A-Step Modules: Introductory Topics

Front 1

Sleep is common to ________ & __________.

Back 1

mammals and birds

Front 2

Sleep has been described as:

Back 2

-basic human need, necessary for some form of recuperation
-essential for healthy metabolic, immune, and cognitive function
-a vulnerable state
-pleasant pastime
-disengagement from the environment

Front 3

Why is sleep necessary?

Back 3

no one knows
"If sleep serves no useful purpose, then it is the greatest mistake nature ever made." Allan Rechtschaffen
-sleep is a biological necessity
-lack of sleep associated with illness and impaired function

Front 4

Sleep medicine is a relatively _______.

Back 4

new field

Front 5

"More has been learned about sleep in the past _____ years than in the preceding 6,000." Hobson

Back 5

60

Front 6

Research on sleep in the early and mid 20th century:

Back 6

-led to the classification of different sleep stages
-emphasized the necessity of all night sleep recordings
-allowed for better descriptions and classification of sleep disorders
-clinical practice of sleep medicine

Front 7

Clinical practice of sleep medicine, seeing pt's with complaints about sleep, developed from research on sleep and began growing in ____.

Back 7

the 1970s

Front 8

Obstacles to the development of sleep programs:

Back 8

-all night diagnostic study was unheard of in the 1970s
-cost of the all night sleep study was high
-all night sleep study was very labor intensive
-difficult to find people to work all night
-In the 1970s, few medical professionals recognized well-described sleep disorders

Front 9

Poly

Back 9

refers to recording of many different parameters

Front 10

Somno

Back 10

relating to sleep

Front 11

Graphy

Back 11

charting of recording parameters

Front 12

The term polysomnography was first used in what year to denote all-night sleep studies?

Back 12

1974

Front 13

PSGs are the simultaneous monitoring of multiple parameters that include:

Back 13

-EEG
-EOG
-EMG
-airflow
-respiratory activity of chest and abdomen
-EKG or ECG
-oxygen saturation, pulse oximetry
-carbon dioxide, end-tidal or transcutaneous CO2

Front 14

Electroencephalogram
EEG

Back 14

brain activity

Front 15

Electro-oculogram
EOG

Back 15

eye movements

Front 16

Electromyogram
EMG

Back 16

muscle activity
-chin muscle submentalis
-leg muscle tibialis anterior
-arm muscle (in some circumstances)

Front 17

Electrocardiogram
EKG or ECG

Back 17

heart rate and rhythm

Front 18

EEGs were first recorded in humans in what year?

Back 18

1929

Front 19

International 10-20 system of measurement was developed in what year?

Back 19

1958

Front 20

Eye movement sensors were added in what year?

Back 20

about 1951

Front 21

Leg leads began to be used in what year?

Back 21

1966

Front 22

AASM Scoring Manual was released in what year?

Back 22

2007

Front 23

In what year were respiratory and cardiac sensors added to PSG in the USA?

Back 23

1972

Front 24

1978: Association of Polysomnography Technologists
APT

Back 24

Professional society for sleep technology specialists that perform technical evaluation of patients with sleep disorders and ensure the proper use of therapeutic interventions.

Front 25

APT
Association of Polysomnography Technologists: 1978

Back 25

Established standards of care, developed training programs and materials, and promoted technical and clinical excellence.

Front 26

APT
Association of Polysomnography Technologists: 1978

Back 26

Organizes an annual meeting for members.

Front 27

APT
Association of Polysomnography Technologists: 1978

Back 27

Prepares candidates for the certification exam of the Board of Registered Polysomnographic Technologists (BRPT)

Front 28

In 2006, the APT changed its name to what?

Back 28

American Association of Sleep Technologists
AAST

Front 29

1978: Board of Registered Polysomnographic Technologists
BRPT

Back 29

An independent, non-profit certification board for sleep technologists.

Front 30

1978: Board of Registered Polysomnographic Technologists
BRPT

Back 30

Sets credentialing standards for technologists.

