure forinspiration and expiration.PAP interface — there are various types of nasal masks, nasal/oralmasks and endonasal cushion interfaces available to enable the sleep technologistto find the most comfortable fit for the patient.polysomnogram — also called a PSG, sleep study, or sleep test; a noninvasivetest that records vital signs and physiology during a night of sleep.It includes measurements of EEG, EMG, EOG, and ECG as well as respiratoryairflow, blood oxygen saturation, pulse rate, heart rate, body position, andrespiratory effort.➟

APT NewZzzPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgperiodic limb movements of sleep — also called PLMS or nocturnalmyoclonus. Characterized by repetitive movement that usually occurs in thelower extremities, but can also occur in the upper extremities. Monitoringthe anterior tibialis EMG reveals repetitive contractions lasting 0.5 to 5.0seconds at approximate intervals of 20-40 seconds in intervals of 5 secondsto 90 seconds. Sleep disruption is noted due to associated short arousalsor awakenings.restless legs syndrome — (RLS) is a movement disorder with complaintsof a strong urge to move the legs and crawling sensation in the legs.These sensations are relieved with movement, such as walking.PurposeTo define the methods and requirements for recording each of the variablesin a polysomnogram and their integration within diagnostic protocols.1.0 IntroductionStandard polysomnography is a complex evaluation used as a quantitativediagnostic measurement of multiple physiological parameters duringsleep. This practice parameter will address PSG evaluations attended by asleep technologist that are provided in a sleep facility.Sleep technologists are specially trained to perform polysomnography forthe diagnosis and treatment of sleep/arousal disorders. They are part of ateam under the direction of a physician who practices sleep disorders medicine.The team works in concert to ensure the proper diagnosis, appropriatemanagement, and education for individuals that experience sleep disorders.They follow patient sensitive standards of care, which are the foundationfor clinical/technical decision-making.This practice parameter does not include pediatric polysomnography,home or unattended PSG evaluations, the therapeutic use of PAP or oxygen.1.1 Indications for Standard PolysomnographyStandard PSG evaluation is necessary because physiological functionschange during the sleeping state and many disorders are specifically inducedby sleep. There are over 80 specific disorders of sleep and arousal that areidentified in the ICSD-2. A PSG evaluation is one of the tools used by physiciansthat can result in a specific diagnosis of a sleep disorder that mightotherwise remain obscure. The AASM Practice Parameter forPolysomnography and Related Procedures: An Update for 2005 1 relates onlyto the recording and use of standard policies and procedures for the diagnosticevaluation of sleep disorders in a sleep facility. It does not addressinterpretation of the PSG evaluation or the management of patients withsleep/arousal disorders.The most common reasons for an individual to be referred to a sleepfacility for evaluation include: (1) episodes of sleep at inappropriate times; (2)difficulty sleeping during scheduled sleep periods; (3) difficulty staying awakeduring scheduled wake periods; (4) atypical behavioral events during sleep;(5) documentation of the effectiveness of various therapeutic interventionsutilized for the management of the documented sleep disorder; (6) witnessedapnea and snoring.1.2 Patient Referral DynamicsStandard PSG evaluations can be carried out within the sleep facilitywhere patients are primarily physician-referred and their subsequent careis the responsibility of the referring physician; or within the sleep facilitywhere patients are either self- or physician-referred and in which completeclinical evaluation and treatment plans are formulated and implemented bythe sleep specialist.2.0 Recording Techniques2.1 Physiological Parameters Measured andEquipment ParametersThis section will discuss the physiological parameters that are necessaryto record during standard PSG to provide adequate data for interpretationby the sleep specialist.2.1.1 Routine Variables2.1.1.0 ImpedanceIt is the goal of polysomnography to capture the best quality recordingsof the physiological channels. The best recordings are artifact free and havethe maximum waveform amplitude possible. Because the subtle variations incurrent are muted by impedance, it is the goal of polysomnography to getthe lowest impedance possible. The pathway in question is comprised of thesource of the current being measured in each locale of the body, the variouslevels of tissue and the actual electrode cups and wires. It is through theselayers that conductance is thwarted by impedance. Lower impedance allowshigher conductance and produces larger amplitude waveforms. It is the goalof electrode application to obtain the lowest impedance possible withoutcompromising patient comfort and skin integrity. To obtain the lowest possibleimpedance values it is necessary to abrade the skin area where the electrodeis to be placed to the extent that the dead outer epidermal layer (stratumcorneum) is removed without disrupting the dermis. To maximize the signalquality and minimize patient discomfort the sleep technologist shouldscrub only the area where the electrode will be placed. For optimal signalquality it is necessary to match the input impedance of all electrodes pairsas closely as possible. Impedance mismatching allows current to passthrough to the amplifier and can lead to artifact. Common mode rejection isthe cancellation of voltages equal to both input electrodes. Impedance mismatchingalso impairs common mode rejection. Therefore, optimal signalquality is possible when impedances are low enough to maximize amplitude,take advantage of common mode rejection, and avoid impedance mismatching.Ideally, impedances should range from 1-5k ohms regardless of theamplifier that is used, although its effect is less pronounced in some recenthigh input impedance amplifier designs.The standard for electrode impedance upper limit is 5k ohms for EEG & EOG. 4The guideline is that impedances are as closely matched as possible. 5The standard for electrode impedance upper limit is 10k ohms for EMG. 6The guideline is that impedances are as closely matched as possible.The standard for electrode impedance upper limit is 20k ohms for EKG.The guideline is that impedances are as closely matched as possible2.1.1.1 Electrode Preparation and ApplicationThe area where the electrode is to be placed is prepared by abradingthe skin to allow optimal impedance without disrupting the dermis. The sleeptechnologist should take care to scrub only the area where the electrode willbe placed. Electrodes should be of ample length for input from the electrodesite to the headbox.There are two methods used to secure the disk electrodes. First, theelectrode disks are filled with electrolyte or electrode paste. The collodionmethod uses an air compressor to attach collodion saturated gauze squaresplaced over the electrode disk securely to the electrode site.With the electrode paste method, for scalp electrode sites, a smallmound of electrode paste is placed on a gauze square. Care should be takencontinued on page 87

APT NewZzzPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgAPT — Practice Parameter forStandard Polysomnographycontinued from page 7to keep the electrode paste around the electrode disk as the electrode siteis the entire area that electrode paste touches the electrode site. For otherelectrode sites, fill the electrode disk with electrode paste and secure to theelectrode site with tape or medical adhesive.Various types of single use adhesive electrode disks are available and “snapon” electrode wires of appropriate length provide for input to the headbox.After use, electrode disks and wires should be cleaned and disinfectedaccording to facility protocols for infection control.2.1.1.2 Electroencephalogram (EEG)The EEG is the primary variable to document wakefulness, arousals andsleep stages during the sleep study. A single central channel referenced toan ear mastoid site (e.g. C3-A2 or C4-A1) is sufficient for evaluating waveforms.The mastoid is located posterior to each pinna. However, additionalchannels are required to provide redundancy and to more accurately determinesleep onset (e.g. O1-A2). The electrodes should be placed on the scalpaccording to the International 10-20 System. 7 Additional electrodes may beused as directed by the sleep facility’s medical director for the evaluation ofa patient with a possible nocturnal seizure disorder. Again, these electrodeswould be placed according to the International 10-20 System. Electrodes areapplied according to section 2.1.1.1. The amplifier settings and calibrationrequirements for the recording of the EEG signal will vary according to theequipment specifications.2.1.1.3 Electro-Oculogram (EOG)The EOG recording aids the identification of sleep onset by monitoring forslow, rolling eye movements that occur with transition to Stage 1 sleep andrapid eye movements (REMs) that occur during Stage REM sleep. At leasttwo channels of EOG are recommended. Each EOG channel records from anelectrode placed approximately 1 cm lateral to, and approximately 1 cmabove or below the outer canthus of the eye. An equal displacement of theelectrodes insures equal amplitude of the conjugate eye movements. An earmastoid site is generally used as a contra-lateral reference for each channel.With these derivations, conjugate eye movements produce out-of-phasevoltage deflections in the two channels; whereas simultaneous EEG activity isusually in phase. To distinguish between vertical and lateral eye movement,additional EOG montages can be applied using a supranasion reference electrodethat produces deflections in phase with vertical eye movements. Asupranasion reference electrode alone, however, may result in the integrationof EEG activity with extra ocular movement potentials. Consequently,other reference locations may be required for specific circumstances.Electrodes are applied according to section 2.1.1.1. The amplifier settingsand calibration requirements for the recording of EOG signals will varyaccording to equipment specification.2.1.1.4 Chin Electromyogram (EMG)The recording of EMG activity in the chin area is used for determiningthe level of muscle tone, which significantly decreases during REM sleep andmay also be reduced with sleep onset. This channel also provides supplementalinformation regarding patient movements and arousals and may beuseful in distinguishing artifact in other channels. A single channel is sufficientwith 2 electrodes placed 2-4 cm apart with one on the mental and oneon the submental region. Alternatively, electrodes can both be placed onmental or submental regions. Another variation with one on the massetermuscle on the jaw line can be used to better distinguish Bruxism. A thirdelectrode is recommended as a back up electrode placement. Electrodes are8applied according to section 2.1.1.1. The amplifier settings and calibrationrequirements for the recording of the EMG signal will vary according toequipment specifications.2.1.1.5 Upper Airway Sound RecordingSnoring is measured with a snore microphone or sound transducer.There are several types of snore monitoring devices available commercially.The snore sensor or microphone should be placed over the trachea or on theside of the neck and can be secured with tape. The sleep technologist shouldfeel for the area of maximum vibration while the patient hums or snores. Thiswill allow for recording of the snore sounds. The polygraph settings for detectingsnore sounds are the same as those used for submental EMG detection.2.1.1.6 Electrocardiogram (ECG)The ECG serves as a monitor of heart rhythm disturbance. A single ECGchannel is sufficient for standard PSG monitoring. The electrode placementis not critical but should be carefully documented. Typically, two or threeelectrodes are used in Lead I or Lead II placement format. Electrodes areapplied according to section 2.1.1.1. The amplifier settings and calibrationrequirements for the recording of the ECG signal will vary according toequipment specifications.2.1.1.7 Respiration (Measures of Airflow andRespiratory Effort)Airflow and respiratory effort channels are utilized during the standardPSG to monitor respiration specifically for the detection of apneas and hypopneasand other sleep related breathing disorders. It is important to recordat least three respiratory parameters: nasal/oral airflow, thoracic effort andabdominal effort. Various transducers may accomplish the recording of airflowexchange. Two widely used but often less sensitive methods are thermistorsand thermocouples. Pressure transducers offer a sensitive methodof recording airflow. It may be necessary to use both methods of measurementto achieve accuracy from nasal and oral flow. It is important that bothnasal and oral flow is monitored because air exchange can occur through acombination of any of the three orifices. Secure flow sensors with tape.Monitoring the respiratory effort can be accomplished by several methods,including intercostals EMG electrodes; thoracic and abdominal piezoelectricbelts, impedance pneumography or strain gauges; or inductiveplethysmography that permits differentiation between abdominal and thoracicmovement. The most accurate measure of respiratory effort isesophageal pressure manometry; however, correct placement of the tube isdifficult and can cause patient discomfort and sleep disturbance.The sleep technologist and medical director should evaluate the variousflow and effort sensors available to determine the most appropriate forrecording of these parameters in the sleep facility. Some of the points tocompare would be the need for a calibrated signal for a quantitative signalversus qualitative signal, patient comfort, cost, replacement frequency, susceptibilityto artifact, etc. The amplifier settings and calibration requirementsfor recording respiration signals will vary according to equipment specifications.Because apneas and hypopneas frequently trigger arousals and interruptthe normal sleep cycle, it is important that respiration is recorded toallow for the development of a sleep profile with which the breathing disturbancecan be correlated.2.1.1.8 Blood Oxygenation (Oxygen Saturation — SpO 2 )The diagnosis of obstructive sleep apnea during the standard PSGrequires the continuous monitoring and display of blood oxygen saturationlevels to provide crucial information about the severity of the sleep relatedbreathing disorder. Pulse oximetry transmits two wavelengths of lightthrough a pulsatile vascular bed to measure arterial oxygen saturation. Pulse➟

