A/Prof. Harry Teichtahl Director Department of Respiratory & Sleep Disorders Medicine
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A/Prof. Harry Teichtahl
Director
Department of Respiratory & Sleep Disorders Medicine
Western Hospital
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1. What does a sleep disorders physician do?
Diagnose and treat numerous sleep related conditions:
a) Snoring/Sleep apnoea: - 2-4% of the middle aged adult population have
obstructive sleep apnoea- snoring is a very common condition
b) Insomnia
c) Parasomnias:- night leg movements- sleep walking- others
d) Circadian rhythm disorders:- shift work- others
e) Sleep (nocturnal) epilepsy
d) Other diseases associated with difficulty of initiating and maintaining sleep
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2. How do we make a diagnosis?
a) History:- what are the patient’s subjective symptoms (problems)
b) Examination of the patient
c) Investigations:- polysomnography (PSG)- limited sleep studies- surrogate markers of sleep e.g: actigraphy and sleep diaries- surrogate markers of sleep disordered breathing events
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3. Treatments
Depend on the diagnosis:
a) snoring:- weight loss- continuous positive airways pressure (CPAP)- various oral devices- surgery
b) Obstructive sleep apnoea - as above
c) Insomnia:- behavioural therapy- pharmaceutical therapy- light therapy
d) Parasomnias:- pharmaceutical therapy- behavioural therapy
e) Epilepsy:- pharmaceutical therapy
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The PSG
Continuous overnight monitoring ( 8 hour) of:
a) Sleep:- electroencephalogram (EEG)- electrooculogram (EOG)- submental electromyelogram (EMG)
b) Respiration:- surrogate for oronasal airflow (nasal pressure signal; thermal
sensor signal; end-tidal CO2 monitor)- abdominal and chest movement sensors (effort to breathe)- oxygen saturation monitor (via surface electrode - oximetry)- transcutaneous blood or end-tidal breath CO2 tension- pneumotachograph (airflow)- oesophageal pressure monitor (surrogate for intrathoracic
pressure changes = effort to breathe)- diaphragm EMG (effort to breathe)
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c) Body position sensor
d) Legs/arm EMG (for abnormal movements)
e) CPAP recordings (if patient having therapy)
f) Electrocardiogram
g) View patient in bed:- either VCR recording- digital video recording
The PSG …..
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FAMILY PHYSICIAN
SLEEP PHYSICIANASSESSMENT
PSG
MANUAL ANALYSIS (Optional Automatic
analysis - Power Spectrum)
DIAGNOSIS + MANAGEMENT
SLEEP PHYSICIANREPORT
SLEEP SCIENTISTREPORT
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Major issues regarding PSG
• Patient comfort.
• Usually only monitor for one night - how good is it in terms of real life?
• Expensive:- technical staff- hardware requirements- interpretation/reporting
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The problems with the physiological measurements:
Major issues regarding PSG …..
• The signal always comes with something on the side.
• Measure what you can and then use what is really required.
• Most monitors used are surrogate measurements of physiological parameters (patient compliance/ease of use).
• Sampling rate for data acquisition (ailasing, harmonics)
• Filter settings:- use of appropriate filter for differing physiological measurements.
• Phasing issues (e.g. abdomen/chest wall movement detectors).
• Analogue to digital conversions.
• Electrical interference (e.g. 50 Hz electric)
• Other interference (motors fans, etc)
• Calibration problems and the electronic integrity of the equipment.- “the black box phenomenon”
• Issues of linearity of output monitoring device.
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CEN APN with arousal
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HYP with arousal
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PLM - Periodic Leg Movement
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Sleep hypnogram
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Potential errors
PRE-AMP/AMPS/FILTERS +sampling rates,time averaging
PATIENT +electrodes/sampling devices
A-D conversion? filter
COMPUTERDISPLAYreal time(raw data)
REPORT GENERATIONcompacted data,time averaging
PHYSICIAN REPORT
PATIENT MANAGEMENT
PATIENTreferred for PSG
CALIBRATION of equipment
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Remember
Measurement errors are:
• additive
• multiplicative
therefore small systemic errors have potential to becomelarge over a number of handling procedures.
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The Future
• Better techniques than PSG
• Better less cumbersome PSG techniques e.g.- in-hospital telemetry (no wires to amp/filters etc)- at home telemetry (to bedside or better still real-time
to central monitoring station in sleep laboratory)- less surrogates for non-invasive physiological
measurements
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The physician / technologist are TECHNOLOGY END-USERS
• Interaction between system designers and end-users is paramount to understand requirements and difficulties of design.
END-USER
(knowledge of what is required)
DESIGNER
(knowledge of what is possible)
BEST PATIENT OUTCOME
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