Front 31

1978: Board of Registered Polysomnographic Technologists
BRPT

Back 31

Established the BRPT Standards of Conduct

Front 32

BRPT Standards of Conduct is:

Back 32

a code providing guidelines for ethical and professional behavior of sleep technologists

Front 33

1978: Board of Registered Polysomnographic Technologists
BRPT

Back 33

Develops, maintains, and administers the RPSGT

Front 34

1979: Registered Polysomnographic Technologists
RPSGT

Back 34

In 1979, eight technologists were certified as the first RPSGTs.

Front 35

1979: Registered Polysomnographic Technologists
RPSGT

Back 35

By mid 2006, there were about 6,000.

Front 36

1979: Registered Polysomnographic Technologists
RPSGT

Back 36

Is an internationally recognized credential and represents the highest certification in the field for sleep technologists.

Front 37

The skilled sleep technician is able to determine the correct positive airway pressure needed to treat what?

Back 37

obstructive sleep apnea

Front 38

Sleep Medicine Milestones:
1964

Back 38

Stanford University, Stanford CA opens a narcolepsy clinic, the first sleep disorder center

Front 39

Sleep Medicine Milestones:
1970

Back 39

Stanford Sleep Disorders Clinic expands to evaluate patients with all types of sleep disorders

Front 40

Sleep Medicine Milestones:
1975

Back 40

Five other sleep disorders centers are in operation and offering overnight sleep studies

Front 41

Sleep Medicine Milestones:
1975

Back 41

Blue Shield of California began to reimburse patients for sleep services

Front 42

Sleep Medicine Milestones:
1977

Back 42

Montefiore Hospital, New York City is the first sleep center to be accredited

Front 43

Sleep Medicine Milestones:
1978

Back 43

The establishment of a board exam in sleep medicine for physicians.

Front 44

Diplomate, American Board of Sleep Medicine
D, ABSM

Back 44

a board certified physician in sleep medicine

Front 45

Sleep Medicine Milestones:
1989

Back 45

First fellowship training in sleep medicine for physicians

Front 46

American Academy of Sleep Medicine
AASM
www.aasmnet.org

Back 46

Originated from other societies established in the 1970s which were dedicated to establish standards for research as well as evaluation and treatment of people with sleep disorders.

Front 47

American Academy of Sleep Medicine
AASM
www.aasmnet.org

Back 47

A professional society which serves the needs of individual members and sleep disorder centers

Front 48

American Academy of Sleep Medicine
AASM
www.aasmnet.org

Back 48

Rose out of the growth of scientific and clinical information about sleep medicine

Front 49

American Academy of Sleep Medicine
AASM
www.aasmnet.org

Back 49

Establishes Practice of Parameters for the practice of sleep medicine

Front 50

American Academy of Sleep Medicine
AASM
www.aasmnet.org

Back 50

publishes 2 journals
-Sleep (1978)
-Journal of Clinical Sleep Medicine (2005)

Front 51

American Academy of Sleep Medicine
AASM
www.aasmnet.org

Back 51

Published the AASM Manual for Scoring of Sleep and Associated Events in 2007

Front 52

NREM Sleep 1937

Back 52

Loomis developed a classification system for brain activity including vertex waves, sleep spindles, k complexes, and delta slowing (NREM). Sleep divided into 5 stages: A, B, C, D and E.

Front 53

REM Sleep 1953

Back 53

-rapid eye movements observed in an infant
-Aserinsky & Kleitman published first paper describing REM sleep

Front 54

NREM and REM Cycles 1957

Back 54

Demont & Kleitman described the human sleep cycle of NREM sleep stages of increasing depth followed by periods of REM sleep with the cycles repeating throughout the night.

Front 55

NREM and REM Cycles 1957

Back 55

Demont & Kleitman proposed a new classification of sleep stages, using 4 stages of NREM sleep plus REM sleep.

Front 56

Rechtschaffen & Kales
Also known as R&K
1968

Back 56

-A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects
-First scoring manual for sleep, developed for use in healthy young volunteers.
-Replaced in 2008 by the AASM Manual for the Scoring of Sleep and Associated Events

Front 57

Normal Sleep in Young Adults

Back 57

-7.5 to 8.5 hours per 24 hours
-normal sleep latency: 10 mins
-normal sleep structure: N1 2-5%, N2 45-55%, N3 15-25%, Stage R 20-25%

Front 58

Normal Sleep in Young Adults

Back 58

-Sleep is entered through NREM sleep
-Episodes of NREM and REM sleep alternate about every 90 minutes
-Over the course of the night there is typically an orderly progression between sleep stages.