APT NewZzzPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgoximetry is frequently the method used to monitor blood oxygen levels in thesleep facility because of the ease and comfort to the patient. Pulse oximetrymeasurement is done with a finger probe, although other placements suchas the earlobe or toe may be used depending on the patient. It should benoted that pulse oximetry does not reflect total gas exchange and therefore,cannot detect changes in PaCO 2 . Commercially available oximeters can beeasily interfaced with the PSG acquisition equipment. It is necessary to carefullyevaluate the pulse oximeter for use in the sleep facility for sampling rateand analog output to interface with the polygraph. The output on the oximetermust be recorded through a DC amplifier and is displayed simultaneouslywith other pertinent PSG variables. The polygraph DC amplifier requirescalibration and the output can be displayed linearly or numerically, dependingon the acquisition system. In some systems, the pulse oximeter may be builtinto the amplifier box of the PSG acquisition equipment.2.1.1.9 CapnographyCapnography can be used to measure the patient’s carbon dioxide (CO 2 )level. There are two types: end tidal and transcutaneous. In a transcutaneousPCO2 (TC PCO 2 ) recording, the sleep technologist would place the TCCO2/PO 2 electrode directly to the skin, heated to 42-45 degrees centigrade.Care must be taken to insure that the electrode temperature doesnot burn patients with fragile skin. This sensor measures the transpiredPCO2, which fairly accurately reflects the tissue PCO 2 . This is the preferredmethod for monitoring neonates in an intensive care setting; however, inadults it is accurate only in patients with good tissue perfusion.End tidal capnography is commonly used in children and some adults tomeasure PCO 2 with a nasal or nasal/oral cannula or a tight fitting mask toproduce numerical and graphical displays of CO 2 levels. End tidal measurementreflects the concentration of CO 2 in the lungs and in the blood at theend of expiration. The normal range is 35-45 mmHg.2.1.1.10 Limb MovementAdditional causes of sleep disturbances that may need to be identifiedand treated are restless legs syndrome (RLS) and periodic limb movementsof sleep (PLMS). These leg movements are often visually detectable duringthe monitoring process. Monitoring the anterior tibialis muscles allows forthe determination of the severity of the disorder by quantifying the rate ofmovements as well as the correlation with EEG arousal. Two electrodes areplaced on the anterior tibialis muscle of each leg and secured with tape torecord each leg separately. Although, one electrode can be placed on eachleg and referenced together to record both legs on one channel, this is notoptimal and may affect scoring periodic limb movements according to AASMpublished guidelines. Electrodes are applied according to section 2.1.1.1.2.1.1.11 Body Position/MovementBody position can be monitored with various commercially available bodyposition monitoring devices. These devices use mercury switches and can beinterfaced on the polygraph if an AC channel is available. Alternatively, the sleeptechnologist can observe the patient and document body position changes onthe recording. For report generation, it is optimal to be able to correlate bodyposition in the assessment of sleep disordered breathing. Simultaneouslyrecorded EEG channels will determine if movements originate from wake orsleep and whether arousals correlate with limb or body movement.2.1.1.12 Behavioral ObservationThe capability to observe the patient during the recording of the standardPSG is required for patient safety as well as clinical and technicalassessment. This can be done with a video monitoring system that allowsthe sleep technologist to visually observe the patient and document observations(i.e. body position, body movements, etc.) during the study. The audiomonitoring allows the patient to communicate with the sleep technologist aswell as providing a mechanism for the technical staff to document snoringsounds and other patient vocalizations during the sleep study. PSG dataacquisition systems often are equipped with the capacity for digital videomonitoring which can be viewed on the computer monitor and archivedsimultaneously with the PSG data.2.2.0 Recording ProtocolThe standard PSG protocol is designed to obtain the maximum clinicallyrelevant physiological information with the least disruption of the patient’snormal sleep patterns. The sleep study should be initiated as close as possibleto the patient’s normal sleep time and conducted in a quiet, comfortableroom that resembles a bedroom or hotel room. PSG acquisition equipmentshould be physically separated from the patient with appropriate shieldingof light and sound. Interruptions during the night can be kept to a minimumwith “back-up” electrodes and sensors utilized when feasible.The standard PSG recording montage should consist of the measurementof the above-defined parameters. An example of a montage is as follows:2.2.1 Montage Filter and Sensitivity SettingsChannel Derivation Sensitivity High Filter Low FilterL outer Canthus LOC-A2 5-7 uv/mm 35 Hz .3 HzR outer Canthus ROC-A1 5-7 uv/mm 35 Hz .3 HzChin EMG Pg1-Pg2-Pgz 10 uv/mm 90-120 Hz 5-10 HzCentral EEG C3-A2/C4-A1 5-7 uv/mm 30-35 Hz .3 HzOccipital EEG O1-A2/O2-A1 5-7 uv/mm 30-35 Hz .3 HzLeft Anterior Tibialis LAT1 LAT2 10 uv/mm 70 Hz 10 HzRight Anterior Tibialis RAT1 RAT2 10 uv/mm 70 Hz 10 HzECG ECG1 ECG2 20 uv/mm 15-35 Hz 1 HzSnore* — 20 uv/mm 70 Hz 10 HzAir Flow* — 20 uv/mm 5 Hz .1 HzThoracic Effort Belts* — 10-100 uv/mm 5 Hz .1 HzAbdominal Effort belts* — 10-100 uv/mm 5 Hz .1 HzCPAP* DCx — 5 Hz —SpO 2 DCx — 5 Hz —*suggested settings vary for different technologies60 Hz notch filters are OFF under normal circumstances so as not to filterout 60 Hz contributions to EEG & EOG 8 .The sleep facility director should determine the specific montage and theequipment and recording devices to be used.2.2.2 InstrumentationThe equipment used to gather, analyze & store the data from the sleepstudy must be maintained and documented as such by a trained biomedicaltechnician or other responsible party. Differential amplifiers are designed to distinguishbetween the desired physiologic voltage at the exploring electrode siteand all other unwanted voltages from the body & the external environmentusing common mode rejection. The standard minimum limit for PSG commonmode rejection ratio is 10,000:1. The signal must be sampled often enoughto provide an accurate waveform but not so often as to use unnecessaryresources. According to Nyquist theory this minimum rate is 2 times the highestfrequency being measured. 9 The standard lowest rate is 2.5 times forpolysomnography and equates to the setting of 256 Hz found in most systems.Proper electrode placement; clean site preparation; proper sampling; filteringand amplification provide good physiologic basis for conversion to acontinued on page 109

APT NewZzzPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgAPT — Practice Parameter forStandard Polysomnographycontinued from page 9digital representation. The digital signals must be displayed and recordedsuch as to maximize appropriate visualization of the recorded signals. Properscreen resolution is most often determined by the video equipment manufacturersand should not be altered to manipulate things like font size. ForPSG viewing on the monitor, use the highest resolution available and recommendedby the manufacturer.2.2.3 CalibrationIn order to validate the study it is necessary to perform a pre- and apost-calibration to illustrate that the system was properly calibrated and allequipment and sensors are working correctly throughout the study.2.2.3.1 Amplifier CalibrationIf available to the PSG data acquisition system, the first calibration shouldbe an all channel calibration that passes a known signal voltage, usually 50uv/sec for an epoch of 30 seconds at 10 mm/sec, through the amplifierswhile each recording channel is set to the same sensitivity and filtering (thisgenerally applies to analog PSG data acquisition systems). The resultingwaveforms should be saved as part of the permanent record. If the waveformsdo not show equal and correct amplitude and fall times then adjustmentsmust be made to the channel in question until there is uniformity.2.2.3.2 Montage CalibrationAfter the specific montage for the study has been chosen, in analog PSGdata acquisition systems a documentation of the sensitivities and filter settingsshould be made (see example chart above). Any further changes tosensitivity and filter settings should be documented in either analog or digitalPSG data acquisition systems. A calibration signal must be validated on adigital PSG data acquisition system to verify signal integrity.2.2.3.3 DC Instrument CalibrationBefore the study is run a calibration check of all attached DC instruments,such as pulse oximeters, must be made to insure that minimum andmaximum values correspond to physiologic variables. For example, the minimumand maximum readings of oximeters should be set to translate at zeroand 100. Many digital PSG data acquisition systems have integrated thisfunction into the amplifiers.2.2.3.4 Physiological CalibrationAfter the amplifier calibration has been performed, physiological calibrationsare conducted to insure the quality of the recorded signal. This providesa reference while monitoring, scoring, and interpreting the polysomnogram.All calibration signals must be annotated.Ask the patient to lie supine, if possible, through the patient calibrationprocedure and follow the instructions listed below in section 2.2.3.3.1.Verify the quality of the signal and make adjustments as necessary to theelectrodes, thermistor, or belts, or to the sensitivity, gain, polarity or filtersettings. Replace electrodes or sensors as necessary.2.2.3.4.1 Physiological Calibration InstructionsAnnotate instructions on the computer screen or write on the paperrecording as the patient is instructed to perform the calibration procedures.Give the instructions slowly and clearly. Below is a standard set of patient calibrations.Follow the facility’s calibration procedure, making sure that thereis one for each type of channel. Body position can be visually verified andoximetry should be double-checked if not within a normal range. Instruct the10patient to relax and try not to move.E/CE/OLRLLLULDBLNXJAWSNOREFLEXIN/OUTHOLDMUELLERSEyes Closed for 30 secondsAsk the patient to close their eyes and look straight ahead.Eyes Open for 30 secondsAsk the patient to open their eyes and look straight ahead.Look RightAsk the patient without moving his/her head look to theright then back to the center.Look LeftAsk the patient without moving his/her head look to theleft then back to center.Look UpAsk the patient to keep their eyes closed and withoutmoving his/her head look up then back to the center.Look DownAsk the patient to keep their eyes closed and withoutmoving his/her head look down and back to the center.Blink eyesAsk the patient to blink his/her eyes 5 times.Bite down on JawAsk the patient to bite down on the jaw or clench the teeth.Snore soundAsk the patient to simulate a snore sound or clear throat.Flex footAsk the patient to point and flex each big toe (foot) separately.Annotate each leg separately on the recording.Repeat 2 times on each leg.Breathe In and OutAsk the patient to breathe normally, and then upon yourinstruction take a breath in and out. Mark the record INand OUT accordingly.Take a deep breath and HoldAsk the patient to breath normally and then on yourinstruction take in a deep breath and hold it for 10 seconds(to a count of 10), then resume normal breathing.Mueller’s maneuverAsk the patient to hold breath and try to take 5 breathsagainst a closed airway, then resume normal breathing.Begin “Lights Out” procedure. Instruct the patient to move to a comfortablesleeping position and go to sleep. Remind the patient that the sleeptechnologist is readily available and if the patient should need anything to callthe sleep technologist.2.2.3.4.2 Post CalibrationsAt the end of the study, perform “Lights On” procedure. Enter the roomto wake the patient and turn on the light. Repeat both amplifier and physiologicalcalibrations before ending the recording.➟

APT NewZzzPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.org2.3 Routine for Standard PSGThe protocol of the standard PSG should be clearly established by thesleep facility. Detailed clinical information about the patient’s sleep-relatedproblem as well as a medical history is necessary. The sleep technologistshould apply the required electrodes and monitoring devices to monitor thechannels listed in the montage. The sleep technologist will begin the recordingafter insuring that impedances are acceptable, sensors and equipmentare functioning properly and all calibrations have been performed. “LightsOut” and “Lights On” times should be clearly documented. The sleep technologistwill continuously monitor the patient’s clinical status, body position,and document changes on the sleep study and/or on a form designed by thesleep facility as defined by written protocol. Ideally, 8 hours of recording timeshould be obtained; however, a minimum of 6 hours is recommended for astandard PSG. The sleep technologist will assist the patient as necessaryduring the recording (helping them to the bathroom, addressing comfortissues, etc.) Intervention with therapy (oxygen, PAP) may be initiated per thefacility’s protocol. After “Lights On” procedures have been performed, theelectrodes and monitoring devices should be removed with care and cleanedaccording to infection control standards.2.4 Artifact Recognition and CorrectionThe sleep technologist is responsible for monitoring and maintaining theintegrity of each recorded channel. This requires that the sleep technologistdifferentiate between normal and abnormal patterns as well as patient-generatedvariations vs. true artifact. Once an artifact is identified, the sleeptechnologist must determine when it is necessary to make appropriateadjustments. Ideally, all channels should be artifact-free during the recording.The sleep technologist should use a systematic approach to troubleshootingartifact by tracing the recorded circuit from the patient to thecomputer monitor. Environmental interference (fans, cell phones, etc.) mayhave an effect on the recording and should be annotated.Typical patient circuit:PATIENT ➞ SENSOR ➞ HEADBOX ➞ AMPLIFIER ➞ COMPUTER3.0 PSG DocumentationThe results of the standard PSG procedure must be presented in a comprehensiveand concise report that summarizes all observations and analysisof the recorded physiological parameters. This report is typically presentedin a chart form containing all paperwork pertaining to the patient’scare at the sleep facility. The sleep technologist is responsible for completinga log and summary of the sleep study findings and events. In addition,the sleep technologist is responsible for ensuring that all other required documentsare available before the study begins (history and physical, previoustest results, referral, insurance information, bedtime questionnaires, etc.)These documents must also provide an integrated report, highlighting thesleep technologist’s observations of possible medical significance for theinterpreting physician. The following sections delineate the minimal informationthat should be included in technical documents. 103.1 Patient IdentificationIn compliance with the Health Insurance Portability and AccountabilityAct (HIPAA), the PSG data and all reports should be clearly labeled on eachpage with the patient’s full name, date of birth and date of the study. Anyadditional information, such as identification numbers required for retrievalcan also be included. Likewise, all long-term storage mediums should be adequatelylabeled.3.2 Patient HistoryThe patient’s chart should contain sufficient history information to documentthe reason why the study was recommended, i.e. any significant existingmedical conditions, currents medications, special therapy (i.e. supplementalO2). Any previous special procedures the patient has had that mightinfluence the study results (i.e. LAUP, UPPP, somnoplasty, bariatric surgery)and any previous sleep studies or diagnostic testing such as nocturnal oximetry.This should be accomplished with a complete sleep history questionnairecompleted prior to arrival at the sleep facility as well as receiving a historyand physical from the referring physician. 113.3 Technical Documentation3.3.1 LogThe sleep technologist should log notable events that occur during thestudy in chronological order. Notable events include “Lights Off”, sleep onset,“Lights On”, the sleep technologist entering or leaving the patient’s room, thepatient getting out of bed, initiating or adjusting PAP or oxygen therapy, positionchanges, technical difficulties, environmental disturbances, and anyother observation that might be helpful to the interpreting physician.3.3.2 SummaryThe sleep technologist should completely summarize the technical andbehavioral observations of the standard PSG. This can be done on a formdesigned by the sleep facility or within the context of the format set forth bythe manufacturer of the PSG data acquisition equipment. The summaryshould include comments on sleep architecture behavioral observations,myoclonus/limb movements, respiratory characteristics and heartrate/ECG observations. The sleep technologist should also add any significantmedical or sleep-related information discovered during patient assessment,testing, or before discharge.3.3.3 Sleep ParametersThe report summary should describe should include the details of theanalysis of sleep stage scoring as well as clinical event scoring.3.3.3.1 Sleep Stage ParametersTotal Recording Time (TRT) / Time in Bed (TIB) is defined as the timefrom “lights out” to “lights on”. Total Sleep Time (TST) is the total time asleepafter sleep onset. To determine the how well the patient slept, the SleepEfficiency (SE) is calculated by dividing the TST by the TRT.Sleep studies are gathered on 30 second “epochs”. The unequivocalsleep onset is the first of three consecutive epochs of Stage 1 sleep or thefirst epoch of any other sleep stage. Sleep Onset Latency (SOL) is the timefrom “lights out” to the sleep onset. Latencies to sleep stages are determinedfrom sleep onset to the first epoch of that sleep stage.Wake after Sleep Onset (WASO) is the time awake after sleep onset until“lights on”. To determine the percentage time spent in each of the sleepstages during the sleep study, the total minutes of the sleep stage is dividedby the TST. This percentage can them be compared to normative values todocument the fragmentation of the sleep architecture. 123.3.3.2 Clinical Event ParametersTo determine the severity of the sleep related disturbances, the indicesof the clinical events is compared to normative values. The sleep technologistwill calculate the index by taking the number of clinical events divided bythe TST. These indices include the apnea index (AI), hypopnea index (HI),apnea/hypopnea index (AHI), periodic limb movement (PLM) index, spontaneousarousal index, apnea/hypopnea arousal index, PLM arousal index, andarousal index.Usually the PSG acquisition equipment will analyze the heart rate and oxygensaturation and report the mean, maximum and lowest value by TRT, TSTcontinued on page 1211