Front 59

Normal Sleep in Young Adults

Back 59

-Wakefulness in sleep occurs less than 5%
-Stages N3 sleep occur in the first third of the night
_REM sleep is more prominent in the second half of the night

Front 60

What is a Sleep Stage Histogram?

Back 60

Graph of stages of sleep vs time line in hours.

Front 61

NREM Sleep

Back 61

-Consists of stages N1, N2 and N3
-75-80% of total sleep time in older children and adults

Front 62

Slow Wave Sleep
SWS

Back 62

Stage N3 or Deep NREM sleep

Front 63

SWS is linked to:

Back 63

-the onset of sleep
-the length of time awake before going to sleep

Front 64

REM Sleep

Back 64

-20-25% of sleep
-occurs in 4-6 discrete cycles throughout the night
-episodes of stage R get longer during the night and are longest in the last third of the night

Front 65

Stage R is linked to:

Back 65

the circadian rhythm (body clock) of body temperature

Front 66

NREM
Physiologic Variable

Back 66

Heart Rate: Regular
Respiratory Rate: Regular
Blood Pressure: Regular
Skeletal Muscle Tone: Reduced

Front 67

REM
Physiologic Variable

Back 67

Heart Rate: Irregular
Respiratory Rate: Irregular
Blood Pressure: Variable
Skeletal Muscle Tone: Absent

Front 68

Brain wave frequencies are measured in:

Back 68

the number of "waves" or cycles per second (cps) or Hertz (Hz)

Front 69

Brain Wave Frequency Categories

Back 69

Alpha: 8-13 Hz
Theta: 4 - <8 Hz
Delta: 0.5 - <4 Hz
(SWS is within a portion of the delta range 0.5 - 2 Hz)
Beta: >13 Hz

Front 70

EEG: Stage W
Awake

Back 70

well formed alpha (8-13 Hz) when patient is relaxed and eyes are closed when >50% of the epoch has alpha over the occipital region

Front 71

EEG: Stage W
Awake
Patients without alpha

Back 71

-eye blinks at a frequency of 0.5 - 2 Hz
-reading eye movements
-irregular conjugate rapid eye movements associated with normal or high chin muscle tone

Front 72

Alpha EEG Rhythm
Examples of Recommended LFF settings by derivation:

Back 72

EEG: 0.3 Hz
EOG: 0.3 Hz
EMG: 10 Hz (chin, leg, intercostal)
ECG: 0.3 Hz

Front 73

Stage N1 Sleep

Back 73

-usually occurs at sleep onset
-may follow an arousal from any other stage of sleep
-EEG is relatively low voltage, mixed frequency but mainly theta activity
-EOG may see slow eye movements
-EMG remains relatively elevated, may decrease from wake
-comprises 2 - 5% of total sleep time

Front 74

Stage N2 Sleep
EEG

Back 74

-one or more trains of sleep spindles 11 - 16 Hz, >0.5 sec
-K complexes unassociated with arousals
-high voltage delta waves may comprise up to 20% of the recording epoch

Front 75

K Complexes

Back 75

Negative sharp wave followed immediately by slower positive component, greater than 5 seconds

Front 76

Stage N2 Sleep
EOG & EMG

Back 76

EOG: no eye movements
EMG: still relatively elevated

Front 77

Stage N2 comprises how much of total sleep time?

Back 77

45 - 55%

Front 78

Stage N3

Back 78

-high amplitude (>75 microvolts) slow waves (0.5 - 2 Hz) constitutes 20% or more of recording epoch
-sleep spindles may persist
-EOG: usually absent
-EMG: variable, often lower than N2 & may be as low as stage R
-predominates in first third of sleep episode

Front 79

Stage N3 comprises how much of total sleep time?

Back 79

15 - 20%

Front 80

Sleep walking, sleep terrors, and confusional arousals usually arise in what sleep stage?