APT NewZzzPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgAPT — Practice Parameter forStandard Polysomnographycontinued from page 11and sleep state, i.e. NREM and REM.3.3.4 Sleep Related Breathing EventsThe summary should document sleep related breathing events withrespect to sleep state. Information should be provided concerning the breathingrate while awake and asleep, the presence or absence of snoring, thepresence of paradoxical breathing, the number and index of apneic and/orhypopneic events, the longest apneic and/or hypopneic event, the mean andnadir oxygen desaturation. Notation should be made if sleep state or bodyposition is related to the apnea/hypopnea index and/or desaturation.3.3.5 Heart Rate/ECG ObservationTypical heart rate values while awake and asleep (REM and NREM)should be annotated and the summary should document extreme valuesoccurring transiently. Arrhythmias should be documented with respect tofrequency of occurrence and type. It is particularly important to describethe occurrence of heart rate changes or arrhythmias with respect to sleepstate (REM, NREM) and sleep related breathing events such as O 2 desaturationsand apneic events. 133.3.6 Limb MovementsLimb movement activity is recorded from the extremities and must beevaluated in terms of frequency of occurrence and periodicity, sleep/wakestatus, and presence or absence of subsequent arousal.Rhythmic leg movements observed during wakefulness can indicateRestless Legs Syndrome (RLS). The sleep technologist should ask aboutsymptoms of RLS during patient assessment (difficulty initiating sleep due toa need to move) and document any relevant patient comments as well as evidenceof RLS in the recording.3.3.7 Behavioral ObservationsAny unusual or atypical behavioral events should be documented duringthe patient’s sleep and wakefulness by the sleep technologist during thestandard PSG. The sleep technologist should describe in detail what thebehavior is and how it relates to the polysomnographic recording (i.e. nocturnaleating, enuresis, rocking). When arousals are noted during the standardPSG, the sleep technologist should document the cause of the arousal,i.e. as the result of apneic events, myoclonus, spontaneous or environmentallyevoked.4.0 Standards of Practice4.1 Qualifications of Sleep TechnologistsSleep technologists performing sleep studies should demonstrateknowledge of the polysomnographic recording instrumentation, includingoperating procedures, electrode application, calibration methods and routinetroubleshooting as well as the ability to recognize sleep stages, as outlinedin the APT/AASM Sleep Technologist, Technician and Trainee JobDescriptions 14 . The sleep technologist must have a thorough understandingof normal and abnormal sleep patterns and sleep disorders. The sleep technologistalso must be trained in basic cardiopulmonary resuscitation (CPR)or professional rescuer adult/child CPR and automated external defibrillator(AED). Refer to the AASM accreditation guidelines for standards onpatient: technologist ratio 15 . The facility should consider the experience ofthe technologists as well as the difficulty of the studies being performedwhen deviating from a 2:1 ratio.124.2 Sleep Facility Organization and Record KeepingThe sleep technologists should follow the sleep facility departmental policyand procedure manual. Patient charts, in either print or electronic formatshould be organized and available for appropriate use in the sleep facility.HIPAA guidelines should be followed regarding confidentiality of patientrecords 16 . Equipment, sensor and recording procedures should meet thestandards of the manufacturer.Storage of the recorded PSG data on CD, DVD, hard drive or othermedia should be both secure and easily available for retrieval. If video recording,either digital or VHS, is used, an edited version that preserves therecorded events is acceptable and should be referenced appropriately. Thelength of storage all patient data should be in compliance with the statutesset forth by the state in which the data is obtained and stored.4.3 Patient SafetyIn the context of the technical sleep study, patient safety begins from thepoint of the patient’s arrival until the patient leaves the lab (see 4.4.5). Ofcourse, ordering and performing the appropriate test based on the patient’shistory and physical and previous test results is the responsibility of the sleepfacility under direction from a physician.4.3.1 Safety of the Sleep FacilityThe sleep facility must be safe and easily accessible to all staff andpatients. The sleep facility must be handicapped accessible, meet fire codeand health department regulations, and maintain electrical and mechanicalsafety. The patient rooms must be clean and have adequate audio and videomonitors for patient safety and clinical assessment 17 . All products used onpatients should have Material Safety Data Sheets available in the sleep facility.All flammable materials must be stored in a fire safe. Follow the sleepfacility policy related to patient safety and security.4.3.2 Safety equipmentThe sleep facility should have equipment available for patient care andemergencies: resuscitation bags, back boards, oxygen, biohazard spill kits,refrigeration for patient medication, blood pressure cuffs, AutomatedExternal Defibrillators (AED) and first aid kits.4.3.3 Patient Medical History and CurrentMedical StatusIt is the sleep technologist’s responsibility to know and understand thepatient’s medical history, allergies and current medical status in order toalter procedures, contact a physician, or transfer the patient to emergencycare, as necessary.4.3.4 CPR CertificationAll sleep technologists must be CPR certified. The Professional Rescuerby the American Red Cross or BLS Healthcare Provider Course by theAmerican Heart Association is recommended.4.3.4 Clinical Intervention and Emergency ProceduresThe sleep facility should have written guidelines for initiating any medicalintervention (supplemental oxygen, patient transfer, CPR). There should alsobe a written plan for handling environmental disasters (e.g. tornado, fire,flood, etc.) 184.3.5 Patient Discharge GuidelinesThe sleep technologist should make sure that the patient has hadenough sleep and is not under the influence of medication or alcohol beforerelease from the sleep facility. An early release form should be completedper sleep facility policy. Patients who have not had enough sleep should be➟

APT NewZzzPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgencouraged to stay and sleep (with visual monitoring), even if the recordinghas been discontinued per facility policy.4.4 Infection Control4.4.1 Patient Contact ProceduresSleep technologists should exercise Universal Precautions and precautionsfor prevention of the spread of tuberculosis or other infectious diseasesas appropriate 19,20 . Frequent hand washing is essential for the protection ofboth patients and sleep technologists. All items that will be in contact with apatient must be cleaned and disinfected before use.4.4.2 Equipment DecontaminationThere must be clearly designated areas for clean and dirty equipmentand sensors.4.4.3 Non-Disposable or Reusable ItemsNon-disposable or reusable items include items such as pneumo-tachometers,electrodes, respiratory belts, thermocouples, and body position sensors.Various disinfectant products are available commercially. These products arelabeled with the instructions for disinfecting reusable items and the reusableitems should have instructions for disinfecting and cleaning recommended bythe manufacturer. When reusable items become contaminated and disinfectingis not feasible, gas or heat sterilization may be used or the item should beproperly disposed of. Bed linens should be handled with the assumption thatbiohazard could be present. Overall, it is recommended to use disinfectingproducts or procedures that are approved for the medical setting.4.4.4 Disposable ItemsThe syringe and flat-tipped needle used to inject electrolyte into the cupof electrodes should be discarded after use with the needle placed in areceptacle for needles 21 . Disposable sensors should be disposed of afteruse. Likewise, nasal cannulas used for administering oxygen or to monitorflow with a pressure transducer are for single patient use only. These typesof products should be disposed after each patient use.Footnotes1. Kushida CA, et al., Practice Parameters for the Indications forPolysomnography and Related Procedures: An Update for 2005 Sleep2005;28:499-529.2. Association of Polysomnographic Technologists, eds. Job Descriptions.Westchester, IL. Available at: http://aptweb.org/pdf/JobDescriptions.pdf3. American Academy of Sleep Medicine, eds. International Classification ofSLEEP DISORDERS, 2nd ed, Diagnostic and Coding Manual. Westchester,Illinois, 2005.4. Chokroverty S. Polysomnographic technique: an overview. In: SleepDisorders Medicine 2nd ed. Boston: Butterworth Heinemann; 1999:158. ; Butkov N. Atlas of Clinical Polysomnography, vol.1. Ashland, OR:Synapse Media, 1996: 11. Lee-Chiong T, Sateia M, Carskadon M, eds.Sleep Medicine. Hanley & Belfus, 2002: 615.5. Tyner F, Knott J, Mayer W Jr. Fundamentals of EEG Technology Volume1: Basic Concepts and Methods. New York: Raven Press;1983: 126.6. Lee-Chiong T, Sateia M, Carskadon M, eds. Sleep Medicine. Hanley &Belfus, 2002: 647.7. Jasper H.H. The ten twenty system of the International Federation.Electrencephalogr Clin Neurophysiol, 1958; 10:371-375.9. Butkov N. Atlas of Clinical Polysomnography, vol.1. Ashland, OR: SynapseMedia, 1996: 6.10. Forouzan BA, Fegan SC. Data Communications and Networking 2nd ed.Boston: McGraw-Hill, 2001:105.10. Chokroverty S. Polysomnographic technique: an overview. In: SleepDisorders Medicine 2nd ed. Boston: Butterworth Heinemann; 1999: 159.11. American Academy of Sleep Medicine, eds. Standard 17: Charting. In:Standards for Accreditation of a Sleep Disorders Center. Westchester,Illinois: 2006.12. Redline S, Kirchner HL, Quan SF, et al. The effects of age, sex, ethnicity,and sleep-disordered breathing on sleep architecture. Arch InternMed 2004; 164:406-418.13. Somers VK, Javaheri S. Cardiavascular effects of sleep-related breathingdisorders. In: Kryger MH, Roth T, Dement WC, eds. Principles andPractices of Sleep Medicine, 4th ed. Philadelphia: Elsevier Saunders;2005: 1182-1186.14. Association of Polysomnographic Technologists, eds. Job Descriptions.Westchester, IL. Available at: http://aptweb.org/pdf/JobDescriptions.pdf15. American Academy of Sleep Medicine, eds. Standard 3: Personnel.Standards for Accreditation of a Sleep Disorders Center. Westchester,IL: 2006.16. Health Insurance Portability and Accountability Act of 1996 Available at:http://www.cms.hhs.gov/HIPAAGenInfo.17. American Academy of Sleep Medicine, eds. Standard 8: Facility andEquipment. Standards for Accreditation of a Sleep Disorders Center.Westchester, Illinois: 2006.18. Occupational Safety & Health Administration, Occupational Safety andHealth Standards: Exit Routes, Emergency Action Plans, and FirePrevention Plans — 1910 Subpart E App. Available at:http://www.osha.gov/pls/oshaweb.19. Centers for Disease Control. Guidelines for preventing the transmissionof tuberculosis in health-care settings, with special focus on HIV-relatedtissues. MMWR 1990; 39 (RR-17): 1-29.20. Centers for Disease Control. Update: Universal Precautions for preventionof transmission of human immunodeficiency virus, hepatitis B virus,and other bloodborne pathogens in healthcare settings. MMWR 1988;37: 377-382, 387-388.21. Occupational Safety & Health Administration, Occupational Safety andHealth Standards: Bloodborne pathogens — 1910.1030. Available at:http://www.osha.gov/pls/oshaweb.APT Continuing EducationCredit Program —NEW Applications areNow AvailableTo meet the growing professional and educational needs of theSleep Technology Profession, the Association of PolysomnographicTechnologists (APT) has revised and expanded the ContinuingEducation Credit (CEC) Program. Educational Providers now havethe opportunity to apply for APT CECs through four educationalcategories:1. In-Service/Case Conference — (one to two hour program)2. Single Lecture/Workshop — (one to two hour program)3. Educational Programs, Training Course, Seminar, etc. —(more than two hour program)4. Computer Based Learning Activities (i.e. CD-ROM’s,DVD’s, Webinars, and Internet)For additional information on the new APT CEC applications,visit the APT Web site at www.APTWeb.org.13

Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgA2Zzz Magazine Continuing EducationCredit OfferingInstructions for Earning ContinuingEducation CreditA Trainee, Technician or Technologist working in the SleepTechnology Profession towards achieving the RegisteredPolysomnographic Technologist (RPSGT) credential or re-certification ofthe RPSGT credential may read A2Zzz Magazine and earn Associationof Polysomnographic Technologists (APT) Continuing Education Credits(CECs) by completing an APT CEC A2Zzz Magazine evaluation form, onthe next page, and fax or mail the completed form to the APT nationaloffice to receive 1.5 APT CECs. This service is an APT member benefitand there is no fee to APT members. Individuals who are not membersof the APT and are interested in earning APT CECs will berequired to pay an administrative fee of $20 per issue.To earn APT CECs, carefully read A2Zzz Magazine and completethe APT CEC Evaluation Form found on the next page. Thecompleted evaluation form must be received by the APT nationaloffice by March 1, 2007. A certificate awarding APT CECs will besent within 4 to 6 weeks of the submission deadline. It is theresponsibility of the individual to maintain a record of their APTCEC certificates.It is required that four out of the six articlesin this issue listed below be read andthat a corresponding page number beincluded on your APT CEC Evaluation Formin order to receive APT CEC credit:Accreditation StatementsThis activity has been planned and implemented by the APT Boardof Directors and approved by the Board of Registered PolysomnographicTechnologists (BRPT). The APT Board of Directors has established thisprogram to meet the educational needs of the Sleep TechnologyProfession. Each individual should only claim those credits that he/sheactually spent in the educational activity.Statement of Educational Purpose /Overall Education ObjectivesA2Zzz Magazine is a peer-reviewed publication addressing theeducational needs of the Sleep Technology Profession. Its missionis to provide progressive technical information and an avenue ofcommunication for members, presented in a professional and constructivemanner, to further the goals, and promote unity in theSleep Technology Profession. Readers of A2Zzz Magazine shouldbe able to: 1) appraise Sleep Technology; 2) interpret new informationand updates relating to the Sleep Technology Profession; 3)analyze articles for the use of sound principles and practices; and4) recognize the inter-relatedness/dependence of sleep medicinewith primary disciplines.Page 6: APT Practice Parameter for Standard PolysomnographyObjective: To impart an understanding of the placement of electrodesand sensors used during polysomnography, polysomnographicrecording techniques and theory, standard recording protocol, includingcalibration, instrumentation, montage, and also the need for documentationand review of patient sleep history.Page 16: Deep Brain Stimulation and SleepObjective: Impart an understanding of the fact that since its introduction,the use of deep brain stimulation (DBS) has been expandedto treat other disorders such as epilepsy and depression, amongothers. Scientists are beginning to investigate the possibility of usingDBS to treat certain sleep disorders. DBS stimulates areas in thebrain involved in sleep and some studies show that it can modifysleep architecture.Page 18: Pulse Transit Time: A Useful Clinical Tool?Objective: Defines Pulse Transit Time (PTT) as the time it takesfor the arterial pulse pressure wave to travel from the aortic valve toa peripheral site. The article discusses the use of PTT in representingrespiratory effort by detecting changes in the blood pressureoscillations associated with pleural pressure swings. Blood pressuresurges, also detected by PTT, have been associated with microarousals.The history of PTT, research findings and its use clinicalpractice are discussed.Page 26: Inadequate Sleep and DepressionObjective: Imparts an understanding that more than 80% of peoplewith depression experience sleep disturbances. Insomnia is thebest predictor for individuals with depression. Predictions state thatmajor depression will be the second leading cause of disability by2020. The article proposes that all patients should be asked if theyhave difficulty sleeping as part of their routine health screenings inconsidering the link between inadequate sleep and depression.Page 28: They Come From the CortexObjective: Discusses where scalp potentials come from, what producesthese voltages and how volume conduction, tissue dipoles andgeometric orientation affect EEG tracings. It also discusses that informationthat can be derived from these waves forms once conductedthrough tissue and recorded through amplifiers.Page 30: Pathological YawningObjective: This case study examines a 50-year-old woman who hasbeen followed for dymelinating disease and who developed excessiveor pathological yawning, or “chasm.” Not from being fatigued orbored, pathological yawning is medically defined as a complex arousalreflex that arises from the brainstem and is thought to counteracthypoxemia in the brain. Some of the known causes of pathologicalyawning include encephalitis, seizures, tumors of the fourth ventricleregion, multiple sclerosis, progressive supranuclear palsy, electroconvulsivetherapy and neuroleptic withdrawal.14

Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgAPT CEC Evaluation FormTo earn APT CECs, carefully read four of the articles (see previous page for list) designated for APT CECs and mark your responses for each articleand its page number on this form. Completely answer all questions and fax or mail this form to the APT national office (fax number/address indicatedat the bottom of this page). In order to receive credit, this evaluation form must be answered completely and postmarked by March 1, 2007.A certificate awarding 1.5 APT CECs will be mailed to you four to six weeks following this date. There is no charge to members of the APT for thisservice. Non-members must include payment of a $20.00 administrative fee with this form.For items 1-2, please use the following scale:5=Strongly Agree, 4=Agree, 3=Unsure, 2=Disagree, 1=Strongly DisagreeArticle 1 Article 2 Article 3 Article 4Page #_____ Page #_____ Page #_____ Page #_____1. Educational value:I learned something new that was important. 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1I verified some important information. 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1I plan to discuss this information with colleagues. 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1I plan to seek more information on this topic. 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1My attitude about this topic changed in some way. 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1This information is likely to impact my practice. 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 12. Readability feedback:I understood what the authors were trying to say. 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1I was able to interpret the tables/figures (if applicable). 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1Overall, the presentation of the article enhanced myability to read and understand it. 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1Please print legibly or type:3. Additional comments/feedback to be used by the APT CEC Committee: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. Commitment to change:What change(s), if any, do you plan to make in your practice as a result of reading any of these four articles? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________5. Statement of completion:I attest to having completed the APT CEC activity (sign below).Signature________________________________________________________________________ Date ______________________________________________________Phone: ______/______/__________ Fax: ______/______/__________ E-mail: __________________________________________________________________________________Name (please print legibly) __________________________________________________ RPSGT ❑Address __________________________________________________________________________________________________________________________________________________________________________________________________________________________________City_______________________________________________________________________ State_______________ Zip ______________________________________________________________________Are you a member of the APT? (circle one): Yes / No APT Membership No:_____________ (If no, complete the following payment information)❑ Check made payable to the APT for $20 is enclosed or ❑ Charge $20 to (circle one): Visa / MasterCard / American ExpressCard Number__________________________________________________________ Expiration Date ______/______Cardholder name (please print)_____________________________________________ Signature________________________________________________________Cardholder Address ______________________________________________________________________________________________________________________________________________________________________________________________________________Please return this completed form, postmarked no later than March 1, 2007, to the APT National Office:One Westbrook Corporate Center, Suite 920, Westchester, IL 60154, or fax to (708) 273-934415

Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgDeep Brain Stimulation and SleepBY REGINA PATRICK, RPSGT, ASSOCIATE EDITORIn 1995 in Europe, Canada and Australia, a newly-approved medicaldevice — a deep brain stimulator — was used to treat people who hadessential tremors (i.e., tremors with no apparent cause). Two yearslater in 1997, the United States Food and Drug Administration gave itsapproval for the device to treat people with essential tremors. Since itsintroduction, use of deep brain stimulation has been expanded to treatother disorders such as epilepsy, depression, and especially the rigidity,tremors, bradykinesia (slow movement), and gait difficulties of advancedParkinson’s disease. More than 30,000 1 people worldwide have beenimplanted with a deep brain stimulator since 1995. Scientists are beginningto investigate the possibility of using deep brain stimulation (DBS) totreat certain sleep disorders. DBS stimulates areas in the brain involvedin sleep and some studies show that it can modify sleep architecture.Deep brain stimulation (DBS) initially came about as a treatment forpain. One theory 2 on the genesis of pain viewed pain as the result ofsomatic signals being blocked from stimulating certain areas (e.g., ventrotposteriornuclei) of the thalamus. With this view in mind, G. J.Mazars 2 and other scientists in the 1970s began experimenting withartificially stimulating the thalamus in an effort to reduce pain. Artificialstimulation was accomplished with the implantation of an electrode tothe brain which was attached to a device that generated pulses.Scientists soon began to note that the surgery also stopped abnormalmovements (e.g., “jumping stumps” in amputees) in intractable painpatients. This led to the speculation 3 that the thalamus plays a role inboth pain and movement and that stimulating the thalamus may alsoreduce abnormal movements. Many studies subsequently investigatedthe use of thalamic surgery to improve movement.Initially, thalamic surgery for restoration of movement involveddestroying tiny areas of the thalamus or nearby structures such as theglobus pallidus and subthalamic nucleus. However in the 1980s, neurosurgeonAlim-Louis Benabid noted during surgery that when a stimulatingelectrode was placed on thalamic areas involved in movement, the person’smovement immediatelyimproved although the areahad not yet undergone tissuedestruction. Thisobservation led him tosuggest that permanentstimulation of the areasrather than destructionof the tissue may be ableto reduce tremors inpeople. He worked incollaboration with amedical device companyto develop animplantable neurostimulatorto specifically treattremors.16Deep brain stimulationsurgery 4 now typicallyinvolves implanting a leadinto two areas near the thalamus: theglobus pallidus and the subthalamic nucleus(STN, a mass of gray matter is locatedjust below the thalamus). The tip of thelead contains four electrodes which eachstimulates a discrete area of tissue. Anextension wire connects the other end ofthe lead to a neurostimulator. The neurostimulatorproduces the stimulatorypulses which are transmitted through theextension wire to the lead.Regina PatrickBefore surgery, the person’s head is placed within a stereotacticframe (e.g., Leksell G frame) so that measurements can be made inorder to determine precisely where to insert the lead. The frame alsokeeps the person’s head stabilized during the surgery.Once measurements are made, a small area on the scalp is anesthetizedand a small circular (approximately 0.5 inch diameter) openingis bored in the skull near the coronal suture (the junction line of thefrontal bone with the parietal bone). The lead is inserted until it reachesthe basal ganglia. Since the patient remains awake during this portion ofthe surgery, a surgeon does neurological tests and asks the patient todescribe sensations the patient is experiencing. This helps the surgeonto more accurately determine that the lead is being inserted into the correctarea. Once the lead is in the right position, the patient then undergoesgeneral anesthesia so that the neurostimulator can be implanted.The neurostimulator is a small device about 3 inches round and 1/2inch thick. It is inserted through an incision made beneath the collarbone. An extension wire from the neurostimulator is passed up beneaththe skin through the neck toward the bore hole in the skull. The extensionwire connects with the lead at the bore hole. Depending on whetherone side or both sides are affected by impaired movement, a personmay be implanted with a unilateral or bilateral stimulator system.After surgery, a physician adjusts the neurostimulator’s stimulationparameters (i.e., amplitude [voltage], signal frequency, and pulse width[length of stimulation]). The usual stimulation parameter ranges are anamplitude of 1 to 3 volts, signal frequency range of 135 to 185 cyclesper second, and a pulse width of 60 to 120 microseconds.The subthalamic nucleus (STN) and globus pallidus are located inclose proximity to each thalamus. The STN and globus pallidus havemany interconnecting pathways with each other. The globus pallidus alsohas connections to the thalamus, midbrain, and other basal ganglia suchas the caudate nucleus.The role of the STN and globus pallidus in sleep is unclear.However, scientists have begun to discern the neural activity of thesestructures during sleep and wake. For example, studies 5,6 show thatcortical activity has an excitatory influence on the STN but the abilityof the STN to respond to the excitatory effects of cortical neurons ismodulated by the inhibitory influence of the globus pallidus which containsmany GABAergic neurons. (GABA, gamma-amino butyric acid, isa neuroinhibitor.)➟

Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgPulse Transit Time: A UsefulClinical Tool?BY KIMBERLY TROTTER, M.A., RPSGT, ASSOCIATE EDITORWhat is Pulse Transit Time?Pulse Transit Time (PTT) is the time it takes for the arterial pulsepressure wave to travel from the aortic valve to a peripheral site 1 .It is usually measured from R wave on electrocardiogram (ECG) to thepulse wave arrival at the finger (using oximetric photopleythsmography).PTT has been shown to represent respiratory effort by detectingchanges in the blood pressure oscillations associated with pleural pressureswings (pulsus paradoxus) 2 . Blood pressure surges, detected byPTT, have been associated with micro-arousals as well 3 .HistoryPulse Transit Time (PTT) has been used since the 1970s as an indicatorof blood pressure changes 1 . Recently, PTT changes have been correlatedwith arousals 4,5 . Some research has gone as far as theorizingthat changes in PTT may denote arousals without the need for EEG 5 .Research ResultsMany studies include both adult and pediatric populations. Correlationsbetween electroencephalogram (EEG) arousals or sleep fragmentation,increased respiratory effort — esophageal pressure (Pes), thoracic, andabdominal respiratory effort — and PTT changes are shown.Pediatric StudiesThere have been many studies that show a correlation between Peschange and PTT change in children 4 , however, some of these studies discusslimitations in studying a pediatric population, including excessivemovement artifact.In some of these pediatric studies, PTT was shown to be slightly moresensitive to detecting respiratory events than Nasal Pressure (NP) alone.PTT is non-invasive, and does not disturb sleep or modify upper airwayas Pes has been shown to do 4,5,6 .Adult StudiesThe adult studies show similar results to pediatric studies. Again, NPwas shown to be just slightly less sensitive that PTT in detecting respiratoryevents, especially upper airway resistance syndrome (UARS) orrespiratory effort related arousals (RERAs).PTT is a desirable measurement for respiratory disturbancebecause it is non-invasive, and it is semi-quantitative. It has been shownto reveal micro-arousals and increased respiratory effort 2,7,8 .Should it be used in your lab?PTT can be a useful addition to NP or replacement for Pes, enablingmore sensitive monitoring for UARS/RERAs. There are PTT monitorsbuilt into some of the sleep monitoring systems, such as the RespironicsAlice 5. It is up to the technologist to let the data acquisition systemmanufacturers know that we are interested in studying PTT as a usefuladdition or tool for recognizing UARS/RERAs. ★References1. Smith, R. et al. Pulse Transit Time: an Appraisal ofPotential Clinical Applications. (1999). Thorax54;452-457.2. Pitson, D. et al. (1995). Use of Pulse Transit Timeas a Measure of Inspiratory Effort in Patients WithObstructive Sleep Apnea. Eu Respir J 8:1669-74.3. Pitson, D. et al. (1994). Changes in Pulse TransitTime and Pulse Rate as Markers of Arousal From Kimberly TrotterSleep in Normal Subjects. Clin Sci 87:269-73.4. Pepin, J. et al. (2005). Pulse Transit Time Improves Detection of Sleep Respiratory Eventsand Microarousals in Children. Chest 127;772-730.5. Katz, E. et al. (2003). Pulse Transit Time as a Measure of Arousal and Respiratory Effortin Children with Sleep-Disordered Breathing. Pediatr Res 53:580-588.6. Pagani, J. et al. (2003). Pulse Transit Time as a Measure of Inspiratory Effort in Children.Chest 124:1487-1493.7. Argod, J. et al. (2000). Comparison of Esophageal Pressure with Pulse Transit Time asa Measure of Respiratory Effort for Scoring Obstructive Non-apneic Respiratory Events.Am J Respir Crit Care Med July;162(1): 87-93.8. Poyares, D., et al. (2002). Arousal, EEG Spectral Power and Pulse Transit Time in UARSand Mild OSAS Subjects. Clin Neurophysiol Oct;113(10):1598-1606.About the AuthorKimberly Trotter, MA, RPSGT, is the Practice Manager for the University of California at SanFrancisco (UCSF) Sleep Disorders Center, Pulmonary Function Lab and PulmonaryDepartment at Mount Zion Hospital. She is a past APT Board Member, Association for theStudy of Dreams former member, and a longtime sleep technologist. She is also an A2ZzzMagazine Associate Editor.Committee on Accreditation forPolysomnographic TechnologyEducation (CoA PSG)Is your Polysomnographic TechnologyTraining Program accredited? The CoAPSG is now accepting applications foraccreditation from allied health educationprograms.CoA PSG accreditation is the gold standardfor Sleep Technology educationalprograms and has several benefits:• Access to formal and standardizededucational resources• Recognition of your program’s qualitycurriculum and instruction• Recognition by the Commission on Accreditation of Allied HealthEducation Programs (CAAHEP)• Prepares your students for the national credentialing examination• Recognition by professional societies, including the AmericanAcademy of Sleep Medicine, Association of PolysomnographicTechnologists and Board of Registered PolysomnographicTechnologistsVisit www.caahep.org/accredit.aspx?ID=obtainCredit for informationon the accreditation standards and guidelines or contact Dr. RichardRosenberg at (708) 492-0930 for more information.18

Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgCognitive Changeson PSG TechniciansAfter Six Monthsof NocturnalShift WorkBY ROGERIO SANTOS DA SILVA, PH.D., RPSGTStudy performed by: Francisco Gregorio de Oliveira, RogerioSantos da Silva, Lia Alves Simoes Matuzaki, Maria de LourdesLefevre Assumpcao, Fernanda Kelly Gimenes Bertini, RuthFerreira Santos, Sergio Tufik.Sleep Institute/AFIP; Sleep Medicine and Biology Discipline —Psychobiology Department — Federal University of Sao Paulo.AbstractObjectivesTo evaluate the effects of nocturnal shift work on cognitive functionof PSG technicians who had never worked during nocturnalshift before.MethodsThe performance of 18 PSG technicians, aged 20-35 years old,were evaluated before and six months after the beginning of nocturnalshift work. The schedule was 3-12 hours shifts. The followingneuropsychological tests battery was administered includingtests of general nonverbal intelligence, attention, verbal andnonverbal memory, and executive functions. The results were statisticallyanalyzed using Student’s t-test.ResultsSignificant differences between the performance of the PSGtechnicians before and after six months of nocturnal shift wereobserved, respectively: attention — increase of wrong answersin the Tolouse-Pieron Test (3.8+/-1.2 vs. 13.8+/-7.7)(p

The APT wishes to acknowledge andthank the following organizationsfor their generous support andinvesting in the future of the SleepTechnology Profession by becomingAPT Supporter Members:Pro-Tech Services Respironics SleepmateDeVilbissCadwell Laboratories

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A New Look...A New Name... American Association of SleepTechnologists (AAST)The Same Mission... To promote and advance thesleep technology professionFor nearly 30 years the Association ofPolysomnographic Technologists (APT) hasbeen the only professional society that is dedicatedexclusively to the needs of sleep technologists.The AAST remains committed to providing opportunitiesfor professional development, to promoting technicaland clinical excellence, and to preserving the autonomyand future of the sleep technology profession.As the field of sleep medicine grows the AASTcontinues to be the leading voice for sleep technologists,making sure that our members are recognized asqualified healthcare professionals who ensure thesafe and accurate assessment and treatment ofsleep disorders.

Very Active Fall forRegional Sleep Education!Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgAPT 2006 FallReview CourseHeld in Indianapolis in October, the course is heldannually and is aimed at technicians preparing to sitfor their board examinations, as well as seasonedprofessionals wanting a comprehensive refreshercourse to obtain continuing education credit. TheAPT’s reputation for being committed to providinghigh-quality education resulted in this year’s annualreview course boasting one of the highest numbersof attendees in APT history.Montana Regional Sleep Seminar 2006The Sleep Center at St. Vincent Healthcare in Billings, sponsors the fall conference annually in the hospital’sadjacent Mansfield Health Education Center. So many sleep technologists attended this year’s conference,it was necessary for at-the-door registrants to participate via overview lecture rooms. A state-of-theartfacility, the center has telecommunications capability in all of the meeting rooms, an auditorium withseating for 250 and a contemporary medical library. Named for the legendary Montana Senator MikeMansfield and his family, the center opened in 2002.Attendees review a PSG paper tracing for artifact.Glenn Roldan, annual speaker, conducts a boardexamination review. The next conference is slatedfor September 6-8, 2007 in Billings, MT.Karen Allen, organizer, and Kim Trotter, popular annualspeaker and A2Zzz Magazine Associate Editor, participatein a CPAP mask-fitting workshop with attendees.Dr. William Dement signs autographs for attendees atthe Talk About Sleep (TAS) Inaugural Patient SleepConference held in Minneapolis, Minnesota in October.Sleep technologists attend clinical breakout sessionsfor CEC credit at the patient conference.The conference was the first of its kind for patients.Dr. James O’Brien, TAS President, and speakers Dr.Dement, Ed Grandi, American Sleep ApneaAssociation Director, Dr. David Rapoport, New York,and Dr. Mark Abraham, Louisiana, with TAS VicePresident and sleep patient Tracy Nasca.23

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Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgInadequate Sleep and DepressionBY JOSHUA COLE, RPSGT, ASSOCIATE EDITORSleep disturbances are becoming quite familiar to those screeningpatients for depression. Inadequate sleep and depression seem tobe inexplicably related, but the answer to the age old “chicken or theegg” quagmire has long been elusive. Are the two linked? Can one leadto the other? Numerous studies seem to express the same sentiment;inadequate sleep and depression are linked but we have yet to determineif one definitively leads to the other.identifying those at risk for depression.“Sleep is as essential as diet and exercise.Inadequate sleep can result in fatigue,depression, concentration problems, illnessand injury.” 3 But, is this true in allcases? How and why does inadequatesleep lead to depression?Poor sleep hygiene will confuse the body and seriously disrupt one’slife. Overconsumption of caffeine and alcohol, conducting physical exercisetoo closely to bedtimes and lingering in bed can all predispose oneto inadequate sleep. Habits such as these have been proven to lead tomood changes, depression and frustration with sleep and everyday activities.2 These interferences eventually decrease one’s quality of life, byrepeating cycles that lead to altered states and increase one’s susceptibilityto depression.Recent debate is more focused on the links of specific sleep disordersto depression as opposed to the bigger picture of whether poorsleep hygiene or sleep patterns contribute to depression and whetherthe treatment of one may possibly alleviate the other or slow the developmentthereof. 2 “Insomnia may also signal depression or anxiety. Oftentimes, insomnia exacerbates the underlying condition by leaving thepatient fatigued and less able to cope and think clearly.” 3Research has shown that restless legs syndrome and sleep apneaare now being addressed along with insomnia as possible indicators for26Approximately 50% of depressed outpatientsand 80% of those hospitalized forJoshua Coledepression experience some form ofsleep disturbance. One disturbance is known as “excessive sleep effort”and is becoming increasingly more common in patients with depression.Excessive sleep effort was identified after researchers began to classifydepression into subgroups, such as “hopelessness depression.” Thosesuffering from hopelessness depression often view themselves as failuresand have difficulty believing in their own ability to live everyday life.Those with symptoms of “excessive sleep effort” experience heightenedfrustration and arousal from trying to fall asleep and being unable to doso. These patients often make statements like, “No matter what I do, Ijust can’t sleep...” A better understanding of mind-body interaction, biologicalprocesses and the effects of sleep in the development of depressivesymptoms is needed to solidify the link between poor sleep hygieneand depression. 4Primary sleep disorders including narcolepsy, sleep apnea andinsomnia have been proven to cause a reduced quality of life.Researchers have classified sleep disordersassociated with depression into oneof two categories: Sleep Apnea andInsomnia. During the years of 1994-1999, a cross section survey of 19,000randomly selected persons between theages of 15-100 years old, showed thatmore than 2% of subjects hadObstructive Sleep Apnea and another2.5% had some other type of respiratoryrelated sleep disorder. Nearly one fifth ofthose with a sleep disorder also had amajor depressive disorder. After the controllingfactors of obesity and hypertensionwere considered and eliminated, theodds of having a sleep disorder were5.26% higher for those who had alsobeen diagnosed with depression. As theunderstanding of the relationshipbetween sleep and depression grows, wemay find that the detection and treatmentof one could be the deciding factor in thesuccessful prevention or slowed progressionof the other. 5Insomnia is still the most commonsleep disorder cited by those with depression.Insomnia predicts mania and converselydepression can predict sleep➟

Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgproblems, creating a potential two-way relationship. Sleep lab studies ofpsychiatric patients show profound sleep abnormalities. Inadequatesleep and problems with sleep continuity contribute to mood and anxietydisorders and increased rates of mental stress among insomniapatients. Approximately 33% of patients with insomnia have a depressiveor anxiety disorder compared to 11% of patients without insomnia.“Insomnia increases the risk for depression later in life. Insomnia precedesdepression 41% of the time and follows depression 29% of thetime. In recurrent depression, insomnia appears first over 50% of thetime,” said Dr. Ruth M. Benca, M.D., Ph.D., professor in theDepartment of Psychiatry at the University of Wisconsin-Madison. Sinceinsomnia precedes depression and acute depression worsens insomnia,could both possibly result from similar neurobiological abnormalities? Dr.Benca poses the question of whether there is an underlying process thatfosters this relationship. 1Neurobiological factors along with psychological and physiologicalprocesses may determine one’s predisposition to depression. The longstruggle to link inadequate sleep and depression led to an early consensusthat depression causes insomnia. However, once antidepressantswere introduced as treatment, studies found that they were successfulat improving symptoms of depression but did not alleviate insomnia andactually interfered with sleep patterns in some cases. 6In 2005, researchers conducted a study hypothesizing that chronicsleep loss can lead to depression, due to the desensitization of theserotonin receptor. This desensitization can eventually lead to the dropor interruption of serotonin transmission, a proven indicator of depression.A link here would be valuable considering serotonin is the verything many antidepressants are designed to regulate. In this study,rats were subjected to only 4 hours sleep per day. After 2 days, therewas no effect on the serotonin levels. After 8 days however, the serotoninreceptor system was desensitized. Control experiments indicatedthat the effects of sleep restriction were not due to forced activityor stress. Most importantly, the desensitization of the serotonin (5-HT1A) receptor persisted for many days even with unlimited recoverysleep. Normalization occurred gradually but took at least 7 days.Findings concluded that, “Chronic sleep restriction causes a gradualand persistent desensitization of the 5-HT1A receptor system,” showinga link between chronic sleep loss and sensitivity to disorders suchas depression associated. 7The long held assumption that insomnia is a symptom or side effectof depression is being challenged with suggestions that insomnia maymake patients more likely to become and/or remain mentally ill. Thosemost at risk for first time onset of depression are those who suffer fromsevere “middle insomnia”, where the patient wakes up frequentlythroughout the night but eventually falls back asleep each time. Two newstudies show that insomnia may indeed precede depression. 6 “The oddsof developing depression are increased during a year of insomnia,” saysDr. Ruth M. Benca, “There is a 40% elevated risk.” 1 Michael Perlis,Director of the University of Rochester Sleep Research Laboratory, said,“The new findings are especially significant because they suggest thattargeted treatment for insomnia will increase the likelihood and speed ofrecovery from depression.” 6Approximately 100 million Americans suffer from insomnia andmore than 80% of people with depression experience sleep disturbances.5 “Insomnia is the best predictor for individuals with depression.Major depression will be the second leading cause of disability by 2020.All patients should be asked if they have difficulty sleeping as part oftheir routine health screening,” according to Dr. Benca. 1 Calling for anemphasis on an “integrative psychophysiological perspective” whenstudying the link between inadequate sleep and depression may be beneficial.4 An acceptance and understanding of this relationship could beexpedited by combining polysomnograms and routine psychologicalexams in patient evaluations. ★References1. Pueschel, Matt. Sleep Shown As Central To Overall Physical Health. U.S. MedicineInformation Central. July 2004; Available at: http://www.usmedicine.com/ AccessedSeptember 26, 2006.2. SleepEducation.com. Inadequate Sleep Hygiene, Updated March 1, 2005. Available at:http://www.sleepeducation.com Accessed August 29, 20063. National Sleep Foundation. Insomnia/Basics Reviewed by David N. Neubauer, M.D., M.A.March 28, 2005 Available at: http://www.sleepfoundation.org/sleeptionary/indexAccessed August 29, 20064. Haynes, Ph.D., Patricia L. No Sweet Dreams Sleep Review Vol. 6, No. 7, Nov 2005 (48-50)5. Zoidis, M.D., John D. Sleep and Depression Sleep Review Vol. 6, No. 3, May/June 2005(38-42)6. Media Release — University of Rochester Medical Center. Relationship Between Insomnia andDepression Revealed, June 22, 2005. Available at: http://www.scienceagogo.com/newsAccessed September 26, 20067. Roman Ph.D, Viktor, Walstra, Irene, Luiten, Ph.D., Paul G.M., and Meerlo, Ph.D, Paul.Too Little Sleep Gradually Desensitizes the Serotonin 1A Receptor System Journal SLEEP,Vol. 28, Issue 12, 2005 (1505-1510) Available at: http://www.journalsleep.org.Accessed August 29, 2006About the AuthorJoshua Cole, RPSGT, is a diagnostic sales representative for Respironics, Inc. He is an associateeditor for A2Zzz Magazine and a member of the APT Communications Committee. Coleresides in Southern California and may be contacted though the APT National Office atapt@aptweb.org.MVAP MEDICAL SUPPLIES • 2005 SLEEP CATALOG • 2005 SLEEP CATALOG • MVAP MEDICAL SUPPLIESMVAP MEDICAL SUPPLIES • 2005 SLEEP CATALOG • MVAP MEDICAL SUPPLIES • 2005 SLEEP CATALOGMVAP MEDICAL SUPPLIES • 2005 SLEEP CATALOG • MVAP MEDICAL SUPPLIES • 2005 SLEEP CATALOGMVAP MEDICAL SUPPLIES • 2005 SLEEP CATALOG • 2005 SLEEP CATALOG • MVAP MEDICAL SUPPLIES27

Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgThey Come From the CortexBY WILL ECKHARDT, BS RPSGT CRT, ASSOCIATE EDITORWhere do scalp potentials come from and what produces thesevoltages? How do volume conduction, tissue dipoles and geometricorientation affect the electroencephalogram (EEG)? What informationcan we derive from these waves forms once conducted throughtissue and recorded through our amplifiers? We will explore these issues.We record the EEG from scalp electrodes commonly placed by whatis know as the International 10-20 System of Electrode Placement(albeit modified generally in sleep studies). Hans Berger recorded thefirst human EEG in the1920’s. We have come along way in the equipmentused in recording the EEG but the source remains the same. EEGis a means of looking at voltages derived from our cortex which vary asa function of time and their spatial distribution in relation to the recordingelectrode.EEG can be recorded via scalp electrodes or from intracranial electrodes.Scalp sites sample from a larger area than intracranial placement.Intracranial sites provide more local sampling giving generallydifferent data from that of the global scalp recordings. Scalp EEG isnow believed to be derived from postsynaptic potentials (postsynapticpotentials are changes in the electrical potential of the neuron thatreceives information at aneuronal junction orsynapse) from the cortexthat summate and reachthe scalp giving us ourEEG waveforms. Intrinsiccell currents (produced byionic channel activation)may contribute to the EEGbut is still under investigation.Action potentialswere once thought tocontribute to the EEG butrecently have been dismissedas their temporallimits are too short.Fig. 1 Pyramidal CellFig. 2 Dipole28The cortex is composedof a dense collectionof neuron cell bodieswith myelinated andunmyelinated fibers runningthrough it. It is lessthen 5 mm thick. The cortexcovers both cerebralhemispheres of the brain.There are millions of neuronswithin the cortex,each having contact withthousands of other neurons.The cortex hasareas with distinct functionsand EEG output. Theneurons receive inputfrom subcortical areas viathe thalamus. The cerebral cortex andthe thalamus often work together in generatingbrain rhythms 1 . These waveforms are derived from the summation ofdifferent rhythms rather than being arhythm generated by a single cell orgroup of cells. The cortex also sendsinput signals to other areas within thecortex via association fibers. EfferentWill Eckhardt(directed away) signals are sent to manyother brain structures e.g. the brainstem,thalamus, cerebellum, the basal nuclei and the spinal cord.Most of the cortex has six layers of neurons and is called the neocortex.Cytoarchitecture is the distribution of these neurons. Pyramidalcells (see Fig 2) the most common neurons within the cortex, arenamed such due to their cell body shape. Although they are found in alllayers other than layer 1, they are they are most predominant in layers2, 3, and 5. 2Pyramidal neurons have a cell body, an axon, a single apical dendriteand a number of basal dendrites. Their axon originating on the base ofthe cell body leaves the cortex being the output pathway of the cortex.Axons can branch many times contacting hundreds of other neurons.These neurons are layered and project into other areas via their axonsand axon collaterals. Pyramidal neurons are associated with excitatoryneurotransmitters. Other neurons in the cortex are local and stay withinthe area of their cell body. These are known as interneurons. Theseneurons are often inhibitory.Presently we believe EEG potentials are due to excitatory postsynapticpotentials (EPSP) and inhibitory postsynaptic potentials (IPSP) propagatedby the cell body and dendrites of thousands of synchronizedpyramidal neurons 3 . The summation of these potentials is facilitated buythe architecture of pyramidal neurons. These neurons are oriented in acolumnar structure with apical dendrites pointing toward the corticalsurface. These very small dipoles (see Fig 2 — a separation of unlikecharges) therefore have similar orientations. The Solid Angle (see Fig 3— a measure of the apparent cross-sectional area of an object asviewed from a distance) of the dipole and the actual voltage of the dipolegenerated by a single cell is too small to produce recordable EEG at thesurface. It is the summation of solid angles and synchronization of potentialsin groups of neuronal synapses that enables the EEG to be recordableat the surface of the head.There can be a great deal of difference in the recording from twoelectrodes spaced only millimeters apart which was previously thoughtto imply the activity was from the immediate proximity of the surfaceelectrode 4 . Those electrodes far apart and producing the same waveforms were considered linked to a common source. The solid angle theorem(discussed below) and summation of the potentials is now consideredto be the means by which we record postsynaptic potentials at thesurface electrode.The small area within the cortex created by summated activity inneighboring active cells has been referred to as a dipole layer (see Fig.➟

Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.org2). A dipole layer can have infinite orientations with respect to scalpelectrodes. The electrodes on the scalp “see” only the potentials andpolarity of the potential pointed at them. Each orientation will producea unique result because of the effect on the solid angle (see Fig. 3) thedipole presents to the recording electrodes. The surface area of thedipole layer and the orientation of the layer with respect to the electrodeshave profound effects on the recording of electrical potentials.Due to volume conduction (the process of current flow through the tissuesbetween the electrical generator and the electrode) and summationof solid angles we see data from sources of at least several centimeters,independent of our electrode size, and potentially generatedby many local sources. Due to the solid angle theorem and volume conductionthe closest electrode to the neuronal generator may not alwaysrecord the largest potential 5 . Differing placement of the recording electrodearound the circumference of the area will result in markedchanges in the solid angle even though the event itself remainsunchanged. The polarity of the event also depends on electrode placementnot whether the event is due to EPSP or IPSP, the former beinga positive potential and the latter being negative.Sleep is a normal function of our brains. There are regions of thebrain and brainstem that promote wakefulness. As the influence of “thewakefulness generators decreases, neurons that promote sleepbecome active. Sleep ensues as a light transitional stage and becomesa more synchronized form (within the bandwidth that we view inpolysomnography) as more neuronal networks are involved.Transmission between neurons is enhanced during wake and REMwhereas during NREM sleep a blocking of afferent information is seen inthe thalamus 1 . The brains activity, during wake and REM, are nearly thesame. Although the afferent information stops during NREM sleep, thecortex remains active. The corticothalamic conection remains active asdo the corticocortical communications. Brainstem stimulation and theresponse of the thalamocortical cells on the other hand are associatedwith EEG activation and neuronal excitability that creates an activatedstate vs. a sleep state.In conclusion what is it that the EEG shows me? As you know we candetermine NREM, REM, and wake. We can also determine normal EEG,being a lack of clinically significant patterns associated with disorders.Abnormal EEG can also be determined but does not necessarily mean aclinically significant disorder. This is why MRI is an often utilized diagnostictool in relation to brain function.Electrophysiologists study potentials generated by just one neuron oreven small groups recorded with microelectrodes or mesoelectrodes.We, in sleep, are dealing with oscillating macroscopic potentials recordedfrom the scalp 6 . To name a few illnesses that EEG may be utilized inthe diagnosis and treatment of: strokes, brain tumors, infectious diseases,severe head injury, and brain death. The EEG is merely one ofmany tools in assessment of brain function but remains the gold standardin evaluation of sleep state.Now I shall block the afferent information from my brainstem reticularformation and let sleep ensue. ★References:1. Mircea Steriade. Principles and Practice of Sleep Medicine 2006 Elsevier Chapter 9 BrainElectrical Activity and Sensory Processing During Waking and Sleep States:1012. Duane E. Haines. Fundamental Neuroscience, Second Edition:5083. Bruce J. Fisch. Fisch & Spehlmann’s EEG Primer Basic Principles of Digital and AnalogEEG, Third Revised and Enlarged Edition: 4-94. R Cooper, J.W. Osselton, J.C. Shaw. EEG Technology Second Edition: 8-135. Volume Conduction Principles in Clinical Neurosurgery. February 2005. VeterinaryNeurology and Neurosurgery.http://www.neurovet.org/Electrophysiology/VolumeConduction/VolCondPartABcite.htm6. Paul L. Nunez, Ramesh Srinivasan Electric Fields of the Brain The Neurophysics of EEGSecond Edition: 3-4About the AuthorWill Eckhardt, RPSGT, CRT, is a member of the APT Board of Directors and serves as theAPT Board Liaison for the APT Standards and Guidelines Committee. He is a board memberof the New England Polysomnographic Society (NEPS) and is NEPS Education CommitteeChair. His full time position is with Sleep HealthCenters where he is the Director of Education.Eckhardt also is a faculty member at Northern Essex Community College where he teachesin the polysomnography program and is a member of the advisory board. He is a member ofthe A2Zzz Magazine editorial board and a recipient of the APT Dr. Allen DeVilbiss LiteraryAward in 2004. He is also a member of the American Academy of Sleep Medicine Committeeon Polysomnographic Technologists Issues.Sleep Disorder TechnologistsUniversity ServicesSleep Diagnostic & Treatment CentersLocations in PA & NJLansdale, NE & South Phila, Pottstown, Warrington, West Chester, PA & Voorhees NJFig. 3 Solid Angle — The voltage recorded by each electrode is proportional tothe product of the solid angle and the actual voltage of the dipole. Even thoughthe cross-sectional area of the dipole layer is the same the voltages measuredby the two electrodes would differ from one another in amount because the solidangles are different.Full/ Part-time positions available. Qualified individuals shouldbe experienced in routine PSG testing, CPAP and BIPAPtitrations and nocturnal seizure testing. Opportunities for furthergrowth and development exist for motivated individuals. Sendresume to (610) 344-7922,employment@uservices.com.Or call (610) 344-9921 for further information.Multiple locations, good working environment, competitive pay.www.uservices.com29

Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgPathological YawningBY JOANNE HEBDING, RPSGT, ASSOCIATE EDITORWhen I was a child, my mother told me yawning was from a lackof oxygen, but I knew it was really from being bored. During mysearch for information on yawning, I found out that Mom was right again!Excessive or pathological yawning, or “chasm,” is medically definedas a complex arousal reflex that arises from the brainstem and isthought to counteract hypoxemia in the brain. This action is not frombeing fatigued or bored.Our Sleep Center recently saw a 50-year-old woman who has beenfollowed for dymelinating disease for the last decade. She recently washospitalized for shortness of breath. Her yawning began during that hospitalizationalthough her demyelinating disease had not worsened. A cervicalspine magnetic resonance imaging (MRI) test, with and without contract,revealed signal alterations consistent with demyelinating pathology,especially at C2-3 and C3-4. The yawning has worsened in the lastseveral months.The phenomenon occurs throughout the day, and appeared todecrease during her sleep period. Her yawning is characterized by awide-open jaw extension that has become quite exhausting for her jaw.The patient does not complain of acute daytime hypersomnolence, andscored well within normal limits on the Epworth Sleepiness Scale score.She has difficulty initiating sleep due to muscular spasms, as well ascomplaints of maintaining sleep for no apparent reason. She has notedleg movements, as well as general body movements, but denied any legparesthesias, sleep paralysis, hypnagogic hallucinations or cataplexy. Noautomobile accidents were reported associated with drowsiness.Her neurologist ordered overnight polysomnography followed by amultiple sleep latency test (MSLT). Sleep efficiency on the polysomnograms(PSG) was reported at 78.5% with a non-rapid eye movementsleep (NREM) respiratory distress index(RDI) of 16.8. Oxygen desaturationswere reported with a nadir of 87%.Snoring was minimal. PLM arousal indexwas 0; however, 16 spontaneousarousals were reported. As per our splitprotocol, CPAP was initiated and titratedup to a maximal pressure of 7 cm. TheMSLT revealed a normal MLTS of 11.2(>10 normal) with no rapid eye movementsleep (REM) periods in 4 separateJoanne Hebdingnaps. The patient has reported a good response to continuous positiveairway pressure (CPAP). Trial dosage of levodopa (Sinemet) at10/100 mg every morning was recommended by the sleep diplomatewho interpreted the studies.Some of the known causes of pathological yawning include encephalitis,seizures, tumors of the fourth ventricle region, multiple sclerosis,progressive supranuclear palsy, electroconvulsive therapy and neurolepticwithdrawal. 1,2,3,4,5 Dopamine agonists, valproate overdose,imipramine, withdrawal from morphine and estrogen substitution mayalso induce pathological yawning. 6,7,8,9 PLMS has been reported withpathological yawning. 10Now every time I yawn, I remember my mom and wonder how shegot to be so smart! ★References1. Arai K, Kita K, Komiyanma A, Saeki N, Nagao KI (1986) Profressive dysautonomia inhemangioblastoma of the fourth venricle region. Brain Nerve 38: 195-2002. D’Mello, DA, Vincent FM, Lerner MP (1988) Yawning as a complication of electroconvulsivetherapy with concurrent neuroleptic withdrawal. J. Nerv Ment Dis 176: 188-189.3. Fletcher S, cohen F, Borenstein F, Regev I, Vardi J(1982) Yawning as a paroxysmal sign of diencephalicseizures. Arch Psychol Psychiatry Neurol 43; 45-544. Postert T, Pohlau D, Meyes S, Nastos I, Przuntek H(1996) Pathological yawning as a symptoms of multiplesclerosis. J.Neurol 243: 300-3015. Van Sweden B, Vanderhoven L, van Erp MG (1994)Excessive yawning. Acta Neurol Belg 94: 150-151.6. Goldberg RL (1983) Sustained yawning as a side effectof imipramine. Int J Psychiatry Med 13: 277-2807. Rollinson RED,Gilligan BS (1979) Post anoxic actionmyoclonus Lance Adams syndrome responding to valproate.Arch Neurol 36_44-458. Stahle L (1992) Do autoreceptors mediate dopamineagonist-induced yawning and suppressionof exploration?A critical view. Psychoparmacology 106:1-13.9. Van Sweden B,Vanderhoven L, van Erp MG (1994)Excessive yawning. Acta Neurol Belg 94:150-15110. Leonhardt M, Abele M, Klockgether T,Dichgans J, WellM (1999) Pathological yawning (chasm) associated withperiodic leg movements in sleep: cure by levodopa. J.Neurol 246; 621-622About the AuthorJoanne Hebding is APT Board Liaison to the APTCommunications Committee and an associate editor forA2Zzz Magazine. A longtime sleep technologist and APTmember, Hebding resides in Miami, Florida.30

Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.org2006-2007 APTCommittee RosterCOMMUNICATIONS COMMITTEEKimberly Burns, Committee Louie ScaliseChairErby WilliamsKenneth ChapmanJoanne Hebding, Board LiaisonChris CookCynthia D. Mattice, Ex-OfficioJ. L. MageePresidentEDUCATION COMMITTEE — CONTINUING EDUCATION CREDITSMelinda Trimble, Committee Ashwani GoyalChairKristine Bresnehan Servidio,W. Michael Chris, Vice Chair Board LiaisonCyndi HamptonCynthia D. Mattice, Ex-OfficioSteven LenikPresidentEDUCATION COMMITTEE — EDUCATIONAL PRODUCTSMelinda Trimble, Committee David WolfeChairKristine Bresnehan Servidio,Michael Delayo, Vice ChairBoard LiaisonChristine MagruderCynthia D. Mattice, Ex-OfficioTerrance MalloyPresidentE. Katrina WarrenMEMBERSHIP COMMITTEEJeffrey Smith, Committee ChairJoseph AndersonIain BoyleLaree FordyceJane HodgesPROGRAM COMMITTEEJeanette Robins, CommitteeChairJenny JacobsonMary Jones-ParkerLaura LinleyMichael RizzitielloRobert EvelynRobert MonroeDavid Gregory, Board LiaisonCynthia D. Mattice, Ex-OfficioPresidentStephen TarnoczyKimberly TrotterHarry WhitmoreDebbie Akers, Board LiaisonCynthia D. Mattice, Ex-OfficioPresidentREGIONAL ACTIVITIES/GOVERNMENT AFFAIRS COMMITTEEMary K Hobby, RRT, Committee Angela Neal,ChairLori SpeyrerShawn Cole, Committee Vice Marilyn Swick, Board LiaisonChairCynthia D. Mattice, MS, Ex-Charlotte FromerOfficio PresidentJennie HallSTANDARDS AND GUIDELINES COMMITTEETina Jenkins, Committee Chair Frank WaltherElise Franko, Committee Vice William Eckhardt, Board LiaisonChairCynthia D. Mattice, Ex-OfficioDennis KeenePresidentGinny Rueber2006-2007 APTBoard of DirectorsEXECUTIVE COMMITTEEPresident: Cynthia MatticePresident-Elect: Jon AtkinsonSecretary: Cindy KistnerTreasurer: Bill RiversAPT DirectoryContact UsAPT National OfficeChristopher WaringAPT CoordinatorOne Westbrook Corporate CenterSuite 920Westchester, IL 60154Phone 708-492-0796Fax 708-273-9344cwaring@aptweb.org25 Madison St.Shillington, PA 19607Phone 610-796-0788Fax 781-823-4787theresa.shumard@sunmed.comDIRECTORS-AT-LARGEDebbie AkersKristine Bresnehan ServidioWilliam EckhardtTerrie EubanksDavid GregoryJoanne HebdingMarilyn SwickIf you have questions about any of the following, pleasecontact the APT National Office: Membership,Advertising, Billing, Publications’ Circulation, MailingLabels, Products, Orders and General Questions.Billing QuestionsPhone (708) 492-0796APTWebWebsite/Technical IssuesE-Mail support@aptweb.orgEditorial QuestionsIf you have editorial questions, please contact:A2Zzz Magazine Editorial OfficeSleep-Related OrganizationsAmerican Academy of Sleep MedicineOne Westbrook Corporate Center, Suite 920Westchester, IL 60154Phone 708-492-0930, Fax 708-492-0943webmaster@aasmnet.orgBRPT Management Office8201 Greensboro Drive, Suite 300McLean, VA 22102Phone 703-610-9020, Fax 703-610-9005brpt@amg-inc.com, www.brpt.orgCommittee on Accreditation for Polysomnographic TechnologyEducation (CoA PSG)Visit www.caahep.org/accredit.aspx?ID=obtainCreditfor information on the accreditation standards and guidelines, orcontact Dr. Richard Rosenberg at (708) 492-0930.31

Technical CornerPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgA2Zzz Technical CornerBY CYNTHIA MATTICE, MS, RPSGT, APT PRESIDENTQuestionI am preparing an instructional lecture for my sleep center staff toimprove hand hygiene. What facts should be included?AnswerIt is important for staff in a sleep center to adhere to facility guidelineson hand hygiene and glove use. Hand hygiene includes hand washingwith soap and water and the use of alcohol-based hand rubs. Ifaccess to a sink for hand washing is not readily available, perhaps designatingalcohol-based hand rub as the primary method for hand hygieneand placing containers in central locations will improve staff compliance.It is important for the staff to know that gloves do not replace properhand hygiene techniques. The technologist should know that wearinggloves protects the patient from contamination and likewise protects themfrom exposure to contaminates. Key to proper use of gloves is to rememberto remove gloves after each use. For example, it is not acceptable toleave the patient hook-up area and answer the phone without removing thegloves. Gloves do become contaminated during patient hook-up and careduring the study. Perform hand hygiene as soon as gloves are removed.cause less hand irritation and drynesswith repeated use. It is recommendedthat a sufficient amount of alcohol-basedhand rub be applied to all surfaces of thehands and fingers and rubbed in for atleast 15 seconds before the hands aredry. Currently, alcohol-based hand rubsare commercially available.It is recommended that hand washingbe performed for 15 seconds withAPT President Cynthia Matticeample soap on all hand and finger surfaces before rinsing. Avoid contaminationof hands after hand washing by using a paper towel to turnoff the faucet and other surfaces.Discuss the following with the staff:1. What types of patient care activities result in hand contamination?2. What are the advantages and disadvantages of hand washing andalcohol-based hand rubs?3. What is the role of contaminated hands in the transmission ofpathogens and viruses?Sleep technologists can become contaminated by toughing thepatient and the electrodes, sensors and continuous positive airway pressure(CPAP) masks. It is important to demonstrate proper precautionswhen caring for multiple patients during a shift in the sleep center.Studies have shown that the use of alcohol-based hand rubs are effectivein reducing the number of viable bacteria and viruses on hands, requireless time to use, can be made more accessible at the point of care andThe Institute for Healthcare Improvement has developed the “How-toGuide: Improving Hand Hygiene.” It is available at www.IHI.org. This documentis a complete resource on the subject, including assessmentquestions and checklists. ★32

Sleep ArtsPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgCrossword PuzzleBY EDWIN CINTRON, RPSGTAcross3. Where Kleitman discovered REM4. Inflammation of the brain6. RBD9. Infant’s Sleep/Wake cycle10. Loss of muscle tone12. This mammal may only sleep for minutesat a time15. A list of correlated symptoms16. soothing sounds17. A group of four symptoms18. A bandstop filter19. Bed accessoryEdwin CintronDown1. Fear of the dark2. To fall asleep5. Sleepwalking6. Charge7. How air creates a splint8. Most effective at regulating the Suprachiasmatic Nuclei11. Where POSTS appear13. Number of winks to mean sleep14. Central is not a brain lobe but a __________15. Nap, in spanishSolution on page 40!About the AuthorEdwin Cintron, RPSGT is an instructor of Polysomnography at Erwin Technical Center inTampa, Florida and has been on the A2Zzz Magazine Editorial Board since 1998. Cintronwas the recipient of the of the 2005 APT Sharon Keenan Award and was the first ever recipientof the APT Dr. Allen DeVilbiss Literary Award in 2002.Movie Review: TheScience of SleepBY TERRIE EUBANKS, RPSGT, A2Zzz Magazine SLEEP ARTSCOLUMNISTThe Science of Sleep is the title of anew movie directed by MichaelGondry. The film is a playful romantic fantasyset inside the topsy-turvy brain ofStephane Miroux, played by Gael GarciaBernal, an eccentric young man whosedreams constantly invade his waking life.An acclaimed music video director,Gondry compiled a DVD of videos that hedirected including Bjork, Beck, and TheWhite Stripes. His original screenplay forEternal Sunshine of the Spotless Mindwon a 2005 Academy Award.Terrie EubanksThe Science of Sleep presents an outof the ordinary look at dream interpretation and its relationship to everyday life. Ghondry explores how the two intertwine and does so in imaginativeand bizarre sequences. A modern day Sigmund Freud, the leadcharacter, Gael, loses himself and his audience somewhere betweenREM and awake. Among elaborate sets, puppet-like characters and PeeWee Herman style antics, Gondry brings to realization my long held opinionthat dreams are too bizarre to replicate on film.For more than 50 years, there has been an underappreciated scienceof sleep. Does the misleading movie title lampoon a sleep discipline?Is sleep to be the Rodney Dangerfield in the realm of medicine?Though sleep may not yet have the respect it deserves, it is morevastly published throughout the arts and media. The fact that a movieabout sleep and dreams is being so highly promoted is a benefit. Afterall, Mr. Dangerfield claimed to “get no respect” but was often in front ofmicrophone while protesting about it. ★About the AuthorTerrie Eubanks is a newly-appointed columnist for the A2Zzz Magazine “Sleep Arts Page.”Because the membership and the sleep field have had a longtime penchant for sleep’s influenceon the arts, Eubanks will continue to explore similar topics where sleep inspires literature,music, art and entertainment. Eubanks, a poet herself, is a member of the APT Boardof Directors, and is a sleep technologist that works the night shift near Centralia, IL.Show you care bywearing the new…Sleep DisordersAwareness PinPRESENTED BY THE APTOrder form page 3833

Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgQuestions About Recertification?Part one of a two-part series on RPSGTs and recertificationQ. Why did the BRPT change the policy to require recertificationevery 5 years?A. The Board of Registered Polysomnographic Technologists (BRPT)is a credentialing body and as such owes a duty to the public as well asto RPSGTs. To ensure patient safety it is important for us to make everyattempt to assure that RPSGTs are properly trained and qualified. Astime goes on, every medical profession expands and adapts to new technologyand science and the field of sleep technology is no exception.We are also helping RPSGTs when we protect and promote the credential.State (and in some cases Federal) regulatory decision-makersincreasingly look to validated credentials in making decisions regardingthe practice of many allied health professions including sleep technology.The BRPT has an obligation to protect, promote and defend the RPSGTcredential and strengthen its value.Today, an allied health field such as polysomnography must providesome credible measure of continued competency which is documentedin order to sustain its value. Ultimately, a rigorous exam and a strongrecertification program will benefit the profession of polysomnographyand will help ensure that the RPSGT is the credential of choice for technologistsperforming sleep studies.Q. I’m a “grandfathered” RPSGT and someone on my staff isunder the 10-year recertification plan. Do the new recertification policiesaffect us?A. Yes! All RPSGTs must now certify every 5 years in order to retainthe use of their credential including those who were previously “grandfathered”or those who were under the 10-year recertification policy.Unless you already voluntarily “switched-early,” your 5-year recertificationperiod is effective January 1, 2007. (If you wrote to BRPT in the pastfew months requesting an earlyswitch,then your 5-year periodbegins from the date yourequested the switch.)Q. Where can I find a listof approved courses that offercontinuing education hours?A. At the BRPT web site youmay click on the Recertificationand Continuing Education buttonand then click on ContinuingEducation. A link is provided tothe APT web site where coursesapproved by the APT are listed.In addition, the BRPT isworking with other organizationsto expand the courses listedand is maintaining a list onthe web site of known creditgrantingorganizations as wellas courses reviewed for applicabilityto the recertificationhours. Most important toRequired for RPSGTRecertification = 50 continuingeducation hours every 5 yearsBRPT recommends earning 10continuing education hours peryear to meet your total requirementof 50 continuing educationhours required in 5 years.Note: You must earn a minimumof 5 per year, but yourtotal at the end of your 5-yearrecertification period still musttotal 50. (BRPT is allowing youto earn less than 10 someyears in order to accommodatethose who have a year or twowhen circumstances such as illness,family matters, or maternityleave, make it difficult toearn 10 in any particular year.remember — as long as your hours are earned from activities approvedby a credit-granting organization AND the hours are directly related tothe duties of a sleep technologist, those hours would likely be acceptablefor recertification.Q. I live in a remote area. Are there ways for me to earn hourswithout attending a sleep conference?A. Yes. For example, the APT offers hours forreading the A2Zzz Magazine by signing up on theirsite so you can get an assessment tool for eachedition. Fees for those who aren’t members of APTmay apply. The link to their page iswww.aptweb.org/CECProgramCalendar.asp. Otherways of earning hours include in-service or casestudy training programs and online courses. If yourinstitution already holds this kind of session,encourage administration to pursue obtaining creditsfrom a credit-granting organization for thesemeetings. BRPT’s Education Advisory Committee isworking with other organizations to ensure theexpansion of these options as well. Check thewww.brpt.org website for updated listings.Q. Does it matter how many continuing educationhours I obtain each year?34A. Yes! While BRPT recommends that you earn10 each year during your 5-year recertificationperiod — thereby accumulating 50 total, be➟

Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgadvised that under the new rules, it is required that you earn a minimumof 5 continuing education hours each year. If at the end of the 5-yearperiod when the recertification application is reviewed, the minimum of5 hours per year are not documented, your recertification by continuingeducation hours will not be approved. Your option to maintain your credentialat that point would be to retake and pass the current RPSGTexamination within 3 months following your recertification date.Q. What if I do not recertify?A. If you don’t recertify within ninety days after the date your recertificationis due, you will no longer have the right to use the RPSGT credential.Q. Can I retake the exam to recertify?A. Yes, absolutely. While the BPRT encourages continuing educationon an ongoing basis, you may recertify by taking and passing the RPSGTexam. If you choose this option, we recommend you take the exam 6months before your recertification deadline to allow for any possibleretesting. Normal examination fees will apply under this option.Q. How should I keep track of my continuing education hours andwhat documentation do I need?A. The BRPT has a form online at our web site that is strictly anoptional sample form that can be used. You do not have to use this form,it is available if you would like to use it. Normally all that is required fordocumentation is a copy of the signed certificate of hours earned. Forcourses where only part of the course meets the applicability of beingrelated to the duties of a polysomnographic technologist, or for courseswhere the content is not clear from the certificate copy you should alsoattach a course outline or course content document. (use pdfs of coverof Recertification Guidelines to illustrate, if needed)More questions about recertification? Look for Part Two of thisseries in the next issue of A2Zzz Magazine, or visit the BRPT Website at www.brpt.org to read the entire “Recertification Guidelines.”For more information, call (703) 610-9020, or visit www.brpt.org. ★Q. How do I know if a course or activity is acceptable for RPSGTcontinuing education hours?A. If the activity has been granted hours by the APT, these hours areacceptable if the activity has been granted hours by another credit-grantingorganization and the activity is directly related to the duties of a sleeptechnologist it should be acceptable.Policy and Procedure Manualfor Sleep Disorders CentersAPT is proud to present a Policy and Procedure Manual forSleep Disorders Centers. At the request of the APT Board ofDirectors, the Standards and Guidelines Committee created areference manual to assist sleep disorders center personnel inthe development of their own policy and procedure manual.This manual provides sample forms and policies, jobdescriptions and core competencies for the Sleep TechnologyProfession. The manual is intended to provide a standardizedguideline in the development of a policy and proceduremanual to quantify service and performance that ultimatelydelivers quality patient care.Order form page 37!35