Back 80

SWS or Stage N3

Front 81

Stage R
EEG

Back 81

-low voltage, mixed frequency activity
-may see sawtooth waves

Front 82

Stage R
EMG

Back 82

-baseline chin muscle activity no higher than any other sleep stage & usually at the lowest level of entire recording
-phasic twitches
-tonic activity

Front 83

Phasic Twitches

Back 83

short bursts of muscle activity occurring in clusters often at the same time as rapid eye movements

Front 84

Tonic Activity

Back 84

periods of relatively little muscle activity

Front 85

Stage R sleep comprises how much of the total sleep time?

Back 85

20 - 25%

Front 86

Stage R sleep occurs in how many discrete cycles over the course of the night?

Back 86

4 - 6

Front 87

Sawtooth waves can be associated with, although they are not necessary for staging what sleep stage?

Back 87

Stage R

Front 88

Respiratory System consists of:

Back 88

upper airway
nose
mouth
pharynx

Front 89

Upper Airway Functions

Back 89

conducts air
protects lungs from foreign objects
aids in speech and spell

Front 90

Nose Functions

Back 90

warms, humidifies, and filters air
air passes from the nose into the back of the throat and to the lungs

Front 91

Mouth Functions

Back 91

air passes directly into the lungs
soft tissues in the mouth (tongue) can cause obstruction to air movement during sleep

Front 92

Pharynx

Back 92

area between the mouth and the lower airway

Front 93

Lower Airway:

Back 93

Larynx
Trachea
Bronchi
Alveoli
Lungs
Diaphragm

Front 94

Larynx

Back 94

located at the base of tongue and upper end of the trachea
includes the vocal cords

Front 95

Trachea

Back 95

main tube into lungs

Front 96

Bronchi

Back 96

branching tubes in the lungs

Front 97

Alveoli

Back 97

tiny sacs at the end of the bronchi
located next to blood vessels
area where gas exchanges occurs

Front 98

Lungs

Back 98

composed of bronchi and alveoli

Front 99

Diaphragm

Back 99

main muscle of breathing
separates the cavity the lungs are in (thoracic cavity) from the cavity with the stomach (abdominal)

Front 100

Inspiration

Back 100

Diaphragm contracts, creating a negative pressure in the lungs. Negative pressure pulls air through the upper airway into the lungs. Air expands the lungs all the way to the alveoli. Oxygen from inspired air diffuses across the border between the alveoli and the tiny blood vessels, pulmonary capillaries

Front 101

Gas Exchange

Back 101

Oxygen diffuses across the alveoli into the blood. Oxygen dissolves into the blood and combines with hemoglobin, a blood compound. Hemoglobin delivers oxygen throughout the body. CO2 diffuses across the capillaries into the alveoli. CO2 is a by-product of cell activity.

Front 102

Expiration

Back 102

The diaphragm relaxes and moves upward. this compresses the lungs and moves air out through the lower airways to the upper airways.

Front 103

Methods of Measurement of Oxygen

Back 103

Partial Pressure of Oxygen (PO2)
Oxyhemoglobin Saturation (SaO2)

Front 104

Partial Pressure of Oxygen
PO2

Back 104

-determined from an arterial blood gas (PaO2)
-most accurate measurement but requires drawing blood from an artery

Front 105

Oxyhemoglobin Saturation
SaO2

Back 105

-noninvasive method
-allows continuous monitoring of SaO2 by pulse oximetry

Front 106

Pulse Oximetry

Back 106

Light is passed through a pulsating arterial vascular bed and the amount passing through is measured on the other side. The amount of light that gets through depends on the degree of saturation of the hemoglobin molecules. When measured by pulse oximetry, oxygen saturation is also called SpO2.

Front 107

Oxyhemoglobin saturation is a measure of how much oxygen is being carried by hemoglobin.

Back 107

*100% - all hemoglobin sites are carrying O2
*Typical saturation 95 - 95%
*Saturation <88% requires therapeutic intervention
*Hypoxemia - low blood oxygen level

Front 108

Oxyhemoglobin Dissociation Curve

Back 108

The relationship between partial pressure of oxygen (PO2) and saturation (SpO2).

Front 109

Oxyhemoglobin Dissociation Curve

Back 109

*The relationship is not a straight line.
*At high saturation, large changes in PO2 lead to small changes in saturation.
*At low saturation, small drops in PO2 lead to large changes in saturation.