NewZzz BriefsPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgPro-Tech Releases SleepEx ®SV — View, Score,Interpret, Online... Anywhere Mukilteo, WA — Pro-Tech ® Services, Inc, the leading manufacturer ofsleep diagnostic sensors, today announced the release of SleepEx SV, sleepcenter management software. SleepEx SV is enhanced with additional keyfeatures to meet the needs of discerning sleep lab managers and physicians.SleepEx SV improves the efficiency of your business by providing youremote access at anytime to manage your lab. Key features of this softwareinclude: online access to patient and staff scheduling for one ormore locations, centralizing your patient and staff database, and securedata transfer of studies to be scored, interpreted and safely archived.“We specifically designed SleepEx SV to meet the data managementneeds of the sleep lab and help support their ability to turn-around studyresults in a timely manner,” said Jim Johnson, President of Pro-TechServices, Inc.SleepEx SV also offers physician over-read management capabilities,core management reports, secure study storage and archiving, and anoptional DME module with digital signature. For a software demonstration,call 800-919-3900.For those times your sleep lab is overloaded with studies to score, Pro-Tech now offers scoring services. Visit www.pro-tech.com for more info.For information on ordering these or other Pro-Tech Services, Inc.products, visit www.pro-tech.com, or call 800-919-3900.Classified AdsPhoenix, AZCarl T. Hayden VA Medical Center is seeking candidates for twoPolysomnographic Technologists (Registered Respiratory Therapist)vacancies in our Outpatient Respiratory Care Department. Theseare permanent full-time positions for the night shift only with workhours from 7:30 p.m. to 8:00 a.m. Excellent benefit package andcompetitive salary. VA is an equal opportunity employer. Interestedapplicants may obtain an application from: Human ResourcesManagement Service (05B1), Carl T. Hayden VA Medical Center,650 E. Indian School Road, Phoenix, AZ 85012. Or call DarcyKinslow, at 602-277-5551 x7808.Resource for CPAPPatients thatTravel by AirThe American Sleep Apnea Association (ASAA) lists informationregarding security regulations for patients traveling by air.Fact Sheet: Steps Taken to Ensure New Security RequirementsPreserve and Respect the Civil Rights of People with Disabilitieshttp://www.sleepapnea.org/news/travel.htmlNew Sleepmate EducationFacility OpensMidlothian, VA — Sleepmate ® Technologies announces the opening ofa state-of-the-art education facility. Located in our corporate headquarters,the classroom provides a complete environment to obtain certifiededucation. Additionally, the lab will have a variety of sleep industry equipmentfrom major vendors and a patient hook-up and testing area to providea complete training facility on the latest in sleep diagnostic practices.Click on Education at our website (www.Sleepmate.com) for a completeclass schedule, or call 800-639-5432. CEC (APT) and CECU(AARC) included.Sleepmate ® Technologies has been setting the standard for excellencein the sleep diagnostic industry since 1985. Sleepmate ® strives toenhance the capabilities of sleep professionals and the success ofpatient diagnostics.We are committed to meeting the ever-changing needs of sleep professionalsas effectively, efficiently and economically as possible. Ourdesire to make things better by finding new solutions, new materials andnew systems for delivering state-of-the-art products and servicesensures that we stay one step ahead of the industry.We Put You First. Because Without You People Don’t Sleep, AndWithout Sleep People Don’t Function Well.Barbara Ludwig Cull, RPSGT36

Product Order FormPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgEducational/Technical Order FormEducational ResourcesAPT Review Course — 3rd Edition (Individual)Intense review preparing for the registry exam. Realtime video alongside an electronic presentation.Includes CD, booklet and review test to complete and return for 15.75 CEC credits. 1003 $325.00 $360.00APT Review Course — 3rd Edition (Institutional)Intense review preparing for the registry exam. Realtime video alongside an electronic presentation.Includes CD, booklet and five review tests to complete and return for 15.75 CEC credits per test. 1004 $895.00 $895.00Normal and Abnormal Record Flashcards 1020 $65.00 $85.00Registry Exam Flashcards 1021 $40.00 $55.00Technical ReferencesAPT National OfficeOne Westbrook Corporate Center, Suite 920Westchester, IL 60154Phone (708) 492-0796, Fax (708) 273-9344APT Policy and Procedure ManualA reference tool designed to assist sleep disorders center personnel in the development of theirpolicy and procedure manual. This manual provides sample forms and policies, job descriptionsand core competencies for the Sleep Technology Profession. 1140 $225.00 $260.00Filter Settings and CalibrationsTechnical article written by Edwin Cintron, RPSGT. 1110 $10.00 $15.002003 Demographic, Salary & Educational Needs SurveyIdentifies PSG technologist practice environments, technologist characteristics, compensation,and education. 1120 $50.00 $85.00R&K Scoring Manual Technical ManualWritten by A. Rechtschaffen and A. Kales. Includes standardized terminology, techniques and ascoring system for sleep stages. 1130 $60.00 $75.00Pediatric Manual of Standardized TerminologyCurrent interest in infant sleep has made necessary a guide similar in scope to the R&K ScoringManual, which applies only to adults. There has been a need for a common system for sleep scoringin the infant, as most researchers tend to employ diverse modifications of the adult scoring criteria. 1133 $60.00 $75.00Artifact & Troubleshooting Guide 1131 $25.00 $35.00“Sleeping on the Job”Answers basic questions on site location, design, setup, staffing and more. Offers resources forlocating equipment and supplies and is highlighted by a sample Policy and Procedure manual 1132 $60.00 $75.00QUANTITYQUANTITYMEMBERSMEMBERSNON-MEMBERSNON-MEMBERSTOTALTOTAL*Please note that the APT does not accept purchase orders or orders over the phone. Shipping and handlingcharges for orders over six items will be charged based on cost. Orders may be expedited via UPS 2-Day(where available) based on cost. International shipping is available through the United States Postal Serviceand charged based on cost. The APT accepts no responsibility for loss of product.Shipping and Handling* $13.007.75% Sales Tax (IL residents only)TotalShipping & Payment InformationName:Shipping To:❑ Residential Address ❑ Commercial AddressMember Number:Payment By:❑ Check (US bank only) ❑ Visa ❑ Mastercard ❑ American ExpressAddress:Credit Card Number:City: State ZipVerification Code:Expiration:Phone Number:Rev. 8/06Signature:37

Product Order FormPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgAPT Promotional Item Order FormAPT National OfficeOne Westbrook Corporate Center, Suite 920Westchester, IL 60154Phone (708) 492-0796, Fax (708) 273-9344APT Promotional ItemsQUANTITYMEMBERSNON-MEMBERSTOTALAPT Membership Pin 2001 $10.00Sleep Disorders Awareness PinShow you care! Makes a great PSG Technologist Appreciation Week gift. 2003 $10.00 $15.00“Celestial Delectables” CookbookSilver Anniversary cookbook. 2020 $25.00 $30.00“Guardian Sleep” Print (Signed)Limited edition series of 500 color prints (certificate included).The original painting was rendered in oil and mixed media. 2010S $40.00 $90.00“Guardian Sleep” Print (Unsigned) 2010 $35.00 $85.00“Sentries of the Night” PrintColor print, measures approximately 8-1/2” x 11”. 2011 $8.00 $10.00APT Santa FlagDisplay holiday spirit in your sleep lab! Measures 24” X 36”, vibrant colors. While supplies last! 2021 $35.00 $45.00APT Apparel ItemsQUANTITY MEMBERS NON-MEMBERSAPT Denim ShirtHigh-quality denim shirt featuring the APT logo. Available sizes: S / M / L / XL / XXL / XXXL 2120 $40.00 $45.00APT T-ShirtHigh-quality t-shirt featuring the APT logo. Available sizes: S / M / L / XL / XXL / XXXL 2130 $20.00 $25.00APT SweatshirtHigh-quality sweatshirt featuring the APT logo. Available sizes: S / M / L / XL / XXL 2140 $35.00 $40.00TOTAL*Please note that the APT does not accept purchase orders or orders over the phone. Shipping and handlingcharges for orders over six items will be charged based on cost. Orders may be expedited via UPS 2-Day(where available) based on cost. International shipping is available through the United States Postal Serviceand charged based on cost. The APT accepts no responsibility for loss of product.Shipping and Handling* $13.007.75% Sales Tax (IL residents only)TotalShipping & Payment InformationName:Shipping To:❑ Residential Address ❑ Commercial AddressMember Number:Payment By:❑ Check (US bank only) ❑ Visa ❑ Mastercard ❑ American ExpressAddress:Credit Card Number:City: State ZipVerification Code:Expiration:Phone Number:Signature:Rev. 8/0638

APT Membership FormPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.org 39

SleepLand CalendarPublication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.org25th Annual Conference on Sleep Disorders in Infancy & ChildhoodJanuary 25-27, 2007The Annenberg Center for Health Sciences will hold this 25thAnniversary meeting in Rancho Mirage, CA, near Palm Springs. Formore information or to register go to www.5StarMedEd.org/sleepdisordersor for more information, please e-mail sleep@annenberg.net.2006 Southern Sleep Society MeetingMarch 1-4, 200729th Annual Meeting will be held at The Francis Marion Hotel, 387 KingStreet, Charleston, SC 29403. For more information, please visitwww.southernsleepsociety.org.Spring Sleep SeminarMarch 2-3 2007Embassy Suites, Rogers, Arkansas. Call for Info 479-527-0471 or emailmtrimble@wregional.com.Pacific Northwest Sleep Association (PNSA) 2007 Biennial MeetingSpring 2007For more information, visit www.pnsleep.net.FocusApril 19-21, 20077th annual conference, Opryland Hotel in Nashville, Tennessee. For budgetingpurposes, attendees should know that the early registration fee willbe $295 and “significant others” will pay only $150 to come and enjoy theconference and all that it offers, with their loved one (except for CEU’s). Allattendees who attended the 2006 Focus Conference will automatically beeligible for a $50 discount off their 2007 registration fee (“significant others”do not receive discount). For more information, visit www.foocus.com.American Association of Sleep Technologists (formerly the APT)Annual MeetingJune 10-13, 2007Minneapolis, MN. More information in Spring 2007.Sleep 2007 — The 21st Annual Meeting of the AssociatedProfessional Sleep Societies (APSS)June 9-14, 2007Minneapolis, MN. Registration information available Spring 2007. Visitwww.apss.org.New England Polysomnographic Society (NEPS) Annual MeetingAugust 2007For more information, visit www.nepolysomnographic.org.World Federation of Sleep Research Societies World Congress 2007September 1-8, 2007Carins, QLD, Austrailia. For more information, please visit www.wfsrsms.org.Montana Regional Sleep SeminarSeptember 6-8, 2007Held at the Mansfield Health Education Center in Billings, Montana sponsoredby The Sleep Center at St. Vincent Healthcare. The TechnologistReview Course will be back by popular demand. Speakers and topics tobe announced at a later date. For more information, call 1 (866) 4SNORES or email karen.allen@svh-mt.org.19th Congress of the European Sleep Research SocietyFall 2008Glasgow, Scotland. For more information visit: www.esrs.org.Medtrade Spring 2007April 24, 2007The 2007 Medtrade Spring Exposition & Conference is about to heatthings up in Las Vegas! Continuum of Care: April 24th. ReimbursementConference. For more information, go to www.medtradespring.com.25th Anniversary Meeting — SE/SW Regional Association ofPolysomnographic TechnologistsMay 3-6, 2007“Sand Man Bring Me A Dream”. Hotel rooms at the Sheraton OceanfrontBeach Hotel, Virginia Beach, Virginia (800-521-5635) are available at adiscounted rate of $129/night for single or double occupancy plus tax.Reservations mentioning SE/SW RAPT must be made by 3/15/07 toreceive the group rate. Rooms reserved after that date will be at the currenthotel room rates. Registration fees begin at $100.00 and higher forpre-registrations. The agenda with the proposed CEUs will be availableafter 11/1/06. For further information, contact Shalanda Virgil,SLVirgil@sentara.com, or visit the website at www.sesw.org.Benelux Sleep Congress 2007May 11-12, 2007Grand Duchy of Luxemburg, Mondorf-les-Bains, the famous Luxemburgthermal station, located near the French border. The conference willfocus on Sleep and Stroke, Sleep and Heart, and Sleep and Health. Thecongress will be held under the patronage of the European SleepResearch Society (ESRS), the Societe des Sciences Medicales ofLuxembourg, and the Ministry of Health of Luxemburg. For more information,visit: www.sommeil2007.lu.40from puzzle on page 33Crossword Puzzle Solution

Publication of the Association of Polysomnographic Technologists • 2006, Volume 15, Number 4 • www.aptweb.orgNew 3rd EditionNew Releases!APT Review Course CD SetsAn excellent tool for registry board prep or as a review to enhance skills!Sleep Stage Scoring • Arrhythmia ReviewArtifact Recognition & TroubleshootingSleep Report Parameters & CalculationsNeurophysiology of Sleep • Nocturnal O 2 TitrationFor more information go to the APT website at www.aptweb.orgor see the APT product ordering form on page 3741

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