Front 110

Oxyhemoglobin Dissociation Curve

Back 110

The shape of the curve makes interpretation of the oxygen content of blood difficult.

Front 111

Oxyhemoglobin Dissociation Curve
SaO2 above 90%

Back 111

The curve is flat, but below this level the PaO2 declines sharply.

Front 112

Oxyhemoglobin Dissociation Curve
SaO2 below 90%

Back 112

Small differences in hemoglobin saturation reflect large changes in PaO2.
Saturation 90% - PaO2 is 60 mmHg
75% - 47 mmHg
50% - 26.6 mmHg
25% - 15 mmHg

Front 113

Cardiac System

Back 113

The heart has four chambers. The two on the top are the right and left atriums. The two on the bottom are the right and left ventricles.

Front 114

Cardiorespiratory System

Back 114

Blood which has circulated in the body has dropped off oxygen and picked up carbon dioxide. This blood goes into the right atrium of the heart. Blood is pumped into the right ventricle. Blood next goes to the lungs through the pulmonary arteries which branch into tiny capillaries that are next to the alveoli. At the alveoli, blood exchanges Co2 for O2. Blood travels through pulmonary veins to the left atrium. Blood then goes into the left ventricle and is pumped back out into the body.

Front 115

Nervous System includes:

Back 115

brain, spinal cord, nerves, and muscles

Front 116

Central control of breathing is in the __________.

Back 116

brain

Front 117

Neurons in the base of the brain in the medula and pons

Back 117

have input into the regularity and rate of breathing

Front 118

There are also feedback inputs (chemo- and mechanical receptors_ into the brain respiratory centers which help to regulate the ________ and __________ of breathing.

Back 118

speed (respiratory rate) and depth

Front 119

Chemoreceptors

Back 119

Specialized nerve structures located in the cartoid bodies, aorta, and medulla.

Front 120

What is essential in maintaining the balance of O2, CO2, and hydrogen ions (acid base balance) in the blood?

Back 120

Breathing (Ventilation)

Front 121

How do chemoreceptors respond to decreases in PO2, increases in PCO2 and more hydrogen ions (acidemia)?

Back 121

By sending signals to the medulla, which then sends a message to increase respiratory rate.

Front 122

The brain's response to a decrease in PO2 is slower or faster during sleep than during wake?

Back 122

slower

Front 123

The brain's response to an increase in PCO2 is slower or faster during sleep than wake?

Back 123

slower

Front 124

During sleep, lower O2 levels and higher CO2 levels are necessary to influence respiration than during wake.
True or False

Back 124

True

Front 125

Mechanical Receptors in the lungs and chest wall

Back 125

*respond to irritation, stretch (inspiration & expiration) and swelling (congestion) of the blood vessels
*stimulation results in rapid, shallow respirations

Front 126

Musculoskeletal System

Back 126

*nerves leave the spinal cord and eventually end on muscles
*control of muscle activity during sleep is different from the control of muscle activity during wake

Front 127

Musculoskeletal System

Back 127

In NREM sleep there is a slight decrease in muscle contraction (tone) compared with wake.

Front 128

Musculoskeletal System

Back 128

In REM sleep there is suppression of muscle tone (tonic activity) in addition to occasional bursts of muscle contraction (phasic activity).

Front 129

Where does the tonic suppression of muscle activity during REM sleep originate?

Back 129

in cells in the pons at the base of the brain

Front 130

What causes the brief muscle contractions during phasic REM sleep?

Back 130

excitatory neuronal (cellular) firing

Front 131

Abnormalities in muscle activity during sleep leads to a variety of sleep disorders which can be diagnosed with PSG.
True of False

Back 131

True

Front 132

Dipoles

Back 132

Electrical sources whose poles are charged differently - one end is negative and one end is positive.

Front 133

_________ are dipoles and generate electrical impulses.

Back 133

Living cells

Front 134

Electrical impulses can be recorded on the PSG and _______ & ________.

Back 134

measured and analyzed

Front 135

Electrical impulses generated by dipoles allow for the PSG parameters to be recorded. What are the parameters?

Back 135

EEG
EOG
EMG
EKG or ECG